Motivational Interviewing – a flavour

1. Motivational Interviewing – a flavour Preparing people for change Dr. Gerard Garbutt

2. You would think . . . • That having had a heart attack would persuade a man to quit smoking, change diet, exercise and take his medication. • That hangovers, damaged relationships, a car crash, and memory blackouts would be enough to convince a woman to stop drinking.

3. Clinician Assumptions • This person ought to change • This person wants to change • Patient’s health is motivation • No change = failure • Now is the right time • Being tough is best • I know • my advice is good • Negotiation is always best

4. First intro 1983 For alcohol problems To ‘prime’ for treatment Enhance intrinsic motivation

5. Cycle of Change Model

6. Behaviour Change Counselling • ‘Ways of structuring a conversation which maximises the individual’s freedom to talk and think about change in an atmosphere free of coercion and the provision of premature solutions’ • Assessing readiness • Weighing up pros and cons • Determining action - moving patients on

7. What is MI? • Cognitive approach • Deals with facts and thought processes • Strategic • Agenda driven & directive • Empathic • Non judgmental, reflective, affirming, respectful • Client-centred • Views from client’s perspective, reinforces personal responsibility • Empowering • Client in control, supports self-efficacy

8. What MI is not: • Giving Information • Giving Advice • Persuading • Warning • Confronting • Agreeing

9. The task of MI is… • Evocation: • critical elements of change are within the person • the clinician’s task is to draw them out • Collaboration: • the clinician is a resource • the client is the expert • Autonomy: • it is the client, not the clinician, who must decide to change and provide the means for it

10. The Basics - Affirmation • The clinician says something positive or complimentary to the client. • “I appreciate you getting here today“ • Encouraging statements • “Good for you” • “Well done”

11. The Basics - Open Questions • Open questions: • Leave latitude for a response. • Client has to think about it • ‘What do you want to do about your drinking?’ versus • ‘Do you want to quit or cut down?’ • Purpose of questions: • To gather information • What, Why, When, How, Where, Who? • To understand a client’s story.

12. Five General Principles of MI • Express Empathy • Explore Ambivalence • Develop Discrepancy • Roll with Resistance • Support Self-Efficacy Throughout – emphasise the desirable

13. Express empathy • Getting alongside • Simple reflective listening • Affirmation • Respectfulness • You want patients say: • ‘I felt heard/understood’ • ‘I wanted to carry on talking’

14. Explore Ambivalence • Seeing both sides • Non-judgemental/dispassionate • Decisional balance

15. Decisional Balance ++++++ -------- ^ • Weighing up pros and con’s • Seesaw • Balance sheet

16. Develop Discrepancy • Explore client values • Establish client goals • Contrast with behaviour • Cognitive dissonance • Conflict between opposing self beliefs and /or behaviour leads to resolution or rationalisation

17. Cognitive Dissonance • I’ve stopped smoking vs • I had a few cigarettes last night • I’m a good mother vs • I injected heroin in front of my son • I must stop this behaviour • I really am addicted, what can I do? • I’m a failure, I have no control

18. What is Resistance? • Suddenly changes tack • Reasons NOT to change • Justifying • Blaming • Ignoring • Arguing • Interrupting • Changing the subject

19. Rolling with Resistance Avoid argumentation through: • Shifting focus • Reframing • Agreement with a twist • Emphasising personal control

20. Support self-efficacy • Optimism • Emphasise client’s past achievements • Convey the success of others • Selectively reinforce optimistic/motivated statements

21. Envisioning • Projecting into the future: • What will happen if behaviour doesn’t change? • What would be different if you could make the change? • Or directively: • if you carried on what would be the downside? • if you changed/stopped, what would be the benefits?

22. Decision making – bringing it all together • Summarise the ambivalence • Elaborate the pros and cons of change • Emphasise personal control • Support self-efficacy • Positive images of the future after change • Ask: • What would you like to do now about your drinking?

23. Conflict Resolution is the key: • Try to elicit a decision: • I’ll stop • I’ll cut down • I’ll get help • I’ll come back to see you • Firm up the decision- Ensure it’s personal

24. A brief MI intervention • Introduction and consent • Decisional balance • Feedback - cognitive dissonance • Envisioning • Decision making

25. Feedback – giving the facts • Common in primary care – eg: • GGT & ALT • Units • Questionnaire results • Behaviour related health check ups • Opportunity to open a motivational dialogue • What do the facts mean to the patient?

26. Feedback method • Introduce test • Describe implications • Check understanding • Check meaning to the client • Provide normative range • Present results • Check understanding • Avoid jargon

27. Feedback exercise Feeding back information from some liver function tests using the methodology described. Check understanding/significance first! Gamma GT (15-35) 150 ALT (10-50) 90

28. Motivational Interviewing • Ways of structuring a conversation which maximises the individual’s freedom to talk and think about change in an atmosphere free of coercion and free of the provision of premature solutions (Rollnick et al. 1999)