INTRODUCTION TO MOTIVATIONAL INTERVIEWING

Lynn S. Massey, LMSWDepartment of Psychiatry

Department of Emergency MedicineUniversity of Michigan

Client centered approach is necessary but not sufficient for behavior change

Client centeredness – the relational component- based on the Spirit of MI (collaboration, evocation, autonomy, respect) and empathy

“It is not a goal unless it is a goal for the patient” Change talk – the technical component – gives a

voice to the person’s inner motivation based on what they value most

The Basics of MI

We’ll practice the skills to listen so people can talk, and to talk so people can

listen

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

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

SPIRIT OF MI

Empathy – genuine curiosity about client’s perspective (understanding)

MI Spirit: Collaboration – fostering power sharing

in the interaction Evocation – elicitation / acceptance /

understanding of client’s own ideas about change

Respect Autonomy – active fostering of client perception of choice

RELATIONAL COMPONENTS OF MI

Motivation “the 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 the clinician’s job Occurs in an interpersonal context “Noncompliance”, “resistance”, and “lack

of motivation” are all partially due to therapists strategies

ASSUMPTIONS OF MI

Ambivalence Is normal, acceptable and understandable

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

Is at the heart of motivation

Usually mistaken for resistance (yes, but…)

ASSUMPTIONS OF MI

1.) 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 prophesy

4 PRINCIPLES OF MI

Open 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 can.”

Reflective listening Summary

EARLY STRATEGIES: OARS

Learning Motivational Interviewing: Is a process of learning about and using strategies to boost problem

recognition, motivation and strengthen commitment to

change.

Practitioners want to help! Leads to strong urge to correct behavior that is harmful – Righting reflex. But it is a natural human tendency to resist persuasion – Resist

The patients own reasons for change are much more powerful than ours – Understand

The answers regarding behavior change come from the patient – Listen

Outcomes are better when patient takes and active role in deciding on outcomes - Empower

BASIC PRINCIPLES

StylesGuiding – “I can help you solve this for yourself”Directing – “I know how you can solve this problem, I know what you should do”Following – “I won’t push or change you, I trust your wisdom to do what is best for you”

SkillsAsking Listening Informing

Styles and Skills may be mixed and matched

COMMUNICATION SKILLS WITHIN A HELPING CONTEXT

Behavior change is at the heart of most modern health care concerns (heart disease, obesity, depression, cancers, diabetes, liver disease, respiratory problems)

Most health care practitioners have conversations / encounters regarding behavior change in daily work

More attention has been on information vs how to approach (style) behavior change with the person

MI INTEGRATION IN BEHAVIOR CHANGE COUNSELING

Brief Interventions in the ED

PRIMARY CARE

Key elements of brief interventions using motivational enhancement techniques (FRAMES):

MI emphasizes:Developing a discrepancy between current

behavior and future goals,Increase problem recognition, motivation

and self efficacyA menu of possible options

ADAPTED MOTIVATIONAL INTERVIEWING

1a. MI will increase client change talk 1b. MI will diminish client resistance 2a. The extent to which clients verbally defend

status quo (resistance) will be inversely related to behavior change

2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change

Are these propositions supported by data? YES

IMPLICIT THEORY OF MI POSITS

SUMMARY OF RESEARCH LITERATURE

100’s of outcome studies meeting meta-analysis criteria have been conducted

Alcohol use, smoking, HIV, drugs, treatment compliance, gambling, diet and exercise

Strongest support found for substance use outcomes

Strong effects found for additive effect on MI to adherence, retention and outcome

Synergistic effect over time when used as a prelude to treatment

In-person MI have been shown effective in primary care (reducing drinking by 20-30%) up to 12-months (Saunders et al., 2004; Moyer et al., 2002)

MI has been demonstrated to be effective across genders; effectiveness across ethnic groups is yet to be established (Poikolainen, 1999; Dunn et al., 2001)

Brief interventions among adolescents and adults in the ED setting show changes in consequences (Monti et al., 1999; 2001; Longabaugh et al., 2001)

EFFECTIVENESS OF MI ALCOHOL PREVENTION

Contact informationLynn Massey, LMSW

lsmassey@med.umich.edu