Motivational Interviewing: Basic Training

1. Alan Lyme, MSW, ICADC, ICCS, SBIRT MI Clinical Supervisor Medical Center of Central Georgia lyme.alan@mccg.org alanlyme@yahoo.com Motivational Interviewing:Basic Training MI Basic Training

2. DEFINITION: Motivational interviewing is a client-centered, evidence- based, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence with the individual. SPIRIT: Collaboration; autonomy; respect; compassion MOTIVATIONAL INTERVIEWINGDEFINITION & SPIRIT MI Basic Training

3. “ A client-centered, goal oriented intervention focused on resolving ambivalence in the direction of change” “…not a series of techniques … but a way of being with clients” MI Basic Training (Information on MI adapted from Motivational Interviewing. Miller and Rollnick, 1991)

4. Why Motivational Interviewing? • Evidence-based >170 clinical trials • Effective in reducing maladaptive behaviors (e.g., problem drinking, gambling, HIV risk behaviors, smoking) • Effective in promoting adaptive health behavior change (e.g., exercise, diet, medication adherence) Miller & Rose, 2009; Lai DTC, Cahill K, Qin Y, Tang J-L, 2010 MI Basic Training

5. Motivational InterviewingUNDERLYING ASSUMPTIONS • Acceptance • Autonomy/Choice • Less is better • Elicit versus Impart • Michelangelo Belief • Ambivalence is normal • Care-frontation • Change talk • Righting reflex MI Basic Training

6. Eight Stages in Learning MI 1. The spirit of MI 2. OARS – Client-centered counseling skills 3. Recognizing and reinforcing change talk • Eliciting and strengthening change talk • Rolling with resistance 6. Developing a change plan 7. Consolidating client commitment 8. Shifting flexibly between MI and other methods Miller, W. R., & Moyers, T. B. Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions. MI Basic Training

7. FIVE GENERAL PRINCIPLES • Express Empathy • Develop Discrepancy • Avoid Arguments, “Right” positions • Support Self-efficacy • Roll with the Resistance MI Basic Training

8. OARS • O: open-ended questions • A: affirm, notice the strengths of the person, see the motivation in what they do…hear their values • R: reflection, use empathy, simple and complex, 2 to 1 statements to questions • S: summarize (5-15 minutes in time together) MI Basic Training

9. Closed Questions • Have a short answer (like Yes/No) • Did you drink this week? • Ask for specific information • What is your address? • Might be multiple choice • What do you plan to do: Quit, cut down, or keep on smoking? • They limit the client’s answer options MI Basic Training

10. Open Questions: • Open the door, encourage the client to talk • Do not invite a short answer • Leave broad latitude for how to respond MI Basic Training

11. Open-ended Questions • “How can I help you?” • “Would you tell me about ___?” • “How would you like things to be different?” • “What are the positive things and what are the less good things about ___?” • “What will you lose if you give up ___?” • “What have you tried before?” • “What do you want to do next?” MI Basic Training

12. Closed Versus Open-Ended Questions • What problems has your alcohol use caused you? • How important is it for you to complete this program successfully? • What else? • Do you feel you have a problem with alcohol? • Is it important to you to complete this program successfully? • Anything else? Motivational Interviewing 3hr Training

13. Some Guidelines with Questions • Ask fewer questions! • Don’t ask three questions in a row • Ask more open than closed questions • Offer two reflections for each question asked MI Basic Training

14. Affirmations • Emphasize a strength • Notice and appreciate a positive action • Should be genuine • Express positive regard and caring • Strengthen therapeutic relationship MI Basic Training

15. Affirmations Include: • Commenting positively on an attribute • You’re a strong person, a real survivor. • A statement of appreciation • I appreciate your openness and honesty today. • Catch the person doing something right • Thanks for coming in today! • A compliment • I like the way you said that. • An expression of hope, caring, or support • I hope this weekend goes well for you! MI Basic Training

16. Reflective Listening “Reflective Listening” is the key to this work. The best motivational advice we can give you is to listen carefully to your clients. They will tell you what has worked and what hasn’t. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen”(Miller & Rollnick, 1991) MI Basic Training

17. Types of Empathic Reflections • Simple/Repeating - Reflect what is said • Simple/Rephrasing – Slightly alter • Amplified - Add intensity to idea/values • Double Sided - Reflect ambivalence • Metaphor - Create a picture • Shifting Focus - Change the focus • Reframing - Offer new meaning • Emphasize personal choice • Siding with the negative (paradoxical) MI Basic Training

18. Repeating:This is the simplest form of reflection, often used to diffuse resistance • Patient: I don't want to quit smoking. • HCP: You don't want to quit smoking. MI Basic Training

19. Rephrasing: Slightly alter what the client says in order to provide the client with a different point of view. This can help move the client forward. • Client: I really want to quit smoking. • HCP: Quitting smoking is very important to you. MI Basic Training

20. Amplified reflection: Reflect what the client has said in an exaggerated way. This encourages the client to argue less, and can elicit the other side of the client's ambivalence. • Client: My smoking isn't that bad. • HCP: There's no reason at all for you to be concerned about your smoking. (Note: it is important to have a genuine, not sarcastic, tone of voice). MI Basic Training

21. Double-sided reflection: Acknowledge both sides of the client's ambivalence. • Client: Smoking helps me reduce stress. • HCP: On the one hand, smoking helps you to reduce stress. On the other hand, you said previously that it also causes you stress because you have a hacking cough, have to smoke outside, and spend money on cigarettes. MI Basic Training

22. Metaphor: Painting a picture that can clarify the client’s position • Client: Everyone keeps telling me I have a drinking problem, and I don’t feel it’s that bad. • HCP: It’s kind of like everyone is pecking on you about your drinking, like a flock of crows pecking away at you. MI Basic Training

23. Shifting focus: Provide understanding for the client's situation and diffuse resistance Client: What do you know about quitting? You probably never smoked. HCP: It's hard to imagine how I could possibly understand. MI Basic Training

24. Reframing: Much as a painting can look completely different depending upon the frame put around it, reframing helps clients think about their situation differently • Client: I've tried to quit and failed so many times. • HCP: You are persistent, even in the face of discouragement. This change must be really important to you. MI Basic Training

25. Emphasizing Personal Choice: Reflect the client’s autonomy • Client: I've been considering quitting for some time now because I know it is bad for my health. • HCP: You're worried about your health and want to make different choices. MI Basic Training

26. Summarizing • Special form of reflective listening • Ensures clear communication • Use at transitions in conversation • Be concise • Reflect ambivalence • Accentuate “change talk” MI Basic Training

27. How Motivational Interviewing is Directive • Selective eliciting questions • Selective reflection • Selective elaboration • Selective summarizing • Selective affirming MI Basic Training

28. Using OARS Micro-skills Eliciting Change Talk • The idea in MI is to have the client present arguments for both sides in making changes. It is the interviewer’s task to facilitate the client’s expression of such change talk. This is a process of shared decision-making, not an attempt to manipulate or sculpt the client’s will. MI Basic Training

29. Listening For or Eliciting Change Talk • DesireI want to… I really like to… I wish… I can…. • AbilityI would… I am able to... I could… I should… • Reason I think it would be good to… Someone wants me to… This is important… • NeedI need to do this…EqualsCommitment Language MI Basic Training

30. Recognizing Readiness Diminished resistance Decreased discussion about the problem Resolve Change talk Questions about change Envisioning Taking steps MI Basic Training 30

31. Decisional Balance • Ambivalence is a normal part of the change process • Use ambivalence to promote positive change • Weigh pros and cons of behavior • Increase discrepancy MI Basic Training

32. DECISIONAL BALANCE SHEET MI Basic Training

33. Decisional Balance Exercise • What are some of the good things about your ___ (drinking, smoking, eating whatever you want)? What else? • What are some of the not-so-good things about your ____? What else? MI Basic Training

34. Double-sided reflection: Acknowledge both sides of the patient's ambivalence. • Patient: Smoking helps me reduce stress. • HCP: On the one hand, smoking helps you to reduce stress. On the other hand, you said previously that it also causes you stress because you have a hacking cough, have to smoke outside, and spend money on cigarettes. MI Basic Training

35. Importance RulerHow important is it to you to change your smoking habit?If 0 was “not important,” and 10 was “very important,” what number would you give yourself? 0 1 2 3 4 5 6 7 8 9 10 MI Basic Training

36. Exploring Importance • Why are you at x and not (x – 2)? (always start with the higher number) • (If 9 or 10) That’s great. I’m curious why it is that important. • What would need to happen for your importance score to move up from x to (x + 2)? • What stops you moving up from x to (x + 2)? MI Basic Training

37. Confidence RulerHow confident are you that if you wanted to change your smoking habit, you could do so?If 0 was “not confident,” and 10 was “very confident,” what number would you give yourself? 0 1 2 3 4 5 6 7 8 9 10 MI Basic Training

38. Building Confidence • I’m curious about your confidence. What makes it an x and not (x – 2)? • What would make you more confident about making these changes, what might move you from x to (x + 2)? • How can I help you succeed? MI Basic Training

39. Building Confidence • Is there anything you found helpful in any previous attempts to change? • What have you learned from the things that went wrong last time you tried? • If you were to decide to change, what might your options be? • Are there any ways you know about that have worked for other people? MI Basic Training

40. Building Confidence • What are some of the practical things you would need to do to achieve this goal? How could you put them into action? • What, if anything, can you think of that would help you feel more confident? MI Basic Training

41. Eliciting and Strengthening Confidence (Ability) Talk Evocative questions The confidence ruler Reviewing past successes Personal strengths and supports Brainstorming Giving information and advice Reframing Hypothetical change MI Basic Training 41

42. Responding to Confidence (Ability) Talk Reflecting Elaborating Summarizing Affirming Raising possible problems and challenges MI Basic Training 42

43. Readiness Ruler How ready are you at this moment to change your smoking habit?If 0 was “not ready,” and 10 was “very ready,” what number would you give yourself? 0 1 2 3 4 5 6 7 8 9 10 MI Basic Training

44. Exploring Readiness • Why do you give yourself an x and not (x - 2) (begin with the higher number)? • What might make you even more ready to make a change? • What would be your first step in making a change? MI Basic Training

45. SIGNS OF READINESS FOR CHANGE • Increased questions about change: asks what they could do about the problem.. • Envisioning: begins to talk about how life might be after a change.. • Experimenting: begun by experimenting with possible change approaches (e.g., going to a support group, going without for a few days, reading/looking up information on the internet).. MI Basic Training

46. Evocative questions for obtaining change talk What concerns you about your drinking/smoking/health habit? What are others worried about regarding your drinking/smoking/health pattern? What relevance/importance does smoking/drinking have in your personal goals? If you decided to change your drinking/smoking/health habit, how would that change your life? Your family’s life? MI Basic Training

47. Negotiating a Change Plan Setting Goals Considering Change Options Arriving at a Plan Eliciting Commitment MI Basic Training 47

48. Negotiate a plan of action • Invite active participation by the patient • Patient determines goals & priorities • Patient weighs options • Together, work out details of the plan MI Basic Training

49. Giving Information and Advice: 3 Kinds of Permission • The person asks for advice • You ask permission to give advice • You qualify your advice to emphasize autonomy MI Basic Training 49

50. Giving information and advice: • Always ask for permission “Other patients have found ___ to be of help. Are you interested in knowing about that or is there something we should discuss first?” • Offer alternatives (menu of options) “We could give you a recommended diet or set up a session with a nutritionist.” • Provide more information according to the interest of the patient “Would you like to know more about Weight Watchers?” MI Basic Training