1. Motivational Interviewing: Conversations that lead to Change
Carol DeFrancesco, MALS, RD
Division of Health Promotion and Sports Medicine, OHSU
Special thanks to: Denise Ernst, Steve Berg-Smith and Bill Miller

2. Motivation changes with our style of interacting.

3. Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.
Motivational Interviewing (MI) is a method of enhancing someone’s intrinsic motivation to change - client-centered - directive

4. Why is Motivational Interviewing (MI) a method to consider?
MI has substantial evidence base supporting it’s effectiveness in facilitating change in behaviors that are hard to change
MI is effective with both psychological (behavior change) and physical outcomes (BMI, BP, BAC)
MI focuses the responsibility for change on the patient; encourages self-management and self- determination

5. The efficacy of MI –meta analyses
MI out performs traditional advice giving in 80% of studies
Effective in minutes
More encounters over longer time period increase likelihood of an effect
Health professionals (MDs, RDs, RNs) can be as effective as psychologists or counselors

6. Profound Positive Influence Discussion

7. The Spirit of MI
Evocation of person’s motivation, hopes, dreams, desires, values, goals, and abilities.
Partnership with the person; MI is done “for” and “with” a person and not “to” a person.
Acceptance including accurate understanding, affirmation, absolute worth of the person, and support of the person’s autonomy.
Compassion; active promotion of the person’s welfare and needs.

8. Self-Efficacy & Hope A person must have hope
This is predictive of how they will do
A provider’s expectation is also predictive
Bandura’s Theory of Self-Efficacy

9. Sitting on the fence of change
Your PE teachers may be ambivalent about the participating in the study – It may be a good thing for me and my students – but I am sick of the principle telling me what to do or sounds like really good stuff – could help me with my curriculum and get my kids more active but goooodddd I don’t have the time – you may feel may feel ambivalent too – This study has great goals but eeekks I’m not really looking forward to working with resistant teachers – or hey this is a great workshop, but Oregon also looks like a great place to go and see and do

10. Cowboy from Klamath Falls
People get defensive when their autonomy is threatened
And what we do strongly influences the amount of defensiveness we see in our teachers/clients – Let me tell you a story that illustrates this – K-falls story – wrap-up

11. What happens if you give advice to a person on the fence
What happens if you give advice to a person on the fence Gas station story
draw a fence – if I am articulating the reasons on one side – what am I leaving for the other person to talk about – Let me give you an example – Gas station story

12. Sustain Talk
The least desirable situation, from the standpoint of evoking motivation, is: when the health provider advocates for change while the patient argues against it

13. Most of us already have pro-change reasons of our own
Most of us already have pro-change reasons of our own. These reasons are more persuasive than those of others.
When Bev talked about know what you want – this is a good thing to keep in mind – you want your PE teachers to articulate reasons to be in the study not excuse – we will work on skills for how to do this – Eliciting counter change talk statements decreases motivation
Bem’s Self-perception theory

14. Strength Cards and Break

15. Specific Skills: OARS
OPEN Questions
AFFIRMATIONS
REFLECTIONS
SUMMARIES

16. Reflective Statements
Statements not questions
Restates what patient says and selectively reinforces change talk
Puts the patient in a more active role when discussing behavior change

17. Reflective Statements
Pt: ‘I need to lose weight.’ Provider: “Being overweight has got you concerned.”
Pt: ‘Healthy food is more expensive.’ Provider: “You are wondering if you can afford to change your eating habits.”
Pt: “I know I could eat better.” Provider:
Pt: “I don’t have time to exercise.” Provider:

18. Forming Reflections with Strength cards: Large group activity then pairs

19. Why not simply ask questions (from Miller & Rollnick 2013, pp 52-53)
“Why respond with a statement After all the listener is not sure if the guess is correct.”
A question requires a response; it places a demand on the other person
Pressing people with questions to explain themselves distances them from what they are experiencing – they step back to analyze and question what they have expressed.
A well formed reflection encourages continued exploration and minimizes defensiveness

20. Debrief Strength Activity

21. OARS
OPEN Questions
AFFIRMATIONS
REFLECTIONS
SUMMARIES

22. Questions that Evoke Change Talk (from Miller & Rollnick 2002)
Category:Disadvantages of the status quo
What concerns you about _______?
What makes you think you need to do something about _______?
What hassles have you had in relation to your smoking (or other behavior)?
How has this stopped you from doing what you want to do in life?
What do you think will happen if you don’t change anything?

23. Questions that Evoke Change Talk (from Miller & Rollnick 2002)
Category: Advantages of change
How would you like things to be different?
What would be the good things about ______?
What would you like your life to be like five years from now?
What are the main reasons you see for making a change?
What do you want?

24. Questions that Evoke Change Talk (from Miller & Rollnick 2002)
Category: Optimism about change
If you decide to make a change, what would you do to be successful?
What do you think would work for you if you decide to change?
When else in your life have you made a significant change like this? How did you do it?
What personal strengths do you have that will help you succeed?

25. Questions that Evoke Change Talk (from Miller & Rollnick 2002)
Category: Intention to change
What are you thinking about your smoking (eating habits, exercise) at this point?
What do you think you might do?
What would you be willing to try?
What do you want to have happen?

26. Affirmations & Self-affirmations
Emphasize a strength (What strengths do you have that will help you be successful?)
Appreciate a positive action (What is working for you?)
How are you keeping yourself healthy?

27. Summaries can: Collect material that has been offered
So far you’ve expressed concern about your pacing, sleep, and options for pain medications.
Link something just said with something discussed earlier.
That sounds a bit like what you told me about that before when you were successful in changing. . .
Draw together what has happened and transition to a new task
Before I ask you the questions I mentioned earlier, let me summarize what you’ve told me so far, and see if I’ve missed anything important. You came in because you were feeling really sick, and it scared you

28. Listening… How to stop the talkers….
Summarize and use a bridging statement
I’d like to shift gears… go back to something you mentioned…
Discuss time limitations
Give value to what you have heard
“We have talked about a lot of things today, if you had to pick on one to work on…”

29. OARS Batting Practice
OPEN Questions
AFFIRMATIONS
REFLECTIONS
SUMMARIES

30. Most of us already have pro-change reasons of our own
Most of us already have pro-change reasons of our own. These reasons are more persuasive than those of others.
When Bev talked about know what you want – this is a good thing to keep in mind – you want your PE teachers to articulate reasons to be in the study not excuse – we will work on skills for how to do this – Eliciting counter change talk statements decreases motivation
Bem’s Self-perception theory

31. Sustain Talk
The least desirable situation, from the standpoint of evoking motivation, is: when the health provider advocates for change while the patient argues against it

32. Listening for Change Talk
Levels:
Preparatory
- I need to, I’ve been thinking about, I’ll try, I want to, I can
Commitment
- I will, I am going to, I have already started

33. Change Talk Levels Court room oath: Wedding Vows
“Do you swear to tell the truth, the whole truth and nothing but the truth, so help you God?”
Wedding Vows
“Do you Jen take Bill to be your husband Will you love him and honor him, in sickness and in health ?”

34. Four Foundational
Processes
Planning
Evoking
Focusing
Engaging

35. Demonstration

36. Set the stage and engage
Conversation Roadmap
Set the stage and engage
“I would like to spend about 10 minutes talking about your eating habit goals, would that be OK?” “What are you already doing to eat healthy?” “What do you notice ”
Decide where to focus
“There are a number of things that go in to healthy eating: more vegetables and fruits, less junk or sugar, regular meals . . Where do you feel ready to make a change?”

37. Healthy Eating Ideas Eat out less Eat regular meals Drink less soda
Cut back on sugar
Increase fruits & vegetables
Shop for food regularly
Drink less soda

38. Plan when client is ready Summarize and Close
Conversation Roadmap
Evoke deeper reasons
“Why did you choose . . .?” “Why else would this be a good thing?”
Plan when client is ready
“What are you willing to try?”
Summarize and Close
“Let me see if I got it all . . .What are you ready to commit to in the next couple weeks?”

39. Your turn: Groups of 3 handout

40. Debrief:
Speakers first: “What seemed to further your change process?”

41. Debrief:
Listeners
What did you notice?

42. “It is through the power of our listening, not the wisdom of our words that we are able to affect the most change”
Carl Rogers