Introduction to Motivational Interviewing (MI) Philosophy & Basic Techniques May 15, 2015

About today’s training Introductory training only Preparation for learning about MI Need to be open to the process Temporarily set aside “expert” role Put assumptions on hold Fully engage in the activities Dr. Eleanor Vincent 2

Objectives Demonstrate an understanding of the MI philosophy and spirit. Distinguish between MI and non-MI techniques. Apply the Stages of Change model to predict change readiness in MI. Describe the basic MI principles. Explain early MI techniques. Use basic MI tools such as the Decisional Balance Sheet, and Interest and Confidence Ruler. Dr. Eleanor Vincent 3

ACTIVITY: Three in a Row List examples of “typical characteristics” of the clients you work with that are “resistant”. Now, consider that you are scheduled to meet with three of these clients in a row and you will be raising the subject of behavior change in these meetings. Write down your emotional reaction to the prospect of the back-to-back sessions with these particular clients. Dr. Eleanor Vincent 4

What is Motivational Interviewing “Client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence”. - Rollnick & Miller, 2002 Stems from working with people in the 1980s who had problems with alcohol. Dr. Eleanor Vincent 5

Efficacy Impressive evidence base: 20 years of MI research and 72 clinical trials have been conducted targeting a wide range of mental health and medical problems (Mason, 2009). Particularly useful with clients who are less motivated or ready to change and more angry or oppositional (Hettema et al, 2005). Can be easily applied in Managed Care settings (cost containment) Taps into client resources and enhances treatment adherence. Limitations: originally designed to prepare clients for treatment, not as a self-contained method (Miller & Rollnick, 2002). Dr. Eleanor Vincent 6

The MI Spirit Collaboration: working in partnership with the client. Evocation: learning from the client through listening and eliciting. Autonomy: client is responsible for change and the professional should respect his/her ability to choose. Dr. Eleanor Vincent 7

Basic Assumptions of MI Motivation is a state of readiness to change that fluctuates with time and situations. Motivation often involves an interaction. People who consider making a change often have mixed feelings or ambivalence. Ambivalence is a normal part of the change process! Dr. Eleanor Vincent 8

4 Principles of MI Express Empathy Develop Discrepancy Roll with the Resistance Support Self-Efficacy Dr. Eleanor Vincent 9

Prochaska & DiClemente’s Stages of Change Readiness Pre-contemplation Not yet considering change Contemplation Considering change but remains ambivalent Preparation Committed to change and planning to make change in the near future Action Actively taking steps towards change but has not stabilized Maintenance/Relapse Prevention Achieved change/stabilized: also known as the “Holding” Stage Dr. Eleanor Vincent 10

Evoking Change Talk (DARNC) Desire: why would you want to make this change? Ability: how might you go about it in order to succeed? Reasons: what are the three best resources for you to do it? Need: how important is it for you to make this change? Commitment: so what do you think you will do? Change versus sustain talk. Dr. Eleanor Vincent 11

ACTIVITY: Persuasion Exercise Form a triad of client, therapist, and observer. The therapist will try to persuade the client to commit to the behavior change. The observer will note each time they recognize a MI Roadblock to Listening (Provided) 1. Ordering, directing, or commanding 2. Warning or threatening 3. Giving advice, making suggestions, or providing solutions 4. Persuading with logic, arguing, or lecturing 5. Moralizing, preaching, or telling clients what they “should” do 6. Disagreeing, judging, criticizing, or blaming 7. Agreeing, approving, or praising 8. Shaming, ridiculing, or labeling 9. Interpreting or analyzing 10. Reassuring, sympathizing, or consoling 11. Questioning or probing 12. Withdrawing, distracting, humoring, or changing the subject Dr. Eleanor Vincent 12

Persuasion Exercise Explain why the person should make this change. Give at least three specific benefits that would result from making the change. Tell the person how they could make the change. Emphasize how important it is for them to make the change – this might include negative consequences of not doing it. Encourage/persuade the person to do it. If you encounter “resistance”, repeat the above, more emphatically 13 Dr. Eleanor Vincent

Some MI Traps Question/Answer Confrontation/Denial Expert Labeling Premature Focus Blaming Dr. Eleanor Vincent 14

Core MI Strategies Open-ended questions Affirming Reflective listening Summarizing GOAL: Elicit positive “change talk” Dr. Eleanor Vincent 15

Open-ended questions to promote change Problem recognition How do you feel about your current alcohol use (or health)? Expression of concern What worries do you have about your alcohol use (health)? Intention to change What would you like to do about this? Optimism What makes you feel now is a good time to get started? Dr. Eleanor Vincent 16

Reflective Listening Is a process of… Hearing what the speaker has to say, Making a “guess” at what he/she means, Giving voice to this “guess” in the form of a statement. Dr. Eleanor Vincent 17

Levels of Reflection Repeating Rephrasing Paraphrasing Reflecting Feeling Dr. Eleanor Vincent 18

ACTIVITY – Reflective Listening Exercise In pairs, talk about a behavior you have been wanting to change, yet are struggling with. One person is the “listener”, the other speaks. At the end of 1.5 minutes, the “listener” uses reflective statements to summarize what the person has been saying, including at least one “feeling” statement. Dr. Eleanor Vincent 19

Assessing Readiness/Eliciting Change Open-ended questions and reflections Interest and Confidence Ruler Decisional Balance Dr. Eleanor Vincent 20

Interest and Confidence Ruler Interest On a scale of 0 to 10, with 10 being very interested, how interested are you to…(Target behavior)? Not at all Somewhat Very Confidence On a scale of 0 to 10, with 10 being very confident, how confident are you that you could succeed? Not at all Somewhat Very Dr. Eleanor Vincent 21

Interest and Confidence Probes Could have been higher You said your interest was… why a … and not 8 or 9? The answer should tell you what road blocks the person has to overcome. Could have been lower You said your confidence was a… why a … and not a 1 or 2? The answer should tell you what the person considers good about the change, how resourceful he/she feels, and what is positive to him/her about the change. What would it take to make it 10? Opportunity for the person to come up with their own solutions, tactics, ways to remove road blocks. Dr. Eleanor Vincent 22

Activity: Decisional Balance Worksheet Using the Decisional Balance Worksheet, weigh the costs and benefits of the behavior change you are contemplating. Consider the “good” aspects of the behavior/reason not to change; and the “not so good aspects” or reason to change. In pairs, talk your rationale for why you list certain things on one side of the balance sheet as opposed to the other. Identify any discrepancies between your goal and your current behavior. 23 Dr. Eleanor Vincent

Recognizing Change Talk I guess this has been affecting me more than I realized I feel terrible about how (----) have hurt my family I don’t know what to do but something has to change Tell me what I would need to do if I went into treatment If I really put my mind to it, I can do it VERSUS I don’t have a problem with ______ I’m not the one with the problem No way am I giving up ______ I’m not going to the hospital/to see a doctor I have so much else going on right now that I can’ think about.. 24 Dr. Eleanor Vincent

Other Important Aspects of MI Get permission In general: “I’d like to spend a few minutes talking about…Is that ok with you?” If offering advice: “if you wish I could share with you some other strategies people have found helpful in…” Dr. Eleanor Vincent 25

Other Important Aspects of MI Providing Information Ask for permission: don’t provide information just to check it off your “list”. Provide only the information the person wants. Provide a menu of ideas rather than an answer without options when clients ask you what to do. Dr. Eleanor Vincent 26

Some other considerations Some clients are not ready to change. Some clients may have poor verbal skills or may have a primary language that is different from yours. How much time can you give to the process? What does your organization/practice require? When should you refer the person? Ethnic and cultural considerations. Follow-up. Dr. Eleanor Vincent 27

MI Key Points Eliciting self-motivational statements from clients about their own reasons for change is important. Prochaska & DiClemente’s stages of change underlies the readiness concept. It is intended to resolve ambivalence and get a person moving toward change. It is empowerment oriented! Dr. Eleanor Vincent 28

MI Key Points Respond to change talk. Couch your responses through the stages of change readiness for THAT issue. MI proficiency takes practice and feedback. Many people find it deceivingly simple. Supervision is critical. Dr. Eleanor Vincent 29

Ten things MI is not! (Miller & Rollnick, 2008) Based on the stages of change model. A way of tricking people into doing what you want them to do. A specific technique (it’s a counseling approach). Decisional balance, equally exploring pros and cons. Assessment feedback. A form of CBT. Just client-centered therapy. Easy to learn. What we were already doing. A panacea for every clinical challenge. Dr. Eleanor Vincent 30

The Key to Success… Be Present, Be Compassionate, LISTEN…. And Let the client NOT you, be responsible for the change. Remember, it is a dance not a wrestling match!!!!! Dr. Eleanor Vincent 31

MI Resources Addiction Transfer Technology Centers (ATTC) Website available at Hettema, J., Steele, J., & Miller, W.R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1, Mason, M.J. (2009). Rogers redux: Relevance and outcomes of motivational interviewing across behavioral problems. Journal of Counseling & Development, 87, Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York, NY: Guildford Press. Dr. Eleanor Vincent 32