motivational interviewing

1. Motivational Interviewing Suzanna Theodoras, RN, CDE Ohio University, College of Osteopathic Medicine Cornwell Diabetes Center Education Program 740-566-4872 theodors@ohio.edu MI has recently become a topic of interest and articles have been written in various diabetes publications.MI has recently become a topic of interest and articles have been written in various diabetes publications.

2. Motivational Interviewing MI is an approach to health behavior change consultation that employs high-quality listening to discuss the why�s and how�s of change, with the goal of increasing the clients� readiness for and commitment to the adoption of a healthier lifestyle. More simply: Encouraging people to resolve their ambivalence about changing their behavior, while not evoking their resistance. Diabetes Spectrum, Volume 19, Number 1, 2006 This is the article that sparked my interest in learning more about MI. I thought of my years in Psych Nursing before Diabetes Education and this sounded like some of the principles we were using in the late 70�s and early 80�s. I worked in the 2nd Stress Management Unit in the US. Clients came to Ochsner Hospital in New Orleans and spent 4 to 6 weeks with us to learn how to make changes in their lifestyle in hopes they would better manage their stressful lives and avoid many of the health problems some were already experiencing. Now of course there are no inpatient Stress Units, that I am aware of, due to Medical Insurances denying coverage. From this background, you can see how this article sparked my attention and so I began to read, not only this article, but many more. Ellen Peterson encouraged Dr. Schwartz to ask me to share some of my interest and enthusiasm as I pursued more information about MI. I am not trained in MI nor am I an expert. I am just here to share some information and some ideas that I have discovered in my MI journey. This is the article that sparked my interest in learning more about MI. I thought of my years in Psych Nursing before Diabetes Education and this sounded like some of the principles we were using in the late 70�s and early 80�s. I worked in the 2nd Stress Management Unit in the US. Clients came to Ochsner Hospital in New Orleans and spent 4 to 6 weeks with us to learn how to make changes in their lifestyle in hopes they would better manage their stressful lives and avoid many of the health problems some were already experiencing. Now of course there are no inpatient Stress Units, that I am aware of, due to Medical Insurances denying coverage. From this background, you can see how this article sparked my attention and so I began to read, not only this article, but many more. Ellen Peterson encouraged Dr. Schwartz to ask me to share some of my interest and enthusiasm as I pursued more information about MI. I am not trained in MI nor am I an expert. I am just here to share some information and some ideas that I have discovered in my MI journey.

3. �Motivational Interviewing: Research Practice and Puzzles� �Foremost in my own mind is the fundamental question of why this approach works at all. . . How could it possibly be that a session or two of asking clients to verbalize their own suffering and reasons for change would unstick a behavior pattern that has been so persistent? What is going on here?� Miller-1996 MI began in the early 1980�s by William (or Bill) Miller In 1996 he wrote an article (Motivational Interviewing: research practice, and puzzles) expressing bewilderment as to why motivational interviewing seems to be so effective in promoting behavior change: �Foremost in my own mind is the fundamental question of why this approach works at all�.How could it possibly be that a session or two of asking clients to verbalize their own suffering and reasons for change would unstick a behavior pattern that has been so persistent?....What is going on here?� Miller-1996, p 840 MI began in the early 1980�s by William (or Bill) Miller In 1996 he wrote an article (Motivational Interviewing: research practice, and puzzles) expressing bewilderment as to why motivational interviewing seems to be so effective in promoting behavior change: �Foremost in my own mind is the fundamental question of why this approach works at all�.How could it possibly be that a session or two of asking clients to verbalize their own suffering and reasons for change would unstick a behavior pattern that has been so persistent?....What is going on here?� Miller-1996, p 840

4. Motivational Psychology The underlying principle is that people will make the most long-lasting behavior change when their motivation is internal rather than external. Working with people to change alcohol and other drug use habits, Miller found that persons were more likely to make lasting changes when they reached the decision themselves rather than through force or coercion. According to Miller the role of the therapist is to release the potential for change that exists within each person. The therapist does this by approaching the client as an ally, to free them from ambivalence that has trapped them in a cycle of alcohol and other drug dependency. No matter what the problem or situation, MI helps clients establish action plans to reach their goals.Working with people to change alcohol and other drug use habits, Miller found that persons were more likely to make lasting changes when they reached the decision themselves rather than through force or coercion. According to Miller the role of the therapist is to release the potential for change that exists within each person. The therapist does this by approaching the client as an ally, to free them from ambivalence that has trapped them in a cycle of alcohol and other drug dependency. No matter what the problem or situation, MI helps clients establish action plans to reach their goals.

5. Motivational Interviewing An amalgam of philosophies, principles and techniques drawn from several existing models. Carl Rogers and his �Force of Life� Bem�s Self-Perception Theory Janis and Mann�s Decisional Balance Theory Prochaska�s Transtheoretical Model Empowerment Model Handbook��Motivational Interviewing: Preparing People for Change� provides more detail of the theoretical background Over the years MI has become an amalgam of different philosophies, principles and techniques drawn from a variety of sources. Each article I have read gives a little different slant or possible use for MI. There is also some differences in technique from institution to institution.Over the years MI has become an amalgam of different philosophies, principles and techniques drawn from a variety of sources. Each article I have read gives a little different slant or possible use for MI. There is also some differences in technique from institution to institution.

6. Motivational Interviewing Network of Trainers (MINT) Founded in 1995 www.motivationalinterviewing.org The Motivational Interviewing Network of Trainers (MINT) was first started back in the �80 but was actually officially founded in 1995. www.motivationalinterviewing.org is an interesting website. It is full of information about training and uses of MI with costs varying from $150 to $1,000. Opportunities for training all over the world. I would like to volunteer to study in Greece or Paris. The Motivational Interviewing Network of Trainers (MINT) was first started back in the �80 but was actually officially founded in 1995. www.motivationalinterviewing.org is an interesting website. It is full of information about training and uses of MI with costs varying from $150 to $1,000. Opportunities for training all over the world. I would like to volunteer to study in Greece or Paris.

7. Motivational Interviewing Client-centered counseling style. Elicits behavior change by helping clients explore and resolve their ambivalence. Help clients recognize the discrepancy between their current behavior and their desired goal. Empathic listening minimizes their resistance. Sobell & Sobell 2003 The effectiveness of using MI comes from the client rather than the HCP The HCP helps the client explore and resolve their ambivalence about changing their behavior.. The client decides on his/her own course of treatment, so therefore the outcome of the treatment is more meaningful to him/her. The underlying principle is that clients will make the most long-lasting behavior changes when their motivation is internal rather than external.The effectiveness of using MI comes from the client rather than the HCP The HCP helps the client explore and resolve their ambivalence about changing their behavior.. The client decides on his/her own course of treatment, so therefore the outcome of the treatment is more meaningful to him/her. The underlying principle is that clients will make the most long-lasting behavior changes when their motivation is internal rather than external.

8. Motivational Interviewing Model of Change Prochaska and DiClemente�s Precontemplation �What problem?� Contemplation � Should I change?� Decision/Preparation �Can I change?� Action �How do I change?� Maintenance �Is it worth it?� Relapse Prochaska & DiClemente, J Consult & Clin Psychol, 1983 MI helps the client move from precontemplation to action. MI tries to establish first of all, whether the client is ready for change. Clients may recognize a problem but still feel ambivalent about changing that behavior. MI is tool to help the client decide whether change is what they truly desire, what this change would entail, and how to go about making this change. Precontemplation�person does not realize he/she has a problem and does not consider making a change related to that situation. Contemplation�is characterized by ambivalence; change is being considered at the same time it is being rejected. Preparation�a person decides he/she needs to make a change and expresses his or her readiness to make a change. Action stage follows in which the behavioral changes are in progress. Maintenance stage in which the individual maintains the behavioral change. The client moves from being unaware or resistant to change, to considering the prospect of change, to becoming ready or prepared to make the change, to taking action and sustaining the change. A person can spiral back and forth through the stages; it is not strictly a forward moving process. Prochaska & DiClemente, J Consult & Clin Psychol, 1983 MI helps the client move from precontemplation to action. MI tries to establish first of all, whether the client is ready for change. Clients may recognize a problem but still feel ambivalent about changing that behavior. MI is tool to help the client decide whether change is what they truly desire, what this change would entail, and how to go about making this change. Precontemplation�person does not realize he/she has a problem and does not consider making a change related to that situation. Contemplation�is characterized by ambivalence; change is being considered at the same time it is being rejected. Preparation�a person decides he/she needs to make a change and expresses his or her readiness to make a change. Action stage follows in which the behavioral changes are in progress. Maintenance stage in which the individual maintains the behavioral change. The client moves from being unaware or resistant to change, to considering the prospect of change, to becoming ready or prepared to make the change, to taking action and sustaining the change. A person can spiral back and forth through the stages; it is not strictly a forward moving process. Prochaska & DiClemente, J Consult & Clin Psychol, 1983

9. Daniel D.Squires and Theresa B Moyers University of New Mexico, Albuquerque, New Mexico I found this figure in one of the articles I read and I liked the visual.I found this figure in one of the articles I read and I liked the visual.

10. The reason I like this diagram better than some I ran across, is it shows that change is not always a smooth revolution around the various stages. This �wheel� may be out of balance or have bumps in it so that it does not rotate nice and smooth. It shows reality in that clients can have the best intentions but something in their life interferes with the cycle and they exit and return to a previous stage or even all the way back to the beginning�precontemplation.The reason I like this diagram better than some I ran across, is it shows that change is not always a smooth revolution around the various stages. This �wheel� may be out of balance or have bumps in it so that it does not rotate nice and smooth. It shows reality in that clients can have the best intentions but something in their life interferes with the cycle and they exit and return to a previous stage or even all the way back to the beginning�precontemplation.

11. Motivational Interviewing and Diabetes Motivational Interviewing (MI) is a counseling approach that is: Non-confrontational Practical Focus Problem solving Goal setting Clients identify behavior they would like to change List benefits of the change Discuss difficulties in making that change Set Realistic goals Motivation interviewing is a counseling approach, originally developed in the alcohol addiction field, which aims to help clients with behavior change. The style of questioning is non-confrontational and the method has a practical focus, using the techniques of problem solving and goal setting from cognitive-behavioral approaches. The client is encouraged to identify aspects of their behavior related to their condition that they would like to change and to articulate the benefits and difficulties of making that change. The clinician�s role is to facilitate this process, help the client think of ways to overcome the difficulties, and set realistic goals for change in their behavior The session is client-centered and they do most of the talking�not the HCP�not us. I am sure a lot of you are doing just this in your daily contact with your clients. But, it still might be a good idea to be reminded of these principles occasionally as we face the �10 Content Areas� that the ADA says we have to cover to stay recognized and the AADE 7�self care behaviors to cover. The next client has already arrived early and is in the waiting area. There�s that important meeting this afternoon that you have to prepare for and of course there�s the evening class you are teaching tonight. Many things are going on and there are many demands for our time and energy�so perhaps we need to think about MI as another tool or skill and how it can help not only our clients but us as well. Motivation interviewing is a counseling approach, originally developed in the alcohol addiction field, which aims to help clients with behavior change. The style of questioning is non-confrontational and the method has a practical focus, using the techniques of problem solving and goal setting from cognitive-behavioral approaches. The client is encouraged to identify aspects of their behavior related to their condition that they would like to change and to articulate the benefits and difficulties of making that change. The clinician�s role is to facilitate this process, help the client think of ways to overcome the difficulties, and set realistic goals for change in their behavior The session is client-centered and they do most of the talking�not the HCP�not us. I am sure a lot of you are doing just this in your daily contact with your clients. But, it still might be a good idea to be reminded of these principles occasionally as we face the �10 Content Areas� that the ADA says we have to cover to stay recognized and the AADE 7�self care behaviors to cover. The next client has already arrived early and is in the waiting area. There�s that important meeting this afternoon that you have to prepare for and of course there�s the evening class you are teaching tonight. Many things are going on and there are many demands for our time and energy�so perhaps we need to think about MI as another tool or skill and how it can help not only our clients but us as well.

12. Motivational Interviewing HCP�s feel responsible for �fixing� Carry-over from acute care model Unrealistic for the chronic care model Use of direct questioning, active persuasion, or advice-giving from �the top down� has proven to be of limited effectiveness in the long term management of chronic illnesses. Face-to-face agreement but weak follow-through Motor boat response��Yes, but. . .�, �Yes, but. . .�, �Yes, but. . .� HCP�s feel responsible for fixing a problem or situation. It is a carry-over from acute care model, but is totally unrealistic for the chronic care model we now find ourselves facing. Use of direct questioning, active persuasion, or advice-giving from �the top down� has proven to be of limited effectiveness in the long term management of chronic illnesses. You receive face-to-face agreement, a lot of head nodding during your session, but see weak follow-through once the client goes home from the session or class. Some give what I call the Motor boat response��Yes, but. . .�, �Yes, but. . .�, �Yes, but. . .� Always a reason they cannot follow up on the advice given. HCP�s feel responsible for fixing a problem or situation. It is a carry-over from acute care model, but is totally unrealistic for the chronic care model we now find ourselves facing. Use of direct questioning, active persuasion, or advice-giving from �the top down� has proven to be of limited effectiveness in the long term management of chronic illnesses. You receive face-to-face agreement, a lot of head nodding during your session, but see weak follow-through once the client goes home from the session or class. Some give what I call the Motor boat response��Yes, but. . .�, �Yes, but. . .�, �Yes, but. . .� Always a reason they cannot follow up on the advice given.

13. The Spirit of Motivational Interviewing Empower and collaborate with our clients A dual expertise � �Let�s put our heads together and look at the options.� Support and respect for the client�s autonomy and problem-solving capabilities. Elicit �change talk� from the client regarding behavior change and goal. MI promotes practitioner-patient collaboration and sharing of power. The concept of �Dual Expertise� is used. The practitioner is the expert in medical care and education while the client is the expert in the whys and hows of their own behavior. For the most part we work with adults that have lived long and productive lives. They have problem-solving skills they have used many times over the years. We want to help them tap into those skills for whatever behavior changes they want to make. One perceived barrier to the use of a dual-expertise relationship is lack of time. Busy and under time-constraints we often fear that collaboration and empowerment will take too much time. Furthermore, there is a pervasive fear among HCP�s that to ask an open-ended question is to initiate a runaway conversation or open a Pandora�s box of problems. Those experienced in the MI counseling style have found that patients typically need only 3-4 minutes of good active listening to communicate their concerns regarding a target behavior and that the act of talking about their health often strengthens their motivation to change.MI promotes practitioner-patient collaboration and sharing of power. The concept of �Dual Expertise� is used. The practitioner is the expert in medical care and education while the client is the expert in the whys and hows of their own behavior. For the most part we work with adults that have lived long and productive lives. They have problem-solving skills they have used many times over the years. We want to help them tap into those skills for whatever behavior changes they want to make. One perceived barrier to the use of a dual-expertise relationship is lack of time. Busy and under time-constraints we often fear that collaboration and empowerment will take too much time. Furthermore, there is a pervasive fear among HCP�s that to ask an open-ended question is to initiate a runaway conversation or open a Pandora�s box of problems. Those experienced in the MI counseling style have found that patients typically need only 3-4 minutes of good active listening to communicate their concerns regarding a target behavior and that the act of talking about their health often strengthens their motivation to change.

14. Key Elements of Motivational Interviewing Express empathy Use Reflective Listening Develop discrepancy Avoid arguing Roll with resistance Support self-efficacy or empowering All of the articles I read listed these key elements of MI. All of the articles I read listed these key elements of MI.

15. Motivational Interviewing1. Expressing Empathy Expressing empathy is the key to building rapport with clients. Accept people as they are and where they are. Recognize ambivalence to change is normal and consistent with reality. Encourage their positive self-motivational statements. Expressing empathy is the key to building rapport with clients. It is best accomplished through reflective listening and acceptance. Accepting clients where they are is not always as easy as it sound. We need to recognize that their ambivalence to change is normal and consistent with reality. We experience that ourselves each day in some new policy at work or some new demand for our time. We all need to be encouraged in our positive self-motivational statements.Expressing empathy is the key to building rapport with clients. It is best accomplished through reflective listening and acceptance. Accepting clients where they are is not always as easy as it sound. We need to recognize that their ambivalence to change is normal and consistent with reality. We experience that ourselves each day in some new policy at work or some new demand for our time. We all need to be encouraged in our positive self-motivational statements.

16. Motivational Interviewing1. Expressing Empathy Seek permission before asking a question, before giving information, or before giving advice. �Do you mind if I ask . . . .� �May I share some information. . . .� �With your permission I would like to . . . .� Asking permission shows respect. Establishes a safe environment.  Asking permission is similar to knocking on the door before entering a room with a closed door. It communicates respect for and acceptance of clients and their feelings. �Do you mind if I ask . . . .� �May I share some information. . . .� �With you permission I would like to suggest. . . .� It shows respect. It establishes a safe environment for the client It compliments rather than denigrates. Asking permission is similar to knocking on the door before entering a room with a closed door. It communicates respect for and acceptance of clients and their feelings. �Do you mind if I ask . . . .� �May I share some information. . . .� �With you permission I would like to suggest. . . .� It shows respect. It establishes a safe environment for the client It compliments rather than denigrates.

17. Motivational Interviewing 2. Reflective Listening Use Reflective listening to: Understand the client�s perspective and let them know you are truly listening to them. Emphasize the client�s positive statements about changing so they hear their positive statements twice�once themselves and once from the HCP. Diffuse resistance. Reflective listening is truly listening. It is giving all of your concentration and attention to the client. It encourages you to emphasize the client�s positive statements about changing so they hear their positive statements twice�once from themselves and once from you, the HCP. You know the more we hear things the more we believe them true. MI gently persuades with the understanding that change is up to the client. Recognizes each client�s unique perspective, feelings, and values�help diffuse resistance. Reflective listening is truly listening. It is giving all of your concentration and attention to the client. It encourages you to emphasize the client�s positive statements about changing so they hear their positive statements twice�once from themselves and once from you, the HCP. You know the more we hear things the more we believe them true. MI gently persuades with the understanding that change is up to the client. Recognizes each client�s unique perspective, feelings, and values�help diffuse resistance.

18. Motivational Interviewing 2. Reflective Listening Simple�reflects exactly what was heard Double-sided�reflects both sides by pointing out ambivalence Amplified�heightens the resistance that is heard Self-motivational statements�client tells how they are changing Affirm�support, encourage, recognize client�s difficulties Summary Statement�pulls together comments made and transitions to the next topic Reflective Listening is an umbrella term that has many spokes. Simple: C: I don�t want to quit smoking. T: You don�t think quitting will work for you? Double: C: No question my kids come first. I wait until I put them to bed before I smoke in the house. T: So on one hand you are clear that your kids are important to you and they come first, but on the other hand you are still smoking in the house where they are sleeping. Amplified: C: I could quit, but what would my friends think? T: It sounds like there would be a lot of pressure from your friends if you tried to stop. S-M: C. I was smoking 2 packs a day, but now I am down to 1 pack a day. T: Sounds like you have made real progress. How do you feel about that? Affirm: C: I am still smoking one pack a day. T: It sounds like you are really struggling with quitting. How do you think you might reduce your smoking even further? Summary: T: You have mentioned a number of things about your current lifestyle and the stress you feel. You spoke of having little energy for doing some of the things you use to like to do. What do you think might help you get back to doing some of those things you once enjoyed.? Reflective Listening is an umbrella term that has many spokes. Simple: C: I don�t want to quit smoking. T: You don�t think quitting will work for you? Double: C: No question my kids come first. I wait until I put them to bed before I smoke in the house. T: So on one hand you are clear that your kids are important to you and they come first, but on the other hand you are still smoking in the house where they are sleeping. Amplified: C: I could quit, but what would my friends think? T: It sounds like there would be a lot of pressure from your friends if you tried to stop. S-M: C. I was smoking 2 packs a day, but now I am down to 1 pack a day. T: Sounds like you have made real progress. How do you feel about that? Affirm: C: I am still smoking one pack a day. T: It sounds like you are really struggling with quitting. How do you think you might reduce your smoking even further? Summary: T: You have mentioned a number of things about your current lifestyle and the stress you feel. You spoke of having little energy for doing some of the things you use to like to do. What do you think might help you get back to doing some of those things you once enjoyed.?

19. Motivational Interviewing 2. Reflective Listening Repeating Rephrasing Empathic reflection Reframing Feeling reflection Amplified reflection Double-sided reflection Author Belinda Borrelli, Phd, MA Dr. Borrelli lists 7 different types of Reflective Listening in her Medscape CME/CE program. Repeating: is the simplest form of reflection, often used to diffuse resistance. �I don�t want to quit smoking.� HCP: You don�t want to quit smoking. Rephrasing: Slightly alter what the client says to provide the client with a different point of view. �I really want to quit smoking.� HCP: Quitting smoking is important to you. Empathic reflection provides understanding for the client�s situation. �What do you know about quitting? You probably never smoked.� HCP: It�s hard for you to imagine how I could possible understand.� Reframing�much as a painting can look completely different depending upon the frame put around it, reframing helps patients think about their situation differently. �I�ve tried to quit and failed so many times.� HCP: You are persistent, even in the face of discouragement. This change must be really important to you. Feeling reflection�reflects the emotional undertones of the conversation. �I�ve been considering quitting for some time now because I know it is bad for my health.� HCP: You�re worried about your health. Amplified�reflects what the client has said in an exaggerated way. This encourages client to argue less and can elicit the other side of the client�s ambivalence. �My smoking isn�t that bad.� HCP: There�s no reason for you to be concerned about your smoking. (Genuine-no sarcasm) Double-sided�acknowledge both sides of the patient�s ambivalence. �Smoking helps me reduce stress.� HCP: On the one hand, smoking helps you reduce stress. On the other hand, you said previously that it also causes you stress because you have a cough, have to go outside to smoke, and you spend money on cigarettes. Author Belinda Borrelli, Phd, MA Dr. Borrelli lists 7 different types of Reflective Listening in her Medscape CME/CE program. Repeating: is the simplest form of reflection, often used to diffuse resistance. �I don�t want to quit smoking.� HCP: You don�t want to quit smoking. Rephrasing: Slightly alter what the client says to provide the client with a different point of view. �I really want to quit smoking.� HCP: Quitting smoking is important to you. Empathic reflection provides understanding for the client�s situation. �What do you know about quitting? You probably never smoked.� HCP: It�s hard for you to imagine how I could possible understand.� Reframing�much as a painting can look completely different depending upon the frame put around it, reframing helps patients think about their situation differently. �I�ve tried to quit and failed so many times.� HCP: You are persistent, even in the face of discouragement. This change must be really important to you. Feeling reflection�reflects the emotional undertones of the conversation. �I�ve been considering quitting for some time now because I know it is bad for my health.� HCP: You�re worried about your health. Amplified�reflects what the client has said in an exaggerated way. This encourages client to argue less and can elicit the other side of the client�s ambivalence. �My smoking isn�t that bad.� HCP: There�s no reason for you to be concerned about your smoking. (Genuine-no sarcasm) Double-sided�acknowledge both sides of the patient�s ambivalence. �Smoking helps me reduce stress.� HCP: On the one hand, smoking helps you reduce stress. On the other hand, you said previously that it also causes you stress because you have a cough, have to go outside to smoke, and you spend money on cigarettes.

20. Motivational Interviewing 2. Reflective Listening Summary Statement Longer than a reflection. Used mid-session to transition. Highlight both sides of client�s ambivalence. Recap major points to end session. Belinda Borrelli, Phd, MA

21. Motivational Interviewing 3. Develop Discrepancy Motivation for change is created when people perceive a discrepancy between their present behavior and an important personal goal. Where do you want to be? Where are you currently? When do you want to be there? With effective listening and communication skills the HCP helps the client understand his/her ambivalence regarding change. Identifying the discrepancy between current behavior and personal goals pushes HEALTHINESS further up the list of daily priorities. Identifying the discrepancy helps open up the conversation about change. Everyone has conflicting feelings about changing familiar routines or habits. From the MI perspective, the goal is to understand and facilitate resolution of the client�s ambivalence in the direction of a healthier lifestyle. Helping clients clarify their own goals and values related to that behavior will increase their readiness to change. Where do you want to be? Where are you currently? When do you want to be there? Identifying the discrepancy between current behavior and personal goals pushes HEALTHINESS further up the list of daily priorities. Identifying the discrepancy helps open up the conversation about change. Everyone has conflicting feelings about changing familiar routines or habits. From the MI perspective, the goal is to understand and facilitate resolution of the client�s ambivalence in the direction of a healthier lifestyle. Helping clients clarify their own goals and values related to that behavior will increase their readiness to change. Where do you want to be? Where are you currently? When do you want to be there?

22. Motivational Interviewing4. Avoid Arguing Start where the client is. Avoid direct confrontation in order to avoid resistance. Avoid labeling. Use open-ended questions MI uses a positive approach and does not use negative confrontation. Clients are not seen as cooperative or uncooperative, or �in denial� of their problem. The goal is not for a person to complete a First Step before meaningful progress can be made. Direct confrontation and arguing are avoided. Instead the style is eliciting, using open ended questions to encourage clients to articulate their concerns and goals. Once the client is more aware of the costs and benefits of their behavior, alternatives to their current behavior will be considered. MI uses a positive approach and does not use negative confrontation. Clients are not seen as cooperative or uncooperative, or �in denial� of their problem. The goal is not for a person to complete a First Step before meaningful progress can be made. Direct confrontation and arguing are avoided. Instead the style is eliciting, using open ended questions to encourage clients to articulate their concerns and goals. Once the client is more aware of the costs and benefits of their behavior, alternatives to their current behavior will be considered.

23. Motivation Interviewing5. Roll with Resistance Reframe statements of clients to create a new momentum towards change. Invite the client to consider new information and perspectives. The client becomes actively involved in finding solutions. Resistance is seen as ambivalence about the change being addressed, and it is an indication that the session may need to return to a previous step. �You seem to be ambivalent about this, let�s come back to this later, � or �Maybe there are other options you can consider.� Rolling with resistance is a sincere attempt to thoroughly understand the client�s reluctance to change. Resistance is seen as ambivalence about the change being addressed, and it is an indication that the session may need to return to a previous step. �You seem to be ambivalent about this, let�s come back to this later, � or �Maybe there are other options you can consider.� Rolling with resistance is a sincere attempt to thoroughly understand the client�s reluctance to change.

24. Motivational Interviewing6. Self-Efficacy/Empowerment Encourage the client to believe in him/herself. Wanting to make a change is only the first half of the behavior change process. Having the confidence to carry out the chosen behavior change is the second half of the process. Sees a way to succeed. Sees a way to persist when roadblocks appear. Client develops the plan and potential solution. By encouraging clients to consider and choose personal options, they develop belief in their own power to make change. Wanting to make a change is only the first half of the behavior change process. Having the confidence to carry out the chosen behavior change is the second half of the process. Sees a way to succeed Sees a way to persist when roadblocks appear. The client begins to develop a plan and potential solution for the behavior change. By encouraging clients to consider and choose personal options, they develop belief in their own power to make change. Wanting to make a change is only the first half of the behavior change process. Having the confidence to carry out the chosen behavior change is the second half of the process. Sees a way to succeed Sees a way to persist when roadblocks appear. The client begins to develop a plan and potential solution for the behavior change.

25. Thinking about the costs and benefits of change.What specific behavior change are you considering? Create some ideas and reflections for each of the four boxes above. This will help clarify your thoughts about what you want to do next. Janis and Mann / Currently being used in an NIH study This is an example of a decisional matrix currently being used in an NIH study and I did not have time to get permission to use it. So please modify it or seek permission if you plan to use it. There is an NIH study in progress�4 year randomized, controlled trial exploring the clinical usefulness of MI protocol delivered by CDE�s to patients with poorly controlled type 2 diabetes. The session starts with an open question about the Status Quo for the target behavior. �Tell me what you like about (problem/target behavior). Open questions are used to understand the benefits of the current behavior from the client�s point of view. �And what about the not-so-good things about (problem/target behavior)� What can you tell me? Again a series of reflections and open questions to explore and clarify the downside of the behavior. The client is delivered a clear message that you are not going to tell him/her what to do. Instead the message is that you are willing to discuss their mixed feelings about the behavior. It allows them to discuss concerns about the present and their hope for the future. The discussion is then summarized, acknowledging all aspects of the ambivalence but with an emphasis on the downside of staying the same and the benefits of behavior change. A client with a low importance around change can be helped to think through the pros and cons of the status quo with the decisional balance tool to increase importance before tackling confidence. The next challenge is to explore the client�s goals and make connections between current behaviors and valued goals or ideals.This is an example of a decisional matrix currently being used in an NIH study and I did not have time to get permission to use it. So please modify it or seek permission if you plan to use it. There is an NIH study in progress�4 year randomized, controlled trial exploring the clinical usefulness of MI protocol delivered by CDE�s to patients with poorly controlled type 2 diabetes. The session starts with an open question about the Status Quo for the target behavior. �Tell me what you like about (problem/target behavior). Open questions are used to understand the benefits of the current behavior from the client�s point of view. �And what about the not-so-good things about (problem/target behavior)� What can you tell me? Again a series of reflections and open questions to explore and clarify the downside of the behavior. The client is delivered a clear message that you are not going to tell him/her what to do. Instead the message is that you are willing to discuss their mixed feelings about the behavior. It allows them to discuss concerns about the present and their hope for the future. The discussion is then summarized, acknowledging all aspects of the ambivalence but with an emphasis on the downside of staying the same and the benefits of behavior change. A client with a low importance around change can be helped to think through the pros and cons of the status quo with the decisional balance tool to increase importance before tackling confidence. The next challenge is to explore the client�s goals and make connections between current behaviors and valued goals or ideals.

26. How important is it for you to change? 0__1__2__3__4__5__6__7__8__9__10 Not at all important Extremely important The continuum exercise gives a clear sense of how ready the client is for change and how to be most helpful.The continuum exercise gives a clear sense of how ready the client is for change and how to be most helpful.

27. How confident are you thatyou can make this change? 0__1__2__3__4__5__6__7__8__9__10 Not at all important Extremely important Once the importance for change has been explored, then the conversation shifts to how confident the client is that he/she can do it. Once they have given you a number then you can pursue: Why are you at 0 and not 10? What would need to happen for you to get from 0 to 10? You can quickly obtain a good idea of the client�s readiness to change a target behavior and whether to focus initially on exploring the importance of changing or building the confidence in their ability to change. Once the importance for change has been explored, then the conversation shifts to how confident the client is that he/she can do it. Once they have given you a number then you can pursue: Why are you at 0 and not 10? What would need to happen for you to get from 0 to 10? You can quickly obtain a good idea of the client�s readiness to change a target behavior and whether to focus initially on exploring the importance of changing or building the confidence in their ability to change.

28. Motivational Interviewing Some people relate well to a continuum, but for those that do not, I find the old-fashioned ruler is a good example. My Mother had difficulty with a continuum. It was a new concept for her and being very old and very ill did not make her a ready or willing recipient of new things in her life. I finally came up with the ruler idea for her. Rulers and yardsticks were things that were familiar to her. Perhaps for someone else it might be a tape measure. So instead of numbers on the continuum, I got her to think about inches on the ruler to relate to her pain or whatever it was that the staff was trying to get her to evaluate. Some of your older patients or less educated patients may have a similar problem. Some people relate well to a continuum, but for those that do not, I find the old-fashioned ruler is a good example. My Mother had difficulty with a continuum. It was a new concept for her and being very old and very ill did not make her a ready or willing recipient of new things in her life. I finally came up with the ruler idea for her. Rulers and yardsticks were things that were familiar to her. Perhaps for someone else it might be a tape measure. So instead of numbers on the continuum, I got her to think about inches on the ruler to relate to her pain or whatever it was that the staff was trying to get her to evaluate. Some of your older patients or less educated patients may have a similar problem.

29. Motivational Interviewing Confidence Ruler Incorporates: Careful listening Appreciating ambivalence Eliciting change talk Empowering Collaborating Confidence Ruler yields a clear sense of readiness for change Confidence Ruler reflects 2 independent dimensions Why should I �? How can I �? Confidence Ruler Incorporates: Careful listening Appreciating ambivalence Eliciting change talk Empowering Collaborating Confidence Ruler yields a clear sense of readiness for change Confidence Ruler reflects 2 independent dimensions Why should I �? How can I �? Using the �ruler� you have a good idea of the client�s readiness to change a target behavior and whether to focus on exploring the importance of changing or building confidence in their ability to change. A client with high initial importance can be moved quickly to a discussion on building confidence and overcoming practical barriers. Summarize the client�s barriers to change and emphasize the disadvantages of staying the same as well as the benefits of change. Confidence Ruler Incorporates: Careful listening Appreciating ambivalence Eliciting change talk Empowering Collaborating Confidence Ruler yields a clear sense of readiness for change Confidence Ruler reflects 2 independent dimensions Why should I �? How can I �? Using the �ruler� you have a good idea of the client�s readiness to change a target behavior and whether to focus on exploring the importance of changing or building confidence in their ability to change. A client with high initial importance can be moved quickly to a discussion on building confidence and overcoming practical barriers. Summarize the client�s barriers to change and emphasize the disadvantages of staying the same as well as the benefits of change.

30. Conclusion Overall, the empirical evidence regarding the impact of MI, particularly as an additive to other effective treatments, is promising. The next wave of MI intervention studies will tell us more and correct some of the methodological weaknesses of many articles to date.

31. Conclusion MI instructs us to appreciate the limits of a direct-persuasion, advice-giving model of clinician influence. MI guides us toward a strong appreciation of the role of ambivalence in behavior change and the value of eliciting client change talk. MI models the use of effective listening skills to build rapport, engage, understand, and facilitate behavior change.

32. Conclusion The spirit of MI shares much with the established Empowerment Model already used in diabetes education training. Whether one has the luxury of extended patient contact or must work within the parameters of a brief scheduled or opportunistic exchange, there are opportunities to integrate elements of the MI guiding style into everyday practice.

33. Conclusion MI Training with Diabetes Educators 2nd year of 4 year randomized controlled trial examining the usefulness of MI in the management of 296 patients with poorly controlled type 2 diabetes. MI spirit and strategies have been woven into the usual educational activities. Patients receive 7 MI based sessions over a 1 year period and a 1 year follow-up. Outcomes include bg control, QOL, self-mgmt behaviors, and health care utilization. Much more research needs to be done but there is encouraging empirical support for Motivational Interviewing. Much more research needs to be done but there is encouraging empirical support for Motivational Interviewing.

34. Conclusion A Pilot Study of Motivation Interviewing in Adolescents with Diabetes at Department of Child Psychology, University Hospital of Wales, UK Despite the limitations of this pilot study, the results suggest that MI has the potential to improve glycemic control in adolescents with diabetes. This merits further investigation using a larger, longer term, randomized controlled study design, with more detailed monitoring to clarify the mechanisms by which MI may produce improvements and whether such improvements can be maintained in the longer term. 22 patients ages 14-18 participated in MI sessions during a 6 month intervention. A1c decreased from 10.8% to 9.7% and remained significantly lower after the end of the study. Fear of hypo � was reduced and diabetes was perceived as easier to live with.Despite the limitations of this pilot study, the results suggest that MI has the potential to improve glycemic control in adolescents with diabetes. This merits further investigation using a larger, longer term, randomized controlled study design, with more detailed monitoring to clarify the mechanisms by which MI may produce improvements and whether such improvements can be maintained in the longer term. 22 patients ages 14-18 participated in MI sessions during a 6 month intervention. A1c decreased from 10.8% to 9.7% and remained significantly lower after the end of the study. Fear of hypo � was reduced and diabetes was perceived as easier to live with.