aase ode mi workshop 5.23.12
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AADE/ODE MI Workshop Series
Michael Fulop, Psy.D.Clinical & Consulting Psychology
FORSTER FULOPRewarding Diabetes
Motivational Interviewing “A work in progress…”
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My AgendaProvide ongoing training to AADE/ODE
providers to improve MI skills
Discuss evidence for MI in psychotherapy
Show examples of MI in practice
Have you practice MI – in your settingHow comfortable role/real playing? 0-10How comfortable taping self in practice? 0-10
Humble + [email protected]
What would like to accomplish today?
• 30 seconds
• Your Name
• Where do you practice?
• What’s one specific take-away from today, imagine what it might be.
• Write down as we go along
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Some Things MI is Not MI not Transtheoretical Model - MI not intended as a
comprehensive theory of change
MI does not trick people into doing what don’t want to do★ Not an end run for outwitting people★ MI is “with” or “for” someone, not “to” or “on”
MI is not what you already are doing★ Near zero-correlation for perceived competence in MI –
★ Attending 1 workshop doesn’t improve outcomes for clients
★ Practice is needed, being coded, being observed and practice
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Some Things MI is Not MI is simple, but not easy
Not easy to integrate complex skills Like learning to play a musical
instrument!
MI is not a Panacea It’s a specific way to address the need to make
behavioral changes when someone is ambivalent
★ People ready for change do not need MI
Mi is not stand-alone therapy – adds effectiveness w/other treatments w/1- 4 sessions
What MI is…After 30 years of research
we have a treatment approach that is evidence-based [over 200 RCT’s published], relatively brief [typically 1-3 sessions], that can be specified, grounded in testable theory, with identifiable methods of action, verifiable as to when it is being delivered competently, generalizable across a wide range of problem areas, complimentary to other treatment methods, and learnable by a wide range of providers – WR Miller, Ph.D.
Recent definition of MI - MI-3MI is a collaborative, goal-oriented style
of communication with particular attention to the language of change, designed to strengthen personal motivation for & commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
[email protected] Miller & Rollnick, 2011
[email protected] David Rosengren, Ph.D. Building Motivational Interviewing Skills
Meta-analyses & reviewsBritt, Hudson & Blampied, 2004Burke et al., 2003Dunn, Deroo & Rivara, 2001Hettema, Steele & Miller, 2005Moyer, Finney, Swearingen & Vergun,
2002Rubak, Sandbaek, Lauritzen &
Christensen, 2005Cochrane Review 2011
Does MI Work?
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Evidence For MI efficacy Dunn, C, Deroo, L, Rivara, F (2001) The Use of brief interventions
adapted from MI across behavioral domains. Addiction, 96; 1725-42.
Burke B, Arkowitz H, Dunn C (2002) The efficacy of MI and it’s adaptations: What we know so far. In Miller & Rollnick [eds] Motivational Interviewing, 2nd [2002]
Burke B, Arkowitz H, Menchola M (2003) The efficacy of MI: A meta-analysis of controlled clinical trials. Journal of Consulting & Clinical Psych, 71 843-61.
Britt, E, Hudson S, Blampied N (2004) MI in health care settings: A review. Patient Education and Counseling, 52, 147-55.
Rubak, S, Sandboek A, Lauritzen T, Christensen B (2005) MI: A systematic review and meta-analysis. British Journal of General Practice, 55, 305-12.
Hettema J, Steele J, Miller W (2005) Motivational Interviewing. Annual Review of Clinical Psychology, 1 91-111.
Further Study - Resources
Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner’s Workbook. New York: Guilford Press.
Arkowitz, H. Westra, H. Miller, W.R., & Rollnick, S. (2008). Motivational Interviewing in the Treatment of Psychological Problems. Guilford: New York.
Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. Guilford:.
Training Tapes: MI SeriesMI Website: www.motivationalinterview.org
MI SpiritCollaborative
Honors client expertise and perspective
Creates an environment that supports changeEvocative
Resources lie within clientEnhance their intrinsic motivation
less about external pressure
Promotes Client Autonomy“Patient is right” they have capacity for self
changeFacilitate informed choice
Compassion - MI-3 [Miller & Rollnick, 2012][email protected]
What is MI Spirit? 1-5 RankingEvocation
CollaborationAutonomy/SupportSpirit = [EV] + __ [CL] + __ [A/S]/3 = ___Evocation + Collaboration + Autonomy/Support/3]
DirectionEmpathy
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A Continuum of Styles
Directing <=> Guiding <=> Following
Behavior therapyCognitive therapyReality therapyDr. Phil
Motivational interviewing Solution-focused therapy
Psychodynamic
Psychotherapy
Client Centered
Psychotherapy
• It’s MI when…
• The communication style involves person-centered, empathic listening (engaging), and
• There is a target of change and that is the focus of conversation (focusing), and
• The interviewer evokes a person’s own motivation & reasons for change (evoking), but
• It may or may not include planning.
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These 4 processes are somewhat linear ….
Engaging necessarily comes first
Focusing (identifying a change goal) is a prerequisite for Evoking
Planning is logically a later step
Engage Focus Evoke Plan
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. . . . and yet also recursive
Engaging skills [& re-engaging] continue throughout MI
Focusing is not just a one-time event; re-focusing often needed; focus may
change
Evoking begins very early in encounters
“Testing waters” with planning may indicate a need for more of the above
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AmbivalenceFeeling 2 ways about change is
common & normal
MI accepts ambivalence; patient gets time to explore & consider both sides of their dilemma
Telling people why they should change evokes the “righting reflex” & increases resistance
AmbivalenceOccurs throughout the change process
Reflects costs and benefits of change and status quo
Is uncomfortable & may become chronic
Resolved by client – Bem’s Self-Perception Theory What people say to themselves, is what they
believe
Ambivalence under pressure…
Leads to discord
Tends to elicit push back
Predicts worse outcomes
Is something we avoid in MI
Reinforcing Change Statements
Be attentive
Don’t have to respond immediately
May collect like a bouquet of flowers
Warning – be attentive to ambivalence
Pair Up - 1 speaker & 1 listener• Speaker talks about a change they are
ambivalent about – they want to change, but have not started yet [real play, or role play patient]. Speaker begins, describes change they want.
• Listener your job is to convince your speaker about why they should change – list your reasons, why you think they should change
• 4 minutes – then we debrief
• What happened to you as the person who wants a change? What’s it like?
• What happens to you, the listener/”convincer” What’s it [email protected]
Installing Motivation?
• Speaker discuss a change you want to make – or play a client, patient
• Listener – Your task is to help this person come hell or high water
• Instead of listening, please:• Explain why s/he should make this change• Give 3 specific benefits of making the change• Tell him/her how to change• Emphasize importance of the change• Tell the participant to do it!
• Don’t use [email protected]
Evoking Motivation?• Speaker continue discussing change
• Listen carefully - goal to understand their dilemma
• Ask these four questions:• Why would you want to make this change?• How might you go about it, in order to succeed?• What are the 3 best reasons to do it?• On a scale of 0-10, how important would you say
it is to make this change? • And why are you a ? and not zero?
[email protected] David Rosengren, Ph.D. Building Motivational Interviewing Skills
OARS
Open Ended questions Strength based questions
Affirmations
Reflective Listening
Summarizing
Engaging a real individual• Remember, you are not their 1st
provider• May need to overcome some barriers –
• My 1st Q -“Have you seen any other mh providers?”
• Relationship building is needed• Accepting ambivalence is particularly
important• Don’t insist on diagnosis acceptance• Target problems and client goals – not
diagnoses
Exercise: On the Nature of Helpfulness
Imagine a major pressing dilemma in your life Professional or Personal Debating this with yourself
Imagine Your thinking is moving in ever tightening circles You’re in a state of perplexity It’s affecting all aspects of your life You’re making little progress on your own
So… you decide to seek out helpActivity from Jeff Allison
Exercise: The Nature of Helpfulness
Who should you discuss this with?Don’t want to make a mistake - Choosing
wrong person leads you in wrong way Go to Powell’s, grab some coffee and sort this
out
What are desirable qualities & skills of such a person? How would you want them to behave?
Make two lists by yourselfMost desirable qualities & skillsWhat will make you feel antagonistic and or
disappointed? This Exercise is from Jeff Allison
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Change Talk Change talk is any client speech that favors
movement in the direction of change
Previously called “self-motivational statements” (Miller & Rollnick, 1991)
Change talk is by definition linked to a particular behavior change goal
DARN CATs
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Preparatory Change TalkDARN Examples
DESIRE to change (want, like to, wish.,)
ABILITYto change (can, could . . )
REASONS to change (if . . then)
NEED to change (need, have to, got to . .)
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Mobilizing Change TalkReflects resolution of ambivalence
COMMITMENT (intention, decision, promise)
ACTIVATION (willing, ready, preparing)
TAKING STEPS
Mobilizing Language
Three Types: Commitment, Activation & Taking Steps I an done with being depressed. I am ready to do something different. My boyfriend said I didn’t need my meds, but I
told him I did.
Is mobilizing language enough?
Some Answers… I wish I could… I’d like to… I think I should… I could if I really wanted to… I have good reasons to…
For some questions... Do you swear to tell the truth, whole truth and…? Do you take this person to have and to hold in
sickness in health…?
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Responding to Change Talk
All EARSE: Elaborating: Asking for elaboration, more
detail, in what ways, an example, etc.
A: Affirming – commenting positively on the person’s statement
R: Reflecting, continuing the paragraph, etc.
S: Summarizing – collecting bouquets of change talk
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Sustain TalkThe other side of ambivalence
I really like marijuana(Desire)
I don’t see how I could give up pot(Ability)
I have to smoke to be creative(Reason)
I don’t think I need to quit (Need)
I’m gonnna keep smoking (Committment)
I’m not ready to quit (Activation)
I went back to smoking this week (Taking Steps)
Righting Reflex Video
Arg Clin Starts at 1:15 & Ends at 3:40
http://www.youtube.com/watch?v=kQFKtI6gn9Y
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What is Resistance?
Behavior
Interpersonal (It takes two to resist)
A signal of dissonance
Predictive of (non)change
The Righting Reflex - Reactance
Handling Resistance • Already in skills repertoire
• May not eliminate, but can reduce “heat”
• Three reflective types:• Simple• Amplified• Double-sided
• Two Strategies• Shifting focus• Emphasize personal choice
Handling Resistance - Reflection
• I thought a little red wine was supposed to be good for your heart.
• I know the meds are good for me, but they make me too drowsy.
• I think you are blowing this way out of proportion, I only got a little messed up, why are you such a prude?
• You don’t understand what it’s like for me, you’ve got a job and career; all I got is these memories.
• Meds don’t help much anymore, but something’s got to, or I am out of here.
• I’ve tried everything you’ve asked. None of that shit works. Why don’t you get it?
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Sustain Talk and ResistanceSustain Talk is about the target behavior
I really don’t want to stop smoking I have to take pills to make it through the day
Resistance is about your relationship You can’t make me quit You don’t understand how hard it is for me
Both are highly responsive to counselor style
Foundational Skills – Simple, Not Necessarily Easy
• Open Questions
• Affirmations
• Reflective Listening
• Summaries
• Offering Information
Asking Develop an understanding of client’s
situation
Allows you to:Follow a decision treeArrive at a diagnosisComplete forms
Closed questions can be:Efficient way to gather specific informationMay create or reinforce the expert-trap
Open-ended Questions
These sets the tone for MI work
Communicates interest and caring
Allows client room to respond
Makes client more a more active partner
You receive information otherwise unavailable
Creates momentum
ListeningMI is built on this skill
Directive use of listening
Attend to some things and not others
Create awareness of gaps
Reinforce change talk
Effective Listening:
Is not asking
More than paying attention
Is not just silence
More than repeating words
Way of thinking
Reflective Listening2 levels of reflection
Simple - content stays close RepeatingRephrasing
Complex – guesses at unexpressed, affect, anticipates, and metaphors Paraphrasing Meaning or IntentReflecting Feeling
Exercise – Two Levels of Reflections
Form groups of 4
Choose a representative to record answers
Record Simple & Depth Reflections for each sentence stem
Being Directional
Not telling client what to do
Choosing to attend to different elements
Usually multiple elements in a statement
Focus will determine path
Examples of being directional
I’m tired and it feels impossible right now.
You’re worn out.
It feels really hard to do.
Right now is a problem, but maybe later won’t be.
Summaries
Special form of reflective listening
Different kinds: Collecting – short, continue flow (change talk) Linking – add recent material to prior info
(ambivalence) Transitional – announces a shift in focus
(change direction)
Affirmations• Some clients are demoralized
• Orients people to their resources
• Be genuine
• Probe partial successes
• Reframe resistance into an affirmation
• What and how questions are helpful
• Use “you” statements, not “I”
Informing Successful communication
requires:Transmission of technical
informationInterpersonal skills
Therefore, a relationship is key to good informing
Useful Informing Ask permission
Offer choices
Use other client examples
Chunk-Check-Chunk
Elicit-Provide-Elicit
Useful Informing Slow down and progress may be quicker
It’s a person not an information receptacle
Consider the client context & priorities
Amount matters and depends on the client
Best method? The individualized one
Beware of righting reflex
Reflections
Reflections are a way of hypothesis testing without the questions
They are a way to attune to the person
They are choosing where you think someone might be going
Heart of MI
Reflective Responses
Three levels of Reflections
Repeats - or parrots
Rephrases - with simple word changes
Paraphrasing – infers a meaning
Reflection – of feeling, value, or attitude Simple Complex
Intensity of Reflections
Understated or attenuating a reflection“You a slightly annoyed”
Which direction will the client go?
Overstating or Amplified ReflectionsYou are outraged
Which direction will the client go?
“I really hate my boss telling me I have to pick up those boxes over and over again.”
Understated reflection Which direction will the client go?
Amplified Reflection Which direction will the client go?
Double Sided
On the one hand you want to … On the other hand you don’t want to.
You’ve told me some good reasons to stop smoking, and in some ways you love it a lot
“My diabetes used to be easy to control, but I’m not sure I can get it under control any more.”
Practice
“Since my accident, I don’t care if I live or die, and I wonder if anyone else cares?”
Reflection Practice
“It’s fun, but something has to give. I can’t go on like this anymore.”
“I know I can do some things differently., but if she would just back off, the this situations would be a lot less tense. These things wouldn’t happen.
I’ve been depressed lately. I keep trying to get back to using exercising more, but my back always hurts, it is so frustrating. A couple of drinks would help.
Reflection Practice “So I’m not too worried, it’s been over a year, and I
can still walk with that knee pain.”
“I know I should lose some weight, everybody tells me that, but nobody knows how hard it is for me. I wish I was on the biggest loser.”
My daughter thinks it’s her body, and so she should be able to do what she wants. Hooking up is no big deal to her. She doesn’t get why I won’t back off.”
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Contact Information
Michael J Fulop, Psy.D.
www.rewardingdiabetes.com
503.539.4932