www.centerforebp.case.edu

Motivational Interviewing - the evidence behind making change

Patrick Boyle PhD, MSSA, LISW-S

Center For Evidence-Based PracticesA partnership between the Mandel School of Applied Social Sciences &

Department of Psychiatry at the School of Medicine

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Making change

•Consider how you presently go about helping people make changes?

•What challenges do you face in helping people make changes?

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Target behaviorsNearly ANY health related behaviors

Substance use and abuse Nutrition

Mood management –anger/anxiety/depression

Weight loss

Treatment retention Smoking

Medication adherence Healthy dental practices

Gambling Diabetes health regimen

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Our culture and context influences the change relationship!

What do WE bring to the relationship?

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YOUValues

Gender Identity

Family Norms

Faith System

TraumaPhysical Health

Mental HealthMood

Substance Use

AbuseAge

Tenure(or Ego)

Schooling

Expectations

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1. What we believe and perceive(Perceptions are about connections…)

2. How we think and feel

3. How we communicate and behave

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Our culture and context has the potential to

HELPand

LIMIT / COMPLICATEour work with others 10

People change voluntarily Only when they become… Become Interested and concerned about the

need for change

Become Convinced change is in best interest or will benefit them more than cost them

Organize plan of action that they are committedto implementing

Take the actions necessary to make and sustain the change

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Stages of Change

• A way of thinking about where people are in regard to a particular change

• Motivation for change is not constant

• People may return to an earlier stage of change – this is NORMAL

Prochaska, Norcross & DiClemente (1994)12

Stages of Change

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Maintenance

Action

Preparation (Determination)

Contemplation

Precontemplation

IntrospectionExerciseThink about a risky behavior you have tried to change at some point in your life.

1. What was your age at start of the behavior and how much time passed before the first time recognized a risk or negative consequence?

2. How much time passed before you noticed the risk or consequence of behavior and

3. How much time then till first time you made earnest attempt to change?

4. How much time till you made changes?

Who was most helpful in the process – Why?Who was least helpful in the process – Why?

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What Does MI Have To Do With Me?

1. Changes who does the talking2. Professional avoids doing all the work3. Includes effective tools for resistance4. Helps prepare consumers for change5. Changes what is talked about

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PrecontemplationIncrease awareness of need to change,

interest, and concern

ContemplationMotivate and increase confidence

in ability to change; risk/reward analysis

ActionImplement plan, reaffirm commitment

and follow-up

Termination

Stages of Change Model

RelapseAssist in Coping

MaintenanceEncourage active problem-solving; life-style changes

PreparationNegotiate a plan

Pro’s Con’s

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Stage of Change Characteristics -Issues

Strategies

Pre-contemplation “Nothing needs to change” • RELATIONSHIP• TRUST

Contemplation“On the Fence”

“I am considering change” • ACKNOWLEDGE MIXED FEELINGS

• DEVELOP DISCREPANCY

Preparation“Testing the Waters”

“I am figuring out HOW to change”

• BUILD CONFIDENCE• INFO, OPTIONS, ADVICE• CAREFUL - DON’T PUSH…

Action“Started Moving”

“I’m working on reaching my goals.”

• PLAN REACHABLE GOALS• MONITOR AND

ENCOURAGE

Maintenance“Holding Steady”

“I’ve changed, now to just keep it up.”

• SUPPORT CHANGE• RELAPSE PRE-PLAN

Relapse Prevention“Falling off the Wagon”“Revisiting the Past”

“I’ve gone back to old behaviors. Have I lost everything I worked for?”

• CAREFUL -AVOID SHAMING

• WHAT WENT WRONG?!• TRY AGAIN!!

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What is Motivational Interviewing (MI)?

A collaborative conversation style for strengthening a person’s own motivation and commitment to change.

"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."

(Miller and Rollnick, 2013)

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MI Studies by EraCurrently:

> 200 Randomized trials> 1000 Total publications

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Communication Styles with SkillsConceptual Framework

(Rollnick, et al, 2008)

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Chart1

DirectingDirectingDirecting

GuidingGuidingGuiding

FollowingFollowingFollowing

Skills

Styles

Informing

Asking

Listening

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10

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Sheet1

InformingAskingListening

Directing503010

Guiding303030

Following103050

To resize chart data range, drag lower right corner of range.

Resistance Ambivalence Motivation

Components of Change Overview

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What we perceive as the “problem” or the “issue”…

…they perceive as a solution to something difficult or painful.

If we try to eliminate what they see as a solution…..

…it is unlikely they will remain engaged.

The “Spirit” of MI: Elements

Collaboration

AcceptanceCompassion

Evocation

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COLLABORATION27

EVOCATION28

COMPASSION 29

Favorite teacher

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Common Obstacles & Solutions

to Engaging People

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7 Obstacles to Engagement

1. Question/Answer (interrogation)2. Being the Expert 3. Premature Focus4. Labeling5. Blaming/Shaming6. Arguing for/demanding Change7. Chat 32

Motivating = Dancing

Not Wrestling33

MI Guiding Principles

1. Express Empathy2. Develop Discrepancy3. Roll with Resistance4. Support Self-Efficacy

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Person-Centered Core Skills:Basic Skills

Utilize O.A.R.S.

• Open-ended questions • Affirm the person• Reflect feelings and change talk• Summarize topic areas related to

changing

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Elicit - Provide – Elicit(Ask – Inform – Ask)

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Elicit

•Ask permission•Clarify information needs

and gaps

•May I? •Would you like to know about...?•What do you know about...?•What would you like to know

about...?

Provide

•Prioritize•Be clear•Support autonomy•Don’t prescribe response

•Avoid jargon•Offer small amounts•Acknowledge freedom•Present w/o your meaning

Elicit•Ask for the client’s

interpretation, understanding or response.

•Ask open questions•Reflect reactions•Allow time to process

Acknowledge Choice

• Explicitly acknowledge the person has a choice

• It conveys respect and promotes the relationship

• Be sincere and genuine

• When offering suggestions – provide multiple options

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Finding a Common FocusStaff’s Hopes, Values, Goals

Goals

Values:

Hopes:

Shared Hopes, Values, Goals

Goal

Values (strengths)

Hopes

Client’s Hopes, Values, Goals

Goals

Values

Hopes

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Agenda Setting

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What influences Readiness?

Importance & Confidence

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Importance Ruler

On a scale of 0 – 10, how important is it for you to (manage your anger)?

1. Why are you at a ____ and not a zero?

2. What would it take for you to be at a ____ (one number higher)?

Confidence Ruler

On a scale of 0 – 10, how confident are you that you can (take care of your daily needs)?

1. Why are you at a ____ and not a zero?

2. What would it take for you to be at a _____ (one number higher)?42

Identifying Change & Sustain Talk

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Change Talk

Any language used by the person that leans in the direction of change

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Sustain Talk

Any language used by the person that leans in the direction of maintaining the status quo.

• Not wanting to change

• Needing to continue with a behavior

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Strategies to Elicit Change Talk

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Eliciting Change Talk - Strategies

• Pros/cons• Importance/Confidence Rulers• Looking back/looking forward• Asking for more information• Exploring goals and values

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Listening

Helps you gather important information

Communicates understanding (allows for a check of understanding)

Promotes the relationship48

Listening Skills

Refrain from distractionsLook at the personSilenceFacilitative responsesReflections

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Relationship is Critical

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Committing to a Change Process

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Signs of Readiness for Change

• Diminished resistance• Decreased discussion about the problem

or need for something to stay the same• Questions or language in favor of making

a change• Expressing (willingness, readiness,

intention, feeling more secure and safe about change)

• Taking small steps 52

HOMEWORK• Increase your self awareness

• Take notice of signs of Discord & Common Traps • Focus on Rolling with Resistance• Increased Engagement

• Share successes and less than perfect experiences with your team

• Next steps for you?

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www.centerforebp.case.edu

Patrick E. Boyle, PHD, MSSA, LISW-SConsulting Director

Center for Evidence-Based Practices (CEBP)Case Western Reserve University10900 Euclid AvenueCleveland, Ohio 44106-7164 216-368-0808 patrick.boyle@case.edu

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Motivational Interviewing �- the evidence behind making change ��Patrick Boyle PhD, MSSA, LISW-S��Slide Number 2Slide Number 3Slide Number 4Making changeTarget behaviors�Nearly ANY health related behaviorsOur culture and context influences �the change relationship!���What do WE bring to the relationship?�Slide Number 8Slide Number 9Slide Number 10People change voluntarily Stages of ChangeStages of ChangeIntrospection�Exercise�Think about a risky behavior you have tried to change at some point in your life. ��1. What was your age at start of the behavior and how much time passed before the first time recognized a risk or negative consequence?��2. How much time passed before you noticed the risk or consequence of behavior and ��3. How much time then till first time you made earnest attempt to change?��4. How much time till you made changes? ��Who was most helpful in the process – Why?�Who was least helpful in the process – Why?What Does MI �Have To Do With Me?Slide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20What is Motivational Interviewing (MI)?MI Studies by EraCommunication Styles with Skills�Conceptual FrameworkSlide Number 24Slide Number 25Slide Number 26COLLABORATIONEVOCATIONCOMPASSIONFavorite teacherCommon Obstacles �& Solutions �to Engaging People 7 Obstacles to Engagement�Motivating = Dancing MI Guiding PrinciplesPerson-Centered Core Skills:�Basic SkillsElicit - Provide – Elicit�(Ask – Inform – Ask) Acknowledge Choice Finding a Common FocusAgenda SettingWhat influences Readiness?Slide Number 41Slide Number 42Identifying �Change & Sustain Talk�Change TalkSustain TalkSlide Number 46Eliciting Change Talk - StrategiesListeningListening SkillsRelationship is CriticalSlide Number 51Signs of Readiness for ChangeHOMEWORKSlide Number 54