Transcript BHICCI MI part 2, with presenter`s notes 2017

Motivational
Interviewing: Part 2
Elizabeth Morrison LCSW, MAC
Michael Mabanglo LCSW, PhD
1
Introduction
Why are we here?
A clinician can influence
what a patient does….
Our relationship with clients/patients influences
their behavior
2
Concepts
Stages of
change
IDENTIFICATION
Source: Prochaska & DiClemente
3
Review
A healthcare professional establishes a
supportive clinical relationship to
promote change

Use open ended
questions, reflective
listening, verbal and
non verbal empathy

Roll with resistance
)
4
Skills
Acknowledge and reinforce AUTONOMY

Acknowledge
other’s autonomy,
the right to make
choices, of free
will.
5
Skills
Acknowledge and reinforce AUTONOMY


Lack of
autonomy
words: must,
have to, need
to, should….
Affirming
autonomy
phrases: It’s
your choice;
your decision,
whatever you
think is best…..
6
Concepts
A person’s commitment to action
(motivation) comes from strong
CONVICTION


“I believe that making this
change is important”
“I am convinced that this is a
problem”
7
Concepts
A patient’s commitment to action
(motivation) comes from strong
CONFIDENCE

“I feel that I can make this
change”

“I am confident that I can make
this change in spite of obstacles
and set-backs”
8
Concepts
Conviction and Confidence reflect
Commitment to Change
High
10
Convinced
Moving: Helping
Conviction
Frustrated
Unaware or
Cynical
Skeptical
Ambivalent
0
Low
Helpless
Confidence
Powerful
10
High
9
Techniques
Discover and Discuss the patient’s
conviction

“How do you feel about
smoking/your weight/taking the
medication….?

”How important is taking your
medication/losing weight/stopping
drinking to you?”
10
Techniques
Assessing Conviction: Scaling
Not at all
convinced
0 1 2 3 4 5 6 7 8 9 10
Totally
convinced
“On a scale of 0 – 10, how convinced are you
that it is important to monitor your blood
sugars?”
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Techniques
Discover and discuss the patient’s
confidence

“How confident are you that
you can make this change?”

“How likely do you think it is
that you will be able to make
this change?”
12
Techniques
Assessing Confidence: Scaling
Not at all
confident
0 1 2 3 4 5 6 7 8 9 10
Totally
confident
“On a scale of 0 – 10, if 1 is not confident
at all, and 10 is absolutely confident,
how sure are you that you can stop
smoking?”
13
Time for Practice!
 Practioner: Practice assessing conviction
and confidence. Try both open ended
questions to assess, as well as a scaling
question
 Practicee: Share a behavior change you are
ambivalent about
 Observer: Note when the practicee has
assess conviction (open ended and scaling)
and confidence (open ended and scaling)
14
Interventions
Interventions for increasing
Conviction are
VERY DIFFERENT
than interventions for
increasing Confidence
15
Concepts
Conviction and Confidence reflect
Commitment to Change
High
10
Convinced
Moving: Helping
Conviction
Frustrated
Unaware or
Cynical
Skeptical
Ambivalent
0
Low
Helpless
Confidence
Powerful
10
High
16
Techniques
Tailor: Low Conviction





Strengthened Relationship
Explore ambivalence
Roll with resistance
Ask permission to follow up
Provide information (Ask,
Ask, Tell, Ask)
17
Techniques
Strengthen the Relationship


Non verbal empathy
Verbal Empathy:




Normalizing
Affirming
Acknowledging
Non-judgement
18
Techniques
Explore Ambivalence
REFLECTION
 Open ended questions
 ’Tell me more about
that….”
 Double sided reflection
 “So on one hand……,
and on the other
hand………”
19
Techniques
Explore Ambivalence

“What’s
the down side of
taking exercising?”

“What are the good things
about smoking pot?”

“Tell me more about the
expense you mentioned”
20
Techniques
Roll with the Resistance…

“It sounds like you just don’t think medication is a
solution for you”

“Sounds like you don’t feel you have any
consequences from drinking, in fact, only benefits.”

“You mentioned some worries about the costs of
some of the medications we have talked about.”

“Many patients have difficulty fitting exercise into
their busy lives.”
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Techniques
Enhance Confidence



Review past experience – especially
successes
Define small steps that are likely to
lead to success
Identify barriers – patient to problem
solve.
22
Techniques
Enhance Confidence
Review past successes
• Ask about past successes
with other behavior changes,
or previous successes with
this behavior change
23
Techniques
Enhance Confidence
Define smaller goals
• Goals need to be small
enough that success is
ensured.
Success begets success
Techniques
Enhance Confidence
Identify Barriers & Problem Solve




What do you think will get in the
way of your goals/steps?
Anything else?
What might help you to overcome
that barrier?
What has helped you overcome this
in the past?
25
PRACTICE!
Intervene to Increase your partners
conviction of confidence
 Low conviction:
 Strengthen the relationship
 Roll with resistance
 Explore ambivalence
 AATA
 Low confidence:
 Baby steps
 Reflect on past successes
 Elicit barriers and solutions to barriers
26
Goals
Deliberate practice is the key to
improvement – for all of us!
Goals…..
27