Motivational Interviewing

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Motivational Interviewing

• Suzanna Theodoras, RN, CDE
• Ohio University, College of Osteopathic Medicine
• Cornwell Diabetes Center Education Program
• 740-566-4872
• theodors_at_ohio.edu

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Motivational Interviewing

• MI is an approach to health behavior change
  consultation that employs high-quality listening
  to discuss the whys and hows of change, with
  the goal of increasing the clients readiness for
  and commitment to the adoption of a healthier
  lifestyle.
• More simply Encouraging people to resolve their
  ambivalence about changing their behavior, while
  not evoking their resistance.
• Diabetes Spectrum, Volume 19, Number 1, 2006

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Motivational Interviewing Research Practice and
Puzzles

• Foremost in my own mind is the fundamental
  question of why this approach works at all. . .
  How could it possibly be that a session or two of
  asking clients to verbalize their own suffering
  and reasons for change would unstick a behavior
  pattern that has been so persistent? What is
  going on here?
• Miller-1996

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Motivational Psychology

• The underlying principle is that people will make
  the most long-lasting behavior change when their
  motivation is internal rather than external.

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Motivational Interviewing

• An amalgam of philosophies, principles and
  techniques drawn from several existing models.
• Carl Rogers and his Force of Life
• Bems Self-Perception Theory
• Janis and Manns Decisional Balance Theory
• Prochaskas Transtheoretical Model
• Empowerment Model
• HandbookMotivational Interviewing Preparing
  People for Change provides more detail of the
  theoretical background

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Motivational Interviewing Network of Trainers
(MINT)

• Founded in 1995
• www.motivationalinterviewing.org

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Motivational Interviewing

• Client-centered counseling style.
• Elicits behavior change by helping clients
  explore and resolve their ambivalence.
• Help clients recognize the discrepancy between
  their current behavior and their desired goal.
• Empathic listening minimizes their resistance.
• Sobell Sobell 2003

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Motivational Interviewing Model of Change

• Prochaska and DiClementes
• Precontemplation What problem?
• Contemplation Should I change?
• Decision/Preparation Can I change?
• Action How do I change?
• Maintenance Is it worth it?
• Relapse
• Prochaska DiClemente, J Consult Clin Psychol,
  1983

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Daniel D.Squires and Theresa B Moyers University
of New Mexico, Albuquerque, New Mexico
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Motivational Interviewing and Diabetes

• Motivational Interviewing (MI) is a counseling
  approach that is
• Non-confrontational
• Practical Focus
• Problem solving
• Goal setting
• Clients identify behavior they would like to
  change
• List benefits of the change
• Discuss difficulties in making that change
• Set Realistic goals

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Motivational Interviewing

• HCPs feel responsible for fixing
• Carry-over from acute care model
• Unrealistic for the chronic care model
• Use of direct questioning, active persuasion, or
  advice-giving from the top down has proven to
  be of limited effectiveness in the long term
  management of chronic illnesses.
• Face-to-face agreement but weak follow-through
• Motor boat responseYes, but. . ., Yes, but.
  . ., Yes, but. . .

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The Spirit of Motivational Interviewing

• Empower and collaborate with our clients
• A dual expertise Lets put our heads together
  and look at the options.
• Support and respect for the clients autonomy and
  problem-solving capabilities.
• Elicit change talk from the client regarding
  behavior change and goal.

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Key Elements of Motivational Interviewing

• Express empathy
• Use Reflective Listening
• Develop discrepancy
• Avoid arguing
• Roll with resistance
• Support self-efficacy or empowering

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Motivational Interviewing1. Expressing Empathy

• Expressing empathy is the key to building rapport
  with clients.
• Accept people as they are and where they are.
• Recognize ambivalence to change is normal and
  consistent with reality.
• Encourage their positive self-motivational
  statements.

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Motivational Interviewing1. Expressing Empathy

• Seek permission before asking a question, before
  giving information, or before giving advice.
• Do you mind if I ask . . . .
• May I share some information. . . .
• With your permission I would like to . . . .
• Asking permission shows respect.
• Establishes a safe environment.

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Motivational Interviewing 2. Reflective Listening

• Use Reflective listening to
• Understand the clients perspective and let them
  know you are truly listening to them.
• Emphasize the clients positive statements about
  changing so they hear their positive statements
  twiceonce themselves and once from the HCP.
• Diffuse resistance.

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Motivational Interviewing 2. Reflective Listening

• Simplereflects exactly what was heard
• Double-sidedreflects both sides by pointing out
  ambivalence
• Amplifiedheightens the resistance that is heard
• Self-motivational statementsclient tells how
  they are changing
• Affirmsupport, encourage, recognize clients
  difficulties
• Summary Statementpulls together comments made
  and transitions to the next topic

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Motivational Interviewing 2. Reflective Listening

• Repeating
• Rephrasing
• Empathic reflection
• Reframing
• Feeling reflection
• Amplified reflection
• Double-sided reflection

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Motivational Interviewing 2. Reflective Listening

• Summary Statement
• Longer than a reflection.
• Used mid-session to transition.
• Highlight both sides of clients ambivalence.
• Recap major points to end session.
• Belinda Borrelli, Phd, MA

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Motivational Interviewing 3. Develop Discrepancy

• Motivation for change is created when people
  perceive a discrepancy between their present
  behavior and an important personal goal.
• Where do you want to be?
• Where are you currently?
• When do you want to be there?
• With effective listening and communication skills
  the HCP helps the client understand his/her
  ambivalence regarding change.

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Motivational Interviewing4. Avoid Arguing

• Start where the client is.
• Avoid direct confrontation in order to avoid
  resistance.
• Avoid labeling.
• Use open-ended questions

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Motivation Interviewing5. Roll with Resistance

• Reframe statements of clients to create a new
  momentum towards change.
• Invite the client to consider new information and
  perspectives.
• The client becomes actively involved in finding
  solutions.

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Motivational Interviewing6. Self-Efficacy/Empower
ment

• Encourage the client to believe in him/herself.
• Wanting to make a change is only the first half
  of the behavior change process. Having the
  confidence to carry out the chosen behavior
  change is the second half of the process.
• Sees a way to succeed.
• Sees a way to persist when roadblocks appear.
• Client develops the plan and potential solution.

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Thinking about the costs and benefits of
change.What specific behavior change are you
considering?

• Create some ideas and reflections for each of the
  four boxes above.
• This will help clarify your thoughts about what
  you want to do next.
• Janis and Mann / Currently being used in an NIH
  study

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How important is it for you to change?

• 0__1__2__3__4__5__6__7__8__9__10
• Not at all important Extremely important

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How confident are you thatyou can make this
change?

• 0__1__2__3__4__5__6__7__8__9__10
• Not at all important Extremely important

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Motivational Interviewing
How important is it for you to change ? How
confident are you that you can make this change?
On a scale of 1 to 10...
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Motivational Interviewing

• Confidence Ruler Incorporates
• Careful listening
• Appreciating ambivalence
• Eliciting change talk
• Empowering
• Collaborating
• Confidence Ruler yields a clear sense of
  readiness for change
• Confidence Ruler reflects 2 independent
  dimensions
• Why should I ?
• How can I ?

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Conclusion

• Overall, the empirical evidence regarding the
  impact of MI, particularly as an additive to
  other effective treatments, is promising.
• The next wave of MI intervention studies will
  tell us more and correct some of the
  methodological weaknesses of many articles to
  date.

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Conclusion

• MI instructs us to appreciate the limits of a
  direct-persuasion, advice-giving model of
  clinician influence.
• MI guides us toward a strong appreciation of the
  role of ambivalence in behavior change and the
  value of eliciting client change talk.
• MI models the use of effective listening skills
  to build rapport, engage, understand, and
  facilitate behavior change.

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Conclusion

• The spirit of MI shares much with the
  established Empowerment Model already used in
  diabetes education training. Whether one has the
  luxury of extended patient contact or must work
  within the parameters of a brief scheduled or
  opportunistic exchange, there are opportunities
  to integrate elements of the MI guiding style
  into everyday practice.

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Conclusion

• MI Training with Diabetes Educators
• 2nd year of 4 year randomized controlled trial
  examining the usefulness of MI in the management
  of 296 patients with poorly controlled type 2
  diabetes.
• MI spirit and strategies have been woven into the
  usual educational activities. Patients receive 7
  MI based sessions over a 1 year period and a 1
  year follow-up. Outcomes include bg control,
  QOL, self-mgmt behaviors, and health care
  utilization.

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Conclusion

• A Pilot Study of Motivation Interviewing in
  Adolescents with Diabetes at Department of Child
  Psychology, University Hospital of Wales, UK

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