A Taste of Motivational Interviewing Elizabeth Jenkins, Ph.D. Health Behavior Coordinator and Clinical Psychologist James A. Haley VA Hospital Member of the International Motivational Interviewing Network of Trainers

Does working with people ever feel like this?

Motivational Interviewing: Getting Started What challenges have you encountered clinically when working with individuals who are homeless or at risk for homelessness? What are some problem situations that you see that you’d like to see change? What are some of the barriers to helping veterans engage in change?

MI Defined A collaborative, person-centered form of guiding [or clinical method] to elicit or strengthen motivation for change By exploring and resolving ambivalence Not just a series of technique but a way of being with people that improves with considerable practice over time Miller and Rollnick, 2009 Client centered Focuses on ambivalence towards change Elicits WHY change may be important to the individual

The Keys to Readiness Readiness Importance Confidence

Motivational Interviewing and Homelessness MI provides a useful framework for working with individuals who are experiencing homelessness and/or struggling with substance use, mental illness, and traumatic experiences Within the spirit of MI is an appreciation of the challenges for changing learned behaviors, some of which may have been an important part of survival Assumptions of MI (Winarski 2003) Motivation is a state (a temporary condition), not a trait (a personality characteristic) 2) Resistance is not a force to be overcome, but a cue that we need to change strategies http://homelessness.samhsa.gov/Resource/Motivational-Interviewing-Assumptions-and-Principles---A-Broad-Framework-32839.aspx

"People are generally better persuaded by the reasons they have themselves discovered than by those that enter the minds of others...“ Blaise Pascal, Mathematician & Theologian (1623-1662)

Origins of Motivational Interviewing MI started with Bill Miller While on sabbatical in 1983, he was asked to mentor young psychologists about behavioral treatments for alcohol problems Their questions about his style led him to articulate components that were not part of the behavioral therapy per se From that emerged a conceptual model and clinical guidelines for MI

The Model Differential responses to an individual’s speech using an empathic, person-centered style Focus of attention: evoke and strengthen individual’s verbalized motivations for change Rather than confronting the lack of change, the therapist responds with empathic understanding Based on Miller’s observations that arguing for change tends to evoke further defenses for maintaining the status quo American Psychologist September 2009 Empathic understanding was in direct contrast with addiction therapy’s the approach of the day

The Spirit of Motivational Interviewing Motivation for change is elicited from the veteran and not imposed on the veteran. It is the veteran’s task, not the counselors, to articulate and resolve his or her ambivalence. Rollnick & Miller, 1995

What is the Spirit of MI? Draw out vs. implant the right ideas: “What concerns you about your financial situation?” VERSUS “You need to start working.” Allow the freedom NOT to change vs. push for commitment: “How ready are you to change?” “If you delay getting sober, you could die.” Collaborate: “What do you think you’ll do?” “You’ve got to take your medications.” Draw out: What do you feel like you need? What do you see as problematic about your ‘financial situation’? Freedom: How ready are you to make this change? Collaboration: What do you think will help? What do you think you’ll do?

The Spirit of Motivational Interviewing Direct persuasion is not an effective method for resolving ambivalence. The counseling style is generally a quiet and eliciting one. The counselor is directive in helping the veteran to examine and resolve ambivalence. Guiding regarding actual behavior change Directive in examining and resolving ambivalence Rollnick & Miller, 1995

The Spirit of Motivational Interviewing Readiness to change is not a permanent trait but rather a changing state. The relationship provider-patient relationship is closer to a partnership and less like an expert-recipient relationship. These are my words for what rollnick and miller said

Confrontation is not consistent with MI Motivation for change is elicited from the veteran and not imposed on the veteran It is the veteran’s task, not the counselors, to articulate and resolve his or her ambivalence.

Common Misconceptions This person OUGHT to (or should WANT to) change. Patients are either motivated or not. If not, there’s nothing we can do for them. Now is the right (only?) time to change. A tough approach is always best. I’m the expert, so he/she should follow my advice. If the person decides not to change, the consultation has failed. Misconceptions First of all that the pt ought to or should want to change. In truth, most informed pts are ambivalent about their behavior, seeing both benefits and drawbacks. Second, that people are either motivated or not, when in truth, motivation is on a continuum. Some smokers very much want to quit, some don’t want to quit at all, and most are somewhere in the middle—still conflicted, still seeing both benefits and drawbacks to continued use. What looks like “lack of motivation” is often simple ambivalence. When asked, I think you’ll find that both sides are already in the person. So our job is to help the person honestly examine the issue and make an informed choice. The next three assumptions have to do with the style of the interaction. That now is the only time for change, and that a tough firm stance is the only one to take with patients. Given the first five assumptions, is it any wonder that some believe that a failed interaction is one where the patient leaves as yet unconvinced and uncommitted to action?

Guiding principle of MI Have veteran voice the argument for change rather than the therapist

There appears to be a synergistic effect of MI with other treatment methods.

MI influences Change Talk What is “change talk”? Study looking at persuasion with confronting vs. reflective listening & differential reinforcement Participants in MI condition verbalized twice as much change talk and ½ as much resistance MI influences change talk, and change talk predicts behavior change Used sequential coding system (MITI) Psycholinguistic analysis of session tapes subcategories (DARN CATS) desire, ability, reasons, need, commitment Amrhein, Miller, Yahne, Knupsky, & Hochstein 2004 DARN predicted strength of commitment but not behavior change-preparatory steps Commitment strength predicted outcome

Why do we want the reasons for change to come from them Why do we want the reasons for change to come from them? Change talk predicts change!

Principals: The Righting Reflex What is it? The natural inclination we have to make it better for another person What’s the danger? We tell the other person what to do, how to do it, and why they should do it without talking to them and learning what they think It creates resistance in that we move away from the partnering stance of MI and into the expert top down role What to do when you find yourself doing this? Stop and Reset “Mrs. Smith, I realize I have been just lecturing you on how you can deal with your diabetes without learning what you are thinking. Let me back up and hear from you, wherever you would like to start.” More on the Righting Reflex (Directing) [Refer back to the discussion after the Persuasion/Engaging Exercise.]

Tenets of MI: Ambivalence "Lack of motivation" is often ambivalence; both sides are already within the person If you argue for one side, an ambivalent person is likely to defend the other As a person defends the status quo, the likelihood of change decreases Resist the "righting reflex" - to take up the "good" side of the ambivalence [This slide continues to make the point that ambivalence is “natural”. We want to explore ambivalence rather than arguing, directing or righting….. The goal is to have the Veteran explore the pros for change, so they makee the case FOR change, not us….

“Righting” Reflex Ambivalence EAJenkins, 2010

It is the Spirit of MI to… Appreciate Ambivalence

Appreciate Ambivalence Using marijuana Quitting marijuana Benefits of: Helps me relax Helps with pain My friends and I have fun when we smoke I feel fine Stay healthy Save money Stay out of jail Finish probation I am less likely to die Costs of: Doctor lectures me I am broke Nasty cough Legal problems My friends will think I’m boring My pain will be worse I will feel more anxious

MI is Dancing rather than Wrestling… Another image of dancing rather than wrestling; we are in synch, linked, connected, moving together. To get to this level or coordination and partnership takes time and practice!!

So how do we guide, nudge, collaborate with individuals to increase the likelihood that they will engage in behavior change?

Methods Important to MI Open ended questions Affirmations Reflective listening Summaries Humanistic/veteran centered techniques All of these methods help with developing empathy, developing discrepancy, rolling with resistance, and supporting self efficacy. #5 method is eliciting change talk and is unique to MI

Open Ended Questions “What worries you about your current situation?” (disadvantages of status quo) “How would you like your life to be five years from now?” (advantages of change) “What encourages you that you can change if you want to?” (optimism about change) “What would you be willing to try (intention) or what do you think you might do?”

Affirmations “Thanks for coming on time today” “That’s a good suggestion” “It seems like you’re a spirited and strong person” “You enjoy being happy with other people and making them laugh” “You are clearly a resourceful person to cope with such difficulties for so long”

Reflective Listening Veteran: “I know we made all these goals about my getting out and meeting people, but I’m just not comfortable around other people.” Provider: “Getting the support you need hasn’t been easy.” Veteran: “I just don’t like the way my family talks to me about my drinking.” Interviewer: “You’re annoyed with your family.” Patient: “Yes, it just irritates me how they are always judging me.”

How might you reflect this statement? “These medications the doctor prescribed just make me feel tired and depressed. Why should I take meds that make me feel worse?” The way you feel taking the meds seems worse than the way you felt without meds.

How might you reflect this statement? “I am never in one place and so it’s hard to check my blood sugars when I’m supposed to.”

How might you reflect this statement? “Look, it’s not like I’m lazy. I just haven’t found the right job yet. ” You’re feeling judged about this, that somehow people think you are a bad person because you don’t have a job (complex)

Summaries Special form of reflective listening Structure: Indicate you’re about to summarize Be selective Note ambivalence & attend to change statements Be concise! End with invitation Use to change directions or ask a key question NEED EXAMPLE

The four C’s of MI Collaboration: expertise not expert Calling forth: eliciting not telling Control: it is up to the patient to decide Curiosity: not authority The counselor’s style in MI: Collaborative: how can we work on this together? Calling forth: what does the patient think? Control: only the patient can decide Curiosity: not authority

Ways to elicit change talk OARS Evocative questions Importance ruler Pros and cons Elaborating Typical day Querying extremes Looking back and looking forward Exploring goals and values

In Summary A large body of literature shows that MI can directly impact client outcomes Both the relational and technical attributes of MI contribute to outcome Training in MI has been shown to improve clinician performance on MI skills that are themselves related to client outcomes (workshops and coaching combined) w

Where do we go from here? Learning MI takes practice and feedback. Starting with a few skills is usually more effective than trying to use every skill you’ve learned at once. There is community training and ongoing coaching available from individuals who are specially trained in MI (MINT). The VA currently offers training in MI through the Mental Health MI roll out. Your local Health Behavior Coordinator may be able to provide requested training as well.

Sources of Information on MI Motivational Interviewing: Preparing People for Change, Miller and Rollnick, Guilford 2012 Motivational Interviewing in Health Care, Rollnick, Miller, and Butler, Guilford 2007 Ten Things that Motivational Interviewing Is Not, Miller and Rollnick, Behavioural and Cognitive Psychotherapy, 2009, 37, 129-140 www.motivationalinterviewing.org Elizabeth.Jenkins@va.gov or 813-972-2000 ext 4963 Additional training in May 2009 (Advanced MI) Supervision under Dunn and Baer Workshop (Brief Alcohol Interventions, 2008) and personal communication, Chris Dunn, PhD & John Baer, PhD, 2008-2013 Workshops (Introduction to MI and Advanced MI by Cathy Cole, MSSW, LCSW, MINT, 2008-2009) 8 tasks in learning MI Learning the Spirit of MI Learning Person-Centered Counseling Skills (OARS) Recognizing Change Talk and Sustain Talk Evoking and Responding to Change Talk Responding to Sustain Talk and Resistance Negotiating a Change Plan Closing Skills: Consolidating Commitment Integrating MI with Other Treatment Methods