Motivational Interviewing: An Introduction

1. Motivational Interviewing:An Introduction by Constance Brooks, Ph.D., PMHCNS-BC, PHCNS-BC Slides are based work of Miller and Rollnick and Tammy Day ( 2013) last modified (February,2014)

2. MOTIVATION: Early Concepts • People are either motivated or not. • If not, there is not much we can do about it. • Motivated means agreeing with the helper. • Confrontation is the best way to bring about change.

3. “Compliant” • Agree with healthcare professional. • Purchase health care insurance • Expresses need for assistance and to make changes. • Show distress about the situation. • Compliant with treatment plan. • Changes are made. • Really careful to take good care of themselves.

4. “Non-Compliant” • Disagreeing with the provider. • Resisting a diagnosis/label. • Refusing or declining help. • Stating no need for assistance or change. • Doesn’t follow treatment plan. • Doesn’t make changes. • Doesn’t care. No effort to obtain access to care

5. Discussion: 16 y/o F student who has come to you seeking help with losing weight • Explain why the student should make the change. • Give at least 3 specific benefits that would result from the change. • Tell the student how to change. • Emphasize how important it is to change. • Emphasize what will happen if no change is made. • Direct the student to do it.

6. How Did That Feel? • Student perspective • School Nurse perspective

7. Basic Human Nature • It is basic human nature to resist direction, especially about something you are ambivalent about. • It is also basic human nature to believe what we hear ourselves say.

8. The Spirit of MI • Starts with Acceptance • Absolute worth • Affirmation • Autonomy • Accurate empathy • Compassion : to have your heart in the right place so that trust you establish is deserved.

9. The Spirit of MI • Collaboration vs. Prescription • Evocation vs. Installation Requires a willingness to no longer operate from the authoritative role and begin to look at the person’s capacity vs. incapacity, with a genuine interest in his or her experience and perspective.

10. Stages of Change Contemplation Preparation We usually jump in here Action Pre-contemplation Maintenance

11. Four Basic Skills • OARS Ask Open-ended questions-not short-answer, yes-no, or rhetorical questions. Affirm the person—comment positively on strengths, effort and intention. Reflect what the person says—active listening. Summarize—draw together the person’s own perspective on change.

12. Ambivalence • If you argue for one side, an ambivalent person is likely to defend the other side. • As a person defends the status quo, the likelihood of change decreases. • Resist the urge to only take up the “good” side of ambivalence. • Resist the reflex to provide a “fix” or solution.

13. Responding to sustain talk • Sustain talk is the persons own motivation and verbalization to maintain the status quo. • Don’t argue: pushing against what is important to the per son only gives fuelto the status quo. • Strategic response of reflection, emphasizing autonomy and reframing .

14. Responding to sustain talk • Some effective responses that tend to defuse resistance and refocus on change: • Reflection—acknowledge by reflecting back. • Amplified reflection—overstating a bit. • Double-sided reflection—on the one hand…and on the other… • Emphasize personal choice, ability to control and maintain autonomy.

15. Looking Forward • If you don’t make any change, what do you think will happen? • Where would you like to be in _____years? • What do you hope will be different? • An how does _____________ fit into that?

16. Giving Advice • The person is more likely to hear and heed your advice if you have permission to give it. • Three forms of Permission: • The person asks for advice. • You ask permission to give it. • There’s something that concerns me here. Would it be all right if I….? • Would you like to know….? • I could tell you some things other persons have tried that worked… • You preface your advice with permission to disagree/disregard. • This may or may not be of interest to you…. • I don’t know how you’ll feel about this…. • Tell me what you think of this... It is better to offer several options, rather than suggesting only one.

17. Stages of Change: Using an MI Approach Explore Ambivalence Explore Goals Preparation Contemplation Action Pre-contemplation Maintenance Explore Strategies Provide support & encouragement Explore Concerns Support/Encourage Anticipate Relapse

18. Change Talk • Counsel in a way that invites the person to make the arguments for change. • Common dimensions to ask about (DARN-C) • Desire—want, prefer, wish. • Ability-able, can, could, possible. • Reasons-specific arguments for change—why do it? What would be good? • Need-important, have to, need to, it matters. • Commitment Language (the goal/action plan): this predicts actual change.

19. Eliciting Change Talk • The simplest way: Ask for it, in open-ended questions to elicit desire, ability, reasons, need. • In what ways would it be good for you to? • If you decide to……., how would you do it? • What would be the good things about….? • Why would you want to…….? • The balance: What are the good things about ____ and what are the not so good things?

20. Responding to Change Talk • When you hear change talk, don’t just sit there!!! • Reflect it—Restate it back to the patient. • Ask for examples/elaboration: when was the last time, in what ways, • Ask for more: What else? What other reasons? • Affirm change talk-reinforce, encourage, support it. • Summarize—”collecting flowers into a bouquet”

21. TIME TO TAKE ACTION • Time to elicit patient/person commitment. • Setting a specific goal will help patient/person stay on track and accountable. • Be specific: what, when, who, where & how? • Set a confidence level. • TAKE NOTES AND FOLLOW-UP! If the patient/person knows you are concerned enough to follow-up, their motivation will be propelled!

22. Practice • A 16 year old girl has come to you for help in losing weight. She opens the conversation with the following statement: I hate being fat. Everybody makes fun of me. • Engage this student in conversation applying principles of MI

23. Four Basic Skills • OARS Ask Open-ended questions-not short-answer, yes-no, or rhetorical questions. Affirm the person—comment positively on strengths, effort and intention. Reflect what the person says—active listening. Summarize—draw together the person’s own perspective on change.

24. DISCUSSION