Bringing Health Care to Schools for Student Success
Motivational Interviewing:
Motivating Youth to Change Behavior
Training of Trainers
September 21 - 23, 2008
Margaret Bavis, DNP, FNP-BC
Sue Murray, RN, MPH
In collaboration with Sharon Stephan, PhD
Center for School Mental Health
1
Workshop Objectives
1)
Participants will be able to name the core
elements of motivational interviewing
2)
Participants will be able to name at least
two techniques used in motivational
interviewing.
3)
Participants will be able to demonstrate the
steps in conducting a motivational
interview session.
2
What does Motivational
Interviewing look like?
Video clip
3
“Motivational interviewing was developed from
the rather simple notion that the way clients are
spoken to about changing addictive behavior
affects their willingness to talk freely about why
and how they might change.”
Stephen Rollnick, PhD
Addiction 2001; 96:1769-70.
4
Introspective Exercise #1*
What expectations do health trainees, who
come into contact with clients for the first
time, have about promoting behavior
change among patients/clients?
*Adapted from Presentation by Edward Pecukonis, PhD
University of Maryland School of Social Work
5
How Does Behavior Change?
Behavior A
Behavior B
6
Introspective Exercise #1
(continued)
What feelings do you experience
when working with
patients/clients to promote
behavior change?
7
Introspective Exercise #1
(continued)
Think of a behavior you’ve
tried to change
8
Introspective Exercise #1
(continued)
How much time elapsed between:
the
first time you engaged in the
behavior, and
the first time you recognized risk or
negative consequences?
9
Introspective Exercise #1
(continued)
• < 1 mo.
• 1 to 3 mo.
• 4 to 6 mo.
• 7 to 12 mo.
• 13 mo. to 2 yr.
• 3 to 5 yr.
• > 5 yr.
10
Introspective Exercise #1
(continued)
How much time elapsed between:
the
first time you recognized risk or
negative consequences, and
the
first time you made an earnest
attempt to change the behavior?
11
Introspective Exercise #1
(continued)
• < 1 mo.
• 1 to 3 mo.
• 4 to 6 mo.
• 7 to 12 mo.
• 13 mo. to 2 yr.
• 3 to 5 yr.
• > 5 yr.
12
Introspective Exercise #1
(continued)
 Did
you ever experience some
success in changing your behavior?
 Did you ever experience a
resumption of or increase in the
undesired behavior after experiencing
some success?
13
Introspective Exercise #1
(continued)
What conclusions would
you draw from the group’s
responses?
14
Possible Conclusions
 Behavioral
issues are common
 Change often takes a long time
 The pace of change is variable
 Knowledge is usually not
sufficient to motivate change
 Relapse is the rule
15
Possible Conclusions
(continued)
 Our
expectations of patients/clients
regarding behavior change are
unrealistic
 Unrealistic expectations can lead to
frustration and burn-out
16
Benefits of Learning About the
Transtheoretical Model &
Motivational Interviewing
 More
realistic expectations
 Greater recognition of small
accomplishments
 Greater success over time
 Less frustration and burn-out
17
Transtheoretical Model
(Prochaska & DiClemente)
 Individuals
progress through stages
of change
 Movement may be forward or
backward
 Movement may be cyclical
18
Transtheoretical Model*
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Action
Termination
*Adapted from Presentation by Edward Pecukonis, PhD
University of Maryland School of Social Work
Synonyms
Determination = Preparation
Termination = Exit
19
Motivational Interviewing can be
used at all Stages of Change:
DURING:
– Precontemplation –
MI can:
raise awareness
– Contemplation –
help decision making
– Action
and Maintenance -
– Relapse -
enhance and remind
of resolution to change
enables
reassessment
20
Spirit of Motivational Interviewing

A “way of being” with a client

The spirit of MI is characterized by:
– a warm, genuine, respectful and egalitarian
stance
– supportive of client self-determination and
autonomy
21
Principles of Motivational
Interviewing
Express Empathy
 Roll with Resistance
 Develop Discrepancy
 Support Self-efficacy
 Avoid Argumentation

22
For which behaviors can we use
motivational interviewing?


Any high risk behavior!
MI has been shown to be effective for:
–
–
–
–
–
–
Substance use
Tobacco use
Sexual activity
Diet and physical activity (e.g. diabetes, obesity)
Truancy
Chronic disease (e.g. asthma)
23
Motivational Interviewing with
Adolescents

Teens: Hardwired for Risky Behaviors?
– Emotion/Social Interaction – active in puberty
– Behavior regulation - still maturing into early
adulthood.

Just because we are giving teens the facts,
that doesn’t mean we are changing their
behavior!
24
Motivational Interviewing
Techniques
25
Assessing Stage of Change
What question(s) would best
assess stage of change?
26
Assessing Stage of Change
(continued)
Sample initial questions:
 How
do you feel about your
[behavior]?
 What do you think about your
[behavior]?
 How does [behavior] fit into your
life?
27
Assessing Stage of Change
(continued)
Sample follow-up questions:
 So,
are you saying that you’re
thinking of [changing] soon, or not
really?
 I’m confused. Are you saying that
you’re ready to [change], or is this
a bad time?
28
3 Stages of Techniques*
 Opening
Strategies
 Responding
 Eliciting
to “Sustain Talk”
“Change Talk”
* Adapted from New York State Office of Alcohol and Substance Abuse Services, Continuing
Education, Steven Kipnis, MD, FACP, FASAM, Patricia Lincourt, LCSW, Robert Killar, CASAC
29
Opening Strategies
(OARS)
Open-ended Questions
 Affirmations
 Reflections
 Summaries

30
Opening Strategies
(OARS)
Open-ended Questions


Close-ended question (one that can be
answered yes/no/maybe): “Have you had
anything to drink today?”; “Would you
like to quit smoking?”
Open-ended question: “What is a typical
drinking day like for you?”; “How do
you feel about your smoking?”
31
Opening Strategies
(OARS continued)
Affirmations

An example of an affirmation is, “I really like the way
you are approaching this problem, I can see that you are
very organized and logical and I am sure this will help
you to succeed in our program.”

An affirmation can be used to reframe what may at first
seem like a negative. “I can see that you are very angry
about being here, but I’d like to tell you that I am
impressed that you chose to come here anyway, and right
on time!”
32
Opening Strategies
(OARS continued)
Reflections

Statements made to the client reflecting or mirroring back to them the
content, process or emotion in their communication.
Reflective listening says:




“I hear you.”
“I’m accepting, not judging you.”
“This is important.”
“Please tell me more.”

Student: “My girlfriend gets really angry when I get stoned and pass out.”

Provider: “She gets mad when you do that.”
33
Opening Strategies
(OARS continued)
Summaries

Summaries are simply long reflections. They can be used
to make a transition in a session, to end a session, to
bring together content in a single theme, or just to review
what the client has said.

An example is: “Let’s take a look at what we have talked
about so far. You are not at all sure that you have a
‘problem’ with alcohol but you do feel badly about your
DWI and it’s effect on your family. You said that your
family is the most important thing to you and you would
consider totally quitting drinking if you believed it was
hurting them.”
34
“Sustain-talk”
Clients may not want to make behavior changes, and
many argue strongly against making these changes.
They may:








Argue
Deny a problem
Accuse
Interrupt
Disagree
Passively resist though minimal answers
Overtly comply due to mandate with little investment
Become angry
35
Examples of Client Sustain Talk
Statements



“I don’t have a problem, it is all a mistake.”
“I don’t drink anymore alcohol than my friends
do.”
“This is your job. You don’t really care if I
change or not.”
36
Responding to “Sustain-talk”


It was shown in a recent University of New
Mexico study that the more, and the earlier a
client argued for change in the treatment process,
the better the treatment outcome.*
Specific techniques have been shown to decrease
“resistance” or “sustain-talk.”
*Amrheim, P., Miller, W.R. (2003)
37
Techniques for Responding to
“Sustain-talk”
Reflective Techniques:
 Simple Reflection
 Complex Reflection
38
Simple Reflection
A simple reflection, mirrors or reflects back to the
client the content, feeling or meaning of his/her
communication. An example of a simple reflection
to respond to “sustain-talk” is:
Client: “I know I made a mistake but the hoops they are
making me jump through are getting ridiculous.”
Counselor: “You are pretty upset about all this. It
seems like everyone is overreacting to a mistake.”
39
Complex Reflection
Complex reflections typically add substantial
meaning and emphasis. They can provide two sides
of points of view, be metaphors, or verbalize
unspoken emotion. For example:
Client: “I know that I made a mistake, but the hoops
they are making me jump through are ridiculous.”
Counselor: “You made a mistake and it sounds like you
feel badly about that, but you also think that people are
asking you to do too much.”
40
Strategic Techniques for
Responding to “Sustain-talk”





Sometimes clients are entrenched or “stuck” in
“sustain-talk”. In this case, there is another set of
techniques referred to as strategic techniques.
The strategic techniques include:
Shifting Focus
Coming Along Side
Emphasizing Personal Choice and Control
Reframe
Agreement with a Twist
41
Shifting Focus
Shifting focus attempts to get around a “stuck”
point by simply side-stepping. An example, using
the same client statement is:
Client: “I know I made a mistake, but the hoops
they are making me jump through are getting ridiculous.”
Counselor: “You are upset by all of these hoops.
Can you tell me more about the mistake you think you
made?”
42
Coming Along Side
This technique is used to align with the client.
This is used when the client has not
responded with a decrease in “sustain-talk”
with previous techniques. An example of
coming along side is:
Client: “I know I made a mistake, but the hoops that
they are making me jump through are getting ridiculous.”
Counselor: “You may be at your limit and might not be
able to keep up with all this.”
43
Emphasize Personal Choice and
Control
Clients ultimately always choose a course of action
and this technique simply acknowledges this fact.
Acknowledging this can sometimes help a client
recognize that they are making a choice. An example
is:
Client: “I know I made a mistake, but the hoops that
they are making me jump through are getting ridiculous.”
Counselor: “You don’t like what others are asking you to
do, but so far you are choosing to follow-through with what
they are asking. It takes a lot of strength to do that. Tell me
what motivates you.”
44
Reframe
This technique takes a client communication and
gives it a different twist. It may be used to take
negative client statement and give it a positive
spin. An example:
Client: “I know that I made a mistake, but the
hoops they are making me jump through are getting
ridiculous.”
Counselor: “You are not happy about others having
so much control, but so far you have been able to keep up
with all their expectations and have been quite
successful!”
45
Agreement with a twist
This is a complex technique that combines a
reflection with a reframe. This gives the client
confirmation that they were “heard” and then offers
another perspective on their communication. It is
similar to a reframe and an example is:
Client: “I know that I made a mistake, but the hoops
that they are making me jump through are getting
ridiculous.”
Counselor: “You are feeling frustrated with all these
expectations. You are also anxious to be successful with
some things so you can keep moving forward.”
46
“Change-talk”
Opposite of Sustain-talk
 Change talk is client speech that favors
movement in the direction of change.

47
Examples of “Change-Talk”



“I really want to be a good daughter and I know I
should make some changes.”
“I quit smoking when I decided I was ready and I
think I can do this too.”
“I know I would be more motivated and do better
in school if I cut down on my use.”
48
Techniques for eliciting “Change-Talk”









Exploring problem
Looking backward
Looking forward
Considering importance
Exploring values and discrepancy with behavior
Considering pros and cons (decisional balance)
Importance/Confidence Ruler
Exploring Extremes
Planning and Committing
49
Exploring Problem




Simply asking open-ended questions, reflecting
and providing opportunity to explore the problem
from the clients perspective. For example:
“Tell me a little more about…”
“What do you think about …?”
“Who influenced you…?”
50
Looking Forward/ Looking
Backward
Ask the client to look at what life was like prior to the
current problem and explore it, in order to identify
potential motivators. Also, look forward to goals and
plans and explore how the current problem behavior
“fits” with these goals. For example:
 “What was life like for you before this became a
problem?”
 “Tell me how you see your life two or three years from
now? How might this current problem effect these goals
or plans?”
 “What kinds of things did you used to do with your time?
What things do you miss?”
51
Considering Importance
Identify reasons that a change is important to the
client. For example:


“You seem pretty committed to making a change.
What motivates you?”
“I can see that you have been through a lot. Tell
me in what ways making a change may help.”
52
Exploring Values and Discrepancy
with current behavior
A conflict with values is often the strongest motivator for
change. Examples include:



“What is most important to you?”
“How does your drinking effect the things in your life that
you value?”
“When you look at your life, what are you most proud of,
least proud of?”
53
Considering Pros and Cons
Decisional Balance
Help the client to weigh the costs versus the
benefits of the behavior in order to identify the
ambivalence and move in the direction of
positive change. Examples include:


“What are the good things about smoking pot and
what are the not-so-good things?”
When you look at this list of pros and cons, what
do you think?”
54
Importance/Confidence Ruler
Students are asked to choose a number between one and ten to
describe the level of importance they perceive about
changing their behavior. They are also asked to place
themselves on the scale in terms of the confidence they
perceive in their ability to make that change. Examples of
scaling questions include:



“On a scale of 1-10 with 10 being the most important and 1 being the
least, how important is it for you to make this change?”
If the client chooses a 4, a follow-up question may be- “You chose a 4,
tell me why you chose a 4 and not a 3 or a 2?” Asking the question in this
way encourages “change” rather than “sustain” talk.
“On that same scale, how confident are you that you could make a change
in this behavior if you decided to?”
55
Exploring Extremes

The counselor asks the client to consider what is
the “worst thing” that could or may happen if
he/she continues with current behavior pattern.

Counselor can also ask what is the best thing or
things that could happen as a result of a behavior
change.
56
Planning and Committing
This includes talking with a client about how to
make a change. Examples of questions include:


“If you were to decide to make a change, what
steps might you take?”
“We have talked a lot about the reasons you think
a change is important, Tell me how you will
know that you are ready.”
57
Change-Plan


When the client has increased “change-talk” and
there is little “sustain” talk this is a signal to the
therapist that the client is ready to make a
decision.
At this point, the therapist should shift to
negotiating a change plan or strategy. This can be
a formal exercise such as the change plan on the
next slide or it can be a more informal
conversation about the client’s options, desires,
ideas about what might work.
58
Change Plan Worksheet






The changes I want to make are:
The most important reasons I want to change are:
The steps I plan to take in making this change are:
The ways other people can help me change are:
Person
Possible ways to help
Some things that could interfere with my plan are:
I will know if my plan is working if:
______________________________
Client Signature
______________________________
Counselor Signature
(From the MET manual NIAAA clearinghouse Publication # 94-3723)
59
Motivational Interviewing Quiz!!

What are the general
principles of MI?:
–
–
–
–
–

Express __________
Develop __________
Roll with __________
Support __________
Avoid ____________
What are some techniques
used in MI?
60
Sustain or Change Talk?





“I really need to stop using or I think my
girlfriend will break up with me.”
“My girlfriend thinks everyone has a problem
because her father is an alcoholic.”
“I know I need to cut down, but I can do it on my
own.”
“I feel ready to make this change and I know it
will be difficult, but I have a good plan.
“Talking to you makes me feel worse. When can
I go back to class?”
61
How can you incorporate MI into
your practice?






Reflect on your current practice
Clarify roles between MH and PC providers
Develop protocols for incorporating MI into both
mental health and primary care practice;
Create appointment times that accommodate
motivational interviews
Get proper training (consult resources)
Practice with your colleagues (see role play)
62
Motivational Interviewing in a
Brief Office Intervention
63
The BNI-ART Institute
Brief Negotiated Interview and
Active Referral to Treatment
Boston, Massachusetts
Co-Directors:
Edward Bernstein, MD; Judith
Bernstein, RNC, PhD
64
Excellent Resource for SA MI

Brief Negotiated Interview and Active
Referral to Treatment (BNI ART
Institute)

http://www.ed.bmc.org/sbirt/
– Information
– Video clips
– Printable handouts for students
65
The Brief Negotiation Interview
• establish rapport & ask permission to raise subject
• provide feedback about norms
• enhance motivation
• explore pros and cons
• assess readiness to change, resilience & assets,
discrepancies between actual state & goals
• develop action plan, using strengths/resources
1
2
3
4
5
6
7
8
9
10
The BNI for Adolescents:
Using decisional balance
tools, CRAFFT, and
negotiating an action plan
video
67
Resources
http://www.motivationalinterview.org/clinical/
 One-stop shop
 Resources for clinicians, researchers and
trainers
 provide background information on the
practice of Motivational Interviewing, its
applications to special populations
 Non-English speaking materials
68
Resources cont.
Enhancing Motivation For Change in
Substance Abuse Treatment (TIP 35)
 Developed by William Miller, PhD and
Steve Rollnick, PhD
 First edition available free from
www.samhsa.gov
 Second edition Motivational
Interviewing, Preparing People for
Change
69
Resource for Substance Abuse
Brief Negotiated Interview and Active Referral
to Treatment (BNI ART Institute)

http://www.ed.bmc.org/sbirt
– Screening, brief intervention and referral to
treatment (SBIRT) toolkit
– Instruction on BNI
– Video clips
– Printable handouts
– Training opportunities
– Technical assistance and consultation
70
Resource for Obesity


School Nurses, School-Based Health Centers
and Childhood Overweight:
A report from a roundtable meeting to explore
the role of school health professionals in
preventing childhood overweight
www.healthinschools.org/Health-inSchools/Health-Services/Schools-andChildhood-Overweight/School-Nurses.aspx
– Recommendations
– Barriers
– Sample programs
71
Contact Information
Margaret Perlia Bavis, DNP, FNP
Instructor, Community and Mental Health Nursing
Rush University College of Nursing
Margaret_A_Bavis@rush.edu
Sue Murray, MPH, RN
Program Consultant
Illinois Coalition of School Health Centers
smurray@ilmaternal.org
72
Case Example and Role Play:
Motivational Interviewing – Obesity
73
Obesity Case Example

Sarah is a 14 year old 9th grade student who has come
to the school-based health center for a comprehensive
risk assessment. Sarah is obese and at risk for Type II
Diabetes (family history). She has a history of
overeating and reports that she does not engage in any
physical activity. She gets short of breath when walking
up stairs between classes, and feels embarrassed to
go to a gym or to participate in group sports even
though she would like to lose weight. Her family and
friends often eat at fast food restaurants, and she
usually goes with them and eats unhealthy meals.
Sarah has tried to diet, but her diets have not lasted
longer than about a week.

Practice a motivational interview with Sarah focused on
improving her motivation to change behaviors
associated with obesity – e.g., overeating, lack of
activity, eating fast food.
74