Using Motivational Interviewing Techniques in Health Promotion: The Basics

1. Using Motivational Interviewing Techniques in Health Promotion:The Basics Tom Davis, MPH Director of Health Programs, Food for the Hungry Presentation for CCIH Conference, May 28, 2006

2. Motivational Interviewing Session Outline • Definition of MI • Skit • Four principles of MI • How MI should influence our behavior change communication • What we know about MI • Studies on MI’s effectiveness • Development of Change Talk Questions • The Stages of Change • Findings on which MI is based • MI Resources & Training

3. What is Motivational Interviewing? • A way to improve a person’s motivation to change, and their ability to actually make a change, by talking with them about their mixed feelings, and helping them to work through those to make a change. • Useful in one-on-one counseling sessions or in groups (modified). • Do basic consciousness raising (e.g., presenting basic facts) about an issue first.

4. The Four Principles of Motivational Interviewing During interviews (multiple sessions, usually): • Express empathy: Use skillful listening. Accept ambivalence about change as normal. • “Like one who takes away a garment on a cold day, or like vinegar poured on soda, is one who sings songs to a heavy heart.” [Prov. 25:20] • Develop discrepancy (between present status and desired goals and values):Help the person to voice the discrepancy between their current status/behavior and where they want to be.

5. Helping People to See Discrepancy (Accountability) 2 Sam 12: 4-7: Now there came a traveler to the rich man, and he was loath to take one of his own flock or herd to prepare for the wayfarer who had come to him, but he took the poor man's lamb, and prepared that for the guest who had come to him.“ Then David's anger was greatly kindled against the man. He said to Nathan, "As the LORD lives, the man who has done this deserves to die; he shall restore the lamb fourfold, because he did this thing, and because he had no pity.“ Nathan said to David, "You are the man! Better -- Self-discovery of Discrepancy: "For what I do is not the good I want to do; no, the evil I do not want to do -- this I keep on doing." [Romans 7:19]

6. The Four Principles of Motivational Interviewing (cont.) During interviews (multiple sessions, usually): • Roll with resistance: Avoid arguing with the person about their current behavior. Refuse to play the adversary. • “But I tell you, Do not resist an evil person. If someone strikes you on the right cheek, turn to him the other also.” [Mat 5:39] • Support Self-efficacy (encourage: Show that you believe the person can change. Let the person choose and carry out the change. • “Preach the Word; be prepared in season and out of season; correct, rebuke and encourage--with great patience and careful instruction.” [2 Tim 4:2]

7. Motivational Interviewing What We Know: • MI Works: Systematic review of 17 randomized trials of MI to change behavior found that 60% of the studies had at least one significant result. (Dunn, DeRoo and Rivara [2001]) • MI was originally used for alcohol and drug addiction. • MI is one method among many. • Particularly effective when a person has high levels of ambivalence. Particularly good for counseling people who are resistant to change. But has been used for simple behaviors, as well. • Comparative advantage when using with people who are less ready to change (Contemplation and Preparation stages of change).

8. Motivational Interviewing in Zambia • From 1999-2001, MI was used in two peri-urban communities in Kitwe, Zambia, where diarrhea and clean drinking water had been identified as major concerns. The goal of the intervention was to encourage adoption of safe water storage practices and purchase of disinfectant in the target communities.

9. Health promotion messages were delivered using MI by neighborhood health committee (NHC) volunteers in weekly visits that were 15-30 minutes long. Health Promotion + MI • An Intervention group received Motivational Interviewing along with education. • A Comparison group received education only.

10. How NHC Volunteers Were Trained • Only the volunteers using MI were trained in MI. All volunteers received diarrhea prevention and safe water education. Local nurses received training in MI, and then developed and delivered MI training for the Neighborhood Health Committee (NHC) volunteers. The NHC volunteers received approximately 10 hours of MI training.

11. Zambia MI Study, Field Trial #2: Bottles of Disinfectant Sold/HH (MI vs. Ed. Only), ’98-’99

12. Field Trial #3: Know That Contaminated Water Causes Diarrhea

13. Field Trial #3: Believe They Can Avoid Diarrhea

14. Field Trial #3: Know They Can Avoid Diarrhea by Boiling or Treating Water

15. Field Trial #3: Ever Used Disinfectant

16. Field Trial #3: Disinfectant Present in Stored Water

17. Stages of Change Model(Prochaska and DiClemente) Maintenance MI’s Focus… Action Person is maintaining a change that has already been made. Preparation Person is engaging in actions with the intention of bringing about change. Change is made. Contemplation Person is open to change and preparing for change (often in the next month) Pre-contemplation Ambivalent; Person both considers and rejects change. Person is not ready to consider a change or unaware of the need to change; sometimes demoralized

18. What We Should Learn from the Stages of Change Model: Use Different Strategies and Activities for Different Stages • What works at one stage often does not work well at another stage. • Most behavior change programs are targeted at people in the Preparation and Action stages – people who are ready to make a change. • Only a fraction of people are actually in these two stages of change.

19. Maintenance Action • Continue positive reinforcement & social supportthrough: • continuance of groups • institutionalization of rewards and recognition for maintaining behaviors. Stages of Change Model:Processes & Activities to be Promoted at Each Stage of Change Preparation Contemplation • Using and fostering social supportand caring relationshipsthrough groups, in families, etc. • Self- and Social Liberation:Belief that one can change and commit to change, and creating social conditions for change by: • Changing community norms to favor change • Drawing attention to those who have made changes • Getting people to commit to making a change Pre-contemplation • Self-Reevaluation:– re-evaluation of self-imagethrough group activities: • values clarification via MI • Change Talk via vs. MI • contact and discussions w/role models • guided imagery (where people imagine them-selves trying out the behavior) • Consciousness Raising: Education and discussion in community groups, religious groups, mass media, and with leaders • Contingency management:Reinforcing positive steps towards desired behaviors (e.g., commit-ments), giving group praise and recognition • Stimulus Control::Removing triggers for unhealthy behaviors; Role-playing to substitute prompts for healthy behaviors. • Dramatic Relief: Taking action to decrease anxiety and other negative emotions through testimonies, role playing, grieving, simulations, and other group activities. • Maintain self-efficacy: Maintain confidence to do the behavior through regular discussions, retraining, accounta-bility system. • Counter-conditioning:Learning to substitute healthy behaviors for problem behaviors • Environmental Re-evaluation:Leaning how one’s actions affects one’s self/others through guided discussions, story telling Use of Mass Media, Motivational Interviewing techniques, and Other Methods Skill Building, Social Support through Small Groups, and Other Methods

20. Findings on which MI is Based: • People who are ambivalent often do not respond logically, and do not respond to logic. Example: Increasing negative consequences • Why? Psychological Reactance: When a person perceives that his or her personal freedom is being infringed upon or challenged, they will do a problem behavior more often, and find the behavior more attractive.

21. Psychological Reactance Efforts to force someone to resolve their ambivalence can actually: • strengthena person’s resolve tonot adopt a positive behaviorthat you wish to promote, or • strengthen a person’s resolve to maintain a negative behavior that you are trying to eliminate. This is particularly true when the person perceives that making a change would lead to some loss of freedom.

22. Findings on which MI is Based: • People have motivations – but we often do not appeal to their true motivations when trying to help them to change. • Motivation is both internal and inter-personal. • Motivation is not just influenced by others – it is often created in relationship with others. • Ambivalence makes change possible. The first step towards changes is often becoming more ambivalent.

23. Findings on which MI is Based (cont): • When a behavior comes in conflict with a deeply-held value, it is usually the behavior that changes. • Importance of making a change = Perceived discrepancy between present status/behavior and desired goal, between how things are and how they would want them to be. • Our tendency is to be “Fixers” • (Skit: 20 mins.)

24. How MI Should Influence How We Do Behavior Change Communication? • Avoid asking: “Why isn’t this person motivated?” Ask instead: “What motivates this person?” • Show the person how the change will be relevant to achieving or preserving something that is truly important or dear to them. • Get the person to use “Change Talk.” • Help the person to choose the approach that they want to use to a desirable goal. Present options where possible. • Learn to avoid a “Fixing” response to ambivalence.

25. The Big Picture: • Just telling people what to do ignores the fact that people are often ambivalent about change. • Debating with a person about change can make them more entrenched. So what can be done? Help project staff to… • Helpthe ambivalent person to voice their arguments for change. Get them to use “change talk.” The goal of MI is to make the change possible for the person by first bringing about these types of “change talk.”

26. Four Types of Change Talk: • Get the person to talk about the disadvantages of keeping things the same (i.e., the status quo). • “What do you not like about how your child is growing presently (without exclusivly breastfeeding)?” • “What do you think will happen if you keep having sex with many partners?”

27. Four Types of Change Talk: • Get the person to talk about the advantages of changing. • What would be good about exclusive breastfeedng? • If you could have one sexual partner immediately, by magic, how might things be better for you?

28. Four Types of Change Talk: • Get the person to talk about optimism for change – hope. • If you decided to exclusively breastfeed, how would you go about doing that? • When else in your life have you made a decision to make a change like this and followed through with it? [“I decided to send my daughter to school no matter how difficult it was.”] • What is there about you that would make it easier for you to exclusively BF than other people? [“I’m very dedicated to do things that I decide to do.”] • What makes you think that if you decided to plan your family that you could do it? [“I would have the support of my husband.”]

29. Four Types of Change Talk: • Get the person to talk about their intention to change • What would you be willing to try in terms of changing the way you breastfeed? • Never mind how to make it happen right now, what do you want to happen in terms of your sex life?

30. Exercise on Development of Change Talk Questions Develop change talk questions for one behavior that you promote in your work

31. Several Motivational Interviewing Resources: This is just an overview – not a full MI training. • Resources on MI: • Motivational Interviewing, Second Edition: Preparing People for Change (Hardcover) William R. Miller, Stephen Rollnick, Kelly Conforti • Websites on MI: • See mi.fhi.net (http://mi.fhi.net) • www.motivationalinterview.org • www.mid-attc.org/accessed/mi.htm#1 • Training • See mi.fhi.net • See www.motivationalinterview.org • See www.cathycoletraining.com