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Lynn S Massey, LMSW Health Services Research University of Michigan August 2013 Slide 2 Do 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? Slide 3 Common Human Reactions to Being Listened to Understood Want to talk more Liking the counselor Open Accepted Respected Engaged Able to change Safe Empowered Hopeful Comfortable Interested Want to come back Cooperative Slide 4 Slide 5 MI Definition-Laymans Motivational Interviewing is a collaborative conversation to strengthen a persons own motivation for and commitment to change. Slide 6 Why do I want to learn MI? Motivational Interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change. Slide 7 Technical Definition Motivational 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. Slide 8 Eight Stages in Learning MI The spirit of MI OARS- client-centered counseling skills Recognizing change talk Eliciting and reinforcing change talk Rolling with resistance Developing a change plan Consolidating client commitment Integrating MI with other methods Miller, W.R., & Moyers, T. B. (2006). Eights stages in learning motivational interviewing. Journal of Teaching in the Addictions Slide 9 Slide 10 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 clinicians job Occurs in an interpersonal context Noncompliance, resistance and lack of motivation are all partially due to therapists strategies Slide 11 Ambivalence Is 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) Slide 12 Slide 13 Definition MI 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 Slide 14 The Spirit of MI Is essential for the full and expert use of MI Underlying 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) Slide 15 Relational Components of MI Empathy genuine curiosity about clients perspective (understanding) MI Spirit: Collaboration fostering power sharing in the interaction Evocation elicitation / acceptance / understanding of clients own ideas about change Respect Autonomy active fostering of client perception of choice Slide 16 Collaboration Fosters collaboration and power sharing so that clients ideas impact the session Encourages power sharing in the interaction in such a way that clients ideas substantially influence the nature of the session Builds rapport Facilitates trust Mutual understanding, not about the therapist being right. Slide 17 Evocation Accepting of the clients own reasons for change and ideas about how change should happen Doesnt attempt to educate or direct if client resists Proactively evokes clients own reasons for change and ideas about how change should happen The 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 it Slide 18 Autonomy Accepting and supportive of client autonomy The true power of change rests within the client Ultimately it is up to the client to change Clients are encouraged to take the lead on developing a menu of options as to how to achieve the desired change Slide 19 Thumbs up Thumbs down C: 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) Slide 20 Thumbs up Thumbs down C: 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) Slide 21 Slide 22 The Basics of MI 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 persons inner motivation based on what they value most Slide 23 4 Principles of MI 1) Express empathy acceptance of people as they are frees them to change whereas non-acceptance immobilizes the change process 2) Develop discrepancy between present behavior and broader goals and values; helping people get un-stuck 3) Roll with resistance avoid arguing for change; new ideas/goals/options are not imposed; used as a signal 4) Support self-efficacy belief in ability to change is a powerful predictor of change; counselor self- fulfilling prophesy Slide 24 Basic Role of MI therapist Is 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) Slide 25 Early strategies: OARS 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 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 completely Slide 26 Affirmations may include Commenting positively on an attribute Youre a strong person, a real survivor. A statement of appreciation I appreciate your openness and honesty today. Catch the person doing something right Thanks for coming in today! A compliment I like the way you said that. An expression of hope, caring, or support I hope this weekend goes well for you! Slide 27 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 Goethe Slide 28 OARS Exercises Open Ended Questions Quiz Thinking Reflectively Group Batting Practice Forming Reflections Miller tape with OARS coding Structured Practice Slide 29 What the speaker says What the listener hears What the speaker means What the listener thinks the speaker means Slide 30 Communication errors 1) 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 mean Slide 31 One 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. Slide 32 Listener Listen carefully with a goal of understanding the dilemma Give 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 change Then ask: So what do you think youll do? and just listen Slide 33 Reflective Listening: Overview The 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) Slide 34 Complex Reflections Adding 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 Slide 35 Categories of Resistance Arguing 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-tracking Slide 36 Responding to Resistance Simple 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 you Slide 37 Change Talk - DARN C Disadvantages of Status Quo Advantages of Change Optimism about Change Intention to Change Desire Ability Reasons (to, not to) Need Commitment Slide 38 The Flow of Change Talk Desire Ability Reasons Need Commitment Change MI Slide 39 Eliciting Change Talk Evocative Questions Elaboration Using Extremes Looking Back Looking Forward Exploring Goals Slide 40 Giving Information and Advice Get permission Qualify, honoring autonomy Ask Provide Ask For suggestions, offer several, not one Slide 41 Thanks Questions Concerns Motivationalinterviewing.com Building Motivational Interviewing Skills a practitioner workbook by David Rosengren Motivational Interviewing: Preparing people for change by William Miller and Stephen Rollnick (3 rd edition) lsmassey@med.umich.edu