Motivational Interviewing Training National Stroke Nurse Forum Kelly Davis Martin 16 th May 2014
Agenda Introductions What is Motivational Interviewing How is it being used Theories that inform Motivational Interviewing How to learn Motivational Interviewing The spirit of MI The core skills of MI The framework for doing MI Sample Interviews Ultra Brief Motivational Interviews How would one design an intervention Resources and questions
When did Motivational Interviewing begin? Founded nearly 30 years ago by Dr. William Miller of the University of New Mexico and clinical psychologist Stephen Rollnick Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Took hold in addictions work and now is spanning into health, corporate and other arenas
What Is Motivational Interviewing? Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for and commitment to a target behavior change by eliciting and exploring an individual s own arguments for change. MI is a conversation about change MI has a particular purpose- to evoke and strengthen personal motivation for change MI honors autonomy and selfdetermination MI evokes the person s own motivation for change MI uses specific skills- OARS MI moves toward a goal or in a direction of change MI elicits and strengthens change talk by be attuned to client language MI responds to change talk in specific ways MI responds to resistance and sustain talk in non-confrontational ways By Bill Miller and Steve Rollnick, ICMI, Stockholm, June 2010
What is Motivational Interviewing? Goal: quietly clarify ambivalence and elicit change talk Based on compassion and engagement Positive behavior change Non confrontational A meeting of experts A dance with patients A way of breaking down barriers An approach shaped by an understanding of what triggers change An approaches that is well-validated and suited for case management encounters The practice of disentangling competing and often obscure motives A way of being with a client, not just a set of techniques Case in Point Special Report, Motivational Interviewing: An Emerging Trent in Medical Management published by Doran Health, 2010, www.dorandhealth.com
How is MI currently being applied? Chronic Care Model (CCM), MacColl Institute for Healthcare Innovation Best practice paradigm to help patients living with chronic conditions Self management support with practitioners using MI The Guided Care Model, Johns Hopkins University, Dr. Chad Boult Coordination of high risk patients with multiple chronic conditions Guided Care nurses trained in MI Penn State Institute for Diabetes and Obesity, supported by National Institute of Health, DYNAMIC (Diabetes Nurse Care Management and Motivational Interviewing for Change)
The Effective Physician: Sample Motivational Interview http://www.youtube.com/w atch?v=urika7cktfc
Theoretical Foundations of Motivational Interviewing Cognitive Behavioral Therapy Health Belief Model Appreciative Inquiry: Define, Discover, Dream, Design, Destiny Nonviolent Communications Self-Compassion, Self-Efficacy and Self-Esteem Positive Psychology Relational Flow Choice Theory Health and Wellness Coaching
Health Behavior Change Theories Self Determination Theory Intrinsic motivation (rather than extrinsinic) People will change if their three basic needs are met: Autonomy, Relatedness and Competence Rational Emotive Behavior Therapy: Albert Ellis A + B = C A= event B= perception of event C= reaction
Health Behavior Change Theories Health Belief Model: Perceived probability and seriousness of consequences Perceived severity of risks Self-efficacy Transtheoretical Model: Precontemplation Contemplation Preparation Action Maintenance
Cognitive Dissonance FOCUSING ON ANY TINY BIT OF MOTIVATION WORKS MUCH BETTER THAN ASKING ABOUT RESISTANCE LEON FESTINGER, 1957, DISSONANE BETWEEN OUR STATEMENT ABOUT OURSELVES AND OUT BEHAVIOR We often change our beliefs to match our behaviors HEARING OURSELVES SAY WHAT WE WANT TO DO HELPS US FIND THE MOTIVATION TO DO IT
THE LAW OF PSYCHOLOGICAL REACTANCE NO ONE ABSOLUTELY HAS TO TO ANYTHING; THE CHOICE IS ALWAYS YOURS IF SOMEONE TELLS YOU TO DO SOMETHING YOU PROBABLY WILL NOT FEEL LIKE DOING IT EVEN IF YOU MIGHT OTHERWISE HAVE WANTED TO. THE HARDER SOMEONE TRIES TO GET YOU TO DO SOMETHING THE LESS LIKELY YOU ARE TO WANT TO DO IT AND TO ACTUALLY DO IT JACK AND SHARON BREHAM, 1966 ONWARDS
Summary of Health Behavior Change Myths about behavior change: This person should change This person is ready to change This persons (ill) health will motivate them to change If they do not change then the intervention/treatment has failed People are either motivated to change or they are not Now is THE time to consider changing A tough approach is the best approach I am the expert and the patient should do as I say Taken from Eileen Britt, U of C, Intervention Manual
Five Steps to Learning MI 1. Unlearn 2. Slow down 3. Be humble 4. Believe in them 5. Go with the clients language about change
The Spirit of Motivational Interviewing Collaboration Compassion Acceptance Evocation
Motivational Interviewing: Key Ideas and Implications Client resistance is a product of the environment and not an intrinsic behavior The patient and the provider relationship should be cooperative and congenial MI centers around overcoming ambivalence (must be resolved before action steps can be taken) The practitioner keeps options open (the power of choice) Responsibility rests on the patient Self-efficacy is paramount Case in Point Special Report, Motivational Interviewing: An Emerging Trent in Medical Management published by Doran Health, 2010, www.dorandhealth.com
Core Skills of Motivational Interviewing OARS AROSE Open-ended inquiry Active listening Reflections Summaries Affirmations Reflective listening Open-ended questions Summaries Elicit change talk
Communication Styles Direct Guide Follow Your emotional state determines which style you use. MI is about 80% guiding. Mindfulness and self compassion are necessary.
Active Listening Most used skill Mindful and present No distractions Your client should talk A LOT more than you do Not thinking of your next question (aggressive) and waiting to jump in Listen for facts (cognitive) Listen for feelings (affective) Accurate empathy and authentic championing Allow for silence Listen and listen some more
Open Ended Questions Least used of the three No judgments Ask ONE QUESTION at a time Avoid too many questions as it will feel like interrogation Difficult to answer with yes or no How and What Questions Positive and authentic affirmations Don t over do this Reframing Affirm and connect strengths
Perceptive Reflections Next used skill 2+ reflections to every 1 question Use the clients words Honest and authentic Types of Reflections: Simple and Complex Summarizing Emphasize personal control, autonomy and responsibility
ACCESSING OUR OWN MOTIVATION EVERYONE ALREADY HAS ENOUGH MOTIVATION MARTIN SELIGMAN 2005: DEPRESSED SUBJECTS FOCUSED ON WHAT THEY MIGHT DO, NOT ON HOW THEY WOULD DO IT
REINFORCING AUTOMONY NO ONE ABSOLUTELY HAS TO DO ANYTHING; THE CHOICE IS ALWAYS YOURS EACH OF US IS FREE TO CHOOSE THE BEHAVIORS IN WHICH WE WANT TO ENGAGE OTHER PEOPLE CAN THREATEN THAT FREEDOM WITH CERTAIN TYPES OF STATEMENTS SUCH AS YOU HAVE TO DO THIS OR YOU CAN T DO THAT WE TEND TO REACT VERY NEGATIVELY WHEN OUR FREEDOM IS VERBALLY THREATENED OUR THREATENED FREEDOM CAN BE RESTORED BY SUCH AUTONOMY-ENHANCING STATEMENTS AS IT S UP TO YOU, THIS REALLY IS YOUR DECISION AND YOU RE THE ONLY ONE WHO CAN DECIDE TO DO THIS
HOW TO RESTORE SOMEONE S AUTONOMY 1. COME OUT WITH THE STRONGEST AUTONOMY-REINFORCING STATEMENT THAT YOU CAN HONESTLY MAKE 2. IF A SITUATION IS DIFFICULT OR UNFAIR, SAY SO, BUT ALWAYS RETURN RESPONSIBILITY TO THE INFLUENCEE 3. BE HONEST ABOUT WHAT YOU WANT 4. DISCUSS THE CONSEQUENCES IN ANOTHER CONVERSATION OR AT THE END OF THIS ONE
Additional Information on Motivational Interviewing Skills Work with a clients stage of change (Transtheoretical Model) Overcome ambivalence: I want to but I don t want too. Develop discrepancy: difference between current behavior and alternative health promoting behavior, decisional balance Elicit change talk: desire, ability, reason, need and/or commitment to change Support self-efficacy: use importance and confidence rulers Designing action: SMART goals
How Important Is This To You? Not At All Extremely 0 1 2 3 4 5 6 7 8 9 10
How Confident Are You? Not At All Extremely 0 1 2 3 4 5 6 7 8 9 10
Framework for doing MI Engage: at least first 20% of your time together Focus: who s direction?, agenda mapping Evoke: desire, action, reasons and need Plan: multiple routes are common
Sample Interview
Effective Brief Interventions FRAMES Feedback that is personalized Responsibility to change lies with the client Advices is provided only with permission and in small doses Menu of options of things to change is provided Empathy is conveyed through reflective listening Self-efficacy is needed for successful behavior change to occur
Ultra-Brief Motivational Interviewing Dr. Michael Pantalon, author of Instant Influence People will listen to THEMSELVES The client will change for their own reasons, not for your reasons The Three Steps of Ultra-Brief Motivational Interviewing: STEP 1: Acknowledge autonomy (freedom of choice) STEP 2: Ask Positive-Why questions and use the readiness to change ruler STEP 3: Reflect only the reasons for change
INSTANT INFLUENCE INSTANT INFLUENCE: HOW TO GET ANYTONE TO DO ANYTHING- FAST. THE ONLY MOTIVATIONAL APPROACH SCIENTIFICALLY PROVEN TO SUCCEED IN LESS THAN 7 MINUTES! HIGHLIGHTS FROM THE BOOK BY MICHAEL PANTALON, PHD
THREE GUIDING PRINCIPLES NO ONE ABSOLUTELY HAS TO DO ANYTHING; THE CHOICE IS ALWAYS YOURS EVERYONE ALREADY HAS ENOUGH MOTIVATION FOCUSING ON ANY TINY BIT OF MOTIVATION WORKS MUCH BETTER THAN ASKING ABOUT RESISENCE
SIX STEPS TO INSTANT INFLUENCE 1. WHY MIGHT YOU CHANGE? 2. HOW ARE YOU READY TO CHANGE- ON A SCALE OF 1 TO 10, WHERE 1 MEANS NOT READY AT ALL AND 10 MEANS TOTALLY READY? 3. WHY DIDN T YOU PICK A LOWER NUMBER? 4. IMAGINE YOU VE CHANGED. WHAT WOULD THE POSITIVE OUTCOMES BE? 5. WHY ARE THOSE OUTCOMES IMPORTANT TO YOU? 6. WHAT S THE NEXT STEP, IF ANY?
How to develop an MI intervention? Best Practice Who can do MI How to train people to do MI How to assess the effectiveness of MI Measure behavior change Self assessments- client and interviewer MITI
Motivational Interviewing Resources Websites Institute for Motivation and Change: www.miinstitute.com Motivational Interviewing Network of Trainers (MINT): www.motivationalinterviewing.org Stephen Rollnick: www.stephenrollnick.com The Motivational Interviewing Page: www.motivationalinterview.org Trainings Achieve Wellness: www.achievewellness.co.nz HMA: www.hma.co.nz Published Research
Motivational Interviewing Books A Toolkit of Motivational Skills: Encouraging and Supporting Change in Individuals, By Catherine Fuller and Philip Taylor Building Motivational Interviewing Skills: A Practitioner Workbook, By David B. Rosengren, Phd Instant Influence: How to Get Anyone to Do Anything FAST, By Michael V. Pantalon, PhD Motivational Interviewing, Third Edition: Helping People Change, By William Miller, PhD, Stephen Rollnick, PhD Motivational Interviewing in Health Care: Helping Patients Change Behavior, By Stephen Rollnick, PhD, William Miller, PhD, and Christopher C. Butler, MD Motivational Interviewing in Nursing Practice: Empowering the Patient, By Michelle Dart, MSN, PNP, CDE Resolving Patient Ambivalence: A Five Session Motivational Interviewing Intervention, By Ann E. Fields, MSE, CADC III
Kelly Davis Martin kelly@achievewellness.co.nz (027) 588-4279