1. Motivational Interviewing & HEALS How to Get Students Off the Couch A Brief Taste of MI Helena Mackenzie, PhD Region 5 Mental Health Specialist

2. Objectives  Identify why more traditional health care approaches often don’t result in behavior change  List a word that reflects the spirit of Motivational Interviewing (“ACE”)  List a key skill used in MI (“OARS”)  Identify one change tool  Feel motivated to learn more about MI and applying it to HEALS

3. Identify a behavior you currently want to change…  Common Choices  Exercise more  Drink less  Eat more fruit/veggies  Stop smoking  Stop being late  Stick to a budget

4. Stages of Change (Prochaska & DiClemente)  Precontemplation: What problem?  Contemplation: Aware of the problem, but not quite ready…  Preparation: Plan to take action in the next month; beginning to take small steps  Action: Modifying behavior to overcome problem  Maintenance: work to prevent relapse and consolidate gains

5. How Do You Increase Someone’s Motivation?

6. The “Righting Reflex” A Practitioner/Helper Problem  Stems from a natural desire to help…  Helper/Practitioner’s “goal”:  “diagnose the problem”  “fix the problem”  “control the problem”  “get good results”  Practitioner tries to create change by…  Providing reasons for change (education)  Provide solution/treatment/skill building

7. Demonstration: Trying to Force Change Provider/Helper Argues for Change  Demonstration of an “Ineffective Provider”  http://www.youtube.com/watch?v =80XyNE89eCs&feature=relmfu http://www.youtube.com/watch?v =80XyNE89eCs&feature=relmfu  Lisa Marlo, PhD, Professor of Psychiatry at the University of Florida Student/Patient Argues Against Change/Shuts Down

8. Resistance or Ambivalence?  Ambivalence:  The True Dilemma of Change  Ambivalence is a state of mind in which a person has co- existing but conflicting feelings about something  Fundamental and NORMAL part of the change process  “I want to, but I don’t want to…”  “You tell me a reason to change, I’ll tell you a reason not to…”

9.  “People are usually more convinced by reasons they discovered themselves than by those found by others.” --Blaise Pascal

10. Motivational Interviewing  Allows the individual to identify and verbalize their own reasons for change… We serve as the guide…  MI Defined:  Motivational interviewing is a form of collaborative conversation for strengthening a person's own motivation and commitment to change. It is a person- centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change. -MINT (2012)

11. Spirit of MI (“ACE”)  Autonomy  NOT confrontation  Collaboration  NOT authoritative  Evocation  NOT education

12. Is this MI Spirit? (place your vote)  Student: I know my RA told you I’m depressed, but I’m not.  Helper: You don’t believe you’re depressed. What do you think she’s seeing that is making her worry this way?  Student: I had no idea I weighed that much. I guess that’s why everyone tells me I shouldn’t eat so much.  Helper: Right. You need to cut down on your eating and I know some good ways to get you started.  Student: I think your BMI thing is wrong because I am not “obese.”  Helper: You don’t think of yourself as someone who has a weight problem.

13. Strategies to Develop a Motivational Conversation OARS  Open-ended questions  Avoid Yes/No  “What types of exercise have you previously tried?”  Affirmations  Provide support & encouragement  “Taking care of yourself is really important to you”  Reflective Listening  Making a statement that guesses at the speaker’s meaning  Summarizing  Organizes and links information

14. Open-Ended Questions  Encourage the person to give you more than a “yes/no” response  Do you drink alcohol daily? (closed)  What are your drinking habits like? (open)  Typically can’t be answered with one word or brief responses  How many fruits and vegetables do you eat daily? (closed)  Tell me about your daily eating habits (open)

15. Open-Ended Questions? Place Your Vote  Are you doing okay today?  How much do you exercise?  What types of healthy foods do you like?  Do you eat fruit and vegetables daily?  What activities in the recreation department sound interesting to you?

16. Affirmations  Statements of appreciation of student/patient’s strengths, successes, efforts to change  Purpose is to empower and support self-efficacy  Avoid using word “I”  Different than compliments

17. Affirmation Practice Student Says…  Student with diabetes tells you they are checking their glucose levels regularly  Overweight student tells you she has stopped drinking pop  Student tells you that he felt discouraged after failing recent TABE, but now has plan and feels confident he will pass next time Possible Affirmation…  You are determined to keep your diabetes under control  Your health is really important to you  When you set your mind to something you feel confident you’ll accomplish your goal

18. Reflections…  Reflections are guesses at what you believe a person is saying. Show the person that you hear and understand them and invite them to continue talking  You can reflect many things…  Speech  Facial Expression  Behavior  Or guess at the deeper meaning of words

19. Example Reflections… Student  You don’t have a clue what it’s like living on this center  There is no way I can lose weight  I don’t eat vegetables and that’s a done deal  Student cries after STD result  I look gross when I work out. No way I’m doing that here Reflection from Helper  You don’t think I can understand how hard it is  Losing weight doesn’t feel possible right now  There is no way you are going to eat vegetables  This news feels overwhelming  Looking good is important to you

20. Applying MI to HEALS A Brief MI-Consistent Conversation

21. ① Agree on the Focus Elevated BMI Explore and agree on a behavior to discuss or ask permission to discuss a particular behavior Exercise ??? Social Activities Alcohol Stress Eating _________________________________________________________________

22. Explore Ambivalence and Strengthen Motivation for Change Change Willing = importance Able= Confidence In order to be READY to change, person must be WILLING and ABLE

23. Follow up questions to elicit change talk:  Why did you pick ____ instead of _____(slightly lower number)?  What would have to happen to make you move up to a ____ (slightly higher number)? Ask about importance and confidence around specific change…

24. Use OARS to clarify pros and cons… Use Reflections and Open-Ended Questions when hear change talk or are met with resistance… Decisional Balance Worksheet: Explore the Ambivalence of Change…

25. Summarize Progress and Identify Next Step  Provide summary of information discussed then…  Ask:  What do you make of all this? Or...  What, if anything, would be a first step? Or…  What do you intend to do next?

26. Guiding Principles to Remember (RULE)  Resist the Righting Reflect  Don’t argue with the student!  Understand the student’s motivation  What is important to this person?  Listen to the student  Ask open-ended questions and use reflections to check your understanding  Empower the student (create self- efficacy)  Affirm the student’s strengths

27. Demonstration of an Effective Provider: MI in Action  http://www.youtube.com/watch?v =URiKA7CKtfc&feature=relmfu http://www.youtube.com/watch?v =URiKA7CKtfc&feature=relmfu  Lisa Merlo, PhD, Department of Psychiatry at the University of Florida

28. Further Reading...

29. Helpful Articles…  Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change. American Psychologist, 47 (9), 1102-1114.  Berg-Smith, M., Stevens, V., et al. (1999). A brief motivational intervention to improve dietary adherence in adolescents. Health Education Research, 14 (3), 399-410.  Butterworth, S., Linden, A., et al. (2006). Effect of motivational interviewing-based health coaching on employees’ physical and mental health status. Journal of Occupational Health Psychology, 11 (4), 358- 365.  Hillsdon, M., Thorogood, M., et al. (2002). Advising people to take more exercise is ineffective. International Journal of Epidemiology, 31, 808- 815.  Resnicow, K., Baskin, M, & McCarty, F. (2005). Results of Go Girls: A weight control program for overweight African-American adolescent females. Obesity Research, 13 (10),1739-1748.  Resnicow, K., Campbell, M., et al. (2004). Body and Soul: A dietary intervention conducted through African-American churches. American Journal of Preventative Medicine, 27 (2), 97-105.  Richards, A., Kattelmann, K., et al. (2006). Motivating 18- to 24-year-olds to increase their fruit and vegetable consumption. American Dietetic Association, 106, 1405-1411.