1. Cherokee Health Systems Introduction to Motivational Interviewing Mary Clare Champion, Ph.D. Cherokee Health Systems Kentucky Primary Care Association Annual Meeting October 18, 2011 Lexington, KY

2. Cherokee Health Systems What is Motivational Interviewing? “Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” www.motivationalinterview.org “Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” www.motivationalinterview.org

3. Cherokee Health Systems What is the spirit of this style of interaction? Motivation comes from within client, not imposed from outside Client is responsible, not the clinician, for identifying ambivalence Direct persuasion is not recommended Motivation comes from within client, not imposed from outside Client is responsible, not the clinician, for identifying ambivalence Direct persuasion is not recommended Style is generally quiet Clinician helps client examine and resolve ambivalence Readiness to change is a ever-changing product of the relationship Relationship between client and clinician is more of a partnership.

4. Cherokee Health Systems Goals? Avoid creating resistance –Avoid direct arguments or direct confrontations “If you don’t stop smoking now, you’re going to die before you’re 40.” Avoid creating resistance –Avoid direct arguments or direct confrontations “If you don’t stop smoking now, you’re going to die before you’re 40.”

5. Cherokee Health Systems Goals Elicit self-motivation –Patient says, “I remember having more energy when I was exercising regularly.” Elicit self-motivation –Patient says, “I remember having more energy when I was exercising regularly.”

6. Cherokee Health Systems Goals Work to create a discrepancy between the patient’s current behaviors and their goals and values for the future –“I‘d like to feel better,” “I’d like to not take so many medicines.” Work to create a discrepancy between the patient’s current behaviors and their goals and values for the future –“I‘d like to feel better,” “I’d like to not take so many medicines.”

7. Cherokee Health Systems Assessing Motivation Keep in mind motivation should come from within, not imposed from without.

8. Cherokee Health Systems How important is it for you to change this aspect of your behavior on a scale of 1-10? Why not lower? What makes you want to change this aspect?

9. Cherokee Health Systems How ready are you to change this aspect on a scale of 1-10? Why not lower? What makes you want to change?

10. Cherokee Health Systems How confident are you that you can make that change on a scale from 1-10? Why not lower? What makes you want to change?

11. Cherokee Health Systems Why does this work? When we ask patients to tell us why they want to change, we help them identify why they want to change. Positive prompts help highlight positive motivation. When we ask patients to tell us why they want to change, we help them identify why they want to change. Positive prompts help highlight positive motivation.

12. Cherokee Health Systems Why not more direct challenges? Statements that challenge the patient tend to put them on the defensive. Reactions tend to create an “us versus them” situation. Patients are prompted to give us excuses or to tell us why they can’t/don’t want to change. Statements that challenge the patient tend to put them on the defensive. Reactions tend to create an “us versus them” situation. Patients are prompted to give us excuses or to tell us why they can’t/don’t want to change.

13. Cherokee Health Systems Listen and Reflect Listen to patient’s responses to the above questions, then reflect answer back to them. –“It sounds to me like you’d like to make some healthier choices regarding your health, but you’re worried making those changes will be challenging.” Listen to patient’s responses to the above questions, then reflect answer back to them. –“It sounds to me like you’d like to make some healthier choices regarding your health, but you’re worried making those changes will be challenging.”

14. Cherokee Health Systems Why? When our patients feel that we have listened to them and have heard what they are saying, they feel more understood, and can be more open to our suggestions and interventions.

15. Cherokee Health Systems Basic Techniques O – Open ended questions A -- Affirmations R – Reflective Listening S – Summaries Easy to remember – OARS give us power to move, especially with sustained effort O – Open ended questions A -- Affirmations R – Reflective Listening S – Summaries Easy to remember – OARS give us power to move, especially with sustained effort

16. Cherokee Health Systems O – Open-ended Questions Cannot be answered with “yes/no” –“Tell me about what brings you here today?” –“Fill me in on what’s been going on since we last met?” –“Why do you feel like it might be time for a change?” Cannot be answered with “yes/no” –“Tell me about what brings you here today?” –“Fill me in on what’s been going on since we last met?” –“Why do you feel like it might be time for a change?”

17. Cherokee Health Systems A -- Affirmations Build rapport Must be sincere Recognize client’s strength Build rapport Must be sincere Recognize client’s strength

18. Cherokee Health Systems R – Reflective Listening LISTEN! Vary levels – can reflect content as well as affect Keep momentum going LISTEN! Vary levels – can reflect content as well as affect Keep momentum going

19. Cherokee Health Systems S – Summaries Extension of reflective listening – tell story back to client Can build rapport, prove interest, call attention to specific pieces of story “Let me make sure I’m getting it all… Did I miss anything?” Extension of reflective listening – tell story back to client Can build rapport, prove interest, call attention to specific pieces of story “Let me make sure I’m getting it all… Did I miss anything?”

20. Cherokee Health Systems Other strategies Typical Day –“Walk me through a normal day.” Takes attention away from just the “problem,” focus is to understand how the concern fits into daily life Looking Back –“What was life like before this was a concern?” Typical Day –“Walk me through a normal day.” Takes attention away from just the “problem,” focus is to understand how the concern fits into daily life Looking Back –“What was life like before this was a concern?”

21. Cherokee Health Systems Other strategies, cont. Good Things/Less Good Things –Explore what sustains behavior –Avoid labeling problem if client is not in agreement Stages of Change –Recall other changes –Give credit for necessary steps Good Things/Less Good Things –Explore what sustains behavior –Avoid labeling problem if client is not in agreement Stages of Change –Recall other changes –Give credit for necessary steps

22. Cherokee Health Systems Other strategies, cont. Assessment Feedback –Can use standardized measures –Clinician provides information, client assigns meaning Exploration of Values –Explore “ideal self,” behavioral ideals Assessment Feedback –Can use standardized measures –Clinician provides information, client assigns meaning Exploration of Values –Explore “ideal self,” behavioral ideals

23. Cherokee Health Systems Other strategies, cont. Looking Forward –Compare visions of two futures Exploring Importance and Confidence –How important is the change? –How confident is patient in being able to make change? Decisional Balance –Pros/Cons of change/no change –Can do as worksheet Looking Forward –Compare visions of two futures Exploring Importance and Confidence –How important is the change? –How confident is patient in being able to make change? Decisional Balance –Pros/Cons of change/no change –Can do as worksheet

24. Cherokee Health Systems Other strategies, cont. Change Planning –Plan for next 30/60/90 days –Can complete form together Change Planning –Plan for next 30/60/90 days –Can complete form together

25. Cherokee Health Systems Other strategies, cont. Do it All in a Moment or Two –Brief intervention – FRAMES So, Bill you are in your third week of treatment and you’re feeling like you've accomplished everything you need to (FEEDBACK). My sense is you've begun exploring what's led to your drinking (FEEDBACK). I am concerned that you've not spent much time thinking about how you'll handle your homelife (FEEDBACK). If you asked for my advice, I would recommend you stick with treatment a little longer and work on this area (ADVICE). However, there may be other ways to do this (MENU OF OPTIONS) and the choice is really yours to make (RESPONSIBILITY). I know you've been feeling antsy (EMPATHY) and I have faith that you can make a good decision (SELF-EFFICACY). What do you think? (reprinted from www.motivationalinterview.org) Do it All in a Moment or Two –Brief intervention – FRAMES So, Bill you are in your third week of treatment and you’re feeling like you've accomplished everything you need to (FEEDBACK). My sense is you've begun exploring what's led to your drinking (FEEDBACK). I am concerned that you've not spent much time thinking about how you'll handle your homelife (FEEDBACK). If you asked for my advice, I would recommend you stick with treatment a little longer and work on this area (ADVICE). However, there may be other ways to do this (MENU OF OPTIONS) and the choice is really yours to make (RESPONSIBILITY). I know you've been feeling antsy (EMPATHY) and I have faith that you can make a good decision (SELF-EFFICACY). What do you think? (reprinted from www.motivationalinterview.org)

26. Cherokee Health Systems Traps! Question/Answer –Can be repetitive, impede going “deeper” –Supports passivity Question/Answer –Can be repetitive, impede going “deeper” –Supports passivity Confrontation/Denial –Argumentative –Repetitive –“Yes, but…”

27. Cherokee Health Systems Traps! Expert –Risk of client assuming passive role Labeling –Labels often carry stigma, and clients can resist them Expert –Risk of client assuming passive role Labeling –Labels often carry stigma, and clients can resist them Premature focus –Risk of focusing on wrong problem –Rise in resistance Blaming –Blame isn’t issue

28. Cherokee Health Systems How is this different from other approaches? More confrontational approaches tend to - assume that the person has a problem that needs to change Offer direct advice and/or solutions Have clinician assume authoritative role Have information pass in unidirectional style Rely on diagnostic labels Have clinician behave in punitive manners More confrontational approaches tend to - assume that the person has a problem that needs to change Offer direct advice and/or solutions Have clinician assume authoritative role Have information pass in unidirectional style Rely on diagnostic labels Have clinician behave in punitive manners

29. Cherokee Health Systems How am I doing? Observe! –Is your client arguing with you? –Are you finding yourself in multiple disagreements? –Is your client ignoring you? –Is your client missing appointments? Observe! –Is your client arguing with you? –Are you finding yourself in multiple disagreements? –Is your client ignoring you? –Is your client missing appointments?

30. Cherokee Health Systems Further resources www.motivationalinterview.net website maintained by MINT (Motivational Interviewing Network of Trainers) www.stephenrollnick.com www.motivationalinterview.net website maintained by MINT (Motivational Interviewing Network of Trainers) www.stephenrollnick.com

31. Cherokee Health Systems Questions? maryclare.champion@cherokeehealth.com