William T. Dalton III, Ph.D. Licensed Psychologist & Assistant Professor

1. Utilizing Motivational Interviewing to Navigate the Rough Waters An Introduction and Opportunities for Practice William T. Dalton III, Ph.D. Licensed Psychologist & Assistant Professor Assistant Director of Clinical Training Elizabeth Conway-Williams, M.A. Doctoral Student Department of Psychology East Tennessee State University

2. Learning Objectives • At the conclusion of this presentation you should be able to… • Describe the characteristics of MI • Understand the guiding principles of MI • Understand the foundational clinical skills of MI • Understand additional clinical tools for practice of MI • Objectives will be met via… • Lecture • Video demonstrations • Practice via case studies

3. MI Defined • MI is a collaborative, person-centered form of guiding to elicit and strengthen motivation to change

4. Number of Hits on PsycINFO for “Motivational Interviewing”

5. Evidence Base for MI • Lundahl & Burke (2009) summarized results of four meta-analyses on effectiveness of MI • Effect sizes (Cohen’s D): • Weak comparison groups (e.g., wait-list): 0.28-0.40 • Strong comparison group (e.g., CBT or 12-step program): 0.04- 0.32 • Suggest that MI is significantly better than no treatment and generally equal to other established treatments for a wide range of problems

6. MI Applications • Alcohol-related problems • Marijuana dependence • Tobacco use • Other drugs (e.g., cocaine, heroin) • Engaging clients in treatment • Reducing risky behavior • Increasing healthy behavior

7. Other MI Applications • Asthma/COPD • Brain Injury • Cardiovascular Health/Hypertension • Dentistry • Diabetes • Diet/Lipids • Domestic Violence • Dual Diagnosis • Eating Disorders/Obesity • Emergency Department/Trauma/ Injury Prevention • Family/Relationships • Gambling • Health Promotion /Exercise/Fitness • HIV/AIDS • Medical Adherence • Mental Health • Offenders • Pain • Parenting Interventions • Reproductive Health • Sexual Behavior • Speech/Vocal Therapy

8. History • Motivational Interviewing Professional Training DVD (1998) • Interview With Founders • William Miller, Ph.D. (Clinical Psychology) • Stephen Rollnick, Ph.D. (Clinical Psychology)

9. History (Cont’d) • Motivation was once considered a trait or ingrained quality • MI was first described in 1983 to help motivate drinkers to change behavior (resistance) • Ambivalence was being considered a normal and defining state and the recognition that change is not usually made without inconvenience • Around the same period the trans-theoretical model of stages of change was being proposed

10. Stages of Change Precontemplation Contemplation Preparation Action Maintenance

11. How MI Works • Recognizes behavior change as a process • Individuals are considered to be in different stages of behavior change • Assists individuals in moving through stages via a combination of a strong patient-provider relationship and specific techniques that encourage patients to discuss the possibility of behavior change

12. Check-It!

13. MI Characteristics • Directive • Client-centered • Honors autonomy • Counseling style • Resolve ambivalence • Evocative • Collaborative • Minimizes resistance • Offers acceptance

14. MI is “Not” • Arguing that a person has a problem and needs to change • Offering advice without the patient’s permission • Doing most of the talking • Simply giving a “prescription” • A quick trick or simple procedure

15. MI Video Demonstration

16. Check-It!

17. Guiding Principles: RULE • Resisting the Righting Reflex • Roll with resistance • Understand Your Patients Motivations • Develop discrepancy • Listen To Your Patient • Express empathy • Empower Your Patient • Support self-efficacy

18. Check-It!

19. Foundational Clinical Skills: OARS • Open-ended questions • Affirmations • Reflective listening • Summarizing

20. Foundational Clinical Skills: OARS (Cont’d) • Open-ended questions • Questions that encourage patients to elaborate, feel respected, and elicit change talk • Examples • “Would you tell me more about ____?” • “How does smoking fit with your dreams of becoming a pro basketball player?” • “How does your current weight interfere with the activities you most enjoy?” • “In what ways is your diabetes a problem for you?” • “How have you overcome other obstacles in the past?”

21. Foundational Clinical Skills: OARS (Cont’d) • Open-ended questions • Avoid questions that can be answered yes/no • Examples • “Did you ____?” • “Will you ____?” • “Can you ____?” • “How many ____?”

22. Foundational Clinical Skills: OARS (Cont’d) • Affirmations • Statements reinforcing positive choices, strengths, and self-efficacy • Examples • “Coming in every week for therapy and doing homework is really tough. You are handling a difficult treatment protocol really well.” • “I’m impressed with how mature you are.” • “Absolutely! It is really tough to do all that you need to do when you’re not feeling well. And sticking to your diet makes it easier for you to do your chores, complete your homework, and hang out with your friends.”

23. Foundational Clinical Skills: OARS (Cont’d) • Reflective listening • Following along by restating what is said, clarifying, adding meaning, or highlighting emotions • Examples • “It sounds like you are feeling ____.” • “It appears that you see no real problem with your current drinking.” • “On the one hand your family really enjoys several hours of television each day and on the other hand you find that it is interfering with your family’s ability to be physically active which you also enjoy and find important.”

24. Foundational Clinical Skills: OARS (Cont’d) • Summarizing • Sum up patients stories, add insight and reinforce statements in favor of change • Examples • “It’s important for you to fit in with your friends. Sometimes adhering to your chest physiotherapy regimen makes that tough.” • “On the other hand, when you don’t adhere to your therapy, you notice that you don’t feel as well. And when you don’t feel as well, it’s even harder for you to keep up with the energy of your friends. Is there anything that you want to add that I may have missed?”

25. MI Video Demonstration

26. Check-It!

27. Additional Clinical Tools • Setting an agenda • Assessing readiness to change • Developing discrepancy • Pros/cons • Values and current behavior

28. Setting an Agenda • Ask permission to discuss a specific topic • “Would you be willing to spend a few minutes discussing your drinking?” • “Are you interested in discussing ways to better take your medicine?” • Ask patient to name an area of concern with the help of a menu of options • “There are several topics we could discuss related to your health. For example, taking your medicine, eating patterns, amount of physical activity or time spent watching television, smoking or drinking behavior, sexual activity, or even others. What is of most concern to you?”

29. Assessing Readiness to Change • Use of Rulers and Scaling • Two useful tools for assessing and enhancing patient readiness for health behavior changes are the Importance and Confidence Rulers • Both on a 11-point scale • 0 = least importance or confidence • 10 = most importance or confidence • Scaling or follow-up questions may be used to facilitate change talk

30. Assessing Readiness to Change (Cont’d) • “On a scale of 0 to 10, with 10 being ‘very important,’ how important is it for you to decrease your drinking?” • Reflect patient’s answer • “You chose _____.” • Ask follow-up questions • “Why did you not choose a lower number?” • “Why did you not choose a higher number?” • “What would it take to move to an _____?”

31. Assessing Readiness to Change (Cont’d) • “On a scale of 0 to 10, with 10 being ‘very confident,’ assuming you decided to drink less, how confident are you that you could succeed?” • Reflect patient’s answer • “You chose _____.” • Ask follow-up questions • “Why did you not choose a lower number?” • “Why did you not choose a higher number?” • “What would it take to move to an _____?”

32. MI Video Demonstration

33. Developing Discrepancy: Pros/Cons • Allows patients to list the pros and cons of changing or of not changing health-related behaviors , and then to assign subjective weights (of importance) to each • “Tell me some good and not so good things about taking your medicine.” • “Let’s list together and discuss the pros and cons of completing your homework. Afterwards, let’s list together and discuss the pros and cons of not completing your homework.”

34. Developing Discrepancy: Values and Current Behavior • Values for You • Good parent • Responsible • Disciplined • Good spouse • Respected at home • On top of things • Spiritual • Others: ____ • Values for Your Family • Cohesive • Healthy • Peaceful meals • Getting along • Spending time together • Others: ____

35. Developing Discrepancy: Values and Current Behavior (Cont’d) • What do you value most? How does your/your child’s/family’s current lifestyle fit in with that? • “On the one hand you value a healthy family and on the other hand you and your child have excess weight and you report that your diets are poor?” • “So where does that leave you?”

36. MI Video Demonstration

37. Review • Characteristics • Guiding Principles • Resisting the righting reflex • Understand your patients motivations • Listen to your patient • Empower your patient • Foundational Clinical Skills • Open-ended questions • Affirmations • Reflective listening • Summarizing • Additional Clinical Tools

38. Questions

39. Practice Application • Review case studies • Case 1 • Case 2 • Turn to your neighbor • Develop a plan • Stage of change? • Goals? • What foundational clinical skills would you emphasize? • Which additional clinical tools may you use?

40. Practice Application (Cont’d) • Role-play between group members • Divide into groups of 3 • One person patient • One person health care provider • One person evaluator • Patient reviews script • Health care provider practices foundational clinical skills (OARS) and at least 1 additional clinical tool (i.e., Assessing readiness to change, Pros/cons, or Values and current behavior) • Evaluator monitors progress and provides feedback

41. References/Resources • Barlow, S. E., & the Expert Committee. (2007). Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics, 120 (Suppl. 4), 164-192. • Erickson, S. J., Gerstle, M., & Feldstein, S. W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings. Archives of Pediatrics and Adolescent Medicine, 159, 1173-1180. • Glynn, L. H., & Levensky, E. R. (2009). Promoting treatment adherence using motivational interviewing: Guidelines and tools. In L. C. James & W. T. O’Donohue (Eds.), The primary care toolkit: Practical resources for the integrated behavioral care provider (pp. 199-231). New York: Springer. • Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245. • Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160. • Resnicow, K., Davis, R., Rollnick, S. (2006). Motivational interviewing for pediatric obesity: Conceptual issues and evidence review. Journal of the American Dietetic Association, 106, 2024-2033.

42. References/Resources (Cont’d) • Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37. • Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: The Guilford Press. • Miller, W., & Rose, G. (2009). Towards a theory of motivational interviewing. American Psychologist, 64, 527-537. • Rollnick, S., Miller, W. R., & Butler, C. C. (1999). Health behavior change: A guide for practitioners. New York: Churchill Livingston. • Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: The Guilford Press. • Sindelar, H. A., Abrantes, A. M., Hart, C., Lewander, W., & Spirito, A. (2004). Motivational interviewing in pediatric practice. Current Problems in Pediatric and Adolescent Health Care, 34, 322-339. • Motivational Interviewing: Resources for Clinicians, Researchers, and Trainers • http://www.motivationalinterview.org/