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Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing
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Page 1: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Motivational Interviewingfor Health Behavior ChangePaul F. Cook, PhD & Laurra M. Aagaard, MS,

MAUniversity of Colorado College of Nursing

Page 2: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

DISCLOSURES (past 12 months)

• Grant Funding: National Institutes of Health, HRSA (Federal), SAMHSA (Federal), CDC (Federal), Merck & Co. Inc., Colorado Health Foundation

• Speaking: University of Colorado Hospital, Children’s Hospital of Colorado, National Food Program Sponsors’ Association, Colorado Dept. of Workers’ Comp.

• Consulting: Takeda Inc., Covance Market Access Inc., Medical Simulation Corp., Academic Impressions Inc., Competency & Credentialing Institute Inc.

Page 3: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

• Health is getting worse over time. From 1994 to 2000, the U.S. obesity rate rose by 1/3

• Patients don’t follow medical recommendations: 50% for medication adherence, lower for diet, exercise, recommended screening & prevention

• Behaviors are independent of each other• Patients aren’t always honest about

behavior Abid, et al., 2005; Goldstein, Whitlock, & DePue, 2004; Polivy & Herman, 2002; WHO, 2002

The Problem

Page 4: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

OUR OBJECTIVES FOR YOU• Use the spirit of MI to guide your work with clients

and avoid unproductive interactions

• Describe the research basis for MI as a best practice

• Identify key MI principles: rolling with resistance, expressing empathy, developing discrepancy, an supporting self-efficacy

• Recognize MI "micro-skills" like reflection, open-ended questions, and the elicit- provide-elicit method of patient education

• Recognize change talk and sustain talk, and apply strategies for responding to each

Page 5: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Behavior Change is Difficult!

• Individuals and systems tend to resist change

• 50% of meds abandoned by 12 mos.• Exercise has even lower adherence• Diet changes are hard to sustain• Environmental pressures and habits

affect behavior outside awareness

• Some barriers are legitimate concerns: cost, time, weather, transportation, pain

• Change in one area does not generalize to changes in other areas

Glasgow, McCaul, & Schafer, 1987 ; Meichenbaum & Turk, 1987; NCPIE, 1994; Polivy & Herman, 2002

Page 6: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Help, I really want to change!

Page 7: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Everyone is Ambivalent• The nonadherent person

– Argues or interrupts: yeah, but …– Denies or ignores problems:

it’s not a big deal …– Still has a part of them that values health– Still has a part of them that wants to change

• The adherent person– Is (probably) telling you the truth– Is doing fine for now– Still has a part of them that resents/resists

change

Page 8: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Beliefs

PARIS

IN THE

THE SPRING

POP

GOES THE

THE WEASEL

Page 9: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

12 Roadblocks• Ordering• Threatening• Persuading• Lecturing• Moralizing• Criticizing

• Shaming

Psychoanalyzing

• Sympathizing• Praising• Questioning• Changing the

SubjectTry it!

Gordon, 1970

Page 10: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

A Way Through Resistance

• Listen carefully

• Understand people’s motivations

• Resist the urge to “fix it”

• Empower the client

Marla Corwin, CU School of Medicine, 2013 (adapted from Rollnick, Miller, & Butler, 2008)

Page 11: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Motivational Interviewing “SPIRIT”• MI is not primarily a set of techniques; it is

an attitude or a different way of being with people

• MI is at the same time …– Empathic (caring) and– Guiding (directive)

• Some characteristics of MI (ACCE):– Accepting – Collaborative / Person-Centered– Compassionate– Evoking and Strengthening Motivation to

Change Miller et al., 2013, Motivational Interviewing, 3rd Ed.

Page 12: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

What Works?

What Works?• Acceptance• Attention• Choice• Support• Reminders• Experimentation• Reinforcement

MI Principles

Develop Discrepancy

Express Empathy

Support Self-Efficacy

Roll with Resistance

Page 13: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Motivational Interviewing

• Developed for substance abuse• Intended to motivate “resistant” clients• Based on social psychology principles

– Social influence/persuasion– People resist your efforts to change them– Person-centered counseling techniques

• “A method for exploring and resolving ambivalence”– NOT: teaching, changing, controlling

• “MI is like dancing”

Miller & Rollnick. (2002). Motivational Interviewing, 2nd Ed.

Page 14: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Four Principles of MI

• Roll with resistance– Listen and try to understand – Avoid arguing – don’t try to “fix it”

• Develop discrepancy– Clients present arguments for change

• Express empathy– Reflection, acceptance, collaboration

• Support self-efficacy– Ask for the client’s perspective– Facilitate hope for change

Rollnick, Miller, & Butler. (2007). Motivational Interviewing in Health Care.

Try it!

Page 15: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

How MI Works

http://youtu.be/9il0RgO5fGM

Page 16: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Avoid the Traps

• Expert Trap• Educator Trap• Premature Focus

Trap• 20-Questions Trap• Fear Trap• Advice Trap

• Client is the expert• Clients choose to

learn• Negotiate an

agenda• Open-ended

questions• Reduce fear &

denial• Clients make

choicesMiller et al., 2013, Motivational Interviewing, 3rd Ed.

Page 17: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

The Evidence for MI• Review of 30 studies with 5541

participants, most with 3-12 month follow-up data

• Total amount of MI provided: 30 min to 4 hrs

• Moderate changes in alcohol use, drug use, diet & exercise, treatment adherence (similar to longer-term counseling methods)

• Smaller but still significant changes for smoking (about half as strong), based on 16 studies

• Smaller effects for safer sex (2 studies), eating disorders (1 study)

Burke, et al. (2003). J Consult Clin Psych, 71(5), 843-861; Hettema & Hendricks. (2010). J Consult Clin Psych, 78(6),

868-884.

Page 18: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

MI Across the Lifespan

• Adolescents– Transitions in care / chronic disease

management– Preventing depression in at-risk

adolescents• Children

– Oral health– Diet– Exercise– Chronic disease management

Berg-Smith et al. (1999). Health Educ Res, 14, 339-410; Gueldner & Merrell (2011). J Educ Psychol Consult, 21, 1-27; Resnicow et al. (2006). J Am Dietetic Assoc, 106, 2024-2033; Schwartz et al. (2007). Arch Pediatr Adolesc Med, 161, 495-501; Suarez & Mullins. (2008). J Devel Behav Pediatr, 29, 417-428; Weinstein et al. (2006). J Am Dent Assoc, 137, 789-793.

Page 19: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

MI “Micro-Techniques”: OARS• Open-Ended Questions

– Problem recognition– Concern about the problem / pros and cons– Optimism about change– Intention to change

• Affirm• Restate

– Reflect content– Reflect emotion (worry, concern, upset)– Reflect intention– Reflect meaning (go one step further)

• Summarize (“what else?”)

Miller & Rollnick, 2002

Page 20: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

• “What I hear you saying is …”• “It sounds like …”• “You’re feeling like …”• “It seems like …”• “You wish …”• “You want …”• “You think …”• “From your perspective …”

Examples of Reflective Listening

Page 21: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Summary Statements Combine Several Previous

Reflections• Reflection #1: You want to help your child

eat a healthy diet• Reflection #2: You’ve talked to her, but

she doesn’t listen• Reflection #3: You’re frustrated with the

situation• Summary Statement: I hear that you

really want to help your child, but you aren’t sure how. The things you have tried don’t seem to work, which is frustrating.

Page 22: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Change These to Open Questions

• “Did your moods feel out of control last night?”• “Did you use meditation or Biofeedback

strategies?”• “You really want to impact your patients don’t

you?”• “Did you use Reflective Listening techniques?”

• “Is the patient ready to work on change goals?”• “Are you being relational?”

Page 23: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Affirmation

• Affirming self-determination– You’re in charge– This is your decision

• Affirming strengths– You have made big changes in the past– You’re sure you could do it if you decided to

• Affirming competence– You know what’s best for your family– You’re the expert in what will work for you

Page 24: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Directing the Conversation

Reflect to communicate understanding• “You don’t brush your children’s teeth very

often”Use open-ended questions to raise new

topics• “How have you tried to gain their

cooperation?”Use summary statements to close topics• “I’m hearing that your dentist lectures,

and that’s frustrating, so your kids resist going there”

Follow with open-ended questions about change

• “How can I help?”

Page 25: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

The Relationship Matters Most

• Client commitment language is the best predictor of behavior change in MI– The more time the client spends talking, vs. you– The amount of time talking about change (desire,

ability, recognition, need, commitment, activation, taking steps)

• Helper’s interpersonal skill predicts outcome better than specific techniques– Experience matters, but not specific knowledge– Do whatever works to strengthen the relationship

Page 26: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

When Can I Educate?

The Traditional Model in Education:

Tell — Ask — Tell

The Motivational Interviewing Model:

Elicit — Provide — Elicit

Rollnick, Mason, & Butler. (1999). Health Behavior Change.

Page 27: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Possible Benefits

• Cut to the chase – a lengthy spiel takes time

• Deliver information in focused chunks• Increase the odds the patient will

remember

• Get to the most important issues more quickly

• Check off boxes in your EMR as the patient talks

Whole pie:What you sayto patients

This half: What patients hear

This quarter: What they understand

This eighth is what they rememberWell enough to use the information!

Page 28: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Recognizing ReadinessShowing Resistance• Seeing benefits of current behavior• Seeing costs of new behavior Strategy: back off, build motivation (the “strong principle of change”: increase

benefits)

Ready for Change• Seeing benefits of new behavior• Seeing costs of current behavior

Strategy: support efforts for change (the “weak principle of change”: decrease

barriers)Prochaska et al. (1995). Changing for Good

Page 29: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Early Stages: Use FRAMES

• Feedback about personal risks

• Responsibility for change is the client’s

• Advice is given in a nonjudgmental way

• Menus of options are suggested

• Empathic counseling style (OARS)

• Self-efficacy of the client is encouraged

Miller & Rollnick, 2002

Page 30: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Getting Stuck:Some “Resistance” is only Sustain

Talk

“To fly, we have to have resistance” – Maya Lin

Some “resistance” is a natural expression ofthe process that moves us toward change.

Roll with resistance; don’t fight against it.

Pushing back against resistance only gets you more of it.

It is often helpful to hear from both sides of the ambivalence:• Why do you want to make this change? And also …• What do you not like about the idea of making this change

Page 31: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Roll With Resistance

• Use reflection to communicate empathy– I hear that this is difficult for you.

• Find out what the client already knows– Wait to offer new information until you are invited– Ask the client her opinion about the new information

• Summarize to communicate understanding– You see three barriers to moving forward: … .– What causes problems doesn’t matter as much as what

you decide to do about them.• Use open-ended questions to refocus on change

– What would you be doing if the situation were different?

When people resist, you might be pushing too hard for change!

RESISTANCEis futile

Page 32: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Change Talk

Listen for DARN CATs in the conversation:

• Desire for change

• Ability to change

• Reasons for change

• Need to change

• Commitment to change

• Activation for change

• Taking steps already for a change

Miller & Rollnick, 2007

Contemplation Stage

ActionStage

Page 33: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

EARS for Change Talk

• Elaboration – what? why? how? tell me …• Affirmation – that sounds like a good

idea. I can see that you’ve considered this carefully.

• Reflection – you think … you want … you need … you intend … you think you can …

• Summary – you have considered … and at this point your plan is …

Page 34: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Questions to Elicit Change Talk

• Advantages of Change (Desire, Reasons) – What makes you think you would like a change?

• Disadvantages of the Status Quo (Need)– What concerns you about the current situation?

• Optimism about Change (Ability)– What do you think would work, if you did want a

change?• Intention to Change (Commitment, Taking Steps)

– What would you like to do at this point?

Miller & Rollnick, 2002

Page 35: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Find the Change Talk …

a. I like it when I’m out drinking with friends, but the next day I usually feel awful.

b. If I’m late to work again because of my drinking, I will get fired.

c. My wife keeps nagging me to give up cigarettes.d. The doctor told me to cut down on drinking.e. I don’t like the idea of taking so many pain

meds, but the pain just won’t go away.f. I’m not sure I can quit smoking pot – it helps me

cope.

Page 36: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Use Naturally Occurring Solutions

• Problems are struggles, failures are efforts– What worked before?– How have you overcome other challenges?– What would you change from past attempts?

• Look for solutions that already exist– What is working already?– When isn’t the problem quite as bad?

• Access support from others– Who in the network is supportive?– Who haven’t you asked, and can they help?– What do others say that you might like to try?

• What do you think is the best plan from here?

Page 37: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Red Light / Green Light

• SUSTAIN TALK– LURE: listen, understand, resist the

urge to “fix it,” empathize

• AMBIVALENCE– OARS: open-ended questions, affirm,

reflect, summarize– Use elicit-provide-elicit to educate

• CHANGE TALK– EARS: explore, affirm, reflect,

summarize– Challenge the change

Dart, M.A. (2011). Motivational Interviewing in Nursing Practice

Page 38: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Next Steps in Using MI

• Active listening (OARS)• Use reflections more than questions• Roll with resistance• Use elicit-provide-elicit to educate• Assess readiness for change• Use FRAMES to motivate change• Listen for change talk (DARN CAT)• Problem-solve using natural supports

Page 39: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Developing the “Spirit” of MI

• The heart of MI is a spirit of …– empathy– acceptance– respect– honesty– caring

• Hope & faith in the client• Interest in others’ well-being and growth• Empathy: 2 reflections per 1 question

(Moyers, Miller, & Hendrickson, 2005)

Page 40: Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA University of Colorado College of Nursing.

Learn More about MI• Miller & Rollnick (2013). Motivational Interviewing,

3rd Ed.• Rollnick, Miller, & Butler (2007). Motivational

Interviewing in Health Care• Rollnick, et al. (1999). Health Behavior Change• MI home page: www.motivationalinterview.org • Prochaska, Norcross, & DiClemente (1995).

Changing for Good• Stages of change home page:

www.uri.edu/research/cprc/transtheoretical.htm • Bothello (2004). Motivate Healthy Habits• Seminars: [email protected]


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