Transcript Motivational Interviewing - NW LINCS

Christine Fiore, Ph.D.,
University of Montana
Department of Psychology
October 19, 2007 Billings, MT
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Introductions
Hopes & Limitations
Background of Participants/Settings you work
in
Amount of contact time with students/clients
Experience with Stages of
Change/Motivational Interviewing?
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Select a behavior topic you are familiar with
from your own work or yourself (acquiring
GED, ESL classes,exercise, etc.)
Spend 1 minute with the person to your left
explaining the reasons to adopt the behavior.
Convince them!
Switch Roles
What did it feel like in each role?
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This is NOT Motivating for this patient.
What is problematic here?
What is happening in their relationship?
What is Chris attempting to do in his
physician role?
What is the patient communicating?
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What have you discovered as problematic in your
working relationships?
How do you know when things are not working?
How do you know when things are working?
Problems:
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Downloading Information
Issuing Recommendations (Marching Orders)
Lost in a Forest of Behavioral Recommendations
Perceptions of “Compliance”
Avoidance
Others?
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Think of one person who you “dread” coming
in to see you.
◦ What thoughts come to mind about the person (why
the dread?)?
◦ What are your specific feelings about working with
the person?
◦ What approach do you take to imparting
information with this person?
◦ How would you describe your relationship?
◦ Write down your answers and consider this person
through the next section
We often are assigned roles or tasks without the
assistance of knowing ‘how to’ manage those who
don’t ‘just do it’. We are not given the knowledge
or tools to work with people who don’t want what
we have to offer or are not ready to do what is
required to succeed. We miss opportunities!
Theories of motivation can provide us the framework
for motivating people to change-
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Transtheoretical Model of Behavior Change
(Prochaska & DiClemente, 1984)
Not “Just Do It”
Studied ‘Self-changers’, those who sought
help in psychotherapy
Studied and applied now to a large number of
behavioral health areas
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Smoking cessation
Addictions
Sunscreen use
Mammography
Organ donation
Condom use
Delinquency
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Domestic violence
Eating disorders
Diet
Exercise
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Chronic disease areas:
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diabetes, heart
disease, etc.
General behavior
change
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Change is a process.
Change is HARD.
Most of us attempt change but return to our
old ways.
We do learn something from every change
attempt◦ The changing process is a learning process;it is not
just about failing.
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We (others) can’t make people change no
matter how hard we try.
We can be helpful.
We can also make it less likely that someone
will change.
We have learned some keys to this process.
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Stages
Process (Strategies)
Decisional Balance (Pros & Cons)
Self-efficacy (Situational Confidence)
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Precontemplation-Not ready for change
Contemplation-Thinking but not doing
Preparation-Preparing but not quite ready
Action-Taking action and doing
Maintenance-Maintaining change for 6
months or more.
These stages are dynamic, moving, and
represent varying levels of motivation for
change (see handout)
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Not Ready for Change
Do not consistently
show the desired
behavior
Really have no
intention of doing so
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What Do we know
about
Precontemplators?
Characteristics:
◦ Can’t , unable or
unwilling to change
◦ Lack awareness
◦ Denial
◦ Demoralized
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Think About
Changing.
◦ Do not consistently
commit to change.
◦ Intend to do so in
next 6 months
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What Do We Know
About
Contemplators?
◦ Characterisics:
 Ambivalent
about change
 Think maybe
they should
change
 Don’t want to
change
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Ready To Change
◦ Still not
entirely
consistenttesting and
getting ready
for change
◦ Intend to in
next 30 days
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Characteristics:
Ready for change
Have a plan
Committed to change
Most will attempt
change in next 6
months but fail
◦ Experiment
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Ready for Change
and taking action
◦ Consistently
making an
effort to do so
◦ Less than 6
Months
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Characteristics:
◦ Making the changes
◦ What ever they are
doing works for
them
◦ Very busy time
◦ Very unstable and
hard stage
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Adopted Behavior
Change:
◦ Consistently
doing so
◦ 6 months or
more
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What do We Know
about Maintainers?
Characteristics:
◦ Risk of relapse low
(unless stress)
◦ Dynamic stage
◦ Stable stage
◦ Stayed in action for
more than 6 months
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15 minutes
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Interact with stage: people use different
processes at different stages for change
These strategies help people to move to the
next stage;
Others may use strategies that cause people
to keep holding hard onto the current
behavior
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Pros and Cons to Change
Important to movement out of early stages
Vary with Stage:
◦ Earlier stages (PC, C) report and feel more cons to
change than pros
◦ Later stages (A, M) report and feel more pros than
cons
◦ Preparation people are on the fence.
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Discover what the pros and cons to change
are!
Early stage:
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Acknowledge the Cons- they are powerful
What makes them so? Curious?
Don’t argue or persuade anyone that they are not.
What about them Pros?
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Early Stage: Not as powerful as cons
Accept this and discover why not-be curious.
Pros gain power as cons loose them-but you
have to let people or yourself let cons gonone can take them from you!
Later stage people can envision or feel the
pros-they can take hold and WIN!
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The situational confidence (or lack of
temptation) about a behavior
NOT self-esteem
Early stage (PC, C) low confidence-high
temptation
Later Stage (A, M) high confidence-low
temptation
Very important for movement into action and
maintenance-HOPE
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We need to instill and find hope.
We need to explore what would build
confidence.
We need to explore and address what makes
one tempted to return to the previous
behavior/situation.
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Understanding change means understanding
how the change process works within us and
those we care about.
We are most helpful when we work with the
process not against it.
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An application of the transtheoretical model
of behavior change.
Emphasizes intrinsic motivation, personal
empowerment and humanistic principles in
it’s approach.
Backbone is counseling and communication
skills applied in a strategic method.
Believes in the importance of adopting the
philosophy of change in which spirit is
connected to technique
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Expects that relationship matters in facilitating
change
Requires a shift in role from expert to
facilitator
Considers that both student/client and
teacher/counselor have agendas that are
meaningful and important
Utilizes principles of change to facilitate
movement
Respects that control of outcomes resides
with the student/client
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G - Create a Gap
R - Roll with resistance
A - Avoid Arguing
C - Can do attitude
E - Express empathy
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A gap is a motivating discrepancy
Discrepancy comes from within the student
Good topics: where I want to be and where I
am
Students present arguments for change
Goal - elicit and reinforce change statements
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Resistance is energy
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Opposing resistance strengthens it
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If resistance increases, change strategies
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Offer new perceptions, don’t impose or argue
them
Use the student as a resource for finding
solutions
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Key to effective MI: keep resistance low
Student resistance influenced by teacher
behavior
Across behaviors-the more confrontation, the
more work avoidance, more drinking, eating
Avoid arguing for change
Acceptance of label (obese, alcoholic),
unnecessary for change
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High self-esteem unnecessary
Without Can Do, risk turns to defensiveness
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Impart belief that change is possible
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The person will choose change, not you
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Create safety to explore conflicts and face
reality.
Use non-possessive warmth, accurate
understanding, and unconditional positive
regard.
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Opposite of breaking through denial
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Acceptance facilitates change, pressure
blocks it
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Be back at 12:30
Please be back promptly!
Afternoon: Motivational Interviewing Skills
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Return: Thoughts? Questions?
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Note in this intake setting example what
Theresa Moyers does.
What is the response of the client? What is he
doing?
What does she accomplish?
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Skills that you probably have already, but may
not use very much
Helping roles may lead us to tell people what
to do instead of work with them
Essential to good rapport
Basic skills we can use when we feel stuck
Backbone of MI
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Open-ended Questions
Affirmations
Reflective listening
Summaries
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Sets the tone for MI work
Creates momentum
Focus broadly
Key question : “What would you like to focus
on today?” “What are you ready to address
about your in your education?”
Rule of thumb: Use more reflections the
more resistance you perceive
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Some students are demoralized
Orients people to their resources
Be genuine
Probe partial successes
Reframe resistance into an affirmation
What and how questions are helpful
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MI is built on this skill
Need to think reflectively
Levels of reflection: simple, reframe, and
affective
Other types: two-sided, amplified
Vary your depth if you can but any reflection
will improve working relationships most of
the time
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Special form of reflective listening
Structure:
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Indicate you’re about to summarize
Be selective
Note ambivalence & attend to change statements
Be concise!
End with invitation
Use to change directions or ask a key
question
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Two Lines
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One line Talkers
Other line reflectors (listeners)
Move on down as directed
PRACTICE
Talk about something you personally are working
on changing or act a common student
◦ Before moving on to the next person, summarize
what you heard the person tell you
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Problem Recognition?
◦ Do they see the need to change?
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Concern about Problem
◦ Are they expressing interest and concern?
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Intention to Change
◦ Do they show readiness for change?
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Hope about Change
◦ How hopeful are they about changing?
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Ambivalence is a natural part of the change process
Just can not decide-fence sitting
There are positive things about adopting the
behavior (pros to change)
There are negative things about adopting the
behavior (cons to change)
Pros and Cons to change are important.
How one looks at them can become the key shifting
point to ACTION
Explore Pros; Acknowledge Cons
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Short-hand method for evaluating readiness
to change
Can be done at many time points (initially,
checking in, when transitioning)
Helps focus your efforts and helps to
organize students
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On a scale of 1-10, how important to you
is (_____)?
On a scale of 1-10, how confident are you
that you could succeed in (_____), if you
decided to make a change?
On a scale of 1-10, how ready are you to
(_____)?
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Ask a scaling question
Follow-up with queries about why that
score
Were there times you felt more confident
or less confident ?
What would it take to move up 1 or 2
points?
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How does he integrate the questions?
Do you hear change statements?
What other MI skills does he use?
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Pairs
Talker - something you have thought about
changing or enact a student
Listener ◦ Use your OARS
◦ Ask the scaling questions
◦ Remember to follow-up
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Continue in this role until asked to switch
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On a scale of 1-10, how important to you
is (_____)?
On a scale of 1-10, how confident are you
that you could succeed in (_____), if you
decided to make a change?
On a scale of 1-10, how ready are you to
(_____)?
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When you feel you have an agreement that
you will work with a person toward a goal it is
time to set that goal(s)
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You work in a setting where goal-setting is a
mandate
Work with choices and readiness to define that
direction:
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This is a process, continuation of what you
discover in ICR.
Since people differ on readiness to change
across behaviors, what does the student want
to work on?
Negotiate: “There are several ways to go in
addressing your education, where would you
like to go with this?
Prioritize: “We like to see people meet
success, where would you like to begin?”
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Work with a partner to set an agenda with a
student like one you typically work with who:
◦ is showing some resistance
◦ and challenges the teacher to work with the
person’s personal material
Maintain an MI approach keeping GRACE and OARS at
the forefront; is there a place for ICR?
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How ready to you feel to implement MI in
your work setting?
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What would be the barriers to using MI?
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What would facilitate using it?
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What do you know about your self, your
environment, and the demands of your
environment that: Could Help? Could DETER?
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How would you be able to maintain the spirit
of this motivational approach but work within
your setting?
When would it no longer be MI?
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Is this possible?
Consider the biggest assets to implementing
MI in your setting:
Consider the biggest barriers:
◦ Given your role
◦ Given your system demands or expectations
◦ Given your personal style or comfort
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One thing
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I learned was …
I relearned was …
that surprised me was …
I could do differently is …
I am confident I could do is …
I want to learn more about
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Practice with people
◦ Possible Google Groups
◦ Need your e-mail
◦ Willingness to set aside time (lunch or before school
1 time a month and make a phone call)
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Seek out additional materials
Obtain advanced training
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Rollnick, Mason & Butler (1999). Health
Behavior Change. Churchill Livingstone:
Edinburgh.
Miller & Rollnick (2002). Motivational
Interviewing Preparing People for Change.
Guilford Press:NY.
Prochaska, Norcross & DiClemente (1994).
Changing for Good. William Morrow & Co.:
NY.
MI Website: www.motivationalinterview.org