Motivational Interviewing • In The Real World Annie Fahy RN, LCSW anniefahy.com
Goals of Training • Foundational Proficiency • New Ideas • Desire to Learn More • Increase Confidence in skills and strategies • Adaptation to Real World setting and Practice~ • HOW DOES THAT SOUND?
Four Processes of MI • Exploration- Importance,Confidence, Readiness • Evoking-of ambivalence versus status quo • Eliciting- Change Talk • Evaluation-Planning, Problem solving, timing interventions • All your senses • Acceptance/Non-Judgement • Curiosity • No Interuption
Listening With... • Presence • Undivided Attention • All Your Senses • Curiousity • No Interuption • Non-Judgement Exploring
Encouragers • mmm-hmmm • I see, go on, oh, what else? • TELL ME MORE Exploring
Summaries • The pearls of what you heard • what stays with you- what’s important • Bring out sooner rather than later • shorter rather than longer Evoking
Did I Get It All? Exploring
GET REAL • RESPECT • EMPATHY • ACTIVE COLLABORATION • LISTENING
Motivational Interviewing • Is a Conversation • Is Client Centered • Is Focused on a Target Behavior • Moves From Client -led (Centered) to Collaborative Goal Directed depending on several factors
MI Recipe ~Importance, Confidence, Readiness 0~~1~~2~~3~~4~~5~~6~~7~~8~~9~~10 “ On a scale of 0-10 How important ?” “Why are you at a (Number) rather than a (lower number)?” “What would it take to get you to a (higher number)?”
Most Current Definition • MI is a collaborative, goal oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for committment to a target behavior change by eliciting and exploring an individual’s own argument for change and plan for change.
Study: Adolescents brought to the ER,injured and intoxicatedLocation: Rhode IslandTreatment: 1 Session of MI (35-40 Min) in ERComparison: ER treatment as UsualFollow Up: 6 Months
Meta-Analysis-Hettema,J.& Miller,W.R.,2005, Motivational Interviewing. Annual Review of Clinical Psychology,1:91-111 • 72 Studies met inclusion criteria • Topics included: HIV/AID/alcohol,smoking,drug abause,treatment compliance,gambling,intimate relationships,water purification,eating disorders,diet and exercise
Meta-Analysis-Hettema,J.& Miller,W.R.,2005, Motivational Interviewing. Annual Review of Clinical Psychology,1:91-111 • Wide variability of effect sizes across studies,even within problem areas • 53% showed significant effect • Effect of MI tends to be seen early • Effect diminishes across a year of follow-up • Additive Effect
Meta-Analysis-Hettema,J.& Miller,W.R.,2005, Motivational Interviewing. Annual Review of Clinical Psychology,1:91-111 • Ethnic composition significantly predicted the strenth of the response, accounting for 19% of the variance. • Effects of MI were significantly larger for minority samples vs, non-minority white samples.
Conclusions • MI has small to medium between-group effect sizes • Effects diminish across time except when MI is added to standard treament • Efficacy increased among ethnic minority populations
Person-Centered Collaboration Engaging Strategies OARS Importance, Confidence &Readiness Guiding & Coaching Change Talk Giving Feedback Action Plans
Anger Management Develop Coping Skills Substance Use Medication Adherence School Attendance Exercise Emotional Management Skills Acheiving a Personal Goal Diet
Resistance Producing Style • Confronting • Persuading • Nagging • Interupting • Ordering • Judging • Too Teachy • Taking Charge Directing • Talking Down to • Exerting authority or Expert • Pressuring, criticizing, scaring, shaming, scolding...
Traps that create push back from client • The question answer trap • The taking sides trap • The expert trap • The labeling trap • The scare tactics-tough love trap • The pouncing trap • The information overload trap • The premature action planning trap
EXPLORING (MI SPIRIT)Primary Goals:Nurture hope and confidenceMinimize resistanceEvoke and resolve ambivalenceElicit & Enhance “change talk” Evaulate & Move to Action
Michaelangelo Belief • Primary Belief (Michelangelo Belief): The capacity and potential for change and adherence is within very person! • “People possess substantial personal expertise and wisdom regarding themselves, and tend to develop in a positive direction, given the proper conditions and support…” • - Miller & Moyers, ’06
Reflective Listening • Simple reflection- restating • Complex- Paraphrasing, reflecting emotion values beliefs, ambivilance • Metaphor- Its as If... • Completing Paragraph
Complex Reflection Bingo! • Emotion- “you feel.. • Process- “this is hard for you...” • Values- “_____ is important to you...” • Descrepancy- internal conflict • Ambivilence • metaphor- “Its as if...”
Targets for OARS Descrepancy (internal conflict) Ambivalence Values Goals Confidence Aspirations Strengths Emotion Process
Maintenance Relapse Action Preparation • Timing Interventions • W Return to Old Thinking Contemplation Precontemplation
Practice Skills=OARS • Open Questions- Disarming Questions, Stength-based questions • Affirmations- culturally based, reflection of ability, confidence, self efficacy • Reflections- skillful and complex is better • Summaries- directional, testing readiness etc
Following Exploring& Evoking Directing Guiding Evoking+Eliciting Finding The Balance
Change Talk • Desire: “I Want to.” • Ability: “I know how to.” • Reasons: “I have reasons to.” • Need: “I need to.” • Comittment: “I Will!”
Change Talk: • Represents movement toward Change! • Highly influenced by couselor style! • A primary vehicle for exploring, resolving ambivalence and promoting behavior change!
Why would Change talk facilitate change? • Facilitates awareness and insight-Engle & Arkowitz • Enhances emotional salience-Wagner & Ingersoll • Persuades speaker what they believe when ambivalent is prominent Miller & Rollnick via Bem
Change Talk DARN- CAT Preparatory Change Talk Desire: “I want to...” Ability: “I can...” Reasons: It’s important; there are good reasons...” Need: “I really need to...” Activating Change Talk Committment: “I’m going to; I intend to; I will; I must.” Taking Steps
Person-Centered Collaboration Guiding & Coaching EXPLORE AMBIVALENCE Reflective Listening OARS Desire Ability Reasons Need Committment Feedback Action Plans Client Led Minimize Resistance Evocative Respectful
Change Talk Script • Why would you want to make the change? • how would you go about doing it? • What are your three top reasons to make the change? • On a scale of 0-------10 how important? • why are you at a ______(number) • Offer summary • what do you think you will do next?
Evoking Change Talk • Asking Evocative questions: What would it be like...? Have you thought about... • Hypotheticals • Exploring pros & Cons-Decisional Balance • Tell me More • Imagining Extremes • Looking Forward... Looking back • Ruler Questions • Stengths & Values
Deciding to Use MI • Is there a healthier target behvior? • What stage of change is the client in? (desire ability reasons...) • What fundamental principal applies? (empathy,descrepancy, autonomy,respect,non-judgement • What strategies do I use? What do I emphasize
Practice The MI Flow • Agenda Setting • Explore • Provide • Check In • Voice Confidence
Practice The MI FlowGiving Feedback/info • Explore- what client already knows • Provide-small nuggets; don’t dump info, offer choices • Check In- what do you think about this? • Voice Confidence
Giving Feedback Guidelines • Ask Permission • Slow Down • Be clear concise- Small nuggets • Aviod info dump • Use visuals • Avoid technical terms and jargon • Offer Choice and also what others do • EXPLORE OFFER EXPLORE
Exploring Ambivalence • Ask Permission: is it ok if we spend a few minutes talking about...? • Ask disarming open ended question: What are some advantages of keeping things the way they are? • Ask a reverse open ended question: On the other hand what are some reasons for making the change? • Sumarize both sides of amvivilence • Check in- Did I get that right? Did I get it all? • What might you do next if anything? • Show Appreciation. Voice confidence • Voice Confidence
Mining for StrengthsStrength Based questions • Values • Goals • Other changes • Past Successes • What is Unseen
Person-Centered Collaboration Guiding & Coaching EXPLORE AMBIVALENCE Desire Ability Reasons Need Committment Feedback Action Plans Reflective Listening OARS Client Led Minimize Resistance Evocative Respectful
Soak one practitioner in acceptance juice until all traces of righting reflex has disapeared. Marinate in MI workshop and allow to simmer gently. Gradually beat in respect for client autonomy and collaboration, Roll out any resistance encountered Stir in Skills practice and allow the MI flavor to grow. Sprinkle with open ended questions, reflections and summaries and serve with a guiding style