Post on 22-Dec-2015
Utilizing Motivational Interviewing to Navigate
the Rough Waters An Introduction and
Opportunities for Practice
William T. Dalton III, Ph.D.Licensed Psychologist & Assistant Professor
Assistant Director of Clinical Training
Elizabeth Conway-Williams, M.A.
Doctoral Student
Department of PsychologyEast Tennessee State
University
Learning Objectives At the conclusion of this presentation
you should be able to…Describe the characteristics of MIUnderstand the guiding principles of MIUnderstand the foundational clinical skills of
MIUnderstand additional clinical tools for
practice of MI Objectives will be met via…
LectureVideo demonstrationsPractice via case studies
MI Defi ned MI is a collaborative, person-centered
form of guiding to elicit and strengthen motivation to change
Number of Hits on PsycINFO for “Motivational Interviewing”
1980-1989 1990-1999 2000-20090
200
400
600
800
1000
1200
Evidence Base for MI Lundahl & Burke (2009) summarized
results of four meta-analyses on effectiveness of MI
Effect sizes (Cohen’s D): Weak comparison groups (e.g., wait-list):
0.28-0.40Strong comparison group (e.g., CBT or 12-
step program): 0.04- 0.32 Suggest that MI is significantly better
than no treatment and generally equal to other established treatments for a wide range of problems
MI Applications Alcohol-related
problems Marijuana
dependence Tobacco use Other drugs
(e.g., cocaine, heroin)
Engaging clients in treatment
Reducing risky behavior
Increasing healthy behavior
Other MI Applications Asthma/COPD Brain Injury Cardiovascular
Health/Hypertension Dentistry Diabetes Diet/Lipids Domestic Violence Dual Diagnosis Eating Disorders/Obesity Emergency
Department/Trauma/ Injury Prevention
Family/Relationships Gambling Health Promotion
/Exercise/Fitness HIV/AIDS Medical Adherence Mental Health Offenders Pain Parenting Interventions Reproductive Health Sexual Behavior Speech/Vocal Therapy
History Motivational Interviewing Professional
Training DVD (1998) Interview With Founders
William Miller, Ph.D. (Clinical Psychology) Stephen Rollnick, Ph.D. (Clinical Psychology)
History (Cont’d) Motivation was once considered a trait or
ingrained quality MI was first described in 1983 to help
motivate drinkers to change behavior (resistance)
Ambivalence was being considered a normal and defining state and the recognition that change is not usually made without inconvenience
Around the same period the trans-theoretical model of stages of change was being proposed
Stages of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
How MI Works Recognizes behavior change as a
process Individuals are considered to be in
different stages of behavior change Assists individuals in moving through
stages via a combination of a strong patient-provider relationship and specific techniques that encourage patients to discuss the possibility of behavior change
Check-It!
MI Characteristics Directive Client-centered Honors autonomy Counseling style Resolve ambivalence Evocative Collaborative Minimizes resistance Offers acceptance
MI is “Not” Arguing that a person has a problem
and needs to change Offering advice without the patient’s
permission Doing most of the talking Simply giving a “prescription” A quick trick or simple procedure
MI Video Demonstration
Check-It!
Guiding Principles: RULE Resisting the Righting Reflex
Roll with resistance Understand Your Patients Motivations
Develop discrepancy Listen To Your Patient
Express empathy Empower Your Patient
Support self-efficacy
Check-It!
Foundational Clinical Skills: OARS Open-ended questions Affirmations Reflective listening Summarizing
Foundational Clinical Skills: OARS (Cont’d) Open-ended questions
Questions that encourage patients to elaborate, feel respected, and elicit change talk
Examples “Would you tell me more about ____?” “How does smoking fit with your dreams of
becoming a pro basketball player?” “How does your current weight interfere with the
activities you most enjoy?” “In what ways is your diabetes a problem for
you?” “How have you overcome other obstacles in the
past?”
Foundational Clinical Skills: OARS (Cont’d) Open-ended questions
Avoid questions that can be answered yes/no
Examples “Did you ____?” “Will you ____?” “Can you ____?” “How many ____?”
Foundational Clinical Skills: OARS (Cont’d) Affirmations
Statements reinforcing positive choices, strengths, and self-efficacy
Examples “Coming in every week for therapy and doing
homework is really tough. You are handling a difficult treatment protocol really well.”
“I’m impressed with how mature you are.” “Absolutely! It is really tough to do all that you
need to do when you’re not feeling well. And sticking to your diet makes it easier for you to do your chores, complete your homework, and hang out with your friends.”
Foundational Clinical Skills: OARS (Cont’d) Reflective listening
Following along by restating what is said, clarifying, adding meaning, or highlighting emotions
Examples “It sounds like you are feeling ____.” “It appears that you see no real problem with
your current drinking.” “On the one hand your family really enjoys
several hours of television each day and on the other hand you find that it is interfering with your family’s ability to be physically active which you also enjoy and find important.”
Foundational Clinical Skills: OARS (Cont’d) Summarizing
Sum up patients stories, add insight and reinforce statements in favor of change
Examples “It’s important for you to fit in with your friends.
Sometimes adhering to your chest physiotherapy regimen makes that tough.”
“On the other hand, when you don’t adhere to your therapy, you notice that you don’t feel as well. And when you don’t feel as well, it’s even harder for you to keep up with the energy of your friends. Is there anything that you want to add that I may have missed?”
MI Video Demonstration
Check-It!
Additional Clinical Tools Setting an agenda Assessing readiness to change Developing discrepancy
Pros/consValues and current behavior
Setting an Agenda Ask permission to discuss a specific
topic“Would you be willing to spend a few
minutes discussing your drinking?”“Are you interested in discussing ways to
better take your medicine?” Ask patient to name an area of concern
with the help of a menu of options“There are several topics we could discuss
related to your health. For example, taking your medicine, eating patterns, amount of physical activity or time spent watching television, smoking or drinking behavior, sexual activity, or even others. What is of most concern to you?”
Assessing Readiness to Change Use of Rulers and Scaling
Two useful tools for assessing and enhancing patient readiness for health behavior changes are the Importance and Confidence Rulers
Both on a 11-point scale 0 = least importance or confidence 10 = most importance or confidence
Scaling or follow-up questions may be used to facilitate change talk
Assessing Readiness to Change (Cont’d) “On a scale of 0 to 10, with 10 being
‘very important,’ how important is it for you to decrease your drinking?”
Reflect patient’s answer“You chose _____.”
Ask follow-up questions“Why did you not choose a lower
number?”“Why did you not choose a higher
number?”“What would it take to move to an
_____?”
Assessing Readiness to Change (Cont’d) “On a scale of 0 to 10, with 10 being ‘very
confident,’ assuming you decided to drink less, how confident are you that you could succeed?”
Reflect patient’s answer“You chose _____.”
Ask follow-up questions“Why did you not choose a lower
number?”“Why did you not choose a higher
number?”“What would it take to move to an _____?”
MI Video Demonstration
Developing Discrepancy: Pros/Cons Allows patients to list the pros and cons
of changing or of not changing health-related behaviors , and then to assign subjective weights (of importance) to each
“Tell me some good and not so good things about taking your medicine.”
“Let’s list together and discuss the pros and cons of completing your homework. Afterwards, let’s list together and discuss the pros and cons of not completing your homework.”
Developing Discrepancy: Values and Current Behavior
Values for Your FamilyCohesiveHealthyPeaceful mealsGetting alongSpending time
togetherOthers: ____
Values for YouGood parentResponsibleDisciplinedGood spouseRespected at homeOn top of thingsSpiritualOthers: ____
Developing Discrepancy: Values and Current Behavior (Cont’d)
What do you value most? How does your/your child’s/family’s current lifestyle fit in with that?“On the one hand you value a healthy
family and on the other hand you and your child have excess weight and you report that your diets are poor?”
“So where does that leave you?”
MI Video Demonstration
Review Characteristics Guiding Principles
Resisting the righting reflexUnderstand your patients motivationsListen to your patientEmpower your patient
Foundational Clinical SkillsOpen-ended questionsAffirmationsReflective listeningSummarizing
Additional Clinical Tools
Questions
Practice Application Review case studies
Case 1Case 2
Turn to your neighbor Develop a plan
Stage of change?Goals?What foundational clinical skills would you
emphasize?Which additional clinical tools may you use?
Practice Application (Cont’d) Role-play between group members
Divide into groups of 3 One person patient One person health care provider One person evaluator
Patient reviews scriptHealth care provider practices foundational
clinical skills (OARS) and at least 1 additional clinical tool (i.e., Assessing readiness to change, Pros/cons, or Values and current behavior)
Evaluator monitors progress and provides feedback
References/Resources Barlow, S. E., & the Expert Committee. (2007). Expert Committee
recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics, 120 (Suppl. 4), 164-192.
Erickson, S. J., Gerstle, M., & Feldstein, S. W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings. Archives of Pediatrics and Adolescent Medicine, 159, 1173-1180.
Glynn, L. H., & Levensky, E. R. (2009). Promoting treatment adherence using motivational interviewing: Guidelines and tools. In L. C. James & W. T. O’Donohue (Eds.), The primary care toolkit: Practical resources for the integrated behavioral care provider (pp. 199-231). New York: Springer.
Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245.
Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160.
Resnicow, K., Davis, R., Rollnick, S. (2006). Motivational interviewing for pediatric obesity: Conceptual issues and evidence review. Journal of the American Dietetic Association, 106, 2024-2033.
References/Resources (Cont’d) Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour
change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: The Guilford Press.
Miller, W., & Rose, G. (2009). Towards a theory of motivational interviewing. American Psychologist, 64, 527-537.
Rollnick, S., Miller, W. R., & Butler, C. C. (1999). Health behavior change: A guide for practitioners. New York: Churchill Livingston.
Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: The Guilford Press.
Sindelar, H. A., Abrantes, A. M., Hart, C., Lewander, W., & Spirito, A. (2004). Motivational interviewing in pediatric practice. Current Problems in Pediatric and Adolescent Health Care, 34, 322-339.
Motivational Interviewing: Resources for Clinicians, Researchers, and Trainers http://www.motivationalinterview.org/