Transcript Slide 1

Motivational Interviewing in
School-Based Health Care
Laura Brey, MS
Mike Palanza, MA, LPA
Daniel Garson-Angert, PhD
School Health Centers and Adolescents: Surviving and Thriving in the Difficult Years,
December 14, 2009 Chapel Hill, NC
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Workshop Objectives
1) Participants will be able to name the core elements
of motivational interviewing
2) Participants will be able to name at least two
techniques used in motivational interviewing.
3) Participants will be able to list three applications
for motivational interviewing use by school health
center service providers
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Traditional Counseling
Confrontational and
Argumentative
↓
Resistance
Denial of Need to Change
Behavior
Miller, WR, Benefield, RG, Tonigan JS, 1993, J
Consult Clin Psychol 61, 455-61.
Behavioral Counseling
Motivational Interviewing
Problem Solving
Identify Barriers
Patient Generated Solutions
Select Solution to Test
Evaluate Solution
WHAT DOES MOTIVATIONAL
INTERVIEWING LOOK LIKE?
Role Play
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Role Play Activity
The Setting: A Wellness Center at any high
school in NC.
The Situation: Dan (senior in high school)
has just completed his Teen Questionnaire
(GAPS like tool) and the provider is going to
review his responses with him using MI
strategies.
“Motivational interviewing was developed from
the rather simple notion that the way clients are
spoken to about changing addictive behavior
affects their willingness to talk freely about why
and how they might change.”
Stephen Rollnick, PhD
Addiction 2001; 96:1769-70.
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Introspective Exercise #1*
What expectations do health providers
who come into contact with clients for the
first time, have about promoting behavior
change among patients/clients?
*Adapted from Presentation by Edward Pecukonis, PhD
University of Maryland School of Social Work
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How Does Behavior Change?
Behavior A
Behavior B
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Introspective Exercise #1 (continued)
What feelings do you experience
when working with
patients/clients to promote
behavior change?
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Introspective Exercise #1 (continued)
Think of a behavior you’ve
tried to change
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Introspective Exercise #1 (continued)
How much time elapsed between:
the
first time you engaged in the
behavior, and
the first time you recognized risk or
negative consequences?
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Introspective Exercise #1
(continued)
• < 1 mo.
• 1 to 3 mo.
• 4 to 6 mo.
• 7 to 12 mo.
• 13 mo. to 2 yr.
• 3 to 5 yr.
• > 5 yr.
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Introspective Exercise #1
(continued)
How much time elapsed between:
the
first time you recognized risk or
negative consequences, and
the
first time you made an earnest
attempt to change the behavior?
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Introspective Exercise #1
(continued)
• < 1 mo.
• 1 to 3 mo.
• 4 to 6 mo.
• 7 to 12 mo.
• 13 mo. to 2 yr.
• 3 to 5 yr.
• > 5 yr.
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Introspective Exercise #1
(continued)
 Did
you ever experience some
success in changing your behavior?
 Did you ever experience a
resumption of or increase in the
undesired behavior after
experiencing some success?
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Introspective Exercise #1 (continued)
What conclusions would
you draw from the group’s
responses?
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Possible Conclusions
Behavioral issues are common
Change often takes a long time
The pace of change is variable
Knowledge is usually not sufficient
to motivate change
• Relapse is the rule
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Possible Conclusions
(continued)
• Our expectations of patients/clients
regarding behavior change are
unrealistic
• Unrealistic expectations can lead to
frustration and burn-out
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Benefits of Learning About the
Transtheoretical Model &
Motivational Interviewing
• More realistic expectations
• Greater recognition of small
accomplishments
• Greater success over time
• Less frustration and burn-out
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Transtheoretical Model (Prochaska &
DiClemente)
• Individuals progress through stages
of change
• Movement may be forward or
backward
• Movement may be cyclical
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Transtheoretical Model*
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Action
*Adapted from Presentation by Edward Pecukonis, PhD
University of Maryland School of Social Work
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Termination
Synonyms
Determination = Preparation
Termination = Exit
Motivational Interviewing can be used at
all Stages of Change:
DURING:
– Precontemplation –
MI can:
raise awareness
– Contemplation –
help decision making
– Action
and Maintenance – Relapse -
enhance and remind
of resolution to change
enables
reassessment
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Motivational Interviewing can be used at
all Stages of Change:
DURING:
– Precontemplation –
MI can:
raise awareness
– Contemplation –
help decision making
– Action
and Maintenance – Relapse -
enhance and remind
of resolution to change
enables
reassessment
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Spirit of Motivational Interviewing
• A “way of being” with a client
• The spirit of MI is characterized by:
– a warm, genuine, respectful and egalitarian stance
– supportive of client self-determination and
autonomy
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Principles of Motivational Interviewing
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Express Empathy
Roll with Resistance
Develop Discrepancy
Support Self-efficacy
Avoid Argumentation
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Components of Motivational
Interviewing
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Establishing a relationship
Data gathering
Setting a collaborative agenda
Exploring ambivalence
Assessing individual change potential
Summary and next steps
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For which behaviors can we use
motivational interviewing?
• Any high risk behavior!
• MI has been shown to be effective for:
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Substance use
Tobacco use
Sexual activity
Diet and physical activity (e.g. diabetes, obesity)
Truancy
Chronic disease (e.g. asthma)
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Motivational Interviewing with
Adolescents
• Teens: Hardwired for Risky Behaviors?
– Emotion/Social Interaction – active in puberty
– Behavior regulation - still maturing into early
adulthood.
• Just because we are giving teens the facts,
that doesn’t mean we are changing their
behavior!
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UNDERLYING THOUGHTS USED IN
MOTIVATIONAL INTERVIEWING (MI)
Taken from Motivational Interviewing in Health Care; Stephen
Rollnick, William R Miller, Christopher Butler (2008)
A Word About Communication Styles
• Three basic styles – used in everyday life;
depending on circumstances
– Directing
• Taking charge
– Following
• Listens and does not change
– Guiding
• “I can help you to solve this for yourself”
• MI is refined form of this
A Word About the Three Core
Communication Skills
• Asking
– Understands the person’s problem
• Listening
– Active, check to understand, communicates what
is important
• Informing
• Education, diagnosis
Guiding & Three Core Skills
• Asking
– “What kind of change makes sense to you?”
• Listening
– “You are feeling concerned about your weight,
and you’re not sure where to go from here.”
• Informing
– “Changing your diet would make sense medically,
but how does that feel for you?”
Guiding
• Enhances the person’s commitment to change
and adherence to treatment.
– Asks where the patient wants to go
– Informs patient regarding options and what
makes sense
– Listens to and respects what the person wants
PRACTICING MOTIVATIONAL
INTERVIEWING (MI)
Taken from Motivational Interviewing in Health Care; Stephen
Rollnick, William R Miller, Christopher Butler (2008)
Understanding Ambivalence
• Conflicting positive and negative feelings
about behavior change
– Conflicting motivation
• Look out for the “but”
• The task – to elicit “change talk” rather than
resistance
Listening for Change Talk (DARN CT)
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Desire - Statements re: preference for change
Ability – Statements regarding capability
Reasons – Specific arguments for change
Need – Statements re: feeling obligated to
change
• Commitment – Statements re: likelihood of
change
• Taking Steps – Statements re: action taken
Six Kinds of Change Talk
• Desire - statements re: preference for change;
What person wants
– “I want to….”
– “I would like to ….”
– “I wish ….”
Six Kinds of Change Talk
• Ability - what person perceives as within their
ability
– “I could….”
– “I can ….”
– “I might be able to”
Six Kinds of Change Talk
• Reasons - specific arguments for change
– I would probably feel better if….
– I need to have more energy to play with my kids”
Six Kinds of Change Talk
• Needs – statements about feeling obligated to
change
– “I ought to …”
– “I have to ….”
– “I really should ….”
Six Kinds of Change Talk
• Commitment – Statements regarding
likelihood of change
– “I am going to…”
– “I will ….”
– “I intend to”
Six Kinds of Change Talk
• Taking Steps – Statements regarding action
taken
– “I actually went out and …”
– “This week I started…”
KEY POINT – ASK QUESTIONS THAT CAN
BE ANSWERED WITH CHANGE TALK
Name That Change Talk
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“What do you want, like, wish, or hope?”
“What is possible?”
“Why would you make this change?”
“What risks would you like to decrease?”
“How important is this change?”
“What do you think you will do”?
“What are you already doing to be healthy?”
KEY POINT – WHEN YOU HEAR CHANGE
TALK, YOU ARE DOING IT RIGHT.
SOME OPENING STRATEGIES
Adapted from New York State Office of Alcohol and Substance Abuse Services,
Continuing Education, Steven Kipnis, MD, FACP, FASAM, Patricia Lincourt,
LCSW, Robert Killar, CASAC
Provided through Training the Trainer Partnership With NASBHC
Opening Strategies
(OARS)
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Open-ended Questions
Affirmations
Reflections
Summaries
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Opening Strategies
(OARS)
Open-ended Questions
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Close-ended question (one that can be
answered yes/no/maybe): “Have you had
anything to drink today?”; “Would you like
to quit smoking?”
Open-ended question: “What is a typical
drinking day like for you?”; “How do you feel
about your smoking?”
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Opening Strategies
(OARS continued)
Affirmations
• An example of an affirmation is, “I really like the way you are
approaching this problem, I can see that you are very
organized and logical and I am sure this will help you to
succeed in our program.”
• An affirmation can be used to reframe what may at first seem
like a negative. “I can see that you are very angry about being
here, but I’d like to tell you that I am impressed that you
chose to come here anyway, and right on time!”
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Reflections
Opening Strategies
(OARS continued)
• Statements made to the client reflecting or mirroring back to them the
content, process or emotion in their communication.
Reflective listening says:
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“I hear you.”
“I’m accepting, not judging you.”
“This is important.”
“Please tell me more.”
• Student: “My girlfriend gets really angry when I get stoned and pass out.”
• Provider: “She gets mad when you do that.”
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Opening Strategies
(OARS continued)
Summaries
• Summaries are simply long reflections. They can be used to
make a transition in a session, to end a session, to bring
together content in a single theme, or just to review what the
client has said.
• An example is: “Let’s take a look at what we have talked about
so far. You are not at all sure that you have a ‘problem’ with
alcohol but you do feel badly about your DWI and it’s effect
on your family. You said that your family is the most
important thing to you and you would consider totally quitting
drinking if you believed it was hurting them.”
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Report: Applications of MI in School
Based/Linked Health Care
• Screening Brief Intervention Referral &
Treatment (SBIRT) at the Wilmington Health
Access for Teens
– Trainings (6) generalize to other areas of practice
– Changing an organization’s culture
• Registered Dietician (RD)
Group Discussion
• Where do we go from here?
– How could NCSCHA support capacity building
through MI training?
– QI Collaborative
– QI Practicum