Transcript Motivational Interviewing – An Overview

Motivational Interviewing:
An Overview for Health Care Professionals
Amethyst, Inc.
Integrated Tobacco Treatment Program
Gretchen Clark Hammond, MSW, LSW, TTS
Our Objectives for Today
Upon completion of this workshop, you will:
• Be familiar with the basic components and
philosophy of Motivational Interviewing (MI).
• Be familiar with the Transtheoretical Model (TTM)
and its application to MI.
• Improve their understanding of the application of MI
to various populations and health concerns.
• Feel like you could put some of these basic concepts
to use in your everyday practice!
Motivational Interviewing: Context
• Motivational Interviewing (MI) is an approach that works
with resistance from a perspective of joining with the
client (The Dance)
• Think of MI as more of a method of communication versus
a set of techniques
• Compliments the Stages of Change Model (Prochaska &
DiClemente)
• MI believes that the resolution of ambivalence can lead to
progression through the stage of change.
MI is used in many settings
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Addiction Treatment
Medical Offices
Public Health
Criminal Justice
Private Practice/Therapy/Counseling
MI is used in many settings
• It is useful in many settings because it
addresses CHANGE, which affects many of
life’s situations:
– Changing behavior
– Changing actions
– Changing thoughts
– Changing emotions
Motivation
• Motivation is an interesting concept, vastly
misunderstood by most of us.
Motivation
Motivation is FUNDAMENTAL to change.
Motivation is comprised of three elements:
• Importance (for the change): willingness, desire or perceived
importance
• Confidence (about being able): self-efficacy
• Readiness (to make the change): priorities
These three elements are not the same and impact motivation
differently.
Motivation
• Importance: My Head
• Confidence: My Heart
• Readiness: My Gut
• Is the fire under me lit, and is it hot enough to
burn?
Motivation and Ambivalence
• Ambivalence refers to having mixed or conflicted
feelings (Pro vs. Con)
• “I really enjoy smoking, but I know it’s bad for my
health”
• Ambivalence is a normal part of any change process
and is usually connected to fears and concerns
• Motivational Interviewing attempts to help the client
resolve the ambivalence towards change.
Facilitating Change
• Change may occur in a stage-like process:
• The Transtheoretical Model/Stages of Change
(Prochaska and DiClemente)
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Precontemplation
Contemplation
Preparation
Action
Maintenance
And, of course, there is RELAPSE, which is also a stage.
Motivational Interviewing (MI) : “The
Dance”
• Three key principles in utilizing Motivational
Interviewing
– Collaboration – NOT confrontation
– Evocation – NOT education/advice
– Autonomy – NOT authority
Motivational Interviewing
Support Self-efficacy:
• Convey faith in the clients’ ability to change
• Client chooses goals
• Point out and support client’s strengths and accomplishments
To Summarize:
• Motivation is complex and often misunderstood
• We understand that ambivalence is normal and often
what holds a person back
• We can work with resistance
• We recognize the autonomy of the individual
• We realize that we must connect with a person in
order to understand how to help them with a change
process.
Motivational Interviewing:
The Components
• Open-ended question/open-ended statement
• Affirm their feelings/thoughts through the use
of reflection
• Reflection of feeling; reflection of actual
statements
• Summarize what was said while posing the
next step back to the individual.
MI: The Components
• We use these four components
interchangeably to address the particulars of
ambivalence, which live in three zones:
– Importance
– Confidence
– Readiness
Our goal is to ENGAGE with the patient so that we
can begin moving forward almost immediately.
MI: The Components
Opening the Conversation
• Ask an open-ended question
• Affirm the client’s feeling
• Recognize their ambivalence, resistance, fears,
etc through the use of reflection.
(No challenges to what they say)
Motivational Interviewing:
The Components
Affirming and Reflecting
– Helps check in with the client; saves you from a false assumption
• Repeating – repeat back something the client has said
• Reflection of feeling – paraphrase the client’s emotions
• Rephrasing – stays close to what was said, but slightly
rephrases
• Paraphrasing – infer meaning into what was said and reflect
back in new words
MI: The Components
Opening the Conversation
HCP (Health Care Professional): Please tell me about your current tobacco
use.
Patient: I know I need to quit smoking, but I don’t want to talk about it. I’m
not ready to quit.
HCP: It sounds like quitting smoking is not a high priority for you right now.
Patient: Right. I have too many things going on.
HCP: So, in your list of priorities for things you need to address, where would
you place this one?
Patient: Well, closer to the bottom than the top.
HCP: Help me understand what’s at the top of that list.
MI: The Components
• One often assumes that asking open-ended
questions is easy.
• One also assumes that providing an affirming,
non-confrontational statement is easy.
• Both of these assumptions are false.
Practice makes Almost-Perfect
• Opening a close-ended question
• Using reflective statements
• Please see your handouts.
MI: The Components
What are we driving at here with this approach?
We want to get at some change talk: Helping people make their
own argument for change.
Purpose: to elicit the client’s own reasons for and advantages of
change.
• Desire
• Ability
• Reason
• Need
Motivational Interviewing: The Components
Change Talk
Essence of change talk:
Get the client to make his or her own argument for
change!
- Ownership and meaning come from this process
Remember: this is not about your reasons – they have
to make their own argument in order for this change
to work. You will not get at this process if you are not
engaged with the patient.
But, Gretchen…
…I don’t have time to have a long conversation
with the patient.
…I am not prepared for them to “open up” and
tell me lots of things that I don’t want to hear.
…this sounds like therapy and I don’t do therapy.
Well, Friends…
…the time we have with the patient is precious and we
certainly don’t have time to smack up against
resistance over and again.
…in a time crunch I want to be INCREDIBLY effective
and efficient so I need to get to the heart of the
matter right quick!
…and, last I checked, my job was to assist people in
making some kind of major change, so I better figure
out how to get that done, and it may involve a
minute of conversation.
Well, Friends…
…if the patient begins to tell you too much, you’ve got a
way to get out of the situation:
- “Thank you for sharing with me all the things going
on in your life. That must be hard for one person. I’m
here to help you with X. I can provide you with a
referral to assist you with Y, Z, A, and B.”
Use this moment to define your role and to let the
person know the kind of help you can provide.
MI: Additional Tools
Assessing Importance and Confidence
• Suggested technique: Scaling
– Ask questions based on a scale of 0 to 10, with 0 being not
important at all, to 10 being extremely important
– Explore the reasons behind the selection of each number
with them (i.e. why are you at a 4 and not a 3?)
– Ask what would move them higher on the scale (i.e. what
would help you move this to a 5 or a 6?)
– Ask how you could be helpful in moving from a 4 to a 5 or
6.
What are we looking for with this tool?
• Scaling allows us to see where we need to
focus our energy!
– If importance is high and confidence is low, then I
need to boost confidence.
– How do I do that?
– You look for moments of ambivalence!
(Let’s look at the previous slides for these moments)
Resolving Ambivalence
• We can resolve ambivalence in several ways:
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Non-threatening education
Myth busting
Exploration
Explanation
We use open-ended questions to understand the source of
the ambivalence, then we reflect and summarize in order
to move forward.
Note to Self:
• Helping people change is a process and they
might not get it all done in one session.
• We are progressing towards change and
looking for change talk to occur.
• Sometimes folks will need to sit with their
ambivalence and awareness for a moment.
MI: Putting it to Use
Explore Past Efforts
• Recognize the past as a valuable piece of
information
• Explore what worked, and what didn’t
• Help them plan a more successful attempt for
change
MI: Additional Tools
• The Decisional BalanceGood things
about
smoking
Not so good
things about
quitting
Not so good
things about
smoking
Good things
about quitting
What are we trying to do with this tool?
Develop Discrepancy:
• Discrepancy between current behavior and
future goals
– Obtain client goals
– Emphasize discrepancy between behavior and
goals
What are we trying to do with this tool?
• Take a look at ambivalence!
• The decisional balance goes beyond a pros
and cons list
What makes it so hard to change?
• Any addiction or disease process has three
major pieces:
– Physical
– Emotional
– Social/Behavioral
All three pieces must be addressed if we are
going to be effective with our patients!
Motivational Interviewing:
Putting it to Use
Food for thought:
Remember, most people don’t want to destroy their
health or not listen to medical advice. They feel
stuck and often have deep emotional connections to
their health problem. When we ask people to make
lifestyle changes they often feel overwhelmed. These
are emotional and social reasons that hold a person
back.
Resources for learning more about
Motivational Interviewing:
• Eberman, K.M., Patten, C.A., & Dale, L.C. (1998). Counseling
patients to quit smoking: What to say, when to say it, and how
to use time to your advantage. Postgraduate Medicine, 104
(6), 89-94.
• Miller W.R., & Rollnick, S. (2003). Motivational Interviewing:
Preparing People for Change. (2nd ed.). The Guilford Press:
New York.
• Rollnick, S., Mason, P., & Butler, C. (1999). Health Behavior
Change: A Guide for Practitioners. Churchill Livingston: New
York.