MOTIVATIONAL INTERVIEWING GEOFF WILSON LCSW LCADC THE OFFICES

MOTIVATIONAL INTERVIEWING GEOFF WILSON, LCSW, LCADC THE OFFICES OF PAUL DALTON/LEXINGTON COUNSELING & PSYCHIATRY

HEALTH STATUS AND BEHAVIOR CHANGE • THE UNITED STATES RANKS AS ONE OF THE LOWEST IN TERMS OF HEALTH STATUS AMONG ECONOMICALLY DEVELOPED COUNTRIES Sch • WHILE MANY FACTORS CONTRIBUTE TO THIS LOW RANKING, HEALTH BEHAVIORS ARE CONSIDERED TO BE ONE OF THE MOST SIGNIFICANT; BEHAVIOR PATTERNS ACCOUNT FOR ALMOST 40% OF ALL DEATHS IN THE US. • SCHROEDER SA. WE CAN DO BETTER – IMPROVING THE HEALTH OF THE AMERICAN PEOPLE. N ENGL J MED 2007; 357: 1221 -8.

HOW DO WE ESTABLISH A HABIT? • THERE ARE PROS AND CONS TO EVERY BEHAVIOR • WE ENGAGE IN A PARTICULAR BEHAVIOR BASED ON AN ASSESSMENT OF THESE PROS AND CONS • AMBIVALENCE IS THE UNRESOLVED CONFLICT BETWEEN THE PROS AND CONS, AND LEADS TO CONTINUES ENGAGEMENT OF THE BEHAVIOR • PERSISTENT AMBIVALENCE IS THE PRINCIPAL IMPEDIMENT TO CHANGE

PROCHASKA & DI CLEMENTE: TRANSTHEORETICAL MODEL OF BEHAVIOR

STAGES INVOLVED IN BEHAVIOR CHANGE 1. IDENTIFYING THE BEHAVIOR 2. IDENTIFYING A PROBLEM 3. DESIRING A CHANGE 4. FEELING CONFIDENT ABOUT A CHANGE 5. DOING IT!

MOTIVATIONAL INTERVIEWING – BACKGROUND • FIRST DESCRIBED IN THE 1980’S BY WILLIAM MILLER AND STEPHEN ROLLNICK, TWO PSYCHOLOGISTS WHO HAD EXPERIENCE IN TREATING ALCOHOLISM • SPIRIT OR PHILOSOPHY OF MI AND BEHAVIOR CHANGE CONSIDERED MOST IMPORTANT; TECHNIQUES FOLLOW

MOTIVATIONAL INTERVIEWING • A DIRECTIVE, CLIENT CENTERED COUNSELING STYLE FOR ELICITING BEHAVIOR CHANGE BY HELPING CLIENTS EXPLORE AND RESOLVE AMBIVALENCE. • DESIGNED TO PRODUCE RAPID, INTERNALLY MOTIVATED CHANGE BY MOBILIZING THE CLIENT’S OWN CHANGE RESOURCES. 1991 MILLER AND ROLLNICK,

GOAL OF MOTIVATIONAL INTERVIEWING • FINDING OUT WHICH STAGE THE CLIENT IS AT, AND ADDRESSING THE CONCERNS SPECIFIC TO THEIR STAGE • HAVE THE CLIENT ARTICULATE THEIR “PROS” AND “CONS” SO THEY CAN BETTER PROCESS AND ULTIMATELY RESOLVE THE CONFLICT BETWEEN THEM. • EMPATHIZING AND EMPOWERING THE CLIENT TO TAKE STEPS TOWARDS CHANGE BY AFFIRMING THEIR STRENGTHS AS WELL AS THE CENTRALITY OF THEIR INITIATIVE IN

CASE PRESENTATION YOU ARE SEEING A 4 YEAR-OLD BOY WITH POORLY CONTROLLED ASTHMA IN CLINIC. HE HAS BEEN ADMITTED THREE TIMES IN THE PAST 6 MONTHS FOR ACUTE EXACERBATIONS. DURING YOUR INTERVIEW WITH THE MOTHER, A PACK OF CIGARETTES FALLS FROM HER COAT. SHE QUICKLY STATES THAT SHE DOES

SO…WHAT STAGE IS OUR CLIENT IN? (HINT: DO WE REALLY KNOW AT THIS POINT? )

YOU GET MORE HISTORY… THE MOTHER SAYS SHE HAS BEEN FEELING VERY STRESSED RECENTLY, ESPECIALLY WITH HER CHILD’S RECENT HOSPITALIZATIONS. SHE HAS BEEN SMOKING SINCE SHE WAS A TEENAGER (SHE IS IN HER MID-20’S) AND SHE SAYS THAT SMOKING RELAXES HER. SHE DOES THINK THAT QUITTING WOULD HELP HER CHILD’S ASTHMA, AND SEVERAL PEOPLE HAVE TOLD HER THAT SHE SHOULD STOP SMOKING IN THE INTEREST OF HER CHILD’S HEALTH. WHEN ASKED ABOUT QUITTING, SHE FROWNS AND SAYS SHE HAS TRIED TO QUIT SMOKING SEVERAL TIMES IN THE PAST WITHOUT SUCCESS.

FOUR TYPES OF MOTIVATIONAL STATEMENTS CAN BE IDENTIFIED COGNITIVE RECOGNITION OF THE PROBLEM (E. G. , "I GUESS THIS IS MORE SERIOUS THAN I THOUGHT. ") AFFECTIVE EXPRESSION OF CONCERN ABOUT THE PERCEIVED PROBLEM (E. G. , "I'M REALLY WORRIED ABOUT WHAT IS HAPPENING TO ME. ") A DIRECT OR IMPLICIT INTENTION TO CHANGE BEHAVIOR (E. G. , "I'VE GOT TO DO SOMETHING ABOUT THIS. ") OPTIMISM ABOUT ONE'S ABILITY TO CHANGE (E. G. , "I KNOW THAT IF I TRY, I CAN REALLY DO IT. ")

USE OF SCALES • A COMMON WAY OF ASSESSING AS WELL AS CULTIVATING CONFIDENCE OR IMPORTANCE IS THE USE OF SCALES CAN HELP CLIENTS/PATIENTS TO VERBALIZE AND PROCESS THEIR AMBIVALENCE FURTHER. IN THIS CASE, • “ON A SCALE OF 1 TO 10, HOW IMPORTANT DO YOU THINK IT IS FOR YOU TO QUIT SMOKING? ” (PATIENT SAYS 9 OUT OF 10) • “ON A SCALE OF 1 TO 10, HOW CONFIDENT ARE YOU THAT YOU CAN QUIT SMOKING? ” (PATIENT SAYS 4 OUT OF 10)

SO, NOW WHAT DO WE DO? • AFFIRMATIONS: RECOGNIZING CLIENT STRENGTHS AND COUNTERING A DEFEATIST ATTITUDE “WHY DID YOU GIVE YOURSELF A 4 INSTEAD OF A 2? ” “I AM IMPRESSED THAT YOU HAVE BEEN TRYING TO QUIT DESPITE ALL THE STRESS YOU ARE GOING THROUGH” • REFLECTING THE PROS AND CONS “SO, IT IS IMPORTANT FOR YOU TO SMOKE IN ORDER TO DEAL WITH THE STRESS IN YOUR LIFE, BUT YOU ALSO WISH YOU COULD QUIT IN THE INTEREST OF YOUR CHILD’S HEALTH” • LOOK FOR CLIENT DRIVEN STRENGTHS “WHAT WOULD MAKE YOU GO UP TO A 6 OR 7? ”

PROBLEMS WITH STANDARD PRACTICE • UNWELCOME ADVICE ELICITS RESISTANCE • ADVICE MUST MATCH MOTIVATION • CLIENT KNOWLEDGE OF FACTS IS WEAKLY CORRELATED WITH BEHAVIOR • ONLY 5% TO 10% OF THE VARIANCE IN CHANGE BEHAVIOR DUE TO KNOWLEDGE • VARIABILITY IN PERSONAL MOTIVATION

MOTIVATIONAL INTERVIEWING: • CLIENT DETERMINES TREATMENT PLAN • AVOID UNSOLICITED ADVICE • INVOLVES THE BEST BASIC COUNSELING SKILLS • EXPRESS EMPATHY • USE GOOD NONVERBAL LISTENING SKILLS • PROBLEM SOLVING PARTNERS

MOTIVATIONAL INTERVIEWING CLINICAL INTERVIEW: PUTTING RESPONSIBILITY FOR CHANGE ON THE PATIENT. • SIMPLE REFLECTION • AVOIDING ARGUMENTS • SHIFTING FOCUS • OPEN-ENDED QUESTIONS • REFRAMING • ROLLING WITH RESISTANCE • LISTEN REFLECTIVELY • SIDING WITH THE NEGATIVE • DEVELOP DISCREPANCY • SELF-EFFICACY • AFFIRM • EXPRESSING EMPATHY

MOTIVATIONAL INTERVIEWING SKILLS: DEVELOP DISCREPANCY • MOTIVATION FOR CHANGE IS ENHANCED WHEN CLIENTS PERCEIVE DIFFERENCES BETWEEN THEIR CURRENT SITUATION AND THEIR HOPES FOR THE FUTURE. • DEVELOPING AWARENESS OF CONSEQUENCES HELPS CLIENTS EXAMINE THEIR BEHAVIOR. A DISCREPANCY BETWEEN PRESENT BEHAVIOR AND IMPORTANT GOALS MOTIVATES CHANGE. THE CLIENT SHOULD PRESENT THE ARGUMENTS FOR CHANGE.

OARS • OPEN ENDED QUESTIONS • AFFIRMATIONS: COMMENT ON STRENGTHS, EFFORT, INTENTION • REFLECTIVE LISTENING • SUMMARIES: • PULLING TOGETHER THE PERSON’S PERSPECTIVES ON CHANGE

GO FROM QUESTIONS TO REFLECTIONS • YOU. . . • IT’S AS IF. . . • SOUNDS LIKE. . . • ATTEND TO VOICE INFLECTION AT END OF STATEMENT, TO TURN IT INTO A REFLECTION. • A QUESTION DEMANDS AN ANSWER. • A REFLECTION INVITES A RESPONSE.

MOTIVATIONAL INTERVIEWING • GET PERMISSION TO PROCEED • OPEN ENDED (STARTING) QUESTIONS (TO GET THE BALL ROLLING) • REFLECTIVE LISTENING (KEEP IT ROLLING) • SUMMARIZING (STOP, ASSESS, MOVE ON) • ELICIT SELF-MOTIVATIONAL STATEMENTS • MENUS VS. SINGLE SOLUTIONS • YOU PROVIDE INFO. , CLIENT INTERPRETS IT

GETTING PERMISSION WHEN GETTING STARTED “IF ITS OK WITH YOU. I’D LIKE TO SPEND A FEW MINUTES TALKING ABOUT… YOUR SMOKING YOUR MEDICATION YOUR ALCOHOL USE “IS THAT OK WITH YOU? ”

OPEN ENDED STARTERS “I SEE FROM YOUR CHART THAT… YOU ARE DRINKING AROUND 4 DRINKS A DAY YOUR BLOOD SUGAR IS A BIT HIGH “HOW DO YOU THINK THIS AFFECTS YOUR HEALTH? ” “WHAT DO YOU MAKE OF THIS…? ” “TELL ME ABOUT YOUR…”

UNIVERSAL SAFE REFLECTIONS • IT SOUNDS LIKE THIS HAS BEEN TOUGH FOR YOU… • IT SOUNDS LIKE YOU ARE NOT HAPPY WITH… • IT SOUNDS LIKE YOU ARE A BIT UNCOMFORTABLE ABOUT… • IT SOUNDS LIKE YOU’RE NOT READY TO… • IT SOUNDS LIKE YOU ARE HAVING A PROBLEM WITH…

DEVELOPING DISCREPANCY • NO DISCREPANCY, NO MOTIVATION • EXAMPLE 1 - WEIGHT LOSS • SO, ACCORDING TO YOUR WEIGHT TODAY, YOU GAINED A FEW POUNDS. YET I KNOW YOU SHARED YOUR GOAL TO LOSE 15 LBS. WHAT DO YOU MAKE OF THIS? • ACCORDING TO YOUR FOOD RECORD, YOUR TRYING TO REDUCE EATING FAST FOOD……. YOU ATE AT MCDONALDS TWICE THIS PAST WEEK. WHAT DO YOU FEEL LIKE YOU WOULD LIKE TO DO

DEVELOPING DISCREPANCY • EXAMPLE 2 - ADDICTIVE BEHAVIOR • YOU MENTIONED THAT YOUR MOTIVATION TO QUIT SMOKING IS A 10 AND YOUR CONFIDENCE IS A 9. YET, YOU HAVEN’T TRIED TO QUIT YET. WHAT DO YOU MAKE OF THIS?

MENU HERE ARE SOME OF THINGS THAT HAVE WORKED FOR OTHER PEOPLE 1. ) AMAZING STRATEGY 1 2. ) AMAZING STRATEGY 2 3. ) AMAZING STRATEGY 3 WHICH OF THESE DO YOU THINK MIGHT WORK BEST FOR YOU? WHICH OF THEE MIGHT YOU BE WILLING TO TRY?

MENU (PRIORITIZING) CONTROLLING YOUR WEIGHT MAY INVOLVE SEVERAL BEHAVIOR CHANGES INCLUDING: 1. ) EATING LESS 2. ) EATING MORE FRUITS AND VEGETABLES 3. ) EATING SMALLER PORTIONS 4. ) EATING FEWER DESSERTS 5. ) EXERCISING MORE WHICH OF THESE WOULD YOU LIKE TO WORK ON FIRST? WHICH OF THESE DO YOU THINK ARE MORE IMPORTANT TO DEAL WITH?

WRAP UP!! QUESTIONS, COMMENTS, AND CONCERNS? ? ? GEOFF WILSON, LCSW, LCADC THE OFFICES OF PAUL DALTON/LEXINGTON COUNSELING & PSYCHIATRY 501 DARBY CREEK RD. , SUITE 11 LEXINGTON, KY 40509 859. 229. 5722 GEOFFWILSON 914@GMAIL. COM GWTRAININGCONSULTING. COM

REFERENCES • “MOTIVATIONAL INTERVIEWING: APPROACHING BEHAVIORAL CHANGE” PRANTIK SAHA, MD, MPH, COLUMBIA UNIVERSITY / CHILDREN’S HOSPITAL OF NEW YORK. • MILLER AND ROLLNICK, 1991. • PROCHASKA & DI CLEMENTE: TRANSTHEORETICAL MODEL OF BEHAVIOR CHANGE