Introduction to Motivational Interviewing

1. Introduction to Motivational Interviewing Healthy Start Quarterly Training September 9, 2008 Susan Potts, LCSW Nearly all top causes of mortality have behavioral components that need to be addressed. Health care providers can be key agents in promoting health behavior change. Motivational interviewing provides some very useful tools for health care providers and counselors to use to promote behavior change. If you have ever tried to change your own behavior, you know that it is not an easy thing to do. It usually takes place over a long time and the pace can vary. You probably also know that knowledge is usually not sufficient to motivate change and that relapse is the rule. One of the benefits of learning about motivational interviewing is that it helps us to have more realistic expectations of clients regarding behavior change and will help us to achieve greater success over time with less frustration and burnout. Nearly all top causes of mortality have behavioral components that need to be addressed. Health care providers can be key agents in promoting health behavior change. Motivational interviewing provides some very useful tools for health care providers and counselors to use to promote behavior change. If you have ever tried to change your own behavior, you know that it is not an easy thing to do. It usually takes place over a long time and the pace can vary. You probably also know that knowledge is usually not sufficient to motivate change and that relapse is the rule. One of the benefits of learning about motivational interviewing is that it helps us to have more realistic expectations of clients regarding behavior change and will help us to achieve greater success over time with less frustration and burnout.

2. Learning Objectives Understand the basic principles of motivational interviewing Learn strategies for evoking change talk Understand resistance and how to respond Learn how to negotiate a change plan

3. How Does Behavior Change

4. Think of a behavior you have tried to change

5. How Much Time Elapsed Between the first time you engaged in that behavior and the first time you realized negative consequences < 1 month 1 to 3 months 4 to 6 months 7 to 12 months 13 months to 2 years 3 to 5 years > 5 years < 1 month 1 to 3 months 4 to 6 months 7 to 12 months 13 months to 2 years 3 to 5 years > 5 years

6. How Much Time Elapsed Between the first time you realized negative consequences and the first time you tried to change the behavior < 1 month 1 to 3 months 4 to 6 months 7 to 12 months 13 months to 2 years 3 to 5 years > 5 years < 1 month 1 to 3 months 4 to 6 months 7 to 12 months 13 months to 2 years 3 to 5 years > 5 years

7. How Many of You Had some success in changing your behavior? Experienced a relapse or an increase in the behavior after achieving some success? < 1 month 1 to 3 months 4 to 6 months 7 to 12 months 13 months to 2 years 3 to 5 years > 5 years < 1 month 1 to 3 months 4 to 6 months 7 to 12 months 13 months to 2 years 3 to 5 years > 5 years

8. Behavior Change Often takes a long time Motivation to change varies Knowledge is usually not sufficient to motivate change Relapse is common Source: Retrieved July 18, 2008 from ahec.allconet.org/newrihp/powerpoint/

9. Unhelpful Assumptions 1. The person ought to change behaviour 2. The person wants to change behaviour 3. Health is the person�s primary motivator 4. The intervention has failed if the person doesn�t choose to change 5. Persons are either motivated to change or not 6. Now is the right time to choose to change 7. A tough approach is the best approach 8. I�m the expert; the person should follow my advice.

10. Benefits of Learning about Motivational Interviewing More realistic expectations Greater recognition of small accomplishments Greater success over time Less frustration and burnout Source: Retrieved July 18, 2008 from ahec.allconet.org/newrihp/powerpoint/

11. What Is Motivational Interviewing Directive, patient centered counseling style that aims to help people explore and resolve their ambivalence about behavior change Source: Michael Wiles and Cross Country Education, Inc. 2005 Mi is a counseling style rather than a set of techniques. It is not a method for tricking people in to doing things they do not want to do. It is a style for eliciting from the person their own motivations for change. It is a way of interacting with people to assess their readiness to change and to help them move through different stages of change. MI focuses on creating a comfortable atmosphere without pressure or coercion to change. It is called interviewing because it involves careful listening and strategic questioning rather than teaching to help people overcome their ambivalence to change. Any change that will happen will come from within the client and not imposed upon them by some outside force. It is the role of the client to be able to articulate and resolve his or her own ambivalence to change. Ambivalence is the I want to but I don�t want to state of mind � feeling 2 ways about something. Direct persuasion is rarely effective at resolving ambivalence. First Developed in 1983 by William Miller in the treatment of problem drinkers and further concepts were elaborated by Bill Miller and Stephen Rollnick in 1991. MI has been used in many health settings . Clinical trials of MI have shown that persons are more likely to enter, stay in and complete treatment; to participate in follow-up visits; to adhere to glucose monitoring and to improve glycemic control; to increase exercise and fruit and vegetable intake; to reduce stress, to improve medication adherence; to decrease alcohol and drug use; to quit smoking; and to have fewer subsequent injuries and hospitalizations. Mi is a counseling style rather than a set of techniques. It is not a method for tricking people in to doing things they do not want to do. It is a style for eliciting from the person their own motivations for change. It is a way of interacting with people to assess their readiness to change and to help them move through different stages of change. MI focuses on creating a comfortable atmosphere without pressure or coercion to change. It is called interviewing because it involves careful listening and strategic questioning rather than teaching to help people overcome their ambivalence to change. Any change that will happen will come from within the client and not imposed upon them by some outside force. It is the role of the client to be able to articulate and resolve his or her own ambivalence to change. Ambivalence is the I want to but I don�t want to state of mind � feeling 2 ways about something. Direct persuasion is rarely effective at resolving ambivalence. First Developed in 1983 by William Miller in the treatment of problem drinkers and further concepts were elaborated by Bill Miller and Stephen Rollnick in 1991. MI has been used in many health settings . Clinical trials of MI have shown that persons are more likely to enter, stay in and complete treatment; to participate in follow-up visits; to adhere to glucose monitoring and to improve glycemic control; to increase exercise and fruit and vegetable intake; to reduce stress, to improve medication adherence; to decrease alcohol and drug use; to quit smoking; and to have fewer subsequent injuries and hospitalizations.

12. What is Ambivalence A state of mind in which a person has coexisting but conflicting feelings about something Wanting to change but not wanting to change. Source: Miller & Rollnick 1991 People are ambivalent about changing their behavior. Ambivalence is not reluctance to do something but the conflict about choosing between two courses of action. Ambivalence is a central feature of the struggle to change. It is present even when it is not obvious Ambivalence is difficult to resolve. Each side has costs and benefits. Ambivalence must be engaged rather than overriddenPeople are ambivalent about changing their behavior. Ambivalence is not reluctance to do something but the conflict about choosing between two courses of action. Ambivalence is a central feature of the struggle to change. It is present even when it is not obvious Ambivalence is difficult to resolve. Each side has costs and benefits. Ambivalence must be engaged rather than overridden

13. Motivational Interviewing Communication style to build rapport Not based on scientific theory Blending of techniques from other theories and interventions Avoids labels and diagnoses Source: Sobell 2007 MI integrates the relationship building principles of Carl Rogers with more active cognitive behavioral strategies targeted to the person�s stage of changeMI integrates the relationship building principles of Carl Rogers with more active cognitive behavioral strategies targeted to the person�s stage of change

14. Characteristics of Motivational Interviewing Guiding more than directing Dancing rather than wrestling Listening as much as telling Collaborative conversation Evokes from persons what they already have Honoring of person�s autonomy Source:S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. 2008 Motivation for change can be shaped and is particularly formed in the concept of relationships. No one is completely unmotivated. We all have hopes and aspirations. The way in which we talk to people can influence their motivation for change. With MI it is a partnership instead of an uneven power relationship where the helping person or health care provider is the expert. Instead of giving people what they lack be it medication, knowledge, skills or insight, MI seeks to evoke the person�s own motivations and resources for change. Even tho the person may not be motivated in the direction you would like, every person has personal goals, values, aspirations and dreams. Part of the art of MI is connecting behavioral health change with the persons values and concerns. This can only be done by understanding the person�s perspectives and evoking their own good reasons and arguments for change. There needs to be a certain detachment from outcomes � not an absence of caring but an acceptance that people can an do make decisions about the course of their lives. By acknowledging the person�s freedom not to change, it makes change possible. With MI there is an acceptance that people make choices and despite what helpers may tell them, they ultimately make the decision.Motivation for change can be shaped and is particularly formed in the concept of relationships. No one is completely unmotivated. We all have hopes and aspirations. The way in which we talk to people can influence their motivation for change. With MI it is a partnership instead of an uneven power relationship where the helping person or health care provider is the expert. Instead of giving people what they lack be it medication, knowledge, skills or insight, MI seeks to evoke the person�s own motivations and resources for change. Even tho the person may not be motivated in the direction you would like, every person has personal goals, values, aspirations and dreams. Part of the art of MI is connecting behavioral health change with the persons values and concerns. This can only be done by understanding the person�s perspectives and evoking their own good reasons and arguments for change. There needs to be a certain detachment from outcomes � not an absence of caring but an acceptance that people can an do make decisions about the course of their lives. By acknowledging the person�s freedom not to change, it makes change possible. With MI there is an acceptance that people make choices and despite what helpers may tell them, they ultimately make the decision.

15. Fundamental Guidelines Resist the righting reflex Understand person�s motivation Listen Empower Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. 2008 Helping professionals want to make things right, heal and prevent harm. When we see someone doing something that is hurtful we want to tell them to stop. But this actually has a paradoxical effect. When the practitioner advocates for change, the person advocates for staying the same. It is a natural human tendency to resist persuasion. When a persons argues against change, she becomes even more committed to maintaining the status quo. We tend to believe what we hear ourselves saying so if we are verbalizing the reasons why we shouldn�t change, we become more committed to not changing. If you as the helping person are arguing for change and the person is resisting or arguing against it, you are in the wrong role. It is the patient or client who should be arguing for change. It is the client�s own reasons for change that are most likely to bring about behavior change. In MI the helper is trying to evoke and explore the person�s perceptions about their situation and their motivation for change MI involves as much listening as informing. Climate of the session is quiet, supporting and non-judgmental. Client needs to be talking 70% of the time and the helper 30%^ of the time. Pace need to be slow enough to listen. A person who is active in the consultation, thinking about why and how of change is more likely to do something afterward. It is important to support their hope that change is possible. Most people don�t have self confidence. We need to show them that they can gain control over thei lives.Helping professionals want to make things right, heal and prevent harm. When we see someone doing something that is hurtful we want to tell them to stop. But this actually has a paradoxical effect. When the practitioner advocates for change, the person advocates for staying the same. It is a natural human tendency to resist persuasion. When a persons argues against change, she becomes even more committed to maintaining the status quo. We tend to believe what we hear ourselves saying so if we are verbalizing the reasons why we shouldn�t change, we become more committed to not changing. If you as the helping person are arguing for change and the person is resisting or arguing against it, you are in the wrong role. It is the patient or client who should be arguing for change. It is the client�s own reasons for change that are most likely to bring about behavior change. In MI the helper is trying to evoke and explore the person�s perceptions about their situation and their motivation for change MI involves as much listening as informing. Climate of the session is quiet, supporting and non-judgmental. Client needs to be talking 70% of the time and the helper 30%^ of the time. Pace need to be slow enough to listen. A person who is active in the consultation, thinking about why and how of change is more likely to do something afterward. It is important to support their hope that change is possible. Most people don�t have self confidence. We need to show them that they can gain control over thei lives.

16. Behavior of Helping Professional Attempt to understand person�s frame of reference Accepting and affirming Eliciting and reinforcing person�s self motivational statements Monitoring degree of readiness to change Affirming person�s freedom of choice Source: Michael Wiles and Cross Country Education, Inc., 2005 Need to understand where the person is coming from. Beliefs frame perceptions of the world. Accepting and affirming the person doesn�t mean accepting the behavior. When you affirm a person you are conveying respect and understanding. It encourages more progress and helps the person to be able to talk about things that are less positive. Eliciting self motivational statements in 4 areas: Problem recognition Expressions of of concern Desire and Intention to change Optimism for change � belief in ability to change Need to understand where the person is coming from. Beliefs frame perceptions of the world. Accepting and affirming the person doesn�t mean accepting the behavior. When you affirm a person you are conveying respect and understanding. It encourages more progress and helps the person to be able to talk about things that are less positive. Eliciting self motivational statements in 4 areas: Problem recognition Expressions of of concern Desire and Intention to change Optimism for change � belief in ability to change

17. Four General Principles of Motivational Interviewing Express empathy Develop discrepancy Roll with resistance Support self efficacy Source: Michael Wiles and Cross Country Education, Inc., 2005 Express empathy - This is the foundation upon which motivational interviewing is built. Acceptance facilitates change. This attitude helps to build a therapeutic alliance. Ambivalence is viewed as normal. Express empathy using reflective listening to convey understanding. Develop discrepancy between the person�s values and their behavior. Show how unhealthy behaviors interfere with wish to be a good parent, have a better future, etc. Discover how they would like to be versus who they are now. Developing discrepancy between where person is and where the person wants to be. Present reality vs desired future. Result is cognitive dissonance � feeling uncomfortable with maintaining the status quo. Roll with resistance. Avoid arguing for change. Respond with understanding rather than confrontation. Confrontation discourages motivation to change because the emphasis is on the authority of the helper rather than on individual responsibility and person�s desire to change. Resistance is a signal to respond differently. Self efficacy is the client�s belief that he/she can succeed. .A person�s belief in the possibility of change is an important motivator. The person, not the counselor, is responsible for choosing and carrying out change The counselor�s own belief in the person�s ability to change becomes a self-fulfilling prophecy Express empathy - This is the foundation upon which motivational interviewing is built. Acceptance facilitates change. This attitude helps to build a therapeutic alliance. Ambivalence is viewed as normal. Express empathy using reflective listening to convey understanding. Develop discrepancy between the person�s values and their behavior. Show how unhealthy behaviors interfere with wish to be a good parent, have a better future, etc. Discover how they would like to be versus who they are now. Developing discrepancy between where person is and where the person wants to be. Present reality vs desired future. Result is cognitive dissonance � feeling uncomfortable with maintaining the status quo. Roll with resistance. Avoid arguing for change. Respond with understanding rather than confrontation. Confrontation discourages motivation to change because the emphasis is on the authority of the helper rather than on individual responsibility and person�s desire to change. Resistance is a signal to respond differently. Self efficacy is the client�s belief that he/she can succeed. .A person�s belief in the possibility of change is an important motivator. The person, not the counselor, is responsible for choosing and carrying out change The counselor�s own belief in the person�s ability to change becomes a self-fulfilling prophecy

18. Express Empathy Acceptance facilitates change Shows interest and caring to understand client�s experience Conveys unconditional positive regard Empathy is a key part of cultivating the spirit of collaboration. Empathy is the helper�s sensitive ability and willingness to understand the person�s thoughts, feelings and struggles from the person�s point of view. Empathy is a key part of cultivating the spirit of collaboration. Empathy is the helper�s sensitive ability and willingness to understand the person�s thoughts, feelings and struggles from the person�s point of view.

19. Develop Discrepancy Difference between the person�s core values and life goals and their health behavior Difference between the person is now and where he/she would like to be in the future Cognitive dissonance is necessary for change to occur

20. Roll with Resistance Resistance often stems from fear of change Reluctance to change is natural and normal Direct persuasion or arguments are ineffective

21. Support Self Efficacy Build confidence Promote self esteem Promote belief in ability to change

22. Phase 1 Goal: build motivation for change

23. Stages of Change Model MI and the transtheoretical model of change developed separately. Stages of change model was originally developed in the late 1970s and early 1980s by James Prochaska and Carlo Diclemente at the University of Rhode Island when they were studying smokers. The determined that people go through a series of stages before change takes place. Change is viewed as a continuum rather than a discrete event. By identifying what stage a person is in, you can better match your intervention. MI is useful for people who are in the early stages of change. As practitioners we are often anxious to cover the list of topics we need to discuss with a patient. We feel we have fulfilled our responsibility but to what extent is this education influencing behavior? People need different approaches during each stage of change. Those in the earlier stages need to build their motivation and confidence for change. Those in the later stages can benefit from education about how to change and prevent relapse. Premature problem solving often results in resistance. �I�ve tried that and it doesn�t work.� Education and problem solving are appropriate for those who are ready and willing to change but is less effective for those who are not ready. Relapse is reversion back to old behavior. Relapse is very common and needs to be planned for so that people don�t feel a sense of failure. It is a normal expected stage of behavior change. It can be reframed as an opportunity to learn. Help client to renew process of contemplation, preparation and action without becoming demoralized.MI and the transtheoretical model of change developed separately. Stages of change model was originally developed in the late 1970s and early 1980s by James Prochaska and Carlo Diclemente at the University of Rhode Island when they were studying smokers. The determined that people go through a series of stages before change takes place. Change is viewed as a continuum rather than a discrete event. By identifying what stage a person is in, you can better match your intervention. MI is useful for people who are in the early stages of change. As practitioners we are often anxious to cover the list of topics we need to discuss with a patient. We feel we have fulfilled our responsibility but to what extent is this education influencing behavior? People need different approaches during each stage of change. Those in the earlier stages need to build their motivation and confidence for change. Those in the later stages can benefit from education about how to change and prevent relapse. Premature problem solving often results in resistance. �I�ve tried that and it doesn�t work.� Education and problem solving are appropriate for those who are ready and willing to change but is less effective for those who are not ready. Relapse is reversion back to old behavior. Relapse is very common and needs to be planned for so that people don�t feel a sense of failure. It is a normal expected stage of behavior change. It can be reframed as an opportunity to learn. Help client to renew process of contemplation, preparation and action without becoming demoralized.

24. Basic SkillsOARS Open ended questions Affirmation Reflective listening Summarizing Source: Michael Wiles and Cross Country Education, Inc., 2005 These skills are represented by the acronym OARS. They help the interviewer to listen, elicit important information and build rapport. They ensure that the interviewer will understand the person�s perspective and behavior. Open ended � not answered by yes or no. Invite clients to tell their stories. Usually begin with �Tell me about, describe� vs. did you keep your appointment? How do you feel about your smoking vs. would you like to quite smoking? Affirmations � Highlighting person�s strengths, personal values and goals by using compliments or encouragement. Affirmations should be genuine and specific. They can also acknowledge efforts to make changes � no matter how small. For example �I know it took some effort for you to get here today.� Reflective listening � short restatements of person�s thoughts and feelings. This can be done by repeating, rephrasing, empathic reflection, reframing, Summarizing � longer than a reflection. Links together discussed material and demonstrates careful listening. Let me see if I understand what you have told me so far. If person has expressed ambivalence, capture both sides of the ambivalence in the summary statement. �So it sounds like on the one hand you want to quit smoking but on the other hand you are concerned with gaiing weight.�These skills are represented by the acronym OARS. They help the interviewer to listen, elicit important information and build rapport. They ensure that the interviewer will understand the person�s perspective and behavior. Open ended � not answered by yes or no. Invite clients to tell their stories. Usually begin with �Tell me about, describe� vs. did you keep your appointment? How do you feel about your smoking vs. would you like to quite smoking? Affirmations � Highlighting person�s strengths, personal values and goals by using compliments or encouragement. Affirmations should be genuine and specific. They can also acknowledge efforts to make changes � no matter how small. For example �I know it took some effort for you to get here today.� Reflective listening � short restatements of person�s thoughts and feelings. This can be done by repeating, rephrasing, empathic reflection, reframing, Summarizing � longer than a reflection. Links together discussed material and demonstrates careful listening. Let me see if I understand what you have told me so far. If person has expressed ambivalence, capture both sides of the ambivalence in the summary statement. �So it sounds like on the one hand you want to quit smoking but on the other hand you are concerned with gaiing weight.�

25. Open Ended Questions Closed ended questions often lead to yes/no or single word answers and discourage further conversation. Open ended questions allow the persons to tell their story, lead to increased understanding and help to build empathy. Open ended questions usually begin with the phrase �Tell me about . . . � or �to what extent . . . � or Describe They allow people to give spontaneous, unguided responses. They help to build rapport and trust. They enable you to learn information you might not think to ask about. Closed questions usually start with �Did you or Do you?� How many times have you quit smoking vs tell me about your past attempts to quit? Becomes a dialogue rather than interrogation Goal is to ask questions with the widest scope of response Open ended questions usually begin with the phrase �Tell me about . . . � or �to what extent . . . � or Describe They allow people to give spontaneous, unguided responses. They help to build rapport and trust. They enable you to learn information you might not think to ask about. Closed questions usually start with �Did you or Do you?� How many times have you quit smoking vs tell me about your past attempts to quit? Becomes a dialogue rather than interrogation Goal is to ask questions with the widest scope of response

26. Affirmations Statements of appreciation and understanding Highlight person�s strengths, personal values and goals by using compliments and encouragement Acknowledge efforts to make changes Affirmations � Highlighting person�s strengths, personal values and goals by using compliments or encouragement. Affirmations should be genuine and specific. They can also acknowledge efforts to make changes � no matter how small. For example �I know it took some effort for you to get here today.� Affirmations � Highlighting person�s strengths, personal values and goals by using compliments or encouragement. Affirmations should be genuine and specific. They can also acknowledge efforts to make changes � no matter how small. For example �I know it took some effort for you to get here today.�

27. Reflective Listening Deepens and extends the conversation By taking time to listen, you convey empathy Validates what clients are feeling Creates a sense of safety for clients to talk Can be used to develop discrepancy between a person�s stated values and present behavior Reflective listening is more effective than questioning Reflective listening is fundamental skill in MI. It is a major way of interacting with clients. Reflective listening involves taking a guess at what the person means and reflecting it back in a short statement. The purpose is to keep the person thinking and talking about change. It can be used to understand the persons perspective and let them know you are listening, to emphasize the persons� positive statements about changing so they hear them twice � once when they say them and again when the helper says them and to diffuse resistanceReflective listening is fundamental skill in MI. It is a major way of interacting with clients. Reflective listening involves taking a guess at what the person means and reflecting it back in a short statement. The purpose is to keep the person thinking and talking about change. It can be used to understand the persons perspective and let them know you are listening, to emphasize the persons� positive statements about changing so they hear them twice � once when they say them and again when the helper says them and to diffuse resistance

28. Reflective Listening Repeating Rephrasing � slightly alter person�s words Empathic reflection � provide understanding for person�s situation Reframing � help person think differently about their situation Feeling reflection � reflect emotional undertones Amplified reflection � exaggerate what was said Double-sided reflection � reflect both sides of person�s ambivalence Source: B. Borelli �Using Motivational Interviewing to Promote Patient Behavior Change and Enhance Health� Repeating � the simplest reflection simply repeats a portion of what was said. Rephrasing � the listener stays close to what was said but substitutes or synonyms or slightly rephrases what was said Empathic reflection is a type of paraphrasing � this is a more major restatement in which the listen infers the meaning of what was said and reflects it back in new words. Reframing � offering a new and positive interpretation of negative information. For example, a nagging wife is reframed as a caring wife OR relapse is reframed as a learning experience. It acknowledged the validity of the client�s observations but helps the client see them in a new way. Amplified reflection � making it worse than what the person said �This is something you will do for the rest of your life.� Person will then argue in the direction of change. Feeling reflection is a paraphrase that emphasizes the emotions behind the wordsRepeating � the simplest reflection simply repeats a portion of what was said. Rephrasing � the listener stays close to what was said but substitutes or synonyms or slightly rephrases what was said Empathic reflection is a type of paraphrasing � this is a more major restatement in which the listen infers the meaning of what was said and reflects it back in new words. Reframing � offering a new and positive interpretation of negative information. For example, a nagging wife is reframed as a caring wife OR relapse is reframed as a learning experience. It acknowledged the validity of the client�s observations but helps the client see them in a new way. Amplified reflection � making it worse than what the person said �This is something you will do for the rest of your life.� Person will then argue in the direction of change. Feeling reflection is a paraphrase that emphasizes the emotions behind the words

29. Examples of Reflective Listening �It sounds like . . .� �It seems as if . . .� �What I hear you saying . . .� �I get a sense that . . .� �It feels as though . . .� �Help me to understand. On the one hand you . . . and on the other hand . . .�

30. Exercise Think of a behavior you have been trying to change or about which you are ambivalent In groups of three, have one person be the speaker, one person practice using OARS and one person be the observer

31. Change Talk Problem recognition � disadvantages of the status quo Exploration of concern � advantages of change Intention to change Optimism for change Source: Michael Wiles and Cross Country Education, Inc., 2005 Questioning should be designed to try and elicit self motivational statements in four distinct areas. Problem recognition � How has your smoking created problems for you? Of How do you think you are being hurt by your drinking? Concern � What worries you about your diet? What are you afraid might happen if you don�t lose wieght? Intent to change � What might be better for you if you change your behavior? Optimism � What might work for you if you did decide to change? What difficult goals have you accomplished in the past?Questioning should be designed to try and elicit self motivational statements in four distinct areas. Problem recognition � How has your smoking created problems for you? Of How do you think you are being hurt by your drinking? Concern � What worries you about your diet? What are you afraid might happen if you don�t lose wieght? Intent to change � What might be better for you if you change your behavior? Optimism � What might work for you if you did decide to change? What difficult goals have you accomplished in the past?

32. Elicit Change Talk Six Types of change talk � DARN C 1. Desire � �I want, I would like to . . .� Ability � �I can or I could . . .� Reasons � �I should . . .because . . .� Need � �I need to . . .� Commitment � �I will . . .� Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. 2008 Task is to elicit change talk rather than resistance. Ambivalence often involves conflict between these four motivational themes. The first 4 are pre-commitment forms of change talk. Tune into change talk and affirm it when you hear it. When you evoke change talk, you are fueling motivation. As DARN motivations are voiced, commitment to change is strengthened. Desire � I wish I could lose some weight I want to feel better I like the idea of getting more exercise Ability � I could probably take a walk before supper Might be able to cut down a bit I can imagine making this change Reasons � I�m sure I would feel better if I exercised I want to be able to play with my children Need � I must get some sleep I have go to get more energy I should but I can�t\ I want to but it hurts Task is to elicit change talk rather than resistance. Ambivalence often involves conflict between these four motivational themes. The first 4 are pre-commitment forms of change talk. Tune into change talk and affirm it when you hear it. When you evoke change talk, you are fueling motivation. As DARN motivations are voiced, commitment to change is strengthened. Desire � I wish I could lose some weight I want to feel better I like the idea of getting more exercise Ability � I could probably take a walk before supper Might be able to cut down a bit I can imagine making this change Reasons � I�m sure I would feel better if I exercised I want to be able to play with my children Need � I must get some sleep I have go to get more energy I should but I can�t\ I want to but it hurts

33. Strategies To Elicit Change Talk Asking Evocative Questions Using Readiness Rulers Exploring the Decisional Balance Looking Back / Looking Forward Using hypotheticals Key Questions Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. 2008 Ask questions that can be answered with change talk. Why might you want to make this change? If you did decide to make this change, how would you do it? Use a ruler � rating scale from 1 to 10. Ask �How strongly do you want to . . . How important is it for you to? How ready to do you feel to make this change? How confident are you in your ability to make this change? Then ask � you rated it a 5. Why not a 3? The answer gives you change talk. Decisional balance � looking at the pros and cons of change. This helps to explore ambivalence. Mention attached forms What are the three most important benefits you see in making this change? What are some good things about what you are doing? What are some not so good things? Hypotheticals � Suppose you did decide to quit? How would your life be different? What would it take for you to go from a 5 to an 8 Looking forward � 5 years down the road, where do you want to be? Looking back � are there times in your life when things were going well? How was your behavior then? Key Question � tests the level of commitment What do you make of all this? What do you think you will do? What would be the first step for you? Ask questions that can be answered with change talk. Why might you want to make this change? If you did decide to make this change, how would you do it? Use a ruler � rating scale from 1 to 10. Ask �How strongly do you want to . . . How important is it for you to? How ready to do you feel to make this change? How confident are you in your ability to make this change? Then ask � you rated it a 5. Why not a 3? The answer gives you change talk. Decisional balance � looking at the pros and cons of change. This helps to explore ambivalence. Mention attached forms What are the three most important benefits you see in making this change? What are some good things about what you are doing? What are some not so good things? Hypotheticals � Suppose you did decide to quit? How would your life be different? What would it take for you to go from a 5 to an 8 Looking forward � 5 years down the road, where do you want to be? Looking back � are there times in your life when things were going well? How was your behavior then? Key Question � tests the level of commitment What do you make of all this? What do you think you will do? What would be the first step for you?

34. Evocative Questions Problem recognition � How has your smoking created problems for you? Of How do you think you are being hurt by your drinking? Concern � What worries you about your diet? What are you afraid might happen if you don�t lose wieght? Intent to change � What might be better for you if you change your behavior? Optimism � What might work for you if you did decide to change? What difficult goals have you accomplished in the past?

35. Importance Ruler How important is it for you right now to change? On a scale of 0 to 10, what number would you give yourself? 0������������������10 Not at all extremely Why are you at 4 and not at 1? What would it take for you to move from a 4 to a 6?

36. Decisional Balance Decisional balance shows that clients usually have good reasons to keep doing what they are doing. The hallmark of many risky behaviors is that people keep doing them in spite of negative consequences This technique helps to explore the costs and the benefits of the behavior. Discussing good things creates a safe context to talk about less good things. When the person describes the not so good things about continuing the behavior and the good things about changing, they are engaged in change talk.Decisional balance shows that clients usually have good reasons to keep doing what they are doing. The hallmark of many risky behaviors is that people keep doing them in spite of negative consequences This technique helps to explore the costs and the benefits of the behavior. Discussing good things creates a safe context to talk about less good things. When the person describes the not so good things about continuing the behavior and the good things about changing, they are engaged in change talk.

37. Eliciting and Strengthening Confidence Talk Evocative Questions The Confidence Ruler Reviewing Past Successes Personal Strengths and Supports Brainstorming Giving Information and Advice Reframing Hypothetical Change Source: �Preparing People for Change� William Miller, PhD Here you are supporting self efficacy � that belief that change is possible. On a scale of 1 to 10, how confident are you that you can make this change? What made you say a 4 rather than a 1? What has worked for you in the past? What enabled you to handle stress in the past? What strengths do you have that could help you make this change? Who in your life would support your behavior change? Examine extremes � what is the worst thing you could imagine would happen if you continue the way you are now? Suppose you did make this change � what do you think it was that made it work? How did it happen?Here you are supporting self efficacy � that belief that change is possible. On a scale of 1 to 10, how confident are you that you can make this change? What made you say a 4 rather than a 1? What has worked for you in the past? What enabled you to handle stress in the past? What strengths do you have that could help you make this change? Who in your life would support your behavior change? Examine extremes � what is the worst thing you could imagine would happen if you continue the way you are now? Suppose you did make this change � what do you think it was that made it work? How did it happen?

38. Confidence Ruler If you did decide to change how confident are you that you could change? On a scale of 0 to 10, what number would you give yourself? 0������������������10 Not at all extremely Why are you at 4 and not at 1? What would it take for you to move from a 4 to a 6?

39. Responding to Change Talk Reflecting Elaborating Summarizing Affirming Source: �Preparing People for Change� William Miller, PhD Elaborating � asking client to tell you more. You said . . . .What did you mean or tell me more about . . . .Elaborating � asking client to tell you more. You said . . . .What did you mean or tell me more about . . . .

40. Demonstration

41. What is Resistance? Behavior Interpersonal A signal of dissonance Predictive of (non)change Highly responsive to counselor style Source: �Preparing People for Change� William Miller, PhD In MI resistance is viewed as a communication problem between the counselor and the client or the patient and the health care provider. It is not something that lies with the person alone. Readiness to change is not a client trait but is a �fluctuating product of interpersonal interactions. In MI resistance is viewed as a communication problem between the counselor and the client or the patient and the health care provider. It is not something that lies with the person alone. Readiness to change is not a client trait but is a �fluctuating product of interpersonal interactions.

42. Four Categories ofResistance Behavior Negating blaming, disagreeing, excusing, minimizing, claiming impunity, pessimism, reluctance, unwillingness to change Arguing challenging, discounting, hostility Interrupting Ignoring Source: �Preparing People for Change� William Miller, PhD When we encounter resistance our tendency is to engage in the �righting reflex� � to set them straight. But if you argue for change, the person will voice arguments against it. Because people who feel ambivalent often have both sides of the argument within them, they will become less resistant when you reflect it non-judgmentally. Miller states �Resistance behavior is the person�s signal of dissonance in the relationship� not being in sync Arguing � person contests the accuracy or expertise of the helper Interrupting � person breaks in and interrupts in a defensive manner Denying � unwillingness to recognize problems, cooperate, accept responsibility or take advice Ignoring � not following through on recommendationsWhen we encounter resistance our tendency is to engage in the �righting reflex� � to set them straight. But if you argue for change, the person will voice arguments against it. Because people who feel ambivalent often have both sides of the argument within them, they will become less resistant when you reflect it non-judgmentally. Miller states �Resistance behavior is the person�s signal of dissonance in the relationship� not being in sync Arguing � person contests the accuracy or expertise of the helper Interrupting � person breaks in and interrupts in a defensive manner Denying � unwillingness to recognize problems, cooperate, accept responsibility or take advice Ignoring � not following through on recommendations

43. Ask Yourself Does my counseling intervention match the person�s readiness to change? Am I dismissing the person�s feelings and concerns? Am I undermining the person�s sense of personal autonomy to make a decision Am I acting as an expert and telling the person what changes are needed? Source: B. Borelli �Using Motivational Interviewing to Promote Patient Behavior Change and Enhance Health�

44. To Reduce Resistance Use reflective listening Use empathic statements Focus on building the relationship rather than getting the person to change Engage by discussing issues important to them Explore concerns Emphasize that change is their decision Source: B. Borelli �Using Motivational Interviewing to Promote Patient Behavior Change and Enhance Health�

45. Informing Ask for permission to share information Offer choices Talk about what others do Two strategies: Chunk-Check-Chunk Elicit-Provide-Elicit Scare tactics are not effective Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. 2008 Asking for permission is like knocking before entering. It directly honors and reinforces the person�s autonomy and active involvement. It emphasizes collaboration and it lowers resistance, Asking for permission makes the person more willing to hear it. �Would it be alright if I shared one of my concerns?� Can I make a suggestion? Would you like to hear what others have done? Offer several options and ask the person to choose among them. If you only offer one choice, you are inviting someone to tell you what is wrong with it. Telling what others have done and then asking what might work for you? Folks have found . . ., Others have benefited from . . ., Chunk-check-chunk � you give information then you check to see what the person thinks about it and then you offer more information. This style conveys respect and allows you to correct any misunderstandings. Elicit-provide-elicit � ask �what would you most like to know about or what do you already know about , then provide information and then ask what does this mean to you or what more would you like to know?Asking for permission is like knocking before entering. It directly honors and reinforces the person�s autonomy and active involvement. It emphasizes collaboration and it lowers resistance, Asking for permission makes the person more willing to hear it. �Would it be alright if I shared one of my concerns?� Can I make a suggestion? Would you like to hear what others have done? Offer several options and ask the person to choose among them. If you only offer one choice, you are inviting someone to tell you what is wrong with it. Telling what others have done and then asking what might work for you? Folks have found . . ., Others have benefited from . . ., Chunk-check-chunk � you give information then you check to see what the person thinks about it and then you offer more information. This style conveys respect and allows you to correct any misunderstandings. Elicit-provide-elicit � ask �what would you most like to know about or what do you already know about , then provide information and then ask what does this mean to you or what more would you like to know?

46. Demonstration

47. Traps to Avoid Premature focus Confrontation Labeling Blaming Question/answer trap Premature focus � focusing before the client is ready. Giving unsolicited advice or information before the person is ready to hear it leads to resistance. Confrontation � helper argues for change and person will argue reason for not changing. Question-answer trap � helper asks questions and person becomes a passive recipient of an investigation. It sets up counselor as the answer giving expert. Premature focus � focusing before the client is ready. Giving unsolicited advice or information before the person is ready to hear it leads to resistance. Confrontation � helper argues for change and person will argue reason for not changing. Question-answer trap � helper asks questions and person becomes a passive recipient of an investigation. It sets up counselor as the answer giving expert.

48. Recognizing Readiness Diminished resistance Decreased discussion about the problem Resolve Change talk Questions about change Envisioning Experimenting Source: �Preparing People for Change� William Miller, PhD You will notice a quieting down of their mannerisms and spirit. Less argumentative Questions about what may happen when I change. Envisioning - when I do change or when this is no longer part of my life . . . .You will notice a quieting down of their mannerisms and spirit. Less argumentative Questions about what may happen when I change. Envisioning - when I do change or when this is no longer part of my life . . . .

49. Exercise Remember that behavior you have been trying to change . . . This time have one person be the observer, one be the speaker and one person be the helper (home visitor or HCP). The helper is to assess readiness for change using readiness rulers, decisional balance, etc. and then provide some information using the MI informing style What was it like assessing for readiness to change? How was it to use that technique? How was it to be asked in that way? What difficulties did you experience?What was it like assessing for readiness to change? How was it to use that technique? How was it to be asked in that way? What difficulties did you experience?

50. Phase 2 Goal: Negotiate a change plan

51. Phase 2 Strategies Preparation Brainstorm best course of action Focus on what client believes if possible Action Assist client with taking steps toward action Help client remove barriers Maintenance Help client identify and utilize strategies for change Source: Michael Wiles and Cross Country Education, Inc., 2005

52. Negotiating a Change Plan Summary reflection Review of concerns Review of self-motivational statements Key Question � What next? Development of a change plan Source: Michael Wiles and Cross Country Education, Inc., 2005 A key question is a good follow-up after discussion of any of the DARN motivations, rulers, pros and concs. The essence of the key question is What Next? Examples: So what do you make of all this? So what are you thinking about smoking at this point? What do you think you�ll do What would be the first step for you? What if anything do you plan to do? You are looking for commitment language A key question is a good follow-up after discussion of any of the DARN motivations, rulers, pros and concs. The essence of the key question is What Next? Examples: So what do you make of all this? So what are you thinking about smoking at this point? What do you think you�ll do What would be the first step for you? What if anything do you plan to do? You are looking for commitment language

53. What Is A Change Plan? Setting specific goals Identifying high-risk situations and possible obstacles to change Identifying strategies and people who can offer support Evaluating whether to obtain a more formal assessment or seek additional help (i.e. in or outpatient treatment, self-help groups) C. Field, D. Hungerford, C. Dunn. �Brief Motivational Interventions: An Introduction� J Trauma 2005; 59:S21-S26 A change plan involves identifying specific steps the person is willing to take to change the behavior and a timeframe for doing so. Here you will want to identify what has worked and not worked for the person in the past. Identify internal and external triggers for the behavior and develop strategies to manage triggers Explore social supports, self reward and environmental change. A change plan involves identifying specific steps the person is willing to take to change the behavior and a timeframe for doing so. Here you will want to identify what has worked and not worked for the person in the past. Identify internal and external triggers for the behavior and develop strategies to manage triggers Explore social supports, self reward and environmental change.

54. Negotiating a Change Plan Setting Goals Considering Change Options Arriving at a Plan Eliciting Commitment Source: �Preparing People for Change� William Miller, PhD Set an implementation date. Set an implementation date.

55. Elements of a Change Plan The changes I want to make are . . . My main goals are . . . The first steps I plan to take are . . . Some things that could inhibit me are . . . Other people could help by . . . I will know the plan is working when . . . Source: Michael Wiles and Cross Country Education, Inc., 2005

56. Eliciting Commitment Summarize Review concerns Reinforce self efficacy Review plan Do you see any problems with it? Final question: Is this what you want to do? Source: Michael Wiles and Cross Country Education, Inc., 2005

57. Efficacy Effective in 75% of randomized controlled trials 94% of the trials used individual interviews MI outperformed traditional advice giving in 75% of these studies Effectiveness was shown even in brief encounters of only 15 minutes Effect was not related to counselor�s education background (physician vs. psychologist) Source: S. Rubak, A. Sandboek, T.Lauritzen and B. Christensen �Motivational Intervierwing: a Systematic Review and Meta-Analysis� British Journal of General Practice, April 2005 A 2003 meta-analysis of controlled clinical trials of adaptations of MI showed efficacy for alcohol, drug, diet and exercise problems. Also showed that the interventions were shorter and as a result may be more cost effective. Overall the percentage of people who improved following AMI treatment (51%) was significantly greater than the percentage who improved with either no treatment or treatment as usual (37%). It has been shown to be effective both as a stand alone treatment and as an adjunct to other treatments.A 2003 meta-analysis of controlled clinical trials of adaptations of MI showed efficacy for alcohol, drug, diet and exercise problems. Also showed that the interventions were shorter and as a result may be more cost effective. Overall the percentage of people who improved following AMI treatment (51%) was significantly greater than the percentage who improved with either no treatment or treatment as usual (37%). It has been shown to be effective both as a stand alone treatment and as an adjunct to other treatments.

58. Significant Effect Body Mass Index Total Blood Cholesterol Systolic blood pressure Blood alcohol concentration Number of cigarettes per day

59. Project Choices Multi-site collaborative study in three states of women age 18-44 who were not using effective contraception and engaged in risky drinking. The intervention used motivational interviewing to increase motivation to change. This randomized trial found that a brief motivational intervention decreased the risk of AEP. involving the CDC and, NOVA Southeastern University in Ft. Lauderdale, University of Texas Health Science Center in Houston, Tx and Virginia Commonwealth University in Richmond. The settings included jails, drug and alcohol treatment centers, primary care practices, hospital based OB GYN clinic, a Medicaid HMO and a media recruited sample. Counselors used motivation interviewing to express empathy, manage resistance with confrontation and support the person�s self efficacy. Participants had 4 counseling sessions and one contraceptive consultation. Risky drinking was defined as five or more drinks in one day. Statistically significant benefits of the Project CHOICES intervention were found for all primary outcomes � Alcohol exposed pregnancy, binge drinking and ineffective contraception. At 3, 6 and 9 month follow-up, the unadjusted odds of being at reduced risk for an AEP were approximately two fold greater in the intervention group than in the control group.involving the CDC and, NOVA Southeastern University in Ft. Lauderdale, University of Texas Health Science Center in Houston, Tx and Virginia Commonwealth University in Richmond. The settings included jails, drug and alcohol treatment centers, primary care practices, hospital based OB GYN clinic, a Medicaid HMO and a media recruited sample. Counselors used motivation interviewing to express empathy, manage resistance with confrontation and support the person�s self efficacy. Participants had 4 counseling sessions and one contraceptive consultation. Risky drinking was defined as five or more drinks in one day. Statistically significant benefits of the Project CHOICES intervention were found for all primary outcomes � Alcohol exposed pregnancy, binge drinking and ineffective contraception. At 3, 6 and 9 month follow-up, the unadjusted odds of being at reduced risk for an AEP were approximately two fold greater in the intervention group than in the control group.

60. Aids to Learning Use clinician who is skilled in MI as coach Set up on-going peer consultations Bring in an expert trainer Client feedback Coach can listen to your practice and give feedback. Staff can meet regularly in groups to discuss MI and listen to each other�s practice. Every time you practice MI your clients give you clues as to how you are doing. You know that you are doing well with a guiding style when clients keep talking to you, when they are expressing their own desire, ability, reasons and need for behavior change. Done well the guiding style opens clients to consider what they might do differently and to commit to taking steps. Coach can listen to your practice and give feedback. Staff can meet regularly in groups to discuss MI and listen to each other�s practice. Every time you practice MI your clients give you clues as to how you are doing. You know that you are doing well with a guiding style when clients keep talking to you, when they are expressing their own desire, ability, reasons and need for behavior change. Done well the guiding style opens clients to consider what they might do differently and to commit to taking steps.

61. Training Resources Motivation Interviewing Resources for clinicians, researchers and trainers http://www.motivationalinterview.org/

62. �Spend time picking flowers in the meadow of ambivalence, share the bouquet and in the process, help people find their own way into a healthier life.�

63. Resources �Preventing Alcohol Exposed Pregnancies: A Randomised Controlled Trial http://www.cdc.gov/NCBDDD/fas/publications/Preventing%20Alcohol-Exposed%20Pregnancies%20A%20Randomized%20Controlled%20Trial.pdf �The Efficacy of Motivational Interviewing: A Meta-Analysis of Controlled Clinical Trials� b. Burke, H. Arkowitz and M. Menchola Journal of Counseling and Clinical Psychology 2003, Vol.71, No.5, 843-861

64. Resources Continued B. Borrelli, �Using Motivation Interviewing to Promote Patient Behavior Change and Enhance Health� http://www.medscape.com/viewprogram/5757 S. Rollnick, P. Mason and C. Butler Health Behavior change: A Guide for Practitioners. Churchill Livingstone 1999 S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. Guilford Press 2008 C. Field, D. Hungerford and C. Dunn �Brief Motivational Interventions: An Introduction. J Trauma 2005; 59:S21-S26 M. Wiles Motivational Interviewing: Overcoming Client Resistance to Change Cross Country Education www.CrossCountryEducation.com