Motivational Interviewing:
The Challenging Patient &
Interactive Case Studies
4th Annual Chronic Disease Self-Management Conference
Michael Vallis, PhD R Psych
Psychologist and Lead, CH Behaviour Change
Institute
Associate Professor, Dalhousie University
Let’s Start With What We Know
•
•
The strongest predictor of future behaviour
is .............?
•
PAST BEHAVIOUR!
What does this say about the likelihood of
behaviour change?
•
NOT!
And, by the way, the
strongest predictor of
changed behaviour is.........?
SELF-EFFICACY
A person’s confidence to perform a
specific behaviour in a specific
context for a specific time period and
in the face of specific barriers
Self-Management
Support Skills
1. Relationship skills - establishing a change
based relationship using motivational
interviewing
2. Motivational skills - getting to the behaviour
3. Behaviour change skills - making sustainable
changes
4. Emotion management skills - helping to
maintain the behaviour
What Does Self-Management
Support Really Mean?
• Fundamental change in the relationship between
the individual and the HCP
• From
• Expert clinician with uninformed helpseeker
• “Let me tell you what you need to do”
• “Let me tell you what you need to know”
• To
• We both have a role to play
• “I understand that you will make your own
decisions and I respect that. Can we have a
conversation about your health”
Change-Based
Relationships
•
A helping alliance involves 3 components:
•
•
•
Bond
Task
Goal
Motivational Interviewing
 Ask questions, Minimize statements
 Express Empathy
 Take a curious, nonjudgmental stance
 Learn to sit with ambivalence
 Avoid argument
 Roll with resistance
 Support Self-Efficacy
Determine Readiness
• Is the behaviour (or lack of it) a problem for
you?
• Does the behaviour (or lack of it) cause you
any distress?
• Are you interested in changing your
behaviour?
• Are you ready to do something to change
your behaviour now?
Getting to the Behaviour
Readiness Assessment
Not Ready
Understanding the
behaviour
Personal
meaning
Seriousness,
personal
responsibility,
controllability,
optimism
Ready
Go Right
to Behaviour
Modification
Ambivalent
Expanding on
readiness
Personal/meaningful
reasons to change
Willingness to work
hard - connect to
principles
Delay of gratification
Decisional Balance
Self-Efficacy
Barriers/Temptations
Especially social, cultural and environmental
Working With the
Behaviour:
Behaviour
Modification
Goal Setting
SMART GOALS
Specific, measurable, achievable, relevant,
timely
Shaping
Importance of NEXT STEP
Stimulus control
Respecting the environment
Reinforcement Management
Maintaining Change:
Emotion Management
•
Your Task
•
•
•
•
Identify
Educate
Recommend
Support
Managing Emotions
Dealing with unhealthy coping strategies
Recognize the value of unhealthy behaviour
and focus on replacing the function
Stress Management
Physical discharge
Physical calming
Express emotions
Seek social support
Referral for psychological intervention
• “I want to eat what I want, when I want”
• “I feel fine, I am sure if my diabetes was a
problem I would feel sick?”
• “Everytime you follow advice new research
gets released that says the old way was
better”
•
•
•
•
CASES
50 yo single female living with elderly mom (depressed
drinker), - diabetes COPD dysthymic - she is stuck - not
moving
17 adolescent male - grass - referred from school cocaine and alcohol - struggle to avoid situations -he’s
becoming concerned
19 yo referred from probation (drinking/driving) - meets
regularly - says wants to make changes (don’t believe
him) - “are you here because of probation” - ambivalent
but slippery
70 yo female - smoker (1ppd) - relapse when stressed motivated - COPD, ca, diabetic and bipolar