Using Motivational Interviewing to Promote Behavior Change

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Using Motivational Interviewing to Promote
Behavior Change
Developed By CICATELLI ASSOCIATES
INC. Funded by RWCA
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Training Goal
To teach multidisciplinary teams of providers to
use an effective behavior change intervention
with clients.
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MULTIDISCIPLINARY TEAM

• The multidisciplinary team is a group of people
  with different areas of expertise that utilizes
  the different perspectives of the members of the
  team and works for a common goal.
• Teamwork enhances the effectiveness of the
  different capacities of the members in the team,
  giving clients a more comprehensive response to
  their various needs.
• It is vital that each member of the team
  continually supports the other members, in order
  to optimize results.

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BARRIERS TO TEAM WORK

• Lack of clarity on the roles
• Lack of communication skills
• Lack of leadership
• Monopolization of ideas
• Hierarchical structure
• Devaluation of team members

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THE MULTIDISCIPLINARY TEAM APPROACH
DOCTORS
Nurses Social Workers Psychologists Nutritionists
Other PLWHA
TRADITIONAL APPROACH
MULTIDISCIPLINARY APPROACH
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Watch Your Assumptions
Many behavior change consultations fail because
the practitioner falls into the trap of making
false assumptions. Consider these

• This person OUGHT to change.
• This person WANTS to change.
• This patients health is the prime motivating
  factor for him/her.
• If he or she does not decide to change, the
  consultation has failed.
• Clients are either motivated to change or not.
• Now is the right time to consider change.
• A tough approach is always best.
• Im the expert he or she must follow my advice.

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POINTS TO CONSIDER ABOUT PROVIDER ASSUMPTIONS

• May not be accurate for the particular client
• Provider-focused rather than client-focused
• Focuses on unproductive attitudes
• Client is more likely to be open to consider
  change if you avoid imposing your assumptions on
  him/her
• Approach based on negotiation could be more
  effective as well as genuinely respectful of the
  clients

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MOTIVATIONAL INTERVIEWING

• The strategies associated with motivational
  interviewing are more persuasive than coercive
  more supportive than argumentative
• The provider seeks to create a positive
  atmosphere that is conducive to change

Motivational Interviewing from the work of Miller
and Rollnick)
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• The overall goal is to increase clients
  intrinsic motivation so that change arises from
  within the client, not imposed from without.
• When done properly, it is the client who
  presents the arguments for change, rather than
  the health care provider or team

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MOTIVATIONAL INTERVIEWING

• Can be used for
• Lessening resistance
• Resolving ambivalence
• Ambivalence
• Mixed feelings or emotions simultaneous and
  contradictory attitudes or feelings
• Inducing change

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RATIONALE AND BASIC PRINCIPLES

• MOTIVATIONAL INTERVIEWING
• Assumes that responsibility and capability
  for change lies within the client.

• Health Care Teams task is to create a set
  of conditions that will enhance the clients
  own motivation for and commitment to
  change.

• Mobilize the clients inner resources,
  helping relationships, support intrinsic
  motivation for change

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FOUR BASIC PRINCIPLES

• EXPRESS EMPATHY
• DEVELOP DISCREPANCY
• ROLL WITH RESISTANCE
• SUPPORT SELF-EFFICACY

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EXPRESS EMPATHY

• Acceptance facilitates change
• Understanding clients feelings and perspectives
  without judging, criticizing, or blaming through
  skillful reflective listening
• Ambivalence is seen as a normal part of change

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DEVELOP the DISCREPANCY

• The client rather than the worker should present
  the arguments for change
• Change is motivated by a perceived conflict
  between present behavior and important personal
  goals or values
• Triggered by an awareness of and discontent with
  the costs of ones present course of behavior and
  by perceived advantages of behavior change

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ROLL WITH RESISTANCE

• Avoid arguing for change
• Client Should not be directly opposed
• New perspectives are invited but not imposed
• A signal to change strategy and respond
  differently
• Includes involving the client actively in the
  process of problem-solving

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SUPPORT SELF-EFFICACY

• Belief in the possibility of change
• The client, not the worker, is responsible for
  choosing and carrying out change
• Workers belief in the clients ability to change
• A reasonably good predictor of treatment outcomes
• Enhances a clients confidence in his/her
  capability to cope with obstacles and to succeed
  in change

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NEGOTIATING BEHAVIOR CHANGE

• The method outlined here comes from two broad
  sources
• developments in the addictions field like
  motivational interviewing and
• the patient/client-centered approach to
  consultation
• This method is not original however, it attempts
  to refine and adapt these ideas and techniques,
  for use in a brief client-centered consultation.

(Miller 1983, Miller Rollnick 1991) and the
stages of change model (Prochaska DiClemente
1998) Stewart et al 1995
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• Refinement and adaptation was necessary because
  one cannot expect practitioners in healthcare
  settings, who have so many other priorities, to
  use the often complex and time-consuming methods
  employed by specialists in the addictions field.
• Paradigm shift in health care from treatment as
  the primary goal of the health care team member
  to prevention and life style change as the
  primary goals.

(Miller 1983, Miller Rollnick 1991) and the
stages of change model (Prochaska DiClemente
1998) Stewart et al 1995
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• Another paradigm shift is from health care team
  member-centered interventions to client-center
  ones.
• The early tasks in negotiating behavior change
  are to establish rapport, set the agenda and to
  assess importance and confidence about changing a
  specific behavior.

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Establish Rapport

Set the Agenda
Multiple Behaviors
Single Behavior
Assess Importance, Confidence and Readiness
Explore Importance
Build Confidence
Health Behavior Change A Guide for
Practitioners, Rollnick, Mason Butler, 1999
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ASSESS IMPORTANCE, CONFIDENCE AND READINESS It
seems that some people cannot change and others
do not want to. Having agreed to talk about a
particular behavior there are a number of
directions one could take. It has been found
that the assessment of importance and
confidence is a useful first step.
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State that the goal of the assessment is to
identify which of the two domains, importance or
confidence, the health care team member should
focus on with the client.
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I M P O R T A N C E
LOW IMPORTANCE HIGH CONFIDENCE Could make the
change if they thought it was important enough
but are not persuaded of the need to change.
LOW IMPORTANCE LOW CONFIDENCE Neither see change
as important nor believe they could succeed if
they tried.
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HIGH IMPORTANCE HIGH CONFIDENCE See importance to
change and believe they could succeed.
HIGH IMPORTANCE LOW CONFIDENCE The problem is not
in willingness to change, but the low confidence
in their ability to succeed.
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C O N F I D E N C E
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READINESS

• Readiness can often provide an explanation for
  resistance, if you overestimate the clients
  general readiness to change a behavior.
• If you decide to stage a clients readiness, the
  question arises whether to use the notion of
  stages of change or that of a continuum. Its
  a matter of comfort .
• A stage-based assessment appears to be clear and
  simple for both health care team member and
  client.

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• A starting point for a stage-based assessment
  would be to ask the client why he or she is in
  one stage and not another.
• This would open up the conversation for the
  client to describe whatever basis there is to his
  or her motivation to change.
• This conversation will inevitably lead to a
  discussion on importance and confidence.
• This assessment, like that of importance and
  confidence, can be done informally or explicitly.
  
• In the latter approach we will use the Readiness
  Ruler (adapted from Stott et al 1995 Thomas
  Gordon) which has shown to be useful in clinical
  practice.

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READINESS RULER
Readiness Ruler adapted from Stoff et al 1995
Thomas Gordon