2 Objectives MI Definitions Processes of MI OARS Change Talk Resistance Learning to use MI
3 MI: A way to talk about behavior change Person-centeredDirectional methodEnhances internal motivation for changeExplores and resolves ambivalenceEmpirically supported
4 Motivational Interviewing . . . . . is a clinical method that overlaps humanistic and cognitive therapies. . . is not behavior therapy although there is some use of reinforcement to elicit and shape client speech. . . Has a strong focus on acceptance and commitment as interpersonal transactions
5 MI is an Evidence Based Practice On the federal NREPP listBeing vetted by American Psychological AssociationStrongest evidence in alcohol and drug abuseGood outcomes for alcohol, drugs, hypertension, bulimia, and compliance in diabetesSupport for smoking, physical activity, and adherence with hyperlipidemia treatmentAMIs (Adaptations of MI) were superior to placebo controls and equal to active treatments.Noonan and Moyers (1997); Dunn (2003)
6 Broader than Behavior Change Decision – to make a choiceForgiveness, Leaving or stayingAttitude - to become a different personTo be more Compassionate, Assertive etc.Resolution - AcceptanceComplicated griefFinding peace regarding a decisionTolerance for anxiety, uncertainty etc.
7 Three Essential Elements in any Definition of MI MI is a particular kind of conversation about change (counseling, therapy, consultation, method of communication)MI is collaborative (person-centered, partnership, honors autonomy, not expert-recipient)MI is evocative, seeks to call forth the person’s own motivation and commitment
8 Definitions of MIThree levels of definition (of increasing specificity)1. A layperson’s definition(What’s it for?)2. A pragmatic practitioner’s definition (Why would I use it?)3. A technical therapeutic definition(How does it work?)
9 1. A layperson’s definition (What’s it for?) Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change
10 2. A pragmatic practitioner’s definition (Why would I use it?) Motivational interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change
11 3. A technical therapeutic definition (How does it work?) Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change
13 Relational Motivational Foundation Interviewing 1. Engaging2. Focusing3. Evoking4. Planning
14 4 Fundamental Processes in MI Engaging – The Relational FoundationPerson-centered styleListen – understand dilemma and valuesOARS core skillsLearn this first
15 4 Fundamental Processes in MI Engaging – The Relational FoundationFocusing – Strategic CenteringAgenda settingFinding a focusInformation & advice
16 4 Fundamental Processes in MI Engaging – The Relational FoundationFocusing – Strategic CenteringEvoking – The Transition to MISelective elicitingSelective respondingSelective summaries
17 4 Fundamental Processes in MI 1. Engaging – The Relational Foundation2. Focusing – Strategic Centering3. Evoking – The Transition to MI4. Planning – The Bridge to ChangeReplacing prior Phase I and Phase IINegotiating a change planConsolidating commitment
19 Engaging ? Focusing ? Evoking ? Planning ? Can it be MI without . . .Engaging ?Focusing ?Evoking ?Planning ?NoYes
20 So it’s MI when . .1. The communication style and spirit involve person-centered, empathic listening (Engage)AND2. There is a particular identified target for change that is the topic of conversation (Focus)3. The interviewer is evoking the person’s own motivations for change (Evoke)
21 The 4 processes are somewhat linear ... . Engaging necessarily comes firstFocusing (identifying a change goal) is a prerequisite for EvokingPlanning is logically a later stepEngage Focus Evoke Plan
22 and yet also recursiveEngaging skills (and re-engaging) continue throughout MIFocusing is not a one-time event; re-focusing is needed, and focus may changeEvoking can begin very early“Testing the water” on planning may indicate a need for more of the above
23 Four Foundational Processes PlanningEvokingFocusingEngaging
24 Engaging – The Relational Foundation Best Developed ProcessPerson-centered styleListen – understand dilemma and valuesMI SPIRITOARS core skills
28 Steve Rollnick (Sophia, Bulgaria 2007) How do we help people solve problems?
29 Directmanage, prescribe, lead, tell, show the way, take charge of, preside, govern, rule, have authority, exert authority, reign, take the reins, take command, point towards; conduct, determine, steer one’s course, pull the stroke oar.
30 FollowGo along with, allow, permit, be responsive, have faith in, go after, attend, take in, shadow, understand, observe.
31 A widespread dichotomy DirectManagePrescribeLeadTellFollowPermitLet beAllowGo along
40 AffirmationsAffirm a person’s struggles, achievements, values, and feelingsEmphasize a strengthNotice and appreciate a positive actionShould be genuineExpress positive regard and caringExamples“It takes courage to face such difficult problems”“This is hard work you’re doing”“You really care a lot about your family”“Your anger is understandable”
42 Bridge the gap by reflection thinks the speaker means The Function of ReflectionBridge the gap by reflectionWhat the listenerthinks the speaker means4What thespeaker means1What thelistener hears3ANIMATION: CLICK FOR EACH POINT.The following exercises form the most important building blocks to understanding and using reflections. Therefore, as a trainer, it is important to be absolutely clear about th flow and reasons for these exercises. Reflections are one of the hardest skills to learn, so depending on the group slow down here. The exercise is in two parts because there are basically two pieces to a reflection. One is that a reflection is a HYPOTHESIS of what may be going on. The second piece is that a reflection is a statement.What thespeaker says2R
43 Reflective Listening A critical MI skill Mirrors what the individual saysIs non-threateningDeepens the conversationHelps people understand themselves59
44 MI Listening MethodReflective listening encourages disclosure and exploration.Listen carefullyGenerate hypothesis about content, meaning, emotionPut your hypothesis in form of a statementKeep voice inflection neutral/down at endListen to individual’s clarificationRestate hypothesis of the clarified content
45 Reflective listening stems So you feel like..It sounds like you….You’re wondering if…In other words you’re saying….Let me see if I heard you correctly….What I hear you saying…Ask for clarification- I want to understand, help me to understand what you’re sayingYou’re feeling. . .It seems that you ….So you….
46 Reflections First, train yourself to think reflectively What does this person really mean?How does this fit with cultural competence?Reflective listening is a way to check in with the patient. Can be a guess about what they really meant.
51 Practice ExercisesWorkbookOARS Practice sheetVirginia Reel
52 Focusing – Strategic Centering Developing a clear direction and goal(s)Sometimes the change goal is clear, but often it’s notMost often, from the client’s agenda; Sometimes prescribed by the context
53 Agenda Setting Eliciting the client’s agenda Offering a menu “Miracle question”Offering a menuWhat are the options?Asking permission to discuss your agendaI’d also like to talk a bit about ? and you can decide if that would be helpful
54 Finding a Focus What is the focus, the “change goal” for MI? Most often, it is from the client’s agendaSometimes prescribed by the contextWhat if you have your own goal(s)that the client does notcurrently share?
55 Evoking – The Transition to MI A clear focus is a prerequisiteEliciting change talkSelective elicitingSelective respondingSelective summaries
56 Change TalkChange talk is any client speech that favors movement in the direction of changePreviously called “self-motivational statements” (Miller & Rollnick, 1991)Change talk is by definitionlinked to a particularbehavior changegoalDARN CATs
57 Preparatory Change Talk Four Examples DARNDESIRE to change (want, like, wish . . )ABILITY to change (can, could . . )REASONS to change (if . . then)NEED to change (need, have to . .)
61 Responding to Change Talk All EARS E: Elaborating: Asking for elaboration, more detail, in what ways, an example, etc.A: Affirming – commenting positively on the person’s statementR: Reflecting, continuing the paragraph, etc.S: Summarizing – collecting bouquets of change talk
62 MI Flow Chart OARS Respond with yes Elaboration Qs Develop a plan, https://adept.missouri.edu/MI Flow ChartOARSDoeschange-talkoccur naturallywithout explicitelicitation?Respond withElaboration QsReflectionAffirmation &orSummarizationDevelop a plan,etcyesnoApply TechniquesFor ElicitingChange-Talk
63 MI Change Talk Strategy Process Asking for Clients Seeing Behavior ChangeDESIRESAssessingreadiness?Client BehavioralChangeStrengthenClient CommitmentTalkABILITIESreadiness?REASONSreadiness?Hearing Strong Commitment TalkCLIENT VALUES CLIENT STRENGTHSHow MI is DirectiveSelective eliciting questionsSelective reflectionsSelective elaborationsSelective summarizingSelective affirmingNEEDS
64 Change Talk and Sustain Talk Opposite Sides of a Coin
65 Examples of Sustain Talk Desire for status quoInability to changeReasons for sustaining status quoNeed for status quoCommitment to status quo
66 Sustain Talk The other side of ambivalence 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 (C) nobody can stop meI’m not ready to quit (A)I went back to smoking this week (T)
68 Giving goal-oriented or target behavior- oriented direction… Evoking Change Talk!Giving goal-oriented or target behavior- oriented direction…
69 Eliciting change talkPreviously, we learned that change talk can flow naturally by simply using OARSIn this lesson, we will learn strategies for eliciting change-talk when it does NOT naturally occurWe will list, define, and discuss 7 strategies for eliciting change talkPreviously, we learned that change talk can flow naturally by simply using OARS
70 How to Evoke Change Talk! (How MI becomes directive) Ask Evocative Questions (Assumes a problem)- What happened the last time you used? How did your little sister react the last time you and your mom fought? Explore Decisional Balance – Weighing Costs & benefits. *Consider short & long term consequences (+/-)Let’s look at each of these strategies briefly. You have seen some of them and others are new. This will put it in a nice format for you to remember.I am also handing out another ‘cheat sheet’ to put on the wall with the one about reflections! This will help when you aren’t sure where to do with someone.Go through the three ECT slides swiftly. See modeling instructions next page.
71 More Strategies…Ask for Elaboration or Examples – What else do you think is going on with that? Tell me a little more about your situation at school… Tell me about the last time you got in a fight…. Looking Back – Think back to a time when things were OK [you weren’t using]? What things did you do to keep you on track?Let’s look at each of these strategies briefly. You have seen some of them and others are new. This will put it in a nice format for you to remember.I am also handing out another ‘cheat sheet’ to put on the wall with the one about reflections! This will help when you aren’t sure where to do with someone.Go through the three ECT slides swiftly. See modeling instructions next page.
72 More Strategies….Looking forward – How would you like your life to look a year form now? What will be different in a year if you stop using? Query Extremes - what is the worst that could happen if you [quit behavior]? What is your worst fear? What is the best thing that could happen if you [quit behavior]?What I usually do here is demonstrate each strategy with someone from the group. I try to go back to something they’ve said before or a roleplay they’ve done and briefly demo the skill. OR use it in a more comprehensive roleplay, for example, “Tony, let’s say you are a drug addict and you just got out of jail on a violation for dirty UA’s” Prior to that you had been on paper for a year without any problems – you were working, staying clean, etc.When you got into trouble again, and had to go back in, your sister, to whom you are very close, stopped talking to you. This is upsetting, but you are afraid to call her and discuss it. You don’t know how she’ll respond.Then, I demonstrate each of these strategies in a mock roleplay with “Tony”. Each is very brief. EX: Elaboration, “Tony, I know this strain between you and your sister has been hard. Tell me more about her concerns.” Evocative question, “How has your sister responded in the past when you’ve gone to her with an apology and requesting support?”, etc.VIDEO OPTIONAL: Oftentimes I don’t need the Eliciting Change Talk video due to time constraints, but if you do show it, be sure to explain that we are trying to demonstrate each of the skills. In most cases, they would probably not use all of them in one session.
73 More Strategies….Use Change Rulers – On a scale of 1-10, how important is it for you to get through treatment? What would it take for you to go even higher on the scale? Explore Goals & Values – What’s most important to you? Where would YOU like to start? Which of these 3 areas would you like to work on first?What I usually do here is demonstrate each strategy with someone from the group. I try to go back to something they’ve said before or a roleplay they’ve done and briefly demo the skill. OR use it in a more comprehensive roleplay, for example, “Tony, let’s say you are a drug addict and you just got out of jail on a violation for dirty UA’s” Prior to that you had been on paper for a year without any problems – you were working, staying clean, etc.When you got into trouble again, and had to go back in, your sister, to whom you are very close, stopped talking to you. This is upsetting, but you are afraid to call her and discuss it. You don’t know how she’ll respond.Then, I demonstrate each of these strategies in a mock roleplay with “Tony”. Each is very brief. EX: Elaboration, “Tony, I know this strain between you and your sister has been hard. Tell me more about her concerns.” Evocative question, “How has your sister responded in the past when you’ve gone to her with an apology and requesting support?”, etc.VIDEO OPTIONAL: Oftentimes I don’t need the Eliciting Change Talk video due to time constraints, but if you do show it, be sure to explain that we are trying to demonstrate each of the skills. In most cases, they would probably not use all of them in one session.
74 Come Alongside – Explicitly side with the negative (or status quo) side of ambivalence. This may be so important to you that changing is out of the questions, no matter what the cost.More Strategies….
75 Change Talk Jeopardy: Examples Change talk: I wouldn’t have a hangover.Open Question: What might be some advantages of quitting?Change talk: I suppose I could go with a buddy.Open Question: What might make it easier for you to get to the program?Mary
76 Recognizing and Attending to Commitment High Commitment StrengthMedium Commitment StrengthI willI definitely willI promiseI swearI guaranteeI know I willI intend toI am ready toI am going toI plan toI think I willI expect to
77 Planning – The Bridge to Change Replacing prior Phase I and Phase IINegotiating a change plan &Consolidating commitment
78 It’s time for the Planning Process when: There is sufficient engagementANDA clear shared goalSufficient client motivation for changeOften a “testing the water” strategy such as recapitulation and key question
79 Planning: A ContinuumClear Plan Menu of Options Unclear What is the client/patient role in planning? How does the interviewer influence planning? What are the key elements of MI-guided planning?
80 Motivation is Interactional If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he.. could be, he will become what he.. could be. (Johann Wolfgang von Goethe)Change the interaction andthe person changes!
81 Ambivalence: A Central Concept Simultaneous motivations leading in different directionsDesire to gain medication benefits and avoid side-effectsDesire to be strong and healthy and to relax and eat enjoyable foodsDesire to be in greater control/feel on top of things, desire to let go and escapeHope for change / fear of failureMI is based on the idea that people generally are not UNmotivated. Even when they don’t change. Instead people tend to have multiple motivations that goes in different directions, or go direct against one another, and someone because of this, people get stuck.When people are stuck, particularly if they have been stuck a long time, or have tried unsuccessfully to change, or have made a change then fallen back, they tend to be a bit demoralized, discouraged, confused, conflicted. They might want things to be different, but feel there’s no hope. Something blocks them. They are too stressed out. Or don’t have certain skills. Or opportunities. Or they have other responsibilities that come before themselves or at least before the thing they are stuck with. Or people might know that they should make a change, or that things could be better, but they also are attached to something that holds them back. Drugs. Friends. A relationship. Convenience. Familiarity. Security.People who are stuck can sometimes be edgy. Especially if their being stuck somehow involves other people. They may feel guilty, responsible, anxious, depressed. Others might have tried to encourage them, then given up with they didn’t change, which can leave people feeling even worse about themselves. Or others might pressure them, sometimes subtly, sometimes directly, even harshly. This can make people defensive, feeling like they need to protect themselves, perhaps by focusing on difficulties involved in changing, or not really “seeing” the problem because it’s too painful, or some other way.
82 Role of AmbivalenceAmbivalence is a normal component of psychological problemsAcknowledge and protect the side that doesn’t want to changeExplore pros and cons of change (decisional balance)Specifics are unique to each person--try not to assumeDo NOT want to join with side that wants to change prematurely or will invoke REACTANCE. Natural tendency to support or protect the opposite viewpoint that exists within the person.MI assumes that people have the capacity to solve their own problems and come up with resourceful solutions…if we help remove the barriers. Research supports this. For example, empirical evidence that large groups of problem drinkers are successful eventually in changing drinking behaviors. ONLY 5% require formal treatment to do so.WE are not the change process---only a small piece.
83 What is Resistance? Behavior (a state not a “trait”) Interpersonal (It takes two to resist)A signal of dissonancePredictive of (non) changeHighly responsive to practitioner styleDissonance – cognitive dissonance, uncomfortable feeling caused by 3 contradictory ideas such as when beliefs and values contradict one’s behavior. People are motivated to reduce the dissonance by changing attitudes, beliefs, and behaviors or justifying or rationalizing attitudes, beliefs, and behaviors.
84 Psychological reactance Individuals will defend their freedom when it is threatened, especially when the threat is perceived as unfair.Restricted behaviors may increase in attractiveness (forbidden fruit)Person may become aggressive or assert other freedomsTherapeutic relationship (advising, addressing problems) may induce reactance (Brehm, 1966)
85 - 2 x 2 Decisional Balance Grid + PROs and CONs of Change Status Quo orOption AChange orOption BAdvantages+Good things about Status Quo or Option ACONGood things about Change or Option BPRODisadvantages-Less-good things about Status Quo or Option ALess-good things about Change or Option B
86 Rolling with Resistance What do you feel when the individualresist?Don’t push backAvoid argumentsReflectRemind the person (and yourself) about autonomy
87 Sustain Talk and Resistance Sustain Talk is about the target behaviorI really don’t want to stop smokingI have to have my pills to make it through the dayResistance is about your relationshipYou can’t make me quitYou don’t understand how hard it is for meBoth are highly responsive to practitioner’s style
88 Traps to Avoid Question/Answer Premature Focus Taking Sides Expert RoleBlamingPremature focus: Underestimate ambivalenceRigid PrescriptionInsufficient Direction
89 Another Trap: The Righting Reflex Born of concern and caringThere’s a problem? Let’s fix it!Fails to consider ambivalence in change processMay engender resistance
90 Possible contraindications for MI Clients who are already ready for change or appear to be at the action stageClients who are low in anger or resistanceClients making a decision we should not be involved with!Possible Contraindications for MI• Clients who are already ready for change• Clients who are low in anger/resistance• If a client appears to be at the action stage,ready for change, there is no need for MI
91 When, in MI, do you give information and advice?
92 Giving information & Advice Three kinds of permission:The person asks for adviceYou ask permission to give advice:“Can I make a suggestion?”“Would you be interested in some resources?”“Would you like to know what has worked for some other people?”)You qualify your advice to emphasize autonomy:“A lot of people find that _____works well, but I don’t know if that’s something that interests you.”Even when the person asks for the advice, it’s important not to jump in if you feel that they are not ready or insincere. It’s okay to ask permission to get more information BEFORE giving advice, “You know, that’s cetainly something I can do, but I’m wondering if I really have enough information about the problem to really give you good advice right now. Would you mind telling me a little bit more about the situation? How do you feel about giving up marijuana?... ““Can I make a suggestion?”“Would you be interested in some resources?”“Would you like to know what has worked for some other people?”)A lot of people find that _____works well, but I don’t know if that’s something that interests you.”
93 The Process for giving advice… Get Permission (sometimes best to ask permission to listen & learn more before giving advice!)Qualify, honoring autonomyFor suggestions, offer several instead of just one
94 Building MI Skills Ongoing training in MI Supervision/Coaching and feedbackReadingMI WorkbookWatching training videos (YouTube)Watching or listening to your own sessionsCoding sessionsPeer support
95 Getting Stuck while learning MI Being open to change & letting go of some old habitsProficiency in reflective listeningRecognizing change talk & evoking change talkSummarizingTransitions to other therapeutic methods
96 The FRAMES Model F – providing feedback R – emphasizing that the individual is responsibleA – giving clear adviceM – providing a menu of alternative optionsE – using empathetic conversational style (reflective listening)S – supporting self-efficacy
97 Using FRAMES in MOSBIRT F – providing feedback on the patient’s screening resultsR – emphasizing that the individual is responsible for their own behaviorA – giving clear advice that the best way to reduce the risk is to cut down or stop engaging in the risky behavior (drinking, using drugs, etc.)M – providing a menu of alternative change optionsE – using empathetic conversational style (reflective listening)S – supporting self-efficacy of the individual
98 Brief EducationProvided when ASSIST Score for Alcohol = 11 to 19 and/or ASSIST Score for Drugs = 4 to 19Consists of 1 SessionFollows (usually immediately) completion of the Screening formsAverage time about 30 minutes
99 Brief Education in 3 Steps Step 1: Orientation & Print Personal Feedback FormStep 2: Build Rapport, Review Personal Feedback Form, Provide Feedback on Screening Results, Give Clear Advise, and Provide a menu of alternativesStep 3: Summarize Session, and emphasize personal responsibility.
100 Brief Education Handout Personal Feedback Form
101 Brief Education Step 1: Orientation & Print Personal Feedback Form Deliver orientation: welcome and rationalBrief Assessment (Pre-Screening)HIPPA Consent FormASSIST & GPRA InterviewsFollow-up Survey Contact Form (when appropriate)Print Personal Feedback Form (PFR)Review the patient’s ASSIST Score to determine level of intervention
102 Brief Education Step 2: Build Rapport, Review Form, Provide Feedback, Advise, and Menu of AlternativesRapport building – focus on strengths (use Empathy & Support self-efficacy)Review Personal Feedback FormProvide Feedback on the screening results – focus on concerns (remind Responsibility of patient use Empathy & Support self-efficacy)Give clear Advice (with permission) that the best way to reduce the risk is to cut down or stop drinkingProvide a Menu of alternatives for change
103 Brief Education Step 3: Summarize Session, Emphasize Responsibility, and Feedback from Patient Emphasize that the individual is Responsible for their own behavior