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Motivational Interviewing
Carol Golin, MD, Associate Professor of Medicine, UNC Chapel Hill
Steve Bradley-Bull, MEd, LPC, Research Associate, UNC Chapel Hill
February 17th, 2016
Society for Public Health Education
Introductions
• Carol Golin
[email protected]
• Steve Bradley-Bull
[email protected]
Think about making a change…
Think about a time when…
• You have EVER tried to change a behavior
related to your health
Think about a time when…
• You have EVER tried to change a behavior
related to your health
AND
• You made some progress
Think about a time when…
• You have EVER tried to change a behavior
related to your health
AND
• You made some progress
AND
• You completely achieved your goal…
Think about a time when…
• You have EVER tried to change a behavior
related to your health
AND
• You made some progress
AND
• You completely achieved your goal…
ON THE FIRST TRY!!
Making a change is…
…NOT always easy!
Motivational Interviewing:
Current Knowledge?
• What do you know about MI?
• What experiences have you had with MI?
Objectives
• Discuss behavior change and become familiar with recognizing “change
talk”
• Gain knowledge about Motivational Interviewing
– Where does it come from?
– What is Motivational Interviewing?
– Does it work (evidence base)?
• Review specific Motivational Interviewing skills and the 4 processes of
Motivational Interviewing
• Observe role plays in Motivational Interviewing
• Provide additional resources for future learning
Where does MI come from?
 Empirically-derived
– Concept evolved from experience in the treatment of
problem drinkers.
– Adapted for health behavior change
 Underpinnings in psychology and health
behavior theory--polytheoretical
 Rogerian Psychology
 Self-Determination Theory
 Social Cognitive Theory, Theory of Reasoned Action,
Stages of Change
Evidence for Efficacy
• MI has been used successfully in RCTs to
change a variety of health behaviors:
– medication-taking / adherence
– smoking cessation
– diabetes self-management
– intake of healthy fruits and vegetables
– safer sexual behavior
– substance abuse
– problem drinking
– weight loss
Sample Recent MI RCT Reviews
• There is moderate quality evidence, coming from two trials
which suggests that MI is effective in reducing short term viral
load and unprotected sexual acts in youth living with HIV.
Mbuagbaw L, Cochrane DB Rev 2012.
• 28 studiesfavorable health outcomes from communicationrelated behavior change methods (15 counseling; 8 motivational
interviewing; 5 education/advice). Noordman J, Pt Educ Couns 2012
• MI increases HAART adherence in patients who are HIV-positive:
A systematic review Hill S, AIDS Care 2012
• Motivational interviewing to improve weight loss in overweight
and/or obese patients: a systematic review and meta-analysis of
randomized controlled trials. Armstrong MJ, Obesity Review 2011
Definition of Motivational Interviewing:
“Motivational Interviewing is a person-centered
counseling style for addressing the common
problem of ambivalence about 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 reasons for change within an atmosphere
of acceptance, collaboration, and
compassion.”
Rollnick S., & Miller, W.R. (2013).
Person-Centered Counseling
•
•
•
•
•
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•
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Partnership and collaboration
Using a menu of options
Ask permission to give information
Use of silence
Staying neutral
Curiosity
Nonverbal cues: being attentive
Asking open questions
Ambivalence
• An important state or stage in the change process
when a person contemplates and explores the
possibility of change
• Can be a hindrance if stuck in never ending
negotiation with one’s self
• A capacity: to see and explore things in more than
one way; to cope with ambiguity and complexity
•
Barth and Nasholm: www.symposium.se
Working through Ambivalence:
Develop Discrepancy
• Raise client’s awareness that their current behavior
and where they want to be are different
• Raise client’s awareness that their most salient
values and their behavior are not fully aligned
• This serves to raise the client’s awareness of their
ambivalence
• Allows opportunity to explore facilitators and
barriers to reach goal or desired behavior
Importance of Timing
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•
•
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Good rapport builds trust
Never know when someone will be ready
Less about outcome
Understanding of timing and present moment
experience
• Not necessarily about what we communicate
but how we communicate
Relationship to Client in MI
• Client is expert of own experience
• Counselor is the learner…teach me about your
experience
• Be curious and non-judgmental
• Join along-side client/partner/collaborate
• Remember…it is always the client’s choice
when and if they want to change
Empathy Video
• http://www.youtube.com/watch?v=cDDWvj_q-o8
Motivational Interviewing:
Communication Skills
MI: Not Just a New Idea!
“People are generally better persuaded
by the reasons they have themselves
discovered, than by those which
have come into the mind of others.”
Pascal, 17th Century
Communication Skills
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•
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Open ended questions
Affirmations
Reflective listening
Summaries
• Asking permission
• Elicit-Provide-Elicit
• Keep it conversational
Open Ended Questions
• Allowing client to express themselves and
their experiences as fully as possible
• Examples:
– Tell me about….
– I am curious to hear more about….
– I’m interested to learn more about…
Communication Skills
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•
•
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Open ended questions
Affirmations
Reflective listening
Summaries
• Asking permission
• Elicit-Provide-Elicit
• Keep it conversational
Affirmations
• Purpose
– Recognize strength, acknowledge effort
• Need to matter to patient/client
– Needs to be genuine
• Affirmations are not praise
– More about the person than the behavior
• Example:
I am proud of you in your ability to commit and focus vs. I
am proud of you for this accomplishment.
Communication Skills
•
•
•
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Open ended questions
Affirmations
Reflective listening
Summaries
• Asking permission
• Elicit-Provide-Elicit
• Keep it conversational
Reflective Listening
• Reflections are statements
• They require listening,
observing, and interpreting
verbal and nonverbal cues
• The listener tries to
understand the client by
using reflective statements
• Helps the counselor to
gather information about
your client
Types of Reflection
Simple:
 Repeating or rephrasing
•
Substitutes synonyms or phrases; stays close to original statement
Complex:
 Paraphrasing
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Makes a major restatement inferring the speaker’s meaning
Reflection of feeling
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Emphasizes emotional aspects through feeling statements
Double-sided reflection
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Presents two sides of an issue: “On the one hand… On the other…”
Summarizing
•
Reflects multiple points, tying them together
Types of Reflections
Client: My doctor referred me here but I am not sure if this is what I need
• Repeating: ‘Your doctor referred you here today but you are not sure if
this will be helpful’
• Paraphrasing: ‘You believe it’s important to listen to your doctor but you
may not always agree with his/her recommendations’
• Feeling reflection: ‘You’re feeling somewhat confused and frustrated
about being referred here’
• Double-sided reflection: ‘(On the one hand) you don’t always agree with
your doctor, but (on the other hand) you’re also a little concerned’
Phrases to Facilitate Reflection
 You…
So you feel like…
You’re wondering if…
 What I hear is that you…
 It sounds like…
Communication Skills
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•
•
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Open ended questions
Affirmations
Reflective listening
Summaries
• Asking permission
• Elicit-Provide-Elicit
• Keep it conversational
Summaries
• Drawing together the person’s own
perspectives on change
• When to use them
• Types of summaries:
• Collection
• Linking
• Transitional
Communication Exercise-Demo
• One person close your fist
• Other person attempt to convince person to
open fist through use of communication skills
• See what happens
OARS Exercise-Demo
• 1.
Open question: “Please tell me one characteristic or aspect of
yourself that you like and how it helps you in your work?”
•
2.
Reflect what you heard and wait for a response
(practice using “you”).
•
3.
Add this affirmation: "From what I have heard you say, not only do you
have this characteristic or aspect, you also have this characteristic/strength
(fill in with new characteristic/strength).....wait for any response.
•
4.
Reflect any response and then summarize the highlights of what you
have heard thus far, perhaps starting with 'Let me see if I have it
right.......'
• 5.
Before switching, the person speaking (client) tells the person facilitating
(counselor) one thing they did that the speaker (client) appreciated.
Communication Skills
•
•
•
•
Open ended questions
Affirmations
Reflective listening
Summaries
• Asking permission
• Elicit-Provide-Elicit
• Keep it conversational
Opening the Conversation:
Start with Permission
• We’re starting a new program in the clinic to talk with
patients about medication adherence. Would you
mind if I talked with you a few minutes about the
questions you answered earlier?
• I always ask my patients about tobacco, alcohol, and
drug use, and safer sex practices. I would like to ask
you also—is that OK?
• If it’s all right with you, I’d like to talk with you now
about how you are taking your medications.
Communication Skills
•
•
•
•
Open ended questions
Affirmations
Reflective listening
Summaries
• Asking permission
• Elicit-Provide-Elicit
• Keep it conversational
When you need to share information
• Avoiding “being the expert” can be tricky
when the counselor feels s/he has information
that may be useful to the client.
• Reflective listening can be used in sharing
information with a technique called “ElicitProvide-Elicit” (Ask-Tell-Ask)
• Often considered the anchor of MI since all
various skills work with EPE.
Elicit-Provide-Elicit
(“Ask-tell-ask”)
Some times when this may be useful:
• You think the client is misinformed
• You think the client lacks information
• You’re thinking of an idea that might be useful
to the client
• The client is asking for information
Elicit-Provide-Elicit
(“Ask-tell-ask”)
• “Ask”: Find out what they already know
• “Tell”: Provide additional information as
appropriate
• “Ask”: Ask for their reaction
Elicit Provide Elicit
Demo
(ASK-TELL-ASK)
Identify these 3 steps
EPE Practice
Medication Adherence
• Client: I have to take a medication every day now…it’s a lot to
figure out.
• Counselor: So tell me, what have you tried before or what do
think might work for you?
• Client: Maybe taking the med with a meal.
• Counselor: Okay, so maybe taking the medication with a
meal…and I work with a lot of people here in the clinic, would
you mind if I shared with you some of their strategies?
EPE Practice
Medication Adherence
• Client: Sure, I am open to hearing some ideas.
• Counselor: First thing in the morning, before bed, brushing
your teeth, meal time, using a pill box, using an alarm,
something related to your daily routine.
• Counselor: Do you think any of those ideas that worked for
other people may work for you?
• Client: I really think setting an alarm on my watch will work
since I always wear my watch….
The Method of MI or 4 Processes
The Method of MI or 4 Processes
• Engaging
– Process of establishing a helpful connection and working
relationship
• Focusing
– Process by which you develop and maintain a specific
direction in the conversation about change
• Evoking
– Process of eliciting the client’s own motivations for change
and lies at the heart of MI
• Planning
– Process of developing commitment to change and
formulating a concrete plan of action
Rollnick S., & Miller, W.R. (2013).
Change Talk
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Desire
Ability
Reasons
Need
Commitment
• Questions to ask?
Responding to Change talk
Change Talk
Reflection
Open Question
I can’t go on this
way…
You realize it is time Where do you think
for you to do
you should begin?
something different.
I haven’t always
been incapable.
You want to believe Tell me about your
in yourself and your strengths…
abilities.
I just have to find
the time whether I
want to or not.
This is becoming a
As you look at your
stronger priority for schedule, where are
you.
some
opportunities?
Take-Aways from Webinar
•
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Curiosity
Be the learner
Timing
Communication skills and techniques
– OARS, Ask permission, Elicit-Provide-Elicit
• 4 Processes
– Engagement, Focus, Evoking, and Planning
• Be yourself…remember the importance of the
relationship
Resources and Training
• http://www.motivationalinterviewing.org/
• http://www.bing.com/videos/search?q=motiv
ational+interviewing+youtube&qpvt=motivati
onal+intervieiwing+you+tube&FORM=VDRE
• http://www.uncmotivationalinterviewing.tum
blr.com/
UNC MI Blog
Resources and Training
• Motivational Interviewing: Helping People
Change Third Edition
– William Miller and Stephen Rollnick
• Motivational Interviewing: Helping People
Change DVD series
– William Miller, Theresa Moyers, and Stephen
Rollnick
Questions & Wrap up