ED4 - Motivational Interviewing

7/29/2019 ED4 - Motivational Interviewing

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Feb 25, 2011

An Introduction toAn Introduction toMotivational Interviewin MIMotivational Interviewin MI

Michael Flaum, MDMichael Flaum, MD

Fonda Frazier, MA, ACADC, MINTFonda Frazier, MA, ACADC, MINT

Division of Public and Community PsychiatryDivision of Public and Community Psychiatry

University of Iowa Carver College of MedicineUniversity of Iowa Carver College of Medicine

&&

MECCAMECCA


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What do you already know (or thinkWhat do you already know (or thinkyou know) about MI?you know) about MI?

What have you heard / been taught?What have you heard / been taught?

a o you n sa o you n s

What has been our ex erience with itWhat has been our ex erience with it

to date?to date?


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Clinical ChallengesClinical Challenges

What have you found (or anticipate) toWhat have you found (or anticipate) tobe most challenging in your clinicalbe most challenging in your clinical

interactions withinteractions with patients?patients?


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ea t care tren s n t eea t care tren s n t e ss centurycentury

A majority of conditions that now causeA majority of conditions that now causepeople to consult health care professionalspeople to consult health care professionals

are largely preventable or remediable throughare largely preventable or remediable through

health behavior changehealth behavior change

. . , , ,. . , , ,

Health care practice is increasingly aboutHealth care practice is increasingly about

--

Motivating people to change behaviorMotivating people to change behavior


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What do we typically do in a clinicalWhat do we typically do in a clinical

session with clients / patients who needsession with clients / patients who needto change behavior?to change behavior?

Explain what patients could do differently inExplain what patients could do differently inthe interest of their health?the interest of their health?

Advise and persuade them to change theirAdvise and persuade them to change their

behavior?behavior? Warn them about what will happen if theyWarn them about what will happen if they

dont change?dont change?

Counsel them about how to change theirCounsel them about how to change theirbehavior?behavior?

Refer them to a specialist?Refer them to a specialist?


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What can / should we be doing?What can / should we be doing?

Assess where the person is at regardingAssess where the person is at regardinghis or herhis or her readinessreadiness andand capacitycapacity toto

make the changemake the change

Stagewise assessment (Stage of ChangeStagewise assessment (Stage of ChangeModel)Model)

A method to promote behavioral change inA method to promote behavioral change in

an inter ersonal contextan inter ersonal context


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Two Complementary Sets of IdeasTwo Complementary Sets of Ideas

Stage of Change ModelStage of Change Model

Target behavior: Cigarette SmokingTarget behavior: Cigarette Smoking

Motivational InterviewingMotivational Interviewing

Target behavior: Alcohol and DrugTarget behavior: Alcohol and Drug


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ages o angeages o ange

PrecontemplationPrecontemplation

ContemplationContemplation

PreparationPreparation

c onc on


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ages o angeages o ange

recon emp a onrecon emp a on

PreparationPreparation

ActionAction

MaintenanceMaintenance

RelapseRelapse


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Stages of Change Can Be DynamicStages of Change Can Be Dynamic


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Stagewise TreatmentStagewise Treatment

Arguably, this model can be applied toArguably, this model can be applied toall clinical problemsall clinical problems

People are complex, problems arePeople are complex, problems are

Different problems, different stagesDifferent problems, different stages

Need to assess stage for each problemNeed to assess stage for each problem


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MI BackgroundMI Background

problem drinkingproblem drinking

Now widely accepted and used withinNow widely accepted and used within

the substance abuse treatmentthe substance abuse treatmentcommun y n erna ona ycommun y n erna ona y

Increasin use and trials in other areasIncreasin use and trials in other areas

of healthcareof healthcare

> 100 randomized clinical trials of efficac> 100 randomized clinical trials of efficac

of MI on a variety of problem areasof MI on a variety of problem areas


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Randomized Controlled Trials with MIRandomized Controlled Trials with MI

Alcohol (31)Alcohol (31) Unsafe sexualUnsafe sexual

behaviorsbehaviors

Smoking (6)Smoking (6)

RelationshipsRelationships

Eating disordersEating disorders

HIV Risk (5)HIV Risk (5)

Med Com liance 5Med Com liance 5

Diabetes managementDiabetes management

Diet and exercise (4)Diet and exercise (4) en a car esen a car es

Healthy agingHealthy aging

Gambling (2)Gambling (2)

Drug abuse among SMIDrug abuse among SMI


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Mean Combined Effect Size by ProblemMean Combined Effect Size by Problem= an om ze n ca r a s= an om ze n ca r a s

0.440.510.51

0.71

3 MonthsHIV Risk

0.040.14

0.41.

Public Health

Gambling

0.290.30.29

0.53

Follow-u

Treatment Adherence

Alcohol

Diet/Exercise

0.140.78

0.26.

Smoking

0 0.2 0.4 0.6 0.8 1


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Mixed resultsMixed results

Some negative studiesSome negative studies

. .,. .,

Some variation acrossSome variation across SitesSites

CliniciansClinicians

Subject demographicsSubject demographics


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The Myth of the UnmotivatedThe Myth of the Unmotivated

PatientPatient

When a client / patient seems unmotivated forWhen a client / patient seems unmotivated forchange or consistently fails to take goodchange or consistently fails to take good

soun a v ce, s o en assume asoun a v ce, s o en assume a

something is wrong with the patient and theresomething is wrong with the patient and there

is not much that can be done about it.is not much that can be done about it.

These assumptions are usually falseThese assumptions are usually false

o person s comp e e y unmo va eo person s comp e e y unmo va e

Most people who do not change problematicMost people who do not change problematic

behaviors arebehaviors are ambivalentambivalent


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AmbivalenceAmbivalence

AbilityAbility

ReasonsReasons

NeedNeed

Sustain Change

Behavior Behavior

vs.


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Paradoxical effect of coercionParadoxical effect of coercion

good side of an ambivalent behavior,good side of an ambivalent behavior,

other side.other side.

e en o e eve w a we ear e en o e eve w a we ear

ourselves say. The more we defend ourourselves say. The more we defend our

,,to sustaining the status quo.to sustaining the status quo.

The more we talk positively about change,The more we talk positively about change,

the more likely we are to change.the more likely we are to change.


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In its simplest form, the implicit theoryIn its simplest form, the implicit theoryof MI posits:of MI posits:

1a. MI will increase client change talk1a. MI will increase client change talk

..

(sustain talk)(sustain talk)

2a. The extent to which clients verbally2a. The extent to which clients verbally

defenddefend status quostatus quo (resistance) will be(resistance) will be

2b. The extent to which clients verbally2b. The extent to which clients verbally

argue for change (change talk) will beargue for change (change talk) will be

directly related to behavior changedirectly related to behavior change


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Developing DiscrepancyDeveloping Discrepancy

Basic Principle: Change is motivatedBasic Principle: Change is motivatedby a perceived discrepancy betweenby a perceived discrepancy between

present behavior and importantpresent behavior and important

personalpersonal goals or values.goals or values.

Job of the clinician: Evoke and amplifyJob of the clinician: Evoke and amplify

from the clients ers ectivefrom the clients ers ective aa

discrepancy between present behaviordiscrepancy between present behaviorand important goals or values.and important goals or values.


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Video ExampleVideo Example

A typical postA typical post--MI followMI follow--up visitup visit


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The Spirit of MIThe Spirit of MI

Collaboration

Autonomy

Support


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How does MI work?How does MI work?

By activating patients own motivation forBy activating patients own motivation for

change and adherence to treatment bychange and adherence to treatment by

The way in which you as a doctor talkThe way in which you as a doctor talkwith your patients can substantiallywith your patients can substantially

influence their personal motivation forinfluence their personal motivation for

Behavioral change in an interpersonalBehavioral change in an interpersonal

contextcontext


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CollaborationCollaboration

The extent to which the clinicianThe extent to which the clinicianbehaves as if the interview is occurringbehaves as if the interview is occurring

betweenbetween two equal partnerstwo equal partners, both, both

having knowledge that might be usefulhaving knowledge that might be useful


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EvocationEvocation

The extent to which the clinicianThe extent to which the clinicianconveys an understanding thatconveys an understanding that

motivation for change, and the abilitymotivation for change, and the ability

to move toward that change resideto move toward that change residemos y w n e c enmos y w n e c en


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Autonomy SupportAutonomy Support

The extent to which the clinicianThe extent to which the cliniciansupports and actively fosters ptsupports and actively fosters pt

perception of choice as opposed toperception of choice as opposed to

trying to control the pts behavior ortrying to control the pts behavior orc o cesc o ces


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The Spirit of MI:The Spirit of MI:

Wrestling vs. DancingWrestling vs. Dancing

Source of metaphor: Jeff Allison


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The Four Guiding Principles (RULE)The Four Guiding Principles (RULE)

R: Resist the Righting ReflexR: Resist the Righting Reflex

: n ers an your pa en s: n ers an your pa en s

motivationsmotivations

L: Listen to your patientL: Listen to your patient


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RResist the Righting Reflexesist the Righting Reflex

If we accept the paradoxical effect ofIf we accept the paradoxical effect ofcoercion, the clinician must activelycoercion, the clinician must actively

resist the temptation to take up theresist the temptation to take up the

good side.good side.

This is difficultThis is difficult when patients are notwhen patients are not

feelin like the can make a chan e wefeelin like the can make a chan e we

want to help them, move them forward.want to help them, move them forward.

..


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UUnderstand your patientsnderstand your patients

motivationsmotivations

If your consultation time is limited (ofIf your consultation time is limited (ofcourse it is), you are better off askingcourse it is), you are better off asking

patients why they would want to makepatients why they would want to make

a change and how they might do ita change and how they might do itra er en e ng em a eyra er en e ng em a ey

shouldshould


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LListen to your patientisten to your patient

SkillfulSkillful reflective listeningreflective listening that clarifiesthat clarifiesand amplifies the persons ownand amplifies the persons own

experience and meaningexperience and meaning

, , , , , ,

or imposing the clinicians own valuesor imposing the clinicians own values

or biases.or biases.


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EEmpower your patientmpower your patient

A patient who is active in theA patient who is active in theconsultation, thinking aloud about theconsultation, thinking aloud about thewhy and how of change is more likelywhy and how of change is more likelyto do something about this afterwardto do something about this afterward

Supporting selfSupporting self--efficacyefficacy


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Self Efficacy TheorySelf Efficacy Theory

--

capable of performing in a certain mannercapable of performing in a certain manner

It is critical that theIt is critical that the clinicianclinician actuallyactuallye eves a e person can ac ua y ma ee eves a e person can ac ua y ma e

a change, and indeed is the only one thata change, and indeed is the only one that

..

It is critical that theIt is critical that the personperson believes theybelieves they

can actually make the change, and thiscan actually make the change, and this

belief itself can be an important motivator.belief itself can be an important motivator.


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Video Example of the Spirit of MIVideo Example of the Spirit of MI

Pulmonary Illness and CigarettePulmonary Illness and Cigarette

SmokingSmoking


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Technique of MITechnique of MI

Key Elements: OARSKey Elements: OARS

OOPEN (questions)PEN (questions)

AAFFIRMATIONSFFIRMATIONS

RREFLECTIONSEFLECTIONS

SSUMMARIZINGUMMARIZING


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OOpen vs. Closed Questionspen vs. Closed Questions

Closed questions:Closed questions: , . .,, . .,

nownow

Multi le choiceMulti le choice

Open questions:Open questions:

The opposite; questions that evoke moreThe opposite; questions that evoke moreelaborate responseelaborate response


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AAffirmationsffirmations

Emphasize a strengthEmphasize a strength

o ce an apprec a e a pos ve ac ono ce an apprec a e a pos ve ac on

Ex ress ositive re ard and carinEx ress ositive re ard and carin

Strengthen the therapeutic relationshipStrengthen the therapeutic relationship

Must be genuine (often the tough part)Must be genuine (often the tough part)


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RReflectionseflections

,,

A hypothesis, that may or may not be rightA hypothesis, that may or may not be right

Has the effect of encouraging the otherHas the effect of encouraging the other

person to elaborate, amplify, confirm orperson to elaborate, amplify, confirm orcorrect.correct.

SimpleSimple

ComplexComplex

AffectiveAffective


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Simple ReflectionsSimple Reflections

RepeatingRepeating

i.e.,i.e.,

element of whatelement of what

the speaker saidthe speaker said

Youre wondering ifYoure wondering if

RephrasingRephrasing It sounds like youIt sounds like you

You feel as ifYou feel as if


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Complex ReflectionsComplex Reflections

Makes a guess to unspoken meaningMakes a guess to unspoken meaning

Metaphors and similesMetaphors and similes

Its kind of like Its as thou hIts kind of like Its as thou h

AmplifiedAmplified

ExampleExample smoking the rest of your lifesmoking the rest of your life

Reflecting an unstated feelingReflecting an unstated feeling


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Reflections Group Exercise p. 89Reflections Group Exercise p. 89

". - - -

really got high and he came home late and we had abig fight. He yelled at me and I yelled back and then he

hit me hard! He broke a window and the TV set, too! It

was like he was crazy. I just don't know what to do!

2. A fifteen-year-old girl says: "I'm really mixed up. A lot

of my friends, they stay out real late and do things their

arents don't know about. The alwa s want me to

come along and I don't want them to think I'm weird orsomething, but I don't know what would happen if I went

".


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SSummariesummaries

Used to collect, link together and reinforceUsed to collect, link together and reinforce

material that has been discussedmaterial that has been discussed

Shows that you have been listening carefullyShows that you have been listening carefully

May allow for further elaboration or sets theMay allow for further elaboration or sets thes age or rans on n ocuss age or rans on n ocus

Three typesThree types

CollectingCollecting

TransitionalTransitional


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So, how does this actually workSo, how does this actually work

towards changing behavior?towards changing behavior?

How is this directive?How is this directive?

ow can e c enow can e c en --cen ere ancen ere an

directive at the same time?directive at the same time?

How do you avoid going in circles?How do you avoid going in circles?


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Answer:Answer:

By skillfully listening for andBy skillfully listening for and

language:language:

Sustain Talk (resistance)Sustain Talk (resistance)


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Resistance can take many formsResistance can take many forms

PassivePassive ActiveActive

OverOver--compliancecompliance

BlamingBlaming

everything)everything) MinimizingMinimizing

,, --

showsshows ExpressingExpressing


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Rolling with ResistanceRolling with Resistance

youyou to change strategiesto change strategies

When you encounter resistance:When you encounter resistance:

Step backStep back

Listen (empathicallyListen (empathically -- try to understandtry to understand

how the patient got there)how the patient got there)

Reflect (simple, complexReflect (simple, complex demonstratingdemonstratingempathy)empathy)

Empower: Put the ball (for change) back inEmpower: Put the ball (for change) back in

their courttheir court


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Specific traps to avoid whenSpecific traps to avoid when

encountering resistance:encountering resistance:

Arguing for ChangeArguing for Change

Assumin the ex ert roleAssumin the ex ert role

Criticizing, shaming, blamingCriticizing, shaming, blaming

LabelingLabeling (focus is on what the client is or(focus is on what the client is orhas rather than what the client does)has rather than what the client does)

Being in a hurryBeing in a hurry

Claiming preClaiming pre--eminenceeminence (paternalistic(paternalistic II

know what is best for you)know what is best for you)


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rans on rom orans on rom o

-- ,,

method of communication for enhancing intrinsicmethod of communication for enhancing intrinsicmotivation to change bymotivation to change by exploring and resolvingexploring and resolving

ambivalenceambivalence..

OARSOARS PersonPerson--centeredcentered

ECTECT DirectiveDirective

ExploringExploringambiambi--valencevalence

eso v ngeso v ngamam --

valencevalence

2/23/2011 4848


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ow arow ar

OARS

Does

change-talkoccur naturally yes Develop a plan,

Respond with

Elaboration Qs

Reflectionelicitation?

no

Affirmation &or

Summarization

Apply Techniques

For Eliciting

-

(this lesson)

4949


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Pre arator Chan e TalkPre arator Chan e Talk

DARNDARN--CC

DESIRE to change (want, like,DESIRE to change (want, like,wish . . )wish . . )

ABILITY to change (can, could . . )ABILITY to change (can, could . . )

o c ange . . eno c ange . . en

NEED to chan e need have toNEED to chan e need have to

got to . .)got to . .)

2/23/2011 5050

,,decision, readiness/taking steps)decision, readiness/taking steps)


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espon ngespon ng o ange ao ange a

ReflectingReflecting

ElaboratingElaborating SummarizingSummarizing

AffirmingAffirming

2/23/2011 5151


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Strate ies forStrate ies for Elicitin Chan e TalkElicitin Chan e TalkStrate ies forStrate ies for Elicitin Chan e TalkElicitin Chan e Talk

IQIQ--LEDGELEDGE--CC

ec s onaec s ona

BalanceBalance

oa soa s

ValuesValues

EvocativeEvocativeImporImpor--

tance/Confitance/Confi

QueryQuery LookingLookingAhead/BackAhead/Back

dencedence RulerRuler

Importance & ConfidenceImportance & ConfidenceImportance & ConfidenceImportance & Confidence


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Importance & ConfidenceImportance & ConfidenceImportance & ConfidenceImportance & Confidence

ange u ersange u ersange u ersange u ers

How important is it for you right now to...?How important is it for you right now to...?On a scale from 0On a scale from 0 -- 10... what number would you10... what number would you

give yourself?give yourself?

00 1010

ConfidenceConfidence

,,

you that you would succeed? On a scale from 0you that you would succeed? On a scale from 0--10... what number would you give yourself?10... what number would you give yourself?

00 101053

Q E tQ E tQ E tQ E t


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Quer ExtremesQuer ExtremesQuer ExtremesQuer Extremes

WorstWorst--case scenariocase scenario

Whats the worst thing that might happen ifWhats the worst thing that might happen if

you eep up your r n ngyou eep up your r n ng

--

Whats the best situation you can imagine forWhats the best situation you can imagine for

ourself if ou uit drinkin ?ourself if ou uit drinkin ?


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Compare life before the problem behaviorCompare life before the problem behavior

to the way life is nowto the way life is now

What was your life like before you startedWhat was your life like before you started

drinking heavily?drinking heavily?

ompare e way e s now w owompare e way e s now w ow

might be if problem behavior continues ormight be if problem behavior continues or

Given the way things are going, how do youGiven the way things are going, how do you

see yourself in five years?see yourself in five years?

If you stopped drinking, what might your lifeIf you stopped drinking, what might your life

be like?be like?


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Decisional Balance: Pros and ConsDecisional Balance: Pros and Cons

What would be some of the good things ifWhat would be some of the good things if

you stopped drinking?you stopped drinking?

What about the notWhat about the not--soso--good things?good things?


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Counselor:Counselor:

So just like that you almost lostSo just like that you almost lost

some pretty important things to you.some pretty important things to you.

Client:Client:

My wife and my daughter are theMy wife and my daughter are the

most important things in my life.most important things in my life.

I couldnt stand the look on myI couldnt stand the look on mydaughters face. In fact, it made medaughters face. In fact, it made me

..


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??Asking for a specific exampleAsking for a specific example

How much? How often?How much? How often?

s ng or a escr p on o e ass ng or a escr p on o e as

time this occurredtime this occurred

Asking What else?Asking What else?


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It sounds like the pros of using stillIt sounds like the pros of using still

far outweigh the cons for you.far outweigh the cons for you.

So it may be that you decide drinkingSo it may be that you decide drinking

is something that you dont want tois something that you dont want to

g ve up esp e e consequencesg ve up esp e e consequences


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Responding to Change TalkResponding to Change Talk

OOPEN QUESTIONS (Explore, elaborate)PEN QUESTIONS (Explore, elaborate)

AAFFIRMATIONSFFIRMATIONS

RREFLECTIONSEFLECTIONS

SSUMMARIZINGUMMARIZING

c. e c. e cc. e c. e c

MI Can be Effective Even in SmallMI Can be Effective Even in Small


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MI Can be Effective, Even in SmallMI Can be Effective, Even in Small

DosesDoses

Key study: Randomization to either getKey study: Randomization to either getor not get a 1 hour MI session prior toor not get a 1 hour MI session prior to

randomization into 3 arms of SArandomization into 3 arms of SA

treatmenttreatment

Key Results: Significantly betterKey Results: Significantly better

outcomes across all 3 treatment armsoutcomes across all 3 treatment arms

both at end of active treatment andboth at end of active treatment andlongerlonger--term followterm follow--up.up.


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It actually works.It actually works.

Try it.Try it.

resources out thereresources out there


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Key Resources and Contact InfoKey Resources and Contact Info

Motivational Interviewing: Resources forMotivational Interviewing: Resources for

clinicians, researchers, and trainersclinicians, researchers, and trainers

www.motivationalinterview.orgwww.motivationalinterview.org

[email protected]@uiowa.edu

[email protected]@meccaia.com

www. cmen a ea .orgwww. cmen a ea .org

(Iowa Consortium for Mental Health)(Iowa Consortium for Mental Health)

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