Buddy Garfinkle and Nancy Schneeloch, Bridgeway Rehabilitation Services, Elizabeth, New Jersey buddy.garfinkle@bridgeway.com nancy.schneeloch@bridgeway.

com

Benefits of Learning about Motivational Interviewing

More realistic expectations Greater recognition of small accomplishments Greater success over time Less frustration and burnout Effective across populations and cultures Actively involves the person in his/her own care Improves adherence and retention Instills hope Consistent with Recovery Transformation

Source: Retrieved July 18, 2008 from ahec.allconet.org/newrihp/powerpoint/

What Is Motivational Interviewing?

Directive, person centered counseling style that aims to help people explore and resolve their ambivalence about behavior change
Source: Michael Wiles and Cross Country Education, Inc. 2005

What is Motivational Int. Cont.

M.I. is a counseling style rather than a set of techniques. It is not a method

for tricking people in to doing things they do not want to do. It is a style for eliciting from the person their own motivations for change. It is a way of interacting with people to assess their readiness to change and to help them move through different stages of change. MI focuses on creating a comfortable atmosphere without pressure or coercion to change. It is called interviewing because it involves careful listening and strategic questioning rather than teaching to help people overcome their ambivalence to change. Any change that will happen will come from within the client and not imposed upon them by some outside force. It is the role of the client to be able to articulate and resolve his or her own ambivalence to change. Ambivalence is the I want to but I dont want to state of mind feeling 2 ways about something. Direct persuasion is rarely effective at resolving ambivalence.

Cont.
First Developed in 1983 by William Miller in the treatment of

problem drinkers and further concepts were elaborated by Bill Miller and Stephen Rollnick in 1991. MI has been used in many health settings . Clinical trials of MI have shown that persons are more likely to enter, stay in and complete treatment; to participate in follow-up visits; to adhere to glucose monitoring and to improve glycemic control; to increase exercise and fruit and vegetable intake; to reduce stress, to improve medication adherence; to decrease alcohol and drug use; to quit smoking; and to have fewer subsequent injuries and hospitalizations.

Three Components of MI Spirit

Collaboration Evocation Autonomy
Working in partnership Draw out ideas and solutions from individuals Decision making left to the person

Spirit of MI
Motivation to change is elicited from the person, not

externally It is the persons task, not the counselors, to articulate and resolve ambivalence Direct persuasion is not an effective method for resolving ambivalence The counselors style is generally a quiet and eliciting one The counselor is directive only in helping the person to examine and resolve ambivalence Readiness to change is a fluctuating product of interpersonal interaction. The therapeutic relationship is more like a partnership or collaboration than expert/recipient role.

Characteristics of Motivational Interviewing

Guiding, more than directing Dancing, rather than wrestling Listening, as much as telling Collaborative conversation Evokes from a person what he/she already has Honoring of a persons autonomy

Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care, 2008.

Characteristics cont.
change.

Motivation for change can be shaped and is particularly formed in the concept of relationships. No one is completely unmotivated. We all have hopes and aspirations. The way in which we talk to people can influence their motivation for With MI it is a partnership instead of an uneven power relationship where the helping person or health care provider is the expert. Instead of giving people what they lack be it medication, knowledge, skills or insight, MI seeks to evoke the persons own motivations and resources for change. Even though the person may not be motivated in the direction you would like, every person has personal goals, values, aspirations and dreams. Part of the art of MI is connecting behavioral health change with the persons values and concerns. This can only be done by understanding the persons perspectives and evoking their own good reasons and arguments for change. There needs to be a certain detachment from outcomes not an absence of caring but an acceptance that people can an do make decisions about the course of their lives. By acknowledging the persons freedom not to change, it makes change possible. With MI there is an acceptance that people make choices and despite what helpers may tell them, they ultimately make the decision.

What do we know about Motivation?

It is fundamental to change It fluctuates It can be modified It is influenced by external factors and social interactions It is very sensitive to interpersonal style There are internal and external sources We want to increase the probability of the person engaging in change behavior Motivating is an inherent part of our job

What is Ambivalence?
I want to, but I dont want to Natural phase in the process of change Normal aspect of human nature, not

pathological Ambivalence is key issue to resolve for change to occur It is our friend

Changing Extrinsic to Intrinsic

Motivation

Changing because I want to Know and explore values Core value discrepancy motivates change Explore life goals; discrepancy between where the person is and where he/she wants to be Choice/Self Determination Reframing the persons negative statements

PRINCIPLES OF MOTIVATIONAL INTERVIEWING

AREDS A- Avoid Arguing R- ROLL WITH RESISTANCE E- EXPRESS EMPATHY D- DEVELOP DISCREPANCY S- SUPPORT SELF EFFICACY

REVIEW RESISTANCE
It is normal 4 types: arguing; denying; ignoring; interrupting The more one talks about non-change behaviors, the

more a person is likely to do them. It is determined by therapist style May mean the therapist is ahead of the person in the change process Resistance often stems from fear of change

Develop Discrepancy
Difference between the persons core values and life goals

and their health behavior Difference between where the person is now and where he/she would like to be in the future Elicit client goals & values.
Evaluate clients current state with regard to those goals & values. Emphasize the discrepancy between them.

Best if the individual makes the argument for change. No discrepancy = No ambivalenceAmbivalence makes

change possible.

Assessment Tools
1. Stage of Change

2. Payoff Matrix
3. ICR Scales

4. Value Cards

STAGES OF CHANGE
CONCEPT PRECONTEMPLATION DEFINITION Unaware of the problem, hasnt thought about change METHODS OF TX. Engagement skills, develop trust, assertive outreach, accept client where they are at, provide concrete care Instill hope, positive reinforcement for harm reduction, discuss consequences, raise ambivalence, motivational interviewing Assist in developing concrete action, problem solve w/ obstacles, build skills, encourage small steps, tx planning Combat feelings of loss and emphasize long term benefits, enhance coping skills, teach how to use self help, tx. Planning, develop healthy living skills, teach to avoid high risk situations Assist in coping, reminders, finding alternatives, relapse prevention Determine the triggers and plan for future prevention

CONTEMPLATION

Thinking about change, in the near future (usually w/in the next 6mos) Making a plan to change plans, setting gradual goals (w/in 1 mo) Specific changes to life style has been made w/in past 6 mos

PREPARATION

ACTION

MAINTENANCE

Continuation of desirable actions, or repeating periodic recommended step's

RELAPSE

PART OF THE PROCESS

PAYOFF MATRIX about Drinking

Drinking as before
Benefits
Helps me relax Enjoy drinking with friends Eases boredom Hard on my health Spending too much $ Might lose my job

Abstaining
Feel better physically Have more $ Less conflict with family, work Id miss getting high What to do about friends How to deal with stress

Costs

The ICR Scales :

IMPORTANCE

How important is it for you to change right now?

CONFIDENCE

If you decide to change, how confident are you that you could do it?
READINESS

How ready are you to change right now?

Value Cards
Sort them into important/not important categories
Have person pick out the five most important values

and share what it means to him\her http://www.motivationalinterview.org/library/valuescar dsort.pdf

MI Skills
OARS

OPEN ENDED QUESTIONS

AFFIRMATIONS REFLECTIVE LISTENING

SUMMARIES
-It is also important to Elicit Change talk.

Reflective Listening
Allows individual to feel heard Allows you to confirm perceptions Simple declarative statement:
-It wasnt your idea to come to see me today -You feel pretty discouraged right now -You have mixed feelings about your drug use

Examples of Reflective Listening

It sounds like . . . It seems as if . . . What I hear you saying . . . I get a sense that . . .

It feels as though . . .
Help me to understand. On the one hand you . . . and

on the other hand . . . Handout exercise 3.4

Strategies To Elicit Change Talk

Asking Evocative Questions
Using Readiness Rulers Exploring the Decisional Balance Looking Back/Looking Forward Using hypotheticals Key Questions
Source: S. Rollnick, W. Miller and C. Butler, Motivational Interviewing in Health Care, 2008.

Resources
B. Borrelli, Using Motivation Interviewing to Promote Patient Behavior Change and Enhance Health http://www.medscape.com/viewprogram/5757 S. Rollnick, P. Mason and C. Butler Health Behavior change: A Guide for Practitioners. Churchill Livingstone 1999 S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. Guilford Press 2008 C. Field, D. Hungerford and C. Dunn Brief Motivational Interventions: An Introduction. J Trauma 2005; 59:S21-S26 M. Wiles Motivational Interviewing: Overcoming Client Resistance to Change Cross Country Education www.CrossCountryEducation.com