Transcript Motivational Interviewing

Deborah L. Drew, Ed. D., LCPC and Evan Williams, PharmD
Husson University
HICHEP Presentation
August 24, 2013
Welcome and Introductions
Hour 1: What is Motivational Interviewing?
Hour 2: Components of Motivational
Interviewing
Hour 3: Tools and Practice
Hour 4: Action Plan: Implementing Change in
Your Practice
Summary and Evaluations
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3
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Clinicians can only provide patients with
clinical knowledge and education
Patients make the ultimate decision to change
What can clinicians do to influence patient
change?
◦ Scare tactics
◦ Lecture and educate
◦ Motivate the patient to change
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Describe the development and evidence for
the use of motivational interviewing
Implement components of the model for
motivational interviewing
Develop an action plan to implement the
elements and principles of motivational
interviewing in practice
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Think of a “bad” habit you have tried to
change
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Dietary habits
Exercise habits
Workplace habits
Relationship habits
How long did it take to realize that this habit
had a negative impact on you or others?
◦ Months? Years?
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Were you successful? Did you relapse?
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Think about patients who have difficulty
making change
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Precontemplation
No intention of changing their behavior for the foreseeable future
Not thinking about changing their behavior
May not see the behavior as a problem
Contemplation
Aware a problem exists
Seriously considers action
Not yet made a commitment to an action
Preparation
Intent upon taking action soon
Often report some steps in that direction
Action
Aware a problem exists
Actively modifies their behavior, experiences and environment in order to overcome the
problem Commitment is clear
Great deal of effort to change
Maintenance
Sustained change
New pattern of behavior has replaced the old
Behavior is firmly established
Threat of relapse becomes less intense
Prochaska, J. O., & DiClemente, C. C.
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“Motivational Interviewing (MI) is a
collaborative, person‐centered form of
guiding to elicit and strengthen
motivation for change.”
Defined by the identification, examination,
and resolution of ambivalence about
changing behavior
– Ambivalence: Feeling two ways about behavior
change
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles
%20&%20Approach%20V4%20012911.pdf
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Method of communication
◦ Not a technique
◦ Increases mutual understanding
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Collaborative
◦ Honors patient autonomy
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Strengthens a person’s own motivation for
and commitment to change
◦ Patient-centered
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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William R. Miller
◦ Motivational Interviewing with Problem Drinkers
 Behavioral Psychotherapy - 1983
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Stephen Rollnick and William R. Miller
◦ 1991 article
◦ Outlines clinical procedures
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Has been revised and applied to many
settings
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change.
New York: Guilford Press.
Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy.
1983, 11 (2); pp 147-172
14
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Growing body of evidence
◦ 6 references 1980-1989
◦ 78 references 1990-1999
◦ 707 references 2000-2009
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Most studies show MI to be beneficial
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Most studies have limitations
◦ Publication bias?
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Small sample size
Weak comparator groups
Various providers offering MI
Providers have differing levels of training in MI
Difficult to assess the manner in which MI is used
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J
Clin Psych 2009;65(11) 1232-45
15
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Pattern of results show MI is likely
◦ To confer at least a 10% advantage in success
rates versus weak comparators
◦ To be as good or better than established
treatments
◦ To take less time and resources
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Best outcomes may be using MI pretreatment
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)
1232-45
16
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Effective regardless of gender or age
Training level does not significantly impact
effectiveness
◦ Versatile
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In what areas is MI most effective?
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
17
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J
Clin Psych 2009;65(11) 1232-45
18
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J
Clin Psych 2009;65(11) 1232-45
19
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A metaanalysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312
20
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Limitations
• Interventions ranged from 10-120 min (60 min most
common)
• Variable follow up periods
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Usefulness
• Provides evidence that MI can elicit significant change
• Overall about 75% of studies show there was an effect
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych
2009;65(11) 1232-45
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of
controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312
21
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Key Elements of MI
◦ Collaboration
◦ Evocation
◦ Autonomy
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Principles of MI
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Express Empathy
Support Self Efficacy
Develop Discrepancy
Roll with Resistance
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20P
rinciples%20&%20Approach%20V4%20012911.pdf
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Collaboration
◦ Dismisses hierarchy
◦ Builds rapport
◦ Non-confrontational
◦ Focus is mutual understanding
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
24
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RG is a 57 year old male with hypertension
and hyperlipidemia. On questioning it is
revealed that he smokes about 1 pack of
cigarettes daily. You would like him to quit
smoking.
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Evocation
◦ Patients discover their own motivation and skills for
change
◦ Draw out the patients own thoughts and ideas
◦ “..lasting change is more likely to occur when the
client discovers their own reasons and
determination to change”
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Pharmacist: “I’ve noticed you have been late
filling these medications the last 2 months.”
Patient: “Yeah, I’ve been having a hard time
keeping up with things as I am moving to a new
home across town in a few weeks. I know taking
my medications is important but I’ve been so
busy lately that I forget sometimes.”
Pharmacist: “It sounds like you would like to take
your medications but it has been a tough time
dealing with the move.”
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Autonomy
◦ Ultimately it is the patient’s decision to change
◦ Empowers the patient and gives them responsibility
◦ As clinicians, we can encourage patients to develop
their own “SMART” goals
 Specific, Measurable, Achievable, Relevant, Timely
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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DK is a 44 year old patient newly diagnosed
with diabetes. After discussion, it is revealed
that he eats desserts for relaxation. When
asked how he thinks this impacts his
diabetes, he states he does not know.
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Express Empathy
◦ See the situation from the patient’s perspective
◦ Gain perspective on what the patient’s motivation
may be
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“It sounds like this has been tough for you”
“It seems like this situation has been difficult
for you to accept”
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
30
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Support Self Efficacy
◦ Focus on strengths and skills patient already has
◦ Highlight previous successes
◦ Patient needs to believe that change is possible
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
31
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Develop Discrepancy
◦ Patients identify their values and goals
◦ Patients evaluate their current behaviors
◦ Ambivalence is discovered when conflict between
values/goals and behaviors is identified
◦ Change is more likely when patients realize their
behaviors are in conflict with their self‐identified
values or accomplishment of goals
◦ “On the one side, you feel unhappy that you cannot
keep up with your grandkids because of your COPD,
but on the other hand, you feel that smoking is one
of the only ways you can relax.”
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
32
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Roll with Resistance
◦ Do not challenge resistant statements
 Confronting resistance promotes defensiveness and
diminishes the likelihood of a patient finding their own
reasons to change
◦ Use the resistance as an opportunity to further
explore the patient’s views
◦ Be aware of when a patient is becoming frustrated
 Closed body language
 Negative verbal responses
 Shortened verbal responses
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
33
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BG is an overweight veteran recently
discharged from the Air Force. He has gained
much of this weight since his discharge 14
months ago. The clinician suggested that BG
enroll in clinic sponsored program for weight
loss. BG declines enrollment. BG states that
he is just not willing to exercise for 30
minutes 5 days a week because he is just too
exhausted after work.
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OARS
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Open-Ended Questions
Affirmations
Reflective Responses
Summaries
RULES of Motivational Interviewing
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Resist the righting reflex
Understand the patient’s motivation
Listen with empathy
Empower the patient
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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Elicit better responses from patients
Make a conversation less one-sided
Are not answerable with a simple yes or no
Open-Ended Question Words Closed-Ended Question
Words
How?
Why?
Tell me more about...
When?
What kinds of…
Do you?
Have you?
Can you?
Will you?
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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Statements that recognize a patient’s
strengths
Help support self efficacy
◦ Tries to help patient believe change is possible
despite past failures
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Restate how the
provider perceives
the patient
Allows for increased
clarity
Allows the listener to
affirm the patient’s
feelings
Patient feels
understood
Words the
patient uses
What the
patient meant
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
Words clinician
hears
What the
clinician thinks
the patient
meant
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Reflection that recaps visit and highlights
important areas
Can clarify ambivalence and discrepancies
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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http://counselingvideos.blogspot.com/2013/0
6/its-not-about-nail.html

“I know what is best”
◦ Removes autonomy from the patient by insinuating
the patient does not know what is best for
themselves
◦ Re-establishes hierarchy
◦ Can undermine the patient’s motivation for change
◦ Can create conflict
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
46
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Patient’s reason for change is more important
than the clinician’s
Explore importance of changing
◦ Ask for a scaled answer
◦ Why is it that number and not another?
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
47
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On a scale from zero to ten how important is it
for you to……?
Tell me why you chose that number?
What could happen that would move you to
higher number?
On a scale from zero to 10, how confident are
you that you can make this change?
Tell me more why you chose that number for
your confidence level?
What do you think might help become more
confident in making a change?
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Use reflective responses
◦ Allows patient to tell you more
◦ Clarifies patient’s concerns
◦ Confirms mutual understanding
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Be aware of body language
◦ Eye Contact
◦ Nodding
◦ Posture
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Do not “understand”
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
49
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S-sit squarely
O-open posture
L-lean forward
E-eye contact
R-relax
(Egan, 2010) – D&E
50
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Patients must believe change is possible
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Failures can be demoralizing
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Focus on previous successes
◦ Even small victories can be uplifting
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Encourage the patient
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Let the patient know that they are in control
of the change
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
51
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Think again about those patients you
identified earlier who are resisting change
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Roll with Resistance
Affirmation
Open – Ended Question
◦ Collaboration
◦ Respected patient’s autonomy
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Reflective Response
◦ Listening with Empathy
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Collaboration
Open – Ended Question
◦ Elaboration
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Listening with Empathy
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What went right?
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How well did the pharmacist do using
reflective responses?
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What could the pharmacist have done to
improve?
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DARN-CAT
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Desire (I want to change)
Ability (I can change)
Reason (It is important to change)
Need (I need to change)
Commitment (I will make changes)
Activation (I’m ready and prepared to change)
Taking steps (I am doing specific things to change)
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
57
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Ask questions that will elicit answers that are
consistent with DARN-CAT
◦ Developing discrepancy
 Desire
 Reason
 Need
◦ Change ruler
 Ability
 Activation
◦ SMART Goal Setting
 Ability
 Activation
 Taking steps
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What concerns you about your current
situation?
What makes you think you need to do
something about your weight?
What concerns you about not checking your
blood glucose on a regular basis?
What do you think might happen if you don’t
change your diet?
How would life be different for you if………?
If you could wake up tomorrow and things
changed by magic, how would things be
better for you?
What are the main reasons you see for ……..?
What would be the benefits of…… for you?
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You mentioned how important it is for you to
be able to play with your grandchildren and
how your current weight interferes with that
You said you would really like to be able to
hike with your friends on vacation and how
your current energy level keeps you from
doing that
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What do you think would work if you decided
to change…?
How confident are you that you can make this
change?
What kind of support would be helpful in
making this change?
What encourages you to change if you want
to do it?
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I can see you are feeling stuck right now.
What is going to have to change?
How important is it for you to …….?
What do you intend to do?
What do you think you might be able to do?

http://www.youtube.com/watch?v=sWc0g2K
9LAI
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Online resources or live classes
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Begin small
◦ Try only adding one component at a time
◦ Reflective responses are a great starting point
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Keep working at it
◦ It may feel uncomfortable the first few times
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Add components as you become more adept
66
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MI is a useful technique to help people
change
It is useful in combination with other
techniques for eliciting change
MI should not replace your method of patient
interaction, but enhance it
67


Motivational interviewing is a collaborative,
person‐centered form of guiding to elicit and
strengthen motivation for change.
Key Elements
◦ Collaboration
◦ Evocation
◦ Autonomy
68

Principles
◦ Express Empathy
◦ Support Self Efficacy
◦ Develop Discrepancy
◦ Roll with Resistance
69
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Strategies for implementation
◦ OARS
 Open-Ended Questions
 Affirmations
 Reflective Responses
 Summaries
◦ RULE
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Resist the righting reflex
Understand the patient’s motivation
Listen with empathy
Empower the patient
70
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Group by profession.
Discuss how you would implement MI in your
work setting.
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Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise
adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare. 2008 14:48
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
Burke B, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta analysis of controlled clinical
trials. Journal of Consulting and Clinical Psychology 2003; 71, 843-861
(Egan, 2010) – D&E
Hettema J, Steele J, Miller W. Motivational Interviewing. Annual Review of Clinical Psychology 2005; 91-111
http://counselingvideos.blogspot.com/2013/06/its-not-about-nail.html
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%
20V4%20012911.pdf
http://www.youtube.com/watch?v=sWc0g2K9LAI
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)
1232-45
Lundahl B, Tollefson D, Kunz C et al. Meta analysis of motivational interviewing: twenty five years of research.
Research on Social Work Practice 2009
Maslow’s Hierarchy – en.wikipedia.org
Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983; 11(2),147-172
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford
Press.
Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, 2nd Ed. New York:
Guilford Press.
Prochaska, J. O., & DiClemente, C. C.
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled
clinical trials. Brit J General Practice 2005; April, 305-312
Vasilaki E, Hosier S, Cox W. The efficacy of motivational interviewing as a brief intervention for excessive
drinking: a meta analytic review. Alcohol and Alcoholism 2006; 41, 328-35
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