motivational interviewing - wsasp · 3/26/2015 4 10 motivational interviewing is a collaborative,...

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Motivational Interviewing An Introduction and Overview

Kevin M. King, Ph.D.

UNIVERSITY OF WASHINGTON

This presentation is intended to give a brief introduction to motivational interviewing (MI).

What is MI?

What MI is like: o What are the spirit and skills

of MI ?

Why don’t people change?

What do people say when they don’t want to make a change? Please respond in the chat

What do they sound like when they do want to change? Please respond in the chat

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Which is MOST effective in producing behavior change? Please respond to the poll

1. Giving someone reasons to change

2. Listening to someone’s thoughts about changing

3. Teaching someone ways to change

4. Providing some consequence for not changing

Exercise: Helping someone change

Think about something in your life that you’d like to change or have thought about changing, but haven’t started changing yet. Could be very small, like drinking less coffee, or getting on a regular

sleep schedule, etc.

Something that would be appropriate to share with your work colleagues.

I need one volunteer from the audience that has a microphone

Solutions to the problem

Group

1.

Individual

1.

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Confrontation and education don’t seem to change people’s minds.

…

Miller & Willborne, 2002

Data are from the “Mesa Grande” study, a review of 361 clinical trials for alcoholism

Origins of MI: Therapist empathy during Tx explained 25% - 66% of variance in outcomes

Drinker’s Checkup MET MI

Miller & Baca, 1983; Luborsky et al.; 1985; 1997; McLellan et al., 1988

Therapist style accounted for the lion’s share of client’s drinking at post-treatment, as well as 12 and 24 months later.

Therapist in-session behaviors influence client’s non-compliance

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Non-Compliant responses Per Minute

Non-Compliance

Patterson & Forgatch, 1986

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Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change.

It is designed to strengthen an individuals motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change.

William R. Miller, Ph.D. Advanced Motivational Interviewing Training New Mexico, November 4-5, 2010

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Motivational Interviewing helps resolve ambivalence.

And works best when…

1. There is a change target—a behavior that the client is at least considering changing.

2. The client is ambivalent about the change—they want to change, but something is preventing them from making that change.

MI works for a broad range of changeable behaviors.

Cardiovascular rehabilitation Diabetes management Dietary change Hypertension Illicit drug use Infection risk reduction Management of chronic mental disorders Problem drinking Problem gambling Smoking Concomitant mental and substance use disorders

(over 200 clinical trials to date!)

Hettema, Steele & Miller, 2005

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MI has been extensively studied for a broad range of behaviors in children and adolescents

Apodaca, T.R., Abrantes, A.M., Strong, D.R., Ramsey, S.E., & Brown, R.A. (2007). Readiness to change smoking behavior in adolescents with psychiatric disorders. Addictive Behaviors, 32, 1119-1130. Atkinson, C. & Woods, K. (2003). Motivational interviewing strategies for disaffected secondary school students: A case example. Educational Psychology in Practice, 19, 49-64. Brown, R. A., Ramsey, S. E., Strong, D. R., Myers, M. G., Kahler, C. W., Lejuez, C. W., Niaura, R., Pallonen, U.E., Kazura, A.N., Goldstein, M.G., & Abrams, D.B. (2003). Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders.

Tobacco Control, 12 (Suppl. 4), 3-10. Colby, S. M., Monti, P. M., Barnett, N.P., Rohsenow, D. J., Weissman, K., Spirito, A., Woolard, R.H., & Lewander, W.J. (1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study. Journal of Consulting and Clinical Psychology,

66, 574-578. Colby, S. M., Monti, P. M., & Tevyaw, T. O., Barnett, N.P., Spirito, A., Rohsenow, D.J., Rigg, S., & Lewander, W. (2005). Brief motivational intervention for adolescent smokers in medical settings. Addictive Behaviors, 30, 865-874. Erol, S., & Erdogan, S. (2008). Application of a stage based motivational interviewing approach to adolescent smoking cessation: The Transtheoretical Model-based study. Patient Education and Counseling, 72, 42-48. Gray, E., McCambridge, J., & Strang, J. (2005). The effectiveness of motivational interviewing delivered by youth workers in reducing drinking, cigarette and cannabis smoking among young people: Quasi-experimental pilot study. Alcohol and Alcoholism, 40, 535-539. Helstrom, A., Hutchinson, K., & Bryan, A. (2007). Motivational enhancement therapy for high-risk adolescent smokers. Addictive Behaviors, 32, 2404-2410. Hollis, J. F., Polen, M. R., Whitlock, E. P., Lichtenstein, E., Mullooly, J., Velicer, W. F., & Redding, C.A. (2005). Teen Reach: Outcomes from a randomized controlled trial of a tobacco reduction program for teens seen in primary medical care. Pediatrics, 115, 981-989. Horn, K., Dino, G., Hamilton, C., & Noerachmanto, N. (2007). Efficacy of an emergency department-based teenage smoking intervention. Preventing Chronic Disease, 4, 1-12. Kelly, A. B., & Lapworth, K. (2006). The HYP program: Targeted motivational interviewing for adolescent violations of school tobacco policy. Preventive Medicine, 43, 466-471. Lawendowski, L.A. (1998). A motivational intervention for adolescent smokers. Preventive Medicine, 27, A39-A46. MacPherson, L., Strong, D.R., Kahler, C.W., Abrantes, A.M., Ramsey, S.E., & Brown, R.A. (2007). Association of post-treatment smoking change with future smoking and cessation efforts among adolescents with psychiatric comorbidity. Nicotine & Tobacco Research.

9, 1297-307. McCambridge, J., & Strang, J. (2004). The efficacy of a single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risks and harm among young people: Results from a multi-site cluster randomized trial. Addiction, 99, 39-52. Norman, C.D., Maley, O., Li, X., & Skinner, H.A. (2008). Using the internet to assist smoking prevention and cessation in schools: A randomized, controlled trial. Health Psychology. 27, 799-810. Patten, C.A., Croghan, I.T., Meis, T.M., Decker, P.A., Pingree, S., Colligan, R.C., Dornelas, E.A., Offord, K.P., Boberg, E.W., Baumberger, R.K., Hurt, R.D., & Gustafson, D.H. (2008). Randomized clinical trial of an Internet-based versus brief office intervention for adolescent

smoking cessation. Patient Education and Counseling, 64, 249-258. Patten, C.A., Decker, P.A., Dornelas, E.A., Barbagallo, J., Rock, E., Offord, K.P., Hurt, R.D., & Pingree, S. (2008). Changes in readiness to quit and self-efficacy among adolescents receiving a brief office intervention for smoking cessation. Psychology Health & Medicine,

13, 326-36. Woodruff, S.I., Conway, T.L., Edwards, C.C., Elliott, S.P., & Crittenden, J. (2007). Evaluation of an internet virtual world chat room for adolescent smoking cessation. Addictive Behaviors, 32, 1769-1786. Woodruff, S.I., Edwards, C.C., Conway, T.L., & Elliot, S.P. (2001). Pilot test of an Internet virtual world chat room for rural teen smokers. Journal of Adolescent Health, 29, 239-243. Aubrey, L. (1998). Motivational interviewing with adolescents presenting for outpatient substance abuse treatment. Dissertation Abstracts International, 59, 1357 3-B. Baer, J. S., Beadnell, B., Garrett, S., Hartzler, B., Wells, E., & Peterson, P. L. (2008). Adolescent change language within a brief motivational intervention and substance use outcomes. Psychology of Addictive Behaviors, 22, 570-575. Baer, J. S., Garrett, S., Beadnell, B., Wells, E., & Peterson, P. L. (2007). Brief motivational intervention with homeless adolescents: Evaluating effects on substance use and service utilization. Psychology of Addictive Behaviors, 21, 582-586. Baer, J. S., & Peterson, P. L. (2002). Motivational interviewing with adolescents and young adults. In W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (2nd ed., 320-332). New York: Guilford Press. Baer, J. S., Peterson, P. L., & Wells, E. A. (2004). Rationale and design of a brief substance use intervention for homeless adolescents. Addiction Research and Theory, 12, 317-334. Berg-Smith, S.M., Stevens, V.J., Brown, K.M., Van Horn, L., Gernhofer, N., Peters, E., Greenbers, R., Snetselaar, L., Ahens, L., & Smith, K. (1999). A brief motivational intervention to improve dietary adherence in adolescents. Health Education: Research, Theory, and

Practice, 14, 399-410. Breslin C., Li, S., Sdao-Jarvie, K., Tupker, E., & Ittig-Deland, V. (2002). Brief treatment for young substance abusers: A pilot study in an addiction treatment setting. Psychology of Addictive Behaviors, 16, 10-16. Channon, S., Smith, V.J., & Gregory, J.W. (2003). A pilot study of motivational interviewing in adolescents with diabetes. Archives of Disease in Childhood, 88, 680-683. Channon, S., Huws-Thomas, M.V., Gregory, J.W. & Rollnick, S. (2005). Motivational interviewing with teenagers with diabetes. Clinical Child Psychology and Psychiatry, 10, 43-51 Channon, S.J., Huws-Thomas, M.V., Rollnick, S., Hood, K., Cannings-John, R.L., Rogers, C., Gregory, J.W. (2007). A multicenter randomized controlled trial of motivational interviewing with teenagers with diabetes. Diabetes Care, 30, 1390–1395. Cowley, C.B., Farley, T., & Beamis, K. (2002). “Well, maybe I’ll try the pill for just a few months.” Brief motivational and narrative-based interventions to encourage contraceptive use among adolescents at high risk for early childbearing. Families, systems, &

Health,20, 183-204. D'Amico, E. J., Miles, J. N. V., Stern, S. A., & Meredith, L. S. (2008). Brief motivational interviewing for teens at risk of substance use consequences: A randomized pilot study in a primary care clinic. Journal of Substance Abuse Treatment, 35, 53-61. Deas, D., Randall, C.L., & Roberts, J.S. (2000). Preventing HIV/AIDS: A brief intervention for adolescent substance abusers. Journal of Child and Adolescent Substance Abuse, 10, 23-32. Dennis, M., Godley, S.H., Diamond, G., Tims, F.M., Babor, T,. Donaldson, J., Liddle, H., Titus, J.C., Kaminer, Y., Webb, C., Hamilton, N., & Funk, R. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse

Treatment, 27, 197-213. Dunn, C., Droesch, R. M., Johnston, B. D., & Rivara, F. P. (2004). Motivational interviewing with injured adolescents in the emergency department: In-session predictors of change. Behavioural and Cognitive Psychotherapy, 32, 113-116. Erickson, S. J., Gerstle, M., & Feldstein, S. W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric settings: A review. Archives of Pediatrics & Adolescent Medicine, 159, 1173-1180. Feldstein, S. W., & Ginsburg, J. I. D. (2006). Motivational interviewing with dually diagnosed adolescents in juvenile justice settings. Brief Treatment and Crisis Intervention, 6, 218-233. Flattum, C., Friend, S., Neumark-Sztainer, D., & Story, M. (2009). Motivational interviewing as a component of a school-based obesity prevention program for adolescent girls. Journal of the American Dietetic Association, 109, 91-94. Greenwald, R.(2002). Motivation-Adaptive Skills-Trauma Resolution (MASTR) therapy for adolescents with conduct problems: An open trial. Journal of Aggression, Maltreatment and Trauma, 6, 237-261. Grenard, J. L., Ames, S. L., Pentz, M. A., & Sussman, S. (2006). Motivational interviewing with adolescents and young adults for drug-related problems. International Journal of Adolescent Medicine and Health, 18, 53-67. Grenard, J. L., Ames, S. L., Wiers, R. W., Thush, C., Stacy, A. W., & Sussman, S. (2007). Brief intervention for substance use among at-risk adolescents: A pilot study. Journal of Adolescent Health, 40, 188-191. Johnston, B.D., Rivara, F.P., Droesch, R.M., Dunn, C., & Copass, M.K. (2002). Behavior change counseling the in the emergency department to reduce injury risk: A randomized, controlled trial. Pediatrics, 110, 267-274. Knight, K.M., Bundy, C., Morris, R., Higgs, J.F., Jameson, R.A., Unsworth, P., & Jayson, D. (2003). The effects of group motivational interviewing and externalizing conversations for adolescents with Type-I diabetes. Psychology Health and Medicine, 8, 148-157. Knight, J. R., Sherrit, L., Van Hook, S., Gates, E. C., Levy, S., & Chang, G. (2005). Motivational interviewing for adolescent substance use: A pilot study. Journal of Adolescent Health, 37, 167-169. Levy, S., & Knight, J. R. (2008). Screening, brief intervention, and referral to treatment for adolescents. Journal of Addiction Medicine, 2, 215-221. Martin, G., Copeland, J., & Swift, W. (2005). The adolescent cannabis check-up: Feasibility of a brief intervention for young cannabis users. Journal of Substance Abuse Treatment, 29, 207-213. McCambridge, J, Slym, R.L., & Strang, J. (2008). Randomized controlled trial of motivational interviewing compared with drug information and advice for early intervention among young cannabis users. Addiction, 103, 1809-1818. Monti, P. M., Barnett, N. P., Colby, S. M., Gwaltney, C. J., Spirito, A., Rohsenow, D. J., & Woolard, R. (2007). Motivational interviewing versus feedback only in emergency care for young adult problem drinking. Addiction, 102, 1234-1243. Monti, P. M., Barnett, N. P., O'Leary, T. A., & Colby, S. M. (2001). Motivational enhancement for alcohol-involved adolescents. In P. M., Monti, S. M. Colby, & T. A. O'Leary (Eds.), Adolescents, alcohol, and substance abuse: Reaching teens through brief interventions (pp.

145-182). New York: Guilford Press. Monti, P. M., Colby, S., Barnett, N., Spirito, A., Rohsenow, D., Myers, M., et al. (1999). Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department. Journal of Consulting and Clinical Psychology, 67, 989-994. Naar-King, S., Wright, K., Parsons, J.T., Frey, M., Templin, T., Lam, P. & Murphy, D. (2006). Healthy choices: Motivational enhancement therapy for health risk behaviors in HIVpositive youth. AIDS Education and Prevention, 18, 1-11. Naar-King, S., Lam, P., Wang, B., Wright, K., Parsons, J.T. & Frey, M.A. (2008). Brief report: Maintenance of effects of motivational enhancement therapy to improve risk behaviors and HIV-related health in a randomized controlled trial of youth living with HIV. Journal of

Pediatric Psychology, 33, 441-445. Newbery, N., McCambridge, J., & Strang, J. (2007) ‘Let’s talk about drugs’: Pilot study of a community-level drug prevention intervention based on Motivational Interviewing principles. Health Education, 107, 276-289. Oliansky, D.M., Wildenhaus, K.J., Manlove, K., Arnold, T., & Schoener, E.R. (1997). Effectiveness of brief interventions in reducing substance use among at-risk primary care patients in three community-based clinics. Substance Abuse, 18, 95-103. Olson, A.L., Gaffney, C.A., Lee, P.W., Starr, P. (2008). Changing adolescent health behaviors: The healthy teens counseling approach. American Journal of Preventive Medicine, 35,S359-364. O'Leary Tevyaw, T., & Monti, P. M. (2004). Motivational enhancement and other brief interventions for adolescent substance abuse: Foundations, applications, and evaluations. Addiction, 99 (Suppl. 2), 63-75. Peterson, P. L., Baer, J. S., Wells, E. A., Ginzler, J. A., & Garrett, S. B. (2006). Short-term effects of a brief motivational intervention to reduce alcohol and drug use among homeless adolescents. Psychology of Addictive Behaviors, 20, 254-264. Resnicow, K., Davis, R., & Rollnick, S. (2006). Motivational interviewing for pediatric obesity: Conceptual issues and evidence review. Journal of the American Dietetic Association, 106, 2024-2033. Resnicow, K., Taylor, R., Baskin, M., & McCarty, F. (2005). Results of Go Girls: A weight control program for overweight African American adolescent females. Obesity Research, 13, 1739–1748. Schwarts, R.P., Hamre, R., Dietz, W.H., Wasserman, R.C., Slora, E.J., Myers, E.F., Sullivan, S., Rockett, H., Thoma, K.A., Dumitru, G., & Resnicow, K.A. (2007). Office based motivational interviewing to prevent childhood obesity: a feasibility study. Archives of Pediatrics &

Adolescent Medicine, 161, 495–501. Sindelar, H. A., Abrantes, A. M., Hart, C., Lewander, W., & Spirito, A. (2004). Motivational interviewing in pediatric practice. Current Problems in Pediatric Adolescent Health Care, 34, 322-339. Skaret, E., Weinstein, P., Kvale, G., & Raadal, M. (2003). An intervention program to reduce dental avoidance behaviour among adolescents: A pilot study. European Journal of Paediatric Dentistry, 4, 191–196. Slavert, J. D., Srtein, L. A. R., Klein, J. L., Colby, S. M., Barnett, N. P., & Monti, P. M. (2005). Piloting the family check-up with incarcerated adolescents and their parents. Psychological Services, 2, 123-132. Smith, D. C., & Hall, J. A. (2007). Strengths-oriented referrals for teens (SORT): Giving balanced feedback to teens and families. Health & Social Work, 32, 69-72. Smith, D. C., Hall, J. A., Jang, M., & Arndt, S. (2009). Therapist adherence to a motivationalinterviewing intervention improves treatment entry for substance-misusing adolescents with low problem perception. Journal of Studies on Alcohol and Drugs, 70, 101-105. Spirito, A., Monti, P. M., Barnett, N. P., Colby, S. M., Sindelar, H., Rohsenow, D. J., et al. (2004). A randomized clinical trial of a brief motivational intervention for alcoholpositive adolescents treated in an emergency department. Journal of Pediatrics, 145, 396- 402. Stein, L. A. R., Colby, S. M., Barnett, N. P., Monti, P. M., Golembeske, C., & Lebeau-Craven (2006). Effects of motivational interviewing for incarcerated adolescents on driving under the influence after release. American Journal of Addictions, 15 (Suppl. 1), 50-57. Stein, L. A. R., Colby, S. M., Barnett, N. P., Monti, P. M., Golembeske, C., Lebeau-Craven, R., & Miranda, R. (2006). Enhancing substance abuse treatment engagement in incarcerated adolescents. Psychological Services, 3, 25-34. Stern, S. A., Meredith, L. S., Gholson, J., Gore, P., & D'Amico, E. J. (2007). Project CHAT: A brief motivational substance abuse intervention for teens in primary care. Journal of Substance Abuse Treatment, 32, 153-165. Suarez, M., & Mullins, S. (2008). Motivational interviewing and pediatric health behavior interventions. Journal of Developmental & Behavioral Pediatrics, 29, 417-428. Tait, R. J., & Hulse, G. K. (2003). A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug. Drug and Alcohol Review, 22, 337- 346. Tober, G. (1991). Motivational interviewing with young people. In W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing: Preparing people to change addictive behavior (pp. 248-259). New York: Guilford Press. Vinner, R.M. Christie, D., Taylor, V., & Hey, S. (2003). Motivational/solution focused intervention improves HbA1c in adolescents with type 1 diabetes: A pilot study. Diabetes, 20, 739-742. Wagner, E., & Macgowan, M., (2006). School-based group treatment for adolescent substance abuse. In H. A. Liddle & C. L. Rowe (Eds.), Adolescent substance abuse: Research and clinical advances (pp.333-356). New York, NY: Cambridge University Press. Walker, D. D., Roffman, R. A., Stephens, R. S., Berghuis, J., & Kim, W. (2006). Motivational enhancement therapy for adolescent marijuana users: A preliminary randomized controlled trial. Journal of Consulting and Clinical Psychology, 74, 628-632. Werch, C.E., Carlson, J.M., Pappas, D.M., Edgemon, P., & DiClemente, C.C. (2002). Effects of a brief alcohol preventive intervention for youth attending school sports physical examinations. Substance Use and Misuse, 35, 421-432. Winters, K.C. & Leitten, W. (2007). Brief intervention for moderate drug abusing adolescents. Psychology of Addictive Behaviors, 21, 151-156. Winters, K.C. & Leitten, W. (2007). Use of brief intervention for drug abusing teenagers within a middle and high school setting. Journal of School Health, 77, 196-206.

MI works better in some unexpected situations.

Clients are ethnic minorities (!)

Procedures are NOT manualized (!) (doubles the effect!)

Change-language is elicited at the END of the session

(but NOT at the beginning!)

Amrhein et al, 2003; Hettema, Steele & Miller, 2005; Miller & Rose, 2009

MI works for a long period of time following intervention.

Hettema, Steele & Miller, 2005

Particularly when it’s added to another treatment!

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MI seems to work because people talk themselves into changing.

"People are generally better persuaded by the reasons which they have themselves discovered, than by those which have come in to the mind of others.” –Pascal (1623-1662)

MI is thought to work through increasing the client’s inherent commitment to change.

Miller & Rose, 2009; Amrhein et al., 2003

…and MI doesn’t work when therapists move towards planning change too early!

Use of MI Skills

Empathy and MI Spirit

Change talk Preparatory Language

Therapist

Commitment to Change

Behavior Change

Client

Persuasion Exercise

Choose one person near you to have a conversation with, and work together

Not with your boss or supervisor

One will be the speaker, the other will be a counselor

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Speaker’s Topic

Something about yourself that you

want to change

need to change

should change

have been thinking about changing but you haven’t changed yet

*and not too personal! (No over-sharing. This isn’t Oprah!)

in other words – something you’re ambivalent about

Counselor: Find out what change the person is considering making, and then:

Explain why the person should make this change

Give at least three specific benefits that would result from making the change

Tell the person how they could make the change

Emphasize how important it is to change

Persuade the person to do it.

If you meet resistance, repeat the above.

P.S. This is NOT motivational interviewing

Counselor: Now, let’s switch roles and try something different. Just ask questions:

Ask the why the person should make this change

Ask what might be some specific benefits that would result from

making the change

Ask how they could make the change if they wanted to

Ask on a scale of 0-10, how important it is for them to make the

change

“How come you’re at ________ and not lower?

P.S. This is more like motivational interviewing

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Continuum of Styles

Directing -------- Guiding -------- Following

Authoritarian -------- MI -------- Rogerian

MI skills without spirit is like trying to drive a car without gas.

Collaborative working with and sharing power - “You, the client, might be right...”

Evocative Rather than insert knowledge, draw it forth from the client - “You have knowledge, wisdom, expertise, and my job is to get that out...”

Respectful of autonomy The client retains the right not to change and the right to change the way they want, even if that isn’t what we want.

MI Approach Opposite Approach

Collaborative -partnership honors client expertise and perspective

Evocative -motivation for change resides within the client, draw that out

Autonomy -counselor affirms the client’s right and capacity for self-direction and choice

Confrontation -overriding the client’s impaired perspective

Education -counselor provides requisite enlightenment

Authority -telling the client what to do

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Recognizing the Spirit of Motivational Interviewing

I’m going to read short client statements and practitioner responses

Is it in the spirit of MI or not?

Why?

Spirit: Collaboration, Evocation, Autonomy

Sarah’s husband (Richard): I’m just furious that she lied to me and had this affair behind my back. I can’t believe I didn’t see it. I feel like such an idiot.

Practitioner: In retrospect what signs did you overlook?


Why?


Arthur: “I know that the teachers are complaining about my daughter’s behavior in class, but that teacher has it out for her and is treating her unfairly!”

Practitioner: “That teacher seems to be worrying needlessly; what do you think she’s seeing that makes her worry this way?”


Why?

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Tanya: “I need to come up with some sort of plan to help me get my kids back on track with school now. This latest crisis has thrown us all for a loop. I can’t think about anything else. What do you think I should do?

Practitioner: “Well, I have some ideas about what might help, but first let’s hear what you’ve already considered.”


Why?


Arthur: “I’m not going to follow through with this stupid homework plan. It’s not going to work for us, I have to work two jobs, and I don’t have anyone else to help me, and it’s just too much to ask us to do.”

Practitioner: Ok, Arthur, you might be right. This works for many folks, but not everyone. Maybe we need to try a different way to approach this. We’ve talked about other ways to approach this issue. What makes sense to you to practice instead?”


Why?


Esi: “The school says that my kids are behind grade level in their reading scores, and want them to meet with a specialist. But I don’t trust them, so I haven’t scheduled it yet.”

Practitioner: “Why take the chance? They’re the experts, after all. Let’s call from this phone right now – maybe you can get in this week.”


Why?

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Sarah (Richard’s wife): “I’ve had it with Richard’s guilt mongering. Okay, so I had an affair. I’m ready to end it and start working on our marriage, but I don’t think he’s ever going to let me forget it. Maybe we should just get a divorce.”

Practitioner: “Sarah, you are the only one who can decide if you should stay in this marriage or leave it. I wonder what signs you would need to feel more optimistic about working on things with Richard.”


Why?


Peggy: “They had a little “surprise party” for me. Everyone showed up when I wasn’t looking and then spent the next 2 hours telling me how my drinking hurt them. They think I’m an alcoholic! I might have a drinking problem, but I’m damn sure not an alcoholic.”

Practitioner: “(gently) Peggy, if it walks like a duck and quacks like a duck, it’s probably a duck. I think if all those people are telling you you’re an alcoholic, they’re probably right. You might be in denial, don’t you think?”


Why?


Tanya: “My doctor gave me a long list of all the things I have to do to manage my care. It’s overwhelming; I have to take medication three times a day. I can’t even remember to feed my dog every single day. I just can’t do it. But I’m afraid I’ll die if I don’t.”

Practitioner: “(encouraging) You can do this. You have to.”


Why?

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What does MI look like? 5:22-11:31

The initial phase of MI is client centered.

Open Ended questions

Open-ended questions

How does smoking fit with your role as lead singer in the chorus?

How does smoking fit with your dreams of becoming a pro basketball player?

How do you feel about smoking?

Closed-ended questions

How many cigarettes did you smoke today?

Did you take your medication?

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Affirmations

Coming in every week for treatment is really tough. You are handling a difficult treatment protocol really well.

I’m impressed with how mature you are.

Absolutely! It is really tough to do all that you need to do when you’re not feeling well. And sticking to your diet makes it easier for you to do your chores, complete your homework, and hang out with your friends.

Reflective listening

You’re tired of being different from the other kids.

It is embarrassing not being able to eat the same things as your friends.

You have already done this for 10 years; having to stick with this diet for longer doesn’t seem fair.

Summary Statements

It’s important for you to fit in with your friends.

Sometimes adhering to your chest physiotherapy

regimen makes that tough. On the other hand, when

you don’t adhere to your therapy, you notice that you

don’t feel as well. And when you don’t feel as well, it’s

even harder for you to keep up with the energy of

your friends. Is there anything that you want to add that I may have missed?

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Hypothesis Testing and Reflecting

Reflections are really a hypothesis – a guess about what someone means with their words

What is empathy?

Empathy is accurately understanding a client’s meaning and being able to reflect it

Empathy is NOT identification, shared experience or storytelling

How might identification, shared experiences or storytelling work against you in a session? Please respond in the chat

Hypothesis Testing and Reflecting, Demonstration

Kevin. Share a quality about yourself.

“I’m an organized person.”

Audience. Make a hypothesis, “Do you mean_______?”

“Do you mean that you like to have things orderly?”

“Do you mean that you tend to rely on routines?”

“Do you mean that your desk is neat?”

“Do you mean that you think logically?”

Please respond in the chat

Kevin. Each time B. guesses, answer with “Yes” or “No”

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A reflection, however, is a guess that isn’t a question – it’s a statement. The inflection turns down at the end, not up.

A hypothesis can be a question, “You’re getting a divorce?”

Or a reflection, “You’re getting a divorce.”


A reflection, however, is a guess that isn’t a question – it’s a statement. The inflection turns down at the end, not up.

Person A. “I’m an organized person.”

Person B.

“You mean that like to have things orderly.”

“You mean that you tend to rely on routines.”

“Your desk is neat.”

“You think logically.”


Reflections often drop the “You mean that…” and just go for guessing.

“You mean that you like to laugh.”

“You mean that you find humor in everyday life.”

“You mean that you don’t take yourself too seriously.”

“You mean that humor helps you lighten the load.”

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Hypothesis Testing and Reflecting II (for Pairs, or live demo with volunteer)

Person A. Share a quality about yourself.

“I love to garden.”

Person B. Reflect, “You mean that________.” (or: “You ________.”)

“You like to make things grow.”

Person A. Each time B. guesses, respond naturally but briefly: “Yes, I love to have fresh tomatoes in the summer” OR “No, I like to be outside in the sunshine in the summer”

Person C. Reflect (to whatever Person A JUST said),

“You mean that ______.” or “You _______.”

Twelve Roadblocks to Listening (Thomas Gordon, Ph.D.)

1. Ordering, directing, or commanding

2. Warning or threatening

3. Giving advice, making suggestions, or providing solutions

4. Persuading with logic, arguing, or lecturing

5. Moralizing, preaching, or telling clients what they "should" do

6. Disagreeing, judging, criticizing, or blaming

7. Agreeing, approving, or praising

8. Shaming, ridiculing, or labeling

9. Interpreting or analyzing

10. Reassuring, sympathizing, or consoling

11. Questioning or probing

12. Withdrawing, distracting, humoring, or changing the subject

What do you get out of reflections?

Communicate understanding

Invite for greater elaboration

Avoid interrogation, and invite collaboration

Reflections are great for responding to conflict and discord

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Reflections can range from simple to complex.

Simple reflections: restate something about what was said “Do you means?”

Complex reflections: move beyond the client’s words to present information in a new light

These reflections are hypotheses about their experiences. Sometimes wrong, but always useful!

Client: “I know I could do some things differently, but if she would just back off, then the situation would be less tense; then these things wouldn’t happen.”

Feelings “You’re upset about this situation.”

Meaning “You’d like things to be different.”

Two sided “She played a part in what happened, and you know there are parts

you might want to do differently too.”

Client: “I know I could do some things differently, but if she would just back off, then the situation would be less tense; then these things wouldn’t happen.”

Amplification “This situation is beginning to feel impossible to you.”

Metaphor or analogies “It’s like having a monkey on your back, always feeling bothered.”

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Exercise to try at home: Levels of Complex Reflection

At least 2 people, preferably more

Person #1:

“Something I feel two ways about is…”

Persons #2 and beyond

#2. Reflect feelings

#3. Reflect meaning

#4. Reflect two sides of the ambivalence

#5. Amplify with a reflection

#6. Use a metaphor or analogy

Exercise to try at home: Practicing extended reflections

Groups of 3

Speaker, Listener, Observer

Realplay: pick from sample topics What it was like growing up in my home

Ways in which I have changed as a person over the years

Good/not-so-good things about my high school years

What I hope and plan to do over the next ten years

Describe one of your parents, or someone close to you

How I came to do the kind of work I am doing

Exercise to try at home: Practicing extended reflections

Speaker: Choose a topic

Listener: Reflect, reflect, reflect, (occasionally, say “Tell me a little bit more about that”)

Try to vary levels of reflection.

See if conversation develops without advice, or direct problem solving. (evoke only!)

Observer gives feedback, then rotate.

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Summaries are a special form of reflections

Collect material that has been offered So far you’ve expressed concern about your children, getting a job,

and finding a safer place to live.

Link something just said with something discussed earlier. That sounds a bit like what you told me about that lonely feeling

you get

Draw together what has happened and transition to a new task Before I ask you the questions I mentioned earlier, let me

summarize what you’ve told me so far, and see if I’ve missed anything important. You came in because you were feeling really sick, and it scared you . . . . . . . . .

Exercise to try at home: Summaries

Groups of 3

Speaker, Listener, Observer

Speaker: “Something I feel two ways about is_____”

Listener 1: Reflect, reflect, reflect, question, reflect, summarize…

Same routine, observer gives feedback, rotate

15 minute break

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Handling change and sustain talk

The RIGHTING Reflex

1. This person OUGHT to (or should WANT to) change.

2. Now is the right (only?) time to change.

3. It is my job to tell people what to do.

4. A tough/clear/directive approach is best.

5. I’m the expert, so he/she should follow my advice.

6. If the person decides not to change, the consultation has failed.

The “Righting”

Reflex Ambivalence

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Feeling two ways about a thing

Common prior to habit change. Common during habit change.

A communication trap! – Argue one side, person defends the other

Social-Psychological Model of Attitude Change/Persuasion (D. Bem): individuals must articulate reasons and intentions for change

Meta-analysis of intentions interventions show that medium-to-large changes in intentions (d = .66) lead to small to medium changes in behavior (d = .36) (Webb & Sheeran, 2006)

Defense of status quo makes change less likely

Ambivalence

"Lack of motivation" is often ambivalence: Both sides are already within the person

If you argue for one side, an ambivalent person is likely to defend the other

As a person defends the status quo, the likelihood of change decreases

Resist the "righting reflex" - to take up the "good" side of the ambivalence

Tenets of MI: Ambivalence

Is to

Appreciate Ambivalence

Spirit of MI:

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Appreciate Ambivalence

Status Quo Change

BENEFITS

OF:

COSTS OF:

Appreciate Ambivalence: Drinking

Status Quo Change

BENEFITS

OF:

Taste

Relaxes me

Fit in

Healthier Save money

Happier marriage

COSTS OF: Poor sleep

Calories

Spouse complains

Mornings sick

New friends

Uncomfortable

socially

Lost enjoyment

(loss)

So what do people sound like when they are ready to make a change?

Please respond in the chat

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Change Talk

Staying the

same:

Changing:

BENEFITS

OF: Life could be better

COSTS OF: I have problems

Sustain Talk STAYING THE

SAME:

CHANGING:

BENEFITS

OF: I like my life

COSTS OF: Your plan

stinks!!

The second phase of MI develops discrepancy: between present and desired state.

Desire: “I want to change” Ability: “I can change” Reasons: “I should change” Need: “I need to change” Commitment (plans, intentions)

Activation (willing, ready, preparing)

Taking steps (actions)

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1. Recognizing

2. Responding

3. Eliciting

Key Skills for Working with Change Talk

Exercise – recognizing for change

Wait for the statement

Choose the correct option in the poll

That’s it!

Change Target: Improved Glycemic Control Component behaviors: Diet, Exercise, Medication, Monitoring, Stress management

1. I think I’m doing about as well as I can at this point.

2. I certainly don’t want to go blind. (R)

3. I’ve just always disliked exercise.

4. I really hate pricking my finger!

5. Well, I wouldn’t mind cutting down on stress in my life. (D)

6. I probably could exercise more. (A)

7. Yes, I’m going to take my medication every day. (C*)

8. It’s really hard to stay on a strict diet.

9. But I love chocolate!

10. I used to exercise regularly.

11. I’ve got to get my blood sugar under control! (N)

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12. I’m going to get my blood sugar under control. (C*)

13. I’m willing to take oral medication, but I don’t want to take insulin shots. (C*)

14. There’s no way I want to take insulin.

15. I would like to lose some weight. (D)

16. I don’t think I really have diabetes.

17. I wouldn’t mind checking my blood sugar once or twice a day. (D?)

18. I don’t like watching what I eat. I mean I guess I have to, but I don’t like feeling restricted. (N)

19. I wish I could have less stress in my life. (D)

20. I might be able to cut down on sweets. (A)


21. I’m not much on eating vegetables. I guess I’ll eat more of them, but I don’t enjoy them. (C*)

22. It’s pretty scary thinking about losing my feet. (R) 23. I’ll think about eating more fruit. (C*) 24. I heard that taking chromium can help with blood sugar levels. 25. I hope to take off about twenty pounds. (C*) 26. I certainly don’t want to wind up on dialysis. (R) 27. I started keeping track of what I ate this week. (TS) 28. I bought a glucose monitor and read the manual. (TS) 29. What kinds of things do I have to eat? 30. There’s no way I’m joining a gym. 31. I don’t mind walking, but I’m not going to a gym. (D*) 32. I want to be a better parent.

We can fish for change talk with some specific strategies, but only at the right time!

Ask Evocative Questions Why would you want to make this change? (Desire) How might you go about it, in order to succeed? (Ability) What are the three best reasons for you to do it? (Reasons) How important is it for you to make this change? (Need) So what do you think you’ll do? (Commitment)

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Query Extremes What’s the worst thing that might happen if you don’t change? What’s the best thing that might happen if you do?


Look Back Ask about a time before the problem emerged. How were things different? Look Forward How would you like your life to be in 5 years? If you were 100% successful in making the changes, what would be different? Explore Goals and Values What do you want in life? How does XX behavior fit in with that? Does it help it, hurt it, or is it irrelevant?

Change talk is selectively reinforced using client-centered techniques, while sustain talk is not.

•Elaborate •Affirmations •Reflections •Summaries

•When we hear change talk, we draw for more through:

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“When you hear change talk, don’t just stand there!”

Elaboration: When was the last time? in what ways? Ask for more: What else? What other reasons?

Affirm change talk: reinforce, encourage, support it

Reflect it: Restate it back to the person

Summarize: - "Collecting flowers into a bouquet"

Responding to Change Talk: EAR

A 16 year old boy comes into your office after being referred by his PCP because of his weight. He had been a wrestler until he tore his ACL, and since then he stopped exercising but continued to eat as if he were still wrestling. He has gained enough weight that his BMI is now in the obese range. He also is suffering from depression, and he seems to binge eat more when his mood is bad. His parents are very concerned about how rapidly he’s gained weight, and although he seems to be concerned he feels hopeless.

Recognizing and Responding to Change Talk

Write out your answers at home. I will ask for responses in the chat in 1 minute

1. Change talk? yes/no

2. If yes, what type? (DARNCAT)

3. If yes, provide a reflective response that would reinforce change talk:

4. If no, write an evocative question that might elicit change talk:

C: “When I tore my ACL, I thought I’d be back on the mat and wrestling really quickly. But it’s been two years and I’m just not sure I’m really interested in it anymore. Besides, my knee still bothers me sometimes, and my parents are always on my back about eating even though I know how to take care of myself.”

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C: (client continues) I know what you’re going to say. I have to eat right and exercise. But don’t you understand how hard that is with a bad knee? I don’t think the doctors fixed it right, and because I stopped wrestling I’m hardly friends with my teammates anymore. I’m just a lot happier when I don’t have to worry all the time about whether I’m eating the right thing or not.






C: I really hate feeling so gross and out of shape. I have to do something about this or else I’m going to end up fat for the rest of my life. But my PT said I should avoid running on my bad knee, because that’s what got me here in the first place, and besides, I tried doing that and starting getting shin-splints because I’m so heavy. It just feels like an impossible goal, to lose all this weight.






C: It’s frustrating, because I even know how to work out and eat well; you don’t get good at wrestling without knowing how to take care of your body. I really want to start getting my body back, I’m not just not sure if I can do it.






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Dissonance, Sustain Talk and Discord

What do people say when they don’t want to make a change?

Sustain Talk STAYING THE

SAME:

CHANGING:

BENEFITS

OF: I like my life

COSTS OF: Your plan

stinks!!

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88

Confrontation

Confrontation is a goal, not a method of intervention

Confrontation is helping someone come face to face with their reality, helping them see something scary

What is the best way to do that?

I really like marijuana (D)

I don’t see how I could give up pot (A)

I have to smoke to be creative (R)

I don’t think I need to quit (N)

I intend to keep smoking and nobody (C)

can stop me

I’m not ready to quit (A)

I went back to smoking this week (T)

Examples of Sustain Talk The other side of ambivalence

90

Thinking about dissonance

“Resistance” is dissonance – a difference between you and the client. It’s basically information. The client is telling you something:

“I’m afraid I’ll hear something I don’t want to hear.”

“You’re not listening to me!”

“You’re not keeping up with me!”

“There’s something you don’t know.”

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91

Dissonance is information about a relationship or interaction

An interpersonal behavior - a reaction to an intervention, not a characteristic or quality of the client.

What is the most common reason for dissonance?

Let’s experiment: Take 30 seconds to decide how you will change…

The natural reaction to coercion is defense.

You take the pro side of changing a behavior, the client will take the con side.

From this perspective, denial is also an interaction.

Sustain Talk is about the target behavior I really don’t want to stop smoking

I have to have my pills to make it through the day

Discord 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

Dissonance: Sustain Talk and Discord

Behavior

Interpersonal (It takes two to have discord)

A signal of dissonance in your relationship

Predictive of (non)change

Should be a SIGNAL …. To remedy relationship….

To change strategies…

What is Discord?

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Defensiveness

Arguing Challenging, Discounting, Hostility

Interrupting Talking over the counselor

Ignoring Inattention ,Changing the subject

Some Discord Signals

Recognizing

Responding

Key Skills for working with Sustain Talk and Discord

Already in skills repertoire

Sustain Talk Acknowledge, honor -- reflect

Generally do not explore – no open questions

Discord Reduce “heat”

Get off the hot seat (reflect, change subject)

Revisit engagement

Responding to Sustain Talk and Discord

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Reflective

Simple Reflection

Amplified Reflection

Double-sided Reflection

Strategic

Shifting Focus

Emphasizing Personal Choice

Reexamine agenda

Responses to Zingers (sustain talk and discord)

Responding to the zinger

I don’t smoke pot every day

You’re paying attention and not smoking daily

Good News? You’re trying to smoke safely

Responding to the Zinger

You keep alcohol and cars away from each other

Well, I never drink and drive

Good News?: You don’t want to endanger others

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You don’t like being labeled.

I’m do not have an eating disorder

Good News?: You’re a good person (boyfriend/girlfriend, son/daughter, student, athlete)


You sure are tired of everyone being in your business ……….

I’m sick of you and all these people telling me what to do…

I appreciate you telling me how you feel. Ultimately its up to you….


This does not make sense to you.

I didn’t do anything wrong!…

You know right from wrong….

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You’re feeling a lot of pressure

I just wish you and all these people would leave me alone…

Good News:? If left to yourself you can solve lots of things.

104

Ways to Dance with Dissonance

Simple reflection

Double-sided reflection

Emphasize the client as decision maker

There are more ways too – but we’ll start here

105


Client: “Why do I have to be here? I know things aren’t perfect, but I am doing better. There have been no incidents with my kids, so why do you still make me come?”

Simple reflection

“You’re ready to be done.”

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106



Double sided reflection

“Things are better, and maybe there are still a few troublesome spots.”

107



Emphasize the client as the decision maker

“It feels like I’m making you come here, rather than your own choice. There’s more we could work on, but really you’re the one who decides about whether it’s worth the hassle of coming. It really is your call.”

Other applications: Providing Information

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Something you can take away: how to give information in an MI consistent way

Information with permission Would you like to know some things that other patients in your

situation have done?

Offer choices

Talk about what others do Some patients really enjoy going for a walk in the morning. What do

you think you might be able or willing to try?

Two strategies for informing

Chunk – Check – Chunk Provide info – What questions do you have/Does that make sense to

you? – Next info

Danger of moving into a directing style!

Elicit - Provide – Elicit What do you already know about/What would you like to know

about?

Provide information

What do you think about that/What do you make of that/What more would you like to know?

How to learn MI effectively

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Learning MI takes time, training and practice with feedback.

1. Getting the spirit of MI

2. Using client-centered skills (OARS)

3. Recognizing change talk

4. Eliciting and reinforcing change talk

5. Rolling with resistance

6. Developing a change plan

7. Consolidating client commitment

8. Integrating MI with other intervention methods

Miller & Moyers, 2008

MI is often confused with a lot of other things. Indeed, MI is NOT:

1. Based on the transtheoretical model

2. A way of tricking people into doing what they don’t want to do

3. A technique.

4. A decisional balance

5. Requiring assessment feedback

6. A form of cognitive-behavior therapy

7. Just client-centered counseling

8. Easy

9. What you were already doing

10. Not a panacea

Miller & Rollnick, 2009

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Resources

William R. Miller Ph.D. and Stephen Rollnick Ph.D. Motivational Interviewing 3rd Edition: Helping People Change. Guilford Press. New York: 2013.

David Rosengren. Building Motivational Interviewing Skills: A Practitioner Workbook. Guilford Press. New York: 2009.

Video: 1998 Motivational Interviewing Professional Training DVD Series. casaa.unm.edu/download/mitrain98.pdf

Motivational interviewing website: www.motivationalinterview.org

http://www.motivationalinterview.org

motivational interviewing - wsasp · 3/26/2015 4 10 motivational interviewing is a collaborative,...

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