Transcript Directing - Motiverande samtal

FOLLOW GUIDE DIRECT
MOVING FROM WHY TO HOW
Barcelona, 2009
Ken Resnicow, PhD
University of Michigan
School of Public Health
Ann Arbor, MI
[email protected]
1
What they tell us….
“Ok, I got the reflection thing. I got
the change talk thing. But where do
I go from there. How do I bring this
all together. ”
2
Perceived Barriers in the Treatment of Overweight
Children and Adolescents
Percentage Responding “Most of the Time” and “Often”
Barrier
RDs
(n= 441)
PNPs
(n = 293)
Pediatricians
(n = 201)
Lack of patient motivation
Lack of parent involvement
61.9
71.8
78.2
82.5
85.7
81.2
Lack of clinician time
Lack of reimbursement
Lack of clinician knowledge
Lack of treatment skills
Lack of support services
Treatment futility
Eating disorder concerns
31.2
68.1
23.8
27.3
55.5
37.4
17.2
45.9
46.8
32.2
32.2
57.0
52.6
12.9
58.0
45.8
44.0
45.0
60.0
53.0
10.0
Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and
training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.
Barriers to Treatment of Pediatric Obesity
% Report Encountering
FPs
PDs
(n=74)
(n=213)
Lack of patient motivation
99%
97%
Poor patient compliance
96%
95%
Lack of effective therapy
83%
78%
No insurance for referrals
74%
67%
Lack of availability of referral services
65%
64%
No insurance for in-office counseling
60%
51%
No time for frequent follow-up
56%
49%
Kolagotla L, Adams W. Ambulatory management of childhood obesity. Obesity Research 2004;12(2):275-83.
Attitudes toward pediatric obesity counseling
Family Practice
Peds
(n=74)
(n=213)
Personal ability to counsel
Poor
Fair
Average
Good
Excellent
11%
30%
44%
15%
0%
6%
17%
47%
27%
3%
Efficacy of obesity counseling
Poor
Fair
Average
Good
Excellent
11%
48%
36%
5%
0%
23%
33%
35%
9%
0.5%
Kolagotla L, Adams W. Ambulatory management of childhood obesity. Obesity Research 2004;12(2):275-83.
Perceived Skill Level in Pediatric Obesity
Management Among Practitioners
% Low Proficiency Level
Use of behavioral management
strategies
Modification of eating practices
Modification of physical activity
Modification of sedentary behavior
Guidance in parenting techniques
Addressing family conflicts
Assessment of the degree of
overweight
RDs
PNPs
Pediatricians
15.8
32.5
38.9
2.4
10.6
12.9
31.0
45.9
4.3
8.2
7.2
11.0
20.7
30.2
22.3
15.1
13.6
18.4
25.0
30.0
16.8
Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent
obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.
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Study Design: Ahluwalia, J. S., Okuyemi, K., Nollen, N., Choi, W. S., Kaur, H., Pulvers,
K., et al. (2006). The effects of nicotine gum and counseling among African American light
smokers: a 2 x 2 factorial design. Addiction, 101(6), 883-891.

Six counseling sessions
– three in-person (at randomization, week 1, week 8)
– three by telephone (week 3, week 6 and week 16).

Health education (HE) focused on providing information and
advice. Review the addictive nature of nicotine, health
consequences of smoking and benefits of quitting, and
concrete strategies for a quit plan.

MI explored the pros and cons of smoking/quitting;motivation
and confidence to quit and values clarification.

Both HE and MI counselors participated in weekly
supervision
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12
13
MI not indicated in highly motivated?
Baseline motivation to quit on a 1-10 scale
was 9.1
AND
Must be willing to set a quit date in the next 14
days and use nicotine gum for 8 weeks
14

Health care professionals want closing
skills.

They want to integrate MI with other
Behavior Change skills

For highly motivated clients, MI might be
contraindicated.
15
6. MI is not a form of cognitive-behavior therapy
Cognitive-behavior therapies generally involve providing clients with something that
they are presumed to lack. The missing piece might be new coping skills,
conceptual education about how behavior is learned, counterconditioning,
environmental contingencies, or the restructuring of faulty cognitions toward
more adaptive ones.
The expertise of CBT providers rests on their knowledge of and technical skill in
applying principles of learning. The typically brief course of MI in one or two
sessions does not involve teaching new skills, re-educating, counterconditioning,
changing the environment, or installing more rational and adaptive beliefs.
It is…. about eliciting from people that which is already there. It is not the
communication of an expert who assumes that “I have what you need”, but
rather the facilitative style of a companion whose manner says, “You have what
you need, and together we’ll find it.”
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The Contradiction
“ In cognitive and behavioral therapies …. the therapist is
there to teach the client strategies for change such as
exposure, social skills, contingency management, and
cognitive strategies for changing distorted thoughts or
beliefs.
….Either implicitly or explicitly, when we do CBT we often
take the role of teacher and advocate for change. In doing
MI the decisions about whether to change and how to
change are left primarily to the client.”
18
Reconciliation
“MI can be viewed as a creative synthesis between ClientCentered Therapy and the action orientation of CBT.
In CBT we do not formally address ambivalence about
change, but in MI there are specific strategies for
understanding and addressing this ambivalence to help the
client become more ready for change. Since …MI does not
assume readiness to change, but works to increase and
maintain motivation for change, it may be a useful
complement for CBT. ”
19
Integrative Approach
“The therapist moves naturally and
smoothly to examining and working
with ambivalence in an MI style as it
arises in the course of therapy. ”
Arkowitz & Westra, 2004
20
Autonomy Supportive Closing
(MI-Consistent Directing)


Action Reflections
Provide Menu of Options for Change
– Usually client helps populate the list


Counselor Undersells Options
Provide Choice
– What to change
–
–
–
–
How much change
When
How Monitored
Contingencies
21
Two Phase Model
MI
Behavior Therapy
Why to Change
How to Change
Low Readiness
(Resistant/Angry/Ambivalent)
High Readiness
(Convinced)
22
MOVING FROM WHY TO HOW
MI CONSISTENT DIRECTING
AUTONOMY SUPPORTIVE CLOSING
WHY Change
HOW to Change
MI Primary Modality
MI Background Platform
Building Motivation
Handling Resistance
Resolving Ambivalence
Building an Action Plan
Self-Monitoring
Shaping
Contract
Contingency Management
Cognitive Restructuring
23
DIRECTING





Manage
Lead
Take Charge
Rule
Steer
Prescribe
Govern
Authorize
Reign
Take Command
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Listening
Advising
Informing
Asking
Following
Guiding
Understanding
Deciding
Directing
Structure
Closing
Acting
Acting
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Three Phases of Consultation

Following (WHAT/WHY/WHY NOT)
–
COMFORT THE AFFLICTED
– Build Initial rapport & Express Empathy
–
–
–

Obtain a history
Collaborative agenda setting
Explore pros, cons, hopes and fears (Reasons)
Guiding (IF)
–
AFFLICT THE COMFORTBLE
– Build Motivation & Discrepancy
–
Elicit change talk
•
0-10 Readiness Rulers
•
•
•
–

Values Clarification (Desire & Need)
SPIN THE BALLS
•
–
–
Importance (Reasons/Desire/Need)
Confidence (Ability)
Where does that leave you?
Obtain COMMITMENT
Move toward a behavior decision
Directing (if a decision/commitment has been made) (WHEN/HOW)
–
–
–
–
–
–
Taking STEPS
Establish a Goal
Provide Menu of Options
Set an Action Plan
Overcome/anticipate barriers
Make a contract & Discuss follow up
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Phase I: Following
– COMFORT THE AFFLICTED
– Build Initial rapport & Express Empathy
– Obtain a history

How long, how often, how much
– Collaborative agenda setting
– Explore pros, cons, hopes and fears (Reasons)

Guiding (IF)
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Phase II: Guiding
– AFFLICT THE COMFORTBLE
– Build Motivation & Discrepancy
– Elicit change talk
•
0-10 Readiness Rulers
• Importance (Reasons/Desire/Need)
• Confidence (Ability)
• Energy (Effort)
•
Values Clarification (Desire & Need)
– SPIN THE BALLS
•
Where does that leave you?
– Obtain COMMITMENT
– Move toward a behavior decision

Directing (if a decision/commitment has been made)
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Phase III: What should we call it?
MI-CONSISTENT DIRECTING
AUTONOMY SUPPORTIVE CLOSING
– ACTION REFLECTIONS
– Provide Menu of Options
– Establish a Goal
– Set an Action Plan
– Overcome/anticipate barriers
– Make contract
– Monitoring Plan
– Discuss follow up
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Types of Reflections

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
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


Content
Feeling/Meaning
Double-Sided
Rolling with Resistance
Amplified Negative
Reflection on Omission
Action
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Moving things forward:
Using reflections that embed
potential solutions
31
Advanced Reflections



Imbed Solutions to Barriers
Imbed Action Plans
Undersell
– You might want to…
– You might want to consider…
– Sounds like…..might be an option…
– If we are to move forward you might
need to address….
32
Bringing the Water….




X has not worked for you
You are looking for something
other than X
Any thoughts about Y
Y might be an option
33
Action Reflections

1) Invert Barrier
– Sounds like we will need to address barrier a,b,c

2) General Behavior Fix
– Sounds like doing something like x,y,z

3) Specific Behavior Fix
– Sounds like doing x may be a possibility

4) Cognitive Fix
– Sounds like you may have to think about x differently
(make peace, no all or nothing thinking)
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Maybe it’s time to quit. I am 55, my dad
died of heart disease…and I am
coughing up all this junk every morning.
But I am dreading it. I cannot deal with
the withdrawal…the cravings, the
edginess, and the hunger..plus it is
annoying having everyone commenting
to me about how proud they are of
me………
35

So if you could find a way to
reduce the withdrawal symptoms,
you might be more willing to quit

Something to reduce cravings,
edginess, and hunger might be of
interest to you
36
Action Reflections

So if you could find a way to reduce the withdrawal symptoms, you
might be more willing to quit (invert barrier)

Something to reduce cravings, edginess, and hunger might be of
interest to you (general fix)

A medicine to reduce craving might be something for us to talk
about (general fix)

Your might be interested in learning about a new drug called
Chantix that helps with craving (specific fix)

You might want to quit without telling others, to avoid being under
the microscope (specific fix)

If you could make peace with your fears, or realize you in fact CAN
handle, that might make quitting easier (cognitive fix)
37
We tried to reduce the amount of TV she watches
but it didn’t go so well. In the morning I need to get
dressed, take a shower, make some breakfast and I
usually end up letting her watch the Wiggles or
Dexter’s Laboratory just to give me some free time.
In the afternoon I feel it might be easier…since
maybe I could get her involved in an art project or
playing outside.
38

So it might be more realistic to
work on the afternoon TV first.

Getting her involved in something
more creative might help her fulfill
her potential.

Art is the way to go
39
I tried giving my kids fruit for snack, if
they don’t have their cookies they
make a huge fuss… they expect
sweets after school and I can’t
stand the sound of their whining
when they don’t get what they
want. Plus, I kind of like baking
homemade treats….
40

So baking something that has
some fruit in it, or is a little more
healthy might satisfy both you and
your kids
41
I've tried everything to help my child
lose weight. I always have carrot
sticks available and don’t let him eat
any fried food. I tell him exactly what
he can have, and watch what he eats
very closely. I also make him
exercise every day. I’m constantly on
him, and yet he hasn’t lost a pound!
42

So trying to control what your child
does hasn’t worked very well.

Telling your child what to eat isn’t
helping him lose weight.
43

So far you have not involved your
son in the decisions

Involving your son might help him
buy into the changes better than
setting new rules for him
44
I really want to lose weight..so this week
I decided to be really good and tried to
cut out all sweets from my diet.
However, I felt miserable by the end of
the day and finally broke down and ate a
whole box of chocolates..
45

So cutting out all sweets entirely
doesn’t work for you.

Finding a way to lose weight might
need to include having a few
sweets.
46
Bringing it all together
F
O
L
L
O
W
G
U
I
D
E
D
I
R
E
C
T
Get permission
Set agenda
Assess current level
Discuss History
Assess 0-10 importance/confidence
 Probe lower/higher/what would it take
Assess core values
 Link behavior to values
Summarize & Spin: Where does that leave you?
Build Menu of Choices
Ask Client to Pick Option
What can you do to make it happen?
 This week
 Today
47
Throughout the session,
listen for action talk
Often, clients will
already have an idea for
what they MIGHT try
Make a mental note and
mention that you may
go back to that idea
later
Action Item Parking LOT
Idea 1
Idea 2
Idea 3
48
Three Steps Toward Change…
MI DIRECTING 101
Build a Menu of Options
1)



2)
3)
List possible ideas mentioned by client
during session
Ask patient for other solutions
Offer “other ideas that have worked with
people with similar concerns”
Ask “which if any of these” might work
best for you”. If they choose one…
Ask “what might you be able to do to
increase your chances of success in
the next day or week”
49
Cognitive Options for Change







Abstinence violation syndrome/Not All or Nothing
Craving/discomfort will pass
You can in fact deal with it
The withdrawal/side effect is normal
Focusing on the benefits
Making peace with the fact that the benefit is difficult to
observe
Taking actions gives you a sense of control
50
Options for Change:
2
BMI
Cognitive

Making peace with the transition phase. It may suck initially

Small changes still count

Healthy eating is not an ALL or NOTHING game

Once in a while it’s ok

It might take some time

Your child will eventually eat it

You PROVIDE they DECIDE
Behavioral

Order Salad at Wendy’s

Limit TV to 1 hr a day

Order apple fries

Walk with your child

Talk to your husband about his ice cream

Have F & V around

Meditate or take Yoga

Provide choice
51
What else are those Public Health MINTies doing?
52
Human Motivation: Corresponding
Intervention Models
Rational
Knowledge
Emotive
Attitude
Planned
Conscious
Left Brain
Linear
Health Belief Model
Social Cognitive Theory
Transtheoretical Model
Theory of Reasoned Action
Spiritual/Metaphysical
Meaning
Epiphany
Unconscious
Right Brain
Chaotic
Self Determination Theory
Chaos Theory
Motivational Interviewing
53
Self Determination Theory: Essential
Human Needs

Competence

Autonomy

Relatedness
54
Intrinsic-Extrinsic Continuum
NOT SELF-DETERMINED
Amotivation
COMPLETELY SELF-DETERMINED
Extrinsic Motivation
Intrinsic Motivation
External
Regulation
Introjected
Regulation
Identified
Regulation
Integrated
Regulation
Compliance
Rewards
Ego
Guilt/Shame
Personal Importance Congruent
Conscious Value
Meaning
Competence/Autonomy/Relatedness
Novelty
Challenge
Pleasure
55
Reflect on Omission

It’s interesting that you didn’t mention…

I suspect you thought about this already and
maybe decided against it, however I am
curious about……

You didn’t seem to respond to……

Reflect on silence
56
Married sedentary female

I really need to find someone to
exercise with. I can’t do it alone. I
just need someone to remind me or
do it with me……but there is no
one….
57

So, it is interesting you have not
mentioned your husband..I assume
that he would no be helpful in any
of this….
58
Metaphors & Similes:
Health/Patient Education is to MI as…

Engine/Fuel/Helm vs. Rudder
– OHMMMM; be the rudder

Seeds in the wind vs. Strategic Planting
– Measure twice; cut once
59
Who Paints: You or the client?
Standardized Patients: Overweight case
60
REPEAT AFTER ME
CRACK ROCKS!

Handling our own resistance
61

I eat at McDonalds a few times a
week. There’s nothing better than a
Big Mac, fries, and a shake.
62

When I am really down, a bowl of
ice cream is sometimes the only
thing that makes me feel better
63

You sound scared that we were
going to ask you to give it up
entirely (rolling with resistance)

This sounds like something we
might have to work in once in a
while (action)
64

Have you ever had Krispy Kreme
glazed donuts…oh my god….you
have to try them.
65

On weekends I love having a few
joints and chilling..
66
Eliciting Change Talk
Stage 1: Diagnosis Strategy 1: Importance and Confidence
Willingness/Importance
On a scale of 0 to 10, with 10 being very important, how important is it for your (and/or your
child) to change XXX ?
0
1
Not at all
2
3
4
5
6
Somewhat
7
8
9
10
Very
Confidence
On a scale of 0 to 10, with 10 being very confident, assuming you decided to change XXX….how
confident are you that you could succeed ?
0
1
Not at all
2
3
4
5
6
Somewhat
7
8
9
10
Very
67
Energy & Dread
How much energy do you think it will take to change XXX?
0
1
Very Little
2
3
4
5
6
Moderate Amount
7
8
9
10
Tons
68
Why Values Clarification?




0-10, Pros & Cons, and other strategies
often fail to tap deeper levels of motivation
Builds discrepancy
Link health behavior to person’s bottom
line
Elicits new and different change talk
69
Values List
Which of the Following Values, Traits, or Characteristics are Important to you?
Good Parent
Good Family Member
Good Spouse/Partner
Good Community Member
Strong
On top of things
Competent
Spiritual
Respected at home
Good Christian (or Jew, Muslim etc)
Successful
Popular (Youth)
Supportive
Attractive
Disciplined
Responsible
In Control
Respected at work
Athletic
Not hypocritical
Energetic
Considerate
Youthful (Older)
Independent (Older)
Choose your top 3 or 4
70
Values for Adolescents
Good student
Healthy & fit
Strong
Responsible
On top of things
Competent
Spiritual
Respected at Home
Successful
Popular
Attractive
Disciplined
Respected at school
In control
Good to my parents
Athletic
Confident
Energetic
Mature
Independent
Other__________
71
Values for Parents of Overweight Youth
Values For Your Child
Be Healthy
Be Strong
Have many friends
Being fit
Not feeling abnormal
Not being teased
Not feeling left out
Be able to communicate
his/her feelings
Fulfill her potential
Have high self-esteem
Values for You
Good Parent
Responsible
Disciplined
Good Spouse
Respected at Home
On top of things
Spiritual
Values for Your Family
Cohesive
Healthy
Peaceful Meals
Getting along
Spending time together
72
Values List: Australian Style
Which of the Following Values, Traits, or Characteristics are Important to you?
Good Parent
Good Spouse/Partner
Good Community Member
Strong
On top of things
Competent
Spiritual
Respected at home
Considerate
Successful
Popular (Youth)
Laid Back/Easy going/Being A good Sport
Environmentally responsible
Being able to Take it
Being able to cope
Privacy
Attractive
Disciplined
Responsible
In Control
Respected at work
Athletic/Good at Sport
Not hypocritical
Energetic
Assertive
Youthful (Older)
Independent (Older)
Be a good/loyal mate
Fare Go/Egalitarian
Honesty/Being Upfront
Resilient
Communalism
Choose your top 3 or 4
73
Values List: The Dutch Experience
Which of the Following Values, Traits, or Characteristics are Important to you?
Good Parent
Good Spouse/Partner
Responsible
Strong
On top of things
Competent
Spiritual
Respected at home
Considerate
Successful
Popular (Youth)
Attractive
Disciplined
Environmental Conscious
In Control
Respected at work
Athletic
Not hypocritical
Energetic
Supportive of others
Youthful (Older)
Independent (Older)
Tolerant
Justice
Respect for Other
Community/Neighbor
Choose your top 3 or 4
74
Values List: South African Adults
Which of the Following Values, Traits, or Characteristics are Important to you?
Good Parent
Disciplined
Good Community Member
Good Spouse/Partner
On top of things
Competent
Spiritual
Respected at home
Considerate
Youthful (Older)
Respected at work
Independent (Older)
Not hypocritical
Energetic
Successful
Popular (Youth)
Strong Extended Family
Responsible Manhood
Strong
Politically Aware
Responsible
At peace with ancestors
(n”guni)
In Control
Choose your top 3 or 4
75
Values List: Singaporean Adults
Which of the Following Values, Traits, or Characteristics are Important to you?
Good Parent
Disciplined
Politically Aware
Good Spouse/Partner
Good Community Member
Responsible
On top of things
Competent
Spiritual
Respected at home
Considerate
Youthful (Older)
Respected at work
Independent (Older)
Not hypocritical
Energetic
Successful
Popular (Youth)
Respect for elders
Success at work
Strong
Freedom
Social Consciousness
In Control
Wealthy
Successful children
Not losing out (kiasu)
Face saving (ai-mian-zi)
Don’t wash your dirty linen/Disgrace (jia-chou-bu-ke-wai-wang)
76
Buying Back Time
– Reduce Unsolicited Information
•
Use E-P-E vs. Information Dump
– Reduce Unsolicited Advice
•
•
Use Action Reflections
Provide Choices vs. Skeet Shooting
77
The 10 Epiphanies of MI Training










Reflections elicit more information than questions
You only need to get the bat on the ball: Reflections don’t have to
be perfect
Deeper level reflections are worth the risk
Health behaviors relate to deeper issues
The counselor’s role is to help clients explore their ambivalence
and the possibility of change, not to ensure change
Behavior change is driven by more by motivation than information
Motivated clients solve their own barriers (or ask for help)
Most of the advice you might offer has already been thought
about, and rejected by your patients
Clients will share a lot, quickly with empathetic, attentive listeners
Much can be covered in a 10-minute encounter
78
Health Behavior Change:
The Feeling Vocabulary







Trapped
Torn
Hopeless
Powerless
Alone
Overwhelmed
Drained
79
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81
BMI²
Brief Motivational Interviewing to Reduce Child BMI
R01 HL085400-A2
INVESTIGATORS
University of Michigan
K. Resnicow
M. Davis
S. Woolford
F. McMaster
AAP
E. Slora
M. Wasserman (UVM)
A. Bocian
D. Harris
J. Gotlieb
American Dietetics Association
E. Myers
J. Foster
Wake Forest S of M
R. Schwartz
NHLBI
C. Pratt
University of Iowa
L. Snetselaar
BMI2 Study Overview
Group 1
(Usual Care)
Group 2
(PED)
Group 3
(PED+RD)
10 practice/200 subjects
10 practice/200 subjects
10 practice/200 subjects
Baseline BMI %
Baseline BMI %
Baseline BMI %
½ day study
orientation
2 day MI/CBT training 2 day MI/CBT training
MI-DVD
MI-DVD
Educational Materials
+ 4 MD MI sessions
(3 sessions in year 1;
1 session in year 2)
+ 4 MD MI &
6 RD MI (in person
and by phone)
Sessions
2 Yr FU BMI %
2 Yr FU BMI %
2 Yr FU BMI %
2-day MI/CBT
training & MI-DVD
NA
NA
Key Study Parameters
• Study Sample
– Children, ages 2-8, with BMI > 85th & < 97th percentile
– Intervene with parents
• Study Setting
– 33-39 PROS offices nationally
– 20 Children per office (600 total)
– Randomize Practices
• Primary Outcome
– Child BMI Percentile Change at 2-year FU
– Powered to detect 3%ntile difference between groups
Primary Hypotheses
• HO1: At 2-year follow-up, children in the
moderate intensity intervention (PED only) group
will show a 3 point (absolute) decrease in BMI
percentile relative to usual care group (UC).
• HO2: At 2-year follow-up, children in the high
intensity intervention (PED + RD) group will
show a 3 point (absolute) decrease in BMI
percentile relative to children in the moderate
intensity group (PED only).
Buddy to Buddy
Communication Skills
A PEER SUPPORT PROGRAM
FOR VETERANS OF THE MICHIGAN
NATIONAL GUARD
Ken Resnicow, PhD
University of Michigan
School of Public Health
Ann Arbor, MI
Phone (734) 647-0212
[email protected]
I drink a bit…..and smoke a little weed…
sure it ain’t good for me…..but I don’t see
how I can make it through the day without
it….I am edgy all the time and have these
nightmare images in my head that are ..I
am not a drug addict..this is just a short
term thing to get through the first few
months back
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Enrolled Practices
(n= 40)
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MD/RD INTERVENTION MAP
PHASE 1: FOLLOWING: Assessment and agenda setting
Assess Weight/Height (MD ONLY)
Explain what you are assessing and why
Convert to BMI Percentile
Elicit-Provide-Elicit
Elicit parent understanding of BMI value
Provide BMI Percentile
Elicit Probe Parent Reaction
Reflect/Probe
Review Parent Questionnaire
Provide Positive Feedback for Behavior (s) in Optimal Range
Elicit Response
Reflect/Probe
Provide Behavior(s) NOT in Optimal Range
Elicit Response
Reflect/Probe
Agenda setting
Query which, if any, of the target behaviors not at optimal range parent/child/adolescent may be
interested in changing or might be easiest to change.
Sample Language
 Which, if any, of these might you and your child be able to change?
 Which of these might be a good place to start?
 Which of these do you think might be the easiest one to start with?
Agree on Possible Target Behavior
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
I really don’t like thinking about it. My
husband makes my appointment. He
orders my drugs. I just show up at the
clinic for my infusion. With adjusting
to this disease I don’t think at this
point I can handle taking care of all
those logistics.
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E-P-E

Empathize/Elicit
–
–
–
–

Provide
–
–
–
–

Reflect
What is your understanding?
What have you heard about?
What do you want to know?
Info
Advice
Choice
Some of what I say may differ from what you have heard?
Elicit
– What do you make of that?
– Where does that leave you?
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Listening
Advising
Informing
Asking
Following
Guiding
Closing
Understanding
Deciding
Acting
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Moving Forward…

What might you be able to do in the
next few days to move things along
(or increase your chances of
success?)

What might you be able to do in the
next few weeks to move things
along?
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What goes on the MENU
1) Solutions listed by counselor suggested or implied by the
client
2) Other ideas generated by the client
Which of these do you think might work best for you?
MI CAFE MENU
Which of these might you be willing to try?
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Five Steps Toward Change…
1)
2)
3)
4)
5)
List possible ideas mentioned during session
Ask patient to offer other solutions
Offer “other ways” to think about it and
“possible” tips to help deal with the problem
(talking points)
Ask “which if any of these” might work best
for you”. If they choose one…
Ask “what might you be able to do to
increase your chances of success in the next
day or week”
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