Using Motivational Interviewing to

Promote Healthy Weight

Melody Cole, MS, RDN, CD, CDEA Member of MINT- Motivational Interviewing Network of Trainers

Disclaimers

• SUCCESSFUL COMPLETION

• To receive contact hours, participants must sign in on the attendance form, attend the entire program and complete an evaluation for each presentation attended

• The evaluation will be sent to you via email. Once completed, you will receive your certificate via email.

• CONFLICTS OF INTEREST

• All activity planners for this program have reported no financial relationships with commercial interest.

• All presenters for this program have reported no conflicts of interest related to their presentation

Participants will be able to:

1. Compare and contrast the traditional advice

giving approach with the MI approach

2. Practice active listening with reflections

3. Share information in an MI consistent way

4. Apply the MI approach in clinical examples

Objectives

Definition of MI

• A collaborative

conversation

style for

strengthening a

person’s own

motivation and

commitment to

behavior changePage 1 Handout

MI Aligns with UW Health’s Mission,

Vision and Values

Motivational Interviewing

• Evidenced Based

• Best Practice

• Is helpful when

working with

patients needing or

wanting to change

behaviors

MI Is Evidence Based

Miller and Rollnick Over 800 Randomized Clinical Trials and 100 Systematic Meta-analyses Indicating that MI helps with:

• Better retention

• More patient satisfaction

• Better outcomes

• Takes less time

• More cost effective

Source: Miller, WR From the Desert. Available at http://www.motivationalinterviewing.org/forum/desert-july-2017-

bill-miller Accessed 4.26.18

160 Obesity Dental

n = 150

120

140 Asthma Violence Family

100Health Prom Psychiatric Diabetes Cardiac HIV/STD Risk Smoking/Tob Adh/Retention Eating Dis Offenders Gambling Dual Dx

n = 93

60

80

n = 54

20

40

n = 6

n = 36

01988‐94 1995‐99 2000‐02 2003‐06 2007‐09

AOD

Reference: www.motivationalinterviewing.org

Evidence: Number of MI Studies/Year

Number of Published Papers in

MI and Health Care

Courtesy: Chang Jun Kim, Member of the Motivational Interviewing Network of Trainers

MI Is Evidenced Based

A Systematic review of randomized controlled trials

concluded that medical providers can use MI to

help patients exercise more, lose weight, lower

blood pressure and lower cholesterol. The review

concluded:

• If medical providers can build relationships

and evoke change talk an expected 10 to 15%

improvement can be seen across a wide

variety of behaviors and medical outcomes.

Lundal, B., Moleni, Teena, Burke, Brian L., Butters, Robert, Tollefson, Derrik, Butler, Christopher, Rollnick, Stephen (2013). A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling, 93. 157-168.

A Continuum Of StylesD

IREC

T

• Administer

• Decide

• Order

• Prescribe

• Tell

GU

IDE

• Accompany

• Collaborate

• Elicit

• Offer

• Support

FOLL

OW

• Allow

• Listen

• Observe

• Understand

• Have faith in

What Our Training Teaches Us:

• Assess medical

condition

• Determine what

needs to change

• Cover all the

important points

The Righting Reflex

Righting Reflex

• Built in desire to set things “right”

• Identified by words such as:

• “You Should”….

• “You Must”……

• “You Need to”….

• “It’s important that you”….

Possible Results of the Righting Reflex

Agitated

• Patient gets defensive

• Patient says “Yeah, but”

Argumentative

• Patient gets angry

• Patient raises voice

Shuts Down

• Patient is quiet or disengaged

• Patient doesn’t come back or doesn’t answer the phone

Practice makes practice!

Traditional Advice Giving Approach

Person 1: ‘Patient’

Identify a change that you

are considering:

-Something you want, should, or need to

change

-A behavior that you might be struggling

with

-Pick something that you have been try

to change…

-But you haven’t changed yet

Person 2: Clinician

-Explain why this change

should be made:

-Give at least three benefits that would

result from making the change

-Give advice about how to do it

-Convince him/her about how

important it is to change

-Summarize the plan and ask for

agreement

You have 60 seconds for this. When finished, switch roles

Debrief- 3 minutes at your tables. Answer the following

questions. Select one recorder at your table.

1. What was it like to be the person on the

receiving end of the advice?

2. What is your overall motivation to make a

change?

3. Describe the characteristics of what the person

might feel like on the receiving end of this

conversation.

Beginning MI Approach

• Pushing Change

• Giving unwanted

information and advice

• Persuading

• Guilting

• Scare Tactics

• Premature Planning

Beginning MI Practice

Draw out the

individual’s

importance and

confidence to

change

Two Key Questions

• Ask the following questions. Listen with the

intent of understanding.

• Resist the “righting reflex” and give no

advice.

1. What are some of your reasons for wanting

to make this change?

2. What do you think you might do?

When finished, switch roles.

Two Question MI Approach

Person 1: ‘Patient’

Identify a change that

you are considering:

-Something you want, should, or

need to change

-A behavior that you might be

struggling with

-Pick something that you have been

try to change…

-But you haven’t changed yet

Person 2: Clinician

-Ask the following 2

questions, resist the

“righting reflex” and give

no advice.1. What are some of your reasons

for wanting to make this change?

2. What do you think you might do?

Debrief1. What was it like to be the person with the behavior

change in this conversation?

2. What is your overall motivation to make a change? Is it

lower, about the same or higher compared to the

traditional, direct, approach?

3. Describe the characteristics of the person or what the

person might feel like on the receiving end of this

conversation.

Debrief: 3 minutes at your tables. Answer the following

questions. Select one recorder at your table.

Large Group Debrief

Blaise Pascal French Philosopher 1623-1662

“We are usually

convinced more

easily by reasons we

have found ourselves

than by those which

have occurred in the

mind of others”

Behave in a way that will

reduce resistance (discord

and sustain talk) and

evoke change talk.

Primary Goal of MI

Change Talk

• CHANGE TALK:

–Any self expressed language

that is an argument for

change

Miller & Rollnick, 3rd ed. Pg. 159

Change Talk

www.boards.weddingbee.com

Common Types of Change Talk

• Desire- want, like, wish

• Ability- can, could, able to

• Reasons- If… then

• Need- need, have to , got to

_________________________

• Commitment- will, going to

• Activation- plan to, ready to

• Taking steps to change

Discord and Sustain Talk

Discord is about your

relationship with the

patient

Sustain Talk is about the

target behavior or

behavior change.

Change Talk and Sustain Talk

Two sides of the same coin

Possible Results of the Righting Reflex

DISCORD

Predictor of

poor clinical

outcomes

Worst Case Scenario

• Provider argues for

change while the

patient argues against

it.

• By simply reducing

discord, we increase

the odds of a good

clinical outcome.

Miller & Rollnick, 2002

Motivational Interviewing

EngageFocus

EvokePlan

-----------------MI SPIRIT-------------------Partnership Acceptance Compassion Evocation

ACTIVE

LISTENING

TARGET

BEHAVIOR

DARNCAT

SMART

GOALS

CHANGE TALK

O

A

R

S

--

E

P

E

Underlying Spirit & Style of MI

Partnership

Acceptance

Evocation

Compassion MI Spirit

Page 2 Handout

Accurate Empathy

A specific therapeutic skill that includes

commitment to understanding the client’s

personal frame of reference and the ability to

convey this heard meaning back to the client

via reflective listening.Carl Rogers, 1959

Clinician Empathy: A Strong Predictor

of Behavior Change

• U-Connect

• Search Motivational

Interviewing

• Key Articles

Acceptance versus Agreement

• Acceptance of who someone is and

acknowledgement of his/her perspective

IS NOT THE SAME AS

• Agreement or approval of his/her opinions

or actions

What does this show you about the

Spirit of MI?

Open Questions

Affirmation

Reflections

Summaries

Page 3 Handout

Reflections

• Validate the patient

• Let’s the patient know

you heard them

• Help prevent Discord

• Requires Active

Listening

• The patient relaxes

and is more receptive

to discussing change

Reflections

Reflections:

• Are statements, not questions

• Prevent the Q&A trap

• Prevent resistance

• Move the conversation forward

Reflections

• Patient feels listened to, heard and cared

about

• Patient speaks about what is on his or her

mind rather than just answering what’s on

Provider’s mind

• More truth from patient

Reflections

Simple:

Tip of the iceberg

Complex:

Underlying

Meaning or

Content

How to Reflect?

“I don’t have time to exercise.”

“You don’t have time to exercise.”

“You’d like to exercise if you could.”

You are a busy person and you are wondering

how to fit exercise in.”

How to Reflect?

“I’ve tried all the diets, I can’t lose weight”

“It’s hard for you to lose weight.”

“You are really wanting to find something that

works for you in the long run.”

“You’ve been working really hard at this.”

How to Reflect?

“I really hate exercise, but I want to lose

weight so I started exercising twice a week”

“You really want to lose weight.”

“You want to lose weight so badly that you are

willing to exercise.

How to Reflect?

“I forget to take my medication at night”

“You forget your medication at night”

“You are pretty consistent with taking your

medication in the morning”

“You’re trying to find a way to remember that

second dose at night”

MI Beginning Practice

A good beginning rhythm in MI is one question

followed by one reflection or a ratio of 1:1

RR

Active Listening

http://www.ourworkinglives.com/chinese-character-for-listening/

Page 6 Handout

Active Listening & Reflecting

Exercise

See one, do one

An Exercise in Listening:

Groups of 2 or 3

Person 1: Speaker

Role play for the next 1-

2 minutes the person

you see in the slide

– Put yourself in the

other person’s shoes

– Keep talking and relay

your issues and

concerns to your

listener

Person 2: Listener

Listen with the intent of

understanding. Do not

offer advice or try to “fix”

the situation.

- DO NOT ASK

QUESTIONS

- Reflections are okay

- Verbal tics are okay

If you finish early, please sit in silence until the time is up.

Speaker: Place yourself in this person’s shoes

Listener: Listen and REFLECT only. No Fixin’

• Overweight her whole

life

• Ridiculed for being

overweight by peers

• Physically abused from

a young age

Speaker: Place yourself in this person’s shoes

Listener: Listen and REFLECT only. No Fixin’

Esther: Accomplished

professional

Multiple fertility

treatments with weight

gain

Now pregnant with twins

Advanced maternal age

High Blood Pressure

Never had to watch what

she eats beforeImage from http://www.uconnruddcenter.org

Speaker: Place yourself in this person’s shoes

Listener: Listen and REFLECT only. No Fixin’

Regina: Stressful job

Recent divorce

3 grown children

Caregiver for her mom

Loves to garden and cook

Knee pain

Urinary incontinence

Type 2 diabetes

Multiple diets without

success Image from http://www.uconnruddcenter.org

Giving Advice or Sharing Information:

Elicit-Provide-Elicit

The person is more likely to hear

and follow your advice if you have

permission to give it

Dr. House

Providing or Sharing Information

• The goal is to share in a manner that

encourages individuals to receive

information and consider acting on it

• Advice giving and sharing of information is

used with permission

• We offer information or advice if» The person is asking for it

» You ask permission to give information

» You feel professionally obligated to give advice or

information

Exchanging Information in an MI

Consistent Way:

Facilitates:

• Engagement

• Rapport

• Trust

• Change Talk

• Empowerment

• A common direction

and focus

Avoids:

• Resistance =

discord +

sustain talk

• Disengagement

• Frustration

• Wasting time

Sharing Information:

Partnering and CollaboratingEsther:

• Tell me what you already know or would like to

know about healthy weight gain during

pregnancy?

• Would it be alright if we spent some time

discussing your blood pressure?

Regina:

• I have some information on healthy lifestyle habits.

Would it be okay if I shared them with you?

• I have the results of your assessment. Would it be

ok if we spent a few minutes reviewing it?

Sharing Information:

Stronger Language

Elicit: I have some information on alcohol use

during pregnancy that I would like to go over,

when I am finished, I would like to know what

your thoughts are.

Provide: Share the information

Elicit: What are your thoughts on what we just

discussed?

Sharing Information:

Stronger Language

May I tell you

what concerns

me?

EPE Practice

MI Guide

Focusing the Conversation:

Agenda Mapping

Beginning MI Practice

What matters to you?

What do you value?

What do you want your health for?

Reference: Berwick, D.M. Era 3 Medicine and Health Care JAMA. 2016;315(13):1329-1330.

Debrief

What Seems Useful So Far?

Resources for Learning MI

Motivational Interviewing Network of Trainers

www.motivationalinterviewing.org

Guilford Press: https://www.guilford.com/

References

• Miller, W. R. & Rollnick, S. (2013) Motivational Interviewing: Helping People

Change (3rd edition). New York: The Guilford Press.

• Miller, W. R. & Rollnick, S. Butler, C. (2008) Motivational Interviewing in

Healthcare: Helping Patients Change Behavior. New York: The Guilford Press.

• Rosengren, David B. (2017) Building Motivational Interviewing Skills: A

Practitioner Workbook. (2nd edition) New York: The Guilford Press.

• http://learning.bmj.com/learning/module-intro/motivational-

interviewing.html?moduleId=10051582 British Medical Journal Learning:

Motivational Interviewing in brief consultations

• www.motivationalinterviewing.org Motivational Interviewing Network of

Trainers Website

• http://www.kognito.com/changetalk/web/ An interactive MI learning experience

focused on childhood obesity and endorsed by the American Academy of

Pediatrics

Unless otherwise noted, all images from shutterstock or pixabay.com