Motivational Interviewing Mini-Workshop

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Motivational Interviewing Mini-Workshop

• Robert P. Schwartz, M.D.
• Department of Pediatrics
• Wake Forest University School of Medicine
• Winston-Salem, NC

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Faculty Disclosure Information

• I have no relevant financial relationship with
  the manufacturer(s) of any commercial product(s)
  and/or provider of commercial services discussed
  in this CME activity.
• I do not intend to discuss an unapproved/investig
  ative use of a commercial product/device in my
  presentation.

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Definition of Motivational Interviewing

• Patient-centered directive method for enhancing
  intrinsic motivation to change by exploring and
  resolving ambivalence.
• Miller WR, Rollnick S. Motivational Interviewing
  Preparing People for Change.
• 2nd ed. New York Guilford Press 2002.

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Motivational Interviewing What its Not

• Not arguing that a person has a problem and needs
  to change.
• Not offering advice without patients
  permission.
• Not doing most of talking.
• Not giving a prescription.

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MI Tools of Trade

• Establishing rapport
• Agenda setting
• Getting permission
• Asking open-ended (starting) questions
• Using reflective listening
• Affirmations

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MI Tools of Trade

• Considering the pros and cons
• Eliciting change talk (interest and confidence)
• Providing menus vs. single solutions
• You provide information, patient interprets it
• Summarizing and closing the deal

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Open-Ended Questions (get the ball rolling)

• Cant be answered yes/no
• Use patients own words
• Not biased or judgmental

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Open vs. Closed-Ended Questions

• Closed-Ended Open-Ended
• Did you have a great vacation? Tell me about..
• Are you depressed? Help me understand..
• Is your job going ok? Whats going on.
• Dont you know you will get diabetes
• if you dont quit drinking sodas? What
  connection, if any

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Open vs Closed-Ended Questions

• Are you happy with your weight?
• Do you have any health concerns related to your
  weight?
• Are you comfortable when your child doesnt clean
  his plate?
• Will not buying sodas increase stress in your
  house?
• Can you start to make these changes in the next
  week?
• Are you exercising regularly?

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Reflective Listening (keep the ball rolling)

• Restate and rephrase
• Statement of understanding (clarifies meaning)
• Builds rapport and keeps patient talking

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Universal Safe Reflections

• It sounds like you are feeling..
• It sounds like you are not happy with.
• It sounds like you are having trouble with..
• As you improve, you can truncate the reflection
• Youre not ready to.
• Youre having a problem with.
• Youre feeling that.
• Its been difficult for you.

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PICKY EATERLittle Roger (3 years old)
just wont eat any vegetables. When I put some
peas or squash on his plate he refuses to even
take a taste. He wont eat anything except tater
tots, liver mush, gravy biscuits and chips. And
he never drinks any milk. He begs for Koolaid
and juicy juice all day. My husband (big Roger)
cant stand to hear him cry and tells me to give
him anything he wants to keep him
quiet.REFLECTION
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FAST FOOD RESTAURANTSI know I should fix more
meals at home and not bring home food from fast
food restaurants so often, but Im exhausted
after working all day, and I just dont have the
energy to spend 2 hours in the kitchen. And even
if I do cook at home the kids dont want to eat
what I fix and will ask for chicken nuggets or
pizza.REFLECTION
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PROS and CONS

• Could you tell me some things you like about
  ________
• What things are not so good about __________
• What might happen if you dont change?
• How would changing ____________ affect your
  family?

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Providing Information

• Ask for permission
• Provide nothing but the facts.
• Let patient interpret it.
• Would it be okay if I shared information with
  you?
• What does this mean to you?

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Interest and Confidence

• INTEREST
• On a scale of 0 to 10, with 10 being the highest,
  how interested are you in changing (INSERT
  BEHAVIOR)?
• 0 1 2 3 4 5 6 7 8 9 10
• Not at all Somewhat Very
• CONFIDENCE
• On a scale of 0 to 10 assuming you wanted to
  change (INSERT BEHAVIOR), how confident are you
  that you can do it?
• 0 1 2 3 4 5 6 7 8 9 10
• Not at all Somewhat Very
• PROBE 1 Why did you not choose a lower number?
• PROBE 2 What would it take to get you to a
  higher number?

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Summarizing and Closing the Deal

• If its ok, I would like to go over what we
  have discussed today.
• Summarize pros and cons of change and link to
  core values.
• Closure What do you think might be a first
  step?
• If ambivalent Would it be okay if I shared some
  strategies
• that have worked for other families?
• If not ready to change It seems that you are
  not ready to make a change at this time .

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FRAMES (brief messages)

• Feedback risks and consequences of behavior.
• Responsibility Its up to you.
• Advice professional recommendation on reasons
  for change.
• Menus variety of strategies, not single
  solution.
• Empathy positive caring manner.
• Self efficacy - you can do it.

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Parent Perceptions of MD Counseling (N16)

• Questionaire Item of Parents
  Agreeing A lot
• My Pediatrician listened to me
  100
• My Pediatrician asked my opinion about things
  88
• My Pediatrician asked permission before giving
  information or advice 81
• My Pediatrician helped me think about changing my
  familys food habits 94
• My Pediatrician was supportive/encouraging
  94
• My Pediatrician discussed values important to
  me 88
• My Pediatrician helped me think about changing my
  familys TV habits 63

Schwartz R P, Hamre R, Dietz WH, et al. Arch
Pediatr Adolesc Med 2007 1611-7