1. Health Behavior Coordinator, Psychologist
“Practical Strategies in Medication Adherence in Patients with Cardiovascular Disease” MOTIVATIONAL INTERVIEWING: What is it? Does it work?
Julie Culligan, PhD
Health Behavior Coordinator, Psychologist
Mountain Home VAMC

2. MI Philosophy
"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.” 
~ Blaise Pascal, French mathematician, physicist and religious philosopher

3. Learning Objectives
Specify and discuss 3 elements of the “spirit” of Motivational Interviewing
Identify the 4 principles of Motivational Interviewing
Identify basic use of the following core MI skills: open-ended inquiry, affirmation, reflective listening and summaries

4. Facilitating Behavior Change
What makes behavior change so hard?
It works for us
“Habit”
It often involves multiple behaviors
Knowledge about how to change isn’t always enough
People are creatures of habit
Health consequences are often delayed
Busy lifestyles require us to make time for self care

5. Motivational Interviewing
“A person-centered, goal-oriented approach for facilitating change through exploring and resolving ambivalence.“ (Miller & Rollnick, 2006)
A clinical “style;” a “way of being with people” (Miller & Rollnick, 2002; Rollnick & Miller, 1995)

6. Motivational Interviewing: Based on Theory
Conceptualized according to stage model of change (Prochaska & DiClemente, 1982)
Not everyone engages in treatment at the same stage of readiness
Different type of approach may be utilized for individuals at different stages

7. Transtheoretical Model: Stages of Change
A STAGE MODEL OF THE PROCESS OF CHANGE
Pre-Contemplation
Determination
Contemplation
Relapse
Action
Maintenance
Permanent Exit

8. Not to change behavior…..
The Goal of MI
The goal of MI is to facilitate:
Fully informed,
Deeply thought out,
Internally motivated choices,
Not to change behavior…..
Resnicow, et al., 2002

9. Traditional vs. Motivational
The “Doctor”:
The “patient”:
Places the importance on the behavior change
Controls the interaction
May direct/select the goals the patient should achieve
Determines the importance of the behavior change
Is listened to, shares concerns and needs
Is supported in decisions about change and goals

10. Empathic Style of MI and Brief Interventions
The key element in brief interventions is empathy
Research on empathy and clinical outcomes:
Strongest predictor of outcomes
Not accounted for by demographics
Not accounted for by treatment type

11. Patient Focus MI supports the patient in articulating
How personally important this change (e.g., dietary) is, as opposed to how important we think it is
What stands in the way of making this change (time, money, cultural factors, emotions, etc.)
Changes that might work in their life
How to increase the chances of success

12. Learning MI
Techniques
Listening Skills
Spirit

13. Spirit of Motivational Interviewing
Evocative (vs. Educational) – patient is responsible for change. (“What would you gain if you changed your drinking?”) vs. implanting the right idea (“You really need to stop drinking.”)
Honoring Autonomy (vs. Authority) – Allow the freedom not to change. (“How ready are you to change?) vs. push for commitment (“If you delay getting sober, you could die.”)
Collaborative (vs. Confrontational) – Work in Partnership. (“How about we discuss some options together” vs. “I would urge you to quit drinking.”)
Honoring patient autonomy – requires a certain degree of detachment from the outcomes, though not an absence of caring. Clinicians may inform, advice, even warn – but ultimately it is up the patient to decide what to do. Humans resist coercion and being told what to do. Ironically, it is the acknowledging the other’s right and freedom not to change that sometimes makes change possible.
Collaborative – a cooperative and collaborative partnership between patient and clinician. Challenges typical uneven power differential, and encourages active collaborative conversations and joint decision-making.

14. The Spirit of MI
Motivation for change is elicited from within the patient, not imposed from outside
The patient must articulate reasons for change
The patient is the one responsible to decide
Direct persuasion is ineffective
The clinician should steer the conversation to focus on change

15. Ambivalence Interesting, natural, human, understandable
Not unique to characterological problems
Not indicative of defense (denial)
“I want to but I don’t want to”
Unhelpful to think of people as “unmotivated”

16. SPIRIT OF MI Ambivalence
APPRECIATE AMBIVALENCE
HONOR, EMBRACE, EXPLORE AMBIVALENCE. It’s the core.
Many brief (and single session) therapies work by focusing on this ambivalence, not on skills (people frequently have the skills)

17. The RIGHTING Reflex “This person SHOULD want to change.”
NOW is the right time to change.
A TOUGH/clear/honest approach is best.
Patient should follow my EXPERT ADVICE.
If patient doesn’t change, the session FAILED.
There’s nothing we can do for the “unmotivated.”
OKAY if suicidal, but NOT IN RESPONSE TO AMBIVALENCE!!!

18. Rather than the Righting Reflex, Understand Ambivalence
Reflective listening
Helps patients to feel understood
Provides comfort to patient (makes change easier)
Acceptance; non-judgmental; no blaming
Acceptance ≠ Agreement
Ambivalence = normal (not pathological)

19. Communication is a Dance

20. Not a Tug of War

21. Evaluate the Pros and Cons
Reducing/Giving up Tobacco
Pros (Good Things)
Cons (Downsides)
Smoking the Same
I can still smoke with I friends
It helps me deal with my stress
It’s hard to breathe
It’s a fire hazard
It’s bad for my health
It’s expensive
Making Changes in Smoking
Feel better
Have more energy
Have more money
I wouldn’t be able to hang out with my friends who smoke
I wouldn’t have a way to deal with my problems
Fill in any behavior change

22. Evaluate the Pros and Cons
Increasing Medication Adherence
Pros (Good Things)
Cons (Downsides)
Stay the Same, i.e., Non-Adherent
I can still smoke with I friends
It helps me deal with my stress
It’s hard to breathe
It’s a fire hazard
It’s bad for my health
It’s expensive
Making Changes,
i.e., Adherent
Feel better
Have more energy
Have more money
I wouldn’t be able to hang out with my friends who smoke
I wouldn’t have a way to deal with my problems
Fill in any behavior change

23. Four Key Principles of MI
Express empathy
Develop discrepancy
Roll with resistance
Support self-efficacy

24. (1) Express Empathy Reflective listening
Helps patients to feel understood
Provides comfort to patient (makes change easier)
Acceptance; non-judgmental; no blaming
Acceptance ≠ Agreement
Ambivalence = normal (not pathological)

25. (2) Develop Discrepancy
Change is motivated by perceived discrepancy between present behavior and personal goals/values
Discrepancy = importance of change for patient
Amplify the discrepancy to move patient from the status quo
Elicit discrepancy from the patient – they should make the argument for change

26. (3) Roll with Resistance
Argument often pushes person in the opposite direction
Resistance is a call for the clinician to change, not the patient
Questions and problems should be reflected back to the patient, not “solved” by the clinician

27. (4) Support Self-Efficacy
Be aware of your own beliefs about a patient’s ability to change (self-fulfilling prophecy)
Enhance patient’s self-belief about his or her capability to make a change
Be genuine

28. Motivational Interviewing December, 2007
What People say about Change predicts Behavior Change
Self-perception theory
Gary S. Rose, Ph.D. Copyright (c) Please do not reproduce without permission.

29. Core MI Strategies Four Early Strategies; OARS Open Questions
Affirming
Reflective Listening
Summarizing
Elicit Positive “Change Talk”
There are 5 early strategies that can help you deliver messages in a motivational style:
Asking open questions – these are questions that can’t be answered with a simple “yes” or “no” and encourage the person to tell you more
Affirming – Validating the patient’s perspective, even when you don’t necessarily agree
Reflective Listening – Selectively reflecting back patient statements that highlight discrepancies, clarify patient’s desires and help them determine the best course of action.
Summarizing – Offer periodic summaries that pull together different parts of the conversation to be sure the health worker accurately understands the patient, and that the patient understands the agreed upon plan.
These strategies, when used together strategically, can elicit positive change talk from patients.

30. Open-Ended Questions Disarms resistance Creates momentum
Avoids arguments
You want them engaged and exploring – with you gently steering

31. Open Questions to Promote Change
Disadvantages of the Status Quo
How do you feel about your weight?
Advantages of Change
What would the benefits be for you, if you were to quit smoking ?
Optimism for Change
What makes you feel that now is a good time to try something different?
Intention to Change
What would you like to see happen?
How might things be different for you, if you did make a change?

32. Affirmation Genuinely highlight patients’ strengths
Antidotes to demoralization
Appreciative of partial success (ex. Focus on success with quitting smoking for 2 years in past)
Appreciates their honesty regarding ambivalence
Support: form of compliments, statement of appreciation & understanding

33. Reflective Listening – The Foundation of MI
“MINI-SUMMARIES” used strategically to lower resistance
Used to highlight patient statements favoring change (“Change Talk”)
A way of thinking, Difficult to learn
Powerful for increasing readiness
Expert ratio 2 reflections for every question vs. Novice ratio .5 reflections for every question

34. Handy Reflections
Double-Sided (reflects both sides of ambivalence) – takes the clinician out of the equation – puts the ambivalence in their own lap
So on the one hand, you like how alcohol makes you feel and at the same time, you worry about your Hepatitis.
Amplified – can go in either direction
Undershoots so patient might elaborate, “You’re a LITTLE confused…”
Overshoots so patient can back down, “So you don’t EVER intend to cut down…”

35. Handy Reflections
Shifting Focus – shift patient’s concern away from a potential stumbling block – around barriers rather than over them
c: “Okay, maybe I’ve got some problems with drinking, but I’m not alcoholic.”
Argument with a Twist – offer initial agreement, but with a slight twist or change of direction

36. Summarizing Helps the other person:
Recall and reflect upon the conversation
Think of new ideas
Understand the importance of these issues
Plan next steps
Feel more confident, instill hope

37. Importance and Confidence
Importance: lets you know how important this issue(s) is to the patient, in the grand scheme of other important values in their life
Confidence: lets you know how able the patient feels he/she is to make specific changes towards his/her goal(s)

38. Readiness Indicators Assessing Importance and Confidence Importance
How important is it to you to ____________?
On a scale of 0 to 10, with 0 being not important at all & 10 being very important…
Not a all Somewhat Very
Confidence
How confident are you that you could _____________, if you decided to? On a scale of 0 to 10, with 0 being not confident at all & 10 being very confident?
Not at all Somewhat Very

39. Evaluating Importance/Confidence
“What made you answer with a (number patient gave) and not a zero?”
“What would it take for you to move from a (number patient gave) to a (slightly higher number)?”

40. Setting Goals Specific Measurable Achievable Realistic Timely
Rather than: “I will exercise regularly”, Aim for “I will walk for minutes 4 days/week starting today”

41. Let’s see how we pull this together…

42. Resources www.motivationalinterview.org Clinical issues The Library
Background
Special Populations
Group Approaches
The Library
Abstracts
Bibliography
MINUET Newsletter
Links
Training
Upcoming Training
MINT Trainers
Training Videos

43. MI Books
Miller, WR & Rollnick, S (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
Miller, WR & Rollnick, S (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.
Arkowitz, H, Westra, HA, Miller, WR, Rollnick, S (Eds.) (2008). Motivational interviewing in the treatment of psychological problems. New York: Guilford Press.
Rollnick, S, Miller, WR & Butler, CC (2008). Motivational interviewing in health care. New York: Guilford Press.

44. MI Articles
Britt, E, Hudson, SM, & Blampied, NM. (2004). Motivational interviewing in health care settings. Education and Counseling, 53,
Emmons, KM, & Rollnick, S. (2001). Motivational interviewing in health care settings. American Journal of Preventive Medicine, 20,
Greaves C, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Steele A, Gale T, Hammerton F, Daly M (2008). Motivational interviewing for modifying diabetes risk: a randomized controlled trial. British Journal of General Practice, 58(553),
Hecht, J, et al. (2005). Motivational Interviewing in community-based research: Experiences from the field. Annals of Behavioral Medicine, 29 Special Supplement,
Resnicow, K, et al. (2001). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21,

45. Soria R, Legido A, Escolano C, and Yeste A (2006)
Soria R, Legido A, Escolano C, and Yeste A (2006). A randomized controlled trial of motivational interviewing for smoking cessation. Br J Gen Prac, 56(531),
Moyers T, Martino S (2006). “What’s important in my life” The personal goals and values card sorting task for individuals with schizophrenia.
Zygmunt A, Olfson M, Boyer A, Mechanic d (2002). Interventions to improve medication adherence in schizophrenia. American Journal of Psychiatry.
Possidente C, Bucci K, McClain W (2005). Motivational interviewing: A tool to improve medication adherence? American Journal of Health-System Pharmacy, 62(12)
Swaminath G (2007). You can lead a horse to water… Indian Journal of Psychiatry, 49(4),
Cole S, Bogenschutz M, Hungerford D (2011). Motivational Interviewing and Psychiatry: Use in addiction treatment, risky drinking and routine practice. FOCUS, 9:42-54.