The use of Motivational The use of Motivational Interviewing To Help Interviewing To Help People Create Healthy, People Create Healthy,

Lasting ChangeLasting Change

Betty Hanna, MFT, MINTBetty Hanna, MFT, MINT

California ConsultingCalifornia Consulting

Listening for Listening for EngagementEngagement

Engagement: Learning about Engagement: Learning about someone newsomeone new

In pairs: 3 minutes eachIn pairs: 3 minutes each

1.1.What are the challenges of our What are the challenges of our work?work?

2.2.Why did you come? What is your Why did you come? What is your interest here today? Hopes and interest here today? Hopes and fears.fears.

3.3.One thing you don’t know about meOne thing you don’t know about me

4.4.Where do you hope to be in 5 years?Where do you hope to be in 5 years?

Share with a colleagueShare with a colleague Introduce yourself – have a natural conversationIntroduce yourself – have a natural conversation Share your answers with each other/ Make sure Share your answers with each other/ Make sure

both get to SHARE...both get to SHARE... Really listen – Do most of the listening not the Really listen – Do most of the listening not the

talking “be with”talking “be with” Bonus: Take a moment. See if you can listen Bonus: Take a moment. See if you can listen

“beyond” or underneath their content. When you “beyond” or underneath their content. When you tune in to that what do you know about this tune in to that what do you know about this person? What is important to them? What do they person? What is important to them? What do they enjoy? What do they value? What makes them enjoy? What do they value? What makes them happy? What are they feeling? See if you can happy? What are they feeling? See if you can listen with your heart.listen with your heart.

Now.....Now.....

30 Seconds. Summarize, then30 Seconds. Summarize, thenShare your bonus with each otherShare your bonus with each otherUse direct language:Use direct language:

You...........You...........Hit your targetHit your target

Agreements for the Agreements for the SessionSession

Collaborative Collaborative Ask lots of questions – let us know what Ask lots of questions – let us know what

you thinkyou think Be mindful of each other – be kindBe mindful of each other – be kind Enjoy, Have fun!!Enjoy, Have fun!! Attitude:Attitude:What the Heck !!” Jump into the experience..

Make Mistakes, “OOPS!”

Confidentiality, make the training your experience Resist the Fixing Impulse

The Learning ExperienceThe Learning Experience

At the end of a foundational motivational interviewing class, you At the end of a foundational motivational interviewing class, you should be able to:should be able to:

* demonstrate more effective communication toolsmore effective communication tools that will improve the helper/probationer-personal relationship and create improve the helper/probationer-personal relationship and create relationships that fosters “real work” of changerelationships that fosters “real work” of change

* improve quantity and quality of a person’s change-talkimprove quantity and quality of a person’s change-talk through improved reflections of strengths, values, andimproved reflections of strengths, values, and

feeling and by asking key questions. feeling and by asking key questions. Meet them where they Meet them where they dream........dream........

* increase the probabilityincrease the probability the persons will initiate and the persons will initiate and maintain maintain LONG-TERM changeLONG-TERM change through increasedincreased

change-talk.change-talk.

6

The Problem

Determinants of HealthDeterminants of HealthSource: U.S. Centers for Disease Control and PreventionSource: U.S. Centers for Disease Control and Prevention

10

20 20

50

0

10

20

30

40

50

60

Access to Care Genetics Environment Behavior

Per

cent

Actual Causes of DeathActual Causes of Death Source: U.S. Centers for Disease Control and PreventionSource: U.S. Centers for Disease Control and Prevention

0 5 10 15 20 25

Illicit Drugs

Motor Vehicles

Sexual Behavior

Firearms

Pollution/Toxins

Infections

Alcohol

Diet/Exercise

Smoking

Percent

You would think . . . You would think . . .

that having had a heart attack would that having had a heart attack would be enough to persuade a man to quit be enough to persuade a man to quit smoking, change his diet, exercise smoking, change his diet, exercise more, and take his medicationmore, and take his medication

that hangovers, damaged that hangovers, damaged relationships, an auto crash, and relationships, an auto crash, and memory blackouts would be enough memory blackouts would be enough to convince a woman to stop drinkingto convince a woman to stop drinking

You would think . . . You would think . . .

that having had a heart attack would that having had a heart attack would be enough to persuade a man to quit be enough to persuade a man to quit smoking, change his diet, exercise smoking, change his diet, exercise more, and take his medicationmore, and take his medication

that hangovers, damaged that hangovers, damaged relationships, an auto crash, and relationships, an auto crash, and memory blackouts would be enough memory blackouts would be enough to convince a woman to stop drinkingto convince a woman to stop drinking

You would think . . . You would think . . .

that the very real threats of blindness, that the very real threats of blindness, amputations and kidney failure from amputations and kidney failure from diabetes would be enough to motivate diabetes would be enough to motivate weight loss and glycemic controlweight loss and glycemic control

that time spent in prison would that time spent in prison would dissuade people from re-offendingdissuade people from re-offending

Any time, 80% in ambivalence, 20% in action – The language of crisis

The language of chronicity

AmbivalenceAmbivalence

It is a very normal human condition It is a very normal human condition simultaneously to want and not want simultaneously to want and not want changechange

It is normal to get stuck in It is normal to get stuck in ambivalence, sometimes for a long timeambivalence, sometimes for a long time

Compliance is the highest form of Compliance is the highest form of resistanceresistance

How should we respond as helping How should we respond as helping professionals?professionals?

MIMI Growth and Development – Moving into Growth and Development – Moving into

more depth and complexity in MI threemore depth and complexity in MI three 1981 Bill Miller changed the way 1981 Bill Miller changed the way

treatment was thought about and treatment was thought about and delivered.delivered.

Just planning – Just telling people what to do. How many Just planning – Just telling people what to do. How many drinks do you have,? Well you drink this much so that is drinks do you have,? Well you drink this much so that is affecting your life this way, You need to stop doing that, it affecting your life this way, You need to stop doing that, it is bad for you.......Do this instead........I’ll give you this is bad for you.......Do this instead........I’ll give you this service that will help you and convince you more. Helping service that will help you and convince you more. Helping professional seen as the “Authority and “Expert” – professional seen as the “Authority and “Expert” – Behavior has consequences.Behavior has consequences.

MI DefinitionMI Definition

Motivational interviewing is a Motivational interviewing is a collaborative, goal-oriented method of collaborative, goal-oriented method of communication with particular communication with particular attention to the language of change. attention to the language of change. It is designed to strengthen an It is designed to strengthen an individual’s motivation for and individual’s motivation for and movement toward a specific goal by movement toward a specific goal by eliciting and exploring the person’s eliciting and exploring the person’s own arguments for changeown arguments for change““Being compassionate and directional Being compassionate and directional will inspire people to do things you will inspire people to do things you cant even image that they can do” cant even image that they can do” S. S. AndrewAndrew

Three Essential Elements Three Essential Elements in any Definition of MIin any Definition of MI

1.1. MI is a MI is a particular kind of particular kind of conversation about change conversation about change (counseling, therapy, (counseling, therapy, consultation, method of consultation, method of communication)communication)

2.2. MI is MI is collaborative collaborative (person-(person-centered, partnership, honors centered, partnership, honors autonomy, not expert-recipient)autonomy, not expert-recipient)

3.3. MI is MI is evocativeevocative, seeks to call forth , seeks to call forth the person’s own motivation and the person’s own motivation and commitmentcommitment

After 30 years of After 30 years of research MI is a research MI is a method that is:method that is:

Evidence-based >180 clinical trialsEvidence-based >180 clinical trials Relatively briefRelatively brief Specifiable (but be careful with manuals)Specifiable (but be careful with manuals) Grounded in testable theoryGrounded in testable theory With specifiable mechanisms of actionWith specifiable mechanisms of action Generalizable across problem areasGeneralizable across problem areas Complementary to other treatment Complementary to other treatment

methodsmethods Learnable by a broad range of providersLearnable by a broad range of providers Verifiable – Is it being delivered properly?Verifiable – Is it being delivered properly?

Motivational Motivational Interviewing (MI)Interviewing (MI)

The goals of MI: The goals of MI: Establish rapport, Establish rapport, Elicit change talk, Elicit change talk, Establish commitment language that motivates Establish commitment language that motivates

the change.the change.

Individuals approach changes in their lives at Individuals approach changes in their lives at different levels of readiness. People move different levels of readiness. People move forwards and backwards through the forest of forwards and backwards through the forest of change (ambivalence), what MI helps people do change (ambivalence), what MI helps people do is to keep moving forward through the forest the is to keep moving forward through the forest the natural process of resolving ambivalence. natural process of resolving ambivalence.

In MI there is intentional arranging of the In MI there is intentional arranging of the conversation to evoke and explore change talk conversation to evoke and explore change talk when you hear it. You can substantially influence when you hear it. You can substantially influence how much change talk a person will voice.how much change talk a person will voice.

MI produces an unusual shift in change talk that in MI produces an unusual shift in change talk that in turn predicts subsequent behavior change.turn predicts subsequent behavior change.

Four ProcessesFour Processes

EngagementEngagement FocusingFocusing EvokingEvoking PlanningPlanning

Engagement: The Forgotten Gem

Exercise #1Exercise #1

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

Not with your boss or supervisor, Not with your boss or supervisor, if possibleif possible

One will be the speaker, the other One will be the speaker, the other will be a helperwill be a helper

Speaker’s TopicSpeaker’s Topic Something about yourself that you Something about yourself that you

want to changewant to change need to changeneed to change should changeshould change have been thinking about changinghave been thinking about changing

but you haven’t changed yetbut you haven’t changed yet

in other words – something you’re in other words – something you’re ambivalent about ambivalent about

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

Explain Explain whywhy the person should the person should make this make this changechange

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

Tell the person Tell the person howhow they could make the they could make the changechange

Emphasize how Emphasize how importantimportant it is to change it is to change Persuade the person to do it.Persuade the person to do it. If you meet resistance, repeat the above.If you meet resistance, repeat the above. P.S. This is P.S. This is NOTNOT motivational motivational

interviewinginterviewing

Let’s Watch An ApproachLet’s Watch An Approach

Just Stop It!Just Stop It!

Speaker’s TopicSpeaker’s Topic Something about yourself that you Something about yourself that you

want to changewant to change need to changeneed to change should changeshould change have been thinking about changinghave been thinking about changing

but you haven’t changed yetbut you haven’t changed yet

i.e. – something you’re ambivalent i.e. – something you’re ambivalent aboutabout

Exercise 2: Same Conversation same speaker and listener

ListenerListener Listen carefully with a goal of understanding the Listen carefully with a goal of understanding the

dilemmadilemma Give no advice. Give no advice. Ask these four open questions and listen with interest:Ask these four open questions and listen with interest:

1. 1. Why would you want to make this change? 2. How might you go about it, in order to

succeed? 3. What are the three best reasons to do it? 4. 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? 30 sec. summary/reflection of the speaker’s 30 sec. summary/reflection of the speaker’s

motivations for changemotivations for change Then ask: “So what do you think you’ll do?”Then ask: “So what do you think you’ll do?”

and just listen (really)and just listen (really)

Increase the CIRCLE OF CARINGIncrease the CIRCLE OF CARING

CONNECT TOCONNECT TOGREATERGREATERPRO-SOCIALPRO-SOCIALCOMMUNITYCOMMUNITY(Family, School, Staff, etc.)(Family, School, Staff, etc.)

SMALL CIRCLE OF FRIENDS(pro and/or anti-social)

CLIENTCLIENT

““MOTIVATING OFFENDERS TO CHANGE – A Guide for Probation & Parole,” Walters, Clark, Gingrich, and Meltzer, (June 2007)MOTIVATING OFFENDERS TO CHANGE – A Guide for Probation & Parole,” Walters, Clark, Gingrich, and Meltzer, (June 2007)

The “Spirit” of Motivational The “Spirit” of Motivational InterviewingInterviewing

CollaborationCollaboration EvocationEvocation AutonomyAutonomy CompassionCompassion

POWER & CONTROL(SOVEREIGNTY)

To love and be loved

BELONGING

Capable

Taking it Deeper -Taking it Deeper -psychologicallypsychologically At the beginning of the conversation clients are more At the beginning of the conversation clients are more

focused on the helping professional ("Can I trust that focused on the helping professional ("Can I trust that s/he will not seek to judge and/or control me?") than on s/he will not seek to judge and/or control me?") than on themselves, and that only when they have (implicitly) themselves, and that only when they have (implicitly) concluded that the encounter is "psychologically concluded that the encounter is "psychologically safe" will they allow shared awareness of two ways of safe" will they allow shared awareness of two ways of thinking about a problem (perhaps their responsibility or thinking about a problem (perhaps their responsibility or contribution) and thus experience increased motivation contribution) and thus experience increased motivation to move through or beyond it. At the same time, once to move through or beyond it. At the same time, once safety is established, the thinking two ways or the safety is established, the thinking two ways or the problem is experienced differently--not as "social problem is experienced differently--not as "social pressure" (or what is going to happen to me “out there” pressure" (or what is going to happen to me “out there” but as but as internal internal pressure or, better, an internal pull pressure or, better, an internal pull towards a better place, or a better me. towards a better place, or a better me.

Don’t trigger Trauma Response...Oppressive Don’t trigger Trauma Response...Oppressive ResponseResponse

Help them build their “emotional muscle”Help them build their “emotional muscle”Think about pace and timing. It takes time to Think about pace and timing. It takes time to

heal and build your emotional muscle when heal and build your emotional muscle when you are coming from an injured place. Be you are coming from an injured place. Be gentlegentle

Creating Engagement – People Creating Engagement – People change, grow, trust and develop in change, grow, trust and develop in

RelationshipRelationship People’s motivation is influenced by the People’s motivation is influenced by the

other person’s expectationsother person’s expectations Conflicting feeling about doing something Conflicting feeling about doing something

different and new is normaldifferent and new is normal Pressure to change behavior or beliefs Pressure to change behavior or beliefs

often evokes resistanceoften evokes resistance Individuals attitudes are shaped by their Individuals attitudes are shaped by their

own wordsown words Individuals can develop solutions to their Individuals can develop solutions to their

problemsproblems Belief in ability to change is an important Belief in ability to change is an important

source of motivationsource of motivation Most people (even those with substance Most people (even those with substance

dependence) change on their owndependence) change on their own

Skills for Engagement:Skills for Engagement:OARSOARS

Open (not closed) questionsOpen (not closed) questions

AffirmationAffirmation

Reflective listeningReflective listening

SummarizingSummarizing

CONTRASTING CONTRASTING Interactive STYLESInteractive STYLES

Motivational Interviewing(Guiding)

Confrontational – Aggressive(Directing, Telling, Pushing)

33

1. What would you like to start talking about today?

2. What have you noticed about …….?3. How important is it for you to change ----?4. How confident do you feel about changing

----?5. How do you see the benefits of ---?6. How do you see the drawback of ---?7. What concerns do you have about ---?8. How might things be different if you ----?9. In what way…..? How might you go about it?10.Where does this leave you now? What will

you do?

open questions through the steps of MI

Use Accurate Empathic Use Accurate Empathic ReflectionReflection

• One of the most important skills...• Response with a clear assertive statement--

acknowledging the person...• NOT a question

It is a process of: Hearing what the speaker said Making a guess at what s/he meant Stating it back to them

Lets watch a Lets watch a demonstrationdemonstration

Forming ReflectionsForming Reflections

1. Speaker: Something you may not know about me is that I am _______________.

2. Make a guess about what it might mean, and ask it as a question: “Do you mean that you . . . ?”

3. Second Listener: Turn the question into a reflective statement: “You . . . . .”

4. Then the Speaker gives a natural reply to #3

Set the FocusSet the Focus

Focus the conversation:Focus the conversation: Client’s goal/choiceClient’s goal/choice Social worker’s agenda with permissionSocial worker’s agenda with permission

Concept of “Equipoise”Concept of “Equipoise”

Agenda SettingAgenda Setting Eliciting the person’s agendaEliciting the person’s agenda

What is the most important thing that we need to What is the most important thing that we need to talk about today? talk about today?

Let’s see we have this, this and this on our Let’s see we have this, this and this on our plates.....?plates.....?

What brings you here today?What brings you here today? ““Miracle question”Miracle question”

Offering a menuOffering a menu Bubble sheetBubble sheet

Asking permission to discuss your agendaAsking permission to discuss your agenda Would it be all right if we also talked a bit about . . .?Would it be all right if we also talked a bit about . . .?

PractitionerPractitioner: I’m glad you came back to see me today.: I’m glad you came back to see me today.

MotherMother: I must do this for my baby : I must do this for my baby

PractitionerPractitioner: This baby is very important to you : This baby is very important to you

MotherMother: Yes.: Yes.

PractitionerPractitioner: And you want it to be healthy : And you want it to be healthy

MotherMother: Yes, I told my husband and he is supportive but there : Yes, I told my husband and he is supportive but there are some issues he is not helping me with – he doesn’t want are some issues he is not helping me with – he doesn’t want to use the condomsto use the condoms

PractitionerPractitioner: What would be most helpful for us to start talking : What would be most helpful for us to start talking about? Is it condoms, your medication, your diet, or perhaps about? Is it condoms, your medication, your diet, or perhaps something else? something else?

MotherMother: I want to talk about the medication: I want to talk about the medication

PractitionePractitioner: Yes, fine, we can come back to other things. The r: Yes, fine, we can come back to other things. The medication feels important to you medication feels important to you

MotherMother: Its very important, I want to know how to take these : Its very important, I want to know how to take these tablets so that I keep well tablets so that I keep well

PractitionerPractitioner: What would you most like to know about the : What would you most like to know about the medicine? medicine?

MotherMother: If I miss doses I worry that it will bring harm : If I miss doses I worry that it will bring harm

EvokingEvoking

Change TalkChange Talk

Change Talk: Panning for Change Talk: Panning for GoldGold

Change talk is any client speech that favors Change talk is any client speech that favors movement in the direction of changemovement in the direction of change

Change talk is by definition linked to a Change talk is by definition linked to a particular behavior change goalparticular behavior change goal

It is the gold that we “pan” for: Strongly It is the gold that we “pan” for: Strongly linked to behavioral change.linked to behavioral change.

PreparatoryPreparatory Change Talk Change Talk (evoking)(evoking)

Four ExamplesFour Examples

DARNDARN DDESIRE to change (want, like, wish . . )ESIRE to change (want, like, wish . . ) AABILITY to change (can, could . . )BILITY to change (can, could . . ) RREASONS to change (if . . then)EASONS to change (if . . then) NNEED to change (need, have to, got EED to change (need, have to, got

to . .)to . .)

Do you Swear to tell the Do you Swear to tell the whole truth?whole truth?

D-I want to do itD-I want to do it A-I can tell the truthA-I can tell the truth R- I’m tired of doing the same old R- I’m tired of doing the same old

thing and everyone being mad at mething and everyone being mad at me N- I need to do it for my kidsN- I need to do it for my kids

-Still not good enough for the Court of -Still not good enough for the Court of law..........law..........

I will!!!!!I will!!!!!

Do you take this person to be Do you take this person to be your lawfully(if possible) your lawfully(if possible)

committed spouse?committed spouse? D-I want toD-I want to A-I canA-I can R-At this time in my life I would really R-At this time in my life I would really

like to share my life with someonelike to share my life with someone N-I need to do this for her. She has N-I need to do this for her. She has

been my girlfriend for 9 years.been my girlfriend for 9 years.

Still not good enough.........Still not good enough.........

I Do!!!!!I Do!!!!!

MobilizingMobilizing Change Talk Change Talk (planning)(planning)

Reflects resolution of ambivalenceReflects resolution of ambivalence

CATsCATs CCOMMITMENT (intention, decision, OMMITMENT (intention, decision,

promise) promise) AACTIVATION (willing, ready, CTIVATION (willing, ready,

preparing)preparing) TTAKING AKING SSTEPSTEPS

Responding to Change Responding to Change TalkTalk

E: Elaboration questions, tell me E: Elaboration questions, tell me moremore

A: AffirmationsA: Affirmations R: ReflectionsR: Reflections

(What you reflect, you will hear more (What you reflect, you will hear more of.)of.)

S: SummariesS: Summaries

Methods to Elicit Change Methods to Elicit Change TalkTalk

Looking forward: If change occurs, Looking forward: If change occurs, does not occurdoes not occur

Looking back: Other successesLooking back: Other successes Values/Goals explorationValues/Goals exploration Elaboration questionsElaboration questions Importance and Confidence RulersImportance and Confidence Rulers

PlanningPlanning

Key Questions or Closing the SaleKey Questions or Closing the Sale Next StepsNext Steps

So….So…. How might you continue learning How might you continue learning

MI?MI? What will you do?What will you do?

Thank you!

Betty Hanna: bettyhanna@comcast.net(925) 984-4300