Conflict of Interest. Motivational Interviewing (MI) What is Motivational Interviewing. Empathy & MI spirit Consistent use of MI

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1 Conflict of Interest Motivational Interviewing (MI) The speaker has no conflict of interest t to disclose Edna Hamera PhD APRN Upon completion you will be able to: Identify philosophy and mechanisms of change for Motivational Interviewing (MI) Describe the evidence for MI Demonstrate use of open questioning, reflective listening, affirming and summaries within the phases of change Identify individual characteristics and situations where MI is most applicable. What is Motivational Interviewing Motivational interviewing is a collaborative, goaloriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion. p. 29 (Miller & Rollnick, 2013) Spirit of MI Collaboration Acceptance Prizing worth of each person Conveying accurate empathy Supporting autonomy, capacity for self direction Affirming of person s strength and efforts Compassion Evocation MI: Processes of change Empathy & MI spirit Consistent use of MI Strengthening th of commitment t & staying with the client Leads to Change behavior Hamera 1

2 MI: Features of Existing Theories Carl Rogers client centered therapy: Acceptance & respect that client have the answers (Rogers &Sanford, 1989) Cognitive Dissonance theory: highlighting inconsistent beliefs between unhealthy behaviors and healthy goals to increase motivation for change (Festinger, 1957) Self-perception theory: hearing oneself argue for change increases motivation for change (Bem, 1967) Self efficacy: belief in ability to complete a behavior (Bandura 1977) Reactance Theory: respond negatively if freedom is threatened (Brehm, 1968) Meta-analysis: Across Behaviors Burke et al.,(2003 & 2004) N=30 effect Hettema et al., (2005) N=72 effect Lundahl et al, (2010) N=119 effect Issues: fidelity of intervention, diversity of health outcomes, heterogeneous behaviors. *Effect size: Small 0.20/Medium 0.5/Large 0.8 Meta-Analysis: Specific Behaviors Substance Use: Jensen et al. (2011) N=21 adolescents: 0.17 effect; Smedslund et al. (2011) N=59 post Intervention 0.79 follow up 0.17 Alcohol: Vasilake et al, (2006) N= effect Smoking: Grimshaw & Stanton, (2010) N=11odds ratio 1.70: Lai, et al (2010) N=14 RR 1.27 Obesity: Armstrong et al. (2011) N=11 effect 0.51 Research using MI with Psychiatric DX Comorbid psychiatric dx with substance abuse Kelly et al, (2012) Comorbid psychiatric dx with smoking addiction Steinberg et al. (2004) MI and motivation for psychotherapy Anxiety Disorders (Westra & Dozois, 2006; Westra et al. (2009) Binge Eating (Cassin et al, 2008) MI to increase healthy behaviors OARS: Open-ended Questions Questions that cannot be answered with yes or no or short answers Tell me more about that? How did you make that decision? How were you successful before? OARS: Affirmations Acknowledging internal attributes of client to build self efficacy You were successful before in quitting Being a healthy h role model for you child is important to you Although you slipped you quickly recovered and resumed taking your medication Hamera 2

3 OARS: Reflection Simple stays close to what person says You have lots of things going on and smoking is a way to relax You don t feel he supports you Amplify enlarges what is said ex. Notes discrepancy You re concerned if you share that you are drinking he will shut you out more Double-sided You re doing the best you can do but sounds to me like a part of you really wants to quit OARS: Summaries Linking: You felt you were used when she didn t help. That is similar to the experience you shared about your ex wife. Collecting: So there are a lot of reasons you would like to quit. You have been successful quitting in the past on your own. Focusing or Transition: You have been able to reduce Dr. Pepper to 1 can a day & would like to increase the fruits and vegetables you eat. Phases of changing behavior Engagement Shall we Focusing Where to Evoking why Planning How, When Engagement Phase: Shall We Indicators: client- talks freely, feels listened to, gives some reflection, verbal & nonverbal agree. Therapist- feels like collaborating OARS: O what hope to happen A courage in coming R content & feelings S of concern Focusing Phase: Where to Evoking Phase: Why Indicators: client- identify topics for focus & interest in changing. Therapist- deal with ambiguity, developing sense of where going. OARS: O We could talk about this or save it for the future. Ask permission A That it is their choice on what to work on R Amplify content S Collecting different directions to go and linking Indicators: Client- voice desire, Reason, need to change, therapists- listen and distinguish sustain from change talk, evoke reasons for change OARS O need, want, desire to change What do you need to change/ How important is it? A motivation for change- You care that your kids would be happier if you stopped smoking Hamera 3

4 Evoking Phase: Why R change talk, ex. you would like to be healthy Amplify feeling/content: You don t have the opportunity to take a break like you husband does Double sided reflection- give change part last: you re know it ll be difficult but worry about your health if you don t S summarize change talk Evoking Hope Want change but lack confidence in changing OARS O what might be a first step/ how confident are you/ what would it take to go from 2 to 6 how could I help you go from 2 to 6 A acknowledging strengths & past successes/tries R self confidence statements S reason to be hopeful/ of strengths Planning Phase: How & When Indicators: client- change talk, sustain talk, therapist- client less defensive, considering reasonable next step OARS O what might you do next A effort & steps in progress R feelings & identification of pitfalls S reasons for change and options of how Caveats in Implementing MI MI becomes cynical unless without compassion strong enough ego if not expert, belief that people most motivated by their own reasons for change Unethical to use in all situations Consent for research Decisions such as whether to get a divorce, adopt a child etc. Response Goals Factor Scoring Basic Proficiency competency % Amplified Reflections # AR/total R 40% 50% % open # OQ/total t Q 50% 70% Questions R to Q ratio # R/# Q % MI consistent # MI consistent/# of MI inconsistent 90% 98% Practicing competencies- Groups of 3 Interviewer: practice using open ended questions and reflections. Interviewee: Choose behavior you want to change but are ambivalent about changing ex. eat more veg, exercise, lose weight, get more sleep, etc Scribe: write down interaction, i.e. what he/she says Hamera 4

5 Role Play Groups of 3 Interviewer: practice using open ended questions and reflections. Interviewee: start the session by stating dilemma about changing g Scribe: write down interaction, i.e. what he says what she says. Continue for 5 minutes- Role Play continue All 3 code interviewer responses for open, closed questions, simple reflection, amplified reflection, affirmations, and summaries. Compute scores on scoring sheet Rotate so each person has opportunity to be interviewer Summary MI effective for wide range of behaviors It is better than no Tx or weak Tx Not better than strong comparison Tx but is easier to use and probably more cost effective Tx Manual not better- embrace Spirit of MI Most effective for minority ethnic groups (not necessarily AA) or those experiencing social rejection. Lundahl et al., (2010) Hamera 5