Motivational Interviewing for Health Behavior Change Ellen R. Glovsky, PhD, RD, LDN The Institute for Motivation and Change And Northeastern University 2010 Missouri WIC Conference October 26, 2010
Motivational Interviewing Definition: A directive, person person-centered counseling style for increasing intrinsic motivation by helping patients explore and resolve ambivalence. (Miller & Rollnick, 2002) MI is a collaborative approach to helping people change their behavior regarding their health. Most applicable in consultations where there is a preferred outcome 2
Look for the Deep Well in Your patient Your patient has all the answers needed to make the necessary changes! Behavior change is about motivation,, not information 3
The Stages of Change Prochaska & DiClemente Permanent Exit? Maintenance Relapse to Previous Behavior Precontemplation Action Contemplation Preparation 4
What Stage is Your patient? Most interventions assume patient is in action No wonder many interventions fail, and we feel frustrated! What really triggers health behavior change? 5
Let s Remember. When we are counseling to foster change in behavior, we are often asking our patients to give up things that are inherently pleasurable, and replace them with things that are not! How you deliver the message is the key to convincing your patient to actually make the changes. 6
Collaboration The Spirit of MI You don t have to make change happen; you can t You don t have all the answers Message to your patient is you have everything you need, and we ll find it together Evocation Calling forth that which the patient already has Not installation therapy Doesn t come from a deficit model clinician is willing to let the patient decide if, when and how they will go about changing. Help your patient to move from Precontemplation to Contemplation by supporting ambivalence 7
Not pathology! Ambivalence A normal part of the process of change Think of a time when you were asked to change something in your life. Were you sure you wanted to change? Were you sure you were able to change? *A telltale sign of ambivalence is the but in the middle of the sentence. 8
Remember. Changing one s behavior is a means to an end, not an end in itself Our patients may not see the necessity for changing their behavior the way we see it Their point of view must be heard, and we must listen! (Even if we think they are wrong) 9
MI: The Guiding Style GUIDE Instruct Listen...*..........*...*... 10
The Ends of the Spectrum Direct Manage Prescribe Lead Tell "I know best. I'm in charge. Listen to me", Follow Permit Let be Allow Go along I won't change or push you. I trust your wisdom about yourself, and I'll let you work this out in your own time and at your own pace. 11
Guide Enlighten, shepherd, encourage, motivate, support, lay before, look after, take along, accompany, awaken, promote autonomy, elicit solutions, point, escort, show, collaborate "I can help you to solve this for yourself" 12
The Guiding Style in Motivational Interviewing Direct Manage Prescribe Lead Guide Support Encourage Motivate Follow Permit Let be Allow 13
4 Fundamental Processes in MI 1) Engaging:The Relational Foundation 2) Guiding: The Strategic Focus 3) Evoking: The Transition to MI 4) Planning: The Bridge to Change MI is always person-centered in style, but not all personcentered counseling is MI 14
1: Engaging This is the relational foundation Listen to understand the client s dilemma OARS: core skills learn these first! Values exploration may occur here 15
2: Guiding The strategic (directional) focus of MI Finding a direction (may include changing the goal) Agenda setting Giving information and advice MI is a guiding style, but not all guiding is MI 16
3: Evoking The bridge to MI There is a clear change goal Selective eliciting and reinforcement (OARS) Use of open-ended ended questions Affirmations Responding to change talk (selective reflection Summarizing change talk 17
4: Planning Negotiating change goals and plans Strengthening commitment Implementing and adjusting 18
Step #1: Build A Power Sharing Relationship: Avoid the Expert Trap Use Wiggle Words: Perhaps Maybe If you don t mind One option is You might consider Here s a thought What do you think? Avoid the Expert Trap 19
Instead of Persuasion Collaboration Your patient is the expert on how s/he will change Share the power! Ask Permission First! 20
Step #2: Find an Alternative to Persuasion The clinician s job is to help the patient find his/her own answer to the problem. 21
Avoid the Righting Reflex: Taking Sides Trap clinician You must change You ll be better off You can do it!! You ll die patient I don t want to change Things aren t half bad. No I can t!! Uncle Fred is 89 and healthy as can be. 22
Step # 2: Reinforce Change Talk: What People Say About Change Predicts Behavior Change Patients are most persuaded when they hear it from their own mouths 23
BENEFITS OF: Decisional Matrix: Diet Eat Whatever I Desire I like the tastes. It s cheaper. I don t have time. I feel fine At least I don t smoke. Healthier Eating Habits Stay healthy. Fewer meds. Control sugars Take charge! I don t want to die! COSTS OF: My dietitian lectures I ve gained another 20 I can t control my sugars Too much $$ Hard to prepare We don t do veggies!! 24
BENEFITS/Pros OF: Decisional Matrix: Exercise No Change, No Exercise I m tired at the end of the day No time Can t afford a gym COSTS/Cons OF: My doctor and dietitian lectures I ve gained another 20 My BP is too high My joints hurt Exercising Stay healthy Fewer meds My doctor won t nag me anymore Probably have more energy Takes too much time I hate exercising and getting sweaty I m not convinced it will give me more energy 25
Looking for Change Talk Benefits No Change Change in Behavior Life could be better Costs I have problems 26
Sustain Talk No Change Change in Behavior Benefits I like my life Costs Your plan doesn t work for me 27
Building Rapport STAYING THE SAME: CHANGING: BENEFITS OF: GOOD PROS COSTS OF: NOT SO GOOD CONS 28
Good and Not So Good Develop a discrepancy Help the patient discover their ambivalence Discrepancy is the ENGINE of change 29
Good and Not-So-Good A) Always start with the good. B) When the list is obtained, offer a summary. C) Remain neutral in the query for not so good. Don t assume that not so good equals bad. D) Use open-ended ended questions to find out why these things are less good. E) Offer a summary statement of both sides. STAYING THE SAME: CHANGING: BENEFITS OF: GOOD PROS COSTS OF: NOT SO GOOD CONS 30
Change Talk: Preparatory and Activating Preparatory Change Talk DARN DARN-C DESIRE to change (want, like, wish.. ) ABILITY to change (can, could.. ) REASONS to change (if.. then) NEED to change (need, have to, got to..) Activating Change Talk: reflects resolution of ambivalence: Commitment language Intention Decision Readiness Taking steps 31
Desire Strength: +5 I definitely want to +4 I really wish +3 I d like to +2 I mostly want to +1 I guess I d like to 32
Ability Strength +5 I m sure that I could +4 I m pretty sure that I could +3 I think I can +2 Probably I can +1 I might be able to 33
Good listening is more than being silent and paying attention So what do you say?
Step #4: Build A Foundation of Listening: Get Your OARS in the Water O: Open-ended ended questions How you ask questions is critical! Can not be answered with yes or no A: Affirm Rapport building R: Reflect Helps to let your listener know you heard and helps to clarify what you heard S: Summarize Like offering a bouquet Link material patient has offered; ask if it s accurate Allows clinician a chance to build argument for change 35
Open Questions Can not be answered with a yes or no Patient will often provide more information when questions are open rather than closed Example Closed: How much fruit do you eat each day? Open: Tell me about the fruit you eat. Ask for Elaboration 36
Affirmations Something positive you have heard the patient say You re a strong person, a real survivor. You juggle so many things in your life. A statement of appreciation I really appreciate your honesty with me. Catch the person doing something right Thanks for coming in today! An expression of hope, caring or support I hope this week goes well for you; I ll be thinking about you. 37
Three Places Communication Can Go Wrong Speaker Words 1 Meaning 2 Listener Words 3 Meaning 38
The Function of Reflection Speaker Words Listener Words Meaning 1 2 Reflection 3 Meaning 39
Reflective Listening Content reflections are short summaries What did she say Meaning reflections add the next sentence to the story What did he mean? 40
Forming Reflections Reflection of Meaning Client: : I need to get myself in line, and lower my blood sugar. I m so worried I won t be able to be there for my grandchildren. Clinician: : Your grandchildren are so important to you that you re willing to change for them. Reflection of Feeling: Client: : I want to quit smoking because I don't want another heart attack; I want to see my kids grow up. Clinician: : Your children are important to you and you ll go to great lengths to be there for them 41
Double-Sided Summaries On the one hand. On the other hand. You feel both and about this. 42
Summaries can: Collect material that has been offered So far you ve expressed concern about not getting pregnant, worrying about your kids, and having enough money to buy the things you need. Link something just said with something discussed earlier. That sounds a bit like the problem you have forgetting to take your pills. Draw together what has happened and transition to a new task Before we talk about a different type of contraception, let me summarize what you ve told me so far, and see if I ve missed anything important. 43
Explore Goals and Values Develop a Discrepancy the difference between one s values and one s behavior ellen Glovsky, 44
Step #5: Roll with Resistance The Flip Side of Change Motivation & Resistance are Ever-Changing States of Readiness 45
Invite resistance into the room Don t try to stop resistance or anger; listen, listen, listen Let patient know you heard and understand When patient feels validated, anger decreases You may learn something very important about your patient Shift gears, ask what they would like to talk about 46
Handling Resistance Dancing, Not Wrestling : Content reflection Meaning reflection Double-sided reflection When you meet resistance, try a different approach! 47
Step 6:Assess Readiness and Set an Agenda 22 Important keys: Be alert for Readiness to Change Shift between Instructing and Listening Overuse of Instruction gets in the way of natural change 48
Recognizing Readiness Diminished resistance Decreased discussion about the problem Resolve Change talk Questions about change Envisioning Taking steps 49
Importance/Confidence 1. How important is it for you right now to change? On a scale of 0 to 10, what number would you give yourself? 0.. 10 not at all important A. Why are you there and not at 0? extremely important B. What would need to happen for you to raise your score a couple of points? 50
Importance/Confidence 2. If you did decide to change, how confident are you that you could do it? 0....10 not at all extremely confident confident A. Why are you there and not at 0? B. What would need to happen for you to raise your score a couple of points? 51
Transitions to Planning Listen carefully Don t wait too long! Small steps If patient says not ready to actually do something, ask What would you do if you were ready? or Would you think about this for next time? 52
Offer a Transitional Summary We ve talked a lot so far about why you would want to make changes, and it sounds like you re ready. What do you think? *Which of these areas are you ready to tackle? So, what you re telling me is that you want to change your diet for yourself, but changing your family s food won t work right now. *Are you ready to make changes for yourself? *What ideas do you have? *Followed by a Key Question 53
Into Action Step #7: Instruct & Negotiate Collaboratively 54
5 4 3 2 1 I guarantee I will I promise I vow I shall I give my word I assure I know Commitment Language I am devoted to I pledge to I agree to I am prepared to I intend to I am ready to I look forward to I consent to I plan to I resolve to I expect to I concede to I declare my intention to I favor I endorse I believe I accept I volunteer I aim I aspire I propose I anticipate I predict I presume I mean to I foresee I envisage I assume I bet I hope to I will risk I will try I think I will I guess I will 55
Giving Information and Advice: 3 Kinds of Permission 1. The person asks for advice 2. You ask permission to give advice 3. You qualify your advice to emphasize autonomy 56
Giving Information and Advice: 3 Kinds of Permission 1. The person asks for advice I d be happy to share some ideas with you, but I m wondering if there are any thoughts you ve got about what might work for you. 2. You ask permission to give advice Would it be OK with you if I make a suggestion about that? 3. You qualify your advice to emphasize autonomy I don t know if this will work for you; you are the best judge. 57
Motivational Interviewing Patient-Centered Advice ***Ask Permission First Provide Expert Advice Maintain Rapport 58
Motivational Interviewing Patient-Centered Advice Elicit-Provide-Elicit 1) ELICIT patient s ideas, needs 2) PROVIDE PROVIDE relevant advice, information 3) ELICIT patient s reactions & commitment to change 59
Elicit Readiness and Interest/ Provide Feedback Readiness: What would you most like to know about the changes you could make to improve your blood sugar? What do you know about the different kinds of birth control available? Provide Information and Feedback 60
Feedback Formula 1. Ask permission to give feedback 2. Explain the meaning of the feedback you are about to give 3. Give only one fact and then only reflect the patient s responses. Do not argue, interpret, defend, or advise. 61
Elicit Meaning What are your thoughts about this information? What do you make of that? How might this information influence your decision about quitting? 62
Find opportunities for reflection breaks Provide a menu of options Maintain rapport There s definitely not just one right way 63
Summary of MI vs. Usual Practice Usual Practice Clinician is in charge, sets agenda for what the patient must do Using Motivational Interviewing Patient sets the agenda Top-Down Approach Collaborative Effort Tell the patient what s important Patient decides what is important in line with core values, beliefs and needs Clinician decides when to move ahead Patient sets pace for the work to be with goals Clinician is responsible for the patient making prescribed changes done Patient is responsible for if, what, and when behavior change happens Clinician is an instructor or director Clinician is a guide or coach Success measured by actual behavior change, changes, in physical measures, etc. Success is measured by patient s own values and goals 64
A Synthesis of Motivational Interviewing The resolution of ambivalence is promoted by accurate empathy and Resolution of ambivalence in a particular direction is influenced by the clinician s differential reinforcement of patient speech 65
Guilford Press, 12/07 www.guilford.com 66
Guilford Press, 11/07 www.guilford.com 67
Guilford Press, 2009 www.guilford.com 68
Ellen Glovsky: ellen@miinstitute.com www.nutrition-coach.com www.miinstitute.com Resources for Motivational Interviewing www.motivationalinterview.org Mi-campus.com 69