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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 5 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 • • • • 6 A theory A set of skills A way of thinking A way of relating EXPERIENTIAL EXERCISE 1 7 Why Do People Change? 1. 2. 3. 4. 5. 6. 8 ? ? ? ? ? ? Why Don’t People Change? 1. 2. 3. 4. 5. 6. 9 ? ? ? ? ? ? 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. 12 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 14 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. 15 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? 16 Change Exercise Key Points • • • • • • • • 17 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 • • • • 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 18 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 19 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) 20 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. 21 Rapid Diffusion Into Health Care Settings… 22 Spirit, Principles, Micro-skills MOTIVATIONAL INTERVIEWING PRACTICE BASICS: 23 MI Spirit • A way of being with patients which is… – Collaborative – Evocative – Respectful of autonomy 24 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 26 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 30 Four Guiding MI Principles: 1. Resist the righting reflex • If a patient is ambivalent about change and the clinician champions the side of change… 31 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. 32 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 33 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. 34 Core MI Skills – (OARS) • Asking • Listening • Affirming 35 Asking o • Use of pen ended questions allows the patient to convey more information • Encourages engagement • Opens the door for exploration 36 Closed Ended Question Open Ended Question • • • • • • • 37 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… • • • • • 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 51 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 DARNCAT 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 67 Affirming • • • • 68 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.) 69 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 70 EXPERIENTIAL EXERCISE 4: THE PERSUASION EXERCISE 71 How Do We Assist Others to Change? • Exercise has 2 parts: – Use Persuasion – Use Motivational Interviewing • Reverse roles & answer same questions 72 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! 73 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? 74 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? 75 Stages of Change Precontemplation Maintenance Relapse Action 76 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. 77 78 REMEMBER: “READINESS TO CHANGE” IS A STATE, NOT A TRAIT. A Precontemplation Stage Tool READINESS RULERS 79 Readiness Rulers: I-C-R • Importance: The willingness to change • Confidence: In one’s ability to change • Readiness: A matter of priorities 80 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 81 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? 84 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 85 Simplified Motivational Categories Importance of Change Confidence in Ability Low High 86 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? 88 Exercise 4: The Readiness Ruler Exercise 89 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 92 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. 96 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 • • • • 102 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?” 111