Using Motivational Interviewing
to Help Your Patients Make
Behavioral Changes
1
WHY SHOULD WE BE INTERESTED
IN PATIENTS’ MOTIVATION FOR
BEHAVIOR CHANGE?
2
Beliefs About Motivation
(True or False?)
1. Until a person is motivated to change, there is not
much we can do.
2. It usually takes a significant crisis (“hitting bottom”)
to motivate a person to change.
3. Motivation is influenced by human connections.
4. Resistance to change arises from deep-seated
defense mechanisms.
Beliefs About Motivation
(True or False?)
5. People choose whether or not they will change.
6. Readiness for change involves a balancing of “pros”
and “cons.”
7. Creating motivation for change usually requires
confrontation.
8. Denial is not a client problem, it is a therapist skill
problem.
Learning Objectives
At the end of the workshop, you will be able to:
1.
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7.
8.
9.
10.
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Define multiple MI techniques to help clients to change
Describe the Stages of Change
Complete a Stage of Change Assessment
Define the 4 principles of MI
Demonstrate skill with OARS
Demonstrate at least 2 methods to elicit change talk
Utilize a Readiness Ruler
Complete a Decisional Balance
Complete a Change Plan
Describe MI strategies to deal with resistance to change
MI is
•
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A theory
A set of skills
A way of thinking
A way of relating
EXPERIENTIAL EXERCISE 1
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Why Do People Change?
1.
2.
3.
4.
5.
6.
8
?
?
?
?
?
?
Why Don’t People Change?
1.
2.
3.
4.
5.
6.
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?
?
?
?
?
?
Sound Familiar?
• “I tell them what to do, but they won’t do it.”
• “It’s my job just to give them the facts, and that’s all I
can do.”
• “These people lead very difficult lives, and I
understand why they _______.”
• “Some of my patients are in complete denial.”
Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.
10
Or Should We?
• Explain what patients could do differently in the
interest of their health?
• Advise and persuade them to change their behavior?
• Warn them what will happen if they don’t change
their ways?
• Take time to counsel them about how to change
their behavior?
• Refer them to a specialist?
Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.
11
The Righting Reflex:
The Best Intentions Can Backfire
• Most patients are ambivalent about unhealthy
behaviors.
• When we (providers) see an unhealthy/risky
behavior, our natural instinct is to point it out &
advise change.
• The patient’s natural response is to defend the
opposite (no change) side of the ambivalence coin.
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Avoid Righting Reflex:
“Taking Sides” Trap
PROVIDER
• “You must change”
• “You’ll be better off”
• “You can do it!!”
• “You’ll die…”
13
PATIENT
• “I don’t want to
change”
• “Things aren’t half bad.”
• “No I can’t!!”
• “Uncle Fred is 89 and
healthy as can be.”
EXPERIENTIAL EXERCISE 2:
THE CHANGE EXERCISE
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Exercise: The Change Exercise
• Stand up and turn to stand face to face in pairs.
• Silently observe your partner for 15 seconds.
• Now turn back to back
and change 3 things
about yourself.
• When you are done, turn
back to face your partner.
• Each person should take a minute to name the 3
things your partner has changed.
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Change Exercise Questions
•
•
•
•
•
•
What was your comfort level during this exercise?
What made you comfortable or uncomfortable?
How hard was it to change things?
How did you decide what things to change about yourself?
What does this exercise tell us about change?
Look around you did you notice how quickly people changed
back to the way they started as soon as they sat down?
• What implications might this have about change for people
and ourselves?
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Change Exercise Key Points
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•
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Change is difficult
Change is not always comfortable
Change requires creativity
We tend to go back to old ways
It is easier to stay the same
We like our comfort zones
Change requires an open mind
Change has emotional and cognitive components
Change Exercise
Key Points
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•
•
•
Change is a process
Change happens over time
The process is as important as the result
Watch out for measuring success only if a change
occurred
• Often there is a difference between what someone
knows they should do and there readiness to do it.
• Greatest chance to impact change is pacing it to the
specific stage of change
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Why Are Health Care Professionals (Outside
Behavioral Health) Interested In MI?
• Behavioral/lifestyle factors in health issues
–
–
–
–
–
Exercise
Smoking
Weight control
Treatment adherence
Diet/nutrition
• Conceptual consistency with patient-centered
approaches
• Positive and promising results from research
on outcomes
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Definition of Motivational
Interviewing
• A patient-centered, yet directive method for
enhancing intrinsic motivation for positive
behavior change by exploring and resolving
ambivalence.”
Miller, W.R. & Rollnick, S.(2002)
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Motivation is viewed as…
•
•
•
•
multidimensional
a state, which is dynamic and fluctuating
modifiable
influenced by communication style
Our job is to elicit and reinforce
patient motivation for change.
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Rapid Diffusion Into Health Care
Settings…
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Spirit, Principles, Micro-skills
MOTIVATIONAL INTERVIEWING
PRACTICE BASICS:
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MI Spirit
• A way of being with patients which is…
– Collaborative
– Evocative
– Respectful of autonomy
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Collaboration
(not confrontation)
• Developing a partnership in which the
patient’s expertise, perspectives, and input is
central to the consultation
• Fostering and encouraging power sharing in
the interaction
25
Evocation
(not education)
• The resources and motivation for change
reside within the patient
• Motivation is enhanced by eliciting and
drawing on the patient’s own perceptions,
experiences, and goals
• Ask key open ended questions
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Autonomy
(not authority)
• Respecting the patient’s right to make
informed choices facilitates change
• The patient is charge of his/her choices, and,
thus, is responsible for the outcomes
• Emphasize patient control and choice
27
Spirit of Motivational Interviewing
• Motivations to change are elicited from within the
client, not imposed from outside.
• It is the client's task, not the counselor's, to articulate
and resolve his or her ambivalence.
• Direct persuasion is not an effective method for
resolving ambivalence.
• Readiness to change is not a client trait, but
fluctuating product of interpersonal interaction.
Spirit of Motivational Interviewing
• The therapeutic relationship is more like a
partnership or companionship than expert/recipient
roles.
• Positive atmosphere that is conducive but not
coercive for change.
• The counselor is directive in helping the client to
examine and resolve ambivalence.
What MI is Not
• A way of tricking people into doing what you
want them to do
• A specific technique
• Problem solving or skill building
• Just client-centered therapy
• Easy to learn
• A panacea for every clinical challenge
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Four Guiding MI Principles:
1. Resist the righting reflex
• If a patient is ambivalent about change and
the clinician champions the side of change…
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Four Guiding MI Principles:
2. Understand your patient’s motivations
• With limited consultation time, it is more
productive asking patients what or how they
would make a change rather than telling
them that they should.
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Four Guiding MI Principles:
3. Listen to your patient
• When it comes to behavior change, the
answers most likely lie within the patient,
and finding them requires some listening
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Four Guiding MI Principles:
4. Empower your patient
• A patient who is active in the consultation,
thinking aloud about the what and how of
change, is more likely to do something about
it.
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Core MI Skills – (OARS)
• Asking
• Listening
• Affirming
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Asking
o
• Use of pen ended questions allows the
patient to convey more information
• Encourages engagement
• Opens the door for exploration
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Closed Ended Question 
Open Ended Question
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•
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•
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Are you having any pain today?
Is there anything that is worrying you right now?
Are you short of breath?
Are you doing okay?
Why haven’t you tried this exercise?
Are you refusing treatment?
Do you have a follow up appointment scheduled?
Open-Ended Questions
What are open-ended questions?
• Gather broad descriptive information
• Require more of a response than a simple yes/no or
fill in the blank
• Often start with words like:
– “How…”
– “What…”
– “Tell me about…”
• Usually go from general to specific
OARS
Open-Ended Questions
Exercise:
Turning closed-ended questions into
open-ended ones
Open-Ended Questions
• Why open-ended questions?
– Avoid the question-answer trap
• Puts client in a passive role
• No opportunity for client to explore ambivalence
OARS
Affirmations
What is an affirmation?
• Compliments, statements of
appreciation and understanding
– Praise positive behaviors
– Support the person as they describe difficult
situations
OARS
Affirmations
• Examples:
– “I appreciate how hard it must have been for you
to decide to come here. You took a big step.”
– “I’ve enjoyed talking with you today, and getting
to know you a bit.”
– “You seem to be a very giving person. You are
always helping your friends.”
Affirmations
Why affirm?
• Supports and promotes self-efficacy, prevents
discouragement
• Builds rapport
• Reinforces open exploration (client talk)
Caveat:
• Must be done sincerely
OARS
Express Empathy
What is empathy?
• Reflects an accurate understanding
– Assume the person’s perspectives are
understandable, comprehensible, and valid
– Seek to understand the person’s feelings and
perspectives without judging
Express Empathy
Empathy is distinct from…
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Agreement
Warmth
Approval or praise
Reassurance, sympathy, or consolation
Advocacy
Express Empathy
Why is empathy important in MI and IDDT?
• Communicates acceptance which facilitates change
• Encourages a collaborative alliance which also
promotes change
• Leads to an understanding of each person’s unique
perspective, feelings, and values which make up the
material we need to facilitate change
Express Empathy
Tips…
Good eye contact
Responsive facial expression
Body orientation
Verbal and non-verbal “encouragers”
Reflective listening/asking clarifying questions
Avoid expressing doubt/passing judgment
Empathy is NOT…
• The sharing of common past experiences
• Giving advice, making suggestions, or
providing solutions
• Demonstrated through a flurry of questions
• Demonstrated through self-disclosure
The Bottom Line on Empathy
• Ambivalence is normal
• Our acceptance facilitates change
• Skillful reflective listening is fundamental to
expressing empathy
- Miller and Rollnick, 2002
Reflective Listening
OARS
Listening
• Clinician accurate empathy is a robust
predictor of behavior change
• Involves careful listening with the goal of
understanding the meaning of what the
patient says
• Skillful reflective listening looks easy, but it’s a
complex skill
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Reflective Listening
“Reflective listening is a way of checking
rather than assuming that you know
what is meant.”
(Miller and Rollnick, 2002)
OARS
Reflective Listening
• Why listen reflectively?
– Demonstrates that you have accurately heard and
understood the client
– Strengthens the empathic relationship
– Encourages further exploration of problems and
feelings
• Avoid the premature-focus trap
– Can be used strategically to facilitate change
Reflective Listening
In motivational interviewing,
• About half of all practitioner responses are
reflections
• 2-3 reflections are offered per question asked
In ordinary counseling,
• Reflections constitute a small proportion of all
responses
• Questions outnumber reflections 10 to 1
Learning Reflective Listening
• Reflective listening begins with thinking
reflectively
• Thinking reflectively requires a continual
awareness that what you think people mean
may not be what they really mean
Thinking Reflectively
Exercise:
1. Split up into triads (1-speaker) (2-listeners).
2. Each person will take a turn being a speaker.
3. Each person will share a personal statement
“One thing I like about myself is …”
(e.g., I am organized. I am creative.)
4. The listeners respond with “Do you mean that…..”
(generate at least 5 for each).
5. The speaker responds with only yes/no.
Reflective Listening
• A reflection is two things:
– A hypothesis as to what the speaker
means
– A statement
• Statements are less likely than questions to evoke
resistance
OARS
Reflections Are Statements
“DO YOU MEAN……?”
• Use a statement to reflect your
understanding
• Inflection turns down at the end
“You...”
“Its...”
“You feel...”
“So you...”
“Its like...”
Reflections Are Statements
• Question:
– You’re thinking about stopping? (inflection goes
up)
• Versus a statement:
– You’re thinking about stopping. (inflection goes
down)
Reflective Listening
Exercise:
1. Split up into triads (1-speaker) (2-listeners).
2. Each person will take a turn being a speaker.
3. Each person will share a personal statement
“One thing I like about myself is …”
OR
“One thing about myself I’d like to change is…”
4. The listeners respond with reflections only.
5. The speaker can respond with yes/no and elaboration.
Levels of Reflection
• Simple Reflection – stays close
– Repeating
– Rephrasing (substitutes synonyms)
• Complex Reflection – makes a guess
– Paraphrasing – major restatement, infers
meaning, “continuing the paragraph’
– Reflection of feeling - deepest
OARS
Not Reflective Listening
Communication Roadblocks:
1. Ordering, directing, commanding
2. Warning, cautioning, threatening
3. Giving advice, making suggestions, providing
solutions
4. Persuading with logic, arguing, lecturing
5. Telling what to do preaching
6. Disagreeing, judging, criticizing, blaming
Not Reflective Listening
7. Agreeing, approving, praising
8. Shaming, ridiculing, blaming
9. Interpreting or analyzing, [also labeling]
10. Reassuring, sympathizing, consoling
11. Questioning, probing
12. Withdrawing, distracting, humoring, changing
the subject
Summaries
• Pull together what has transpired thus far in a
session
• Strategic use: practitioner selects what
information should be included & what can be
minimized or left out
• Additional information can also be incorporated
into summary – e.g., past conversations,
assessment results, collateral reports etc.
OARS
Summarizing
Exercise 3(part 1):
1. Choose a partner.
2. Speaker: for 90 seconds talk about a habit,
behavior, situation you are thinking about
changing.
3. Listener: listen only and then give a
summary of what you’ve been told.
4. Change roles and repeat.
Summarizing
Exercise (part 2):
1. Change partners.
2. Speaker: once again tell your story for 90
seconds w/out interruption.
3. Listener: listen only and then give a
summary, but this time include what you
think is the underlying meaning, feeling,
dilemma in the story.
4. Change roles and repeat.
Listen For Change Talk
DARNCAT Change
• Desire: I want/wish/prefer to
• Ability: I can, could, able, possible
• Reason: why do it? what would be good?
• Need: important, have to, matter, got to
• Commitment: I will/am going to – signals
behavior change
• Activations: I am ready to do this
• Taking Steps: I am taking steps
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Affirming
•
•
•
•
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Supports patient self-efficacy
Emphasize patient strengths
Notice and appreciate positive action
Genuineness is critical
Affirmations May Include:
• Commenting positively on an attribute
– (You are determined to get your health back.)
• A statement of appreciation
– (I appreciate your efforts despite the discomfort
you’re in.)
• A compliment
– (Thank you for all your hard work today.)
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Theoretical Framework of
Motivational Interviewing
“Readiness to Change”
1. Precontemplation – not yet considering
change
2. Contemplation – evaluating reasons for and
against change
3. Preparation – planning for change
4. Action – making the identified change
5. Maintenance – working to sustain changes
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EXPERIENTIAL EXERCISE 4: THE
PERSUASION EXERCISE
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How Do We Assist Others to Change?
• Exercise has 2 parts:
– Use Persuasion
– Use Motivational Interviewing
• Reverse roles & answer same questions
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Let’s see if it works…
Persuasion Exercise
• Ask your partner about a behavior that they have
considered changing?
• Explain why participant should make a change
• List at least 3 specific benefits of making this change
• Tell the participant how to change
• Emphasize how important it is for them to make the
change
• Tell the person to do it!
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Exercise Part 3: Now Let’s Try
Using MI
1. Ask you partner to select a personal change
2.
3.
4.
5.
they’ve have made in the past
What change did you make?
How did you decide to make this change?
What people or events influenced your
decision?
What steps did you take to make the change?
6. What did you learn from the process?
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Exercise Part 3: Now Let’s Try
Using MI
7. Now, what’s a new change you’re considered now?
8. What prompted you to look @ this issue now?
9. How might you go about it in order to it, succeed?
10.What are the 3 reasons to do it now?
11.Summarize what you heard.
12.Close by asking, what will you do next?
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Stages of Change
Precontemplation
Maintenance
Relapse
Action
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Contemplation
Preparation Determination
Stages of Change Model
CONCEPT
DEFINITION
APPLICATION
PRE-CONTEMPLATION
Not considering
possibility of change.
Does not feel there is a
Problem.
Goal: Raise awareness.
Task: Inform and encourage.
Validate lack of readiness.
CONTEMPLATION
Thinking about change,
in the near future.
Goal: Build motivation and
Confidence.
Task: Explore ambivalence.
Evaluate pros and cons.
PREPARATION
Making a plan to
change,
setting gradual goals.
Goal: Negotiate a plan.
Task: Facilitate decision making.
ACTION
Implementation of
specific action steps,
behavioral changes.
Goal: Implement the plan.
Task: Support self-efficacy.
MAINTENANCE
Continuation of
desirable
actions, or repeating
periodic recommended
step(s).
Goal: Maintain change or new
status quo.
Task: Identify strategies to
prevent
relapse.
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REMEMBER:
“READINESS TO
CHANGE” IS
A STATE, NOT
A TRAIT.
A Precontemplation Stage Tool
READINESS RULERS
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Readiness Rulers: I-C-R
• Importance: The
willingness to change
• Confidence: In one’s
ability to change
• Readiness: A matter
of priorities
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Confidence
Importance Ruler
On a scale of 1 to 10, how important is it for
you to make a change?
1
2
Not at all
important
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3
4
5
Somewhat
important
6
7
8
9
10
Extremely
Important
Importance to Change Readiness
Ruler
• We show the patient the Importance
Readiness Ruler & ask:
– On a scale of 1 to 10, how important is it to
you to make a change in . . . ?
– Example, If you are a 5, why are you a 5 and
not a 3?
– Or if you are a 5, what need to happen for you
to go to a 7?
– How could I assist you in getting to a 7?
82
Confidence Ruler
On a scale of 1 to 10, how confident are you that
you could make a change if you wanted to?
1
2
Not at all
confident
83
3
4
5
Somewhat
confident
6
7
8
9
10
Extremely
confident
Confidence to Change
Readiness Ruler
• We show the patient the Confidence
Readiness Ruler & ask:
– On a scale of 1 to 10, how confident are you to
make a change in . . . ?
– Example, If you are a 5, why are you a 5 and not a
3?
– Or if you are a 5, what need to happen for you to
go to a 7?
– How could I assist you in getting to a 7?
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Strategies to Enhance Confidence
• Review past successes
• Define small steps that can lead to success
• Problem solve to address barriers
– Hypothetical change (“If you were able to quit
smoking tomorrow, how do you think things
would be different?”)
• Attend to the progress and use slips as
occasions to further problem-solve rather
than failure
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Simplified Motivational Categories
Importance of Change
Confidence
in Ability
Low
High
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Low
High
Group 1 – Little interest
in change; don’t think
they could even if they
wanted to.
Group 2 – Want to
change, but don’t
think they are able.
Group 3 – Believe they
could change, but not
interested right now.
Group 4 – Want to
change and believe
they have the ability.
Readiness Ruler
On a scale of 1 to 10, how ready are you to
make a change?
1
2
Not at all
ready
87
3
4
5
Somewhat
ready
6
7
8
9
10
Extremely
Ready
Readiness to Change
Readiness Ruler
• We show the patient the Readiness Ruler &
ask:
– On a scale of 1 to 10, how ready are you to make a
change in . . . ?
– Example, If you are a 5, why are you a 5 and not a
3?
– Or if you are a 5, what need to happen for you to
go to a 7?
– How could I assist you in getting to a 7?
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Exercise 4:
The Readiness Ruler Exercise
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Exercise 4:
Let’s Try Using Readiness Rulers
• How important is it for you to learn about MI?
• What are the challenges at your agency that
makes this MI training important ?
• How confident are you that you can begin to
use utilizing what you’ve learned about MI in
the next week?
• How ready are you to start utilizing what
you’ve learned about MI in the next week
90
Exercise 4:
Utilizing Readiness Rulers
• You will be working with your partner in both the
role of helper & helpee utilizing Readiness Rulers
• Start off by using the
3 questions from
previous slide with
your partner
• Then utilize importance,
confidence & importance rulers
• Summarize outcome
91
A Contemplation Stage Tool
DECISIONAL BALANCE
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Decisional Balance:
An Explanatory Model Of Behavior Change
• Highlights the individual’s ambivalence
regarding maintaining vs changing a behavior
• it is a balancing of the costs of status quo with
the costs of change
• and the benefits of change with the benefits
of the status quo.
93
Decisional Balance
Decisional Balance Worksheet
(Fill in what you are considering changing)
Good things about behavior:
Not so good things about behavior:
Not so good things about changing behavior:
Good things about changing behavior
94
Decisional Balance Sheet
Reasons for staying the same
Good things about:
Not so good things about:
1.
2.
3.
1.
2.
3.
Not so good things about changing:
1.
2.
3.
95
Reasons for making a change
Good things about changing:
1.
2.
3.
Decisional Balancing—Benefits and
Costs Worksheet
Continuing Behavior
Costs
Stopping Behavior
Benefits
Costs
Benefits
1.
1.
1.
1.
2.
2.
2.
2.
3.
3.
3.
3.
4.
4.
4.
4.
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Conducting a Decisional Balance
Discussion
• Accept all answers. (Don’t argue with answers
given by patient.)
• Explore answers.
• Be sure to note both the benefits and costs of
current behavior and change.
• Explore costs/benefits with respect to client’s
goals and values.
• Review the costs and benefits.
97
Exercise 5:
The Decisional Balance Exercise
98
Exercise 5: Decisional Balance
1. Partners will take turns as helper & helpee.
2. Helper begins by asking helpee to identify either:
a) “something I know I need to change & am considering”
or
b) “something I feel 2 ways about”
3. Helper assists helpee in completing a decisional balance
4. Helper processes decisional balance with helpee using
OARS
99
Exercise 5: Decisional Balance
1. Ask your partner to think of an area of their life in
which they have been contemplating making a
change.
2. For example:
a) Starting a diet or exercise program
b) Going back to school
c) Moving to a new home.
100
Negotiating a Change Plan
– Patient sets a goal
– Have patient develop a menu of strategies—
brainstorm.
– Have patient decide on a specific plan &
summarize it.
– Elicit commitment
• Have patient restate what they intend to do.
• Involve others: the more the patient verbalizes the plan
to others, the more commitment is strengthened (“no
going back now” concept)
101
Summary: Benefits of Using MI
•
•
•
•
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Evidence-based
Patient Centered
Provides structure to the consultation
Readily adaptable to health care settings
What Do You Think?
1. On a scale of 1 to 10, how important is it for you to
start using motivational interviewing in your
practice?
2. On a scale of 1 to 10, how confident are you to start
using motivational interviewing in your practice?
3. On a scale of 1 to 10,how ready are you to start
using motivational interviewing in your practice?
103
THANK YOU FOR COMING & LEARNING
ABOUT MI!
104
ANY QUESTIONS?
More Information on Motivational
Interviewing
• Literature on MI: www.motivationalinterview.org
• Miller and Rollnick. Motivational Interviewing:
Preparing People for Change. Guilford Press. New
York and London. 2002
• Rollnick, Miller and Butler. Motivational Interviewing
in Health Care: Helping Patients Change Behavior.
Guilford Press. New York and London. 2008
105
Other Experiential Exercises
106
Imagine Extremes
• “What is the worst that can happen if you
continued?”
• What do you think would have to happen to
make you decide to tell yourself, “ok that’s
enough?”
107
Looking Back
• “When was the last time things were going
well for you and what was it like for you?”
• “What do you think could have prevented this
setback?
• “What was your life like before this
happened?”
• “As you step back and look at all this, what do
you make of it?”
108
Looking Forward
• “What would you like your life to be like in 2
years?”
• “How does what you are doing now make that
difficult?”
• “What would it be like if you continue with the
way things are now?”
• Suppose things don’t change, how do think
your life will look?”
109
Motivation for Change
• Motivation is an intrinsic process
• Ambivalence
– Alternative behaviors have pluses and minuses
• Motivation arises out of discrepancy
– Values/goals conflict with current behavior
• Ambivalence  discrepancy  change
• “Change Talk” facilitates change
110
Strengthening Commitment
• Summarize patient’s own perception of
problem, ambivalence, desire/intention to
change, and can include your own
assessment.
• Ask a “key question”, i.e.: “What is the next
step?”
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