MOTIVATIONAL INTERVIEWING

Transcription

1 MOTIVATIONAL INTERVIEWING Facilitating Behaviour Change Dr Kate Hall MCCLP MAPS Senior Lecturer in Addiction and Mental Health School of Psychology, Faculty of Health, Deakin University. Lead, Treatment Stream: Deakin University Centre for Drug, Alcohol and Addiction Research (CEDAAR)

2 LEARNING OBJECTIVES To understand the key theoretical underpinnings of Motivational Interviewing (MI). To have an informed opinion about when MI may be of use in facilitating behaviour change. To experience an MI Interaction. To differentiate an MI interaction from advice and information giving. To view MI as an additional tool in General Practice for facilitating behaviour change.

3 WHAT IS MOTIVATION? Motivation is a dynamic state that can be influenced. Motivation fluctuates in response to a practitioner s style. An authoritative or paternalistic therapeutic style may in fact deter change by increasing resistance

4 IMB MODEL, FISHER AND FISHER, 2005.

5 MODIFIABLE DETERMINANTS OF MOTIVATION SUMMARISED BY ABRAHAM, 2017 If the advantages outweigh the disadvantages Anticipate a positive emotional benefit of the behaviour If the behaviour aligns with social (normative) pressure (particularly young people) Perceive the behaviour to align with self-image Believe they are capable (high self-efficacy)

6 MOTIVATIONAL INTERVIEWING Motivational Interviewing is a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Miller & Rollnick, 2002 Motivational Interviewing is a collaborative conversation style for strengthening a person s own motivation and commitment to change. Miller and Rollnick, 2013

7 MI SNAPSHOT Strategies Building commitment to change Principles Building commitment to change Building motivation to change Spirit

8 THE SPIRIT OF MI Collaboration Compassion MI Spirit Acceptance Evocation

9 SPIRIT OF MI Fundamental approach of MI Collaboration: Create an atmosphere conducive to change by developing a partnership that honours the client s expertise and perspectives Evocation: The resources and motivation for change are presumed to reside within the client. Autonomy: The counsellor affirms the client s right and capacity for selfdirection and facilitates informed choice. Compassion: the counsellor empathises with the client s dilemma about change. Mirror-image opposite approach to counselling Confrontation: Counsellor imposes their reality that the client cannot see or will not admit to. Education: The client is presumed to lack key knowledge necessary for change to occur. Authority: The counsellor tells the client what he or she must do. Judgment: the counsellor is judgemental or blames the client for not changing. Source: Miller & Rollnick, 2002; 2013

10 MI REQUIRES INHIBITION OF STANDARD PRACTITIONER RESPONSES FOR ADHERENCE THEREFORE Not necessary unless Ambivalence about change Resistance to change Feel stuck Low on importance of change Low on willingness to change Low on self-efficacy that they can change Low on skills to change

11 AMBIVALENCE IS A NORMAL STATE A conflicted state where opposing attitudes or feelings coexist in an individual Stuck between simultaneously wanting to change and not wanting to change Common when conflict between an immediate reward and longer term adverse consequences (eg. substance abuse, weight management) Getting stuck in ambivalence can intensify problems

12 CHARACTERISE THE TARGET BEHAVIOUR

13 REFLECT ON PRACTITIONER STYLE Be curious Thoughts on in session case notes? Withhold advice or problem solving Summarise Check in to hone your understanding Amplify/underestimate Elicit by reflecting on others in their situation Gather sufficient information to characterise the problem.

14 PRINCIPLES OF MI: RULE Resist the righting reflex Understand the patient s own motivations Listen with empathy Empower the patient

15 DEVELOP A FORMULATION OF THE TARGET BEHAVIOUR Step 1: Identify and describe the target behaviour Include a behavioural, cognitive, affective, somatic, description of symptoms Q? What, when, where, with whom, how often? Q? What are the patient s own beliefs about the problem? Q? How distressing, how disruptive (severity)? Step 2: Contexts and modulating variables: Q? In what situations is it better or worse? What behaviours, cognitions, interpersonal interactions, affective or physiological states make it better? Worse?

16 DEVELOP A FORMULATION OF THE TARGET BEHAVIOUR Step 3: Develop an hypothesis about what has maintained the presenting problem or primary mental health issue (Perpetuating factors) Situational, behavioural, cognitive, interpersonal, affective, physiological, avoidance Step 4: Describe a relevant history to identify biopsychosocial Predisposing and Protective factors. Strengths and coping, social resources History of past treatment and responses

17 Acceptance AND Change Problem Solving Validation

18 PAIRS EXERCISE

19 EXERCISE - PERSUASION Pairs exercise (clinician, client) Patient: Choose something about yourself that you want to change should change have been thinking about changing... BUT, you haven t done anything about yet. Practitioner: Find out what they want to change. Explain why they should make the change Give 3 benefits of changing Emphasise how important it is to change Persuade them to do it! If they say yes, but.. or resist, persuade harder.

20 WHAT MOTIVATES US? RULE no. 1 Nobody likes being told what to do. RULE No 2 Persuasion doesn t work, when you are ambivalent about change. Righting reflex + ambivalence = resistance to change RULE no. 3 Making people feel bad, shaming them, scaring them means they are less likely to change.

21 NORMAL HUMAN RESPONSE TO THE RIGHTING REFLEX (ADVICE/TEACH/DIRECT) Invalidated Not respected, not heard, not understood, shamed, uncomfortable, angry, unable to change Miller, Resist Argue, discount, defend, deny, justify, justify Withdraw Disengage. dislike., tune out, passive, avoid, leave, don t come back

22 EXERCISE - LISTEN Patient (same topic). Practitioner: Listen with interest, try to understand the dilemma Give no advice Ask 4 questions: 1. Why do you want to make this change? 2. How might you go about it? 3. What are the 3 best reasons for you to do it? 4. On a scale from 1 to 10, how important is for you to make this change? Why are you at and not zero? Now give the client a summary of everything they ve told you. Then ask, So what do you think you will do?

23 NORMAL HUMAN RESPONSE TO A GOOD LISTENER/EMPATHIC STYLE Affirmed Understood, accepted, respected, heard, safe, empowered, hopeful, able to make change. Miller, 2013 Accept Open, interested, cooperative, not defensive, listening. Approach Talk more, liking, engaging, activated, come back.

24 STAGES OF CHANGE

25 Client Stage Pre contemplation (not ready) Contemplation (Getting ready) Action (ready) Maintenance (sticking to it) Relapse (learning) Your Tasks Raise doubt increase the patient s perception of risks and problems with current behaviour. Provide harm reduction strategies. Explore ambivalence and alternatives Identifying reasons for change/ risks of not changing Increase the patient s confidence in their ability to change Clear goal setting help the patient to develop a realistic plan for making a change Help the patient to identify and use strategies to prevent relapse. Help the patient to renew the processes of contemplation and action without becoming stuck or demoralised because of relapse.

26 MI Strategies Principles Building commitment to change Spirit

27 PRINCIPLES OF MI 1. Express Empathy 2. Develop Discrepancy 3. Roll with Resistance 4. Support Self-Efficacy

28 MI Strategies Strengthening commitment to change Principles Spirit

29 STRATEGIES OF MI (2002) Phase 1: Building motivation to change Core Skills OARS Open ended questions Affirm Reflective Listening Summarising Phase 2: Strengthening commitment to change Elicit change talk Decide on a change plan

30

31

32 RULERS If you can think of a scale from zero to 10 of how important it is for you to finish you to change {behaviour}. On this scale, zero is not important at all and 10 is extremely important. Where would you be on this scale? Can I ask why are you at and not zero? What would it take for you to go from to (higher number)?

33

34

35 STRATEGIES TO ELICIT CHANGE TALK Ask targeted questions from the following four categories: disadvantages of the status quo advantages of change optimism for change intention to change

36 KEY MI QUESTIONING Disadvantages of the status quo What worries you about your motivation to change {the behaviour}? What difficulties have resulted from {the behaviour}? In what way does {the behaviour} concern you? Advantages of change Where would you like {the behaviour} to be in 5 months time? (note: young people next week) What are the advantages of reducing {the behaviour}? What would be different in your life if you had changed {the behaviour}?

37 Optimism for change When have you made a significant change in your life before? How did you do it? What strengths do you have that would help you make a change? In what ways do you want your life to be different in 5 years? Intention to change Forget how you would get there for a moment. If you could do anything, what would you change about {the behaviour}?

38 BUILD A CHANGE PLAN It sounds like things can t stay the same as they are. What do you think you might do? What changes were you thinking about making? What do you want to do at this point? How would you like things to turn out? After reviewing all of this, what s the next step for you?

39

40

41 4 PROCESSES IN MI (2013) Planning Evoking Change plan Focusing Expand understanding, Develop discrepancy, roll with resistance, Elicit Change talk Engaging Clear direction and goals, agenda setting Spirit and OARS, be curious about client and behaviour.