HOW CAN I PUT MOTIVATIONAL INTERVIEWING INTO PRACTICE? Lynn S. Massey, LMSW University of Michigan Departments of Psychiatry and Emergency Medicine

Why do people change? Consequences Dose of treatment Faith, hope, “self-efficacy” Counselor effects – empathy vs. confrontation Change talk Willing to Change - importance Able to Change - confidence Ready to Change - priority Steve

MI Integration in Behavior Change Counseling Behavior change is at the heart of most modern health care concerns (heart disease, obesity, depression, cancers, diabetes, liver disease, respiratory problems) Most health care practitioners have conversations / encounters regarding behavior change in daily work More attention has been on information vs how to approach (style) behavior change with the person

What types of settings? Mental Health Substance Abuse Access/Intake Primary Care Emergency Department Hospital School Setting Probation

How do I determine if MI would be useful in my setting? Are you working with people who need/want to change a behavior? Are you working with people who would benefit from being more motivated? Would you like to increase participation in a treatment program?

Overworked

Elements of mi MI Spirit Change Talk OARS MI Principles Reference: Rosengren, D. B. (2009). Building Motivational Interviewing Skills; A Practitioner Workbook. NY: The Guilford Press.

Learning Motivational Interviewing: Is a process of learning about and using strategies to boost problem recognition, motivation and strengthen commitment to change Steve

Assumptions of mi Motivation “the probability that a person will enter into, continue, and adhere to a specific change strategy” or plan Motivation is a dynamic state (of readiness to change) Part of clinician’s job Occurs in an interpersonal context “Noncompliance”, “resistance” and ”lack of motivation” are all partially due to therapists strategies

Assumptions of MI Ambivalence is normal, acceptable and understandable helps clinician to appreciate the complexity of the individual and their situation is at the heart of motivation Usually mistaken for resistance (yes, but…)

Elements of mi: MI SPIRIT Change Talk MI Principles OARS Reference: Rosengren, D. B. (2009). Building Motivational Interviewing Skills; A Practitioner Workbook. NY: The Guilford Press.

MI SPIRIT Empathy – genuine curiosity about client’s perspective (understanding) MI Spirit: Collaboration – fostering power sharing in the interaction Evocation – elicitation / acceptance / understanding of client’s own ideas about change Respect Autonomy – active fostering of client perception of choice

Elements of mi: OARS OARS MI Spirit Change Talk MI Principles Reference: Rosengren, D. B. (2009). Building Motivational Interviewing Skills; A Practitioner Workbook. NY: The Guilford Press.

Early strategies: OARS Open Ended Question: (“are you concerned about your health?” vs “to you, what are important reasons to cut down on your drinking?”) Affirmation: (“It really sounds like you have been committed to being the best father you can”) Reflection: (“It sounds like on one hand you feel …..and were scared by the emergency room visit, but on the other hand, you don’t want to give up drinking completely right now”) listening Summary(“Let me try to pull together what we have been talking about, let me know if I missed something……”) Kate

Responding to Resistance Simple Reflection – you feel stuck, etc. Amplified Reflection – C: My wife thinks its worse than it is. I: It seems to you she has no reason for concern. Double-sided Reflection - You don’t like the way this makes you feel sometimes, and you’re not sure how you might change things. Reframing – C: I’ve tried to quit 3 times and failed. I: You’ve given it 3 good tries, and every try gets you closer. Its probably helped you learn some things that will and won’t work for you. Emphasize personal choice and control – What you decide to do is completely up to you

Elements of mi: MI Principles MI Spirit Change Talk MI Principles OARS Reference: Rosengren, D. B. (2009). Building Motivational Interviewing Skills; A Practitioner Workbook. NY: The Guilford Press.

4 Principles of MI Acceptance of people as they are frees them to change whereas non- acceptance immobilizes the change process Between present behavior and broader goals and values; helping people get un-stuck Avoid arguing for change; new ideas/goals/options are not imposed; used as a signal Belief in ability to change is a powerful predictor of change; counselor self-fulfilling prophesy

MI principles Practitioners want to help! Leads to strong urge to correct behavior that is harmful – Righting reflex. But, it is a natural human tendency to resist persuasion – Resist The patients own reasons for change are much more powerful than ours – Understand The answers regarding behavior change come from the patient – Listen Outcomes are better when patient takes and active role in deciding on outcomes - Empower

Elements of mi: Change talk MI Spirit Change Talk MI Principles OARS Reference: Rosengren, D. B. (2009). Building Motivational Interviewing Skills; A Practitioner Workbook. NY: The Guilford Press.

Change Talk (Bem Self Perception Theory) “It is the truth we hear ourselves speak rather than the treatment we receive that heals us.” - O. Hobart Mowrer Lynn – Change Talk

Desire, Ability, Reasons, Need The Flow of Change Talk MI Desire, Ability, Reasons, Need Commitment Change

Eliciting Change Talk Evocative Questions Importance Ruler Exploring Decisional Balance Querying Extremes (worst thing if you continue. . ., best things if you change) Looking Back (prior to the problem and compare with now) Looking Forward (If you make a change . . ., Suppose you don’t make a change, what do you think your live might be like)

Video example http://www.youtube.com/watch?v=URiKA7CKtfc Reference: Demonstration of the motivational interviewing approach in a brief medical encounter. Produced by University of Florida Department of Psychiatry. Funded by Flight Attendant Medical Research Institute Grant #63504

PRIMARY CARE

Brief Interventions in the ED

Virtual Therapist

Brief Intervention

Brief Intervention

Brief Intervention

RESOURCE: thank you MI website to visit: www.motivationalinterview.org Contact information: Lynn Massey, LMSW lsmassey@med.umich.edu