1. Motivational Interviewing
Yolanda N. Evans MD MPH
Seattle Children’s Hospital

2. Case
Tory is a 16 year old coming to see you because parents are concerned about depression
You excuse parents from the room
Emphasize confidentiality when speaking with Tory alone
You begin to ask Tory questions. The responses are…
‘I don’t know’
Shoulder shrug
Now what?
Over this hour, we’ll plan to help give ideas and tools on how to engage teens in conversation. We’ll go through some Motivational Interviewing skills, but really want this to be a discussion amongst all of us. We’d like to hear your experiences and share our own on what’s worked and what hasn’t when engaging teens in conversation.

3. Addressing Ambivalence
Feeling two ways about a thing
Common prior to and during habit change
Examples:
Difficulty scheduling appointments
Missed appointments
Intervention plans not being followed
Goals of family have little substance
Treatment progress uneven
Family members not forthcoming about important issues

4. Principles of Motivational Interviewing
Collaborative
Evocative
Honor Autonomy
Instead of the expert clinician directing, there is an active collaborative conversation and joint decision-making process
Evoke from patients what they already have; activate their own motivation
Requires an acceptance that people can and do make decisions about the course of their lives
Erik

5. O.A.R.S. Build rapport Open ended question Summary statement
Affirmations Reflective listening
Summary statement
Before beginning: ask permission
O.A.R.S is the cornerstone of Motivational Interviewing. (BTW way, all of this is in your notes)
Skills you likely already have
Essential for good rapport development
Backbone of MI
Before beginning – always ask permission
Example: is it OK if we take a few minutes to talk about your activity level today? Many other examples in your job aid that we are providing today.

6. O.A.R.S. Open-ended Questions
Invites person to reflect and elaborate
Helps to understand their internal frame of reference
Creates impetus for forward movement to help the person explore change
3 minutes
Cannot answer yes or no…
Instead of, “Are you making sure your child is physically active every day?” ask: “what activities do you enjoy with your child?”
Instead of, “Do you fix your child breakfast every morning?” ask: “what do you like to have for breakfast?”

7. Closed-ended vs Open-ended Questions
Did you…
Can you…
Will you…
Is it…
Open-ended
To what extent…
How often…
Tell me about…
What, if any,…
More examples

8. #2 Practice Open-ended Questions
Speaker: Describe what you are working on
Listener: Goal of understanding the dilemma. Give no advice.
Why might you want to make this change?
How might you go about it, in order to succeed?
What are three reasons to do it?
Observer: Reflect on interaction and provide feedback using worksheet as a guide.
How did it go?
What did you notice (body language, tone, likelihood of change)?
How did the speaker feel? How did the listener feel?
2-3 minutes each
How did this feel different? 8

9. O.A.R.S.: Affirmations Statements of recognition about strengths
Helps person feel change is possible
Point out strengths where only failure is perceived by individual
Consider partial successes
Use resistance
Examples:
I see you had breakfast once this week
Although you didn’t succeed, I saw how hard you worked
I see your struggling with this, but it’s shows you are interested in changing because you’re here
3 minutes
This is important to you vs. that is great that you are here.
I see that this is a difficult thing to talk about for you. A bit of struggle with how to answer my question shows that you are thinking about it! In fact, this is better than last week when you refused to talk with me.

10. O.A.R.S.: Reflective Listening
Helps you understand what’s working or not
Statement, not question
Trust and rapport will deepen even if you don’t get it “right”
Ex.: “I hear you are making progress and taking a walk a couple of times per week”.
ALSO: If wrong or individual not ready to deal with, he/she corrects you and the conversation moves forward

11. Reflective Listening Starts with:
So…
Sounds like…
You…
So, one hand…But on the other…
Use 2-3 reflections before moving on to next question
Can be a skill to use when “stuck”
If you are right, emotional intensity of session will deepen.
If wrong or person not ready to deal with, they’ll correct you and the conversation moves forward

12. O.A.R.S. Summaries
Communicates interest in the person and helps develop rapport
Can shift direction if necessary
How to do this:
Begin with announcement that you are about to summarize
Be selective and concise
Note ambivalence
Invitation to correct anything
End with an open–ended question
So you were nervous about coming here but you decided to try to have breakfast. Come up with good example -

13. #5 Practice OARS #3 Speaker: Describe what you are working on
Listener: Goal of understanding the dilemma using open-ended questions, affirmations, reflective listening and summaries. Refer to handout.
Observer: Reflect on interaction and provide feedback using worksheet as a guide.
How did it go?
What did you notice (body language, tone, likelihood of change)?
How did the speaker feel? How did the listener feel?
2-3 minutes each

14. Change Talk If you hear anything close to: Desire (want, like, wish)
Ability (could, can, might be able to)
Reasons (argue for change)
Need (ought to, have to, really should)
This will open the door to talk about commitment and possible plan/goals.
Desire: I would like to keep up with my friends; I want to buy some fun clothes;
Ability: I could set my alarm 5 minutes earlier; Mom: I could set some breakfast items right when I get up; I might be able to walk to the bus
Reasons: I need to have more energy to stay up late; I would probably feel better if I ate lunch
Need: I must get some sleep; I really need to get some exercise
I really should eat breakfast (need) but I can’t get up (ability) = ambivalence
So it sounds like you are thinking about having breakfast, but you are wondering how to make that happen. Could we talk about this a bit more?

15. Case – an update You begin by engaging Tory using OARS
Weekly visits over the next few months have lead to…
Attending school with accommodations
Playing soccer
Significantly reduced household stress!

16. Reflections on patient care
MI takes practice
It’s easy to go back to ‘old habits’
Patient engagement is a good indicator of effective MI

17. How to engage in culturally appropriate care?
What aspects of MI fit with your patient population?
What things might not work?
How might the cultural background of your patients shape the clinical encounter?

18. Discussion/Questions