MOTIVATIONAL INTERVIEWING
16th Annual Primary Care Conference
Julie Culligan, PhD
Health Behavior Coordinator, Psychologist
and
Heather Coburn, PA-C
Health Promotion & Disease Prevention Coordinator
Mountain Home VAMC
3/29/12
MI Philosophy
"People are generally better persuaded by
the reasons which they have themselves
discovered than by those which have come
in to the mind of others.”
~
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Blaise Pascal, French mathematician, physicist and religious philosopher
Facilitating Behavior Change
What makes behavior change so hard?
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It works for us
“Habit”
It often involves multiple behaviors
Knowledge about how to change isn’t always
enough
People are creatures of habit
Health consequences are often delayed
Busy lifestyles require us to make time for self
care
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Motivational Interviewing
“A person-centered, goal-oriented approach
for facilitating change through exploring and
resolving ambivalence.“ (Miller & Rollnick,
2006)
A clinical “style;” a “way of being with
people” (Miller & Rollnick, 2002; Rollnick &
Miller, 1995)
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Motivational Interviewing:
Based on Theory
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Conceptualized according to stage model
of change (Prochaska & DiClemente, 1982)
Not everyone engages in treatment at the
same stage of readiness
Different type of approach may be utilized
for individuals at different stages
Transtheoretical Model: Stages
of Change
A STAGE MODEL OF THE PROCESS OF CHANGE
Pre-Contemplation
Contemplation
Determination
Relapse
Maintenance
Permanent Exit
Action
The Goal of MI
The goal of MI is to facilitate:
 Fully informed,
 Deeply thought out,
 Internally motivated choices,
 Not
to change behavior…..
Resnicow, et al., 2002
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Traditional vs. Motivational
The “Doctor”:
 Places the importance on
the behavior change
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Controls the interaction
May direct/select the
goals the patient should
achieve
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The “patient”:
 Determines the
importance of the
behavior change
 Is listened to, shares
concerns and needs
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Is supported in decisions
about change and goals
Empathic Style of MI and Brief
Interventions
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The key element in brief interventions is empathy
Research on empathy and clinical outcomes:
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Strongest predictor of outcomes
Not accounted for by demographics
Not accounted for by treatment type
Patient Focus
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MI supports the patient in articulating
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How personally important this change (e.g.,
dietary) is, as opposed to how important we
think it is
What stands in the way of making this change
(time, money, cultural factors, emotions, etc.)
Changes that might work in their life
How to increase the chances of success
Learning MI
Techniques
Listening Skills
Spirit
Spirit of Motivational Interviewing
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Evocative
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Honoring Autonomy (vs. Authority) –
(vs. Educational) – patient is
responsible for change. (“What would you gain if you
changed your drinking?”) vs. implanting the right idea (“You
really need to stop drinking.”)
Allow the freedom not to change. (“How ready are you
to change?) vs. push for commitment (“If you delay getting
sober, you could die.”)
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Collaborative (vs. Confrontational) – Work in
Partnership. (“How about we discuss some options together”
vs. “I would urge you to quit drinking.”)
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The Spirit of MI
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Motivation for change is elicited from
within the patient, not imposed from
outside
The patient must articulate reasons
for change
The patient is the one responsible to
decide
Direct persuasion is ineffective
The clinician should steer the
conversation to focus on change
Ambivalence
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Interesting, natural, human,
understandable
Not unique to characterological problems
Not indicative of defense (denial)
“I want to but I don’t want to”
Unhelpful to think of people as
“unmotivated”
SPIRIT OF MI
Ambivalence
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APPRECIATE AMBIVALENCE
HONOR, EMBRACE, EXPLORE
AMBIVALENCE. It’s the core.
Many brief (and single session) therapies
work by focusing on this ambivalence, not
on skills (people frequently have the skills)
The RIGHTING Reflex
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“This person SHOULD want to change.”
NOW is the right time to change.
A TOUGH/clear/honest approach is best.
Patient should follow my EXPERT ADVICE.
If patient doesn’t change, the session
FAILED.
There’s nothing we can do for the
“unmotivated.”
Rather than the Righting
Reflex, Understand
Ambivalence
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Reflective listening
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Acceptance; non-judgmental; no blaming
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Helps patients to feel understood
Provides comfort to patient (makes change
easier)
Acceptance ≠ Agreement
Ambivalence = normal (not pathological)
Communication is a Dance
Not a Tug of War
Evaluate the Pros and Cons
Reducing/Giving up
Tobacco
Pros
(Good Things)
I can still smoke with I
friends
Smoking the Same
It helps me deal with
my stress
Feel better
Making Changes in
Smoking
Have more energy
Have more money
Cons
(Downsides)
It’s hard to breathe
It’s a fire hazard
It’s bad for my health
It’s expensive
I wouldn’t be able to
hang out with my
friends who smoke
I wouldn’t have a way
to deal with my
problems
Evaluate the Pros and Cons
Increasing Medication
Adherence
Pros
(Good Things)
I can still smoke with I
friends
Stay the Same, i.e.,
Non-Adherent
It helps me deal with
my stress
Feel better
Making Changes,
i.e., Adherent
Have more energy
Have more money
Cons
(Downsides)
It’s hard to breathe
It’s a fire hazard
It’s bad for my health
It’s expensive
I wouldn’t be able to
hang out with my
friends who smoke
I wouldn’t have a way
to deal with my
problems
Four Key Principles of MI
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Express empathy
Develop discrepancy
Roll with resistance
Support self-efficacy
(1) Express Empathy
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Reflective listening
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Acceptance; non-judgmental; no blaming
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Helps patients to feel understood
Provides comfort to patient (makes change
easier)
Acceptance ≠ Agreement
Ambivalence = normal (not pathological)
(2) Develop Discrepancy
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Change is motivated by perceived discrepancy
between present behavior and personal
goals/values
Discrepancy = importance of change for patient
Amplify the discrepancy to move patient from
the status quo
Elicit discrepancy from the patient – they should
make the argument for change
(3) Roll with Resistance
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Argument often pushes person in the
opposite direction
Resistance is a call for the clinician to
change, not the patient
Questions and problems should be
reflected back to the patient, not “solved”
by the clinician
(4) Support Self-Efficacy
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Be aware of your own beliefs about a
patient’s ability to change (self-fulfilling
prophecy)
Enhance patient’s self-belief about his or
her capability to make a change
Be genuine
What People say about Change
predicts Behavior Change
Self-perception theory
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Core MI Strategies
Four Early Strategies; OARS
 Open Questions
 Affirming
 Reflective
Listening
 Summarizing
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Elicit Positive
“Change Talk”
Open-Ended Questions
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Disarms resistance
Creates momentum
Avoids arguments
You want them engaged and exploring –
with you gently steering
Open Questions to Promote Change
Disadvantages of the Status Quo
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How do you feel about your weight?
Advantages of Change
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What would the benefits be for you, if you were to quit smoking ?
Optimism for Change
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What makes you feel that now is a good time to try something
different?
Intention to Change
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What would you like to see happen?
How might things be different for you, if you did make a change?
Affirmation
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Genuinely highlight patients’ strengths
Antidotes to demoralization
Appreciative of partial success (ex. Focus
on success with quitting smoking for 2
years in past)
Appreciates their honesty regarding
ambivalence
Reflective Listening – The
Foundation of MI
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“MINI-SUMMARIES” used strategically to lower
resistance
Used to highlight patient statements favoring
change (“Change Talk”)
A way of thinking, Difficult to learn
Powerful for increasing readiness
Expert ratio 2 reflections for every question vs.
Novice ratio .5 reflections for every question
Handy Reflections
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Double-Sided (reflects both sides of
ambivalence)
– takes the clinician out of the equation – puts the ambivalence in their own lap
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So on the one hand, you like how alcohol
makes you feel and at the same time, you
worry about your Hepatitis.
Amplified – can go in either direction
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Undershoots so patient might elaborate,
“You’re a LITTLE confused…”
Overshoots so patient can back down, “So
you don’t EVER intend to cut down…”
Handy Reflections
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Shifting Focus – shift patient’s concern
away from a potential stumbling block –
around barriers rather than over them
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c: “Okay, maybe I’ve got some problems with
drinking, but I’m not alcoholic.”
Argument with a Twist – offer initial
agreement, but with a slight twist or
change of direction
Summarizing
Helps the other person:
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Recall and reflect upon the conversation
Think of new ideas
Understand the importance of these issues
Plan next steps
Feel more confident, instill hope
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Importance and Confidence
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Importance: lets you know how
important this issue(s) is to the patient, in
the grand scheme of other important
values in their life
Confidence: lets you know how able the
patient feels he/she is to make specific
changes towards his/her goal(s)
Readiness Indicators
Assessing Importance and Confidence
Importance
How important is it to you to ____________?
On a scale of 0 to 10, with 0 being not important at all & 10 being very
important…
0
1
Not a all
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3
4
5
6
Somewhat
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8
9
Very
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Confidence
How confident are you that you could _____________, if you decided to? On a
scale of 0 to 10, with 0 being not confident at all & 10 being very confident?
0
1
Not at all
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2
3
4
5
6
Somewhat
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8
9
10
Very
Evaluating Importance/Confidence
• “What made you answer with a (number
patient gave) and not a zero?”
• “What would it take for you to move from
a (number patient gave) to a (slightly
higher number)?”
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Setting Goals
 Specific
 Measurable
 Achievable/Action
Oriented
 Realistic
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 Timely
Let’s see how we pull this together…
Resources
www.motivationalinterview.org
Clinical issues
Background
Special Populations
Group Approaches
The Library
Abstracts
Bibliography
MINUET Newsletter
Links
Training
Upcoming Training
MINT Trainers
Training Videos
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http://vaww.chce.research.va.gov/apps/bmiforsuv/default.html
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MI Books
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Miller, WR & Rollnick, S (1991). Motivational interviewing:
Preparing people to change addictive behavior. New York:
Guilford Press.
Miller, WR & Rollnick, S (2002). Motivational interviewing:
Preparing people for change (2nd ed.). New York: Guilford
Press.
Arkowitz, H, Westra, HA, Miller, WR, Rollnick, S (Eds.) (2008).
Motivational interviewing in the treatment of psychological
problems. New York: Guilford Press.
Rollnick, S, Miller, WR & Butler, CC (2008). Motivational
interviewing in health care. New York: Guilford Press.
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MI Articles
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Britt, E, Hudson, SM, & Blampied, NM. (2004). Motivational interviewing in
health care settings. Education and Counseling, 53, 147-155.
Emmons, KM, & Rollnick, S. (2001). Motivational interviewing in health
care settings. American Journal of Preventive Medicine, 20, 68-74.
Greaves C, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Steele A, Gale
T, Hammerton F, Daly M (2008). Motivational interviewing for modifying
diabetes risk: a randomized controlled trial. British Journal of General
Practice, 58(553), 535-40.
Hecht, J, et al. (2005). Motivational Interviewing in community-based
research: Experiences from the field. Annals of Behavioral Medicine, 29
Special Supplement, 29-34.
Resnicow, K, et al. (2001). Motivational interviewing in health promotion:
It sounds like something is changing. Health Psychology, 21, 444-451.
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Soria R, Legido A, Escolano C, and Yeste A (2006). A randomized controlled trial of motivational
interviewing for smoking cessation. Br J Gen Prac, 56(531), 768-774.
Moyers T, Martino S (2006). “What’s important in my life” The personal goals and values card
sorting task for individuals with schizophrenia.
Zygmunt A, Olfson M, Boyer A, Mechanic d (2002). Interventions to improve medication
adherence in schizophrenia. American Journal of Psychiatry.
Possidente C, Bucci K, McClain W (2005). Motivational interviewing: A tool to improve
medication adherence? American Journal of Health-System Pharmacy, 62(12) 1311-1314.
Swaminath G (2007). You can lead a horse to water… Indian Journal of Psychiatry, 49(4), 228230.
Cole S, Bogenschutz M, Hungerford D (2011). Motivational Interviewing and Psychiatry: Use in
addiction treatment, risky drinking and routine practice. FOCUS, 9:42-54.
www.ComprehensiveMI.com