110812--Motivational Interviewing--Fader

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Principles and Practice of
Motivational Interviewing
An Introduction
Jonathan Fader, PhD
Palmetto Health
Columbia, SC
November 8, 2012
Disclosures
I have no relevant disclosures
related to this activity.
Jonathan Fader, PhD
Honoring Each Other’s Participation
• Respect for effort makes for a good training
• We can honor fellow participants by:
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High Five, Handshake or Pound
Hug
ET hug
Bow
ASL applause
• Real Play
• Respect for varying viewpoints
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Training Objectives
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Become familiar with theory of Motivational
Interviewing
Learn Basic Motivational Interviewing
technique
Be able to apply that technique to working
with your clients
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Warm-Up
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Find a partner in the room
Decide who is going to speak and who is going to listen
Listener: Ask your partner ,“What could you do to lead a
more fulfilling life?”
Speaker: speak for 90 seconds to your listeners about
how you can be helped.
This is not a ‘role-play’: this is a ‘real-play’.
Listener is to hold complete silence, to use your
non-verbal interviewing skills
Begin!
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Warm-Up Continued
• Offer your listener one piece of positive feedback.
What’s one thing you saw them doing or not
doing that made it easy for you tell your story?
• What are some examples of positive feedback you
just offered your listener?
• Please extend gratitude and thank your listener for
listening
• What was challenging and/or easy about listening
in silence?
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Outline
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Background on behavior change theories
Review theory of Motivational Interviewing
Introduce Motivational Interviewing Technique
Videos
Practice Motivational Interviewing technique
Wrap up discussion and questions
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Important Theorists
“Look children, this is all I’m going to
say about drugs…Stay away from
them…There’s a time and a place for
everything…and it’s called college.”
Chef
Parker & Stone, South Park
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Mechanisms For Change
• Transtheoretical Model (Prochaska &
DiClemente, 1986)
– Change as a continuous variable
– Stages of change
– Individuals can continuously cycle through stages
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Mechanisms For Change
Precontemplation
Contemplation
Relapse
Preparation
Maintenance
Action
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Michael Jackson Said It Best
I Said You Wanna Be Startin' Somethin'
You Got To Be Startin' Somethin'
I Said You Wanna Be Startin' Somethin'
You Got To Be Startin' Somethin'
It's Too High To Get Over (Yeah, Yeah)
Too Low To Get Under (Yeah, Yeah)
You're Stuck In The Middle (Yeah, Yeah)
And The Pain Is Thunder (Yeah, Yeah)
It's Too High To Get Over (Yeah, Yeah)
Too Low To Get Under (Yeah, Yeah)
You're Stuck In The Middle (Yeah, Yeah)
And The Pain Is Thunder (Yeah, Yeah)
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Stages of Change in Problem Behavior:
Intervention Strategies
Precontemplation
Stage
Contemplation
Stage
Action
Stage
Maintenance
Relapse Stage
MOTIVATIONAL
ENHANCEMENT
STRATEGIES
TREATMENT
RELAPSE
PREVENTION &
MANAGEMENT
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What is Motivational Interviewing?
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VIDEO- What isn’t MI?
What happens when we tell people what to do?
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Brief Interventions
• Motivational Enhancement Therapy
(Motivational Interviewing) Miller and
Rollnick, 2009
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MI is a collaborative, person-centered
form of guiding to elicit and strengthen
motivation for change
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Five Principles of MI
Express Empathy
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Five Principles of MI
Develop Discrepancy
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Five Principles of MI
Avoid Argumentation
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Five Principles of MI
Roll with Resistance
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Five Principles of MI
Support Self-Efficacy
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Five Principles of MI
Video
What to look for in the video
– Three examples of actions or words that you
observe that look like MI to you
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What Is Resistance?
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I don't exercise. If God had wanted me to bend
over, he would have put diamonds on the floor.
- Joan Rivers
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Types of Resistance: Exercise
Split up into pairs. Write down on a note card a
resistance statement that a client you work with would say.
These cards will be collected by the trainer afterwards
• Argument
– Challenging
– Discounting
– Hostility
• Denial
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Blaming
Disagreeing
Excusing
Reluctance
Minimizing
Pessimism
Unwillingness to change
– Claiming immunity
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Motivational Interventions
The “Hook”
– A person’s behavior-related issue or problem
that, if addressed, can promote change
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The “Hook”
Negative Consequences
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Relationships
Financial
Legal
Health
What else??
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Case # 1
Juan is a 50 year old unemployed man who is an
aspiring artist. He was diagnosed with type 2 DM
when we was 45. He complains that he and his
girlfriend are always fighting because since he was
diagnosed with DM she is always trying to limit his
diet. He tells you that he’s tried to cut back on eating
high fat foods before but that he always starts to eat
them when one of his paintings gets passed over for an
art gallery.
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Case #1
Juan’s Possible Hooks
• Impact on relationship with girlfriend
• Importance of his artwork
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Motivational Interviewing
Techniques
Open-ended
Questions
Reflective
Listening
Affirm
Summarize
Elicit
Change Talk
Core Components
Express
Empathy
Avoid
Argumentation
Roll with
Resistance
Develop
Discrepancy
Support
Self-efficacy
Spirit
Collaboration
Evocation
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Autonomy
Miller and Rollnick, 2002
OARS
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Open-Ended Questions
Affirmations
Reflective Listening
Summaries
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OARS – CLOSED Ended
Questions
Did you have more than one alcoholic
beverage this week?
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OARS – CLOSED Ended
Questions
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OARS
• Open-Ended Questions
– What are the words that usually begin
CLOSED ended questions?
• Is
• Are
• Do
– What are the words that usually begin OPEN
ended questions?
• What
• How
• Why
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Eliciting Negative
Consequences Motivationally
•What difficulties have you had from not taking breaks at work?
•What do see happening if you continue to eat as you are?
•In what ways do you think other people have been affected
you not taking your medication?
•What do you think will happen if you don’t make a change?
•What is there about your mood that you or other
people might see as reasons for concern?
Modified From Miller, W.R., Zweben, A., DiClemente, C.C., Rychtarik, R.G. Motivational Enhancement Therapy Manual, National
Institute on Alcohol Abuse and Alcoholism, Project MATCH Monograph Series, Volume 2.
Examples of Key Questions
• What do you think you will do?
• What does this mean about your eating habits?
• It must be uncomfortable for you now, seeing all
this…What's the next step?
• What do you think has to change?
• What could you do? What are your options?
• It sounds like things can't stay the way they are
now. What are you going to do?
• Of the things we have mentioned here, which for
you are the most important reasons for a change?
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They speak of my drinking,
but never of my thirst.
-Scottish Proverb
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Addressing the Positives
• What are the reasons you don’t want to take your
medicine?
• What do you get out of eating high fat foods?
• What do you like about fighting?
• How does {problem behavior} help?
• What are your reasons for not wanting to these
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exercises?
Reasons not to Change!
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“To alcohol, the cause of,
and solution to, all of life's problems"
- Homer Simpson
Motivational Interviewing
Strategies
Reflection: The key to developing discrepancy
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Motivational Interviewing
Strategies
• Reflection: The key to developing discrepancy
– Simple Reflection
– Amplified Reflection
– Double-Sided Reflection
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Motivational Interviewing
Strategies
• Reflection: The key to developing discrepancy
– Simple Reflection
– I can’t start exercising, none of my family or
friends do!
– It’s difficult for you to think about starting to be
more physically active because you are
surrounded by people who don’t exercise.
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Motivational Interviewing
Strategies
• Reflection: The key to developing discrepancy
– Amplified Reflection
– My Dad is exaggerating. I’m not that overweight!
– It seems to you that he has no reason at all to worry
about you.
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Motivational Interviewing
Strategies
• Reflection: The key to developing discrepancy
– Double-Sided Reflection
Client: So I’m trying to eat right most days… I know I gotta bring my
weight down so I don’t get sick… it’s just such a hassle.
Clinician: So on one hand paying attention to what you are eating is a lot of
work, but on the other hand, you have to do it so that you stay healthy…
Client: Yeah… I know that my weight is pretty high and thinking about
what might happen if it stays that way, kind of freaks me out.
Clinician: Seeing that your weight was high scared you.
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Important Theorists
“Named must be your fear before
banish it you can.”
Yoda
Exercise: Practicing Rolling
with Resistance
• Facilitator will play the client with statements
suggesting resistance representing types of
resistance described previously (From the cards
you turned in!!)
• You, as the group, are our counselors
• Please respond to these statements with reflections
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Affirmations
• Acknowledgement of…
– Struggles or difficulties
– Successes
– Skills and/or strengths
– Goals and values
– Notice and appreciate a positive action−
“Catch them being good”
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Affirmation Examples
– “It takes courage to face such
difficult problems”
– “This is hard work you’re doing”
– “You really care a lot about your
family”
– “Your anger is understandable”
– “It must have taken a lot of
courage to come in today knowing
that you haven’t meet your goals
regarding exercising/losing
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weight”
Practicing Affirmations
Write down 1 affirmation for the following statement:
“I'm sick of this, everything just keeps getting
messed up. I do good for a week on my diet and then the
kids start getting on my nerves, my children are so
annoying. I go to this clinic…I think it's helping and then
my sugars go up and I gain 10 pounds. Doctors don’t like
me… my co-workers don’t like me. I can't do anything
right. They're always on my case. I don't know what you all
want from me. I'm just trying to get by here. It's not as easy
as you make it sound.”
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Summaries
• Collect material already offered
– So far you’ve expressed concern about your family, getting a
job, and staying clean…
– What else?
• Link something just said with something discussed earlier
– That sounds a bit like what you told me about that lonely feeling
you get when no one comes to visit.
• Transition: Draw together what has happened and transition to a
new task
– Let me summarize what you’ve told me so far. You came in
because you were …, and it scared you when . . . Then you
mentioned… and now…
– …Where does that leave you?
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Exercise: The 7 minute MI Interview
Pair up
• 1 – Ask Permission
• 2 – Ask open-ended questions/Scaling Question
• 3 – Summarize
• 4 – Ask about next steps
• 5 – Use Affirmations
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Ways to Keep Learning MI
• Be willing to try it
• Further reading:
– MI 2nd Edition
– motivationalinterviewing.org
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Seek supervision/coaching
Form a peer discussion group
Learn it from watching your clients
Attend more training
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Questions?
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