1. An introduction to Motivational Interviewing: A brief intervention Angela Kubacki akubacki@sgul.ac.uk Katherine Joekes

2. Learning Objectives By the end of this session you will be able to: – Outline the main principles of Motivational Interviewing (MI) – Discuss some of the evidence that supports MI – Understand “the Spirit of MI” – Demonstrate an ability to implement some of the principles of Motivational Interviewing when discussing health behaviour change

3. What is Motivational Interviewing? “A collaborative, client-centered form of guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2009), by exploring and resolving ambivalence.”

4. What is Motivational Interviewing? A clinical method aimed at helping patients to recognise and do something about their current or potential problems. A directive, patient-centred consultation for eliciting behaviour change by helping patients to explore and resolve ambivalence.

5. Uses for Motivational Interviewing... Smoking cessation Promoting condom use Weight loss Pedometer use Medication concordance Exercise uptake Preoperative cardiac surgery preparation Source: Anstiss (2009); Knight et al (2006) Chronic pain management Stroke rehabilitation Fibromylagia Diabetes management Victims of domestic abuse Chronic leg ulcers Mental health problems including depression, anxiety, obsessive compulsive or eating disorders and dual diagnosis

6. Is it effective? Two review studies (including 72 studies) suggests that it is. MI had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases (Rubak et al, 2005). Found robust and enduring effects when MI is added at the beginning of treatment (Hettema et al, 2005). More recent update: Lundahl et al (2010)

7. Threat messages are less effective A meta-analysis of fear appeals including 93 studies (Witte & Allen, 2000) showed that: Strong threat messages show a small effect (of limited clinical relevance) on behaviour change, but…. …only when combined with a sense of personal efficacy (i.e. how confident a person feels about changing the behaviour) and personal relevance.

8. Major components of MI 1. The underlying spirit of MI 2. Ambivalence : Identifying pro’s and con’s 3. Assessing ‘importance’ and ‘confidence’ 4. Specific communication skills 5. ‘Rolling with resistance’ 6. The 4 A’s

9. 1. Underlying Spirit of MI Collaboration not confrontation Eliciting not Instilling Autonomy not Authority “After all, when you seek advice from someone, it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself” Terry Pratchett, Jingo

10. Dangerous assumptions? The person ought to change The person wants to change This person is primarily motivated by ______ People are either motivated or not Now is the right time to consider change A tough approach is always best I’m the expert – he/she must follow my advice

11. 2. Ambivalence: Pro’s and Con’s Identifying the advantages & disadvantages of the existing & new behaviour ‘CHANGE TALK’

12. Research has shown that change talk is the most important predictor of successful change (Miller & Moyers, 2006) and demonstrates a shift from ambivalence towards confidence and motivation. Change talk is identified by your patient’s increasing use of phrases that move from “I could” or “I might” to “I will”, “I can”, and “I’ll do” (Scott, 2010). MI and eliciting “change talk”

13. “Exploring Ambivalence” / “Thinking Critically” ProsCons If I Continue Smoking Social ‘Easy’ Smelly Expensive Have to stand outside If I Quit Smoking Healthier Boyfriend Extra cash Proud of self Stressful Setting self up for failure

14. 3. Importance and confidence “On a scale of 1 to 10.....” motivation high low high importance confidence

15. 4. Specific Communication Skills open questions listening & silence affirmation Reflection (2 to 3 times more reflection than questions) summarising

16. Levels of reflection Repeating Rephrasing/paraphrasing Reflection of feeling Double-sided reflection Amplified reflection “I really do want to lose weight. I mean, I want to feel better and be healthy, but I’ve tried so many diets but they don’t work and I just can’t help myself.”

17. 5. ‘Rolling with resistance’ Avoid arguing for change Emphasise personal control Summarise, and reflect feeling Remember: Resistance is a signal to respond differently

18. 6. The 4A’s: How to structure a brief intervention Ask Advise Assist Arrange

19. Motivational interviewing case study role development (10 minutes) Role play in triads (40 minutes) A- patient B- GP C- observer/timekeeper Summary and consolidation (10 minutes) PRACTICE EXERCISE

20. Major components of MI 1. Underlying philosophy of MI 2. Ambivalence : Identifying pro’s and con’s 3. Assessing ‘importance’ and ‘confidence’ 4. Specific communication skills 5. ‘Rolling with resistance’ 6. The 4 A’s Remember: Take account of readiness to change

21. So What Is Motivational Interviewing ? It is a particular approach that can be adopted within a consultation to discuss health behaviour change It takes into account that not everybody is ready for change It uses specific communication skills It avoids confrontation or ‘scare tactics’ Effective when implemented as a ‘brief intervention’

22. The Spirit of MI Ask yourself these questions: Am I genuinely interested in people? Am I able to accept other people as they are or do I have a desire to direct or change them? Am I willing to understand others? From : www.hma.co.nz/Files/PI-The-spirit-of-Mot-Interview.pdf by Margaret Robinson

23. The Spirit of MI Ask yourself these questions: How comfortable am I in letting go of being an expert? How able am I to let go of solving other people’s problems? How confident am I that patients have inner resources to change? From : www.hma.co.nz/Files/PI-The-spirit-of-Mot-Interview.pdf by Margaret Robinson

24. References Anstiss T (2009) Motivational interviewing in primary care. Journal of Clinical Psychology in Medical Settings; 16: 87-93. DiClemente CC & Velasquez MM (2002) Motivational Interviewing and the Stages of Change In: Motivational Interviewing. Preparing People for Change. Miller WR & Rollnick S (eds). Guilford Press: New York. Hettema et al (2005) Motivational interviewing. Ann Rev Clin Psychol, 1, 91-111. Knight KM et al (2006) A systematic review of motivational interviewing in physical health settings. British Journal of Health Psychology; 11: 319-32. Lundahl et al (2010). A Meta-Analysis of MI: Twenty-five years of empirical studies. Research on Soc Work Practice, 20: 13.

25. References Mason P, Butler C & Rollnick S (2010) Health Behavior Change. A guide for practitioners. Churchill Livingstone/Elsevier: Edinburgh. Miller WR & Rollnick S (2009). Ten things that Motivational Interviewing is not. Behavioural & Cognitive Psychotherapy, 37, 129-140 Miller WR & Moyers TB (2006) Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions; 5: 1, 3-17. Rubak et al (2005) Motivational Interviewing: a systematic review and meta-analysis. Br J of Gen Pract, 55, 305-312. Scott, G (2010) Motivational interviewing I: background, principles, and application in healthcare. Nursing Times; 106:34, early online publication. Acknowledgement: Thanks to Dr Lisa McNally and Pip Mason for materials