The use of Motivational Interviewing To Help People Create Healthy, Lasting Change

1. The use of Motivational Interviewing ToHelp People Create Healthy, Lasting Change Betty Hanna, MFT, MINT California Consulting

2. Listening for Engagement Engagement: Learning about someone new In pairs: 3 minutes each What are the challenges of our work? Why did you come? What is your interest here today? Hopes and fears. One thing you don’t know about me Where do you hope to be in 5 years?

3. Share with a colleague • Introduce yourself – have a natural conversation • Share your answers with each other/ Make sure both get to SHARE... • Really listen – Do most of the listening not the talking “be with” • Bonus: Take a moment. See if you can listen “beyond” or underneath their content. When you tune in to that what do you know about this person? What is important to them? What do they enjoy? What do they value? What makes them happy? What are they feeling? See if you can listen with your heart.

4. Now..... • 30 Seconds. Summarize, then • Share your bonus with each other • Use direct language: • You........... • Hit your target

5. Agreements for the Session • Collaborative • Ask lots of questions – let us know what you think • Be mindful of each other – be kind • Enjoy, Have fun!! • Attitude: What the Heck !!”Jump into the experience.. Make Mistakes, “OOPS!” • Confidentiality, make the training your experience • Resist the Fixing Impulse

6. The Learning Experience • At the end of a foundational motivational interviewing class, you should be able to: • * demonstrate more effective communication tools that will improve the helper/probationer-personal relationship and create relationships that fosters “real work” of change • * improve quantity and quality of a person’s change-talk through improved reflections of strengths, values, and • feeling and by asking key questions. Meet them where they dream........ • * increase the probabilitythe persons will initiate and maintain LONG-TERM change through increased • change-talk. 6

7. The Problem

8. Determinants of HealthSource: U.S. Centers for Disease Control and Prevention

9. Actual Causes of DeathSource: U.S. Centers for Disease Control and Prevention

10. You would think . . . that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking

11. You would think . . . that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking

12. You would think . . . that the very real threats of blindness, amputations and kidney failure from diabetes would be enough to motivate weight loss and glycemic control that time spent in prison would dissuade people from re-offending Any time, 80% in ambivalence, 20% in action – The language of crisis The language of chronicity

13. Ambivalence It is a very normal human condition simultaneously to want and not want change It is normal to get stuck in ambivalence, sometimes for a long time Compliance is the highest form of resistance How should we respond as helping professionals?

14. MI • Growth and Development – Moving into more depth and complexity in MI three • 1981 Bill Miller changed the way treatment was thought about and delivered. • Just planning – Just telling people what to do. How many drinks do you have,? Well you drink this much so that is affecting your life this way, You need to stop doing that, it is bad for you.......Do this instead........I’ll give you this service that will help you and convince you more. Helping professional seen as the “Authority and “Expert” – Behavior has consequences.

15. MI Definition Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change “Being compassionate and directional will inspire people to do things you cant even image that they can do” S. Andrew

16. Three Essential Elements in any Definition of MI MI is a particular kind of conversation about change (counseling, therapy, consultation, method of communication) MI is collaborative (person-centered, partnership, honors autonomy, not expert-recipient) MI is evocative, seeks to call forth the person’s own motivation and commitment

17. After 30 years of research MI is a method that is: Evidence-based >180 clinical trials Relatively brief Specifiable (but be careful with manuals) Grounded in testable theory With specifiable mechanisms of action Generalizable across problem areas Complementary to other treatment methods Learnable by a broad range of providers Verifiable – Is it being delivered properly?

18. Motivational Interviewing (MI) • The goals of MI: • Establish rapport, • Elicit change talk, • Establish commitment language that motivates the change. Individuals approach changes in their lives at different levels of readiness. People move forwards and backwards through the forest of change (ambivalence), what MI helps people do is to keep moving forward through the forest the natural process of resolving ambivalence. In MI there is intentional arranging of the conversation to evoke and explore change talk when you hear it. You can substantially influence how much change talk a person will voice. MI produces an unusual shift in change talk that in turn predicts subsequent behavior change.

19. Four Processes Engagement Focusing Evoking Planning

20. Engagement: The Forgotten Gem

21. Exercise #1 Choose one person near you to have a conversation with, and work together Not with your boss or supervisor, if possible One will be the speaker, the other will be a helper

22. Speaker’s Topic Something about yourself that you want to change need to change should change have been thinking about changing but you haven’t changed yet in other words – something you’re ambivalent about

23. Helper:Find out what change the person is considering making, and then: Explain why the person shouldmake this change Give at least three specific benefits that would result from making the change Tell the person how they could make the change Emphasize how important it is to change Persuade the person to do it. If you meet resistance, repeat the above. P.S. This is NOT motivational interviewing

24. Let’s Watch An Approach Just Stop It!

25. Speaker’s Topic Something about yourself that you want to change need to change should change have been thinking about changing but you haven’t changed yet i.e. – something you’re ambivalent about Exercise 2: Same Conversation same speaker and listener

26. Listener Listen carefully with a goal of understanding the dilemma Give no advice. Ask these four open questions and listen with interest: 1. Why would you want to make this change? 2. How might you go about it, in order to succeed? 3. What are the three best reasons to do it? 4. On a scale from 0 to 10, how important would you say it is for you to make this change? Follow-up: And why are you at __ and not zero? 30 sec. summary/reflection of the speaker’s motivations for change Then ask: “So what do you think you’ll do?” and just listen (really)

27. CLIENT SMALL CIRCLE OF FRIENDS (pro and/or anti-social) CONNECT TO GREATER PRO-SOCIAL COMMUNITY (Family, School, Staff, etc.) Increase the CIRCLE OF CARING “MOTIVATING OFFENDERS TO CHANGE – A Guide for Probation & Parole,” Walters, Clark, Gingrich, and Meltzer, (June 2007)

28. The “Spirit” of Motivational Interviewing Collaboration Evocation Autonomy Compassion

29. POWER & CONTROL(SOVEREIGNTY) To love and be loved BELONGING Capable

30. Taking it Deeper -psychologically At the beginning of the conversation clients are more focused on the helping professional ("Can I trust that s/he will not seek to judge and/or control me?") than on themselves, and that only when they have (implicitly) concluded that the encounter is "psychologically safe" will they allow shared awareness of two ways of thinking about a problem (perhaps their responsibility or contribution) and thus experience increased motivation to move through or beyond it. At the same time, once safety is established, the thinking two ways or the problem is experienced differently--not as "social pressure" (or what is going to happen to me “out there” but as internal pressure or, better, an internal pull towards a better place, or a better me. Don’t trigger Trauma Response...Oppressive Response Help them build their “emotional muscle” Think about pace and timing. It takes time to heal and build your emotional muscle when you are coming from an injured place. Be gentle

31. Creating Engagement – People change, grow, trust and develop in Relationship • People’s motivation is influenced by the other person’s expectations • Conflicting feeling about doing something different and new is normal • Pressure to change behavior or beliefs often evokes resistance • Individuals attitudes are shaped by their own words • Individuals can develop solutions to their problems • Belief in ability to change is an important source of motivation • Most people (even those with substance dependence) change on their own

32. Skills for Engagement:OARS Open (not closed) questions Affirmation Reflective listening Summarizing

33. CONTRASTING Interactive STYLES Motivational Interviewing (Guiding) Confrontational – Aggressive (Directing, Telling, Pushing) 33

34. open questions through the steps of MI • What would you like to start talking about today? • What have you noticed about …….? • How important is it for you to change ----? • How confident do you feel about changing ----? • How do you see the benefits of ---? • How do you see the drawback of ---? • What concerns do you have about ---? • How might things be different if you ----? • In what way…..? How might you go about it? • Where does this leave you now? What will you do?

35. Use Accurate Empathic Reflection • One of the mostimportant skills... • Response with aclear assertive statement--acknowledging the person... • NOT a question It is a process of: • Hearing what the speaker said • Making a guess at what s/he meant • Stating it back to them

36. Lets watch a demonstration

37. Forming Reflections 1. Speaker: Something you may not know about me is that I am _______________. 2. Make a guess about what it might mean, and ask it as a question: “Do you mean that you . . . ?” 3. Second Listener: Turn the question into a reflective statement: “You . . . . .” 4. Then the Speaker gives a natural reply to #3

38. Set the Focus • Focus the conversation: • Client’s goal/choice • Social worker’s agenda with permission • Concept of “Equipoise”

39. Agenda Setting • Eliciting the person’s agenda • What is the most important thing that we need to talk about today? • Let’s see we have this, this and this on our plates.....? • What brings you here today? • “Miracle question” • Offering a menu • Bubble sheet • Asking permission to discuss your agenda • Would it be all right if we also talked a bit about . . .?

40. Practitioner: I’m glad you came back to see me today. Mother: I must do this for my baby Practitioner: This baby is very important to you Mother: Yes. Practitioner: And you want it to be healthy Mother: Yes, I told my husband and he is supportive but there are some issues he is not helping me with – he doesn’t want to use the condoms Practitioner: What would be most helpful for us to start talking about? Is it condoms, your medication, your diet, or perhaps something else? Mother: I want to talk about the medication Practitioner: Yes, fine, we can come back to other things. The medication feels important to you Mother: Its very important, I want to know how to take these tablets so that I keep well Practitioner: What would you most like to know about the medicine? Mother: If I miss doses I worry that it will bring harm

41. Evoking Change Talk

42. Change Talk: Panning for Gold • Change talk is any client speech that favors movement in the direction of change • Change talk is by definition linked to a particular behavior change goal • It is the gold that we “pan” for: Strongly linked to behavioral change.

43. Preparatory Change Talk (evoking)Four Examples DARN • DESIRE to change (want, like, wish . . ) • ABILITY to change (can, could . . ) • REASONS to change (if . . then) • NEED to change (need, have to, got to . .)

44. Do you Swear to tell the whole truth? D-I want to do it A-I can tell the truth R- I’m tired of doing the same old thing and everyone being mad at me N- I need to do it for my kids -Still not good enough for the Court of law.......... I will!!!!!

45. Do you take this person to be your lawfully(if possible) committed spouse? D-I want to A-I can R-At this time in my life I would really like to share my life with someone N-I need to do this for her. She has been my girlfriend for 9 years. Still not good enough......... I Do!!!!!

46. Mobilizing Change Talk (planning)Reflects resolution of ambivalence CATs • COMMITMENT (intention, decision, promise) • ACTIVATION (willing, ready, preparing) • TAKING STEPS

47. Responding to Change Talk • E: Elaboration questions, tell me more • A: Affirmations • R: Reflections • (What you reflect, you will hear more of.) • S: Summaries

48. Methods to Elicit Change Talk Looking forward: If change occurs, does not occur Looking back: Other successes Values/Goals exploration Elaboration questions Importance and Confidence Rulers

49. Planning Key Questions or Closing the Sale Next Steps So…. How might you continue learning MI? What will you do?

50. Thank you! Betty Hanna: bettyhanna@comcast.net (925) 984-4300