Motivational Interviewing: Practices from the Heart

1. Antoine Douaihy, MD Associate Professor of Psychiatry University of Pittsburgh School of Medicine Medical Director Addiction Medicine Services Western Psychiatric Institute and Clinic Member of Motivational Interviewing Network of Trainers, Inc (MINT) douaihya@upmc.edu Motivational Interviewing: Practices from the Heart

2. Recommended Skill-Development Format How to Integrate this Workshop Study • Workshops • Readings • Tapes • Videos • Website • Review Research Practice • Training • Audio/Video critiques • Coaching • Feedback Extend • In-vivo application • Further training • Mint • List serve • Measure effectiveness

3. Initial Workshop • A workshop is only the beginning of learning MI. • Learning Goals: • 1. To understand the underlying spirit and approach of MI. • 2. To recognize the reflective listening responses and differentiate them from other counseling responses. • 3. To be able to provide at least 50% reflective listening responses during a conversation. • 4. To recognize change talk and be able to differentiate commitment language from other types of change talk. • 5. To list and demonstrate several different strategies for eliciting client change talk. • A workshop without follow-up is unlikely to make a significant difference in practice. • Research indicates that personal feedback and performance coaching are necessary to effectively integrate MI skills.

4. Principles of Motivational Interviewing Use this scale to rate your understanding of motivational interviewing methodology 0 1 2 3 4 5 6 7 8 9 10 None Moderate Very High

5. A Motivational Interviewing Parable A traveler in ancient Greece had lost his way and, seeking to find it, asked a man by the roadside who turned out to be Socrates. “How can I reach Mt. Olympus?” asked the traveler. To this inquiry Socrates is said to have gently replied “Just make sure that every step you take goes in that direction.” Source: Discover the Power Within You By: Jeff Butterworth (Chapter 3)

6. The Transtheoretical Model of Stages of Change Prochaska, DiClemente, and Norcross (1994)

7. Stages of Change Model Precontemplation Increase Awareness Contemplation Motivate & increase self-efficacy Relapse Assist in coping Preparation Negotiate plan Maintenance Reaffirm commitment Active problem solving Action Implement Plan F/U Termination

8. The Spiral of Change

9. As the degree of mismatch increases between yourself and the patient in readiness for change, the likelihood of resistance increases proportionately Your Viewpoint Mismatch Other person Maintenance Action Preparation Contemplation Pre-Contemplation Differing viewpoints on readiness for change.

10. Movement Along the Motivational Continuum ? ? ? 1 10 Not Ready Unsure Very Ready People come in within a certain range of motivation. What you say influences where they end up.

11. Readiness Levels

12. Summary: Stages of Change • About the process of change • Compatible with different treatment models • Change occurs all the time • Many people change without help • People fluctuate among SOC • Emphasizes positive reasons for change • People require more motivation in early stages • It is NOT MI • Combined with MI, it helps people decide on their own • plan of action

13. “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.” - Charles Darwin (1809-1882)

14. Motivational Interviewing:An Overview W. Miller & S. Rollnick (2013, 3rd Ed.)

15. “Motivation is a fire from within. If someone else tries to light that fire under you, chances are it will burn very briefly.” - Stephen R. Covey, (1932-Present)

17. Why Do People Change? • People change voluntarily only when: • They become interested in or concerned about the need for change. • They become convinced that the change is in their best interests or will benefit them more than cost them. • They organize a plan of action that they are committed to implementing. • They take the steps necessary to make and sustain the change.

18. Sources of Motivation External Pressure + Internal Motivation Externally motivated subjects had long term outcomes only when they also had high levels of internal motivation (Deci, 2000)

19. Self Determination Theory: SDT • Internal motivation is enhanced by: • Autonomy - Freedom to choose • Competence - Self efficacy • Relatedness - Relationships heal BEHMS REACTANCE THEORY = whenever a particular behavior is threatened, the desirability of that behavior increases. Ex: “You can not use drugs while on probation!” 1. (Brehm 1981) 2. (Miller, Rollnick 2002) 3. (Hubble Duncan and Miller, 1999)

20. New Findings on Motivation • Motivation predicts action • Motivation is changeable • Motivation is behavior specific • Motivation is interactive • Internal motivation lasts longer than external

21. How to Learn MI: 8 Skills • Openness to underlying assumption and spirit of MI. • Proficiency in client centered interpersonal skills, especially accurate empathy. • Recognize change talk and commitment language. • Minimize resistance in responding to sustain talk. • Skill in eliciting and responding to change-talk. • Formulate an effective change plan. • Enlist commitment to the plan. • Blending MI with other therapies. • (Explore and resolve ambivalence – ongoing) • Miller & Moyers, 2006

22. Where people get stuck in MI 1.Underlying Assumptions 2. Reflective Listening 3. Recognizing Change Talk 4. Evoking Change Talk 5. Collecting Bouquets (Summarizing) 6. Responding to Resistance 7. Evoking and Strengthening Commitment 8. Transfer to Other Therapeutic Methods

23. Probability of Behavior Change Clinician talks about why change is important. Client nods head. Client thinks about why change is personally important Client talks about why change is personally important Client makes verbal commitment to change Low High

24. Definition of MI • Motivational interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change Miller & Rollnick 2009

25. NumberofMIstudiesby year 160 Obesity Dental n=150 140 Asthma Violence Family 120 Health Prom Psychiatric Diabetes Cardiac HIV/STD Risk Smoking/Tob Adh/Retention Eating Dis Offenders Gambling Dual Dx 100 n=93 80 60 n=54 n=36 40 20 n=6 AOD 0 1988‐94 1995‐99 2000‐02 2003‐06 2007‐09

26. The Spirit of Motivational Interviewing CollaborationEvocationAutonomy Acceptance Compassion ConfrontationEducationAuthority VS.

27. ‘Spirit’ • The way of being with a patient • The patient resolves ambivalence, not the practitioner • Elicited from the patient, not imposed • Quiet, eliciting style • Listening and understanding the patient

28. Method of MI: 4 Processes • Engaging • Focusing • Evoking • Planning

29. Engaging and Focusing • Opening Strategies • A. Use OARS Open-ended questions • Affirm • Reflect • Summarize • B. Agenda Mapping • C. Scaling Questions • Decrease Resistance: minimizing discord • A. Reflections • 1. Paraphrase • 2. Amplified • 3. Double-sided B. Others 1. Shift-focus 2. Reframe 3. Agree w/twist (Reflect/Reframe) 4. Emphasize Personal Control 5. Coming Along Side

30. 3. Evoke “Change-Talk” • A. Types: • 1. Disadvantage of Status Quo • 2. Advantage of change • 3. Optimism for change • 4. Intention to change B. Methods: 1. Evocative questions 2. Elaborate 3. Importance/Confidence rulers 4. Explore decisional balance 5. Query extremes 6. Look behind/look forward 7. Explore goals (values) C.Look for: DARN-CaT Desire Ability Reasons Need ---------------- Commitment And Taking Steps 4. Responding to Change-Talk (EARS) 1. Elaborate 2. Affirm 3. Reflect 4. Summarize

31. From Evoking to Planning • Recapitulation (Grand Summary) • Ask Key Questions • · Where do we go from here? • · What do you want to happen? • · What’s the next step • · Where do you see yourself in 2-4 weeks? • · What might interfere with this? • · Who are your support people? • 3. Provide information/Advise with permission • · May I offer some possibilities/options? • · Are you interested in some suggestions? • · Are you open to other considerations? • · Would a review of some options be helpful? • · Are you looking for helpful information?

32. Negotiate a Change Plan • · Go to Change Plan worksheet • End tasks: • · Summary Reflection • · Close the deal- “How do you feel about what you decided to do?” • Helpful Hints • · 2 Reflections/questions • · We can dance or wrestle • · Empathy=accurate reflection of client’s meaning • · Avoid questions or comments that elicit resistance/discord • · Reduce resistance, evoke change-talk • · Stabilize the changes

33. “If a patient wants to go, let him go. If he wants to stay, let him stay. Do not deny him what he wants and do not suppress him. If we comply to his wishes and let him satisfy his needs, then all of his excessive positive force will be appropriately discharged and he will consequently get well.” - Zhang Zhongiing Ca. 200 A.D.

34. Motivational Interviewing Facilitates Change By: • Reducing resistance/harmony in the relationship • Raising discrepancy • Eliciting change-talk • Responding to change-talk • Sustaining change

35. Conditions that Enhance Change elicits change from within, (not imposed) makes patient responsible for change avoids direct persuasion is interactive/directive resolves ambivalence works through the therapeutic “partnership” Motivational Interviewing:

36. Key Assumptions Behind MI Encourage empathy Maintain congruence Promote collaborative spirit Recognize ambivalence is normal Discord can be altered Support self-efficacy

37. Empathy • Acceptance facilitates change • Skillful reflective listening is • fundamental • Ambivalence is inevitable

39. “Being empathic is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto...it means to sense the hurt or pleasure of another as he senses it and to perceive the causes thereof as he perceives them...” - Carl Rogers

40. Discrepancy “Are your current behaviors leading toward or away from your goals/values?” Status Quo “Sustain-Talk” (No Change) = Goals “Commitment-Language” (Behavior Change) = vs. Discord Motivation

41. Traps to Avoid • Question-Answer Trap • Trap of Taking Sides • Expert Trap • Labeling Trap • Premature Focus Trap • Blaming Trap

42. Communication can go wrong because… • The speaker does not say exactly what is meant. • The listener does not hear the words correctly. • The listener gives a different interpretation to what the words mean. • The speaker does not “feel” understood.

43. Active Listening (Thomas Gordon, Ph. D.) Client Facilitator 2 What is said What is heard 3 1 What is understood What is meant/felt 4

44. Not Listening: Roadblocks 1.Ordering, directing, commanding 2. Warning, cautioning, threatening 3. Giving advice, making suggestions, providing solutions 4. Persuading with logic, arguing, lecturing 5. Moralizing 6. Disagreeing, judging, criticizing, blaming 7. Agreeing, approving, praising 8. Shaming, ridiculing, labeling 9. Interpreting, analyzing 10. Reassuring, sympathizing, consoling 11. Questioning, probing 12. Withdrawing, distracting, humoring, changing the subject [Thomas Gordon]

45. MI into Application Using O.A.R.S. • Ask open-ended questions. • Directly affirm and support the client. • Listen reflectively. • Summarize periodically.

46. EXERCISE Is it an open or closed question? 1.What do you like about your current situation? ___ 2. Is this strategy effective? ___ 3. What kind of specific assistance are you looking for? ___ 4. Have you ever considered just going to AA? ___ 5. Isn’t it important to you to follow your doctors orders? ___ 6. What obstacles do you anticipate in making the specific changes we’ve discussed? ___ 7. What are the most important reasons for making these changes? ___ 8. Don’t you care about your health? ___ 9. What do you think about coming back for a follow-up visit? ___ 10. Is this an open or closed question? ___

47. Open-Ended Questions • Stimulates elaboration • Asks for more than 1 word responses • Examples: • “What would you be doing differently if you • had already made the change you're • considering?” • “How might you get from where you are today • to where you want to be in the near future?”

48. Affirm/Support • Use statements of appreciation and understanding NOT cheerleading • Examples: • “You are very courageous that you decided to want to tackle this problem.” • “I appreciate your willingness to discuss this.”

50. Reflective Listening/Practice Essential Skill That Reduces discord/elicit change talk Simple Reflections Complex Reflections