Taste of Motivational Interviewing (MI)

1. Taste ofMotivational Interviewing (MI) Charles H. Bombardier, Ph.D. Department of Rehabilitation Medicine University of Washington School of Medicine chb@u.washington.edu

2. Financial Disclosures 2011-2013 • Research Funding by Non-Profit entities: • National Institute on Disability and Rehabilitation Research, Dept. of Education • Outside pay from Non-Profit entities: • Hines VA—MI consulting • Long Beach VA—MI consulting • West Roxbury VA—MI consulting • Outside pay from For-Profit Corporations: • EMD Serono—MI consulting

3. Overview Review • The problem of nonadherence • What is motivational interviewing • Theoretical and empirical foundation Putting into practice • Learning MI core skills • Putting it all together • Next Steps

4. MI Style Patient-oriented Collaborative Focus on motivation Explore ambivalence Elicit reasons to change Elicit concerns Clinician listens more Traditional Fixer Style Goal-oriented Expert role Focus on action Direct persuasion Give reasons to change Give warnings Clinician talks more Contrasting Therapeutic Styles

5. What is Motivational Interviewing? Motivational interviewing is a patient-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence www.motivationalinterview.org

6. MI Acronym-OARS • Open-ended questions • Affirmations • Reflections • Summaries Listening

7. Process of Motivational Interviewing PHASE ONE PHASE TWO • Open-ended questions-Elicit change talk: • Desire, Ability, Reasons, Need • Good things, not so good things… • Important-Confidence Ask Key Question Elicit Commitment Negotiate Change Plan Reflections and Affirmations Summaries Empathy, Autonomy, Collaboration, Self-Efficacy Adapted from Miller and Rollnick, 1991

8. WHY BOTHER LEARNING MOTIVATIONAL INTERVIEWING?

9. The Problem of Non-adherence Simply giving patients advice to take medications or make lifestyle changes is often not effective. Rates of Nonadherence • Anti-hypertension drugs: 50% • Physical therapy: 33%-66% Sluijs, 1993 • Home exercise program: 36% never do Forkan, 2006 • Antibiotics: 27% (qd), 48% (tid), 58% (qid) • Rule of one-third (Meichenbaum & Turk, 1987)

10. Determinants of Patient Adherence Meichenbaum and Turk, 1987

11. Communication Training Helps • Nonadherence is 1.47 times greater among physicians who are poor communicators • Odds of adherence are 2.16 times greater if the physician is a good communicator • Odds of adherence are 1.62 better if the physician has had communication skills training. Zolnierek & DiMatteo, Medical Care 2009;47: 826-34

12. Stages of Change Heuristic • Precontemplation (~40%) -- not considering change; reluctant, resigned, resistant, unaware • Contemplation (~40%) – thinking about change, exhibits normal ambivalence about change, both pros and cons of change are present within the person • Action (~20%) – person ready to make behavioral change now • Maintenance – requires different strategies than adoption • Relapse is common (3-8 times is modal) Norcross et al 2012; Velicer et al., 1995

13. Indications and Contraindications for Motivational Interviewing If the person is ready to change or accept advice, no need for motivational interviewing. Move right in to negotiating an action plan. • They ask for advice or commitment language: • “I will do that..””I am going to do that…” • Readiness to change is rated at least 7-8/10 If the person is ambivalent or resistant, motivational interviewing works better than usual care • “I could, should, would like to…do that” • “Yes, but…” • “I have tried that before…” • “There’s no way I can…”

14. Theoretical Foundation

15. What Inhibits Change?Teaching and Confronting • Patterson-therapist teaching and confronting increase observable patient resistant behaviors in therapy sessions. • Therefore, we avoid confronting patients with information or giving unsolicited advice. We ask for permission before giving advice. We reflect rather than confront resistance.

16. What Facilitates Change? Empathy • Rogers-Accurate empathy promotes change. • Therefore, we use reflective listening to demonstrate understanding and acceptance of the patient’s subjective situation

17. What Facilitates Change?“Change Talk” “People are generally better persuaded by the reasons which they themselves discovered, than by those which have come into the mind of others.” Pascal's Pensees (17th century) “As I hear myself talk I learn what I believe.”Daryl Bem (1972) Therefore, we use open questions to elicit “change talk”, that is, statements of desire, ability, reasons and need to change from the person and avoid the opposite, creating situations where they argue against change.

18. What Facilitates Change?--Choice • Sanchez-Craig - Choice enhances adherence. • Brehm/Theory of Reactance - Threats to freedom elicit resistance. • Therefore, we try to give the patient choices and explicitly emphasize their autonomy and right to choose or even refuse.

19. What Facilitates Change?Values Discrepancy • Rokeach-Awareness of a discrepancy between behavior and core values creates change • Therefore, we elicit the person’s core values or goals and then clarify how their behavior fits or does not fit with these important ideas.

20. What Facilitates Change? Affirming Affirmations increase openness to feedback and treatment • Therefore we affirmaspects of the person’s character or experience • Different than praising, agreeing, judging • Start with You…. • Must be genuine. Use in moderation. *Harris et al., Health Psychol. 2007 Jul;26(4):437-46.

21. What Facilitates Change? Confidence • Bandura/Self-efficacy Theory: Optimism and hope facilitate change. • Therefore, we try toreinforce successive approximations to the goal. We affirm the person, point out their successes, even small ones. We reframe “failures” as intermediate successes whenever possible.

22. What Facilitates Change? Implementation Intentions • Goal intentions don’t trigger change: • “I want to start exercising.” • Implementation intentions do trigger change: • On M, W, and F, I will get up at 6:00 go to the gym and do 30 mins of aerobic exercise on the elliptical trainer. • Therefore, we ask open questions to have patients to spell out what, when, where, and how their goal will be put into action. (SMART goals) Gollwitzer Am Psychol 1999

23. Empirical Foundation

24. Efficacy of MI • Multiple meta-analyses document the efficacy of MI in multiple domains such as substance abuse, exercise, diet, HIV risk reduction adherence to treatment and tobacco use • Burke, Arkowitz, & Menchola, 2003 (30 studies) • Hettema, Steele, & Miller, 2005 (72 studies) • Vasilaki, Hosier, & Cox, 2006 (n=22 studies on drinking) • Lundahl et al., 2010 (119 studies)

25. The Efficacy of MI • Overall 75% of subjects improve; 50% make small but meaningful changes; 25% make moderate to large changes • Tends to produce comparable effects to other interventions in less time • Stronger effects are observed with the addition of individualized relevant feedback • Effects are durable at 3, 12, 24 months • Effects are similar across gender, age, race, ethnicity (may be better for minority persons) Lundahl et al., 2010

26. Trying Out Selected Motivational Interviewing Strategies

27. PRECONTEMPLATIONResistance = Red Light Non-Verbal • Poor eye contact • Arms/legs crossed • Turned away • Volume • Facial/body tension • Clenched jaw/fists • Slouched posture Verbal • Arguing • Interrupting • Denying • Disagreeing • Minimizing • Pessimism • Sidetracking (Miller & Rollnick, 1991)

28. CONTEMPLATIONAmbivalence = Yellow Light • Ambivalence about changing • Yes…..but, • I’m not sure… • Half-hearted commitment • I’ll try to … • I wish I could… • Giving in • If you say so…

29. DETERMINATION OR ACTIONCommitment = Green Light • “Tell me what I need to do.” • “I will do that.” • “I am going to do that.” • “I am committed to doing that.” • On a scale of 0-10 readiness I am 8, 9 or 10

30. Core MI Skills (OARS) • Open-ended questions • Affirmations • Reflections • Summaries Listening Miller and Rollnick, 2002

31. Reflective Listening • Mirrors back what the person is communicating and facilitates self-understanding, insight • Demonstrates/checks your understanding • Demonstrates empathy, acceptance • Decreases resistance (rolling with resistance)

32. Reflective Listening • Attention to the persons thoughts and feelings. • Think of it as “mirroring” or “checking in” • Functions are: • conveys empathy and understanding • reduces resistance • use to reinforce change talk

33. Forming Simple Reflections • An effective reflective listening response is a statement, not a question. The inflection stays down at the end. • Example: Depressed outpatient, “I thought I could get over this without counseling.” • So you did not follow up on the referral I gave you.? • So you did not follow up on the referral I gave you. • What is the effect of questions versus statements?

34. Tips on reflective listening • Guess at what they mean • You can use stems or no stems • “So, you think…” • “You are wondering if…” • “It sounds like …” • Just repeat an element • Paraphrase with synonyms • Reflect the content or their feelings

35. Open Questions--Basics • Open questions are ones that cannot be answered with a “yes’ or “no” • Open questions do not elicit specific answers like name or date. • Open questions often start with What or How

36. Open Questions--Functions • Open questions activate and engage the patient • Open questions get the patient talking, hopefully about change • Open questions can be used to demonstrate empathy, acceptance and elicit “change talk” • Use open questions to “steer” the conversation • Rules of thumb: • Open questions often start with “what” or “how” • Don’t ask more than 3 questions in a row. • Try to do at least one reflection for every question.

37. Open Questions-Advanced Elicit DARN • Desire to change • Ability to change • Reasons to change • Need to change Elicit Commitment to Change • “I will do that” • “I am going to…”

38. Strategic Open Questions • What are the good things about [behavior]?…How about the not-so-good things? • Advantages of change-How do you think exercising might help you? • Optimism about change-What makes you think you could check your blood sugar if you wanted to? • Intention to change-What sort of exercise would you be willing to try? • Disadvantages of the status quo-What concerns would you have about waiting to start an antidepressant?

39. Strategic Open Questions:Good things, less good things • Ask about the good things about the “bad” behavior first---Why? • Reflect, reflect, summarize • Ask about the not so good things about the “bad” behavior • Reflect, reflect, summarize • Summarize both sides • Ask key question: Where does this leave you?

40. Readiness-Two Dimensions 10 Readiness Importance 0 0 10 Confidence Rollnick, S., Mason, P., & Butler, C. (1999)

41. Strategic Open QuestionsImportance and Confidence • How important is it right now for you to …? On a scale from 0 to 10 what number would you give yourself? • Why are you at X and not at [lower number]? • What would need to happen for you to get from X to [slightly higher number]? Rollnick, 1999

42. Strategic Open QuestionsImportance and Confidence • If you decided to change, how confident are you that you would succeed? On a scale from 0 to 10 what number would you give yourself? • Why are you at X and not at [lower number]? • What would need to happen for you to get from X to [slightly higher number]? Rollnick, 1999

43. Using Strategic Open Questions • 46 yo female new onset diabetes, overweight, hyperlipidemia and HTN 2 years ago. Still smokes ½ to 1 pack a day and knows she needs to quit. • What are the good things about smoking for you? • What concerns do you have about your smoking? • How do you think stopping smoking would benefit you? • On a scale from 0-10, how important is cutting back on your smoking? • On a scale from 0-10, how confident are you that you could cut back if you wanted to? • What changes in your smoking would you be willing to try?

44. Affirmations • Good: Focus on healthy behaviors • “I appreciate how hard you are working on cutting back on smoking.” • Better: Focus on characteristics unrelated to the potential change behaviors • “I can see you are a good father.” • Even better: Use “You” statements, rather than “I” statements • “You are a good father.” • Best: Keeping your judgments out of it • “Being a good father is important to you.”

45. Summarize • Collecting summary-reinforces (elements of) what has been said, lets them know you are following • Reflect, reflect, what else? Summarize • Linking summary-ties together what the person has just said with earlier material, usually to help them reflect upon ambivalence • On one hand you feel x, y, z and on the other hand you also feel a, b, c. • Transitional summary-wrap up the end of a session or move on to another topic

46. Two Step Process of Change Desire Ability Reasons Need Commitment Language Behavior Change Amrhein, Miller, Yahane JCCP, 2003

47. Moving toward action with key question • Summarize both sides focusing on change talk • Ask a key question: • Where does this leave you now? • What is the next step? • What, if anything, are you willing to do at this point? • If they cannot come up with anything you may ask permission to give advice • Give menu of options (include status quo) • Have them choose; no change should be an option Miller and Rollnick, 2002

48. Giving Advice: Elicit-Provide-Elicit • Elicit what they already know and think • Provide information • Ask for permission to give information • Use neutral, non-personal language • “What other people in your situation have done …” • Be a little reluctant “You’re the expert about your life, but if you want I’ll offer some ideas.” • Offer at least two potential options • Elicit their reaction “Now I wonder what you make of all this?”

49. Agenda Setting: Menu of Options “When we work with people who deal with being overweight and increased cardiovascular risks, a variety of strategies can help. Which strategy seems like it would be most helpful for you? Increasing lifestyle activity Eating more fruits and veggies Eating less fast foods Starting an Exercise program Something else? Decreasing sedentary behaviors

50. For more information... • Miller W. & Rollnick, S. (1991, 2002) Motivational Interviewing: Preparing People for Change. Guilford Press: New York. • Rollnick, S., Miller, W. & Butler, C. (2008). Motivational Interviewing In Health Care. Guilford Press: New York. • www.motivationalinterviewing.org • Google “[your city] motivational interviewing training” • Questions? chb@uw.edu