Motivational Interviewing: Conversations that lead to Change

Carol DeFrancesco, MALS, RD

Division of Health Promotion and Sports Medicine, OHSU

defrance@ohsu.edu

Special thanks to: Denise Ernst, Steve Berg-Smith and Bill Miller

Motivation changes with our

style of interacting.

Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.

MI has substantial evidence base supporting it’s effectiveness in facilitating change in behaviors that are hard to change

MI is effective with both psychological (behavior change) and physical outcomes (BMI, BP, BAC)

MI focuses the responsibility for change on the patient; encourages self-management and self-determination

Why is Motivational Interviewing (MI) a method to consider?

MI out performs traditional advice giving in 80% of studies

Effective in 10-20 minutesMore encounters over longer time period

increase likelihood of an effectHealth professionals (MDs, RDs, RNs)

can be as effective as psychologists or counselors

The efficacy of MI –meta analyses

Profound Positive InfluenceDiscussion

Evocation of person’s motivation, hopes, dreams, desires, values, goals, and abilities.

Partnership with the person; MI is done “for” and “with” a person and not “to” a person.

Acceptance including accurate understanding, affirmation, absolute worth of the person, and support of the person’s autonomy.

Compassion; active promotion of the person’s welfare and needs.

The Spirit of MI

Self-Efficacy & HopeA person must have hope

This is predictive of how they will do

A provider’s expectation is also predictive

Bandura’s Theory of Self-Efficacy

Sitting on the fence of change

Cowboy from Klamath Falls

People get defensive when their autonomy is threatened

What happens if you give advice to a person on the fence. . .

Gas station story

Sustain Talk

The least desirable situation, from the standpoint of evoking motivation, is:

when the health provider advocates for change while the patient argues against it

Most of us already have pro-change reasons of our own.

These reasons are more persuasive than those of others.

Bem’s Self-perception theory

Strength Cards and Break

Specific Skills: OARS

OPEN Questions

AFFIRMATIONS

REFLECTIONS

SUMMARIES

Reflective StatementsStatements not

questions

Restates what patient says and selectively reinforces change talk

Puts the patient in a more active role when discussing behavior change

Reflective StatementsPt: ‘I need to lose weight.’

Provider: “Being overweight has got you concerned.”

Pt: ‘Healthy food is more expensive.’Provider: “You are wondering if you can afford to change your eating habits.”

Pt: “I know I could eat better.”Provider:

Pt: “I don’t have time to exercise.”Provider:

Forming Reflections with Strength cards:

Large group activity then pairs

Why not simply ask questions (from Miller & Rollnick 2013, pp 52-53)

“Why respond with a statement . . . After all the listener is not sure if the guess is correct.”

A question requires a response; it places a demand on the other person

Pressing people with questions to explain themselves distances them from what they are experiencing – they step back to analyze and question what they have expressed.

A well formed reflection encourages continued exploration and minimizes defensiveness

Debrief Strength Activity

OARS

OPEN Questions

AFFIRMATIONS

REFLECTIONS

SUMMARIES

Questions that Evoke Change Talk (from Miller & Rollnick 2002)

Category:Disadvantages of the status quoWhat concerns you about _______?What makes you think you need to do something about _______?What hassles have you had in relation to your smoking (or other behavior)?How has this stopped you from doing what you want to do in life?What do you think will happen if you don’t change anything?

Questions that Evoke Change Talk (from Miller & Rollnick 2002)

Category: Advantages of change

How would you like things to be different?

What would be the good things about ______?

What would you like your life to be like five years from now?

What are the main reasons you see for making a change?

What do you want?

Questions that Evoke Change Talk (from Miller & Rollnick 2002)

Category: Optimism about change

If you decide to make a change, what would you do to be successful?

What do you think would work for you if you decide to change?

When else in your life have you made a significant change like this? How did you do it?

What personal strengths do you have that will help you succeed?

Questions that Evoke Change Talk (from Miller & Rollnick 2002)

Category: Intention to change

What are you thinking about your smoking (eating habits, exercise) at this point?

What do you think you might do?

What would you be willing to try?

What do you want to have happen?

Affirmations & Self-affirmationsEmphasize a strength (What

strengths do you have that will help you be successful?)

Appreciate a positive action (What is working for you?)

How are you keeping yourself healthy?

Summaries can: Collect material that has been offered

So far you’ve expressed concern about your pacing, sleep, and options for pain medications.

Link something just said with something discussed earlier. That sounds a bit like what you told me about that

before when you were successful in changing. . . Draw together what has happened and

transition to a new task Before I ask you the questions I mentioned earlier, let

me summarize what you’ve told me so far, and see if I’ve missed anything important. You came in because you were feeling really sick, and it scared you . . . . . . . . .

Listening… How to stop the talkers….

Summarize and use a bridging statement

I’d like to shift gears… go back to something you mentioned…

Discuss time limitations Give value to what you have

heard “We have talked about a lot of

things today, if you had to pick on one to work on…”

OARS Batting Practice

OPEN Questions

AFFIRMATIONS

REFLECTIONS

SUMMARIES

Most of us already have pro-change reasons of our own.

These reasons are more persuasive than those of others.

Bem’s Self-perception theory

Sustain Talk

The least desirable situation, from the standpoint of evoking motivation, is:

when the health provider advocates for change while the patient argues against it

Listening for Change Talk

Levels:

Preparatory

- I need to, I’ve been thinking about, I’ll try, I want to, I can

Commitment

- I will, I am going to, I have already started

Change Talk Levels

Court room oath:“Do you swear to tell the truth, the whole truth

and nothing but the truth, so help you God?”

Wedding Vows“Do you Jen take Bill to be your husband . . .

Will you love him and honor him, in sickness and in health . . . ?”

Engaging

Focusing

Evoking

PlanningFour FoundationalProcesses

Demonstration

Conversation Roadmap

Set the stage and engage“I would like to spend about 10 minutes talking

about your eating habit goals, would that be OK?” “What are you already doing to eat healthy?” “What do you notice . . .”

Decide where to focus“There are a number of things that go in to

healthy eating: more vegetables and fruits, less junk or sugar, regular meals . . Where do you feel ready to make a change?”

Increase fruits & vegetables

Drink less soda

Eat regular meals

Shop for food regularly

Healthy Eating Ideas

Eat out less

Cut back on sugar

Conversation Roadmap

Evoke deeper reasons“Why did you choose . . .?” “Why else would

this be a good thing?”

Plan when client is ready“What are you willing to try?”

Summarize and Close“Let me see if I got it all . . .What are you

ready to commit to in the next couple weeks?”

Your turn: Groups of 3handout

Debrief:

Speakers first: “What seemed to further your change process?”

Debrief:

Listeners

What did you notice?

“It is through the power of our

listening, not the wisdom of our

words that we are able to affect the

most change”

Carl Rogers