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: – – – – – High Five, Handshake or Pound Hug ET hug Bow ASL applause • Real Play • Respect for varying viewpoints www.jonathanfader.com Training Objectives • • • Become familiar with theory of Motivational Interviewing Learn Basic Motivational Interviewing technique Be able to apply that technique to working with your clients www.jonathanfader.com Warm-Up • • • • • • • • 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! www.jonathanfader.com 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? www.jonathanfader.com Outline • • • • • • Background on behavior change theories Review theory of Motivational Interviewing Introduce Motivational Interviewing Technique Videos Practice Motivational Interviewing technique Wrap up discussion and questions www.jonathanfader.com 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 www.jonathanfader.com Mechanisms For Change • Transtheoretical Model (Prochaska & DiClemente, 1986) – Change as a continuous variable – Stages of change – Individuals can continuously cycle through stages www.jonathanfader.com Mechanisms For Change Precontemplation Contemplation Relapse Preparation Maintenance Action www.jonathanfader.com 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) www.jonathanfader.com Stages of Change in Problem Behavior: Intervention Strategies Precontemplation Stage Contemplation Stage Action Stage Maintenance Relapse Stage MOTIVATIONAL ENHANCEMENT STRATEGIES TREATMENT RELAPSE PREVENTION & MANAGEMENT www.jonathanfader.com What is Motivational Interviewing? www.jonathanfader.com VIDEO- What isn’t MI? What happens when we tell people what to do? www.jonathanfader.com Brief Interventions • Motivational Enhancement Therapy (Motivational Interviewing) Miller and Rollnick, 2009 • MI is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change www.jonathanfader.com Five Principles of MI Express Empathy www.jonathanfader.com Five Principles of MI Develop Discrepancy www.jonathanfader.com Five Principles of MI Avoid Argumentation www.jonathanfader.com www.jonathanfader.com Five Principles of MI Roll with Resistance www.jonathanfader.com www.jonathanfader.com Five Principles of MI Support Self-Efficacy www.jonathanfader.com www.jonathanfader.com 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 www.jonathanfader.com What Is Resistance? www.jonathanfader.com I don't exercise. If God had wanted me to bend over, he would have put diamonds on the floor. - Joan Rivers www.jonathanfader.com 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 – – – – – – – Blaming Disagreeing Excusing Reluctance Minimizing Pessimism Unwillingness to change – Claiming immunity www.jonathanfader.com Motivational Interventions The “Hook” – A person’s behavior-related issue or problem that, if addressed, can promote change www.jonathanfader.com The “Hook” Negative Consequences • • • • • Relationships Financial Legal Health What else?? www.jonathanfader.com 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. www.jonathanfader.com Case #1 Juan’s Possible Hooks • Impact on relationship with girlfriend • Importance of his artwork www.jonathanfader.com 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 www.jonathanfader.com Autonomy Miller and Rollnick, 2002 OARS • • • • Open-Ended Questions Affirmations Reflective Listening Summaries www.jonathanfader.com OARS – CLOSED Ended Questions Did you have more than one alcoholic beverage this week? www.jonathanfader.com OARS – CLOSED Ended Questions www.jonathanfader.com 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 www.jonathanfader.com 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? www.jonathanfader.com They speak of my drinking, but never of my thirst. -Scottish Proverb www.jonathanfader.com 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 www.jonathanfader.com exercises? Reasons not to Change! www.jonathanfader.com “To alcohol, the cause of, and solution to, all of life's problems" - Homer Simpson Motivational Interviewing Strategies Reflection: The key to developing discrepancy www.jonathanfader.com Motivational Interviewing Strategies • Reflection: The key to developing discrepancy – Simple Reflection – Amplified Reflection – Double-Sided Reflection www.jonathanfader.com 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. www.jonathanfader.com 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. www.jonathanfader.com 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. www.jonathanfader.com 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 www.jonathanfader.com Affirmations • Acknowledgement of… – Struggles or difficulties – Successes – Skills and/or strengths – Goals and values – Notice and appreciate a positive action− “Catch them being good” www.jonathanfader.com 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 www.jonathanfader.com 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.” www.jonathanfader.com 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? www.jonathanfader.com 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 www.jonathanfader.com Ways to Keep Learning MI • Be willing to try it • Further reading: – MI 2nd Edition – motivationalinterviewing.org • • • • • Seek supervision/coaching Form a peer discussion group Learn it from watching your clients Attend more training www.jonathanfader.com www.jonathanfader.com Questions? www.jonathanfader.com