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Motivational Interviewing Nicotine Dependence Center Mayo Clinic Thomas Gauvin, MA, CTTS

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What We’ve Learned

• Old method

• Instruct

• Fixed process

• Teachable moments

• New method

• Engage

• Individualized process

• Learning opportunities

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• People tend to resist that which is forced upon them

• People tend to support that which they helped to create

Vince Pfaff

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“Spirit” A way of Being with People

Collaboration

Autonomy

Evocation

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The Spirit of Motivational Interviewing (MI) “The Dance”

• Collaboration

• Not confrontation

• Evocation

• Not Education/Advice

• Autonomy

• Not Authority

Careful eliciting of the values, assumptions, fears, expectations and hopes of the patient

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Behavior Change

Change is a process

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Patient’s Motivation

• Importance of change

• Confidence in one’s ability to change

• Readiness to change

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Motivation

Can be internal

or interpersonal

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“What are your thoughts about…”

Meet the patient

at his/her place

of readiness

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Principle of MI

• Express empathy

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How Do You Express Empathy?

• Understanding without judging, criticizing or blaming

• Willingness to accept “where” a patient is

• A desire to understand the patient’s perspectives

• (Does not mean that you agree)

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Principles of MI

• Express empathy

• Support self-efficacy

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Support Self-Efficacy

• Enhance the patient’s confidence in his/her capability to succeed with change

• Show the patient that you see the potential for change; believe in the patient

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Discouraged Patient

“I’ve tried sixteen times to quit smoking.”

Support self-efficacy

Counselor: “Wow, you’ve already showed

your commitment to trying to stop smoking

several times. That’s great! More

importantly you’re willing to try again.”

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Ambivalence

I’m afraid

I’m going to

die young

Smoking

helps me

concentrate

I really

enjoy

smoking

I hate the

way I smell

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Ambivalence

• Ambivalence is common and a stage in the process of change

• Getting stuck in ambivalence is normal

• Ambivalence leads to discrepancy

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Discrepancy

• Change is motivated by a perceived discrepancy between present behaviors and personal goals or values

• Use strategies to assist patient in identifying discrepancy and move toward change

Patient: “I want to be a good role model for my children.”

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Developing Discrepancy

“Let’s put aside the “how to do it,” for

right now, and just talk about how you

would like things to be different.”

Future?

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Values Activity

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Principles of MI

• Express empathy

• Support self-efficacy

• Develop discrepancy

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Communication Methods

•Open-ended questions

•Affirm

•Reflective Listening

•Summarize

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Open-Ended Questions

Patient Benefits

• Allows patient to express himself

• Patient verbalizes what is important to him at the moment

Counselor Benefits

• Learn more about the patient

• Sets a positive tone for the session

“How would you do that?”

“What do you see as your biggest challenge?”

“Tell me more about that.”

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Open-Ended Questions Exercise

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Affirm

• A supportive, appreciative statement that conveys respect

• Useful throughout the entire session to build and maintain rapport

“I admire your strength and can appreciate how difficult this is for you.”

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Affirm

“You are very brave to be so revealing about this.”

“I admire your perseverance.”

“You’ve accomplished a great deal in a very short time.”

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Reflective Listening

• Making a statement to clarify meaning and to encourage continued exploration of content

• Client: “It is stressful to think about how my smoking affects my 12-year old. I hate it when she sees me smoke.”

Counselor: “You’re worried about the impact your smoking has on your child.”

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Reflective Listening

• By utilizing the skill of reflective listening, the counselor is conveying:

• “I am listening.”

• “This is important to you.”

• “I would like to hear more.”

• “I am not judging you.”

• “I can understand why you might feel this way.”

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Summarize

• Gather what you’ve heard and give it back by highlighting important aspects

• Summarizing conveys to the client:

• “I am listening carefully to what you tell me.”

• “Did I understand you correctly?”

• “I value what you say.”

• “Here are the salient points.”

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Summarize

• Can be used to gather more information (“…what else?”)

• Can be used to move into a new direction (“…now can we talk about…?”)

• Can be used to link both sides of ambivalence (“On the one hand… on the other hand…) (Linking Summary)

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Discussion

What happens when you

begin your session?

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Resistance is an Interpersonal Phenomenon

How we respond matters

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“Yeah, but…”Syndrome

• I can’t afford the medications

• I am afraid I’ll gain weight

• I don’t smoke nearly as much as some other people I know

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Simple Reflections

• Repeating

• Repeats an element of what the speaker said

• Rephrasing

• Stays close to what was said but, slightly rephrases what was offered

• Paraphrasing

• Restatement, infer meaning in what was said and reflect back in new words-adds to or extends what was said

• Reflection of feeling

• Paraphrase emotional dimension

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“I just can’t quit smoking right now.

I’m a single mother trying to deal

with a very active four year-old.

I have no money and can barely

afford to live. On top of all that,

I’m taking care of my sick father.”

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Reflective Listening to Decrease Resistance

• Simple reflection

• Acknowledges the patient, reflecting “here is what I heard you say”

• Amplified reflection

• Reflect back the resistant issue in an exaggerated way, usually the patient will back off

• Double-sided reflection

• Reflect back the patient’s ambivalence, “both sides of the coin”

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Roll with Resistance Reflective Listening

Simple reflection: An acknowledgment of the person’s disagreement, feelings or perception.

Patient: “I’m trying the best I can to at least cut back on smoking. Geez, I’ve already made a lot of other changes in my life too, like dieting and exercise.”

Practitioner: “You’re working hard on the changes you need to make.”

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Reflective Listening

Amplified reflection: Exaggerate to encourage the person to back off a bit and talk about the other side of the argument.

Patient: “My mother is a worrier. She drives me crazy, hounding me all the time about my smoking.

Practitioner: “Your current health is really none of your mother’s business.”

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Reflective Listening

Amplified reflection: Exaggerate to encourage the person to back off a bit and talk about the other side of the argument.

Patient: “My mother is a worrier. She drives me crazy, hounding me all the time about my smoking.

Practitioner: “Your current health is really none of your mother’s business.”

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Reflections Responding to Resistance

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Resistance Interpersonal Phenomenon

• Causes

• Misjudge readiness/ jumping ahead

• Arguing/ lecturing

• Taking away control

• Strategies

• Re-assess readiness

• Reflective Listening

• Emphasize personal choice and control

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Practice Responding to Resistance

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Principles of MI

• Express empathy

• Support self-efficacy

• Develop discrepancy

• Roll with resistance

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Resistance vs Change Talk

Resistance

Change

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Change Talk and Moving Towards Change

• Counsel in a way that invites the patient to make arguments for change

• Desire

• Ability

• Reason

• Need

• Commitment language

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Change Talk

• What to look for

• Desire – “I really want to be a nonsmoker.”

• Ability – “I’ve quit before.”

• Reason – “I’d have whiter teeth if I quit.”

• Need – “I really have to do this.”

• Commitment – “I’m going to do this!”

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Change Talk Activity

• Desire

• Ability

• Reason

• Need

• Commitment

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Change Talk Methods

• Evocative Statements

• “What worries you about your smoking?”

• Ask for Elaboration

• “Tell me more about that.”

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Change Talk Methods

• Looking Forward

• Helping the patient envision a changed future

“How would you like things to be

different?”

“How would you like

your life to be like in five years?”

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Change Talk Methods

• Highlights the discrepancy between how things are at present and the possibility of life being better

“How has your life changed since

you started smoking?”

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Change Talk Methods

• Looking back

• Helpful when patient has a period of success in the past

“What was is like for you when you

quit for six months?”

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Responding to Change Talk

• Open-ended questions to elaborate

• “Why else… ”

• “In what ways…”

• “Tell me more about that..”

• Affirm to reinforce it

• “That sounds like a great idea.”

• Reflective Listening to clarify & encourage more

• Summarize

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Getting Started

Exploring and enhancing

motivation for a behavior

change may be more important

than giving a “how to” plan

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Exploring and Enhancing Motivation

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Practice Scaling

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What to Address First…

Importance or Confidence?

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Re-assess Readiness

“Where does this leave you now?”

Next steps…

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Reach Agreement

• Think about it

• Read brochures

• Bring it up at next visit

• Take one small step

• Follow-up

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Closing the Session

• Summarize

• Praise

• Review the agreement

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Brief Interventions

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Brief Intervention ‘PAPA’ Permission-Ask-Provide-Ask

• Get Permission

• “Do you mind if I ask you about…?”

• “Would you be willing to talk about…?”

• “Is it OK with you if we discuss …?”

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PAPA

• Ask what the patient knows or would like to know

“What do you know

about the effects of

smoking on the

unborn fetus?”

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PAPA

• Provide

• Information in a neutral nonjudgmental fashion

• “Research suggests that…” vs

• “You’re putting your fetus at risk every time you take a puff off that cigarette.”

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PAPA

• Ask

• The patient’s interpretation

• “What does this mean to you? How can I help?” vs

• “It’s obvious from this information that you have no choice and you must quit.”

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Summary

• Importance, Confidence & Readiness = Motivation

• OARS – Listen for “Change Talk”

• Scaling – understand and encourage importance and confidence

• Decisional Balance – examine pros & cons

• “Spirit” – Collaboration, Evocation & Autonomy

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Research on MI 2008 Clinical Practice Guideline

• Study of 137 smokers with cancer, found MI significantly increased quit attempts, compared to advice component.

• Study of a brief MI session with smokers with schizophrenia found: more likely to contact tobacco counselor and attend initial session then those who got brief psychoeducational or advice

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Research on MI 2008 Clinical Practice Guideline

• “… evidence of the reviewed motivational interventions, such as MI, increase quit attempts…” with those less motivated to quit.

• However, not find … “higher long-term abstinence rates.”

• Studies are difficult to compare, since the adherence to MI principles can vary widely in the studies.

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Research on Effectiveness of Motivational Interviewing

• Meta-analysis of controlled studies:

• Demonstrate 10-20% more effective then no treatment

• And at least as effective as other treatments up to one year post treatment

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Meta-analysis (cont)

• Shows a dose effect (although MI is typically used as brief treatment)

• Effective regardless of problem severity, age, gender, or ethnic minority clients

• Equally learnable by practitioners of diverse professions, optimally in 2-day workshops with follow-up supervision

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References/Resources

Dunn, C. & Rollnick, S. (2003). Lifestyle change. London: Elsevier Limited.

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. US Department of Health and Human Services, Public Health Service. (May 2008)

Miller, W. R. & Rollnick, S. (2002). Motivational interviewing (2nd ed.). New York: The Guilford Press.

Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change. New York: Churchill Livingstone.

Lundahl, Brad., Burke, Brian L. The Effectiveness and Applicability of Motivational Interviewing: A Practice-Friendly Review of Four Meta-Analyses. Journal of Clinical Psychology: In Session, Vol. 65(11), 1232-1245 (2009)

http://ndc.mayo.edu