Melanie Bunn, RN, MS, GNP melanie.bunn@yahoo.com
Geriatric Grand Challenge Institute: Dementia Care
Duke University School of Nursing
March, 2013

Demonstrate motivational interviewing & discuss how it helps older adults make lifestyle changes that can modify risk factors for dementia

Christensen AJ. Patient adherence to medical treatment regimens: bridging the gap between behavioral science and biomedicine . New Haven: Yale University
Press; 2004. Current perspectives in psychology.

not
• Don’t know wha t to do
• Don’t know how to do it
• Don’t know why it’s important
• Don’t believe they can
4

The dilemma…
• How can we help our clients change…
• Because they want to change…
• Not because you want them to change?
• Or…how do we MOTIVATE change?

• “a directive, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence”
Rollnick S, Miller WR. What is motivational interviewing? Behavioural and cognitive psychotherapy 1995;23(4):325-34
– FIRST : find out what is important to the client
– THEN : Use this to motivate the client to change
• A method to help people change for themselves
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• Motivational interviewing was developed to help individuals
– Change health behaviors (prevention)
– Manage chronic diseases (compliance)
– Deal with substance abuse
• But the approach can work with other behaviors and with teams (and students)

• Short, 10-20 minutes
• Because
– people know how to solve their own problems
– people prefer to solve their own problems
– their solutions are more likely to work
– provides individualized strategies
– promotes buy-in

Behavioral change as a process
Five stages
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy 1982;19(3):279-88.

• Not 1-2-3-4-5
• Relapse
• Times of motivation
• Other influences (for better or worse)

• Tell them what to do…expect them to do it
• Tell them what to do…don’t expect them to do it
• Threaten
• Reward
• Encourage
• Scare tactics
• Bribe

• List 3 health behaviors that YOU would like to work on:
1.
2.
3.

• Find a partner
• Choose an A and a B person
• A person: tell the B person what your health behavior is
• B person: in 30 seconds, tell the A person what to do to improve this behavior, be directive
• Reverse roles, repeat

• Client is in the driving seat
• Promote motivation by asking probing questions that allows clients discover for themselves the reasons for their habits
• Give suggestions only when asked and as infrequently as possible
• Share personal experiences that are relevant to the situation to establish rapport and trust

• Avoid arguing, even when you strongly disagree
• Clients will be at different stages of being ready to change – accept level of readiness for making a change this time
• Avoid being judgmental – accept reasons for not making a change in their habits

People change because they want to
NOT because you want them to

• Knowledge alone does not usually lead to change
• How many of you know…
• How many of you do…
• People also need to become motivated to change

Adapted from Levensky et all

• Express empathy
• Develop a discrepancy
• Roll with resistance
• Support self efficacy

• Understands and accepts experience… including ambivalence about change
• Different from sympathy or telling your own story

• Enhance awareness of inconsistencies between behavior and goals and values
• Motivate change
• Facilitate…don’t identify

• Don’t directly oppose resistance
• Invite, not impose, new perspectives

• Belief that the person is able to do this
• Confidence in Competence!!!

• The first step is to create a partnership
• Trustful partnerships are created by:
– Listening
– Asking questions

• Listening actively
• Asking open questions
• Affirming
• Summarizing

Clarify  “Could you explain that more?”
Restate  “What you are saying is….”
Remain neutral  nod, “uh- huh..”
Reflect  “It sounds like….”
Affirm  “I think this is a plan you can achieve”
Summarize  “So, the problem is…”

• Go back to your partner
• A person: take 1 minute to tell the B person what you’d like to change, why you’d like to change and why it’s difficult
• B person: listen, but engage in other activities (email, notebook)
• Reverse roles, repeat

• Closed ended questions
• Open ended questions
• A key to effective MI is getting people to think more deeply about behaviors and choices.
• This can be done by asking open ended questions.

• Question that allows many responses
• Invites a story/ explanation
• There is no “one – word” answer (which would be closed-ended)
• Encourages communication

Practice question skills:
Change these to Open Ended Questions
• Did you smoke this week?
• Don’t you want to lose weight?
• Will it be hard to take your medications like the doctor ordered?
• Don’t you know you’re not supposed to eat that salt?
• Did you do your exercises?
• Do you want to get sick and die?
• Did you take your medications like you’re suppose to?
• You didn’t drink any alcohol this week, did you?
• Do you want to be a burden to your children?

• Seem accusatory
• Resulting in defensiveness
• Leading to strengthening of positions
• Break down in communication

• Recognize strengths, abilities, efforts
• Must be sincere, adult, accurate, believable
• Builds confidence and enthusiasm

• Use when the person finishes to make sure you understand and the person knows you understand
• Helpful for transitions
• Keep it short
• Ask for confirmation of your understanding

• Go back to your partner
• A person: take 1 minute to tell the B person what you’d like to change, why you’d like to change and why it’s difficult
• B person: use active listening, open ended questions, affirming & summarizing
• Reverse roles, repeat

• Willing
• Able
• Ready

• Are you interested in changing? Why?
• What do you want to change?
• How important is it to you to change?
– Are you happy where you’re at and have no interest in change? OR
– Are you torn between wanting to change and staying the same (“on the fence”)? OR
– Is your desire to change strong enough for you to start taking action?

How WILLING Am I to Make the Change
Needed to Achieve My Goal?
Behavior:
Reasons I have for Not Changing
What benefits am I getting by staying the same, not changing?
Reasons I have for Changing
What is the worst outcome I can imagine if I don’t change?
What are my fears about changing?
What would my life be like if a miracle happened and I was able to change tomorrow (benefits of change)?

How WILLING are You to Change?
The ruler of change
• On a scale of 0 to 10, how strong are the reasons you gave on the left side of the Decision Balance chart for not changing?
0
Very weak
1 2 3 4 5 6 7 8 9 10
Very Strong
• On a scale of 0 to 10, how strong are the reasons you gave on the right side of the chart for changing?
0
Very weak
1 2 3 4 5 6 7 8 9 10
Very Strong

Are your reasons for staying the same stronger than your reasons for changing?
• If so, you’re not quite willing to change.
• What is your role with people who are not thinking about change?
• Help them increase their motivation and/or decrease their resistance so they start thinking more about making a change
• Ask,
• What would it take to reduce your reasons for staying the same?
• What would it take for you to increase your reasons for changing?

Are your reasons for staying the same about the same as your reasons for changing?
• If so, you are thinking about change but are split between taking action and staying the same
• When you’re “on the fence” like this, its hard to take action
• What’s your role with people who are “on the fence”?
Ask questions to help them increase their motivation and/or decrease their resistance so they can get over the fence to the side of taking action

Are your reasons for changing greater than your reasons for staying the same ?
• If so, you are not only thinking about making a change but you are willing to prepare and take some action to make a change.
• What is your role with people who are ready to take action?
• Take the next step
• Are you ABLE?

• Do you have what it takes to change?
– Ability?
– Confidence?
• Can you overcome the barriers and setbacks that can make it difficult to change?

ABLE - Assessing your confidence and ability to achieve your goal
Understanding your confidence and ability can help you:
• Redefine your goals if your sense of confidence and ability is low (such as, start with smaller goals)
• Start thinking about what it would take to increase your confidence or your ability to change.

ABLE : Confidence and Ability
• Score your confidence, from 1 to 10, to make a change
0
None
1 2 3 4 5
Low Medium
6 7 8 9 10
Very High
• Score your ability to make change.
0
None
1 2 3 4 5
Low Medium
6 7 8 9 10
Very High

Increasing your confidence & ability to change
Increase your motivation by asking questions – evoking change talk:
• Ask yourself,
“What would it take to increase my confidence to make this change (the change being eating smarter, moving more, stop smoking, etc )?”
• Ask yourself,
“What would it take to increase my ability to make this change?”

• People with high confidence and a high sense of their ability to make the change
• More likely to occur when external supports are there to help people change.
• Ask questions that can uncover these supports.

• Questions that help you define the supports
– What encourages you to believe that you can change?
– What else would help you change?
– Who else would help you change?
• You are one of the most important supports
– You can give people a higher sense of confidence and ability and encourage their optimism .

If you are willing and able,
• How will you do it? Do you have a plan?
• Can you “troubleshoot” as your plan unfolds?
– Are you prepared with alternate plans if barriers and obstacles arise that can cause setbacks?
– Are you prepared to monitor your progress in completing the steps in your plan?

• Setting goals and making plans for action
• Being prepared for dealing with setbacks

Set and plan a goal – SMART method
• If you are Willing and Able, you are Ready to take the actions needed to make your goal.
• But to create success, define a goal in a way that is S pecific, can be
M easured, is A ction oriented, is R ealistic, and is set in a specific T ime frame.

What’s wrong with the following goals?
• “I will start walking.”
• “I’ll put down exercise as my New Year’s resolution.”
• “I will swim an hour everyday.”
• “I will start exercising when it gets warm.”
• “I will be more active.”
• “I’ll run in a marathon next spring.”
• “I’ll buy an exercise bike.”
• “Soon I’ll start a walking program.”
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Set and plan a goal – SMART method
• If you use the SMART method to set your goals, it will increase the chances that you will achieve them .
o S pecific o M easurable o A ction oriented o R ealistic o T ime focused

• Diabetes
• Hypertension
• Coronary artery disease
• Sleep apnea
• Depression
• Smoking
• Nutrition
• Exercise
• Medication compliance
• Use of devices
• Monitoring

How WILLING Am I to Make the Change
Needed to Achieve My Goal?
Behavior:
Reasons I have for Not Changing
What benefits am I getting by staying the same, not changing?
Reasons I have for Changing
What is the worst outcome I can imagine if I don’t change?
What are my fears about changing?
What would my life be like if a miracle happened and I was able to change tomorrow (benefits of change)?

How WILLING are You to Change?
The ruler of change
• On a scale of 0 to 10, how strong are the reasons you gave on the left side of the Decision Balance chart for not changing?
0
Very weak
1 2 3 4 5 6 7 8 9 10
Very Strong
• On a scale of 0 to 10, how strong are the reasons you gave on the right side of the chart for changing?
0
Very weak
1 2 3 4 5 6 7 8 9 10
Very Strong

ABLE : Confidence and Ability
• Score your confidence, from 1 to 10, to make a change
0
None
1 2 3 4 5
Low Medium
6 7 8 9 10
Very High
• Score your ability to make change.
0
None
1 2 3 4 5
Low Medium
6 7 8 9 10
Very High

Set and plan a goal – SMART method
• If you use the SMART method to set your goals, it will increase the chances that you will achieve them .
o S pecific o M easurable o A ction oriented o R ealistic o T ime focused

• After taking action and beginning to change a habit, setbacks will occur
• Lapses and relapses are natural parts of the change process
• The key to staying motivated is to view setbacks as learning experiences, not as failures

• Setbacks are not failures
• You can help people acquire this attitude
• A Progress Check can be helpful in identifying setbacks and learning from them

• My goal was_____________
• I was______ successful in reaching my goal
• What helped______________
• ______________was difficult
• I learned that________________

READY - Staying Ready &
Motivated
• When you make your goal,…
Don’t Forget to Reward Yourself!!!
• A reward provides an incentive to stay motivated.
• Try the “when…then”
• Add note: the reward shouldn’t sabotage your goal!!!
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• Always include in your plan
• Provide encouragement for any change in the right direction, even if people fall short of the goal
• Focus on sense of control and success

• What do you know?
• This is what I know
• What do you think or feel?

• Confrontation (leader gives reasons or suggestions, client counters)
• Question-answer (leader asks serial questions with client giving short answers)
• Expert trap (leader gives direction, advice, client responds passively)
• Premature focus (leader’s priority)

• Motivation and Emotion come from the same Latin word MOVERE meaning “to move”
• We’ MOVING towards being better!!! Not perfect!!!

• https://www.miclab.org/sites/default/files/i mages/Lundahl2010%20Meta-analysis.pdf
• Miller WR, Rollnick S, editors. Motivational interviewing: preparing people for change.
2nd ed. New York: Guilford Press; 2002
• Levensky ER, Forcehimes A, O’Donohue
WT &Beitz K. Motivational Interviewing.
AJN 2007; 107(10): 50-58
( http://www.nursingcenter.com/pdf.asp
?AID=744988_)