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Motivational Interviewing: Motivational Interviewing: Some Basic ToolsSome Basic Tools

Ana Moseley, LISW, ACSWAna Moseley, LISW, ACSWThomas Peterson, Ph.D.Thomas Peterson, Ph.D.,,

Sponsored by:Sponsored by:

Sangre de CristoSangre de CristoSangre de CristoSangre de CristoCommunity Health PartnershipCommunity Health Partnership

Substance Abuse and Mental Health Substance Abuse and Mental Health Services AdministrationServices AdministrationServices AdministrationServices Administration

Tennessee Primary Care AssociationTennessee Primary Care Association

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GoalsGoals

•• Brief intro to MI:Brief intro to MI:

•• Focus on some specific MI skills:Focus on some specific MI skills:

••Using reflectionsUsing reflections

••Rolling with resistanceRolling with resistancegg

••Giving information or adviceGiving information or advice

When working with a client,

would you rather be

or

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What is MIWhat is MI

A person centered goal orientated approach for A person centered goal orientated approach for facilitating change by exploring & resolving facilitating change by exploring & resolving g g y p g gg g y p g gambivalenceambivalence ((Miller 2006)Miller 2006)

…a method of communication rather than a set …a method of communication rather than a set of techniques. It is not a bag of tricks for getting of techniques. It is not a bag of tricks for getting people to do what they don’t want to do; rather, it people to do what they don’t want to do; rather, it p p y ; ,p p y ; ,is a fundamental is a fundamental way of being with & for peopleway of being with & for people–– a facilitative approach to communication that a facilitative approach to communication that evokes change”evokes change” (Miller & Rollnick 2002)(Miller & Rollnick 2002)

The Spirit of MI vs. Its The Spirit of MI vs. Its Mirror ImageMirror Image

COLLABORATION VS. CONFRONTATION

EVOCATION VS. EDUCATING

AUTONOMY VS. AUTHORITY

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AmbivalenceAmbivalenceThe Dilemma of ChangeThe Dilemma of Change

•• “I want to, and I don’t want to”“I want to, and I don’t want to”

•• Ambivalence is a normal aspect of Ambivalence is a normal aspect of human nature.human nature.

•• Passing through ambivalence is a Passing through ambivalence is a natural phase in the process of natural phase in the process of change.change.

•• Ambivalence is a reasonable place to Ambivalence is a reasonable place to visit but you wouldn’t want to live visit but you wouldn’t want to live there.there.

Typical StrategiesTypical Strategies

Give them Give them InsightInsight -- if you can just make if you can just make ll th th ill hth th ill hpeople people seesee, then they will change, then they will change

Give them Give them KnowledgeKnowledge -- if people just if people just knowknow enough, then they will changeenough, then they will change

Give them Give them SkillsSkills -- if you can just teach if you can just teach peoplepeople howhow to change then they will do itto change then they will do itpeople people howhow to change, then they will do itto change, then they will do it

Give them Give them HellHell -- if you can just make if you can just make people feel people feel badbad or afraidor afraid enough, they will enough, they will changechange

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Stages of ChangeStages of Change

Maintenance

Contemplation

Relapse

Precontemplation

Permanent exit

Preparation

Action

PrecontemplationPrecontemplationKeyword: Doesn’t know or not readyKeyword: Doesn’t know or not readyTask: Increase recognition and Task: Increase recognition and Task: Increase recognition and Task: Increase recognition and

concern about behaviorconcern about behavior

ContemplationContemplation

Keyword: AmbivalenceKeyword: AmbivalenceTask: Tip the balanceTask: Tip the balance

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PreparationPreparation

Keyword: ThresholdKeyword: Threshold

Task: Negotiate a change planTask: Negotiate a change plan

ActionAction

Keyword: MovementKeyword: Movement

Task: Help person implement change Task: Help person implement change planplan

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MaintenanceMaintenance

Keyword: BalanceKeyword: Balance

Task: Help person continue changeTask: Help person continue change

Relapse/RepeatRelapse/Repeat

Keyword: Guilt and ShameKeyword: Guilt and Shame

Assist return to change behavior, Get Assist return to change behavior, Get back on trackback on track

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Traditional Health Care ApproachTraditional Health Care Approach

•• Explain why the person Explain why the person shouldshould changechangeGive benefits that would result from Give benefits that would result from •• Give benefits that would result from Give benefits that would result from making the changemaking the change

•• Tell the person how they could make the Tell the person how they could make the changechange

•• Persuade the person to do itPersuade the person to do it•• If you meet resistance, repeat the above.If you meet resistance, repeat the above.If you meet resistance, repeat the above.If you meet resistance, repeat the above.•• Warn the speaker what may happen if Warn the speaker what may happen if

change is not made.change is not made.•• P.S. This is P.S. This is NOT NOT motivational Interviewingmotivational Interviewing

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The Righting ReflexThe Righting Reflex

•• The desire to set things right.The desire to set things right.

•• Acting on the inclination to advise, Acting on the inclination to advise, teach, persuade, counsel or argue for teach, persuade, counsel or argue for a particular resolution to a clients a particular resolution to a clients ambivalenceambivalenceambivalence.ambivalence.

Reactions to Righting ReflexReactions to Righting Reflex

Angry, agitatedAngry, agitated OppositionalOppositional

HelplessHelpless OverwhelmedOverwhelmed OppositionalOppositional

DiscountingDiscounting DefensiveDefensive JustifyingJustifying Not understoodNot understood

N t h dN t h d

OverwhelmedOverwhelmed AshamedAshamed TrappedTrapped DisengagedDisengaged Not come backNot come back--

avoidavoid Not heardNot heard ProcrastinationProcrastination AfraidAfraid

avoidavoid UncomfortableUncomfortable

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In Motivational Interviewing:In Motivational Interviewing:

Direct persuasion is not very useful for Direct persuasion is not very useful for resolving ambivalenceresolving ambivalence

Motivation is elicited from the patient and Motivation is elicited from the patient and not imposed from withoutnot imposed from without

The patient is supported in identifying The patient is supported in identifying and resolving ambivalenceand resolving ambivalence

Patient values and autonomy respectedPatient values and autonomy respected

“Change talk” recognized & responded to“Change talk” recognized & responded to

Resistance is treated constructivelyResistance is treated constructively

Four General Principles of MIFour General Principles of MI

1. Express empathy 1. Express empathy

2. Develop discrepancy 2. Develop discrepancy

3. Support self3. Support self--efficacyefficacy

4. Roll with resistance4. Roll with resistance

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Principle 1: Express EmpathyPrinciple 1: Express Empathy

Listen actively with the goal of Listen actively with the goal of understandingunderstandingunderstandingunderstanding

Skillful reflective listening is Skillful reflective listening is fundamental.fundamental.

Acceptance facilitates change.Acceptance facilitates change.

Ambivalence is normal.Ambivalence is normal.

Principle 2: Develop DiscrepancyPrinciple 2: Develop Discrepancy

Motivation for change occurs when Motivation for change occurs when people perceive a discrepancy between people perceive a discrepancy between people perceive a discrepancy between people perceive a discrepancy between where they are and where they want to where they are and where they want to bebe

Values and beliefs are key factorsValues and beliefs are key factors

The person rather than the practitioner The person rather than the practitioner should make the arguments for changeshould make the arguments for change

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Principle 3: Support SelfPrinciple 3: Support Self--EfficacyEfficacy

A person's belief in the possibility of A person's belief in the possibility of h i i t t ti th i i t t ti tchange is an important motivator.change is an important motivator.

The patient, not the practitioner, is The patient, not the practitioner, is responsible for choosing and carrying responsible for choosing and carrying out change.out change.

The practitioner's own belief in the The practitioner's own belief in the The practitioner s own belief in the The practitioner s own belief in the person’s ability to change becomes a person’s ability to change becomes a selfself--fulfilling prophecy.fulfilling prophecy.

Principle 4: Roll with ResistancePrinciple 4: Roll with Resistance

Avoid arguing for change.Avoid arguing for change.Resistance is not directly opposed.Resistance is not directly opposed.New perspectives are invited and not New perspectives are invited and not

opposed.opposed.The patient is the primary resource The patient is the primary resource

in finding answers and solutionsin finding answers and solutionsin finding answers and solutions.in finding answers and solutions.Resistance is a signal to respond Resistance is a signal to respond

differently.differently.

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Roll with ResistanceRoll with ResistanceReluctance and ambivalence are to be Reluctance and ambivalence are to be

acknowledged (and even respected) and acknowledged (and even respected) and g ( p )g ( p )not confronted directlynot confronted directly

Questions and problems may be turned Questions and problems may be turned back to the patient for solutionback to the patient for solution

Explicit permission is given to disregardExplicit permission is given to disregardExplicit permission is given to disregard Explicit permission is given to disregard what the interviewer is sayingwhat the interviewer is saying

Resistance supplies energy which can be Resistance supplies energy which can be used therapeuticallyused therapeutically

ADDRESSINGADDRESSINGADDRESSING ADDRESSING RESISTANCERESISTANCE

What Does Resistance Look What Does Resistance Look Like…?Like…?

What Kind of Resistance have What Kind of Resistance have You Encountered?You Encountered?

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Four Categories of Four Categories of Resistance BehaviorResistance Behavior

ARGUING: Contesting the accuracy, ARGUING: Contesting the accuracy, ti i t it f th i t iti i t it f th i t iexpertise or integrity of the interviewerexpertise or integrity of the interviewer

INTERRUPTING: Cutting off or talking over INTERRUPTING: Cutting off or talking over the interviewer in a defensive waythe interviewer in a defensive way

UNWILLINGNESS: Not recognizing UNWILLINGNESS: Not recognizing problems, cooperating, taking responsibility problems, cooperating, taking responsibility problems, cooperating, taking responsibility problems, cooperating, taking responsibility or accepting adviceor accepting advice

IGNORING: Being silent, inattentive, nonIGNORING: Being silent, inattentive, non--responsive or sideresponsive or side--trackingtracking

Responding to Resistance: Responding to Resistance: Reflective ResponsesReflective Responses

Simple ReflectionSimple Reflection (focused on feelings; (focused on feelings; e g “You’re angry about being sent e g “You’re angry about being sent e.g., You re angry about being sent e.g., You re angry about being sent here.”)here.”)

Amplified ReflectionAmplified Reflection (overstating (overstating feelings; e.g., “You’re feelings; e.g., “You’re furiousfurious about being about being sent here.”)sent here.”)

DoubleDouble--Sided Reflection Sided Reflection ("On one hand ("On one hand you like the way things are; and on the you like the way things are; and on the other hand there’s part of you that would other hand there’s part of you that would like to make a change.")like to make a change.")

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Responding to Resistance: Responding to Resistance: Strategic responsesStrategic responses

EmphasizingEmphasizing Personal Choice and Personal Choice and ControlControl ("It's really your decision...")("It's really your decision...")

Shifting FocusShifting Focus (“We've gotten ahead of (“We've gotten ahead of ourselves...”)ourselves...”)

ReframingReframing

Agreement with a twistAgreement with a twist

Siding with the negative (Coming Siding with the negative (Coming alongside)alongside)

MI Tools: OARSMI Tools: OARS

O O -- Open QuestionsOpen Questions

A A -- AffirmAffirm

R R -- ReflectReflect

SS -- SummarizeSummarizeS S SummarizeSummarize

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O. OpenO. Open--ended Questionsended Questions

Patients should do most of the talkingPatients should do most of the talkingUseful early in session to build rapport Useful early in session to build rapport

& provide direction& provide directionAsk for “both sides of the coin”Ask for “both sides of the coin”The general pattern in MI is to ask an The general pattern in MI is to ask an

open question setting the topic of open question setting the topic of open question, setting the topic of open question, setting the topic of exploration, and then follow with exploration, and then follow with reflective listening. reflective listening.

Good question or not?Good question or not? In what ways has alcohol been a problem for In what ways has alcohol been a problem for

you?you?

What do you think keeps you from What do you think keeps you from abstaining?abstaining?

Why don’t you try going to AA?Why don’t you try going to AA?

Why would you want to put your baby at risk Why would you want to put your baby at risk by drinking?by drinking?

What’s wrong with trying a few days without What’s wrong with trying a few days without alcohol?alcohol?

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A. AffirmingA. Affirming

Compliments or statements of Compliments or statements of i ti d d t dii ti d d t diappreciation and understanding.appreciation and understanding.

The point is to notice and appropriately The point is to notice and appropriately affirm the patient’s strengths and affirm the patient’s strengths and efforts.efforts.

Genuineness is criticalGenuineness is criticalGenuineness is criticalGenuineness is criticalAppreciation vs. approval Appreciation vs. approval

R. ReflectR. Reflect

Demonstrates a desire for mutual Demonstrates a desire for mutual d dd dunderstandingunderstanding

Start with simplest levels of reflection Start with simplest levels of reflection and move forward as rapport buildsand move forward as rapport builds

Good follow up to openGood follow up to open--ended questionended question

“Listen more than tell”“Listen more than tell”

Being selective as we hold up a mirror Being selective as we hold up a mirror for the people we work withfor the people we work with

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S. SummarizingS. Summarizing

Periodic summaries reinforce what Periodic summaries reinforce what h b id h th t h h b id h th t h has been said, show that you have has been said, show that you have been listening carefully, and prepare been listening carefully, and prepare the patient to elaborate further.the patient to elaborate further.

It’s like collecting flowers one at a It’s like collecting flowers one at a It s like collecting flowers one at a It s like collecting flowers one at a time and then giving them to a time and then giving them to a person in a bouquet.person in a bouquet.

Reflective Listening:Reflective Listening:Reflective Listening: Reflective Listening: Review & PracticeReview & PracticeThink of reflective listening as a way to Think of reflective listening as a way to

act as a mirror and help clients see act as a mirror and help clients see themselvesthemselves--hopefully at a deeper level hopefully at a deeper level themselvesthemselves hopefully at a deeper level hopefully at a deeper level

because of your reflections.because of your reflections.

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Reflective ListeningReflective Listening

One of the most important and most One of the most important and most challenging skills required for MIchallenging skills required for MIchallenging skills required for MIchallenging skills required for MI

The essence of reflective listening is that it The essence of reflective listening is that it makes a guess as to what the speaker makes a guess as to what the speaker means.means.

The reflective listener gives voice to the The reflective listener gives voice to the guess in the form of a statement of guess in the form of a statement of

d t did t diunderstanding.understanding. Start with simple reflections and move Start with simple reflections and move

towards complex reflections towards complex reflections

Forming reflectionsForming reflections

•• A reflection states an hypothesis, makes A reflection states an hypothesis, makes a guess about what the person meansa guess about what the person meansa guess about what the person meansa guess about what the person means

•• It is a statement not a questionIt is a statement not a question(reflections should outnumber questions)(reflections should outnumber questions)

--Start with your questionStart with your question--Cut the question wordsCut the question words--Inflect your voice down at the endInflect your voice down at the end

•• No penalty for missingNo penalty for missing

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Levels of ReflectionLevels of Reflection

CONTENTCONTENT

FEELINGFEELING

MEANINGMEANING

“I want to live at home to see my grand kids “I want to live at home to see my grand kids grow up.grow up.

Content:Content:“St i t h i “St i t h i “Staying at home gives you more “Staying at home gives you more

contact with your grandkids.”contact with your grandkids.”Feelings:Feelings:“You’re worried that they might forget “You’re worried that they might forget

about you if you’re not around .”about you if you’re not around .”Meaning:Meaning:“Your grand children mean a lot to you “Your grand children mean a lot to you

and you want to be there for them.”and you want to be there for them.”

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Ready to listen?Ready to listen?

Getting presentGetting present g pg p

Turning down the noise in my headTurning down the noise in my head

Being clear about my own goals for Being clear about my own goals for the interaction the interaction

Focusing on the person or family in Focusing on the person or family in front of me front of me

Levels of ReflectionLevels of Reflection

Repeating (same words)Repeating (same words)

Rephrasing (same content, different Rephrasing (same content, different words)words)

Paraphrasing (reflecting meaning)Paraphrasing (reflecting meaning)

Reflection of feelings (“You feel ”)Reflection of feelings (“You feel ”)Reflection of feelings ( You feel… )Reflection of feelings ( You feel… )

Deeper meaning (“You feel ____ Deeper meaning (“You feel ____ BECAUSE…”)BECAUSE…”)

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Sentence stems for reflectionsSentence stems for reflections

You mean that…You mean that…You’re wondering if…You’re wondering if…So you feel… You’re feeling…So you feel… You’re feeling…You…You…

Client statements for practiceClient statements for practice

(36 year old female) “I can’t quit drinking. (36 year old female) “I can’t quit drinking. Everyone I hang out with drinks all the Everyone I hang out with drinks all the Everyone I hang out with drinks all the Everyone I hang out with drinks all the time.”time.”

(19 year old male) “Hey, I get smashed (19 year old male) “Hey, I get smashed because its fun. It’s not a problem because its fun. It’s not a problem ---- I just I just drink on the weekends.”drink on the weekends.”

(31 year old male) “You can’t understand (31 year old male) “You can’t understand (31 year old male) You can t understand (31 year old male) You can t understand what I’ve been through unless you’ve what I’ve been through unless you’ve been there yourself.”been there yourself.”

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Client Client Statements from ParticipantsStatements from Participantspp

Communication StylesCommunication Styles

DirectDirectGuideGuideFollowFollow

––A child runs into the roadA child runs into the roadh ld l d b kh ld l d b k––A child is learning to ride a bikeA child is learning to ride a bike

––A child is crying and you don’t know A child is crying and you don’t know whywhy

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Guiding StyleGuiding Style

May be the most effective way to May be the most effective way to t lk t ti t b t lif t l t lk t ti t b t lif t l talk to patients about lifestyle talk to patients about lifestyle changeschanges

Motivational Interviewing Motivational Interviewing –– a refined a refined form of this guiding styleform of this guiding styleform of this guiding styleform of this guiding style

Core Communication SkillsCore Communication Skills

AskingAskingSho t openSho t open ended q estionsended q estions––Short, openShort, open--ended questionsended questions

ListeningListening––Active use of reflection, especially with Active use of reflection, especially with

change talk or resistancechange talk or resistance

InformingInforming––Ask permission, elicitAsk permission, elicit--provideprovide--elicitelicit

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Before giving advice, ask…Before giving advice, ask…

“Have I elicited the client’s own ideas “Have I elicited the client’s own ideas d k l d th bj t?”d k l d th bj t?”and knowledge on the subject?”and knowledge on the subject?”

“Is what I am going to convey “Is what I am going to convey important to the client’s safety, or important to the client’s safety, or likely to enhance the client’s likely to enhance the client’s motivation for change?” motivation for change?” motivation for change? motivation for change?

Miller and Rollnick, 2002, pg. 131Miller and Rollnick, 2002, pg. 131

Key Elements for Using MIKey Elements for Using MIin a Brief Interventionin a Brief Intervention

AskAsk--ProvideProvide--AskAskReflection/Roll with ResistanceReflection/Roll with Resistance Importance (or Interest) RulerImportance (or Interest) RulerConfidence RulerConfidence RulerSummarySummaryyyMenu of OptionsMenu of Options “What do you think you’ll do”“What do you think you’ll do”

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Before giving advice or Before giving advice or information…information…

Ask:Ask: “Would it be okay with you to share “Would it be okay with you to share some information/advice I have some information/advice I have some information/advice I have some information/advice I have about_______”about_______”

“Elicit the patient’s own ideas and “Elicit the patient’s own ideas and knowledge on the subject?”knowledge on the subject?”

ProvideProvide the information/advicethe information/advice

Ask:Ask: “What do you make of that?”“What do you make of that?”

Readiness to ChangeReadiness to ChangeAssessing Interest, Importance, & Assessing Interest, Importance, &

Confidence with RulersConfidence with Rulers

Not at all importantNot at all important extremely importantextremely important

5 6 7 8 92 101 3 40

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Using RulersUsing Rulers

Importance RulerImportance Ruler“On a scale of one to ten how important is it “On a scale of one to ten how important is it On a scale of one to ten how important is it On a scale of one to ten how important is it

to make a change in your behavior?”to make a change in your behavior?”Query:Query: “What makes it an 8 and not a 2?”“What makes it an 8 and not a 2?”

Confidence RulerConfidence Ruler“On a scale of one to ten how confident do “On a scale of one to ten how confident do

you feel that you can make a change in you feel that you can make a change in your behavior?”your behavior?”

Query:Query: “What would it take to move it up to an 8?”“What would it take to move it up to an 8?”

Summarize and Offer OptionsSummarize and Offer Options

Summary of information and change Summary of information and change y gy gtalktalk

Menu of choices / Agenda settingMenu of choices / Agenda setting

Ask the client: “What do you think Ask the client: “What do you think you will do?”you will do?”

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BI DemonstrationBI Demonstration

Agenda SettingAgenda Setting

Ask permission to discuss topicAsk permission to discuss topic“I wonder if it would be ok with you if “I wonder if it would be ok with you if I wonder if it would be ok with you if I wonder if it would be ok with you if we talked about your medications?”we talked about your medications?”

Explain you will not insist on immediate Explain you will not insist on immediate action action action action “I’d like to get a better idea of how you “I’d like to get a better idea of how you feel about your meds, don’t worry, I’m feel about your meds, don’t worry, I’m not going to lecture you, ok?”not going to lecture you, ok?”

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Agenda SettingAgenda Setting ChartChart

Encouraging Talk about ChangeEncouraging Talk about Change

Arranging conversation so that Arranging conversation so that li t k th t f li t k th t f clients make the argument for clients make the argument for

changechangeSeveral strategies to elicit selfSeveral strategies to elicit self--

motivational statementsmotivational statementsEasiest is to ask questions which Easiest is to ask questions which Easiest is to ask questions which Easiest is to ask questions which

elicit concern, intent to change and elicit concern, intent to change and optimism (see handout for sample optimism (see handout for sample questions)questions)

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Preparatory Change TalkPreparatory Change TalkFour KindsFour Kinds

DARNDARN--CCDesire Desire to change (want, like, wish )to change (want, like, wish )

Ability Ability to change (can, could …)to change (can, could …)

Reasons Reasons to change ( if .. then )to change ( if .. then )

Need Need to change (need, have to, got to …)to change (need, have to, got to …)

Commitment to making change ( I will, Commitment to making change ( I will, I’ve decided…)I’ve decided…)

Sustain TalkSustain Talk

Sustain talk is a normal part of Sustain talk is a normal part of ambivalence.ambivalence.

DARNDARN--C: C: Desire for status quo Desire for status quo “Inability” to change“Inability” to changeReasons to keep status quo Reasons to keep status quo “Need” to keep status quo“Need” to keep status quoCommitment to status quoCommitment to status quo

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Resistance vs. Sustain TalkResistance vs. Sustain Talk

Resistance is interpersonal behavior, a Resistance is interpersonal behavior, a signal of dissonance predictive of signal of dissonance predictive of signal of dissonance, predictive of signal of dissonance, predictive of nonnon--change, and highly responsive change, and highly responsive to counselor style (for example: to counselor style (for example: discounting, interrupting, arguing)discounting, interrupting, arguing)

O t diff ti t th t i O t diff ti t th t i One way to differentiate the two is One way to differentiate the two is that resistance needs a partner while that resistance needs a partner while sustain talk you could say to yourselfsustain talk you could say to yourself

A Change of RoleA Change of Role

•• You don’t have to make change happen.You don’t have to make change happen.Y ’tY ’tYou can’tYou can’t

•• You don’t have to come up with all the You don’t have to come up with all the answers.answers.

You probably don’t have the best onesYou probably don’t have the best ones

•• You’re not wrestlingYou’re not wrestlingYou’re dancingYou’re dancing

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Staying In TouchStaying In Touch

amoseley444@yahoo.comamoseley444@yahoo.com

thomas.peterson@sdcchp.nm.orgthomas.peterson@sdcchp.nm.org

nancy.miquelon@ihs.govnancy.miquelon@ihs.gov

mady.maraia@sdcchp.nm.orgmady.maraia@sdcchp.nm.org

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Thank You!Thank You!