motivational interviewing the basics - · pdf filemotivational interviewing the basics funded...

Funded by: www.sbirtonline.org

Alan Lyme, LCSW

Sylvia Shellenberger, PhD

Southeastern Consortium for Substance Abuse Training – Advanced Practice Registered Nurses

Funded by Grant 1U79T1025372-01

Substance Abuse and Mental Health Services Administration (SAMHSA)

Last revised: March 31, 2014

Motivational InterviewingThe Basics

Funded

by:

SECSAT-APRNSoutheastern Consortium for Substance Abuse Training -

Advanced Practice Registered Nurses

Key Contributors &SECSAT – APRN Site Coordinators

Mercer University, School of MedicineJ. Paul Seale, MD

Principal Investigator

Annie Biers, LPC, Project Coordinator

Sylvia Shellenberger, PhD

Mercer University, Georgia Baptist College of NursingDr. Frieda Fuller Dr. Laura K. Baraona

Armstrong Atlantic University

Dr. Anita NivensDr. Linda Tuck

Emory University, Nell Hodgson Woodson

School of Nursing Dr. Carolyn Clevenger

Dr. Ursula KellyDr. Phyllis Wright

University of North Georgia Dr. Sharon Chalmers

South UniversityDr. Doris Parrish

Johns Hopkins University

Dr. Christine SavageDr. Deborah Finnell

Georgia College & State University

Dr. Deborah MacMillanDr. Sallie Coke

University of Alabama, Birmingham

Dr. Susanne Fogger

Why Should We Be Interested in

Patients’ Motivation for Behavior

Change?

SECSAT – APRN © 2014 3

Motivation Pretest

Let’s find out what you think about motivation.


Beliefs About Motivation

1. Until a person is motivated to change, there is not much we can do.a. True

b. False



2. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change.a. Trueb. False



3. Motivation is influenced by interpersonal relationships.a. Trueb. False



4. Creating motivation for change usually requires confrontation.

a. Trueb. False

8SECSAT – APRN © 2014

Southeastern Consortium on Substance Abuse Training

- APRN © 2014

Why Do People Change?1. ?

2. ?

3. ?

4. ?

5. ?

6. ?


Why Don’t People Change?1. ?

2. ?

3. ?

4. ?

5. ?

6. ?


At the end of the session, you will be able to—1. Define motivational interviewing (MI).

2. Identify the tasks of MI.

3. Describe the spirit of MI.

4. Define the principles of MI.

5. Identify MI intervention to explore potential change.

12

Learning Objectives

SECSAT – APRN © 2014

Definition of Motivational Interviewing

“Motivational interviewing is a patient-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”

Miller & Rollnick, Motivational Interviewing: Helping People Change, 3rd edition, 2013


Motivational Interviewing

The tasks of MI are to—

Engage, through having sensitive conversations with patients.

Focus on what’s important to the patient regarding behavior, health, and welfare.

Evoke the patient’s personal reasons and means for change.

Plan, collaborating with patient and exploring options.

Motivation often results from helping the patient resolve conflicting and ambivalent feelings and thoughts.


Video Demonstration


http://youtu.be/ZGETDcFcAbI

http://youtu.be/ZGETDcFcAbI

Discussion of video

What were the strengths of this doctor’s approach?

What was his goal?


How willing do you think this patient

will be to change his drinking or

reduce his risk as a result of this

conversation?

Not willing Very willing

______________________________________

0 1 2 3 4 5 6 7 8 9 10


Video Demonstration


http://youtu.be/uL8QyJF2wVw

http://youtu.be/uL8QyJF2wVw

Discussion of video

What were the strengths of this doctor’s approach?

What was his goal?


How willing do you think this patient

will be to change his drinking or

reduce his risk as a result of this

conversation?

Not willing Very willing

______________________________________

0 1 2 3 4 5 6 7 8 9 10


21

Motivational Interviewing Spirit


“People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others.”

—Blaise Pascal


Spirit of MI

A way of communicating with patients that is…

Collaborative

Evocative

Respectful of autonomy

Compassionate


Spirit of MI

Collaboration (not confrontation) Developing a partnership in

which the patient’s expertise, perspectives, and input are central to the consultation.

Fostering and encouraging power sharing in the interaction.


Spirit of MI

Evocation (not education)

Motivation for change resides within the patient.

Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals.

Ask key open-ended questions.


Spirit of MIAutonomy (not authority) Respecting the patient’s right to make

informed choices facilitates change.

The patient is in charge of his/her choices and thus is responsible for the outcomes.

Emphasizing patient control and choice. Patients are experts in their own needs, experience, and what worked in the past.


Spirit of MI

Compassion

Empathy (not sympathy) for the experience of others.

Desire to promote the wellbeing of others.

Belief and commitment to act in the best interests of the patient.


Collaboration

Acceptance

Evocation

CompassionMI

Spirit

MI Core Skills 2013


29

Motivational Interviewing Principles


MI Principles

MI is founded on four basic principles:

Express empathy

Develop discrepancy

Dance with discord

Support self-efficacy

Resisting the “Righting Reflex”


MI Principles

Express empathy


Express Empathy

What is empathy?

Reflects an accurate understanding

– Assumes the person’s perspectives are understandable, comprehensible, and valid.


Express Empathy Empathy is:

– The ability to accurately understand the patient’s meaning

– The ability to reflect that accurate understanding back to the patient

– Seeking to understand the patient’s feelings and perspectives without judging


Express Empathy

Why is empathy important in MI?

Encourages a collaborative alliance, which also promotes change.

Leads to an understanding of each person’s unique perspective, feelings, and values, which make up the material we need to facilitate change.

Communicates acceptance, which facilitates change.


What do we mean by communicating acceptance?

Not acceptance of unhealthy behaviors or high risk lifestyle, but acceptance of the person who is struggling with competing needs, feelings and concerns.

Empathy is the ability to see that to struggle with shortcomings is to be human.

Empathy is also the ability to recognize that everyone has strengths, and small strengths can pull us through bad times.


Express EmpathyTips…

Good eye contact

Responsive facial expression

Body orientation

Verbal and nonverbal “encouragers”

Reflective listening/asking clarifying questions

Avoid expressing doubt/passing judgment


Listen actively

• Pair up in twos

• Speaker (Partner A) share something about yourself – where you are from, what kind of work you do, what you like about your life (home, family, work).


Partner B will listen actively with:

Presence – undividedattention

Patience Eyes, ears, heart Acceptance & non-judgment Curiosity Delight No interruptions Encouragers (uh-huh, wow,

tell me more)

1 minute 15 seconds38SECSAT – APRN © 2014

Speaker (Partner A) Ask for permission saying, “May I share with you

some positive feedback?”

Tell the listener/Partner B: what made it easy to share your story?

20 seconds

Reverse roles


The Bottom Line on Empathy

An opportunity to understand the patient

Our acceptance facilitates change.

Skillful reflective listening is fundamental to expressing empathy.

Miller, W. R. & Rollnick, S. (2013)


MI PrinciplesDevelop discrepancy.


Make transparent and amplify the patient’s own ambivalence:

– Decisional balance “Good” vs. “Not-so-good”

Develop Discrepancy


Develop Discrepancy

Current behavior versus future goals

Example: “You enjoy your work, and doing well in your job is very important to you, and sometimes when you drink during the week, you can’t get out of bed to get to work. Last month, you said you missed 5 days.”


MI Principles Dance with Discord


Dance with Discord So as to avoid patients thinking…

When will

this be

over?You’re wrong

Yes, but...

If I just play along…45

Traditionally viewed as patient denial or resistance

– “I don’t think my drinking is that bad.”

Now thought to be a product of a practitioner who utilizes a confrontational interviewing style –creating discord

– “Can’t you see that your drinking is seriously damaging your liver?”

Motivational Interviewing in Health Care Settings: Opportunities and Limitations. Karen M. Emmons, PhD, Stephen Rollnick, PhD. Am J Prev Med 2001;20(1) 68-74

Dance with Discord


Dance with Discord Confrontation may have a deleterious impact on

patient self-efficacy

– The more practitioners confront patients about their drinking, the more patients drink at follow-up

An empathic approach builds self-efficacy

Practitioners are more effective if they elicit arguments for change from the patients themselves

Motivational Interviewing in Health Care Settings: Opportunities and Limitations. Karen M. Emmons, PhD, Stephen Rollnick, PhD. Am J Prev Med 2001;20(1), 68-74


Dance with DiscordPatient: You can’t make me quit drinking.

Clinician: You don’t think that abstinence would work for you right now.

Patient: Look, I’m just fine. I can take care of

myself, OK? Can I go now?

Clinician: It sounds like you are tired of dealing with this issue and want to move on.


MI PrinciplesSupport self-efficacy.

“Can-do”


Support Self-Efficacy

Patients are responsible

for choosing and carrying

out actions to change.

We help them build

confidence and have a

“can-do” attitude.


MI Principles: Resist Righting Reflex

Resist the righting reflex (urge to fix) If a patient is ambivalent

about change, and the clinician champions the side of change…


Conclusion of MI Basics The Four Principles: Engage, Focus, Evoke, and

Plan provide structure to the consultation

Collaboration, evocation, autonomy and compassion are the foundation of the model


QUESTIONS?

What’s Next?

In the next session, you will learn the steps and core skills of MI.


motivational interviewing the basics - · pdf filemotivational interviewing the basics funded...

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