Using Motivational Interviewing to Help Your Patients Make Behavioral Changes
Why Should We Be Interested In Patients’ Motivation For Behavior Change?
Beliefs About Motivation(True or False?) • Until a person is motivated to change, there is not much we can do. • It usually takes a significant crisis (“hitting bottom”) to motivate a person to change. • Motivation is influenced by human connections. • Resistance to change arises from deep-seated defense mechanisms.
Beliefs About Motivation(True or False?) • People choose whether or not they will change. • Readiness for change involves a balancing of “pros” and “cons.” • Creating motivation for change usually requires confrontation. • Denial is not a client problem, it is a therapist skill problem.
Learning Objectives At the end of the workshop, you will be able to: • Define multiple MI techniques to help clients to change • Describe the Stages of Change • Complete a Stage of Change Assessment • Define the 4 principles of MI • Demonstrate skill with OARS • Demonstrate at least 2 methods to elicit change talk • Utilize a Readiness Ruler • Complete a Decisional Balance • Complete a Change Plan • Describe MI strategies to deal with resistance to change
MI is A theory A set of skills A way of thinking A way of relating
Why Do People Change? • ? • ? • ? • ? • ? • ?
Why Don’t People Change? • ? • ? • ? • ? • ? • ?
Sound Familiar? Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008. “I tell them what to do, but they won’t do it.” “It’s my job just to give them the facts, and that’s all I can do.” “These people lead very difficult lives, and I understand why they _______.” “Some of my patients are in complete denial.”
Or Should We? Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008. Explain what patients could do differently in the interest of their health? Advise and persuade them to change their behavior? Warn them what will happen if they don’t change their ways? Take time to counsel them about how to change their behavior? Refer them to a specialist?
The Righting Reflex:The Best Intentions Can Backfire Most patients are ambivalent about unhealthy behaviors. When we (providers) see an unhealthy/risky behavior, our natural instinct is to point it out & advise change. The patient’s natural response is to defend the opposite (no change) side of the ambivalence coin.
Avoid Righting Reflex:“Taking Sides” Trap PROVIDER • “You must change” • “You’ll be better off” • “You can do it!!” • “You’ll die…” PATIENT • “I don’t want to change” • “Things aren’t half bad.” • “No I can’t!!” • “Uncle Fred is 89 and healthy as can be.”
Exercise: The Change Exercise • Stand up and turn to stand face to face in pairs. • Silently observe your partner for 15 seconds. • Now turn back to back and change 3 things about yourself. • When you are done, turn back to face your partner. • Each person should take a minute to name the 3 things your partner has changed.
Change Exercise Questions What was your comfort level during this exercise? What made you comfortable or uncomfortable? How hard was it to change things? How did you decide what things to change about yourself? What does this exercise tell us about change? Look around you did you notice how quickly people changed back to the way they started as soon as they sat down? What implications might this have about change for people and ourselves?
Change Exercise Key Points Change is difficult Change is not always comfortable Change requires creativity We tend to go back to old ways It is easier to stay the same We like our comfort zones Change requires an open mind Change has emotional and cognitive components
Change Exercise Key Points Change is a process Change happens over time The process is as important as the result Watch out for measuring success only if a change occurred Often there is a difference between what someone knows they should do and there readiness to do it. Greatest chance to impact change is pacing it to the specific stage of change
Why Are Health Care Professionals (Outside Behavioral Health) Interested In MI? • Behavioral/lifestyle factors in health issues • Exercise • Smoking • Weight control • Treatment adherence • Diet/nutrition • Conceptual consistency with patient-centered approaches • Positive and promising results from research on outcomes
Definition of Motivational Interviewing Miller, W.R. & Rollnick, S.(2002) A patient-centered, yet directive method for enhancing intrinsic motivation for positive behavior change by exploring and resolving ambivalence.”
Motivation is viewed as… Our job is to elicit and reinforce patient motivation for change. multidimensional a state, which is dynamic and fluctuating modifiable influenced by communication style
Spirit, Principles, Micro-skills Motivational Interviewing Practice Basics:
MI Spirit • A way of being with patients which is… • Collaborative • Evocative • Respectful of autonomy
Collaboration(not confrontation) Developing a partnership in which the patient’s expertise, perspectives, and input is central to the consultation Fostering and encouraging power sharing in the interaction
Evocation(not education) The resources and motivation for change reside within the patient Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals Ask key open ended questions
Autonomy(not authority) Respecting the patient’s right to make informed choices facilitates change The patient is charge of his/her choices, and, thus, is responsible for the outcomes Emphasize patient control and choice
Spirit of Motivational Interviewing • Motivations to change are elicited from within the client, not imposed from outside. • It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. • Direct persuasion is not an effective method for resolving ambivalence. • Readiness to change is not a client trait, but fluctuating product of interpersonal interaction.
Spirit of Motivational Interviewing • The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. • Positive atmosphere that is conducive but not coercive for change. • The counselor is directive in helping the client to examine and resolve ambivalence.
What MI is Not A way of tricking people into doing what you want them to do A specific technique Problem solving or skill building Just client-centered therapy Easy to learn A panacea for every clinical challenge Source: Miller & Rollnick (2009)
Four Guiding MI Principles: • Resist the righting reflex • If a patient is ambivalent about change and the clinician champions the side of change…
Four Guiding MI Principles: • Understand your patient’s motivations • With limited consultation time, it is more productive asking patients what or how they would make a change rather than telling them that they should.
Four Guiding MI Principles: • Listen to your patient • When it comes to behavior change, the answers most likely lie within the patient, and finding them requires some listening
Four Guiding MI Principles: • Empower your patient • A patient who is active in the consultation, thinking aloud about the what and how of change, is more likely to do something about it.
Core MI Skills – (OARS) Asking Listening Affirming
Asking Use of open ended questions allows the patient to convey more information Encourages engagement Opens the door for exploration
Closed Ended Question Open Ended Question Are you having any pain today? Is there anything that is worrying you right now? Are you short of breath? Are you doing okay? Why haven’t you tried this exercise? Are you refusing treatment? Do you have a follow up appointment scheduled?
Open-Ended Questions What are open-ended questions? • Gather broad descriptive information • Require more of a response than a simple yes/no or fill in the blank • Often start with words like: • “How…” • “What…” • “Tell me about…” • Usually go from general to specific OARS
Open-Ended Questions Exercise: Turning closed-ended questions into open-ended ones
Open-Ended Questions • Why open-ended questions? • Avoid the question-answer trap • Puts client in a passive role • No opportunity for client to explore ambivalence OARS
Affirmations What is an affirmation? • Compliments, statements of appreciation and understanding • Praise positive behaviors • Support the person as they describe difficult situations OARS
Affirmations • Examples: • “I appreciate how hard it must have been for you to decide to come here. You took a big step.” • “I’ve enjoyed talking with you today, and getting to know you a bit.” • “You seem to be a very giving person. You are always helping your friends.”
Affirmations Why affirm? • Supports and promotes self-efficacy, prevents discouragement • Builds rapport • Reinforces open exploration (client talk) Caveat: • Must be done sincerely OARS
Express Empathy What is empathy? • Reflects an accurate understanding • Assume the person’s perspectives are understandable, comprehensible, and valid • Seek to understand the person’s feelings and perspectives without judging
Express Empathy Empathy is distinct from… • Agreement • Warmth • Approval or praise • Reassurance, sympathy, or consolation • Advocacy
Express Empathy Why is empathy important in MI and IDDT? • Communicates acceptance which facilitates change • Encourages a collaborative alliance which also promotes change • Leads to an understanding of each person’s unique perspective, feelings, and values which make up the material we need to facilitate change
Express Empathy Tips… • Good eye contact • Responsive facial expression • Body orientation • Verbal and non-verbal “encouragers” • Reflective listening/asking clarifying questions • Avoid expressing doubt/passing judgment
Empathy is NOT… The sharing of common past experiences Giving advice, making suggestions, or providing solutions Demonstrated through a flurry of questions Demonstrated through self-disclosure
The Bottom Line on Empathy Ambivalence is normal Our acceptance facilitates change Skillful reflective listening is fundamental to expressing empathy - Miller and Rollnick, 2002
Reflective Listening OARS