What is Motivational Interviewing? (A Beginning Definition) Implementing Motivational Interviewing Kelly Wurdelman, MSN, RN Behavioral Health Clinic CentraCare St. Cloud Hospital What s it for? Motivational interviewing is a collaborative conversation style for strengthening a person s own motivation and commitment to change. MI involves attention to natural language about change, with implications for how to have more effective conversations about it, particularly in contexts where one person is acting as a helping professional for another. In simplest form, the implicit theory of MI posits: MI will increase client change talk Increasing client change talk (particularly commitment language) promotes behavior change The extent to which clients verbally argue for change (change talk) will be directly related to behavior change The extent to which clients verbally defend status quo (resistance) will be inversely related to behavior change MI will diminish client resistance Change talk is any selfexpressed language that is an argument for change. Miller and Rollnick, 2013 3 Taste of MI: The Speaker TOPIC: Something about yourself that you want to change need to change should or ought to change but you haven t changed yet i.e.--something you re ambivalent about Taste of MI: The Listener Listen carefully with a goal of understanding the dilemma Give no advice Ask these four open questions: 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 doing it? On a scale from 0 to 10, how important would you say it is for you to make this change? Follow-up: And why are you at and not zero? 5 6 1
Taste of MI: The Listener Finally, give a short summary/reflection of the speaker s motivation for change Desire for change Ability to change Reasons for change Need for change Then ask: So what do you think you ll do? and just listen with interest Arguments both for and against change already reside within the ambivalent person. The most common place to get stuck on the road to change is ambivalence. Miller and Rollnick, 2013 So what is ambivalence all about? 7 His Last Day of Smoking (David Premack, 1970) A man had gone to pick up his children at the city library. A thunderstorm greeted him as he arrived there, and as he waited, engine running, a search of his pockets disclosed a familiar problem: he was out of cigarettes. He pulled away from the curb to quickly buy a pack at the corner store. What was the event that caused this smoker to quit for good that day? What happened? Glancing back at the library, he caught a glimpse of his children stepping out in the rain, but he continued around the corner, certain that he could find a parking space, rush in, buy the cigarettes, and be back before the children got seriously wet. 9 10 Factors in this man s decision to quit for good: The Ineffective Physician He had to make a decision He had to resolve his ambivalence Ambivalence is simultaneously wanting and not wanting something, or wanting both of two incompatible things. Resolution of ambivalence involves a consideration of values Resolving his ambivalence led to a recognition that change was needed 11 12 2
Spirit of Motivational Interviewing So what is this underlying spirit, the set of heart and mind with which one enters into the practice of MI? MI embraces a person-centered counseling style with 4 interrelated elements that reflect the MI spirit: Partnership (avoid expert trap) MI is done for and with a person MI is not a way of tricking people into changing; it is a way of activating their own motivation and resources for change. 13 14 Spirit of Motivational Interviewing Spirit of Motivational Interviewing Acceptance Related to the spirit of partnership is an attitude of profound acceptance of what the client brings. To accept a person in this sense does not mean that t you necessarily approve of the person s actions or acquiesce to the status quo. Four aspects of Acceptance: Absolute worth: involves the inherent worth and potential of every human being. Accurate empathy: an active interest in and effort to understand the other s internal perspective. Autonomy support: honoring and respecting each person s autonomy, their irrevocable right and capacity of self-direction. Affirmation: to seek and acknowledge the person s strengths and efforts. 15 16 Spirit of Motivational Interviewing Compassion To be compassionate is to actively promote the other s welfare, to give priority to the other s needs. Evocation The spirit of MI starts from a very different strengthsfocused premise, that people already have within them much of what is needed, and your task is to evoke it, to call it forth. What is Motivational Interviewing? (A technical therapeutic definition) How does it work? Motivational interviewing is a collaborative, goal- oriented method of communication with particular attention to the language of change. It is designed to strengthen an individual s motivation for and movement toward a specific goal by eliciting and exploring the person s own arguments for change. 17 18 3
Four Fundamental Processes in MI Relational Foundation Focusing Engaging Motivational Interviewing i Evoking Planning 4 Fundamental Processes in MI 1. Engaging--The Relational Foundation Engaging the client in a collaborative working relationship reflects the degree to which someone feels like a comfortable and active participant in the consultation. Engaging is the process of establishing a mutually trusting and respectful helping relationship. Expert-driven directing does not work well when what is needed is personal change. 19 20 The Effective Physician How can I engage my patient and build the provider-patient relationship?...... through Person Centered Listening Skills (OARS) Open Questions Affirmations Reflections Summarizations 21 22 Asking Open Questions How can open-ended questions help engage your patient? Closed Questions... Open Questions... help you understand your clients point of view have a short answer (like yes/no) What possible long-term consequences Do you want to stay in that relationship? concern you the most? ask for specific information What is your address? might be multiple choice What do you plan to do: Quit, cut down, or keep on smoking? solicit additional information in a neutral way What would you like to talk about today? elicit client feelings about a given situation What is the most important reason why you want to do this? Some Guidelines with Questions Ask fewer questions! Ask more open than closed questions. Offer two reflections for each question asked. Response benefits the clinician Response benefits the patient 23 24 4
Affirming MI is affirming: to accentuate the positive. It s easy to forget the positive when doing problem-talk. Affirming clients... conveys respect, positive regard, and caring supports and promotes their sense of self-efficacy; acknowledges their difficulties; validates their experiences and feelings; and increases their confidence to take action and change their behavior Affirmations include... Commenting positively on an attribute. You re a strong person, a real survivor. A statement of appreciation. I appreciate your openness and honesty today. Catching the patient doing something right. It must have been hard for you to decide to come here. You took a big step. A compliment. I like the way you said that. That s a good suggestion. An expression of hope, caring, or support. I hope this weekend goes well for you! 25 26 Summarizing Summaries are essentially reflections that pull together several things that a person has told you. They can also be affirming because they imply, I remember what you tell me and want to understand how it fits together. Summarizing Summaries can-- distill the essence of what clients have expressed --So far you ve expressed concern about your children, getting a job, and finding a safer place to live. link something just said with something discussed earlier. --That sounds a bit like what you told me about that lonely feeling you get. draw together what has happened and transition to a new task. --Before I ask you the questions I mentioned earlier, let me summarize what you ve told me so far, and see if I ve missed anything important. You came in because you were feeling really sad, and it scared you... 27 28 MI Practice Skill: Listen Reflectively In presenting a summary, the clinician selects what information to include and what to minimize and leave out. A reflection involves a reasonable guess about what the client means; and rephrasing the client s statement to reflect what the clinician thinks he or she heard. 29 30 5
In general, a reflection should not be longer than a client s statement. A reflection forms a statement, not a question. You re feeling uncomfortable? You re feeling uncomfortable. You re angry with your mother? You re angry with your mother. Reflective listening... Provides clients a different way of considering what they have said. Reduces the likelihood lk lh of resistance. Encourages the clients to talk. Communicates respect. Clarifies exactly what clients mean, and; Reinforces motivation. 31 32 Types of Reflection Category 1 Category 2 Simple Reflection: Simple Reflection Amplified Reflection Double-sided Reflection Shifting focus Reframing Agreeing with a twist Emphasizing Personal Choice and Control Coming Alongside A simple acknowledgement of the person s disagreement, feeling, or perception can permit further exploration rather than continued defensiveness. Example: Client: I m trying! If my probation officer would just get off my back, I could focus on getting my life in order. Interviewer: You re working hard on the changes you need to make. 33 34 Simple Reflection Amplified Reflection To reflect back what the person has said in an amplified or exaggerated form. Example: Client: I couldn t just give up drinking. What would my friends think? Interviewer: You couldn t handle your friend s reaction if you quit. 35 36 6
Amplified Reflection Double-Sided Reflection Acknowledges what the client has said and adds to it the other side of this or her own ambivalence (not yours) The use of and rather than but is encouraged. Example: Client: I know that what you re trying to do is help me, but I m just not going to do that! Interviewer: On the one hand, you know that there are some real problems here I m trying to help you with, and, on the other, what I suggested is just not acceptable to you. 37 38 Double-Sided Reflection Batting Practice There s no penalty for missing! 39 40 Our Goal with MI... From Contemplation Increase Change Talk Decrease Sustain Talk 7
To Action and once readiness is present, little else may be needed 8