Motivational Interviewing Overview Module 12 Blake Beecher Ph

Motivational Interviewing Overview Module 12 Blake Beecher, Ph. D Eastern Washington University

Learning Objectives: 1. 2. 3. 4. Spirit of MI, DEARS OARS practice Stages of Change informed Intervention Eliciting, recognizing, and sustaining change talk

You would think. . . that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking losing one’s life savings and children’s inheritance in slot machines would be enough to help a man to quit gambling

You would think. . . that the very real threats of blindness, amputations and other complications from diabetes would be enough to motivate weight loss and glycemic control that time spent in the dehumanizing privations of prison would dissuade people from re-offending

And yet so often it is not enough for people to change: What is the Key to change?

Client Motivation is a Key to Change Successful treatment outcomes are predicted by: l Pretreatment motivation measures l Treatment attendance l Treatment adherence/compliance l Counselor ratings of motivation and prognosis That is, more “motivated” clients do better

Beliefs About Motivation (True or False? ) 1. Until a person is motivated to change, there is not much we can do. 2. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change. 3. Motivation is influenced by human connections. 4. Resistance to change arises from deep-seated defense mechanisms.

Beliefs About Motivation (True or False? ) 5. People choose whether or not they will change. 6. Readiness for change involves a balancing of “pros” and “cons. ” 7. Creating motivation for change usually requires confrontation. 8. Denial is not a client problem, it is a therapist skill problem.

Client Motivation is Greatly Influenced by the Counselor Clients’ motivation, retention and outcome vary with the particular counselor to whom they are assigned Counselor style strongly drives client resistance (confrontation drives it up, empathic listening brings it down) That is, the counselor is one of the biggest determinants of client motivation and change

Readiness for What? Rather than asking: “Why isn’t this person motivated? ” Ask: “What is this person motivated for? ” Potential Pitfall: Assuming you know.

The Righting Reflex: NOT Motivational Interviewing If following the righting instinct, you will ineffectively ask: Why don’t you want to change? Why don’t you try… ? l Okay then, how about… What makes you think you are not at risk? How can you tell me you don’t have a problem?

NOT Motivational Interviewing Argues that person has a problem and needs to change – emphasis on acceptance of problem/diagnosis. Offers direct advice or prescribes solutions (e. g. , coping strategies) without actively encouraging person to make his/her choices.

NOT Motivational Interviewing Uses authoritative/expert stance and leaves client in passive role. Does most of talking or if acts as unidirectional information system – focus on imparting information.

NOT Motivational Interviewing Identifies and modifies maladaptive cognitions. Allows the client to determine the content and direction of the counseling. Behaves in a punitive or coercive manner.

You take one side; I another When you strong argue one side, the ambivalent naturally argue the other The stronger the argument the less likely change occurs

Common Human Reactions to the Righting Reflex Angry, agitated Oppositional Discounting Defensive Justifying Not understood Not heard Procrastinate Afraid Helpless, overwhelmed Ashamed Trapped Disengaged Don’t come back – avoid Uncomfortable Resistant

Common Human Reactions to Being Listened to Understood Want to talk more Liking the counselor Open Accepted Respected Engaged Able to change Safe Empowered Hopeful Comfortable Interested Want to come back Cooperative

A Change of Role You don’t have to make change happen You can’t You don’t have to come up with all the answers You probably don’t have the best ones You’re not wrestling You’re dancing

Ambivalence “I want to change, but I don’t want to change. ” Very few decisions in life are made with 100% certainty Ambivalence is normal and part of the change process for everyone

Ambivalence Exercise 1. Find a partner. 2. Each of you write down something you are interested in doing but have mixed feelings about (e. g. , studying, buying a new car, quitting smoking, exercising, etc. ). 3. Select who will speak first. 4. The speaker presents what it is that s/he would like to do (but haven’t done yet). 5. The listener then argues strongly in favor of one of the options or sides. 6. Speaker, your job is to listen and note what you are thinking and feeling. 7. Switch roles.

Ambivalence Exercise What were your thoughts/feelings as the speaker? What happens when ambivalence collides with persuasion, prescription, convincing?

Motivational Interviewing Motivational interviewing is a semi-directive, client-centered counseling style that enhances motivation for change by helping the client clarify and resolve ambivalence about behavior change. The goal of motivational interviewing is to create and amplify discrepancy between present behavior and broader goals. Create cognitive dissonance between Where one Is now Where one wants to be

MI is Semi-Directive Nondirective/ Rogerian Motivational Interviewing Allows client to determine content and direction of counseling Systematically directs client toward motivation for change Explores client’s conflicts and emotions without specific goals for change Uses empathic reflection noncontingently Avoids interjecting counselor’s advice/feedback Seeks to evoke and amplify discrepancy to enhance motivation for change Uses reflection selectively to reinforce motivation for change Offers feedback where appropriate

Two Phases of MI Phase I: Building Motivation to Change Phase II: Strengthening commitment to change

Appropriate Motivational Strategies for Each Stage of Change Client's Stage of Change Precontemplation Appropriate Motivational Strategies for the Clinician Establish rapport, ask permission, and build trust. Raise doubts or concerns The client is not yet in the client about considering change or is unwilling or unable to change. problematic patterns Express concern and keep the door open.

Client's Stage of Change Appropriate Motivational Strategies for the Clinician Normalize ambivalence. Help the client "tip the decisional balance scales" toward change. The client acknowledges concerns and is considering Elicit and summarize selfmotivational statements of the possibility of change intent and commitment from but is ambivalent and the client. uncertain. Elicit ideas regarding the client's perceived self-efficacy and expectations regarding treatment. Contemplation

Client's Stage of Change Preparation The client is committed to and planning to make a change in the near future but is still considering what to do. Appropriate Motivational Strategies for the Clinician Explore treatment expectancies and the client's role. Clarify the client's own goals. Negotiate a change--or treatment--plan and behavior contract. Consider and lower barriers to change. Help the client enlist social support.

Client's Stage of Change Appropriate Motivational Strategies for the Clinician Engage the client in treatment and reinforce the importance of retaining behavior change. Acknowledge difficulties for the The client is actively client in early stages of change. taking steps to change Help the client identify high-risk but has not yet reached situations through a functional a stable state. analysis and develop appropriate coping strategies to overcome these. Action

Client's Stage of Change Maintenance Appropriate Motivational Strategies for the Clinician Support lifestyle changes. Affirm the client's resolve and self-efficacy. The client has achieved Help the client practice and initial goals such as use new coping strategies to abstinence and is now avoid a relapse. working to maintain gains. Develop a "fire escape" plan if the client resumes problematic behaviors. Review long-term goals with the client.

Client's Stage of Change Recurrence The client has experienced a recurrence of symptoms and must now cope with consequences and decide what to do next. Appropriate Motivational Strategies for the Clinician Help the client reenter the change cycle and commend any willingness to reconsider positive change. Explore the meaning and reality of the recurrence as a learning opportunity. Assist the client in finding alternative coping strategies. Maintain supportive contact.

3 Critical Components of Motivation: Readiness Ruler - WAR Willing Able Ready Willing: The importance of change: desires, wants or wills change Able: Confidence for change; feels willing but unable- “I wish I could” may use defense mech. Ready: A matter of priorities; “I want to but now. ”

Five Principles of MI-- DEARS Develop Discrepancy l Person rather than the counselor should present the arguments for change l Change is motivated by a perceived discrepancy between present behavior and important personal goals or values Express Empathy l Research indicating importance of empathy l Skillful reflective listening is fundamental l Ambivalence is normal

Five Principles of MI Avoid Argumentation l. Confrontation increases client resistance to change l. Labeling is unnecessary

Five Principles of MI Roll with Resistance ▫ Provider’s role is to reduce resistance, since this is correlated with poorer outcomes ▫ If resistance increases, providers shift to different strategies ▫ The person’s objections or minimization do not demand a response ▫ The person is a primary resource in finding answers and solutions

Five Principles of MI Support Self-Efficacy ▫ A person’s belief in the possibility of change is an important motivator ▫ The person, not the counselor, is responsible for choosing and carrying out change ▫ The counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy

What Is Resistance? Verbal and non-verbal behaviors Expected and normal Function of interpersonal communication Continued resistance predictive of reduced change Resistance is highly responsive to counselor style Getting resistance? Change strategies.

Types of Resistance Argument l Challenging l Discounting l Hostility Interruption l Talking over l Cutting off Ignoring l l Inattention Non-response Non-answer Side-tracking Denial l l l Blaming Disagreeing Excusing Reluctance Minimizing Pessimism Unwillingness to change l Claiming immunity l WHAT ELSE? ? ?

Resistance and Persuasion Many older approaches to behavior change relied on the counselor to persuade or even intimidate client into changing These approaches often elicit reactance and reduce the chances that a resistant client will consider changing a problem behavior

Dancing vs. Wrestling Many MI proponents use the metaphor of dancing with clients to illustrate this method of gently moving with them around the ambivalence of change

The Importance of Values “The Hook” If Values are not identified, there is no discrepancy—a main component of MI l. What makes their life worth living? l. What do they value in their life that is affected by the problem? l. What is most important to them? l. What gives their life meaning?

Areas of Values 1. Family/Parenting 7. 2. Love/Intimate 8. relationships 3. Friends/Social 9. connectedness 4. Work/Career 5. Education/Training 6. Recreation/Fun Spirituality Citizenship/ Community Life Health/Physical Self Care

Case # 1 Juan is a 40 year old unemployed plumber who would like to get back to work, but has difficulty working due to obesity and uncontrolled diabetes. Juan has tried to alter his diet and take his medication consistently a few times in the past, but has slipped back each time has made any changes. He is in the clinic due to his diabetes and you received a referral to meet with him.

Case # 2 Gina is a 42 year-old part time college student. She is a single mother with 4 kids and is working part time. She has hypertension, anxiety, and depression, and receives her medication from the clinic for all three. She comes to the clinic frequently stressed about her health problems and her life situation.

Case # 3 Rafael is a 29 year old man who is HIV+. He reports to you that he is having regular unprotected sex. He tells you that he usually goes to church right afterwards and prays forgiveness but “can’t seem to stop” himself from continuing this behavior. He also remarks that although he has been feeling “fine” he visits his primary care doctor frequently.

The “Spirit of MI” 1 Too much focus on the techniques of MI results in a loss of its essential style, “sprit” or way of being • Motivation elicited from the client, not imposed from without • Client's task, not the counselor's, to articulate + resolve ambivalence • Persuasion is not an effective method for resolving ambivalence

“Spirit of MI” 2 • Readiness to change not a client trait, but a fluctuating product of interpersonal interaction • The therapeutic relationship is a partnership rather than expert/recipient roles

“Spirit of MI” 3 Central therapist behaviors • Understand the person's frame of reference via reflective listening • Express acceptance and affirmation • Eliciting + reinforcing the client's self motivational statements expressions of problem recognition • Monitoring the client's degree of readiness to change + ensuring that resistance is not generated • Affirming the client's freedom of choice and selfdirection

Behaving Motivational Interviewing Techniques Open-ended Questions Reflective Listening Affirm Summarize Elicit Change Talk Core Components Express Empathy Avoid Argumentation Roll with Resistance Develop Discrepancy Support Self-efficacy Being Spirit Collaboration Evocation Autonomy

MI Research Support in Health Settings 4, 5, 6 Substance use decrease Treatment adherence increase Treatment engagement increase HIV risk reduction Diet and exercise Gambling decrease Healthy behavioral change Motivational interviewing consistently outperforms traditional advice giving in the treatment of a broad range of behavioral problems and diseases. Hettema, J. et al. , 2005; Lundahl & Burke 2009; Ruback, S. et al. , 2005

References 1. Miller, W. R. & Rollnick, S. (2002). Motivational interviewing (2 nd ed. ): Preparing people for change. New York: Guilford Press. 2. Miller, W. R. & Rollnick, S. (2002). Motivational interviewing (2 nd ed. ): Preparing people for change. New York: Guilford Press. 3. Miller, W. R. & Rollnick, S. (2002). Motivational interviewing (2 nd ed. ): Preparing people for change. New York: Guilford Press. 4. 4. Hettema, J. , Steele, J. , & Miller, W. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 91– 111. 5. 5. Lundahl, B. W. , & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology: In session, 65, 1232 -1245. 6. 6. Ruback, S. , Sandbaek, A. , Lauritzen, T. , & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-analyses. British Journal of General Practice, April, 305 -312. 7. Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 35. ) Available from: http: //www. ncbi. nlm. nih. gov/books/NBK 64967/