Motivational Interviewing: Motivating Youth to Change Behavior Training of Trainers September 21 - 23, 2008 Margaret Bav

1. Bringing Health Care to Schools for Student Success Motivational Interviewing: Motivating Youth to Change Behavior Training of Trainers September 21 - 23, 2008 Margaret Bavis, DNP, FNP-BC Sue Murray, RN, MPH In collaboration with Sharon Stephan, PhD Center for School Mental Health

2. Workshop Objectives • Participants will be able to name the core elements of motivational interviewing • Participants will be able to name at least two techniques used in motivational interviewing. • Participants will be able to demonstrate the steps in conducting a motivational interview session.

3. What does Motivational Interviewing look like? Video clip

4. “Motivational interviewing was developed from the rather simple notion that the way clients are spoken to about changing addictive behavior affects their willingness to talk freely about why and how they might change.” Stephen Rollnick, PhD Addiction 2001; 96:1769-70.

5. Introspective Exercise #1* What expectations do health trainees, who come into contact with clients for the first time, have about promoting behavior change among patients/clients? *Adapted from Presentation by Edward Pecukonis, PhDUniversity of Maryland School of Social Work

6. How Does Behavior Change? Behavior A Behavior B

7. Introspective Exercise #1 (continued) What feelings do you experience when working with patients/clients to promote behavior change?

8. Introspective Exercise #1 (continued) Think of a behavior you’ve tried to change

9. Introspective Exercise #1 (continued) How much time elapsed between: • the first time you engaged in the behavior, and • the first time you recognized risk or negative consequences?

10. Introspective Exercise #1 (continued) • < 1 mo. • 1 to 3 mo. • 4 to 6 mo. • 7 to 12 mo. • 13 mo. to 2 yr. • 3 to 5 yr. • > 5 yr.

11. Introspective Exercise #1 (continued) • How much time elapsed between: • the first time you recognized risk or negative consequences, and • the first time you made an earnest attempt to change the behavior?

12. Introspective Exercise #1 (continued) • < 1 mo. • 1 to 3 mo. • 4 to 6 mo. • 7 to 12 mo. • 13 mo. to 2 yr. • 3 to 5 yr. • > 5 yr.

13. Introspective Exercise #1 (continued) • Did you ever experience some success in changing your behavior? • Did you ever experience a resumption of or increase in the undesired behavior after experiencing some success?

14. Introspective Exercise #1 (continued) What conclusions would you draw from the group’s responses?

15. Possible Conclusions • Behavioral issues are common • Change often takes a long time • The pace of change is variable • Knowledge is usually not sufficient to motivate change • Relapse is the rule

16. Possible Conclusions (continued) • Our expectations of patients/clients regarding behavior change are unrealistic • Unrealistic expectations can lead to frustration and burn-out

17. Benefits of Learning About the Transtheoretical Model & Motivational Interviewing • More realistic expectations • Greater recognition of small accomplishments • Greater success over time • Less frustration and burn-out

18. Transtheoretical Model (Prochaska & DiClemente) • Individuals progress through stages of change • Movement may be forward or backward • Movement may be cyclical

19. Transtheoretical Model* Precontemplation Relapse Contemplation Maintenance Determination Action SynonymsDetermination = PreparationTermination = Exit Termination *Adapted from Presentation by Edward Pecukonis, PhDUniversity of Maryland School of Social Work

20. Motivational Interviewing can be used at all Stages of Change: DURING:MI can: • Precontemplation – raise awareness • Contemplation – help decision making • Action and Maintenance - enhance and remind of resolution to change • Relapse - enables reassessment

21. Spirit of Motivational Interviewing • A “way of being” with a client • The spirit of MI is characterized by: • a warm, genuine, respectful and egalitarian stance • supportive of client self-determination and autonomy

22. Principles of Motivational Interviewing • Express Empathy • Roll with Resistance • Develop Discrepancy • Support Self-efficacy • Avoid Argumentation

23. For which behaviors can we use motivational interviewing? • Any high risk behavior! • MI has been shown to be effective for: • Substance use • Tobacco use • Sexual activity • Diet and physical activity (e.g. diabetes, obesity) • Truancy • Chronic disease (e.g. asthma)

24. Motivational Interviewing with Adolescents • Teens: Hardwired for Risky Behaviors? • Emotion/Social Interaction – active in puberty • Behavior regulation - still maturing into early adulthood. • Just because we are giving teens the facts, that doesn’t mean we are changing their behavior!

25. Motivational Interviewing Techniques

26. Assessing Stage of Change What question(s) would best assess stage of change?

27. Assessing Stage of Change (continued) Sample initial questions: • How do you feel about your [behavior]? • What do you think about your [behavior]? • How does [behavior] fit into your life?

28. Assessing Stage of Change (continued) • Sample follow-up questions: • So, are you saying that you’re thinking of [changing] soon, or not really? • I’m confused. Are you saying that you’re ready to [change], or is this a bad time?

29. 3 Stages of Techniques* • Opening Strategies • Responding to “Sustain Talk” • Eliciting “Change Talk” * Adapted from New York State Office of Alcohol and Substance Abuse Services, Continuing Education, Steven Kipnis, MD, FACP, FASAM, Patricia Lincourt, LCSW, Robert Killar, CASAC

30. Opening Strategies(OARS) • Open-ended Questions • Affirmations • Reflections • Summaries

31. Opening Strategies (OARS) Open-ended Questions • Close-ended question (one that can be answered yes/no/maybe): “Have you had anything to drink today?”; “Would you like to quit smoking?” • Open-ended question: “What is a typical drinking day like for you?”; “How do you feel about your smoking?”

32. Opening Strategies (OARS continued) Affirmations • An example of an affirmation is, “I really like the way you are approaching this problem, I can see that you are very organized and logical and I am sure this will help you to succeed in our program.” • An affirmation can be used to reframe what may at first seem like a negative. “I can see that you are very angry about being here, but I’d like to tell you that I am impressed that you chose to come here anyway, and right on time!”

33. Opening Strategies(OARS continued) Reflections • Statements made to the client reflecting or mirroring back to them the content, process or emotion in their communication. Reflective listening says: • “I hear you.” • “I’m accepting, not judging you.” • “This is important.” • “Please tell me more.” • Student: “My girlfriend gets really angry when I get stoned and pass out.” • Provider: “She gets mad when you do that.”

34. Opening Strategies(OARS continued) Summaries • Summaries are simply long reflections. They can be used to make a transition in a session, to end a session, to bring together content in a single theme, or just to review what the client has said. • An example is: “Let’s take a look at what we have talked about so far. You are not at all sure that you have a ‘problem’ with alcohol but you do feel badly about your DWI and it’s effect on your family. You said that your family is the most important thing to you and you would consider totally quitting drinking if you believed it was hurting them.”

35. “Sustain-talk” Clients may not want to make behavior changes, and many argue strongly against making these changes. They may: • Argue • Deny a problem • Accuse • Interrupt • Disagree • Passively resist though minimal answers • Overtly comply due to mandate with little investment • Become angry

36. Examples of Client Sustain Talk Statements • “I don’t have a problem, it is all a mistake.” • “I don’t drink anymore alcohol than my friends do.” • “This is your job. You don’t really care if I change or not.”

37. Responding to “Sustain-talk” • It was shown in a recent University of New Mexico study that the more, and the earlier a client argued for change in the treatment process, the better the treatment outcome.* • Specific techniques have been shown to decrease “resistance” or “sustain-talk.” *Amrheim, P., Miller, W.R. (2003)

38. Techniques for Responding to “Sustain-talk” Reflective Techniques: • Simple Reflection • Complex Reflection

39. Simple Reflection A simple reflection, mirrors or reflects back to the client the content, feeling or meaning of his/her communication. An example of a simple reflection to respond to “sustain-talk” is: Client: “I know I made a mistake but the hoops they are making me jump through are getting ridiculous.” Counselor: “You are pretty upset about all this. It seems like everyone is overreacting to a mistake.”

40. Complex Reflection Complex reflections typically add substantial meaning and emphasis. They can provide two sides of points of view, be metaphors, or verbalize unspoken emotion. For example: Client: “I know that I made a mistake, but the hoops they are making me jump through are ridiculous.” Counselor: “You made a mistake and it sounds like you feel badly about that, but you also think that people are asking you to do too much.”

41. Strategic Techniques for Responding to “Sustain-talk” Sometimes clients are entrenched or “stuck” in “sustain-talk”. In this case, there is another set of techniques referred to as strategic techniques. The strategic techniques include: • Shifting Focus • Coming Along Side • Emphasizing Personal Choice and Control • Reframe • Agreement with a Twist

42. Shifting Focus Shifting focus attempts to get around a “stuck” point by simply side-stepping. An example, using the same client statement is: Client: “I know I made a mistake, but the hoops they are making me jump through are getting ridiculous.” Counselor: “You are upset by all of these hoops. Can you tell me more about the mistake you think you made?”

43. Coming Along Side This technique is used to align with the client. This is used when the client has not responded with a decrease in “sustain-talk” with previous techniques. An example of coming along side is: Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.” Counselor: “You may be at your limit and might not be able to keep up with all this.”

44. Emphasize Personal Choice and Control Clients ultimately always choose a course of action and this technique simply acknowledges this fact. Acknowledging this can sometimes help a client recognize that they are making a choice. An example is: Client: “I know I made a mistake, but the hoops that they are making me jump through are getting ridiculous.” Counselor: “You don’t like what others are asking you to do, but so far you are choosing to follow-through with what they are asking. It takes a lot of strength to do that. Tell me what motivates you.”

45. Reframe This technique takes a client communication and gives it a different twist. It may be used to take negative client statement and give it a positive spin. An example: Client: “I know that I made a mistake, but the hoops they are making me jump through are getting ridiculous.” Counselor: “You are not happy about others having so much control, but so far you have been able to keep up with all their expectations and have been quite successful!”

46. Agreement with a twist This is a complex technique that combines a reflection with a reframe. This gives the client confirmation that they were “heard” and then offers another perspective on their communication. It is similar to a reframe and an example is: Client: “I know that I made a mistake, but the hoops that they are making me jump through are getting ridiculous.” Counselor: “You are feeling frustrated with all these expectations. You are also anxious to be successful with some things so you can keep moving forward.”

47. “Change-talk” • Opposite of Sustain-talk • Change talk is client speech that favors movement in the direction of change.

48. Examples of “Change-Talk” • “I really want to be a good daughter and I know I should make some changes.” • “I quit smoking when I decided I was ready and I think I can do this too.” • “I know I would be more motivated and do better in school if I cut down on my use.”

49. Techniques for eliciting “Change-Talk” • Exploring problem • Looking backward • Looking forward • Considering importance • Exploring values and discrepancy with behavior • Considering pros and cons (decisional balance) • Importance/Confidence Ruler • Exploring Extremes • Planning and Committing

50. Exploring Problem • Simply asking open-ended questions, reflecting and providing opportunity to explore the problem from the clients perspective. For example: • “Tell me a little more about…” • “What do you think about …?” • “Who influenced you…?”