Transcript QIV Checklists Presentation - Christian Connections for

Using Motivational Interviewing
Techniques in Health Promotion:
The Basics
Tom Davis, MPH
Director of Health Programs, Food for the Hungry
Presentation for CCIH Conference,
May 28, 2006
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Motivational Interviewing
Session Outline
• Definition of MI
• Four principles of MI
• What we know about MI
• Studies on MI’s effectiveness
• The Stages of Change
• Findings on which MI is based
• Skit
• How MI should influence
our behavior change
communication
• Development of Change
Talk Questions
• MI Resources
& Training
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What is Motivational
Interviewing?
• A way to improve a person’s motivation to
change, and their ability to actually make a
change, by talking with them about their
mixed feelings, and helping them to work
through those to make a change.
• Useful in one-on-one counseling sessions or
in groups (modified).
• Do basic consciousness raising (e.g.,
presenting basic facts) about an issue first.
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The Four Principles of Motivational
Interviewing
During interviews (multiple sessions, usually):
1. Express empathy: Use skillful listening. Accept
ambivalence about change as normal.
“Like one who takes away a garment on a cold day, or
like vinegar poured on soda, is one who sings songs
to a heavy heart.” [Prov. 25:20]
2. Develop discrepancy (between present status and
desired goals and values): Help the person to voice
the discrepancy between their current
status/behavior and where they want to be.
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Helping People to See Discrepancy
(Accountability)
2 Sam 12: 4-7: Now there came a traveler to the rich
man, and he was loath to take one of his own flock or
herd to prepare for the wayfarer who had come to
him, but he took the poor man's lamb, and prepared
that for the guest who had come to him.“ Then
David's anger was greatly kindled against the man. He
said to Nathan, "As the LORD lives, the man who has
done this deserves to die; he shall restore the lamb
fourfold, because he did this thing, and because he
had no pity.“ Nathan said to David, "You are the man!
Better -- Self-discovery of Discrepancy: "For what I
do is not the good I want to do; no, the evil I do not
want to do -- this I keep on doing." [Romans 7:19]
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The Four Principles of Motivational
Interviewing (cont.)
During interviews (multiple sessions, usually):
3. Roll with resistance: Avoid arguing with the
person about their current behavior. Refuse to play
the adversary.
“But I tell you, Do not resist an evil person. If
someone strikes you on the right cheek, turn to him
the other also.” [Mat 5:39]
4. Support Self-efficacy (encourage: Show that you
believe the person can change. Let the person
choose and carry out the change.
“Preach the Word; be prepared in season and out of
season; correct, rebuke and encourage--with great
patience and careful instruction.” [2 Tim 4:2]
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Motivational Interviewing
What We Know:
• MI Works: Systematic review of 17 randomized
trials of MI to change behavior found that 60% of
the studies had at least one significant result. (Dunn,
DeRoo and Rivara [2001])
• MI was originally used for alcohol and drug addiction.
• MI is one method among many.
• Particularly effective when a person has high levels of
ambivalence. Particularly good for counseling people
who are resistant to change. But has been used for
simple behaviors, as well.
• Comparative advantage when using with people who are
less ready to change (Contemplation and Preparation
stages of change).
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Motivational Interviewing in Zambia

From 1999-2001, MI was used in two peri-urban
communities in Kitwe, Zambia, where diarrhea
and clean drinking water had been identified as
major concerns.
The goal of the
intervention was to
encourage adoption
of safe water storage
practices and
purchase of
disinfectant in the
target communities.
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Health Promotion + MI
Health promotion messages were
delivered using MI by neighborhood
health committee (NHC) volunteers
in weekly visits that were 15-30
minutes long.
An Intervention group received
Motivational Interviewing along with
education.
A Comparison group received
education only.
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How NHC Volunteers Were Trained

Only the volunteers using MI were trained in MI.
All volunteers received diarrhea prevention and
safe water education.
Local nurses received training
in MI, and then developed and
delivered MI training for the
Neighborhood Health
Committee (NHC) volunteers.
The NHC volunteers received
approximately 10 hours of MI
training.
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Zambia MI Study, Field Trial #2: Bottles of
Disinfectant Sold/HH (MI vs. Ed. Only), ’98-’99
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Field Trial #3: Know That
Contaminated Water Causes Diarrhea
80%
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Control 2
Follow-up
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Field Trial #3: Believe They Can Avoid
Diarrhea
95%
90%
85%
80%
75%
70%
MI
Control 1
Baseline
Control 2
Follow-up
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Field Trial #3: Know They Can Avoid
Diarrhea by Boiling or Treating Water
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Control 2
Follow-up
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Field Trial #3: Ever Used Disinfectant
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Control 2
Follow-up
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Field Trial #3: Disinfectant Present in
Stored Water
70%
60%
50%
40%
30%
20%
10%
0%
MI
Control 1
Baseline
Control 2
Follow-up
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Stages of Change Model
(Prochaska and DiClemente)
Maintenance
Action
Person is
engaging in
Contemplation Person is
actions with
open to
the intention
Pre-contemplation
Ambivalent; change and
of bringing
Person
both
preparing for about
Person is not
considers
change
ready to
change.
and
rejects
(often in the Change is
consider a
change.
next month)
change or
made.
unaware of the
need to change;
sometimes
demoralized
Preparation
Person is
maintaining a
change that
has already
been made.
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What We Should Learn from the
Stages of Change Model:
Use Different Strategies and
Activities for Different Stages
• What works at one stage often does not work well
at another stage.
• Most behavior change programs are targeted at people
in the Preparation and Action stages – people who are
ready to make a change.
• Only a fraction of people are actually in these two
stages of change.
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Stages of Change Model:
Processes & Activities
to be Promoted at Each Stage of Change
Maintenance
Action
Preparation
Contemplation
Pre-contemplation
• Consciousness Raising:
Education and discussion
in community groups,
religious groups, mass
media, and with leaders
• Dramatic Relief: Taking
action to decrease anxiety
and other negative
emotions through
testimonies, role playing,
grieving, simulations, and
other group activities.
• Environmental Reevaluation: Leaning how
one’s actions affects one’s
self/others through guided
discussions, story telling
• SelfReevaluation: –
re-evaluation of
self-image through
group activities:
 values clarification
via MI
 Change Talk via
vs. MI
 contact and
discussions w/role
models
 guided imagery
(where people
imagine themselves trying out
the behavior)
• Self- and Social
Liberation:
Belief that one
can change and
commit to
change, and
creating social
conditions for
change by:
 Changing
community
norms to favor
change
steps towards
desired behaviors
(e.g., commitments), giving
group praise and
recognition
 Drawing attention
to those who
have made
changes
 Getting people to
commit to
making a change
Use of Mass Media, Motivational Interviewing
techniques, and Other Methods
• Continue positive
reinforcement &
social support
through:
• Using and fostering
social support and  continuance of groups
caring relationships  institutionalization of
rewards and
through groups, in
recognition for
families, etc.
maintaining
• Contingency
behaviors.
management:
Reinforcing positive • Stimulus Control::
Removing triggers
for unhealthy
behaviors; Role-
playing to substitute
prompts for healthy
behaviors.
• Maintain selfefficacy: Maintain
Learning to substitute confidence to do the
behavior through
healthy behaviors for
regular discussions,
problem behaviors
retraining, accountability system.
• Counterconditioning:
Skill Building, Social Support through Small
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Groups, and Other Methods
Findings on which MI is Based:
• People who are ambivalent often do not respond
logically, and do not respond to logic. Example:
Increasing negative consequences
• Why? Psychological Reactance: When a person
perceives that his or her personal freedom is being
infringed upon or challenged, they will do a problem
behavior more often, and find the behavior more
attractive.
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Psychological Reactance
Efforts to force someone to resolve
their ambivalence can actually:
1. strengthen a person’s resolve to not adopt
a positive behavior that you wish to
promote, or
2. strengthen a person’s resolve to maintain
a negative behavior that you are trying
to eliminate.
This is particularly true when the person perceives that
making a change would lead to some loss of freedom.
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Findings on which MI is Based :
• People have motivations – but we often do not appeal
to their true motivations when trying to help them to
change.
• Motivation is both internal and inter-personal.
• Motivation is not just influenced by others – it is often
created in relationship with others.
• Ambivalence makes change possible. The first step
towards changes is often becoming more ambivalent.
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Findings on which MI is Based (cont):
• When a behavior comes in conflict with a deeply-held
value, it is usually the behavior that changes.
• Importance of making a change = Perceived
discrepancy between present status/behavior and
desired goal, between how things are and how they
would want them to be.
• Our tendency is to be “Fixers”
(Skit: 20 mins.)
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How MI Should Influence How We Do
Behavior Change Communication?
• Avoid asking: “Why isn’t this person motivated?”
Ask instead: “What motivates this person?”
• Show the person how the change will be relevant to
achieving or preserving something that is truly
important or dear to them.
• Get the person to use “Change Talk.”
• Help the person to choose the approach that they
want to use to a desirable goal. Present options where
possible.
• Learn to avoid a “Fixing” response to ambivalence.
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The Big Picture:
• Just telling people what to do ignores the fact that
people are often ambivalent about change.
• Debating with a person about change can make
them more entrenched.
So what can be done?
Help project staff to…
• Help the ambivalent person to voice their arguments
for change. Get them to use “change talk.”
The goal of MI is to make the change possible for the
person by first bringing about these types of “change
talk.”
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Four Types of Change Talk:
1. Get the person to talk about the
disadvantages of keeping things the same
(i.e., the status quo).
 “What do you not like about how your child is
growing presently (without exclusivly
breastfeeding)?”
 “What do you think will happen if you keep
having sex with many partners?”
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Four Types of Change Talk:
2. Get the person to talk about the advantages
of changing.
 What would be good about exclusive
breastfeedng?
 If you could have one sexual partner
immediately, by magic, how might things be
better for you?
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Four Types of Change Talk:
3. Get the person to talk about optimism for
change – hope.
 If you decided to exclusively breastfeed, how
would you go about doing that?
 When else in your life have you made a decision to
make a change like this and followed through with
it? [“I decided to send my daughter to school no
matter how difficult it was.”]
 What is there about you that would make it easier
for you to exclusively BF than other people? [“I’m
very dedicated to do things that I decide to do.”]
 What makes you think that if you decided to plan
your family that you could do it? [“I would have
the support of my husband.”]
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Four Types of Change Talk:
4. Get the person to talk about their intention
to change
 What would you be willing to try in terms of
changing the way you breastfeed?
 Never mind how to make it happen right now,
what do you want to happen in terms of your sex
life?
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Exercise on Development of Change Talk Questions
Develop change talk questions for one
behavior that you promote in your work
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Several Motivational Interviewing Resources:
This is just an overview – not a full MI training.
1.
Resources on MI:
 Motivational Interviewing, Second Edition:
Preparing People for Change (Hardcover) William R.
Miller, Stephen Rollnick, Kelly Conforti
2. Websites on MI:
 See mi.fhi.net (http://mi.fhi.net)
 www.motivationalinterview.org
 www.mid-attc.org/accessed/mi.htm#1
3. Training
 See mi.fhi.net
 See www.motivationalinterview.org
 See www.cathycoletraining.com
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