INTRODUCTION TO LEARNING MOTIVATIONAL INTERVIEWING

INTRODUCTION TO LEARNING MOTIVATIONAL INTERVIEWINGLynn S Massey, LMSWHealth Services ResearchUniversity of MichiganAugust 2013Do you.Explain what the person could do differently to improve their health?Advise / persuade / warn what will happen if they do not change?Counsel the person about how to change?Refer to a specialist?Set goals for change?Common Human Reactions to Being Listened toUnderstoodWant to talk moreLiking the counselorOpenAcceptedRespectedEngagedAble to change

SafeEmpoweredHopefulComfortableInterestedWant to come backCooperative3DefinitionsMI Definition-LaymansMotivational Interviewing is a collaborative conversation to strengthen a persons own motivation for and commitment to change.Why do I want to learn MI?Motivational Interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change.Technical DefinitionMotivational Interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for and commitment to a change goal by eliciting and exploring an individual's own arguments for change.Eight Stages in Learning MIThe spirit of MIOARS- client-centered counseling skillsRecognizing change talkEliciting and reinforcing change talkRolling with resistanceDeveloping a change planConsolidating client commitmentIntegrating MI with other methods

Miller, W.R., & Moyers, T. B. (2006). Eights stages in learning motivational interviewing. Journal of Teaching in the Addictions AssumptionsMotivationThe probability that a person will enter into, continue, and adhere to a specific change strategy or plan

Motivation is a dynamic state (of readiness to change)

Part of clinicians job

Occurs in an interpersonal context

Noncompliance, resistance and lack of motivation are all partially due to therapists strategies

AmbivalenceIs normal, acceptable and understandable

Helps clinician to appreciate the complexity of the individual and their situation

To explore ambivalence is to work at the heart of motivation

Usually mistaken for resistance (yes, but)

Spirit of MIDefinitionMI is not a set of methods to learn, but a therapeutic way to being and interacting with a person not everyone will be able to do it

Context or interpersonal relationship within which the techniques are employed

Spirit of MI is necessary for expert use, but not to begin to learn MI spirit of MI can emerge from therapist-client interactions using the method

The extent of initial curiosity and willingness to learn MI seems to be a good predictor for speed and ease of acquiring MI skills

The Spirit of MIIs essential for the full and expert use of MIUnderlying assumption that health is waiting inside each person, and your role is to help it emerge (Humanistic Psychology)Contrasted with the model that the patient is flawed Therapists expression of spirit as measured by independent raters predicts client engagement, collaboration, and affect in sessions (Moyers et al, 2005)14Relational Components of MIEmpathy genuine curiosity about clients perspective (understanding)MI Spirit:Collaboration fostering power sharing in the interactionEvocation elicitation / acceptance / understanding of clients own ideas about changeRespect Autonomy active fostering of client perception of choice

CollaborationFosters collaboration and power sharing so that clients ideas impact the sessionEncourages power sharing in the interaction in such a way that clients ideas substantially influence the nature of the sessionBuilds rapportFacilitates trustMutual understanding, not about the therapist being right.EvocationAccepting of the clients own reasons for change and ideas about how change should happenDoesnt attempt to educate or direct if client resistsProactively evokes clients own reasons for change and ideas about how change should happenThe therapists job is to draw out the clients own motivations and skills for change, not to tell them what to do or why they should do itAutonomyAccepting and supportive of client autonomyThe true power of change rests within the clientUltimately it is up to the client to changeClients are encouraged to take the lead on developing a menu of options as to how to achieve the desired changeThumbs up Thumbs downC: I know my dad told you Im depressed, but Im not. Just because I dont want to play football doesnt mean Im depressed.

T: Your father is worrying needlessly. What do you think hes seeing that makes him worry this way?

Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren (2009)

Collaboration and evocation19Thumbs up Thumbs downC: They told me I have to have this surgery right away. But I dont trust them, so I havent scheduled it yet.

T: Why take the chance? Theyre the experts, after all. Lets call from this phone right now-maybe you can get in this week?

Building Motivational Interviewing Skills: A practitioner's workbook by David B. Rosengren (2009)Misses opportunity for autonomy20MI Skills and StrategiesThe Basics of MIClient centered approach is necessary but not sufficient for behavior changeClient centeredness the relational component- based on the Spirit of MI (collaboration, evocation, autonomy, respect) and EmpathyIt is not a goal unless it is a goal for the patientChange talk - the technical component gives a voice to the persons inner motivation based on what they value most224 Principles of MI1) Express empathy acceptance of people as they are frees them to change whereas non-acceptance immobilizes the change process2) Develop discrepancy between present behavior and broader goals and values; helping people get un-stuck3) Roll with resistance avoid arguing for change; new ideas/goals/options are not imposed; used as a signal4) Support self-efficacy belief in ability to change is a powerful predictor of change; counselor self-fulfilling prophesy23Basic Role of MI therapistIs to help the client become his / her own advocate for change

Is to elicit rather than instill expertise on how to change

Join with a persons own intrinsic motivation to move towards more adaptive behavior (i.e. those that are in line with their values and goals)24Early strategies: OARSOpen Ended Questions are you concerned about your health? vs to you, what are important reasons to cut down on your drinking?Affirmations It really sounds like you have been committed to being the best father you canReflective listeningSummary Let me try to pull together what we have been talking about, let me know if I missed something; it sounds like on one hand you feel and were scared by the ER visit, but on the other hand, you dont want to give up drinking completely25Affirmations may includeCommenting positively on an attributeYoure a strong person, a real survivor.A statement of appreciation I appreciate your openness and honesty today.Catch the person doing something rightThanks for coming in today!A complimentI like the way you said that.An expression of hope, caring, or supportI hope this weekend goes well for you!If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be.- Johann Wolfgang von Goethe27OARS ExercisesOpen Ended Questions QuizThinking ReflectivelyGroup Batting PracticeForming ReflectionsMiller tape with OARS codingStructured Practice28What the speaker saysWhat the listener hearsWhat the speaker meansWhat the listener thinks the speaker meansCommunication errors1) The speaker does not say exactly what is meant

2) The listener does not hear correctly

3) The listener gives a different interpretation to what the words meanOne thing that I like about myself is that..

One thing you should know about me is..

One thing about myself Id like to change is.31ListenerListen carefully with a goal of understanding the dilemmaGive no advice. Ask these four open questions and listen with interest: Why would you want to make this change? How might you go about it, in order to succeed? What are the three best reasons to do it? 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?Give a short summary/reflection of the speakers motivations for changeThen ask: So what do you think youll do? and just listen32Reflective Listening: OverviewThe essence is that it makes a guess as to what the speaker means

Statements rather than questions

Continue the paragraph not just re-iteration

It is an active process (counselor decides what to reflect or ignore, what to emphasize, preferentially reflects change talk)33Complex ReflectionsAdding content (interpretation or feeling)Metaphor/Simile (picture language)Amplification (stronger or weaker)Double-sided (reflects two sides of persons view)Reframing (put situation in a different light)Verbalization of unspoken emotion

Categories of ResistanceArguing challenging, discounting, hostility

Interruption talking over, cutting off

Negating blaming others, yes, but, excuse making, claiming impunity, minimizing, pessimism, reluctance, unwillingness to change

Ignoring inattention, non-answers, no response to questions, side-tracking35Responding to ResistanceSimple Reflection you feel stuck, etc.Amplified Reflection C: My wife thinks its worse than it is. T: It seems to you she has no reason for concern.Double-sided Reflection - You dont like the way this makes you feel sometimes, and youre not sure how you might change things.Reframing C: Ive tried to quit 3 times and failed. T: Youve given it 3 good tries, and every try gets you closer. Its probably helped you learn some things that will and wont work for you.Emphasize personal choice and control What you decide to do is completely up to you36Change Talk - DARN CDisadvantages of Status QuoAdvantages of ChangeOptimism about ChangeIntention to Change

DesireAbilityReasons (to, not to)NeedCommitmentThe Flow of Change TalkDesireAbilityReasonsNeed

Commitment

ChangeMIEliciting Change TalkEvocative QuestionsElaborationUsing ExtremesLooking BackLooking ForwardExploring Goals

Giving Information and AdviceGet permission Qualify, honoring autonomy Ask Provide Ask For suggestions, offer several, not oneThanksQuestionsConcerns

Motivationalinterviewing.comBuilding Motivational Interviewing Skills a practitioner workbook by David RosengrenMotivational Interviewing: Preparing people for change by William Miller and Stephen Rollnick (3rd edition)

lsmassey@med.umich.edu