Transcript Stage of Change Theory

Introduction to
Motivational Interviewing
Nimi Singh, MD, MPH
Division of Adolescent Health and Medicine
University of Minnesota Amplatz Children’s
Hospital
(adapted from Kelly Lundberg, Ph.D. University of Utah)
Disclosure
I
I
have no financial relationships to disclose
will not be discussing off-label use of any
medications
OUTLINE







What is Motivational Interviewing?
Stages of Change
Impact of the counselor/ health care provider
Principles of motivational interviewing
Philosophical approach
Specific methods
Resources/ References
Motivational Interviewing

Empathetic, patient-focused directive counseling
style
 Seeks to create conditions for positive
behavioral change
 Well-suited for brief clinical encounters
 Evidence-based (>200 clinical trials, both adults
and adolescents)
(grounded in theory, verifiable, generalizable, delivered
by wide range of health care practitioners)
Two Assumptions:
1. Motivation: due to interpersonal interaction
(not just innate character trait)
• Confrontation leads to resistance
• Empathy and understanding lead to change
2. Ambivalence to change: normal and natural
• Competing positive and negative feelings
• Decision balance: pros and cons
Motivational Interviewing (con’t)


Counselor/ Health care provider: facilitator
“Client/ Patient: presents arguments for change

Counselor:



Listens for ambivalence in patient’s own words
Reflects back negative and positive aspects of
behavior AND of changing behavior
Supports client self-efficacy:
•
•
•
•
Points out strengths
Points out previous successes
Acknowledges difficulties of making behavioral change
Avoids resistance by avoiding lecturing and arguing with
patient
Stage of Change Theory
Prochaska and DiClemente (1992)






Pre-contemplation
Contemplation
Action
Maintenance
Relapse
PRE-CONTEMPLATION
 Not
even thinking about change
CONTEMPLATION
 Wax
and wane toward the idea of change
 Often influenced by emotionally salient
evens
 Is the stage of ambivalence
ACTION
 Ambivalence
is gone
 Actual working on the change
MAINTENANCE
 “Losing
weight is easy. I’ve done it
hundreds of times.”
 Behavior change takes repeated
implementation of new life skills
 Changes in the physiology of our brain
takes even longer
 This is often when services/ support are
withdrawn
RELAPSE
 Return
to the previous behavior
 Once there has been a lapse or relapse,
the individual re-enters at either:



Pre-contemplation
Contemplation
Action
Counselor plays KEY role in
influencing re-entry point!

Clients will experience shame even when there
is no one blaming them

Have the conversation about how you, as a
health care provider, would respond to a relapse
prior to it happening

Call your clients when they don’t show for their
appointment
Why we like working with patients in
Action stage
Our tools fit well with their stage of
change
 They cooperate and typically do what we
suggest
 We tend not to experience anger,
frustration and impatience
 We tend to feel disappointment when they
don’t show for their appointment

Why we DON’T like working with clients
in Precontemplation or Contemplation
 Our
tools don’t work with their stage of
change
 They don’t do what we suggest
 We tend to experience anger, frustration
and/or impatience
 We tend to feel relieved when they don’t
show for their appointment
 We feel impotent
So what do we tend to do?

Spend more time with clients who are in the action stage
then those who are not
 Use derogatory labels for those who are in the precontemplation or contemplation stage
 Forget that ambivalence is normal
 Train clients to lie to us
 Shrug our shoulders and say, “I can’t help someone who
doesn’t want to be helped.”
 Shrug our shoulders and say, “I can’t help someone who
doesn’t admit to having a problem.”
Who are our clients?

Most of the conventional health care tools we
have are for individuals who are in the Action
stage

It is estimated that 30% of patients who present
to clinic for care are in the Action stage (varies
depending on type of clinic)

We tend to overestimate the motivation of those
who say they’re ready to change and
underestimate the motivation of those who
indicate no interest in change.
Motivational Interviewing is
the treatment of choice for
AMBIVALENCE
PRINCIPLES OF MOTIVATIONAL
INTERVIEWING

Express empathy
 Develop discrepancy
 Roll with resistance


Don’t argue against it
Encourage elaboration of resistance
• What makes it so hard?
• What would help?


Allow silence
Support self-efficacy
PHILOSOPHICAL APPROACH OF
MOTIVATIONAL INTERVIEWING
 Respectful
 Nonjudgmental
 Reflective
 Encourages
“Change” talk from client
One of the biggest difference
between MI techniques and other
techniques is that the CLIENT is
the one who verbalizes the need
for change rather than the
counselor
EIGHT METHODS OF
EVOKING CHANGE TALK








Elaborating
Asking evocative questions
Using the “Importance ruler”
Querying extremes
Exploring decisional balance
Looking back
Looking forward
Exploring goals and values
ELABORATING

Understand your client’s world view


Tell me about your (behavior). When did it start?
When did it become a problem for you/ for others?
“How do you feel about it?”
• “What do you get out of (problem behavior)?
• “How do you think it causes difficulties for you?

Express empathy
• “I can see why this must be hard for you…”

Summarize ambivalence
 Begin to develop discrepancy between the
polarized urges

Examples
• So on one hand…and on the other…
• Part of your wants…And the other part…
ASKING EVOCATIVE
QUESTIONS
Evoking an emotionally “charged”/ evocative
response is important for change to take place
 You know your question is evocative if the client
has to think about his or her response
 Tone of voice is exploratory, not critical
 Examples
 What if you choose to continue _____?
 What if you choose to decrease/ stop _____?

USING THE “IMPORTANCE
RULER”

Three parts:

First Part:
• On a scale of 1 to 10, 10 being “absolutely
yes” and 1 being “no way”, how motivated
are you to ______?
• Ten is always direction you want the change to go
• Sometimes it’s necessary to exaggerate the
extremes
USING THE IMPORTANCE
RULLER

Second Part:


Whatever number they give you, select one or two
numbers BELOW and ask: Why a 6 instead of a 4?
By choosing a number below, you are eliciting
change talk from the client
USING THE IMPORTANCE
RULER
 Third

Part:
Take a number or two above what they gave you and
ask: What would it take to move you to a 7, not
actually (changing the behavior), but a little more
comfortable with the idea?
 Be
sure to elicit something the client has
control over
 Whatever the client tells you becomes the
treatment plan.
USING THE IMPORTANCE
RULER

Make sure the plan is something the client can
actually accomplish
 Work with the client exploring potential barriers
to the plan and appropriate solutions
 Set an appropriate time line for implementing the
plan (client-directed, if at all possible)
 Sometimes an appropriate plan is that the client
will think about the issue.
USING THE IMPORTANCE
RULER

Sometimes the issue is not importance or
motivation, but confidence

This is often obvious when the client provides an
8 or 9 on the Importance Ruler and yet remains
stuck
USING THE IMPORTANCE
RULER

If you believe motivation has increased during a
session, use the ruler again

Group Application:



Clients identify where they are on the ruler
Have the clients with low numbers ask the clients with higher
numbers to reflect on how they got there
Have the clients with high numbers ask the clients with low
numbers how they intend to move
QUERYING EXTREMES
 Always
target CURRENT behavior
 Example


What’s the worst thing about it?
What’s the best thing about it?
EXPLORING DECISIONAL
BALANCE
 Always
 Elicit


target CURRENT behavior
pros and cons
“What do you get out of (behavior)?”
“What problems does it cause?”
LOOKING BACK


Always target CURRENT behavior
Example:



When was the last time _____ really made you feel good/ better/ worked for you?
The phrase “really worked for you” refers to all aspects
of life
If this elicits a poignant reply, your best response is
SILENCE



HARD, for us health care providers
We’re TRAINED to fix and intervene…silence often feels like
failure or inaction
Often can be a powerful therapeutic tool in that it can powerfully
deepen the client’s insight into the issues at hand)
EXPLORING GOALS (LOOKING
FORWARD) AND VALUES
 Three

Parts:
First Part:
• What do you see yourself doing ___ months/ years
from now ( or next year)?
 Do


not use with individuals who :
You suspect are potentially suicidal
Terminal
EXPLORING GOALS (LOOKING
FORWARD) AND VALUES
 Second

Part:
What are your top three values and why?
 Define
a value if necessary
 Always
get three (never settle for “I don’t
know” from clients)
EXPLORING GOALS (LOOKING
FORWARD) AND VALUES
 Third

Part:
How do you think (current behavior) fits with
these values?
 Tone
of Voice is exploratory, NOT critical
 Best used following some discussion
about the key issue to be changed
 This technique alone has been correlated
with change
It is CRITICAL to engage clients
in treatment plan
(especially adolescents!!!)
Giving information and advice

Ask for permission
 Qualify honoring autonomy


Ask – Provide – Ask


“Of course, while I can only suggest, you’re ultimately
the one to decide…”
“….what do you think of that? Do you think that would
work for you? Why? Why not?”
For suggestions, offer several, not one
(otherwise it looks like the “right” answer)
Remember

Stress physiology is often driving “problem
behavior”

Make sure you/ someone on health care team is
exploring stress reduction techniques with client

When stress is managed in a more healthy, prosocial way, need for problem behavior
diminishes
Resources
 www.motivationalinterview.org
 TIPS
Manual (SAMHSA)
 Project Match (NIAAA)
 Motivational Interviewing (Miller and
Rollnick)
References

Lundberg, KJ. “Introduction to motivational interviewing”; on-line
Powerpoint presentation at:
http://humanservices.slco.org/pdf/Long_MI_without_ASAM.pdf

Miller WR, Rollnick S. Motivational Interviewing: preparing people for
change, 2nd ed. New York, NY: Guilford Press; 2002.

Miller WR, Rollnick S. What’s new since MI-2? Presentation in Stockholm,
Sweden, June 2010 (at www.motivationalinterview.org

Prochaska, JO, DiClemente CC. Stages of change in the modification of
problem behaviors. Prog Behav Modif 1992;28:183.

Levy S, Knight JR. “Office-based management of adolescent substance
use and abuse”, in Adolescent Health Care: a practical guide, 5th ed.
Philadelphia, PA: Lippincott, Williams and Wilkins; 2008.