camh ipe 2013 pub

Motivational Interviewing

Marilyn Herie PhD, RSW

CAMH Interprofessional Student EducationFebruary 6, 2013

Confidence Ruler

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No Way I am Bill Miller

http://www.williamrmiller.net/

First, empty your cup

A scientist went to visit a famous Zen master. While the master quietly served tea, the scientist talked about Zen. The master poured the visitor's cup to the brim, and then kept pouring. The scientist watched the overflowing cup until he could no longer restrain himself. "It's overfull! No more will go in!" the scientist blurted. "You are like this cup," the master replied, "How can I show you Zen unless you first empty your cup?"

http://users.rider.edu/~suler/zenstory/emptycup.html

A hypothetical scenario…

How are you feeling?

http://www.lifehack.org/articles/lifestyle/sentences-that-can-change-your-life.html

Learning Objectives

1. Identify practical strategies to motivate change

2. Reflect on how you can adapt these strategies with your clients

3. Set concrete objectives for clinical practice

Persuasion Exercise

• Choose one person near you to have a conversation with, and work together

• One will be the speaker, the other will be a counsellor

14Miller & Rollnick, 2013

Speaker’s Topic• Something about yourself that you

want to changeneed to changeshould changehave been thinking about changing

but you haven’t changed yet…in other words – something you’re

ambivalent about15

Miller & Rollnick, 2013

Counsellor: Find out what change the person is considering making, and then:

• Explain why the person should make this change

• Give at least three specific benefits that would result from making the change

• Tell the person how they could make the change

• Emphasize how important it is to change• If you meet resistance, repeat the above.

P.S. This is NOT motivational interviewing16


Listeners:

What were you thinking or feeling during this conversation?


Common Reactions to Righting Reflex

• Angry, agitated• Oppositional• Discounting• Defensive• Justifying• Not understood• Not heard• Procrastinate

• Afraid• Helpless, overwhelmed• Ashamed• Trapped• Disengaged• Not come back – avoid• Uncomfortable


“Unsolicited advice is the junk mail of life.” (Bern Williams)

“Advice is what we ask for when we already know the answer but wish we didn’t.” (Erica Jong)

A taste of Motivational Interviewing21

Speaker’s Topic:• Something about yourself that you

want to changeneed to changeshould changehave been thinking about changingbut you haven’t changed yet

i.e. – something you’re ambivalent about

A Taste of Motivational Interviewing:Conversation with one speaker and one listener.


Listener

23

• Listen carefully with a goal of understanding the dilemma• Give no advice. • Ask these four open questions and listen with interest:1. Why would you want to make this change?2. How might you go about it, in order to succeed?3. What are the three best reasons to do it?4. 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?• Give a short summary/reflection of the speaker’s

motivations for change• Then ask: “So what do you think you’ll do?” and

just listenMiller & Rollnick, 2013

Speakers:

What were you thinking or feeling during this conversation?


Common Human Reactions to Being Listened to

• Understood• Want to talk more• Liking the counselor• Open• Accepted• Respected• Engaged• Able to change

• Safe• Empowered• Hopeful• Comfortable• Interested• Want to come back• Cooperative

25Would you rather work with these people…


Common Reactions to Righting Reflex

• Angry, agitated• Oppositional• Discounting• Defensive• Justifying• Not understood• Not heard• Procrastinate

• Afraid• Helpless, overwhelmed• Ashamed• Trapped• Disengaged• Not come back – avoid• Uncomfortable

26

…or these?


What is it for?

Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change


Spirit of MI

The “Righting Reflex”

“I try to get my daughter to eat healthy, but that food is expensive and she doesn’t like it anyway.”

“Injecting Oxycodone isn’t so great for my veins, but it’s better than a lot of other crap out there.”

“I only have unprotected sex with my boyfriend, and I know he wouldn’t cheat on me.”

Practitioner to the rescue!

It is your choice whether to make this change…

But giving your kids healthy food is very important in preventing future problems

But if you keep injecting, your veins aren’t the only serious thing to worry about

You are the one who has to decide…

But even people we trust make mistakes sometimes, and that includes your boyfriend

Regardless of what you do, I will be here to support you…

It is your choice whether to make this change…

But giving your kids healthy food is very important in preventing future problemsBut if you keep injecting, your veins aren’t the only serious thing to worry about

But even people we trust make mistakes sometimes, and that includes your boyfriend

Regardless of what you do, I will be here to support you…

You are the one who has to decide…

• “It is your choice whether to make this change.”

• “You are the one who has to decide.”• “Regardless of what you do, I will be

here to support you.”

“People are most able to change when they feel free not to.”

- Carl Rogers

The “Spirit” of Motivational Interviewing

• Partnership• Acceptance• Compassion• Evocation

• Absolute worth• Accurate empathy• Autonomy support• Affirmation


Partnership

“You are the best judge of what is going to work for you.”

Acceptance

“I am here to help whatever you decide to do.”

Compassion

Guide me to be a patient companion, to listen with a heart as open as the sky. Grant me vision to see through his eyes, and eager ears to hear his story…Let me honour and respect his choosing of his own path.

Adapted from Miller, 2013, “A Meditative Preparation” (p.24)

Evocation

“What were you hoping for by coming here today?”

Why would I use it?Motivational interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change.


http://tinyurl.com/c5gamll

Where am I in MI?

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“Spirit” of MI – Resist the Righting Reflex

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“Spirit” of MI – Directional (versus directive)

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“Spirit” of MI – Evoke (versus educate)

The Evidence Base for Motivational Interviewing

Research publications evaluating MI effectiveness have been doubling every three years.

www.motivationalinterview.org

MI Outcome Studies by Era

020406080

100

1988-94 1995-99 2000-02 2003-06

Alcohol Drugs Dual Dx GamblingOffenders Eating Dis Adh/Retention SmokingHIV Risk Cardiac Diabetes PsychiatricHealth Prom Family Violence AsthmaDental

55Slide from Bill Miller, 2010

MI Applications• Public health &

workplace• Sexual health• Dietary change• Weight management• Voice therapy• Gambling• Physical activity• Stroke rehab• Chronic pain

• Medication adherence• Diabetes• Mental health• Addictions• Fibromyalgia• Chronic leg ulceration• Self-care• Criminal justice• Vascular risk• Domestic violence

Anstiss, 2009

A Causal Chain for MI

Therapist MI-consistent speech

Increased client change talk

Improved treatment outcomes

Moyers et al., 2009

“What [practitioners] reflect, they will hear more of.”

Moyers et al., 2009

“Miller and Mount, 2001 have suggested that learning MI involves at least two processes, one of adding preferred behaviors, and another of suppression of non-preferred behaviors.”

(Baer, 2004)

“There is some evidence that eliminating those responses such as confrontations, advice without permission, directing, threatening, and raising concern without permission is more important than just adding MI-consistent responses.”

(Moyers and Ernst, 2001)

2002

2009 612012

2008 2011 62

2012 2013

But what if the person refuses to change?

A 'No' uttered from the deepest conviction is better than a 'Yes' merely uttered to please, or worse, to avoid trouble.

Mahatma Gandhi

“He that complies against his willis of the same opinion still.”

Samuel Butler1612-1680English Poet

The Ineffective Practitioner

“Sal”http://www.youtube.com/watch?v=kN7T-cmb_l0&feature=related

Four Processes in MI1. Engaging: The relational foundation2. Focusing: Clarify directions: What is the

horizon?3. Evoking: The person’s own arguments for

change4. Planning: Developing commitment to

change + formulating a plan of action

Miller and Rollnick, 2013

“Planning is the clutch that engages the engine of change talk” (p.30)

Engaging

FocusingEvoking

Planning

Four Processes in MI

Adapted from Miller and Rollnick, 2013, p. 26

Engaging

Focusing

PrioritiesDiagnosis Treatment

Plan

Symptoms

Benefits

Agenda-Mapping Worksheet

PrioritiesDiagnosis Treatment

Plan

Symptoms

Benefits

Finances

Stress

Relationship

Agenda-Mapping Worksheet

Video Demonstration

Agenda Mapping conversation with "Sal"

http://www.youtube.com/watch?v=klnHJ4coG8o

“Readiness Ruler”

• How important is it to change this behaviour?

• How confident are you that you could make this change?

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People usually have several things they would like to change in their lives – this may be only one of those things. Answer the following two questions with respect to your goal for this week.

Evoking

The Effective Practitioner“Sal”

http://www.youtube.com/watch?v=-RXy8Li3ZaE&feature=related

Planning

Change Talk

Change Talk and Sustain Talk

Opposite Sides of a Coin

Sustain Talk and Resistance

• Sustain Talk is about the target behavior• Resistance is about your relationship• Both are highly responsive to counsellor

style• We respond to both in the same way

Change Talk:

I should really cut back on the drinking…

Sustain Talk:

But beer is good!

Change Talk:

Smoking is unhealthy…

Sustain Talk:

But it is part of who we are

Change Talk:

I should practice this motivational interviewing stuff…

Sustain Talk:

But I am booked back-to-back with clients and there is no time!

DARN CAT

• Desire• Ability• Reasons• Need

• Commitment• Action• Taking Steps

Yet another metaphorMI Hill

Preparatory Change Talk Mobilizing Change Talk

Contemplation Preparation Action(Pre-)

Slide from Bill Miller, 2010

D A R N C A T

DARN CAT



Snap fingers = DARN

Clap = CAT

Silence = No change talk

Listening for Change Talk

“I am getting too old for this lifestyle.”



“My probation order is the only reason I am coming here.”



“I am not addicted. I can quit anytime I want.”



“I want to get well again, but my pain is still really bad.”



“I have started a modified exercise program, quit smoking and drinking, am practicing mindfulness meditation for one hour daily and will do whatever else I need to return to work.”



When you are not sure where to go next…

“Tell me more…Tell me more…”

Where am I in MI?

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Evoking Change Talk

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Recognizing Change Talk

Foundation Skills:

O A R S

FOUR KEY STRATEGIES – OARSOPEN questions (to elicit client change talk)

AFFIRM the client appropriately (support, emphasize personal control)

REFLECT (try for complex reflections)

SUMMARIZE ambivalence, offer double-sidedreflection


Mylopoulos, M, Lohfeld, L, Norman, GR, Dhaliwell, G, Eva, KW (2012). Renowned physicians' perceptions of expert diagnostic practice, Acad Med. 87(10):1413-7.

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“To Listen”

IMPERIAL

Simple Reflection

Complex Reflection

http://tinyurl.com/ara93vh

Simple Reflection

Complex Reflection

They are really on your case about coming to a support group.

It wasn’t your idea to come to group, and you’re not sure this is going to be at all helpful to you.

“I’m only coming to group today because my doctor and my probation officer are both pressuring me.”

Practicing Reflective Listening

Individually, take a moment to write down an example of a simple and a complex reflection for the following statement (coming up – next slide).

Then compare what you wrote with others at your table. As a group, choose the best examples to share with the larger group.

Practicing Reflective Listening (1)

“How I live my life is no one else’s business, and certainly not yours!”

Simple Reflection:

___________________________________

___________________________________

Complex (Enhanced) Reflection:

___________________________________

___________________________________

“How I live my life is my own business and certainly not yours.”

Simple Reflection:

You are the only one to decide how to live your life.


You’re being told you have to make all these changes, and that doesn’t feel very respectful of your choice and autonomy.

“How I live my life is my own business and certainly not yours.”

Practicing Reflective Listening (2)

“I know you mean well, but I don’t need this medication any more.”

Simple Reflection:

___________________________________

___________________________________


___________________________________

___________________________________


Simple Reflection:

You see that I am concerned, but you are ready to stop taking the medication.


You feel like I am pushing for you to take this medication, and not really appreciating where you are at.


Reflecting Panel

1. Four volunteers: Counsellors

2. One volunteer: Client Something you are considering changing and struggling with

3. One volunteer: Coach A sounding board for the client

Reflecting Panel Instructions

1. Client: Share a paragraph with the Reflecting Panel about your struggle/experience

2. Panel: Take turns offering a single reflection3. Client: After ALL Panel members are done,

talk to your coach about which reflection resonates most for you and why

4. Client: Offer this feedback to the panel, and continue the paragraph

“A Psychological Law”

I learn what I believe as I hear myself speak.

Bill Miller (Based on D. Bem, 1967, “Self-Perception: An alternative interpretation of cognitive dissonance phenomena”)

…or put another way…

The word you keep between your lips is your slave. The word you speak is your master.

- Arabic proverb

Where am I in MI?

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Simple Reflections

0 1 2 3 4 5 6 7 8 9 10

Complex Reflections

Additional Reflections and Next Steps

Confidence Ruler

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No Way I am Bill Miller

http://www.williamrmiller.net/

If you have built castles in the air, your work need not be lost. That is where they should be. Now put the foundation under them.

Henry David Thoreau

Castles in the air?

Engaging

Focusing

Evoking

Planning

Motivational Interviewing: Practice TipsMI Spirit: The Essential Foundation

Partnership: You and the client are equal experts

Acceptance: Absolute worth, accurate empathy, autonomy support, affirmation

Compassion: Beneficence, caring, focus on the other

Evocation: The client’s wisdom is most important

OARS: Key Skills

Open Questions:What are your reasons for change? How might you go about it in order to succeed?

Affirmation: You have worked hard to make this happen. I can see that you’ve given this a lot of thought.

Reflections: You wish that… You would like to…

Summary Statements: Let me make sure I understand how this all fits together…

Diagnosis Treatment Plan

Symptoms

Benefits

Finances

Stress

Relationship

Agenda‐MappingCan we take a few minutes to talk about the different issues or concerns that you or others have? Just to get a “big picture” view of what you are coping with right now…

Given all of these possible areas for change, what are your priorities? Where would be the most helpful place for us to start?

0 1 2 3 4 5 6 7 8 9 10

People usually have multiple or competing priorities. On a scale of zero‐to‐ten, how important is it to change…? How confident are you that you could make this change?

Readiness Ruler

Why did you say [lower number] and not [higher number]?

What would it take to go from [lower number] to [higher number]?

Elicit:What do you already know about…?

Provide information: Be brief!

Elicit: How does that fit for you? What do you make of that?

Listen for Change Talk: DARN CATDesire, Ability, Reasons, Need

Commitment, Activation, Taking Steps

Reference: Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd Edition). New York: Guilford.© 2013 Marilyn Herie, PhD RSW [email protected]

Four MI Processes

Life can only be understood backwards, but it must be lived forwards.

‐Kierkegaard

Recommended ResourcesMartino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C., Hamilton,

J., and Hausotter, W. (2006). Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA STEP). Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University.

http://www.motivationalinterview.org/Documents//MIA-STEP.pdfMiller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (Third

Edition). New York: Guilford.Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural

and Cognitive Psychotherapy, 37, 129-140. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416

Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: The Guildford Press.

First chapter and table of contents available at www.motivationalinterview.orgRosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. New

York: Guilford.Wagner, C.C. & Ingersoll, K.S. (2013). Motivational Interviewing in Groups. New York: Guilford

Useful WebsitesMotivational Interviewing Websitehttp://www.motivationalinterview.net/Motivational Interviewing Network of Trainers (MINT) Websitewww.motivationalinterviewing.orgExamples of Motivational Interviewing Videos on YouTubehttp://www.youtube.com/user/teachproject#p/u

Motivational Interviewing Glossary of AcronymsCompiled by Marilyn Herie, PhD, RSW November, 2012ACE (Spirit of MI from Miller and Rollnick 2002 edition)Autonomy / Collaboration / Evocation versusAuthority / Coercion / EducationOARS (Fundamental strategies of MI)Open questions / Affirmations / Reflections / Summary statementsEARS (Strategies for eliciting change talk)Evocation / Affirmation / Reflective listening / Summary statementsRULE (Fundamental strategies in MI v.2)Resist the righting reflex / Understand reasons for change (motivation) / Listen empathically / Empower

the client to use own resourcesDARN CAT (Types of preparatory change talk and commitment language)Desire / Ability / Reasons / Need / Commitment / Action / Taking stepsFRAMES (Ingredients of brief, motivational interventions)Feedback / Responsibility / Advice / Menu (of strategies)/ Empathy / Self-efficacyRAISE (How to give advice)Relationship / Advice to change / “I” statements (affirmation) / Support autonomy / EmpathyREADS (Principles of MI)Roll with resistance / Express empathy / Avoid argumentation / Develop discrepancy / Support self-

efficacyPACE (Spirit of MI from Miller and Rollnick 2013 edition)Partnership / Acceptance / Compassion / EvocationMIST (Coding form)Motivational Interviewing Supervision and Training ScaleMITI (Coding form)Motivational Interviewing Treatment Integrity Coding FormMET (Manual-based motivational intervention)Motivational Enhancement TherapyMIA (Coding abbreviation, used in the MITI)Motivational Interviewing AdherentMINA (Coding abbreviation, used in the MITI)Motivational Interviewing Non-AdherentMIA-STEP (MI supervision manual and coding resource)Motivational Interviewing Assessment – Supervisory Tools for Enhancing ProficiencyAMIAdaptations of Motivational Interviewing

Thank you

[email protected]

www.educateria.com

@MarilynHerie