Motivational Interviewing: Conversations that lead to Change Carol DeFrancesco, MALS, RD Division of Health Promotion and Sports Medicine, OHSU defrance@ohsu.edu Special thanks to: Denise Ernst, Steve Berg-Smith and Bill Miller

Motivation changes with our style of interacting.

Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change. Motivational Interviewing (MI) is a method of enhancing someone’s intrinsic motivation to change - client-centered - directive

Why is Motivational Interviewing (MI) a method to consider? MI has substantial evidence base supporting it’s effectiveness in facilitating change in behaviors that are hard to change MI is effective with both psychological (behavior change) and physical outcomes (BMI, BP, BAC) MI focuses the responsibility for change on the patient; encourages self-management and self- determination

The efficacy of MI –meta analyses MI out performs traditional advice giving in 80% of studies Effective in 10-20 minutes More encounters over longer time period increase likelihood of an effect Physicians and other health providers can be as effective as psychologists or counselors

Profound Positive Influence Discussion

The Spirit of MI Evocation of person’s motivation, hopes, dreams, desires, values, goals, and abilities. Partnership with the person; MI is done “for” and “with” a person and not “to” a person. Acceptance including accurate understanding, affirmation, absolute worth of the person, and support of the person’s autonomy. Compassion; active promotion of the person’s welfare and needs.

Self-Efficacy & Hope A person must have hope This is predictive of how they will do A provider’s expectation is also predictive Bandura’s Theory of Self-Efficacy

Sitting on the fence of change Your PE teachers may be ambivalent about the participating in the study – It may be a good thing for me and my students – but I am sick of the principle telling me what to do or sounds like really good stuff – could help me with my curriculum and get my kids more active but goooodddd I don’t have the time – you may feel may feel ambivalent too – This study has great goals but eeekks I’m not really looking forward to working with resistant teachers – or hey this is a great workshop, but Oregon also looks like a great place to go and see and do

Cowboy from Klamath Falls People get defensive when their autonomy is threatened And what we do strongly influences the amount of defensiveness we see in our teachers/clients – Let me tell you a story that illustrates this – K-falls story – wrap-up

What happens if you give advice to a person on the fence What happens if you give advice to a person on the fence. . . Gas station story draw a fence – if I am articulating the reasons on one side – what am I leaving for the other person to talk about – Let me give you an example – Gas station story

Sustain Talk The least desirable situation, from the standpoint of evoking motivation, is: when the health provider advocates for change while the patient argues against it

Most of us already have pro-change reasons of our own Most of us already have pro-change reasons of our own. These reasons are more persuasive than those of others. When Bev talked about know what you want – this is a good thing to keep in mind – you want your PE teachers to articulate reasons to be in the study not excuse – we will work on skills for how to do this – Eliciting counter change talk statements decreases motivation Bem’s Self-perception theory

Strength Cards and Break

Specific Skills: OARS OPEN Questions AFFIRMATIONS REFLECTIONS SUMMARIES

Reflective Statements Statements not questions Restates what patient says and selectively reinforces change talk Puts the patient in a more active role when discussing behavior change

Reflective Statements Pt: ‘I need to lose weight.’ Provider: “Being overweight has got you concerned.” Pt: ‘Healthy food is more expensive.’ Provider: “You are wondering if you can afford to change your eating habits.” Pt: “I know I could eat better.” Provider: Pt: “I don’t have time to exercise.” Provider:

Forming Reflections with Strength cards: Large group activity then pairs

Debrief Strength Activity

OARS OPEN Questions AFFIRMATIONS REFLECTIONS SUMMARIES

Questions that Evoke Change Talk (from Miller & Rollnick 2002) Category:Disadvantages of the status quo What concerns you about _______? What makes you think you need to do something about _______? What hassles have you had in relation to your smoking (or other behavior)? How has this stopped you from doing what you want to do in life? What do you think will happen if you don’t change anything?

Questions that Evoke Change Talk (from Miller & Rollnick 2002) Category: Advantages of change How would you like things to be different? What would be the good things about ______? What would you like your life to be like five years from now? What are the main reasons you see for making a change? What do you want?

Questions that Evoke Change Talk (from Miller & Rollnick 2002) Category: Optimism about change If you decide to make a change, what would you do to be successful? What do you think would work for you if you decide to change? When else in your life have you made a significant change like this? How did you do it? What personal strengths do you have that will help you succeed?

Questions that Evoke Change Talk (from Miller & Rollnick 2002) Category: Intention to change What are you thinking about your smoking (eating habits, exercise) at this point? What do you think you might do? What would you be willing to try? What do you want to have happen?

Affirmations & Self-affirmations Emphasize a strength (What strengths do you have that will help you be successful?) Appreciate a positive action (What is working for you?) How are you keeping yourself healthy?

Summaries can: Collect material that has been offered So far you’ve expressed concern about your pacing, sleep, and options for pain medications. Link something just said with something discussed earlier. That sounds a bit like what you told me about that before when you were successful in changing. . . Draw together what has happened and transition to a new task Before I ask you the questions I mentioned earlier, let me summarize what you’ve told me so far, and see if I’ve missed anything important. You came in because you were feeling really sick, and it scared you . . . . . . . . .

Listening… How to stop the talkers…. Summarize and use a bridging statement I’d like to shift gears… go back to something you mentioned… Discuss time limitations Give value to what you have heard “We have talked about a lot of things today, if you had to pick on one to work on…”

Four Foundational Processes Planning Evoking Focusing Engaging

Demonstration

Set the stage and engage Conversation Roadmap Set the stage and engage “I would like to spend about 10 minutes talking about your eating habit goals, would that be OK?” “What are you already doing to eat healthy?” “What do you notice . . .” Decide where to focus “There are a number of things that go in to healthy eating: more vegetables and fruits, less junk or sugar, regular meals . . Where do you feel ready to make a change?”

Healthy Eating Ideas Eat out less Eat regular meals Drink less soda Cut back on sugar Increase fruits & vegetables   Shop for food regularly Drink less soda

Plan when client is ready Summarize and Close Conversation Roadmap Evoke deeper reasons “Why did you choose . . .?” “Why else would this be a good thing?” Plan when client is ready “What are you willing to try?” Summarize and Close “Let me see if I got it all . . .What are you ready to commit to in the next couple weeks?”

Your turn: Groups of 3 handout

Debrief: Speakers first: “What seemed to further your change process?”

Debrief: Listeners What did you notice?

“It is through the power of our listening, not the wisdom of our words that we are able to affect the most change” Carl Rogers