Motivational Interviewing

• Phase 1: resolve ambivalence and build intrinsic motivation for change

• Phase 2: strengthening commitment to change and developing a plan to acomplish it

Reason for motivational interviewing: the client perceives less importance for a change

that the councesllor does

Motivational Interviewing

• Express empathy: acceptance, reflective listening, ambivalence

• Develop discrepancy: the client rather than councellor should present the arguments for change

• Roll with resistance: avoid arguing for change, new perspectives are invited but not imposed

• Support self-efficacy: a person´s belief in the possibility of change is an important motivator; the client is responsible for choosing and carrying out change

Change and resistance

AmbivalenceA Decisional Balance Sheet

Continue to drink as beforeBenefits: • helps me relax• Enjoy drinking with friendsCosts:• Could loose my family• Bad example for my children• Damaging my health• Spending too much money• Impairing my mental ability• Might loos my job• Waisting my time/life

Abstain from alcoholBenefits:• Less family conflict• More time with my children• Feel better physically• Helps with money problemsCosts:• I enjoy getting high• What to do abyout my friends• How to deal with stress

Resistance

• Arguing: challenging, hostility• Interrupting: talking over, cutting off• Negating: blaming, disagreeing, excusing,

minimizing, pesimism, unwillingness to change• Ignoring: inatention, nonanswer, no response

Change talk and resistance

Change talk• Disadvantages of status quo• Advantages of change• Intention to change• Optimism about change

Resistance talk• Advantages of status quo• Disadvantages of change• Intention not o change• Pessimism about change

TRAPS• Question-Answer (Do you think you drink too much? What is your

favourite drink?)• Taking Sides (Well it seems clear to me that you have a serious drinking

problem. You are showing a lot of signs of alcoholism…What do you mean?)

• Expert Trap (Conveying the impression of having all the answers)• Labelling trap (You are an alcoholic x So you are implying that I am an

addict? No, I am really not concerned that much about labels. But it sounds like you are, that itś a worry for you.)

• Premature focus trap (Pushing the client to talk about councellor´s own conception of the problem)

• Blaming trap: Whose fault is the problem? Who is to blame?

Blame talk

• „It sounds like you are worried about who is to blame here. I should explain that councelling is not about deciding who is at fault. That is what judges do, but not good concellors. Councelling has no-fault policy. I am not interested in looking for who si to blame but rather what is troubling you and what you might be able to do about it“

Opening session

Opening structure

• „We have about an hour together now. In this time I want to get a beginning understaning of what brings you here. I will spend more time listening so that I can understand how you see things and what your concerns are. You must also have some hopes about what will and will not happen here and I will want to hear about those. Toward the end of this hour I will need to ask you some specific information that I need. What is on your mind?“

Diabetes management

• „As you know there are a number of things that we could discuss today- such a s monitoring your blood sugar levels, healthy diet, exercies and your medication. What are you most concerned about? What would you like to talk about today? Perhaps there are other things that you feel are more important to discuss.“

Five early methods: OARS

Ask open questionsAffirm

Listen reflectivelySummarize

Elicit change talk

Open questions

• Questions that do not invite brief answers• Establish an atmosphere of acceptance and

trust within which client will explore their concerns

• „I would like to understand how you see things. What´s brought you here?“

• „I understand that you have some concerns about….Tell me about them.“

Practice

Is it open or a closed question?

• 1. What do you like about drinking?• 2. (4.) Are you willing to come back for a follow-up

visit?• 3. (5) What brings you here today?• 4. (7) Have you ever thought about walking as a

simple form of exercise?• 5. (8). What do you want to do about your smoking:

quit, cut down or stay the same?• 6. (11). What possible long-term consequences of

diabetes concern you most?• 7. (12). Do you care about your health?

Practice

Inquisitive Neighbour

Questions: TRAPS

• Close Question-Answer Trap dia 01

• Open Question followed by Close Question Trap dia 02

Questions: Invitation to dialogue

• Open questions dia 03, dia 04

Listen reflectively

Identify reflective listening

P: I'm not able to exercise the way I need to.D: Oh, I wouldn't worry about it. Lots of people don't even

try.

P: I am not very good at putting things into words. D: I think you have described the situation very well.

P: I was scared to death. D: I can understand how those experiences must have

frightened you, but I think it is very likely they'll respond to treatment.

Identify reflective listeningP: Work is almost unbearable. My supervisor watches me like

a hawk and criticizes the tiniest little mistake I make.D: Why not write her a memo and outline your grievances?

P: …crying… Doctor: „Even now it brings tears to your eyes when you talk

about your mother..

P: „I cannot fall asleep, after I told my wife about meeting with my new girlfriend, everything has changed.“

D: How do you think your wife felt when she found out about your affair?

What is not listening: Roadblocks• Ordering, directing or commanding• Warning, cautioning or threatening• Giving advice, making suggestions or providing solutions• Persuading with logic, arguing or lecturing• Telling people what they should do, moralizing• Disagreeing, judging criticizing or blaming• Shaming, ridiculing or labeling• Interpreting or analyzing• Questioning or probing• Withdrawing, distracting, humoring or changing the subject

Message: Listen to me, I know the

best

What is not listening: Roadblocks

• Shaming, ridiculing or labeling• Interpreting or analyzing• Questioning or probing• Withdrawing, distracting, humoring or

changing the subject

Reflective listening

• Reflexion is a reasonable guess as to what the speaker means

• The listener has to hear the words accurately and then decode their meaning

„Continuing the paragraph“

• P. I worry sometimes that I may be drinking too much for my own good.

• D. You have been drinking quite a bit.• P. I don´t really think I dring that much. I can drink a lot and

not feel it.• D. More that most people.• P. Yes, I can drink most people under the table.• D. And that´s what worries you.• P. Well, that and how I feel. The next morining I am usually in

bad shape.• D. And that does not seem right to you.

Affirmation

The point is to notice and appropriately affirm the patient´s

strengths and efforts

Practice

Give compliment to your neighbour…

Statement of appreciation and understanding, compliments

• Thanks for coming on time today.• I appreciate that you took a big step in coming

here today.• You are clearly a resourceful person, to cope

with such difficulties for so long.• That´s a good suggestion.• I have enjoyed talkong with you today and

getting to know you a bit.

How to make an enemy easily and quickly (dia5)

Identify 3 bad habits in communication

Change talk and resistance

Change talk• Disadvantages of status quo• Advantages of change• Intention to change• Optimism about change

Resistance talk• Advantages of status quo• Disadvantages of change• Intention not o change• Pessimism about change

Responding to resistancewith nonresistance

P: I just do not want to take pills. I ought to be able to handle it by my own.

Simple reflexion???

P: I couldn´t keep the weight off even if I lost it.Simple reflexion???

Responding to resistancewith nonresistance

• Double-sided reflextion

P: I know it makes sense, but you don´t seem to understand how bad the pain is. When I even try to get out of the bed, let alone exercise, the pain in my back is terrible. I hurt all the time.

D: You think that in the long run exercise is likely to help you decrease your pain and at the same time you are suffering quite a lot and that makes it hard to get started walking or even to think about it.

How to be a patient´s sparingpartner (dia 6)

Identify OARS

Eliciting change talk

• Recognizing disadvantages of the status quo (This is serious!)

• Recognizing advantages of change (Probably I´d feel a lot better)

• Expressing optimism about change ( I did quit smoking a few years ago. That was tough, and it took a few tries, but I did it.)

• Expressing intention to change (I definitely don´t want to keep going the way I have been.)

Importance and confidence ruler

• How important would you say it is important for you to …….? • On a scale from 0 to 10 where 0 is not at all important and 10

is extremely important, where sould you say you are?• 0 1 2 3 4 5 6 7 8 9 10• And how confident would you say you are, that if you decide

to…., you could do it? On the same scale, where 0 is not confident aa all and 10 is extremely confident, where would you say you are?

Importance and confidence ruler

• Why are you at a …..and not zero?• What would it take for you to go from …..to ( a higher

number?)

Methods for evoking change talk

• Disadvantages of the stats quo:• What worries you about current situation?• Advantages of change:• What would be the good things about loosing weight?• Optimism about change: • What personal strenghts do you have that will help you

succeed?• Intention to change• How important is this to you?

Signs of readiness for change

• Decreased resistance• Decreased discussion about the problem• Resolve • Change talk• Questions about change• Envisioning• Experimenting between sessions

Information sharing

Elicit-provide-elicit:• Ask client what he knows (or wants to know)

about an area of interest (elicit)• After describing, provide the information• Ask the client what is his view (elicit)

Dia 08Crime and

punishment

Dia 09The patient is curious. What does it mean?

Giving advice

• Ask permission. Make sure the client is interested in what you are about to offer

• Offer ideas, do not persuade.• Use a menu• Solicit what the client thinks

Dia 07Identify 3 methods of motivational interview

Summary: how to motivate the patient for the change

• Open questions• Reflective listening• Affirmation• Summarization• Change talk• Advice after permission• Choice offering

Source

• Miller WR., Rollnick S. Motivational interviewing. Preparing people for change

• Second edition, The Guilford Press, 2002