Motivational Interviewing – a flavour

Preparing people for change

Dr. Gerard Garbutt

You would think . . .

• That having had a heart attack would persuade a man to quit smoking, change diet, exercise and take his medication.

• That hangovers, damaged relationships, a car crash, and memory blackouts would be enough to convince a woman to stop drinking.

Clinician Assumptions

• This person ought to change• This person wants to change• Patient’s health is motivation• No change = failure• Now is the right time• Being tough is best• I know

– my advice is good

• Negotiation is always best

First intro 1983

For alcohol problems

To ‘prime’ for treatment

Enhance intrinsic motivation

Cycle of Change Model

Behaviour Change Counselling

• ‘Ways of structuring a conversation which maximises the individual’s freedom to talk and think about change in an atmosphere free of coercion and the provision of premature solutions’

– Assessing readiness– Weighing up pros and cons– Determining action - moving patients on

What is MI?• Cognitive approach

– Deals with facts and thought processes

• Strategic– Agenda driven & directive

• Empathic– Non judgmental, reflective, affirming, respectful

• Client-centred– Views from client’s perspective, reinforces personal

responsibility

• Empowering– Client in control, supports self-efficacy

What MI is not:

• Giving Information

• Giving Advice

• Persuading

• Warning

• Confronting

• Agreeing

The task of MI is…

• Evocation:– critical elements of change are within the

person– the clinician’s task is to draw them out

• Collaboration:– the clinician is a resource– the client is the expert

• Autonomy:– it is the client, not the clinician, who must

decide to change and provide the means for it

The Basics - Affirmation

• The clinician says something positive or complimentary to the client.– “I appreciate you getting here today“

• Encouraging statements– “Good for you”– “Well done”

The Basics - Open Questions

Open questions: Leave latitude for a response. Client has to think about it ‘What do you want to do about your drinking?’

versus ‘Do you want to quit or cut down?’

Purpose of questions: To gather information What, Why, When, How, Where, Who? To understand a client’s story.

Five General Principles of MI

• Express Empathy• Explore Ambivalence• Develop Discrepancy• Roll with Resistance• Support Self-Efficacy

Throughout – emphasise the desirable

Express empathy

• Getting alongside• Simple reflective listening• Affirmation• Respectfulness

• You want patients say:– ‘I felt heard/understood’– ‘I wanted to carry on talking’

Explore Ambivalence

• Seeing both sides

• Non-judgemental/dispassionate

• Decisional balance

Decisional Balance

++++++ --------

^

• Weighing up pros and con’s

• Seesaw

• Balance sheet

Develop Discrepancy

• Explore client values• Establish client goals• Contrast with behaviour• Cognitive dissonance

– Conflict between opposing self beliefs and /or behaviour leads to resolution or rationalisation

I’ve stopped smoking vs I had a few cigarettes last night

I’m a good mother vs I injected heroin in front of my son

I must stop this behaviour I really am addicted, what can I do? I’m a failure, I have no control

Cognitive Dissonance

What is Resistance?

• Suddenly changes tack• Reasons NOT to change

– Justifying– Blaming– Ignoring– Arguing– Interrupting– Changing the subject

Rolling with Resistance

Avoid argumentation through:

• Shifting focus

• Reframing

• Agreement with a twist

• Emphasising personal control

Support self-efficacy

• Optimism

• Emphasise client’s past achievements

• Convey the success of others

• Selectively reinforce optimistic/motivated statements

Envisioning

• Projecting into the future:– What will happen if behaviour doesn’t change?– What would be different if you could make the

change?

• Or directively:– if you carried on what would be the downside?– if you changed/stopped, what would be the benefits?

Decision making – bringing it all together

• Summarise the ambivalence• Elaborate the pros and cons of change• Emphasise personal control• Support self-efficacy• Positive images of the future after change• Ask:

– What would you like to do now about your drinking?

Conflict Resolution is the key:

• Try to elicit a decision:• I’ll stop• I’ll cut down• I’ll get help• I’ll come back to see you

• Firm up the decision- Ensure it’s personal

A brief MI intervention

• Introduction and consent

• Decisional balance

• Feedback - cognitive dissonance

• Envisioning

• Decision making

Feedback – giving the facts

• Common in primary care – eg:– GGT & ALT– Units– Questionnaire results– Behaviour related health check ups– Opportunity to open a motivational dialogue

• What do the facts mean to the patient?

Feedback method

• Introduce test• Describe implications• Check understanding• Check meaning to the client• Provide normative range• Present results• Check understanding• Avoid jargon

Feedback exercise

Feeding back information from some liver function tests using the methodology described.

Check understanding/significance first!

Gamma GT(15-35) 150ALT (10-50) 90

Motivational Interviewing

• Ways of structuring a conversation which maximises the individual’s freedom to talk and think about change in an atmosphere free of coercion and free of the provision of premature solutions

(Rollnick et al. 1999)