An introduction to

Motivational Interviewing:A brief intervention

Angela Kubacki akubacki@sgul.ac.ukKatherine Joekes

Learning Objectives

By the end of this session you will be able to:

– Outline the main principles of Motivational Interviewing (MI)– Discuss some of the evidence that supports MI– Understand “the Spirit of MI”– Demonstrate an ability to implement some of the principles of

Motivational Interviewing when discussing health behaviour change

What is Motivational Interviewing?

“A collaborative, client-centered form of guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2009), by exploring and resolving ambivalence.”

What is Motivational Interviewing?

A clinical method aimed at helping patients to recognise and do something about their current or potential problems.

A directive, patient-centred consultation for eliciting behaviour change by helping patients to explore and resolve ambivalence.

Uses for Motivational Interviewing...

• Smoking cessation• Promoting condom use• Weight loss• Pedometer use• Medication concordance• Exercise uptake• Preoperative cardiac surgery

preparation

Source: Anstiss (2009); Knight et al (2006)

• Chronic pain management• Stroke rehabilitation• Fibromylagia• Diabetes management• Victims of domestic abuse• Chronic leg ulcers• Mental health problems including

depression, anxiety, obsessive compulsive or eating disorders and dual diagnosis

Is it effective?

Two review studies (including 72 studies) suggests that it is.

MI had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases (Rubak et al, 2005).Found robust and enduring effects when MI is added at the beginning of treatment (Hettema et al, 2005).

More recent update: Lundahl et al (2010)

Threat messages are less effective

A meta-analysis of fear appeals including 93 studies (Witte & Allen, 2000) showed that:

Strong threat messages show a small effect (of limited clinical relevance) on behaviour change, but….

…only when combined with a sense of personal efficacy (i.e. how confident a person feels about changing the behaviour) and personal relevance.

Major components of MI

1. The underlying spirit of MI

2. Ambivalence : Identifying pro’s and con’s

3. Assessing ‘importance’ and ‘confidence’

4. Specific communication skills

5. ‘Rolling with resistance’

6. The 4 A’s

1. Underlying Spirit of MI

Collaboration not confrontationEliciting not InstillingAutonomy not Authority

“After all, when you seek advice from someone, it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself”

Terry Pratchett, Jingo

Dangerous assumptions?• The person ought to change• The person wants to change• This person is primarily motivated by ______ • People are either motivated or not• Now is the right time to consider change• A tough approach is always best• I’m the expert – he/she must follow my advice

2. Ambivalence: Pro’s and Con’s

Identifying the advantages & disadvantages

of the existing & new behaviour

‘CHANGE TALK’

Research has shown that change talk is the most important predictor of successful change (Miller & Moyers, 2006) and demonstrates a shift from ambivalence towards confidence and motivation.

Change talk is identified by your patient’s increasing use of phrases that move from “I could” or “I might” to “I will”, “I can”, and “I’ll do” (Scott, 2010).

MI and eliciting “change talk”

““Exploring Ambivalence” / “Thinking Critically”Exploring Ambivalence” / “Thinking Critically”

Pros Cons

If I Continue Smoking

Social

‘Easy’

Smelly

Expensive

Have to stand outside

If I Quit Smoking

Healthier

Boyfriend

Extra cash

Proud of self

Stressful

Setting self up for failure

3. Importance and confidence

“On a scale of 1 to 10 .....”

motivation

highlow

high

impo

rtan

ce

confidence

4. Specific Communication Skills

• open questions

• listening & silence

• affirmation• Reflection (2 to 3 times more reflection than questions)

• summarising

Levels of reflection

• Repeating

• Rephrasing/paraphrasing

• Reflection of feeling

• Double-sided reflection

• Amplified reflection

“I really do want to lose weight. I mean, I want to feel better and be healthy, but I’ve tried so many diets but they don’t work and I just can’t help myself.”

5. ‘Rolling with resistance’

• Avoid arguing for change

• Emphasise personal control

• Summarise, and reflect feeling

Remember:

Resistance is a signal to respond differently

6. The 4A’s: How to structure a brief intervention

• Ask

• Advise

• Assist

• Arrange

Motivational interviewing case study

role development (10 minutes)

Role play in triads (40 minutes)

A- patient

B- GP

C- observer/timekeeper

Summary and consolidation (10 minutes)

PRACTICE EXERCISE

Major components of MI

1. Underlying philosophy of MI

2. Ambivalence : Identifying pro’s and con’s

3. Assessing ‘importance’ and ‘confidence’

4. Specific communication skills

5. ‘Rolling with resistance’

6. The 4 A’s

Remember: Take account of readiness to change

So What Is Motivational Interviewing ?

It is a particular approach that can be adopted within a consultation to discuss health behaviour change It takes into account that not everybody is ready for changeIt uses specific communication skills

It avoids confrontation or ‘scare tactics’Effective when implemented as a ‘brief intervention’

The Spirit of MIAsk yourself these questions:

Am I genuinely interested in people?

Am I able to accept other people as they are or do I have a desire to direct or change them?

Am I willing to understand others?

From : www.hma.co.nz/Files/PI-The-spirit-of-Mot-Interview.pdf by Margaret Robinson

The Spirit of MIAsk yourself these questions:

How comfortable am I in letting go of being an expert?

How able am I to let go of solving other people’s problems?

How confident am I that patients have inner resources to change?

From : www.hma.co.nz/Files/PI-The-spirit-of-Mot-Interview.pdf by Margaret Robinson

References• Anstiss T (2009) Motivational interviewing in primary care. Journal of

Clinical Psychology in Medical Settings; 16: 87-93.• DiClemente CC & Velasquez MM (2002) Motivational Interviewing and

the Stages of Change In: Motivational Interviewing. Preparing People for Change. Miller WR & Rollnick S (eds). Guilford Press: New York.

• Hettema et al (2005) Motivational interviewing. Ann Rev Clin Psychol, 1, 91-111.

• Knight KM et al (2006) A systematic review of motivational interviewing in physical health settings. British Journal of Health Psychology; 11: 319-32.

• Lundahl et al (2010). A Meta-Analysis of MI: Twenty-five years of empirical studies. Research on Soc Work Practice, 20: 13.

References• Mason P, Butler C & Rollnick S (2010) Health Behavior Change. A guide

for practitioners. Churchill Livingstone/Elsevier: Edinburgh.• Miller WR & Rollnick S (2009). Ten things that Motivational Interviewing

is not. Behavioural & Cognitive Psychotherapy, 37, 129-140• Miller WR & Moyers TB (2006) Eight stages in learning motivational

interviewing. Journal of Teaching in the Addictions; 5: 1, 3-17.• Rubak et al (2005) Motivational Interviewing: a systematic review and

meta-analysis. Br J of Gen Pract, 55, 305-312.• Scott, G (2010) Motivational interviewing I: background, principles, and

application in healthcare. Nursing Times; 106:34, early online publication.

Acknowledgement: Thanks to Dr Lisa McNally and Pip Mason for materials