Motivational Interviewing & HEALS How to Get Students Off the Couch A Brief Taste of MI Helena Mackenzie, PhD Region 5 Mental Health Specialist
Objectives Identify why more traditional health care approaches often don’t result in behavior change List a word that reflects the spirit of Motivational Interviewing (“ACE”) List a key skill used in MI (“OARS”) Identify one change tool Feel motivated to learn more about MI and applying it to HEALS
Identify a behavior you currently want to change… • Common Choices • Exercise more • Drink less • Eat more fruit/veggies • Stop smoking • Stop being late • Stick to a budget
Stages of Change(Prochaska & DiClemente) • Precontemplation: What problem? • Contemplation: Aware of the problem, but not quite ready… • Preparation: Plan to take action in the next month; beginning to take small steps • Action: Modifying behavior to overcome problem • Maintenance: work to prevent relapse and consolidate gains
The “Righting Reflex”A Practitioner/Helper Problem • Stems from a natural desire to help… • Helper/Practitioner’s “goal”: • “diagnose the problem” • “fix the problem” • “control the problem” • “get good results” • Practitioner tries to create change by… • Providing reasons for change (education) • Provide solution/treatment/skill building
Demonstration:Trying to Force Change Provider/Helper Argues for Change Student/Patient Argues Against Change/Shuts Down • Demonstration of an “Ineffective Provider” • http://www.youtube.com/watch?v=80XyNE89eCs&feature=relmfu • Lisa Marlo, PhD, Professor of Psychiatry at the University of Florida
Resistance or Ambivalence? • Ambivalence: • The True Dilemma of Change • Ambivalence is a state of mind in which a person has co-existing but conflicting feelings about something • Fundamental and NORMAL part of the change process • “I want to, but I don’t want to…” • “You tell me a reason to change, I’ll tell you a reason not to…”
“People are usually more convinced by reasons they discovered themselves than by those found by others.” --Blaise Pascal
Motivational Interviewing • Allows the individual to identify and verbalize their own reasons for change… We serve as the guide… • MI Defined: • Motivational interviewing is a form of collaborative conversation for strengthening a person's own motivation and commitment to change. It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change. -MINT (2012)
Spirit of MI (“ACE”) • Autonomy • NOT confrontation • Collaboration • NOT authoritative • Evocation • NOT education
Is this MI Spirit? (place your vote) • Student: I know my RA told you I’m depressed, but I’m not. • Helper: You don’t believe you’re depressed. What do you think she’s seeing that is making her worry this way? • Student: I had no idea I weighed that much. I guess that’s why everyone tells me I shouldn’t eat so much. • Helper: Right. You need to cut down on your eating and I know some good ways to get you started. • Student: I think your BMI thing is wrong because I am not “obese.” • Helper: You don’t think of yourself as someone who has a weight problem.
Strategies to Develop a Motivational ConversationOARS • Open-ended questions • Avoid Yes/No • “What types of exercise have you previously tried?” • Affirmations • Provide support & encouragement • “Taking care of yourself is really important to you” • Reflective Listening • Making a statement that guesses at the speaker’s meaning • Summarizing • Organizes and links information
Open-Ended Questions • Encourage the person to give you more than a “yes/no” response • Do you drink alcohol daily? (closed) • What are your drinking habits like? (open) • Typically can’t be answered with one word or brief responses • How many fruits and vegetables do you eat daily? (closed) • Tell me about your daily eating habits (open)
Open-Ended Questions?Place Your Vote Are you doing okay today? How much do you exercise? What types of healthy foods do you like? Do you eat fruit and vegetables daily? What activities in the recreation department sound interesting to you?
Affirmations • Statements of appreciation of student/patient’s strengths, successes, efforts to change • Purpose is to empower and support self-efficacy • Avoid using word “I” • Different than compliments
Affirmation Practice Student Says… Possible Affirmation… You are determined to keep your diabetes under control Your health is really important to you When you set your mind to something you feel confident you’ll accomplish your goal • Student with diabetes tells you they are checking their glucose levels regularly • Overweight student tells you she has stopped drinking pop • Student tells you that he felt discouraged after failing recent TABE, but now has plan and feels confident he will pass next time
Reflections… • Reflections are guesses at what you believe a person is saying. Show the person that you hear and understand them and invite them to continue talking • You can reflect many things… • Speech • Facial Expression • Behavior • Or guess at the deeper meaning of words
Example Reflections… Student Reflection from Helper You don’t think I can understand how hard it is Losing weight doesn’t feel possible right now There is no way you are going to eat vegetables This news feels overwhelming Looking good is important to you • You don’t have a clue what it’s like living on this center • There is no way I can lose weight • I don’t eat vegetables and that’s a done deal • Student cries after STD result • I look gross when I work out. No way I’m doing that here
Applying MI to HEALS A Brief MI-Consistent Conversation
Agree on the Focus • Explore and agree on a behavior to discuss or ask permission to discuss a particular behavior Elevated BMI _________________________________________________________________ Stress Exercise Eating Social Activities ??? Alcohol
Explore Ambivalence and Strengthen Motivation for Change In order to be READY to change, person must be WILLING and ABLE Change Willing = importance Able= Confidence
Ask about importance and confidence around specific change… • Follow up questions to elicit change talk: • Why did you pick ____ instead of _____(slightly lower number)? • What would have to happen to make you move up to a ____ (slightly higher number)?
Decisional Balance Worksheet: Explore the Ambivalence of Change… Use OARS to clarify pros and cons… Use Reflections and Open-Ended Questions when hear change talk or are met with resistance…
Summarize Progress and Identify Next Step • Provide summary of information discussed then… • Ask: • What do you make of all this? Or... • What, if anything, would be a first step? Or… • What do you intend to do next?
Guiding Principles to Remember (RULE) • Resist the Righting Reflect • Don’t argue with the student! • Understand the student’s motivation • What is important to this person? • Listen to the student • Ask open-ended questions and use reflections to check your understanding • Empower the student (create self-efficacy) • Affirm the student’s strengths
Demonstration of an Effective Provider: MI in Action http://www.youtube.com/watch?v=URiKA7CKtfc&feature=relmfu Lisa Merlo, PhD, Department of Psychiatry at the University of Florida
Helpful Articles… Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change. American Psychologist, 47 (9), 1102-1114. Berg-Smith, M., Stevens, V., et al. (1999). A brief motivational intervention to improve dietary adherence in adolescents. Health Education Research, 14 (3), 399-410. Butterworth, S., Linden, A., et al. (2006). Effect of motivational interviewing-based health coaching on employees’ physical and mental health status. Journal of Occupational Health Psychology, 11 (4), 358-365. Hillsdon, M., Thorogood, M., et al. (2002). Advising people to take more exercise is ineffective. International Journal of Epidemiology, 31, 808-815. Resnicow, K., Baskin, M, & McCarty, F. (2005). Results of Go Girls: A weight control program for overweight African-American adolescent females. Obesity Research, 13 (10),1739-1748. Resnicow, K., Campbell, M., et al. (2004). Body and Soul: A dietary intervention conducted through African-American churches. American Journal of Preventative Medicine, 27 (2), 97-105. Richards, A., Kattelmann, K., et al. (2006). Motivating 18- to 24-year-olds to increase their fruit and vegetable consumption. American Dietetic Association, 106, 1405-1411.