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Debra Poole, PA-C UIHC Department of Psychiatry

debra-poole@uiowa.edu

IPAS

October 3, 2016

!  I have no disclosures !  Thank you to Michael Flaum, MD

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!  Introduction to Motivational Interviewing !  Turn on a few light bulbs with

"  Example "  Chance to engage with each other

!  Share research about efficacy !  Resources for further learning if interested

!  MI is a collaborative conversational style for strengthening a person’s own motivation and commitment to change

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!  A majority of conditions that now cause people to consult health care professionals are largely preventable or remediable through health behavior change "  (e.g. obesity, heart, liver, respiratory diseases)

!  Health care practice is increasingly about long-term condition management

!  Motivating people to change behavior becomes a

primary focus in most healthcare interactions

!  Explain what he/she could do differently? !  Advise and persuade them to change their

behavior? !  Warn them about what will happen if they

don’t change? !  Counsel them about how to change their

behavior? !  Refer them to a specialist?

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!  Assess the person’s readiness and capacity to make the change "  Stage-wise assessment (Stage of Change

Model) !  Motivational Interviewing

!  Stage of Change Model "  Prochaska and DiClemente (1970’s) "  Target behavior: Cigarette Smoking

!  Motivational Interviewing "  Miller and Rollnick (1980’s) "  Target behavior: Alcohol and Drug Addictions

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Precontemplation

Contemplation

Preparation

Action

Maintenance

Relapse

An emergent theory of MI emphasizes two specific active components:

"  a relational component focused on empathy and the interpersonal spirit of MI

"  a technical component involving the differential evocation and reinforcement of client change talk

Source: Miller and Rose, Toward a theory of motivational interviewing. American Psychologist. Sep 2009

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!  When a provider takes up the “good” side of an ambivalent behavior, the client is more likely to argue the other side.

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!  The more we hear ourselves defending our behavior, the more committed we become to sustaining the status quo.

!  The more we hear ourselves talk positively

about change, the more likely we are to change.

…actively try to arrange the conversation so that it is the client rather than the clinician voicing the argument for change.

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!  Began with Bill Miller: researcher at University of New Mexico studying outcomes of therapy on change (drinkers)

!  Exposed to Carl Rogers –accurate empathy !  Most important factor seemed to be empathy of

providers !  Sabbatical 1982 in Norway working with young

graduate students, teaching accurate empathy !  Caused him to reflect on his own process !  Eventually published a paper on the process which

he called motivation interviewing, published in Behavioral Psychotherapy.

!  Met in Australia on another sabbatical !  Rollnik had read his 1982 article and due to his

efforts it had become a popular method in England.

!  Continued collaboration: three editions of the book and trainings around the world

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!  1a. MI will increase client “change talk” !  1b. MI will diminish client (“sustain

talk”) !  2a. The extent to which clients verbally

defend status quo will be inversely related to behavior change

!  2b. The extent to which clients verbally argue for will be directly related to behavior change 

!  Why would you want to make this change? (desire)

!  How would you do it if you decided? (activation)

!  What are the 3 best reasons? (reason) !  How important is it (0-10) and why? (need) !  What do you think you’ll do? (commitment)

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Source of metaphor: Jeff Allison

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!  Focus on technique is like “teaching the words without the music”

!  MI can be misused as a “cynical trick” to try to manipulate people to do what we want them to do. "  If so – that is employing MI in service of the

“righting reflex”.

Collaboration

Acceptance

Evocation

Compassion

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!  MI is not done “to” someone. It is done “for” and “with” someone.

!  Active collaboration between experts. "  People are the experts on themselves

!  Seek to create an atmosphere conducive to change, but not coercive.

!  Dancing vs. Wrestling !  Profound Respect !  Seek to understand, to see the world through patient’s

eyes

!  Different than approval or acquiescence !  Four aspects (Rogerian) The 4 A’s:

" Absolute worth " Affirmation " Autonomy " Accurate empathy

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!  An intentional way of identifying and communicating a person’s strengths and self-worth

!  We will talk more about this with technique

!  Different from sympathy !  Different from identification !  Ability to understand another’s perspective !  Conviction that doing so is important !  To sense the clients inner world as if it were

your own, but never losing the “as if” quality

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!  Opposite of imposing, giving, providing "  Expert trap

!  Strengths-based "  You have what you need…together we will find it

!  A deliberate commitment to pursue the welfare and best interests of the other. "  To prioritize the other’s needs above our own. "  Without this, manipulation of the other for self-

interest remains possible.

Compassion is the wish to see others free from suffering.

-The Dalai Lama

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!  How is this directive? !  How can MI be “client-centered” and directive

at the same time? !  How do you avoid “going in circles”?

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Ch. 12

Ambivalence: Change and Sustain Talk

!  By skillfully listening for and differentially responding to two types of language: " “Sustain Talk” (resistance?) " “Change Talk”

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!  Step 1 – recognize change talk !  Step 2 – Do not let it pass unnoticed

"  Shine a light on change talk

!  Step 3 – Strengthen it with OARS !  Open Ended Questions !  Affirmation !  Reflection !  Summaries

!  OPEN-ENDED (questions)

!  AFFIRMATIONS

!  REFLECTIONS

!  SUMMARIZING

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!  Closed questions: "  Those that invite brief answers, e.g., yes or now "  Multiple choice

!  Open questions: "  The opposite; questions that evoke more elaborate

response

!  Closed: "  Are you a smoker?

"  Have you ever been a smoker?

"  For how many years did you smoke?

"  When did you quit?

"  How much did you smoke? !  Open: "  What, if anything, has been your experience with

cigarette smoking?

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!  “It sounds as if you have really thought a lot about this and have some good ideas about how you might want to change your … You are really on your way!”

!  “That must have been really difficult for you. You are really trying hard to work on yourself.”

!  “I appreciate your candor and honesty…” !  “Good job keeping your cool just then…”

!  Not a question, a statement "  A hypothesis, that may or may not be right

!  Has the effect of encouraging the other person to elaborate, amplify, confirm or correct.

!  2 Basic Categories "  Simple "  Complex

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!  Repeating "  Repeats an element of

what the speaker said !  Rephrasing

"  Uses new words

i.e., !  It seems to you that… !  You’re wondering if… !  It sounds like you… !  You feel as if…

!  Paraphrasing "  Adds more and makes a guess as to unspoken meaning

!  Metaphors and similes "  “It’s kind of like…” “It’s as though…”

!  Amplified "  Example – “…smoking the rest of your life”

!  Affective "  Reflecting an unstated feeling

!  Double sided "  Reflects both sides of ambivalence – “on the one hand…”

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Video example of what MI might look like

!  1200 current publications, including 200 RCT !  MI associated with small to medium effects

sizes with strongest regarding addiction.

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Motivational interviewing: a systematic review and meta-analysis Br J Gen Pract. 2005 Apr 1; 55(513): 305–312. PMCID: PMC1463134

Sune Rubak, MD, Research FellowDepartment and Research Unit of General Practice, University of Aarhus, Denmark, Annelli Sandbæk, MD, PhD, Associate Professor, Torsten Lauritzen, MD, DMSc, Professor, and Bo Christensen, MD, PhD, Associate Professor and DirectorDepartment of General Practice, University of Aarhus, Denmark

!  Motivational interviewing in a scientific setting outperforms traditional advice giving in the treatment of a broad range of behavioral problems and diseases. Large-scale studies are now needed to prove that motivational interviewing can be implemented into daily clinical work in primary and secondary health care.

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!  Groups of three "  Client: pick a habit or life-style choice in your life

where you are contemplating a change and discuss this with your interviewer

"  Interviewer: practice OARS, responding to change and sustain talk, observing “righting reflex.”

"  Observer: using Coding sheet record the OARS, change and sustain talk, and use of righting reflex you observe

Interviewer   Client  OARS      -Open ended questions      

     

-Closed ended questions    

     

-Affirmations    

     

-Reflections    

  Change Talk ReflectionsSustain Talk

-Summaries    

     

Righting reflex Responses  

     

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!  How did it feel to be client? !  How did it feel to interview? !  What did observer notice? !  Comments

!  Practice: find colleagues to collaborate with. Use Coding sheet in your own practice

!  Motivational Interviewing: Helping People Change, 3rd ed., Miller and Rolnick. Guilford Press, London, 2013.

!  Motivational Interviewing: Resources for clinicians, researchers, and trainers "  www.motivationalinterview.org

(or Google: “motivational interviewing”) !  Motivational Interviewing Network of Trainers

(MINT) "  www.motivationalinterviewing.org/

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!  Debra Poole, PA-C, MPAS !  debra-poole@uiowa.edu

!  Motivation to change is elicited from the client and not imposed from without.

!  Motivational interviewing is designed to elicit, clarify, and resolve ambivalence and to perceive benefits and costs associated with it.

!  Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction.

!  Resistance and ‘denial’ is often a signal to modify motivational strategies.

!  Eliciting and reinforcing the client's belief in ability to carry out and succeed in achieving a specific goal is essential.

!  The therapeutic relationship is a partnership with respect of client autonomy.

!  Motivational interviewing is both a set of techniques and counselling style.

!  Motivational interviewing is directive and client-centered counselling understanding and eliciting behavior change.