It’s fun, freeing,
and fruitful!
Motivational
Interviewing
Jen Carlson & Katie Miller
March 14, 2016
Overview:
• Example of non-motivational interviewing
• Assess current comfort level and areas of interest
• MI basics
• Assumptions about motivation
• What, when and how
• Rolling with Resistance pointers
• Practice skills with a partner
First, let’s visit a patient room near you:
• Hint: This is not motivational interviewing
Thoughts?
• Have you been here?
• From a doctor perspective, how did this go?
• From the patient perspective, how did this go?
Motivational Interviewing
to the Rescue!
• What does it mean?
• What’s your comfort level?
• Where do you need help?
MI Basics
• What
• When
• How
Assumptions About Motivation
• Motivation is malleable
• Subject to change in context of patient-provider relationship
• The ways in which one talks with patients can influence
personal motivation for behavior change
What is MI?
• A collaborative method of communication
• Designed to strengthen motivation for and movement
toward a specific behavior change
• Key is to elicit and explore the person’s own arguments for
change
Where did it come from?
• Grew out of the “Stages of Change” model of behavior
change
• Rollnick and Miller developed initially for work in substance
abuse treatment (1980s)
Stages of Change/Provider tasks
Patient Stage
Provider tasks
Contemplation
(getting ready)
Explore ambivalence about change
Identify reasons for change/risks of not changing
Increase confidence in ability to change
Preparation
(ready)
Goal setting: help patient develop a realistic plan for making
change
Maintenance
(sticking to it)
Help identify and use strategies to prevent relapse
Relapse
(learning)
Help patient renew the processes of contemplation and action
without becoming stuck/demoralized
Precontemplation
(not ready)
Increase patient’s perception of the risks and problems with
current behavior. Assist with harm reduction strategies.
When to use MI
• When you are working with a patient on behavior change
• What kind of behaviors?
• medication adherence, smoking, nutrition, alcohol, physical
activity, diabetes control, sexual risk taking, substance abuse
problems, problem internet use, completion of recommended
screening or diagnostic tests or specialist/psychologist
referrals, stress management
You find yourself
banging your head
on your desk
You want to have
an enjoyable
patient interaction
You don’t want to
be the cause of a
patient’s resistance
You will not use MI style of
communication all the time:
Styles of Communication:
Directing
Following
Guiding
All are valid and useful to mix and match: guiding is most
effective for building motivation and eliciting behavior change
Attitude is Everything
Style/Spirit of MI:
• Collaboration (partnership between patient and doctor with
doctor acknowledging the patient’s expertise about themselves)
• Evocation (doctor evokes the patient’s own motivation and reasons
for change)
• Honoring patient autonomy (though doctor can provide
information/advice, acknowledges that change “is up to you”)
• https://www.youtube.com/watch?v=80XyNE89eCs
https://www.youtube.com/watch?v=URiKA7CKtfc
6 Guiding Principles:
• Resist the righting reflex—tendency to tell people the right
way to do things
• Understand the patient’s own motivations
• Listen with empathy and express empathy
6 Guiding Principles:
• Empower the patient and support self-efficacy
• Develop discrepancy: help point-out differences between a
patient’s current behavior and future goals or values
• Roll with resistance: avoid argument, simple
acknowledgement of a patient’s
disagreement/emotion/perspective, verify your
understanding matches the patient’s perspective, shift the
patient’s attention away from the stumbling block, assure
the patient that they are in charge of the decision to change
How: Some practical tips
• You may use 1 or 2 of these techniques during a visit
• In a typical clinic visit you will likely not have time to use all
of these techniques
How:
• Ask permission to discuss the topic further.
• Ex: “Would it be okay if we spend a few minutes talking more about
______?”
• Help the patient hone in on a specific behavior
• Ex: If the patient wants to lose weight, do they want to focus today’s
discussion on eating or physical activity?
How:
• Ask open-ended questions to explore patient perspective
• Ex. Tell me about your exercise habits? What concerns you
about your eating habits? What are the pros and cons to
changing and staying the same? What is a typical day like
for you and where does exercise fit in? Good things/Not-sogood things about target behavior?
How:
• Use reflective listening—listen carefully and then rephrase or
replay the key points of a patient’s statements.
• Ex. -You are getting frustrated by your mom telling you to
exercise.
• -So on the plus side TV helps you unwind and spend time
with your friends, the downside is you are sedentary for
hours and are getting to bed too late.
How
• Use summarizing—ensures mutual understanding, can point
out discrepancies between the person’s current situation and
future goals, can move conversation toward discussion about
change
• Ex. You enjoy watching TV after work since it helps you
unwind and you can spend time with your partner, but you
are beginning to worry that you are not getting enough
exercise, and you are getting sucked in so you are getting to
bed too late.
How
• Make affirmations: can take the form of pointing out
personal strengths/efforts or statements of appreciation and
understanding of struggles/skills/goals/values
• Ex. -I know that you worked very hard and were able to
quit smoking in the past, which makes me think you will be
able to tackle this challenge.
• Ex. -I appreciate that this is an emotional topic for you to
discuss, thanks for helping me understand the issue more
fully.
How
• Listen for “change talk”: ex “I’m not ready to change” “I
want to change” “I should change” “I will make changes”
How
• Assess commitment to change/Set goals if appropriate
• Try using an “importance ruler”:
• Ex. On a scale from 1-10, with 1 being “not important at
all” and 10 being “extremely important” where would you
put getting more sleep? Why are you a __ instead of a
_____(lower number)?
How
• Try using a “confidence ruler”:
• Ex. On a scale from 1-10 with 1 being “no confidence” and
10 being “extremely confident,” how confident are you that
you can increase your exercise? Why are you a ___ instead of
a ____ (lower number)?
• Assess stage of change (precontemplation, contemplation,
preparation, etc.) and stick to appropriate provider tasks
How
• If patient is ready to make steps toward change, decide on a
“change plan” together.
• Ex. Where do you want to go from here? What changes are
you thinking of making?
• Explore challenges
• Write down action plan and summarize
Skills for Rolling with
Resistance
Shifting focus
• Temporarily shift attention away from contentious area to
one of common ground
Emphasizing personal choice and control
• Assure that any decision about whether or not to change is
the patient’s choice; only he/she can take action towards
change
Reframing
• Restates what was said and invites patient to consider this
viewpoint.
Agreement with a twist
• Combines a reflection and a reframe
• Requires a light touch and sensitivity so that it does not
sound like sarcasm or criticism
Coming alongside
• A last resort: agreeing with expressions of negativity.
• Extreme exaggeration intended to bring patient back to a
more open posture.
Pick a partner
Case 1:
• Philip is an 18-year-old high school senior who comes to
your office for a regular health supervision visit. His dad
stopped you in the hall prior to the visit to say that he
wants you to “make Philip stop smoking.” The psychosocial
history reveals that Philip smokes about a pack of cigarettes
a day and has no interest in cutting back or quitting. In fact,
he volunteers, “I love to smoke.” Philip is planning to work
as a car mechanic after graduation from high school. He
plays no sports. His physical examination is completely
normal.
• How do you start using MI?
Case 2:
• Janie is a 16-year-old junior in high school who comes in for
follow-up of a new prescription for contraception. She is sexually
active with one male partner and had started an oral
contraceptive 4 months before. Janie states that she stopped
taking the pill a month ago because she was having a lot of vaginal
spotting. When you ask how taking the pill at the same time each
day worked for her, she sighs, “I just couldn’t seem to remember
to take it, no matter what I tried. Maybe I’ll just stick with
condoms for now. Maybe I will be able to remember to take the
pill more regularly when I get back to school in the fall.” You
thank Janie for being honest about her difficulties in taking the
pill.
• What do you do next?