Motivational Interviewing

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Communication & Counseling
Does your communication with clients inspire motivation to change their lives? Change requires more than: Knowledge Competent skills The client needs to want to change behavior AND the motivation to change.
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Paula Ackerman, MS, RD, CDE UPDON www.diabetesinmichigan.org

Motivation
The mental process, function, or instinct that produces and sustains incentive or drive in human and animal behavior. Components Willing: degree of discrepancy between current behavior and future values Able: Ready: confidence for change setting priorities
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Counter-Motivation
Characteristics
Resistance Hopelessness Low self-efficacy

Signs
Interrupting Ignoring Arguing Denying Changing subject Talking off subject Daydreaming
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Motivational Interviewing
Introduced by William Miller and Stephen Rollnick in early 1990’s (drug and alcohol addiction). Revised in 2008 with Christopher Butler for health care. New definition (2008) “A skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.”
Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior, 2007.
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Spirit of MI
Collaboration
Partnership, shared decision making between client and hcp

Evocative
Understand client goals Connecting behavior change with what client cares about (beliefs, values, concerns) Use these to evoke arguments for change

Honor Client Autonomy
Client ultimately decides what to do
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BUT…. willing and able to listen “I won’t push you.” The more a client hears themselves talk of the disadvantages of changing.Motivational Interviewing Style A refined form of guiding (vs directing or following) Helps the client make his or her own decisions about behavior change Principles of MI Resisting the Righting Reflex Health care providers (hcp) have a powerful desire to fix things Becomes automatic or like a reflex Problem: human tendency is to resist persuasion (especially when they are ambivalent) Principles of MI Resist the Righting Reflex Understand Client Motivations Listen to Client Empower the Client 7 “Its not that bad…I feel fine”. “I know I should exercise more. values and motivations. the more committed they are to status quo. be flexible 11 12 Directing: take charge. motivator “I can help you solve this for yourself. supporter. Ask “Why they want to make a change and how they might do it. 8 Principles of MI Resisting the Righting Reflex Client ‘s Role: argue and provide reasons for change Principles of MI Understand Client Motivations Be interested in the clients own concerns. I’ll let you work it out on your own time” Core Skills of MI Asking: to understand client’s problems Listening: to understand the meaning of their problem correctly Informing: educating the client Must balance these skills. resource.” 3 styles often intermixed. shifting styles as appropriate to client and situation . Understand their motivations Empower the Client Helping the client explore how they can make a difference in their own health 9 10 3 Communication Styles Following: follows clients lead.” Listen to your Client Should listen as much as you inform Use empathy HCP’s Role: Guide them through ambivalence. tell client what to do “I know what you should do” Guiding: tutor.

” Set expectations: how have client and hcp expectations changed over the yrs 14 Client Roles OLD Roles NEW Roles Client Roles OLD Roles Rely on hcp to solve problems Learn about condition from hcp Respond to hcp questions on progress during appointments Don’t worry about meds 15 Defer to hcp authority Share responsibility for own health Be passive. (HCP role is to coach. as your educator. Self-manage health by the hcp and condition. “What…” “How…” as lead ins. Use “Tell me…”. But we will work together to improve your condition and quality of life. beliefs and preferences Follow hcp orders Decide on tx plan with provider NEW Roles Seek provider support in solving problems Learn from provider. Seek new info Track own progress between hcp visits. avoid using “Why…” “Tell me how you feel about having diabetes. It may be difficult and challenging.” 17 Building Relationships Ask open ended questions Requires more than a one word answer Allows client to share their story or express concerns and feelings so the clinician can understand where they’re coming from. support and sometimes provide direction) Share history when Be assertive: share goals. history. at times. to guide and support you. Just remember. asked values. You will be doing most of the work. Be “fixed” Be active. inform self also. Share info during visits Share responsibility for keeping med list up to date 16 Set Expectations “You are in a position to do more to improve your diabetes than anyone else. we don’t have to do this all at once.newhealthpartnerships. My job.org 13 Emphasize Client Role Client to take more responsibility/initiative in their health and self-management skills “I look forward to helping you do a better job in dealing with your DM.MI Goals: Components of SelfManagement Support (SMS) Emphasize client role Build relationships Include family Share info Collaborate on goals and action plans Problem solving Follow up on progress www.” ”What is the most difficult part of managing your diabetes” 18 . is to provide you with the latest information on diabetes.

direct or command Give advice. but you did!” Remember.” Express understanding Normalize “Many people have higher blood sugar readings in the morning. 23 In communication. which of the following has the biggest influence on message delivery? A. caution or threaten Persuade with logic. Examples: “So you’ve started walking this past week!” “You didn’t want to come today. lecture Disagree.” Self-disclose (when appropriate) “I also struggle with finding time to get my physical therapy exercises in.” or “So. fears “Sounds like you feel pretty overwhelmed with managing your diabetes.Building Relationships Reflective listening Listen. Their attitudes are shaped by our words. most who need to make change have tried and are failed self-changers 20 Roadblocks to Reflective Listening Order. correct. Words we use (7%) B. thoughts. Believe in your client and their ability to change: promote self-esteem. Tone of voice (38%) C. judge. add or refine 19 Building Relationships Affirmations Identify and acknowledge client’s strengths. Body language (55%) 24 . you are worried about walking safely outside in the winter months. criticize or blame Question or probe Distraction. Be genuine. humor or changing the subject 21 Building Relationships Expressing empathy Strive to understand the clients emotions. argue. make suggestions or provide solutions Warn.” “It sounds like…. values.” 22 Building Relationships Expressing empathy Use nonverbal communication Face client Keep an open posture (do not fold arms) Lean toward client at times Maintain good eye contact Be relaxed.” “What I’m hearing you say is…” Allow time for client to verify. you are saying…. express interest and understand the meaning of what client is saying (even if you disagree with it) Repeat back to the client your understanding of his/her experience or feelings from their point of view (using a short summary) “So.

be active. goal achievement Monitor for self-care police 25 Info Sharing Encourage clients to share Feelings What do they find hard Record keeping (BG. food. help with med adherence. where. wt. even with some slip ups) Goal Setting Specific activity that you will do. Priorities) 30 . activity. negative or no support = poorer outcomes) Ask client if they want family involved in appts (include in materials sent home to client) Don’t want the family member to speak for the client. Behavior-specific – “What. but you do want their input Encourage family to eat healthy also. how often. with who? The more specific the better You have a level of confidence 7 or higher on a scale of 1 to 10 27 28 Problem Solving Identify a problem or barrier to achieving goal Brainstorm with client options that may help to overcome the problem/barrier Select one of the options and try it Assess results. groups. Concerns with ambivalence 29 Ambivalence Feeling 2 or more ways about something Not committed to change. undecided Values not aligned with change: not important enough Don’t have sufficient DARN Desire (Values. great If not. 1:1?” 26 Collaborate on Goals Success dependent on 2 kinds of motivation Positive expectation or hope (the belief that change will do some good) Confidence or self efficacy (the belief that they can successfully make the change. steps) Sharing what you know “What do you want to learn about eating?” “Would you rather I talk about meal planning or would you rather just ask me questions?” “How do you like to learn…reading. It must be something: You WANT to do.Include Family Family support is a major factor in self-mgt outcomes (positive support = positive outcomes. bp. video. You reasonably CAN do. seeing. doing. Self-Efficacy) Reasons (Pros/Cons) Needs (Importance. If works. Emotions) Ability (Confidence. when. brainstorm other options.

. Reinforce Change Talk Desire for change: “I want to…” Ability to change: “I know I can…” Reasons to change: “It will help me to. Listen and Respond to Change Talk (client needs to be the one voicing the argument for change).Resolving Ambivalence Key to behavior change First goal: increase the discrepancy between current status and desired goal Second goal: Elicit. consider. may Desire Ability Reasons Need Commitment Language (Change Talk) Behavior Change ↓ Taking Steps 31 32 Eliciting Change Talk Ask evocative questions “How do you feel about checking your BG?” (D. How confident is the client about making the change. N) “If you could see a future with your DM better controlled. promise. R) “What is most important to you right now about your health?”(R. 36 . what would that look like?” (D.. will. N) “What have you done to successfully lose weight in the past?” (A) “What would need to happen for you to begin an exercise program?” (D. plan to. R) (Tool for exploring ambivalence) Cons Negatives about Changing changing behavior behavior? Not changing behavior 33 Decisional Balance Explore decisional balance Use readiness to change scale Pros Positives about changing behaviors? Positives about Negatives status quo? about status quo? 34 Quitting Concerns with smoking smoking Mother died of cancer Father died of emphysema Personal illness My children will smoke Cost Smell Cough Still Benefits of Smoking smoking Relaxation Wakes me up I enjoy it Helps me think Benefits of quitting Breathe and feel better Please my family Have more money Not embarrassed of smell Concerns with quitting Wt gain Fail at quitting Life not as fun More stressed 35 Exploring Readiness to Change Use readiness scale Readiness = importance X confidence How important is it to the client to change.” Need to change: “I have to because…” Commitment Language Terms: Vow.

low confidence High importance. when. where Check on goal progress Identify new or ongoing problems Need for exams/labs Reminder of upcoming appts Document follow-up 39 40 Questions to elicit change talk: “Why are you at a ____ and not a zero?” “What would it take for you to go from ___ to a (higher number)? “What might help you overcome that barrier?” Collaborative Goal Setting Must agree on a goal and work with hcp to develop a plan Offer options “What behavior would you like to change?” “What appeals to you the most?” Barriers: Goal: Describe: Action Plan How What When Plans to overcome barriers: Conviction and Confidence rating (1-10): Follow-up 41 42 Where Frequency HCP must support clients choice of a goal Accept small steps toward change . low confidence Low importance.Readiness Scale 1 2 Readiness Scale How important is it for you to make the change? 3 4 5 6 7 8 9 10 1 Pre-c ontem platio n 2 3 Unsure tion Con temp la 4 5 tion 6 7 8 9 10 Not ready Somewhat Ready Prep aratio n emp la Very Ready Not important Very Important _____________________________________________________________ How confident are you that you can make the change? Actio n C ont 1 2 3 4 5 6 7 8 9 10 Not confident Very Confident 37 38 Building Motivation and Confidence for Change Group A: Group B: Group C: Group D: Low importance. high confidence High importance. high confidence Follow Up Designate someone to do follow-up How.

Miller and Butler (2007).Action Plan Goal: become more active Describe: How: walk What: 20 min Where: home on treadmill Frequency: 3 X/week General Guidelines Talk less than your client. Motivational Interviewing in Health Care. On the Cutting Edge.motivationalinterviewing. Offer 2-3 reflections for every question you ask Ask twice as many open-ended questions as closed Overall goal of MI is help client to argue for behavior change. 26(2):17-21. 43 44 When: after I wake in the morning Barriers: not waking up in time Plans to overcome barriers: set alarm. L. 46 .newheatlhpartnerships. Resources for Trainers www. get to be early Conviction and Confidence rating (1-10): 8 Follow-up: keep activity log Motivational Interviewing References www. Listen more. s. What technique will you try in the next week? 45 Maurer.org: Motivational Interviewing. (2005) Counseling Strategies to Promote Behavior Change.org and click on health care providers for info on self management support Rollnick.. Mesznik.