Motivational Interviewing: Enhancing communications to improve health outcomes
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1Celeste A. Hunter; MS, CRC 9/15/11
Motivational Interviewing:Enhancing communications to improve health outcomes
Celeste Hunter, MS, CRCDoctoral Candidate
Department of Rehabilitation PsychologyUniversity of Wisconsin-Madison
2011 Wisconsin Health Improvement and Research Partnership Forum
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Celeste A. Hunter; MS, CRC 9/15/11
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Overview• Introduction to Motivational Interviewing
• Basic Tenants of MI
• Motivational Interviewing (MI) is designed specifically to alter patient motivation
• Use of MI in primary care settings can increase successful patient care
• Applications of MI across: o Patient populationso primary care clinic implementation (time permitting).
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Just wondering….
• What do we know about MI so far?
• What are our assumptions about how people change?
• To whom does this apply?
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Celeste A. Hunter; MS, CRC 9/15/11
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Rehabilitation is hard work!
oAdhere to self-care, medication, & therapy• i.e. OT,PT, Speech
oExercise & eat rightoShow up to all appointments on timeoStop or curb substance useoUse “appropriate” behavior
In PC or other rehabilitation, we often ask patients to make significant changes in their behavior:
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“Challenges” to pursuing “well” behaviorsPeople without acute/chronic health issues: No immediacy & importance to putting forth effort of:
Exercising Eating right Stop drinking, etc…
People with acute/chronic health issues:-May wonder… “why bother”-Already struggling w/ challenges of illness
(Lynch, in press)
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Motivation & Health Care Outcomes“
• How successful people are towards rehab goals = what they do
• Clients are often > ready, willing, and able to make change
• Most clients seeking treatment or change are ambivalent about it:.
• They want it…and they don’t
Client motivational problems are a primary barrier to successful rehabilitation outcomes” Thoreson, et., al 1968.
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Easy to say… But hard to do…
Arising from people's: internal cognitions significant others environment
Convenience or lack of: Facilities transportation
lack of information (Stuifbergen et al., 1990)
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Barriers to Health Promo: Patient perceptions of the: unavailability,
inconvenience or difficulty of a particular health-promoting option
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Motivation:Traditional Clinicians Perspective
• Motivation is the patients problem
• The patient “just isn’t ready to change
• The patient is getting “something”out of status quo: i.e.; social security, attention, relaxed lifestyle, etc.
orCeleste A. Hunter; MS, CRC 9/15/11
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Introspective Exercise #1
• Think of a behavior you have tried to change and write it down.
• Think about how long it took you to make an earnest attempt at change after noticing the behavior.
• Who was helpful in that process and why?
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Motivational Interviewing: A Definition
Motivational Interviewing is a collaborative, person
centered form of guiding to elicit and strengthen
motivation for change.
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Motivation: MI’s Perspective• Motivation is the
probability that a person will change*
• Motivation is influenced by clinician responses
• Low patient motivation can be thought of as a clinician deficit
*Miller & Rollnick, Motivational Interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.
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Assumptions About Behavior Change
• Attitude is everything: Impart belief in the possibility of change
• Empathy: Create an atmosphere in which the client safely explores
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MI is Theoretically Sound
MI strategies are theoretically & empirically basedo Substance abuse (Miller & Rollnick, 2002)o Chronic pain treatment (Jensen, 2002)o Exercise and MS (Bombardier et al, in
progress)
Focus on Ambivalence: Feeling 2 ways about something: o Wanting to change, but not wanting to
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Theoretical Basis of MICognitive Dissonance Theory (Festinger):
-‘If I say it and no one has forced me to say, I must believe it.’
Client-Centered Therapy (Rogers): • Accurate empathy, warmth, and
genuineness promote change.Belief System Theory (Rokeach): • Awareness of a discrepancy between
behavior and core values creates change.
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Theoretical Basis of MI (continued)
Learned Optimism (Seligman): • Optimism and hope facilitate change.
Importance of Choice (Sanchez-Craig): • Choice enhances adherence.
Reactance Theory (Brehm): • Threats to freedom elicit resistance.
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Stages of Change:Transtheoretical Model of Change Prochaska & Velicer, 1997
Transtheoretical model of change:• Explains or predicts a person's success or failure in
achieving a proposed behavior change, such as developing different habits.
• It attempts to answer why the change "stuck" or alternatively why the change was not made.Celeste A. Hunter; MS, CRC 9/15/11
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Motivational Interviewing: 2 Phases
Phase #1
Increase Motivation to Change
Counselor evokes client’s:
• Desire• Ability• Reasons• Need for change
By responding with reflective listening
Phase #2
Consolidating Commitment
• Strength of language (not frequency) = change
• Low level = “I’ll try" or “I’ll think about it”
• High Level = “I promise” or “I will!”
• Final min of session = strongest predictor of behavior change (Amrhein et al. 2003)“I will do it!”
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SKILLS
SPIRIT
STRATEGIES
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“Spirit” is the foundation of MI practice
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Research Shows…
General practitioners trained in MI can positively affect patients’ attitude to change behavior: Tend to open up and talk more in telling
their stories Tend to view professionals more positively
and express greater satisfaction with care received
Tend to follow treatment recommendations
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The Spirit of Motivational Interviewing
3 main concepts:oCollaborationoEvocationoAutonomy
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Spirit: Underlying Assumption:
oClients can and will develop direction of health and adaptive behavior
Essential for the full and effective use of MI
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MI: Four General Principals
#1: Express empathy: (using short reflections)
• Acceptance facilitates change• Judgment change• Ambivalence is normal
#2 Develop discrepancy: (good things/not so good things)
o Client (rather than counselor) argues for changeo Change when perceived discrepancies in present behavior
important personal goals & values
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MI: Four General Principals#3: Roll with Resistance:• giving advice change and resistance• New perspective are invited-- with permission• Resistance = Signal
- DO SOMETHING DIFFERENT!
#4: Support Self-Efficacy:• Person’s belief in possibility of increases
initiation & persistence of adaptive behavior
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CollaborativeDancing Wrestlingvs.
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We’ve all done it…, but…Lecturing provides little in the way of motivationUsual response = Annoyance or guilt Jensen, 2005
Information is to behavior change
as wet noodles are to bricks -Wilbert Fordyce
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Accepting & Non-judgmental
The paradox of change:when people feel accepted for who they are and what they do - no matter what…
- it allows them the freedom to consider change rather than needing to defend against it.
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Spirit… Facilitative CommunicationNothing ‘magical’ about the MI SPIRIT… …it’s just good communication skills that:
Honors Autonomy: Respects the other person’s freedom of
choice, personal control, perspective, and ability to make decisions
Elicits:Encourages the other person to do most of the talking
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Please remember......• Just because MI seems SIMPLE,
that doesn’t mean it is EASY• Just because it seems like
COMMON SENSE, that doesn’t mean it is COMMON PRACTICE!
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Spirit Summary
Underlying assumption that clients can develop in the direction of health and adaptive behaviorEssential for the full and effective use of MICan learn if curious and willing to entertain possibility of…
• Evocation• Autonomy• Collaboration
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Applications to Rehabilitation Settings
There are many things you can do to increase motivation…
#1= LISTEN!
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What to listen for…
Is this person ready to change? Identifying stage of change
What does this person value? Link rehabilitation outcomes to the person’s own goals
Why would this person want to participate?
Use the person’s own arguments for change
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Change-talk is client speech that favors movement in the direction of change
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What do we know about change talk?
Change talk...Predicts behavior changeIs suppressed by confrontationIs enhanced by listeningIs under the control of the counselor
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Change Talk DefinedChange talk is client speech that favors movement in the direction of change towards a specific target behavior.
Before we can EVOKE change talk… We need to learn to RECOGNIZE it.Celeste A. Hunter; MS, CRC
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Preparatory Change Talk:DARN!
DESIRE to change (want, like, wish . . )ABILITY to change (can, could . . )REASONS to change (if . . Then)NEED to change (need, have to, got to .
.)
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Ask for DARN to get DARN!• Why would you want to make this change?
(Desire)• How might you go about making this
change? (Ability)• What are the three best reasons to do it?
(Reasons)• On a scale of 0-10, how important would
you say it is for your to make this change? And why aren‘t you at a _____ (2 points lower)? (Need)
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Two Kinds of DARN
It may reveal itself as:
-Attraction to change
“I want to change because I want to look great in a swimsuit.”
oras avoidance of the status quo
“I want to change because I don’t want to have low energy.”
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Desire
They want or wish to change: “ I wish I could remember to test my blood sugars everyday.”
“I want to get off of disability.”
“I like the idea of eating better.”
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Ability
They can or have change in the past…
“ I think I can lower my pain meds.”
“I used to exercise at least 3 times per week…”
“I might be able to fit in more fruits and vegetables …”
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ReasonsThey have good reasons to change:
“I’m sure I would feel better about myself if exercised more.”“I want to healthy so I can have enough energy to keep my job.”“Eating more fruits and veggies would help me help me feel healthier…. And I’d set a good role model for my kids.”
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NeedThey need to (have to, got to, should, ought to, must) change…
“ I must stop smoking...”“I’ve really got to loose weight… I don’t want a knee replacement.”“Cutting down on my drinking will help me keep my kids …”
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C A T
• Commitment: What do you intend to do? • Activating: What are you ready or willing
to do? • Taking steps: What have you already
done?
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Recognizing & Attending to Commitment
STRONG Commitment Talk Medium Commitment Talk
I willI definitely will
I promiseI swear
I guaranteeI know I will
I intend toI am ready toI am going to
I plan toI think I willI expect to
*Given more time, we would excavate this further… Celeste A. Hunter; MS, CRC 9/15/11 43
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When in doubt, just remember…
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Listening Practice to get DARN!
OARS
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Key MI Skills: OARS
• Open-ended questions
• Affirmations
• Reflective listening
• Summarize
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OARSWe use OARS to give our interactions..
Movement&
DirectionCeleste A. Hunter; MS, CRC 9/15/11 47
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Open-Ended Questions
Questions can’t be answered yes or no
Questions that can’t be answered with
one or two words
Questions that are not rhetorical
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Open-Ended Questions
Probe widely for information
Help uncover patients’ priorities and values
Avoid socially desirable responses
Draw people out
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Open or closed? What do you like about drinking?
Where did you grow up?
Isn’t it important for you to take your insulin regularly?
What brings you here today?
Do you want to continue receiving services?
Have you ever thought about how alcohol might effect
your memory?
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Example 1:
“Would you like to come back for your follow-up appointment?
A more open-ended question?
Open-ended questions (continued)
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Example 2:
“How much pot do you smoke?”
A more open-ended question?
Open-ended questions (continued)
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Open ended questions
Using only open ended questions, find out what
your partner will be doing this weekend
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Reflective listening says:
“I hear you.”
“I’m accepting, not judging you.”
“This is important.”
“Please tell me more.”
“ I want to be sure I have this right.”
Reflective Listening
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ReflectionsRemembering to reflect is easier said than done…
After a long client narrative, the most important things to reflect are:
Client experience
Client’s reaction to the experienceCeleste A. Hunter; MS, CRC
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Types of Reflections - SimpleRepeating (repeats an element of the what the speaker said) Rephrasing (uses new words)
Note: Inflection turns D O W N ……at the end
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Types of Reflections: Complex
Paraphrase: (makes an educated stab at
unspoken meaning)
Accurate reflections of deeper meaning: (deeper, succinct reflections are ventured
as understanding increases)
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Example 1:
“I really want to stop eating junk food, but no one in my family will stop bringing it into the house. I’m tired of trying.”
Reflective response?
Reflective Listening (continued)
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Exercise #2• Choose a behavior you are
interested in changing and willing to share with a partner in this room
• Review the “DARN” principles as they relate to this change
• Role play with a partner as “counselor” and “client”
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Persuasion Exercise: Debrief
- Did the clinician observe movement in the direction of positive change?
- Did the speaker feel like making positive change?
- What are the underlying messages conveyed by advice giving and lecturing?
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SummaryConveys to the patient/client:
“What you’ve said is important.”
“I value what you say.”
“Here are the salient points.”
“Did I hear you correctly?”
“We covered that well. Now let's talk about ...”
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When do you know it is working?- You are speaking slowly
- The patient keeps talking
- The patient is talking more than you
- You are following and understanding
- The patient is working hard and seeming to come to new realizations
- The patient is asking for information or advice
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Benefits of Motivational Strategies
• Makes our job easier
• More rewarding
• More effective
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In Conclusion…• Motivational issues are central to
effective Rehabilitation• We cannot make patients change
behavior• We can help to motivate patients in the
direction of positive changes by: Listening rather than lecturing Identifying the stage of change Matching our response to stages to encourage
movement to the next stageCeleste A. Hunter; MS, CRC 9/15/11 64