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The use of MI in people with eating disorders
• To work with the ambivalence of the patient about change ED symptoms and maintaining factors.
• To model and teach improved emotional intelligence and communication skills for patients.
• To work with the ambivalence of close others to change some of their maintaining factors (e.g. expressed emotion, accommodating and enabling).
• To model and teach a communication style for parents. Treasure J, Schmidt U. Motivational Interviewing in the Management of Eating Disorders. In: Arkowitz H, Westra HA, Miller WR, Rollnick S, editors. Motivational Interviewing in the treatment of psychological problems. New York: The Guilford Press; 2008. 194-224.
A typical AN scenario • You go down stairs at 6 am, your daughter has already left for the
gym. • There is a cup and bowl in the sink as if she had breakfast know that
the cereal has not been touched. • This happens every day. She says she eats at lunch but you
suspect this is not the case. • You start crying when you tell your husband who gets angry and
says he has had enough and is going to have it out with her that evening.
• Role play the evening meeting in threes: daughter, mother, father. • Before the daughter starts her role, think about how ready to
change she is on a 1-10 scale, (0=not ready, 10 very ready)
A typical AN, BN scenario
• You wake to hear your daughter returning from the 24 hour supermarket at midnight with many bags.
• Later in the night you wake with the smoke alarm going off- triggered by her cooking.
• You go downstairs to have it out with her. The whole family have had their sleep disrupted so many nights- then there are the food bills and the mess. You are angry.
• In pairs role play the meeting between parent and child.
Feedback about following elements
• What did daughter feel about meeting. • What strategies did parents use ? • What strategies did daughter use ? • What did mother feel about meeting. • What did father feel about meeting. • How ready to change was daughter
before and after the meeting.
A Change Clash
Other will argue
• Confronting by directly disagreeing, arguing, correcting, shaming, blaming, criticizing, labelling, moralizing, ridiculing, or questioning the honesty. Uneven power sharing, accompanied by disapproval or negativity
• Directing by giving orders, commands or imperatives. Don’t do that!
• Advising without permission: should, why don’t you ? • Less than 5% of confrontation reduces readiness to
change (Miller).
Parents want something to be done about behaviour
Motivational interviewing is a style of interaction that works if there is ambivalence, resistance and hostility about change
Motivational Interviewing
• introduced in 1983
• to enhance intrinsic motivation for change
WR Miller
S Rollnick
• Client-centered AND Directive • Client-centered = What the
client thinks, sees, hopes for, plans and does is important
• Directive = Counselor guides conversation, explores client’s point of view & reinforces & focuses on selfself--motivational motivational statements or change talkstatements or change talk
MI-health warning
DeterminationDetermination DecisionDecision
Motivational interviewing unhelpful if individual is ready for change
MI can "worsen outcomes" in those committed to change or in the change process Lundahl B.W, Kunz C., Brownell C. et al. (2010). A meta- analysis of motivational interviewing: Twenty-five years of empirical studies Research on Social Work Practice: 2010, 20(2), p. 137-160.
MI can be integrated with other treatments
• Mi is not a panacea but a specific tool to be used with other treatment methods.
• When MI is added to other treatment methods the efficacy of both tends to increase.
• Flexible shifting in and out of MI is normal in ordinary practice.
• When MI is associated with structured assessment feedback it is called motivational enhancement therapy (MET) .
• For the active planning stage of MI- the target moves from contemplating onto visualising & preparing change strategies
Exploration of the Process (Arnheim et al 2003, Moyers et al 2009 )
• The spirit of MI: autonomy, empathy, affirmation.
• Eliciting arguments for change increases the likelihood of change. Reflecting change talk increases it.
• Helping the client when ready to develop a specific change plan also increases the likelihood of change.
• Gentle Guidance
• In pairs one person clenches their fist tightly.
• “The other tries to get the person to open up their first anyway you can, using what you typically think would work and following your instincts. Be creative and go!"
• You have 5 minutes,
• What did feel like to be the person with the closed fist.
• If the fist opened- • What strategies were successful if any?
• If the fist remained closed • What strategies were less successful?
The way questions are asked can have a profound effect on
motivation to change
Mind Experiment 1: one goal I have not achieved is ……
Think about a goal you want to achieve • Whose fault is it? • Why haven’t you done anything about it yet? • What’s stopping you doing something? • What does this problem say about you as a person? • What forces outside of your control are contributing to this? • What are the negative consequences? • What further problems is this leading to? Reflection Task What was it like to be asked those questions ? How do you feel about
yourself and the probability that you can do it on a scale of 1-10?
Experiment one thing I would like to change about myself is ……
• What, specifically, would you like to be different • What, specifically, could you do to get started? • If the first step is successful, then what? • Who else could you ask for support, assistance, if
anyone? What could you ask for? • What would be signs that things are going well? • How would you know if you were off-track? • What would you do if you got off-track? Reflection task How do you feel about yourself after being asked
these questions. How ready do you feel about change?
• Which of these styles was the most compassionate?
• If there was a change in readiness to change what caused this?
Motivational Spirit
or giving opinions. • Collaboration Negotiate and avoid an authoritarian stance • autonomy . Accept the choice to not change yet do not
push for immediate commitment at expense of “taking the long view”
Evocation
DM will argue
patient can hear their change ideas.
X
Beware the righting reflex! Collaboration/Autonomy
Collaboration/Autonomy Beware the righting reflex
• A desire to put things right when they are awry • Clinicians have a desire to put things right • This creates difficulties when a person is
ambivalent • If clinician campaigns for change then the
young adult defends status quo- they ACT OUT the ambivalence
• Then the young adult will no longer be in two minds about change- as they are in one mind and so are you
Assume competency ! Collaboration/
The battle between the North Wind and the sun (Aesop)
What does this fable tell us
Four General Principles
• Support Self-Efficacy (confidence, interest, inspiration and hope).
• Roll with Resistance- no confrontation or defensiveness: step back, accept and manage withdrawal, coldness, hostility, anger.
• Develop Discrepancy (positive envisioning as well as negative elaboration).
Developing-self efficacy with empathy
What does this dog feel? What does this dog need?
Increasing Efficacy
• People with ED have low self esteem, submissive behaviours and a negative focus.
• A positive sense of confidence and ability is needed for change.
• Building on the positive is a key component of change (compassionate affirmation).(Connan et al.,2003
2007, Troop et al., 2008, Troop et al., 2003).
Its not just what you say it’s the way you say it
• Posture
The Tools of MI- OARS • Open questions: • Affirmations: • Reflective listening: • Summarizing:
OPEN Question or Not?
• Why don’t you go to see the dietician?
• In what ways has AN been a problem for you? • What do you think keeps you from being able to care
for your nutritional health? • Why don’t you eat what I have put on this plan? • What are the good and the not so good aspects of
controlling your diet? • When are you going to admit that you have AN?
• Have you noticed that the quality of your life is less than optimal in any way?
AFFIRM Look for positive processes
• Adaptive vs. maladaptive emotional regulation
• Intimacy vs. isolation, secrecy • Flexible vs. rigid • Big picture vs. detail • I am impressed that you have been able to have
flexible and spontaneous in plans with others • It can’t have been easy to be open about your
jealous feelings-
Be a Bee: Look for the positive
Do not be a fly: do not focus on the negative-criticism and hostility
Reflections
• Simple: convey understanding but add little or no meaning (or emphasis)
• Complex: add substantial meaning or emphasis
• Why : Reflections convey empathy. Statements do not require and answer but pause for thought
Avoid Argumentation: Roll with Resistance
• Logical argument about food & weight issues is useless & harmful (essence is feelings not food)
• Confrontation gives Ed an opportunity to do Ed sustain talk
• What we say gets to be what we believe and do
• Ed talk is harmful as fuels Ed • Do not get drawn into detail- go for
the bigger picture, what is the essence? What is the gist?
If you argue for change
Other will argue
Avoid Argumentation: Roll with Resistance
• Be Reflective think about big picture do not get lost in detail.
• Take a low power position assume competency in other.
• Be kind, patient ,and compassionate
Rolling strategies (double sided reflection, moderate)
• Part of you says …….. and yet part of you wants …
• On the one hand you think …(ED talk) and on the other you …..
• When you focus on ….. and when you reflect on the bigger picture ………
• Zooming in on now you …………….and if you take the broad life perspective you……
• You do not think you are ready to……yet • At the moment you ………..
Theory
• We tend to do what we hear ourselves say we will do.
• How can we elicit change talk? • How can we develop discrepancy?
How to elicit change talk…
Ask evocative questions: “in what ways is this a problem for you?”
• Explore pro’s and con’s: “what are the good and not so good aspects of your current caring style?
• Ask for elaboration : “I’d like to know more …” • Visualising change: “What would it feel like to work
on your anxiety?” • Looking forward: “Think ahead 5 years…” • Looking back: “Tell me about M, 10 years ago” • Importance and confidence ruler: “On a scale of 1-
10…”
Eliciting self motivational statements
• Problem recognition reflections. 1. What things make you think there is a
problem? 2. In what ways is this has this been a
problem for you? 3. How has the anorexia stopped you doing
what you want to in life?
Eliciting self motivational statements
Eliciting Concern 1. What do you think other people are so
worried about? 2. How do you feel about the results of your
bone scan? 3. What do you think will happen if you’re
weight drops further?
Not important
Very important
0 1 2 3 4 5 6 7 8 9 10
How important is it to change –could you mark it on the 1-10 scale “I am interested that you have given yourself that score ” What makes you score that rather than say 0”. .. Or a score x+1 or 10”. What would you sacrifice to get to 10 “Is there any help that would enable you to move nearer to the 10”
A tool to measure confidence able
Not
confident
Very confident
0 1 2 3 4 5 6 7 8 9 10
How confident are you that u could put change in place “I am interested that you have given yourself that score ” What makes you score that rather than say 0”. .. Or a score a +1 of 10”. What help would you need to get through the backlash from change. What would you sacrifice to get to 10 “Is there any help that would enable you to move nearer to the 10”
Eliciting self motivational statements
Intention to change: 1. What’s good about the anorexia, what
does it do for you? And what about the other side ? What make you think it’s time to change?
2. It seems to me that you’re struggling with feeling stuck at the moment , what small thing could change to help get you more of what you want in life?
Moving from the dark side
What would family and friends say are your strengths? What would you like family & friends to think are your values? How could you make changes so that you live more consistently with your guiding values. If you step back and look at yourself here are you able to reflect on where are you going with your life.
Wagner CC & Ingersoll KS Beyond cognition: J Psychoth Integration 18 (2) 2008
Eliciting self motivational statements
Optimism 1. What makes you think that if you decided
to change you could do that? 2. What do you think would work for you if
you decided to change? 3. What strengths can you draw on if you
decide to change? 4. When you have put change in place in
the past how did you do it?
DARN- for change
• Desire (Importance)
In what ways would it be good for you? • Ability (confidence)
If you did decide…how would you do it? • Reasons (importance)
What would be the good things about? • Need (importance)
Why would you want to?
MI summary
Commitment
Change
MI
Responding to change talk (EARS)
• Elaboration & explore (how, why, in what ways, when was last time)
• Affirm • Reflections • Summary
Video
• Early session with patient building commitment for a change in eating behaviour.
• How does this score on MI spirit- collaboration, evocation and autonomy?
• Are MI tools-OARS- open questions, affirmations, reflections and summaries being used?
Implementing Change
• Where does this leave you now? • Check in on importance and confidence –
any changes in your ratings? • What’s your commitment – 0 to 10?
(explore) • What, if anything, can you commit to doing
in the next week?
Committing to change
• The changes I want to make in my relationship with nutrition/social life/anorexia ……….are:
• The most important reasons why I want to make these changes are:
• The steps I plan to take in changing are: • The ways other people can help me are: • Person: Possible ways to help: • I know that my plan is working if: • Some things that could interfere with my
plans are:
Merging MI with behaviour Change
Once you have some commitment then elicit, reinforce, advise with permission, support autonomy i.e. be MI CONSISTENT to move on.
• Effective behaviour change strategies • Emotional regulation strategies. • Cognitive management.
How not to get change
DeterminationDetermination DecisionDecision
•Giving advice when it is not wanted is ignored.
•Arguing for change when person is in 2 minds means they take up the anti-change argument
Ignoring or dismissing change talk means it can fall into stony ground
Failure to respect the challenge of change can make it falter. Work to increase confidence) Small goals & evidence based skills
Criticism & hostility with a shortfall on goals reduces confidence in change attempts
DVD
Anorexia researchers
2002) Drop-out: • Predicted by motivation to change (Gowers et
al., 2004) Weight gain during treatment: • Predicted by motivation and SoC (Gowers et
al., 2004; Rieger et al., 2000)
Interventions for AN using MI
• Pre-therapy (Feld et al., 2006; Wade et al., 2009)
• Motivational enhancement therapy (MET) (Feld et al., 2006)
• Conjoined therapy with CBT (Gowers, Clarke, Robets & Griffin, 2007; Gowers, Smyth & Shore, 2004) with cognitive interpersonal e.g. MANTRA (Maudlsey Model of anorexia nervosa for adults) (Wade et al 2010, Schmidt 2010).
Interventions for BN using MI
– MI plus CBT self-help better than pure self- help (Dunn, 2003)
– MET as prelude to group CBT no advantage to CBT alone – but no worse either (Katzman et al., submitted)
– Repeated personalised motivational feedback throughout CBT improves outcome (Schmidt et al., 2006)
Motivational interviewing
• Lundahl B.W, Kunz C., Brownell C. et al. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies Research on Social Work Practice: 2010, 20(2), p. 137-160
• Burke BL, Arkowitz, H, & Menchola M (2003) The efficacy of motivational interviewing: a meta-analyis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71:843-861
• Rubak S, Sandboek A, Lauritzen T, & Christensen B (2005) Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice, April: 305-312
MI competency
• On average, reflect twice for each question you ask
• When you reflect, use complex reflections more than half the time
• When you do ask questions, ask mostly open questions
• Avoid getting ahead of your client level of readiness (warning, confronting, giving unwelcomed advice or direction, taking the "good" side of the argument)
Conclusions
• There are over 250 RCT using MI. • MI is recognised to be evidence based
approach to substance abuse. • There is large variation in its effect
between practitioners • It takes skill and practice to do it well. • It is your choice how much you will try.
Further Information
Stockholm in June – motivational interviewing.com
• Can you think of one thing that you learned.
• Was there anything that you will put into your clinical practice.
• Was there anything that would surprise you.
1) When you approach this as all or nothing, it doesn't seem to work for you.
2) Allowing yourself to do XX once in while might be an option for you 3) It sounds like you may need to make peace with XXX if you are
going to move forward 4) Thinking about this differently might make it easier for you to
succeed or to be less critical of yourself..... 5) It seems you are not giving yourself credit for the XX you are already doing... 6) Having absolute rules about XX seems to make it harder on you.......cutting yourself some slack might give you more confidence... 8) Realizing you have made other difficult changes in the past could help inspire you to try this.... (9) Trying to control things a little less might make actually give you a greater sense of control......
Exercise: How ready am I to change?
• Get into groups of 3 . One person talks about something you want to change (this could be something related to your behaviour with Ed or not) eg One thing I want to change………
• The two others asks questions from motivational ruler to find out how ready for change you are (one person takes a lead and the other can help) eg can you tell me on this ruler how ready you are to change………etc etc
• At end of conversation ask where would they put themselves on motivational ruler
Exercise - Practice rolling with resistance
• Demonstration
• Practice rolling with resistance in 3’s. One person makes a resistance statement, the next person rolls with it. Take turns.
• Use
– Simple reflections i.e., paraphrase what you’ve heard
– Double-sided reflections i.e., on the one hand you feel …., on the other hand …..
• In BA (Martell et al., 2001) this basic model is presented to the client as
• the acronym TRAP (Trigger, Response, and Avoidance Pattern).
• The • goal in BA is to “get out of the TRAP and
get on TRAC” (Martell et al., 2001, • p. 102) by replacing the avoidance
patterns with Alternate Coping behaviors
• which the target variable is identified and assessed, reinforcement • is applied contingent on the occurrence of the target variable, • and procedures for generalization are used. Almost all of the above
interventions • depend on the ability of the clinician to observe the targeted • behavior as it occurs and apply reinforcement contingencies. It is a
fundamental • principle of these applied interventions that if the therapist has • direct access to these contingencies and can manipulate them
directly, treatment • should be more efficient and more effective
• Therapists may identify rumination as a CRB and target it directly, gently
• letting the client know that it affects the therapeutic relationship negatively
• (e.g., it is boring), is not a good use of therapeutic time, and blocks attempts
• at effective problem solving during the therapy hour.
• During session, clients may avoid difficult topics, begin to show
• some emotion but then make a joke or change the topic, or stay on superficial
• material. • The simple question, “Are you avoiding • something right now?” may be en
• In many cases, the difference between an intimacyenhancing • client behavior and an intimacy-defeating client behavior may • not so much be what was said but how it was said. For example,
subtleties • of voice tone, eye contact, facial expression, body posture, and
timing all • interact to influence how someone will respond to a particular
disclosure. • These subtleties may be targeted in therapy as a CRB, as the
therapist may • be more sensitive and more patient with the client in shaping
changes in • subtle behaviors or qualities of behavior compared to others in the
client’s
• Assertiveness CRBs may be seen in session in many forms.
• In general, if assertiveness is conceptualized as a treatment target for a particular
• client, then any appropriate client request to the therapist may be an
• instance of CRB2, and avoidance of such a request may be a CRB1. Such
• requests may be quite simple, such as the client asking to change the session
• time or open a window if it is hot inside the room. • Such requests may be trickier if the request appears
countertherapeutic
• In good MI practice, a client who • signals readiness for change would be responded to with change
planning • (Phase 2) rather than contemplative (Phase 1) strategies. • MI can "worsen outcomes" when introduced to people already
committed to change or> engage in a change process as reported in: