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Enhancing Motivation to Enhancing Motivation to ChangeChange

Developed by DATA of Rhode IslandDeveloped by DATA of Rhode IslandThrough a special grant from the Rhode Island Through a special grant from the Rhode Island

Department of Human Services Department of Human Services September 2006September 2006

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Motivational InterviewingMotivational Interviewinghas been successfully used to assist has been successfully used to assist

people with a variety of problems:people with a variety of problems:

•Alcohol Abuse•Drug Abuse•Dual Diagnosis•Diabetes•Gambling•Mental Health

•Smoking•Cardiovascular Health•Eating Disorders•Health Promotion•HIV Risk

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The Goal of Today’s The Goal of Today’s Training is:Training is:

For trainees to learn about:stages of readiness to changemotivational interviewing (MI) how to utilize MI techniques to more effectively assist people to make life changes in a variety of areas

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Group Discussion Questions: Group Discussion Questions: Why Why don’tdon’t People Change? People Change?

1.1. ____________________________________________________________

2.2. ____________________________________________________________

3.3. ____________________________________________________________

4.4. ____________________________________________________________

5.5. ____________________________________________________________

6.6. ____________________________________________________________

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Group Discussion Questions: Group Discussion Questions: Why Why dodo People Change? People Change?

1.1. ____________________________________________________________

2.2. ____________________________________________________________

3.3. ____________________________________________________________

4.4. ____________________________________________________________

5.5. ____________________________________________________________

6.6. ____________________________________________________________

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Motivational Interviewing: Motivational Interviewing: Readiness to Change Readiness to Change

4 possible change options:4 possible change options:

1.1. Not readyNot ready

2.2. UnsureUnsure

3.3. ReadyReady

4.4. TryingTrying

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The Goal of MI:The Goal of MI:To Assist People to Become To Assist People to Become

Ready, Willing, and AbleReady, Willing, and Able

WillingWilling: The Importance of Change: The Importance of Change

AbleAble: Confidence for Change: Confidence for Change

ReadyReady: A Matter of Priorities: A Matter of Priorities

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What Motivates Change?What Motivates Change?

Self questioningSelf questioning

ValuesValues

NeedsNeeds

ReadinessReadiness

AnxietiesAnxieties

InsightInsight

DesireDesire

DiscoveryDiscovery

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Motivational InterviewingMotivational InterviewingA Definition – Bill Miller, PhDA Definition – Bill Miller, PhD

Motivational interviewing is a Motivational interviewing is a person-centered person-centered directive method of communicationdirective method of communication for enhancing intrinsic motivation to change for enhancing intrinsic motivation to change

by exploring and resolving ambivalenceby exploring and resolving ambivalence

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Four Basic MI Skills: OARSFour Basic MI Skills: OARSAsk Ask OPENOPEN questions questions not short-answernot short-answer yes/noyes/no rhetorical questionsrhetorical questions

AFFIRMAFFIRM the person the person comment positively on strengths, effort, intention,comment positively on strengths, effort, intention,

REFLECTREFLECT what the person says what the person says "active listening“"active listening“

SUMMARIZESUMMARIZE draw together the person's own perspectives on changedraw together the person's own perspectives on change

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Formulate Open and Closed Q’s regardingFormulate Open and Closed Q’s regarding:: About changing (i.e., smoking, diet, exercise, etc.)About changing (i.e., smoking, diet, exercise, etc.) About what may happen in the future (without change, with change)About what may happen in the future (without change, with change) About the negative consequences already experiencedAbout the negative consequences already experienced About the differences in _________ between now & thenAbout the differences in _________ between now & then

ConfidenceConfidence About changing (i.e., smoking, diet, exercise, etc.)About changing (i.e., smoking, diet, exercise, etc.)

ImportanceImportance About what may happen in the future (without change, with change)About what may happen in the future (without change, with change) About coping with temptationAbout coping with temptation About maintaining motivationAbout maintaining motivation About what could be of help to youAbout what could be of help to you

Open/Closed QuestionsOpen/Closed Questions

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Stages of Change ModelStages of Change Model

Precontemplation

Maintenance

ActionPreparation -

Determination

ContemplationRelapse

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Stages of ChangeStages of ChangePre-contemplationPre-contemplation

ContemplationContemplation

Preparation/DeterminationPreparation/Determination

ActionAction

MaintenanceMaintenance

RelapseRelapse

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PRE-CONTEMPLATIONPRE-CONTEMPLATION“Who, me?”“Who, me?”

No No considerationconsideration to changeto change

Lack of motivation Lack of motivation to changeto change

Low self-efficacyLow self-efficacy

Lack of Lack of informationinformation

Contentment with Contentment with status quostatus quo

No No intentionintention of of changing target changing target behaviorbehavior

No No actionaction toward toward changechange

EngagesEngages in targeted in targeted behavior freelybehavior freely

Does not connectDoes not connect life life difficulties to the difficulties to the behaviorbehavior

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PrecontemplationPrecontemplation

ClientClient

1 Person is not yet Person is not yet considering the considering the possibility of possibility of change.change.

2 Person does not Person does not actively pursue actively pursue treatment.treatment.

HelperHelper

a Helper needs to provide Helper needs to provide information and information and personalized feedback in personalized feedback in order to increase client’s order to increase client’s awareness.awareness.

b Giving advice is Giving advice is counterproductivecounterproductive

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A Typical DayA Typical Day

A. Explain the purpose & define a time-frameA. Explain the purpose & define a time-frame Can we spend the next few minutes talking Can we spend the next few minutes talking

about ______so that I can better understand about ______so that I can better understand how it fits into your everyday life?how it fits into your everyday life?

B. Locate the day/session to be describedB. Locate the day/session to be described Think of a typical recent day (time) which Think of a typical recent day (time) which

would give me a good picture of how you would give me a good picture of how you use ___. Can you think of one?use ___. Can you think of one?

C. Ask for a detailed descriptionC. Ask for a detailed description I’d like you to take me through this day, a I’d like you to take me through this day, a

step at a time and tell me how _____ fits into step at a time and tell me how _____ fits into the day. You woke up at _____?the day. You woke up at _____?

D. Follow the person’s statements with open-D. Follow the person’s statements with open-ended questions and short summariesended questions and short summaries

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Core Value DiscrepancyCore Value Discrepancy Which of the following Which of the following values, traits, or values, traits, or

characteristicscharacteristics are important to you? are important to you?good parentgood parent

good spouse/partnergood spouse/partner

god communitygod community

membermember

strongstrong

on top of thingson top of things

competentcompetent

spiritualspiritual

respected @ homerespected @ home

good Christian,good Christian,

Jew, Moslem, etc.Jew, Moslem, etc.

attractiveattractive

disciplineddisciplined

responsibleresponsible

in controlin control

respected by othersrespected by others

athleticathletic

organizedorganized

energeticenergetic

compassionatecompassionate

dependabledependable

honesthonest

open-mindedopen-minded

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Core Value DiscrepancyCore Value Discrepancy

How, if at all, is your current behavior related to How, if at all, is your current behavior related to these?these?

How, if at all, does your current behavior affect your How, if at all, does your current behavior affect your ability to achieve these goals or live out these ability to achieve these goals or live out these values?values?

I’m curious…..I’m curious….. Do you see a connection between your ____ behavior and Do you see a connection between your ____ behavior and

any of these values/goals?any of these values/goals?

I’m curious…..I’m curious….. Do you see a connection between your health and any of Do you see a connection between your health and any of

these values/goals?these values/goals? Do you see any connection between your ___ behavior and Do you see any connection between your ___ behavior and

your health?your health?

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Readiness RulerReadiness Ruler

““How important is it for you to change?”How important is it for you to change?”

How confident are you that you could change if How confident are you that you could change if you decided to?”you decided to?”

11 22 33 44 55 66 77 88 99 1010

                             

Not ReadyNot Ready UnsureUnsure ReadyReady

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CONTEMPLATIONCONTEMPLATION“yes, but”“yes, but”

Highly ambivalentHighly ambivalentWaivers Waivers considerably; considerably; ponders change ponders change than rejects itthan rejects it““Yes-but” Yes-but” rationalizationsrationalizationsLow intention to Low intention to change & no change & no sustainedsustained actionaction

Not to Change

To Change

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AmbivalenceAmbivalence is the Issue --is the Issue --

To change

Not to Change

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ContemplationContemplation

ClientClient

1 Person is Person is ambivalent about ambivalent about change.change.

2 Client might bring Client might bring up the issue or ask up the issue or ask for assistance.for assistance.

HelperHelpera.a. Aim is to tip the balance Aim is to tip the balance

in favor of change.in favor of change.

b.b. Elicit reasons for changeElicit reasons for change

c.c. Strengthen client’s Strengthen client’s confidenceconfidence

d.d. Help assess reasons for Help assess reasons for and against changeand against change

e.e. Action steps will most Action steps will most likely be met with likely be met with resistance.resistance.

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The Good and Not So GoodThe Good and Not So Good“ “ I’d like to understand the role _____ plays in your I’d like to understand the role _____ plays in your life” life” Always start with the goodAlways start with the good

What are some of the good things about _______?What are some of the good things about _______? What do you like about _______?What do you like about _______?

When the list is obtained offer a summary.When the list is obtained offer a summary.Remain neutral in query for not so good (don’t Remain neutral in query for not so good (don’t assume not so good = bad)assume not so good = bad)

What are some of the less good things about _______?What are some of the less good things about _______? What about the other side. What’s the not so good side of What about the other side. What’s the not so good side of

_________?_________?

Use opened ended questions to find out why the Use opened ended questions to find out why the person thinks these things are “less good”person thinks these things are “less good”Offer a summary statement as succinctly as possibleOffer a summary statement as succinctly as possibleThank the client for their assistance.Thank the client for their assistance.

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Decisional Balance SheetDecisional Balance Sheet

Good things about:1. 2. 3.

Not so good things about:1. 2. 3.

Not so good things about changing:1.2.3.

Good things about changing:1. 2.3.

Reasons for staying the same Reasons for making a change

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PREPARATIONPREPARATION“uh-oh”“uh-oh”

Commitment to actCommitment to actInternal motivation replacing Internal motivation replacing external motivationexternal motivationWindow of opportunityWindow of opportunityRisk takingRisk takingSerious intention to changeSerious intention to changeMoving towards action, but still not Moving towards action, but still not sustainedsustainedRecognizes that change must Recognizes that change must occur, but not sure howoccur, but not sure howMay not believe change must be May not believe change must be permanentpermanent

Need to assess:Need to assess: FEARSFEARS BARRIERSBARRIERS STRENGTHSSTRENGTHS

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Preparation/DeterminationPreparation/Determination

ClientClient

1.1. A window of A window of opportunity that opportunity that opens for a period of opens for a period of time.time.

2.2. Person may be Person may be modifying current modifying current behavior in behavior in preparation for future preparation for future change.change.

HelperHelpera.a. Help the client strengthen Help the client strengthen

commitment and motivation commitment and motivation for change.for change.

b.b. Help client find a strategy Help client find a strategy that is acceptable, that is acceptable, accessible and effectiveaccessible and effective

c.c. May be met with resistanceMay be met with resistance

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☻ How IMPORTANT is it for you to change right now? How IMPORTANT is it for you to change right now?

On a scale of 0 to 10, what number would you give yourself?On a scale of 0 to 10, what number would you give yourself?

0---------------------------5----------------------100---------------------------5----------------------10

not at all important extremely importantnot at all important extremely important

a. Why are you at a. Why are you at XX and not 1? and not 1?

b. What would need to happen for you to get from b. What would need to happen for you to get from XX to to YY??

c. How can I help you get from X to Y?c. How can I help you get from X to Y?☺ If you decided to change, how CONFIDENT are you If you decided to change, how CONFIDENT are you

that you could do it? that you could do it?

On a scale of 0 to 10, what number would you give yourself?On a scale of 0 to 10, what number would you give yourself?

0---------------------------5-----------------------100---------------------------5-----------------------10

not at all confident extremely confidentnot at all confident extremely confident

a. Why are you ata. Why are you at X X and not 1? and not 1?

b. What would need to happen for you to get from b. What would need to happen for you to get from XX to to YY??

c. How can I help you get fromc. How can I help you get from X X to to YY??

Scaling QuestionsScaling Questions

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ASK Key QuestionsASK Key Questions““So, what’s next?”So, what’s next?”

There’s no ‘right” road that works for There’s no ‘right” road that works for everybody. I can try to help you everybody. I can try to help you figure out what might works for you.”figure out what might works for you.”

““Where do we go from here?”Where do we go from here?”

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End of Section 1End of Section 1

BREAKBREAK

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Signs of Readiness to Signs of Readiness to ChangeChange

Decreased ResistanceDecreased Resistance

Lots of Lots of change talkchange talk

Envisioning the futureEnvisioning the future

Questions about changingQuestions about changing

Experimenting with small changeExperimenting with small change

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Negotiate Achievable GoalsNegotiate Achievable Goals

Offer a MENU of optionsOffer a MENU of options Avoid jargonAvoid jargon Start with simplest strategies [baby steps]Start with simplest strategies [baby steps] Use language the client understandsUse language the client understands

AGREE on a next stepAGREE on a next step Which option seems the most reasonable?Which option seems the most reasonable? ““Do you feel ready to act on may of these Do you feel ready to act on may of these

choices?”choices?”

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ACTION --- ACTION --- “do it”“do it”Change is occurringChange is occurringGoal directedGoal directedRespond to Respond to challengeschallengesExperimentationExperimentationSkill buildingSkill buildingTakes clearly Takes clearly identifiable steps identifiable steps toward changetoward changeEfforts are sustained Efforts are sustained despite setbacksdespite setbacks

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ActionActionClientClient

1.1. Person engages in Person engages in actions intended to actions intended to bring about change.bring about change.

2.2. Change areas are client Change areas are client specific and include: specific and include: attitude, behavior, attitude, behavior, thoughts and feelings.thoughts and feelings.

HelperHelper

Affirm commitment to Affirm commitment to change.change.

Help identify Help identify necessary steps for necessary steps for change.change.

Identify additional Identify additional resources.resources.

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MAINTENANCE – MAINTENANCE – “Living life on life’s terms”“Living life on life’s terms”

Maintain change for a significant Maintain change for a significant time period (6 mo.)time period (6 mo.)Focuses efforts on preventing Focuses efforts on preventing relapse & developing the relapse & developing the capacity to live a recovery capacity to live a recovery lifestylelifestyleRe-evaluationRe-evaluationLong-term goalsLong-term goalsNew skillsNew skillsOpen to feedbackOpen to feedback

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RELAPSERELAPSE“back to the drawing board”“back to the drawing board”

RecurrenceRecurrence

Cope with the Cope with the consequences consequences

Avoid becoming Avoid becoming demoralized demoralized

Decide what to do nextDecide what to do next

Renew process of Renew process of contemplationcontemplation

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Relapse/RecyclingRelapse/Recycling

ClientClient

1.1. Has returned to Has returned to previous behavior.previous behavior.

2.2. May occur in any May occur in any stage.stage.

3.3. Client may feel like a Client may feel like a failure and be failure and be discouraged about discouraged about ability to change.ability to change.

HelperHelper

a.a. Assure client that slips Assure client that slips may happen.may happen.

b.b. Help client avoid Help client avoid becoming discouraged becoming discouraged and demoralized.and demoralized.

c.c. Help client renew Help client renew determination and determination and confidence to resume confidence to resume change efforts.change efforts.

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Motivational Interviewing and Motivational Interviewing and Motivational EnhancementMotivational Enhancement

Uses helper skills to elicit statements from Uses helper skills to elicit statements from client about goals, desires, motivation levels;client about goals, desires, motivation levels;

Acknowledges stages of change and Acknowledges stages of change and differential levels of motivation through which differential levels of motivation through which individuals typically pass (and may return, individuals typically pass (and may return, over and over again);over and over again);

Advocates that helpers “roll with resistance” Advocates that helpers “roll with resistance” and reinforce client movement and attempts and reinforce client movement and attempts toward change.toward change.

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What is Motivational What is Motivational Interviewing?Interviewing?

Listening with empathetic Listening with empathetic understandingunderstanding

Evoking client’s own concerns & Evoking client’s own concerns & motivationsmotivations

Avoiding argument for changeAvoiding argument for change

Nurturing hope & optimismNurturing hope & optimism

Eliciting & shaping client language Eliciting & shaping client language toward adaptive changetoward adaptive change

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What Motivational What Motivational Interviewing Interviewing

is is NotNot::Giving informationGiving information

Giving adviceGiving advice

Using logic to persuadeUsing logic to persuade

WarningWarning

ConfrontingConfronting

AgreeingAgreeing

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Four General Principles of MIFour General Principles of MI

1.1. Express EmpathyExpress Empathy

2.2. Develop DiscrepancyDevelop Discrepancy

3.3. Roll with ResistanceRoll with Resistance

4.4. Support Self-EfficacySupport Self-Efficacy

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1. Express Empathy1. Express Empathy

Acceptance facilitates changeAcceptance facilitates change

Skillful reflective listening is fundamentalSkillful reflective listening is fundamental

Ambivalence is normalAmbivalence is normal

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2. Develop Discrepancy2. Develop Discrepancy

The person rather than the counselor The person rather than the counselor should present the arguments for should present the arguments for changechange

Change is motivated by a perceived Change is motivated by a perceived discrepancy between present behavior discrepancy between present behavior and important personal goals or valuesand important personal goals or values

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Roll with ResistanceRoll with ResistanceAvoid arguing for changeAvoid arguing for change

Resistance is not directly opposedResistance is not directly opposed

New perspectives are invited, not New perspectives are invited, not imposedimposed

Resistance is a signal to respond Resistance is a signal to respond differentlydifferently

The person is a primary resource in The person is a primary resource in finding answers and solutionsfinding answers and solutions

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Support Self-EfficacySupport Self-EfficacyA person’s belief in the possibility of A person’s belief in the possibility of change is an important motivatorchange is an important motivator

The person, not the counselor, is The person, not the counselor, is responsible for choosing and carrying responsible for choosing and carrying out changeout change

The counselor’s own belief in the The counselor’s own belief in the person’s ability to change becomes a person’s ability to change becomes a self-fulfilling prophecyself-fulfilling prophecy

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Five MI MethodsFive MI Methods

1.1. Ask Open QuestionsAsk Open Questions

2. Listen Reflectively2. Listen Reflectively

3. Affirm3. Affirm

4. Summarize4. Summarize

5. Elicit Change Talk5. Elicit Change Talk

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1. Ask Open Ended 1. Ask Open Ended QuestionsQuestions

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2. Listen Reflectively2. Listen Reflectively

Avoid roadblocksAvoid roadblocks

Think reflectively (hypothesis Think reflectively (hypothesis testing)testing)

A statement, not a questionA statement, not a question

Levels of reflectionLevels of reflection

Understating and overstatingUnderstating and overstating

Continuing the paragraphContinuing the paragraph

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3. Affirm3. Affirm

Provide ‘attaboys' & 'attagirls' Provide ‘attaboys' & 'attagirls'

Acknowledge difficulty of seeking Acknowledge difficulty of seeking assistance, considering change, making assistance, considering change, making change, & sustaining changechange, & sustaining change

Focus on & reinforce successesFocus on & reinforce successes

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4. Summarize4. Summarize

CollectingCollecting Summary Summary

LinkingLinking Summary Summary

TransitionalTransitional Summary Summary

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5. Elicit Change Talk5. Elicit Change Talk

Asking Evocative QuestionsAsking Evocative Questions

Using The Importance RulerUsing The Importance Ruler

Exploring the Decisional BalanceExploring the Decisional Balance

ElaboratingElaborating

Querying ExtremesQuerying Extremes

Looking Back / Looking ForwardLooking Back / Looking Forward

Exploring Goals and ValuesExploring Goals and Values

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Goals for Effective MIGoals for Effective MITalk less than the client doesTalk less than the client does

Reflect twice for every question asked Reflect twice for every question asked (2:1 ratio)(2:1 ratio)

Ask mostly opened questions (OEQS)Ask mostly opened questions (OEQS)

Avoid getting ahead of the client’s Avoid getting ahead of the client’s change readiness (helper offering change readiness (helper offering change talk or unsolicited advice)change talk or unsolicited advice)

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DemonstrationDemonstration

MI in PracticeMI in Practice

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Discussion of DemonstrationDiscussion of Demonstration

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Questions?Questions?

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Closing ExerciseClosing Exercise

1.1. Something I liked?Something I liked?

2.2. Something I’ll use?Something I’ll use?

3.3. This training will help me?This training will help me?

4.4. Something more I wanted more of?Something more I wanted more of?

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Suggested Articles or ReadingsSuggested Articles or ReadingsMiller, W. & Rollnick, S. (2002Miller, W. & Rollnick, S. (2002)). . Motivational Motivational

Interviewing: Preparing People for ChangeInterviewing: Preparing People for Change. 2nd . 2nd edition. NYC, NY: Guilford Press.edition. NYC, NY: Guilford Press.

Prochaska, J., Norcross, J. & DiClemente, C. (1994). Prochaska, J., Norcross, J. & DiClemente, C. (1994). Changing for GoodChanging for Good. NYC, NY: Avon Books.. NYC, NY: Avon Books.

SAMHSA. (2002) TIP Manual 35: SAMHSA. (2002) TIP Manual 35: Enhancing Enhancing Motivation for Change in Substance Abuse Motivation for Change in Substance Abuse TreatmentTreatment. Washington, DC: SAMHSA (US . Washington, DC: SAMHSA (US Government Document)Government Document)

SAMHSA. (1999). SAMHSA. (1999). Quick Guide for Clinicians Based Quick Guide for Clinicians Based on TIP Manual 35: Enhancing Motivation for on TIP Manual 35: Enhancing Motivation for Change in Substance Abuse TreaChange in Substance Abuse Treatment. tment. Washington, DC: SAMHSA (US Government Washington, DC: SAMHSA (US Government Document)Document)

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Suggested WebsitesSuggested Websiteswww. motivationalinterview.orgwww. motivationalinterview.org

www.casa.unm.eduwww.casa.unm.edu