Unlocking the Secrets to Motivational Interviewing for Chronic Disease Prevention and Treatment

Transcription

1 Unlocking the Secrets to Motivational Interviewing for Chronic Disease Prevention and Treatment Rhonda DiNovo, LMSW Clinical Assistant Professor, COSW

2 Today s Learning Objectives Intro to Motivational Interviewing: Brief History Theoretical Framework Definition Style Spirit Process and Techniques

3 The Basic Facts of Motivational Interviewing Founders: Dr. Miller & Stephen Rollnick, 1991 MI evolved from the addiction field, and now applies to numerous behavior changes (ie. Mental health, co-occurring disorders, weight change and nutrition, HIV, medication adherence, gambling, smoking cessation, and non-clinical settings such as schools, universities, etc. MI is evidence-based, that is has been shown through research methodologies to be successful and replicable MI is designed to work fairly quickly, often requiring just 2 to 4 sessions, which makes it relatively fast acting and inexpensive. MI is NOT a form of cognitive-behavioral therapy, but rather a tool for addressing a problem and motivating change MI is NOT a therapeutic technique, but rather a conversational style (copyright, K. Sciacca, 2009)

4 New Material: Constructing a Theoretical Framework for MI MI practice aligns with four foundational social work theories: Person-Centered Approach: non-directive, empathic approach that empowers and motivates Self Determination Theory: examination of psychological needs and continuum of motivation Trans-theoretical Model of Change: understanding fluctuations in and incremental stages of changes Mindfulness: A state of active, open awareness and attention on the present moment

5 Person-Centered Approach Carl Rogers, American psychologist and founder of humanistic theory (person-centered care) Miller and Rollnick s Principles of Person Centered Care: The needs of our clients have priority. Change is self change. Our service is one of facilitation. People are their own experts. We don t make change happen. Change requires partnership. Motivation for change is not installed, rather evoked. Clients make their own decisions. XvO8tvrtOms X6fidphMX38 xi76tmxejig

6 Self Determination Theory People have natural or intrinsic tendencies to behave in healthy & effective ways. Three psychological needs must be met: Competence The need to be effective in dealing with environment Autonomy The need to control the course of their lives Relatedness The need to have close, affectionate relationships with others SelfDeterminationTheory.org

7 The Self-Determination Continuum What s the source? A-Motivation Ex-External Ex-Somewhat external Ex-Somewhat internal Ex-Internal In-Internal What regulates MOTIVATION? Nonintentional, incompetence, lack of control Compliance, external rewards/punishment Self-control, ego, internal rewards/ punishment Personal importance, conscious valuing Congruence, awareness, synthesis with self Interest, enjoyment, inherent satisfaction Based on Ryan, R.M. & Deci, E.L. (2000). Self-Determination Theory & the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. American Psychologist. 55(1),

8 Fall back into old patterns of behavior Stable, safer lifestyle Trans theoretical Model: Theory of Change Go Back (Relapse) Precontemplatio n No intention of changing behavior Contemplati on Aware a problem exists, but no commitment to action Sustained change new behavior replaces old Maintenance Preparation Intent upon taking action Action Actively modifying behavior

9 Mindfulness Theory Definition: A state of active, open awareness and attention on the present moment. Observation of thoughts and feelings from a distance, without judging them as good or bad. We have thoughts, but we are not our thoughts.

10 Mindfulness Principles Live in the present, here-and-now moment. Engage fully in what you are doing rather than getting lost in your thoughts Consciously set intentions. They set the stage for what is possible and directly determine outcomes. Experience awareness of here-and-now moments with openness, interest and receptiveness. (In this way, even painful thoughts, feelings, sensations and memories can seem less threatening or unbearable) Facilitate being, rather than doing. Be still and observe in a non-judging, non-striving way. Allow your feelings to be as they are, let them come and go rather than trying to control them. Become aware in four main areas: body (breath), feelings, mind (awareness, concentration), mind-object (what we think about).

11 Definition of Motivational Interviewing A collaborative conversation style for the primary purpose of strengthening a person s own motivation and commitment to change

12 The Style of MI Not just techniques A way of being present with a person A way of guiding through communication Approach the relationship with exploration and wonder

13 The Spirit of MI Habits of the Heart We are a privileged witness to change Four key elements Partnership Acceptance Compassion Evocation

14 Partnership is Working together Showing interest and support is not Done by someone, to someone Persuasion and argument How do you achieve this? - Practice self-awareness - Ask, don t tell - Keep your righting reflex in check *Client centered About you (the facilitator) A waltz A wrestling match Motivational Interviewing, Miller & Rollnick

15 Acceptance is about worth autonomy empathy affirmation is not about approval of actions acquiescence to status quo How do you achieve this? Demonstrate: Absolute Worth Accurate Empathy Autonomy Affirmation Motivational Interviewing, Miller & Rollnick

16 Compassion What: Seek and value the well being of another Deserve the trust you been given How do you achieve this? Actively promoting and committing to the pursuit of another s welfare Giving priority to their needs

17 Evocation is Trusting the *client Drawing water from the well is not Strengthsfocused Deficitfocused Believing you know best Watering from a garden hose How do you achieve this? Drawing out Evoking and strengthening change motivations that are already within Motivational Interviewing, Miller & Rollnick

18 The MI Process Two phases: 1. Building motivation 2. Strengthening commitment to change Engaging Focusing Evoking Planning The four processes flow, overlap, and recur.

19 Process Step #1: Engagement Establishment of mutual trust and respect Agreement on treatment goals Collaboration on mutually negotiated tasks to reach the goals

20 Technique for Engaging: Four Basic Listening Skills OARS: Open-ended questions Affirming Reflective Statements Summarizing

21 Technique for Engaging: Utilizing OARS to Explore Values and Goals Exploring client s top 5-10 values is important/key to: Appreciating client s internal frame of reference Knowing/utilizing what motivates client Promoting engagement Focusing and guiding their actions Reflecting on discrepancies and inconsistencies

22 Process Step #2: Focusing Clarifying, developing and maintaining a specific direction in the conversation about change Goals may/may not involve behavior change. Change can also occur in attitude, thoughts, acceptance of not change

23 Three Sources of Focus The client (presenting problem and concerns) The setting (agency is funded to address specific issues and provide certain services) The SW (own perceptions of the issues to address)

24 Technique for Focusing: Agenda Mapping Agenda mapping involves a sequence of actions: Structuring Statement: Would you mind if we consider, Can we take a moment to discuss Considering Options: list the options we might focus on together Allow client to reflect on options, include affirmations, invite new ideas, reflect, and include your opinions Zooming In: Consider priorities, urgent attention items, limits to focus, negotiate best option Summarize: Wrap up by mentioning the big picture of what you ve considered together, then pinpoint one or two top priorities, remind client that we can return to the map when needed, and finish by asking for client s response what else?

25 Technique for Focusing: Exchanging Information Utilizing Elicit-Provide-Elicit It s unhelpful to provide info the client already has considered or tried EPE: the information is sandwiched between two questions of permission Respectful way to provide information that prevents you from telling client what they already know, which increases client s willingness to listen Allows you to use the time wisely by providing them with info they do need/want to know, and allows client to decide

26 Technique for Focusing: Information Exchange Utilizing Elicit-Provide-Elicit Elicit (Ask): Ask permission, allow them to choose what to do or think, agree or disagree Explore client s prior knowledge, clarify information needs and gaps Ask about their interest in whatever information you may be able to provide Ask: May I.?, Would you like to know.?, Is there any info I can offer?, What do you know about..? Provide (Tell): Prioritize what information to provide Give clear, manageable doses, Use every day language Use autonomy-supportive language, Acknowledge freedom to disagree or ignore Elicit (Ask): Checking back in to inquire about their understanding, interpretation or response to the info Ask open-ended questions: What do you think about the information?, What do you think you will do with the information?, How does this information relate to your situation? Reflect reactions: You seem surprised, You look resolved, You are thinking about something

27 Process Step #3: Evoking Social worker elicits motivation for change through OARS Clients respond, and their own talk moves them into change

28 Acronym: DARN Evoking Part #1: Preparatory Change Talk None of these, alone or together, indicate that change in going to happen D- Desire Statements I want to make my life better. A-Ability Statements I can do it. R-Reason Statements Here are the reasons I have to quit. N-Need Statements I need to do this.

29 Evoking Part #2: Mobilizing Change Talk Acronym: CAT Committing language signals likelihood of action C-Commitment I will, I promise, I intend to, I guarantee A-Activation Language that describes when and how the change will occur T-Taking Steps Speech that indicates steps have been taken in the direction of change

30 Technique for Evoking: Decisional Balance Ambivalence (mixed feelings about change) is normal and necessary Ambivalence can be uncomfortable and complex Solution: Neutrality (not encouraging movement in a particular direction) Rather, explore both pros/cons of options in a balanced way h?v=7vj8jbqzvqu

31 Technique for Evoking: Decisional Balance

32 Process Step #4: Planning Developing commitment to change and formulating a plan for action by eliciting the client s own solutions, promoting autonomy and strengthening change talk

33 Technique for Planning: Development With several clear options, task is to prioritize and choose Steps: (Path mapping/similar to agenda mapping) Confirm the goal Itemize the options (ask permission) Elicit the client s preferences (explore pros/cons) Summarize the plan Troubleshoot

34 Technique for Planning: The plan is not a final step, but rather a beginning step Implementation (doing the plan) requires: specificity (ready, willingness, and ability to do) intention (what, when, and how is the reasonable next step?) Commitment (how will monitoring and support happen? Implementation

35 Technique for Planning: Supporting Change Assume: Change is not linear, takes time Motivation and persistence fluctuates Setbacks occur Support persistence with MI spirit and style Flexible Revisiting Re-planning Reminding (re-evoking) Re-focusing Re-engaging

36 Five Questions for MI Beginners Why would you want to make this change? How might you go about it in order to succeed? What are the three best reasons for you to do it? How important is it for you to make this change, and why? So what do you think you ll do? and your *client will feel Engaged. Empowered. Comfortable. Understood. Motivational Interviewing, Miller & Rollnick

37 What changes might our clients consider? If they want to keep smoking How to address tension with a family member Whether they want to go through the treatment process If (or how) to break the news of their diagnosis to a loved one The amount of time or money they spend on AOD Addressing their weight issue How much they drink on a nightly basis How many hours they dedicate to exercise Whether or not they re going to take their medicine

38 Still yearning for more?

39 Wrap Up: Questions & Answers Rhonda DiNovo, LMSW Phone- (803)