1. Motivational Interviewing for Health Behavior Change
Paul F. Cook, PhD & Laurra M. Aagaard, MS, MA
University of Colorado College of Nursing

2. DISCLOSURES (past 12 months)
Grant Funding: National Institutes of Health, HRSA (Federal), SAMHSA (Federal), CDC (Federal), Merck & Co. Inc., Colorado Health Foundation
Speaking: University of Colorado Hospital, Children’s Hospital of Colorado, National Food Program Sponsors’ Association, Colorado Dept. of Workers’ Comp.
Consulting: Takeda Inc., Covance Market Access Inc., Medical Simulation Corp., Academic Impressions Inc., Competency & Credentialing Institute Inc.

3. The Problem
Health is getting worse over time. From 1994 to 2000, the U.S. obesity rate rose by 1/3
Patients don’t follow medical recommendations: 50% for medication adherence, lower for diet, exercise, recommended screening & prevention
Behaviors are independent of each other
Patients aren’t always honest about behavior
Abid, et al., 2005; Goldstein, Whitlock, & DePue, 2004; Polivy & Herman, 2002; WHO, 2002

4. OUR OBJECTIVES FOR YOU
Use the spirit of MI to guide your work with clients and avoid unproductive interactions
Describe the research basis for MI as a best practice
Identify key MI principles: rolling with resistance, expressing empathy, developing discrepancy, an supporting self-efficacy
Recognize MI "micro-skills" like reflection, open-ended questions, and the elicit provide-elicit method of patient education
Recognize change talk and sustain talk, and
apply strategies for responding to each

5. Behavior Change is Difficult!
Individuals and systems tend to resist change
50% of meds abandoned by 12 mos.
Exercise has even lower adherence
Diet changes are hard to sustain
Environmental pressures and habits affect behavior outside awareness
Some barriers are legitimate concerns: cost, time, weather, transportation, pain
Change in one area does not generalize to changes in other areas
Glasgow, McCaul, & Schafer, 1987 ; Meichenbaum & Turk, 1987; NCPIE, 1994; Polivy & Herman, 2002

6. Help, I really want to change!

7. Everyone is Ambivalent
The nonadherent person
Argues or interrupts: yeah, but …
Denies or ignores problems: it’s not a big deal …
Still has a part of them that values health
Still has a part of them that wants to change
The adherent person
Is (probably) telling you the truth
Is doing fine for now
Still has a part of them that resents/resists change

8. Beliefs
PARIS
IN THE
THE SPRING
POP
GOES THE
THE WEASEL

9. 12 Roadblocks Ordering Shaming Threatening Psychoanalyzing Persuading
Lecturing
Moralizing
Criticizing
Shaming
Psychoanalyzing
Sympathizing
Praising
Questioning
Changing the Subject
Exercise: MI script for Head Start dental issues, or MI script for adolescent obesity program
Try it!
Gordon, 1970

10. A Way Through Resistance
Listen carefully
Understand people’s motivations
Resist the urge to “fix it”
Empower the client
See if we can locate a story for this one – your answer is right for you, someone else’s answer is right for them
Marla Corwin, CU School of Medicine, 2013 (adapted from Rollnick, Miller, & Butler, 2008)

11. Motivational Interviewing “SPIRIT”
MI is not primarily a set of techniques; it is an attitude or a different way of being with people
MI is at the same time …
Empathic (caring) and
Guiding (directive)
Some characteristics of MI (ACCE):
Accepting
Collaborative / Person-Centered
Compassionate
Evoking and Strengthening Motivation to Change
Miller et al., 2013, Motivational Interviewing, 3rd Ed.

12. What Works? What Works? Acceptance Attention Choice Support Reminders
Experimentation
Reinforcement
MI Principles
Roll with Resistance
Develop Discrepancy
Express Empathy
Support Self-Efficacy
Exercise: stand up, etc.

13. Motivational Interviewing
Developed for substance abuse
Intended to motivate “resistant” clients
Based on social psychology principles
Social influence/persuasion
People resist your efforts to change them
Person-centered counseling techniques
“A method for exploring and resolving ambivalence”
NOT: teaching, changing, controlling
“MI is like dancing”
“drinker’s check-up” story – MI is designed for people who aren’t interested in change and don’t think they have a problem
Miller & Rollnick. (2002). Motivational Interviewing, 2nd Ed.

14. Four Principles of MI Try it! Roll with resistance Develop discrepancy
Listen and try to understand
Avoid arguing – don’t try to “fix it”
Develop discrepancy
Clients present arguments for change
Express empathy
Reflection, acceptance, collaboration
Support self-efficacy
Ask for the client’s perspective
Facilitate hope for change
Try it!
Rollnick, Miller, & Butler. (2007). Motivational Interviewing in Health Care.

15. How MI Works

16. Avoid the Traps Expert Trap Educator Trap Premature Focus Trap
20-Questions Trap
Fear Trap
Advice Trap
Client is the expert
Clients choose to learn
Negotiate an agenda
Open-ended questions
Reduce fear & denial
Clients make choices
Miller et al., 2013, Motivational Interviewing, 3rd Ed.

17. The Evidence for MI
Review of 30 studies with 5541 participants, most with 3-12 month follow-up data
Total amount of MI provided: 30 min to 4 hrs
Moderate changes in alcohol use, drug use, diet & exercise, treatment adherence (similar to longer-term counseling methods)
Smaller but still significant changes for smoking (about half as strong), based on 16 studies
Smaller effects for safer sex (2 studies), eating disorders (1 study)
Burke, et al. (2003). J Consult Clin Psych, 71(5), ; Hettema & Hendricks. (2010). J Consult Clin Psych, 78(6),

18. MI Across the Lifespan Adolescents Children
Transitions in care / chronic disease management
Preventing depression in at-risk adolescents
Children
Oral health
Diet
Exercise
Chronic disease management
Berg-Smith et al. (1999). Health Educ Res, 14, ; Gueldner & Merrell (2011). J Educ Psychol Consult, 21, 1-27; Resnicow et al. (2006). J Am Dietetic Assoc, 106, ; Schwartz et al. (2007). Arch Pediatr Adolesc Med, 161, ; Suarez & Mullins. (2008). J Devel Behav Pediatr, 29, ; Weinstein et al. (2006). J Am Dent Assoc, 137,

19. MI “Micro-Techniques”: OARS
Open-Ended Questions
Problem recognition
Concern about the problem / pros and cons
Optimism about change
Intention to change
Affirm
Restate
Reflect content
Reflect emotion (worry, concern, upset)
Reflect intention
Reflect meaning (go one step further)
Summarize (“what else?”)
Miller & Rollnick, 2002

20. Examples of Reflective Listening
“What I hear you saying is …”
“It sounds like …”
“You’re feeling like …”
“It seems like …”
“You wish …”
“You want …”
“You think …”
“From your perspective …”
Exercise: best teacher

21. Summary Statements Combine Several Previous Reflections
Reflection #1: You want to help your child eat a healthy diet
Reflection #2: You’ve talked to her, but she doesn’t listen
Reflection #3: You’re frustrated with the situation
Summary Statement: I hear that you really want to help your child, but you aren’t sure how. The things you have tried don’t seem to work, which is frustrating.

22. Change These to Open Questions
“Did your moods feel out of control last night?”
“Did you use meditation or Biofeedback strategies?”
“You really want to impact your patients don’t you?”
“Did you use Reflective Listening techniques?”
“Is the patient ready to work on change goals?”
“Are you being relational?”
GROUP EXERCISE

23. Affirmation Affirming self-determination Affirming strengths
You’re in charge
This is your decision
Affirming strengths
You have made big changes in the past
You’re sure you could do it if you decided to
Affirming competence
You know what’s best for your family
You’re the expert in what will work for you
EXERCISE: affirm 3 things about your neighbor (take turns)

24. Directing the Conversation
Reflect to communicate understanding
“You don’t brush your children’s teeth very often”
Use open-ended questions to raise new topics
“How have you tried to gain their cooperation?”
Use summary statements to close topics
“I’m hearing that your dentist lectures, and that’s frustrating, so your kids resist going there”
Follow with open-ended questions about change
“How can I help?”

25. The Relationship Matters Most
Client commitment language is the best predictor of behavior change in MI
The more time the client spends talking, vs. you
The amount of time talking about change (desire, ability, recognition, need, commitment, activation, taking steps)
Helper’s interpersonal skill predicts outcome better than specific techniques
Experience matters, but not specific knowledge
Do whatever works to strengthen the relationship

26. When Can I Educate?
The Traditional Model in Education: Tell — Ask — Tell The Motivational Interviewing Model: Elicit — Provide — Elicit
Rollnick, Mason, & Butler. (1999).
Health Behavior Change.

27. Possible Benefits Cut to the chase – a lengthy spiel takes time
Deliver information in focused chunks
Increase the odds the patient will remember
Get to the most important issues more quickly
Check off boxes in your EMR as the patient talks
This half: What patients hear
Whole pie:
What you say
to patients
This quarter: What they understand
This eighth is what they remember
Well enough to use the information!

28. Recognizing Readiness
Showing Resistance
Seeing benefits of current behavior
Seeing costs of new behavior
Strategy: back off, build motivation
(the “strong principle of change”: increase benefits)
Ready for Change
Seeing benefits of new behavior
Seeing costs of current behavior
Strategy: support efforts for change
(the “weak principle of change”: decrease barriers)
Prochaska et al. (1995). Changing for Good

29. Early Stages: Use FRAMES
Feedback about personal risks
Responsibility for change is the client’s
Advice is given in a nonjudgmental way
Menus of options are suggested
Empathic counseling style (OARS)
Self-efficacy of the client is encouraged
Miller & Rollnick, 2002

30. Getting Stuck: Some “Resistance” is only Sustain Talk
Roll with resistance; don’t fight against it.
Pushing back against resistance only gets you more of it.
Some “resistance” is a natural expression of
the process that moves us toward change.
Sustain talk is a normal part of the process
It is often helpful to hear from both sides of the ambivalence:
Why do you want to make this change? And also …
What do you not like about the idea of making this change
“To fly, we have to have resistance” – Maya Lin

31. Roll With Resistance Use reflection to communicate empathy
When people resist,
you might be pushing too hard for change!
Use reflection to communicate empathy
I hear that this is difficult for you.
Find out what the client already knows
Wait to offer new information until you are invited
Ask the client her opinion about the new information
Summarize to communicate understanding
You see three barriers to moving forward: … .
What causes problems doesn’t matter as much as what you decide to do about them.
Use open-ended questions to refocus on change
What would you be doing if the situation were different?
RESISTANCE
is futile

32. Change Talk Listen for DARN CATs in the conversation:
Desire for change
Ability to change
Reasons for change
Need to change
Commitment to change
Activation for change
Taking steps already for a change
Contemplation Stage
Action
Stage
Miller & Rollnick, 2007

33. EARS for Change Talk Elaboration – what? why? how? tell me …
Affirmation – that sounds like a good idea. I can see that you’ve considered this carefully.
Reflection – you think … you want … you need … you intend … you think you can …
Summary – you have considered … and at this point your plan is …

34. Questions to Elicit Change Talk
Advantages of Change (Desire, Reasons)
What makes you think you would like a change?
Disadvantages of the Status Quo (Need)
What concerns you about the current situation?
Optimism about Change (Ability)
What do you think would work, if you did want a change?
Intention to Change (Commitment, Taking Steps)
What would you like to do at this point?
Handout of questions from Miller & Rollnick (2002) book
Miller & Rollnick, 2002

35. Find the Change Talk …
I like it when I’m out drinking with friends, but the next day I usually feel awful.
If I’m late to work again because of my drinking, I will get fired.
My wife keeps nagging me to give up cigarettes.
The doctor told me to cut down on drinking.
I don’t like the idea of taking so many pain meds, but the pain just won’t go away.
I’m not sure I can quit smoking pot – it helps me cope.
Exercise – identify DARN CATs in each statement (as a group)

36. Use Naturally Occurring Solutions
Problems are struggles, failures are efforts
What worked before?
How have you overcome other challenges?
What would you change from past attempts?
Look for solutions that already exist
What is working already?
When isn’t the problem quite as bad?
Access support from others
Who in the network is supportive?
Who haven’t you asked, and can they help?
What do others say that you might like to try?
What do you think is the best plan from here?

37. Red Light / Green Light SUSTAIN TALK AMBIVALENCE CHANGE TALK
LURE: listen, understand, resist the urge to “fix it,” empathize
AMBIVALENCE
OARS: open-ended questions, affirm, reflect, summarize
Use elicit-provide-elicit to educate
CHANGE TALK
EARS: explore, affirm, reflect, summarize
Challenge the change
Dart, M.A. (2011). Motivational Interviewing in Nursing Practice

38. Next Steps in Using MI Active listening (OARS)
Use reflections more than questions
Roll with resistance
Use elicit-provide-elicit to educate
Assess readiness for change
Use FRAMES to motivate change
Listen for change talk (DARN CAT)
Problem-solve using natural supports

39. Developing the “Spirit” of MI
The heart of MI is a spirit of …
empathy
acceptance
respect
honesty
caring
Hope & faith in the client
Interest in others’
well-being and growth
Empathy: 2 reflections per 1 question
(Moyers, Miller, & Hendrickson, 2005)

40. Learn More about MI
Miller & Rollnick (2013). Motivational Interviewing, 3rd Ed.
Rollnick, Miller, & Butler (2007). Motivational Interviewing in Health Care
Rollnick, et al. (1999). Health Behavior Change
MI home page:
Prochaska, Norcross, & DiClemente (1995). Changing for Good
Stages of change home page:
Bothello (2004). Motivate Healthy Habits
Seminars: