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MOTIVATIONAL INTERVIEWING: A Way of Caring without Controlling 11th HIV Nursing Network Conference

Karena Franses, LCSW Motivational Interviewing Network of Trainers www.miformds.com

What frustrates you when

taking care of

patients with chronic

illnesses?

What is MI ?

MI is a collaborative conversation style 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.

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Technical Definition:

MI is a collaborative, goal-oriented communication style with particular attention to the language of change.

It is designed to strengthen personal

motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within and atmosphere of acceptance and compassion.

MOTIVATION, MI SPIRIT, CHANGE TALK

Part 1

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The Wind & The Sun

Ambivalence: a normal stage in the change process

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Confrontation Effect

Patterson & Forgatch, 1985

Miller et al. 1993

MOTIVATION IS PARTICULARLY SENSITIVE TO INTERPERSONAL COMMUNICATION STYLES

Counsel in a directive, confrontational manner—

•Resistance increases

•Change talk decreases

Counsel in a reflective, empathic manner—

•Resistance decreases

•Change talk increases

Miller & Rollnick, Motivational Interviewing, 2002

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Counselor Empathy Effect

Miller et al, 1980

Miller & Baca, 1983

Spirit of MI: 4 Aspects

Collaboration

Acceptance

Evocation

Compassion

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Spirit of MI: Acceptance

Acceptance

Absolute Worth

Autonomy

Accurate Empathy

Affirmation

The Way Out of Ambivalence

•Ready •Willing •Able

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Willing: Importance of Change

•Discrepancy between current behavior and a value or goal determines importance of change.

•Develop discrepancy and willingness to change increases.

Able: Confidence to Change

•If people are willing to change, they then need effective avenues for change.

•Building self-efficacy builds confidence in change.

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Ready: Prioritizing Change

•A behavior change needs to move up the hierarchy of importance.

•Dealing first with other life needs, allows a behavior change to be given more priority.

Recognizing Change Talk

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and Elicit – ChangeTalk

D A R N - CAT

Desire to change:

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D A R N – C A T

Ability to change:

“ I could …”

D A R N – C A T

Reasons to change:

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D A R N – C A T

Need to change:

Encourage & Reinforce Change Talk

• D: desire -- Want, wish, like

• A: ability -- Can, could, able

• R: reason -- Specific reason for change

• N: need -- Need to, have to, must, important

• COMMITMENT LANGUAGE PREDICTS CHANGE

• C: commitment — Will, intend to, going to

• A: activation — Ready to, willing to (w/o specific commitment)

• T: taking steps — Report recent specific action toward change

Amrhein et al., 2003

DARN CAT

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Drumming for change (talk) • Sam wants to cut down on her drinking . When you hear change talk: • D – A – R – N: Drum on your table. • Or commitment language: C – A – T

Clap! (When you hear sustain talk or neither: silence.) • Pat wants to stop using drugs.

Four Processes in MI

Miller and Rollnick, 2013

Engaging

Focusing

Evoking

Planning

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Engaging

• Do I understand this person’s perspectives and concerns?

• How comfortable does this person feel talking with me?

• Does this feel like a collaborative relationship?

Miller and Rollnick, 2013

Focusing

• What goals for change does this person really have? • Are we working together with a common

purpose?

• Do I have a clear sense of where we are going?

Miller and Rollnick, 2013

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Evoking

• What are this person’s own reasons for change?

• What change talk am I hearing?

• Is the righting reflex pulling me to be the one arguing for change?

Miller and Rollnick, 2013

Planning

• Am I remembering to evoke rather than prescribe a plan?

• What would help this person to move

forward?

• Am I offering needed information or advice with permission?

Miller and Rollnick, 2013

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Stages of Change

• Pre-contemplation • Denial, Minimization

• Contemplation • Ambivalence

• Preparation • New Years resolution

• Action • Less than 6 months

• Maintenance • More than 6 months

OARS: MOTIVATIONAL INTERVIEWING’S FOUR MICRO-SKILLS

Part II

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Building Motivation: OARS (the microskills)

•Open-ended Questioning

•Affirming

•Reflective Listening

•Summarizing

•O

•A

•R

•S

OARS: Open-Ended Questions

• Avoid ‘yes/ no’ or other specific answers

• Evoke change talk:

• Elicits person’s narrative

• If you did decide to make this change, how might you go about it in order to succeed?

• “Where are you at with your meth use?”

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Open-Ended Questioning

• Evokes change talk:

• Looking forward: “Where do you see yourself in 5 years, if you keep regularly using meth?”

• Looking back: “What was your life like before your chronic pain?’

• “What would have to happen for you to decide to quit smoking?”

OARS: Affirmations

It’s really

good that

you’re taking

good care of

yourself by ...

I’m

impressed.

How were

you able to

follow-up on

that AA

meeting?

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OARS: Reflective Listening Model from Thomas Gordon (Parent Effectiveness Training)

What the speaker means What the speaker says

What the listener hears What he listener thinks the

speaker means

• Communication can go wrong because:

1. The speaker doesn’t say exactly what is meant.

2. The listener doesn’t hear the words correctly.

3. The listener gives a different interpretation to what the words mean.

• The process of reflective listening is meant to correct the 2 boxes on the left

4. To check on whether “what the listener thinks the speaker means” is the same as

”what the speaker means.”

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Reflective Statements

• Offers a hypothesis about what the speaker means.

• A good reflective listening response is a statement. Its inflection turns down at the end. (question may sound judgmental)

”You’re still using cocaine, even after having a heart

attack?" (up) vs.:

"You're still using cocaine, even after having a heart attack." (down)

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Reflective Statement Levels Examples

“I’m cutting back my drinking, but my liver tests aren’t any better.”

• SIMPLE

• Repeating Simply repeats an element of what the speaker has said: “You’re cutting back on drinking, but your liver isn’t any better.”

• Rephrasing Substitutes synonyms or slightly rephrases what was offered: “Your liver isn’t improving, despite drinking less.”

“I’m cutting back my drinking, but my liver tests aren’t any better.”

• COMPLEX

• Paraphrasing Listener infers the meaning. Continues the paragraph: “Even though you’re drinking less, you can’t figure out why your health isn’t improving.”

• Reflection of feeling Deepest, emphasizes emotional dimension through feeling statements: “You’re frustrated because you’re trying to drink less, but its not paying off.”

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Reflections for Sustain Talk

“What’s not so good about using meth?”

• “Well, I overdo it sometimes, but meth gives me energy.”

• Coming alongside: “You feel meth makes your work easier and don’t see it as an issue.”

• Amplified reflection: “Your meth use has never really caused any problems or unpleasant effects in your life.”

• Double-sided reflection: “You think you use too much at times, but you also don’t think of yourself as a problem user.”

PRACTICE REFLECTIVE LISTENING Batting Practice – Exercise Using Reflections to Engage

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Think of difficult statements patients have made:

• Write down at least 3 or 4 of them

• In groups of 6-8

• One person at a time takes a turn as a batter

• Other members of the group throw out your statements and the batter responds with a short simple reflection. Then switch batters so everyone has a turn.

• Goals: To “get on base”; home runs are not necessary.

Summarizing Statement

•Special form of reflection

• Pick a bouquet of flowers •Focus on change talk or underlying dilemmas

• Reassures that you heard person •Moves the conversation along.

“you are trying to cut back on your drinking because you know its bad for your liver but you hang out with your friends and they all drink so it’s hard for you to not drink”

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Summarizing Exercise

• In pairs, one person will talk for 90 seconds about something they would like to change. The other person will only listen and then give a 1 minute summary.

• Then switch

BRIEF MI TOOLS

Part III

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MI TOOLS

• ASK-TELL-ASK

• PROS AND CONS

• IMPORTANCE AND CONFIDENCE SCALES

• ACTION PLANNING

Tool #1 Ask-Tell-Ask

• Ask: What is your understanding about… ?

• Tell: Would you mind if I tell you some further info? (ask permission) What happens to some people is that…

• Ask: What do you make of this…?

• Case: My patient admits that she has been quite depressed. I am worried about her mood worsening especially with her drinking daily. She says 2 beers but I suspect its more

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Ask - Tell – Ask (Case cont’d.)

• KF: ‘Let’s talk about drinking & depression. Do you see a connection?’

• Pt: ‘Yes, a couple of beers help me to feel much better.’

• KF: ‘Right, while you’re drinking, you feel pretty good.’

• Pt: ‘Yeah, but by the next morning I’m down again.’

• KF: ‘Would you mind if I give you some further info on the brain chemical relationship between drinking & depression?’

• Pt: ‘No. You’re the doctor.’

• KF: ‘When you actually drink, it lifts your mood. But overall, alcohol lowers the chemicals that protect the brain from depression. That’s why in between the times you drink, you still feel down. So even a couple of daily beers worsen depression. What do you make of that?’

• Pt: (surprised) ‘I didn’t know that drinking is actually making my mood worse.’

Ask – Tell – Ask You can use it for

• A person has cirrhosis and continues to drink 2 beers on most nights.

• To begin:

• PCP: “Mr./Ms. _____, what’s your understanding about (drinking when you have this diagnosis of cirrhosis?)”

• “May I share some information with you about ___?”

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Ask – Tell – Ask Or for the person

who had an MI one year ago, and still uses crank 2 – 3 times per week because they want to have more energy.

Tool #2 Pros & Cons

• Pros first: “What works for you about _____?”

• Repeat using a reflective statement

• Cons: “What’s less useful for you about _____?”

• Repeat using a reflective statement

• “Anything else?”

• End with a summarizing statement

• “Where do you want to go from here?”

• Moves pt from denial to contemplation

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Tool #3 Importance & Confidence

• “From 0-10, How Important is It for

You To …?” • Why did you choose this (number) and not a

(lower number)?

• What would have to happen for this # to go to 8 or 9?

• “From 0-10, How Confident Do You Feel that You can …?”

• What made you choose this (number) and not a (lower number)?

• What would have to happen for this # to go to ____ (a higher number?

Tools for Action Planning

• Keep it simple & realistic • If bite of more than they can chew, will fail.

• What, where, and how? • Write down the specifics

• Have pt predict obstacles • What might get in the way? • Address these obstacles

• Ask: How confident do you feel that you can do this from 0-10?

• <7, probably won’t happen

• Set-up a follow-up plan • “May I call you next week to see how it’s going?”

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Many Thanks to:

• Sharone Abramowitz, MD

• Tom Freese, PhD

• Jennifer Hettema, PhD

• Steve Berg-Smith, PhD

Recommended Reading

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Recommended videos

• Http://www.youtube.com/watch?v=EvLquWI8aqc

MI interview for excessive drinking: Cathy Cole, LCSW, demonstrates and elaborates MI with comments about her interview with a young woman (5:35).

• http://www.youtube.com/watch?v=s3MCJZ7OGRk MI, An Introduction, by Bill Matulich, PhD, Animated Ppt slide presentation (17:22).

Recommended videos (continued):

• Time issues and MI:

• https://vimeo.com/67088727 Can listening save time? – Steve Rollnick and Fiona McMaster. Dr. Ng shares her experience about her patient refusing dialysis (7:52).

• http://www.youtube.com/watch?v=0z65EppMfHk Damara Gutnick, MD, “Mr. Smith’s Smoking Evolution” - MI for Busy Clinicians. A cute, animated Ppt slide show (9:59).