Motivational Interviewing Melissa Santos, PhD Joanne Arena, MS,RD

Reflection

…….change is hard……

Agenda Overview of Motivational Interviewing Discuss its use in every stage of meeting with a client Next steps

What is Motivational interviewing?

Let’s start with what it is not… Mw Mw

...and an exercise…

What is motivational interviewing? Developed in the early 1980s from the substance abuse field…now has been extended to a range of health promoting areas..

What is motivational interviewing? A client centered, directive method for enhancing intrinsic motivation for change by exploring and resolving ambivalence Miller & Rollnick

What is motivational interviewing? A client centered – Provider partners with patient – Focus is on the patient’s current values not the providers

What is motivational interviewing? A client centered Directive method – Direct the patient toward a goal of making lasting change

What is motivational interviewing? A client centered Directive method For enhancing intrinsic motivation for change – Change comes from within the patient – Not from external means “DCF is going to be called” “you’ll lose a leg” “you’ll violate probation and go to jail” “your wife will leave you”

What is motivational interviewing? A client centered Directive method For enhancing intrinsic motivation for change By exploring and resolving ambivalence – Helping patients identify solutions and become empowered to achieve their goals – Ambivalence = primary reason that change has not occurred

Foundation of Motivational interviewing MI is not about a set of tools..it’s about how you sit with and communicate with a client

Planning to take action within the next month Actively making changes for less than 6 months Behavior change is stable Working to prevent relapse; maintaining new behaviors for 6 months or more Intending to change within next 6 months; understand positives of changing but focused on cons Stage of Ambivalence Return to previous behaviors No problem awareness; no intention to change

Introduction to Motivational Interviewing

When is the first time we might use MI in a WIC clinic? The first phone call Say it with a smile on your face Don’t sound frustrated, sound helpful, interested Don’t verbalize everything you are thinking! Be personal but not TOO personal Don’t eat, drink or chew gum Speak a little slower without being condescending if English is 2 nd language Recommend everyone agree on consistent greeting to use

The Front Desk Rosaria scenario (handout)

Tools for the Provider

Express empathy and establish rapport Remember: Changes that last are those that the client decides to do… 3 Barriers to establishing rapport and empathy – Asking close ended questions – Giving instruction – Moving right to your agenda

Express empathy and establish Rapport Overcoming barrier: Moving right to your agenda – Build Rapport Open the interview with a compliment – Allow clients to set the agenda Circle chart Allows not only for clients to be able to set agenda but allows for provider to do so as well in a non-threatening way. Entry for future sessions

Reducing screen time Take medications Eating Better Regular Exercise Feeling Less Sad

Express empathy and establish rapport – Overcoming barrier: Asking close ended questions Ask open ended questions – Open questions encourage people to talk about whatever is important to them. Avoids the question-answer trap – Helps to establish rapport, gather information, and increase understanding. – Allows the client to tell their story In MI, the client should do the majority of the talking – Provider must do active listening!

An exercise…..closed questions Are you feeling better today? Are you doing OK today? Can I help you with that? Does your weight bother you? Do you eat out? Do you smoke? Are you married? Did you have a good day in school today? Are you suicidal?

Open ended questions Would you tell me more about... ? Would you help me understand... ? How would you like things to be different? What are the positive things and what are the less good things about... ? What do you think you will lose if you give up.. ? What have you tried before? What do you want to do next?

Express Empathy & Establish Rapport Reflections – The goal in MI is to not ask more than three questions in a row Goal: Mix of open questions and reflective listening – Standard phrases: “So you feel...” “It sounds like you...” “You're wondering if...” – An exercise….

Express empathy and establish rapport – Overcoming barrier: Giving instruction Normalize the situation – Helps clients know that their struggles are common “I hear this from clients a lot…” Ask Permission – “Is it okay if I share something with you?” – “I have some ideas”

Readiness Ruler Explore readiness for change – Readiness Ruler On a scale of 1-10, how ready are you to …. – Sample questions to follow up (be curious!): » “Why a X?” » “Why not (chose a lower number)” » “What do you think would help you get from a X to a Y (higher number)?” » “Where were you six months ago? How did you get from there to here?”

On a scale from 0-10, how important is it to you to make healthy changes in your eating and exercise habits? Not Somewhat Very Important Important Important On a scale from 0-10, how confident are you that you can make healthy changes in your eating and exercise habits? NAME: DATE: After learning about Fit 5 and the level of commitment the programs involves, please rate how important it is for you to make healthy changes in your eating and exercise habits and how confident you are that you can make these changes on the scales below. Are you ready? Not Somewhat Very Confident Confident Confident

Can help you gauge the best place to continue your conversation

Pros and Cons of Change Explore ambivalence using a decision balance sheet Pro of making behavior change Con of making behavior change Pro of not making behavior change Con of not making behavior change

Pros and Cons of Change Weigh pros and cons – “What are the advantages of keeping things the same?” – “What are the disadvantages of keeping things the same?” – “What are the advantages of making a change?” – “What are the disadvantages of making a change?” Summarize ambivalence – “Let me make sure I understand what you have said so far..” » Summarize reasons for keeping things the way they are first » Summarize reasons for making a change last » “Did I get that all right?”

Close the conversation “If it’s okay, I would like to go over what we have discussed today…” – Summarize discussion, review pros and cons (emphasize pros) “Is there anything I missed or that you would like to add?”

Close the conversation “What might be a first step?” – “May I share what has worked for other families” – “I have some ideas about how x, y or z might work. Would you like to hear about them now?” “It seems you are not ready to x, y or z…perhaps you can think more about our conversation and if it is okay with you we can talk more about this when I see you again.”

Goal Setting

MI in 2 minutes Provider: – “On a scale of 1-10 where 10 is a lot, how much do you want to…….” Client: – “2” Provider: – “Why so high, why not a 1?” Client: – Response Provider: – “What might you like to do about it?” Sim, 2009

Homework Use open ended questions – As a general guidelines, avoid asking three questions in a row If possible, try a circle chart with a client

Back to Rosario!

Where do you go from here? Keeping MI learning and practice alive in your work place What research shows: peer review and consistent practice Find an MI “champion” in your office

CT Children’s Clinical Nutrition Department Initiative Educate and Promote MI in department – DTN/RDs: training, observation, feedback, practice, peer groups, taped sessions, Newsletter – Barriers: Motivation, commitment, time: lack of understanding of MI

CCMC>Our Care>Nutrition>Resources>MI for Nutrition Professionals The Eight Stages of Learning MI Reference Articles and Books on MI Helpful Websites for learning MI MI Practice and Peer Review – Open Ended Questions Open Ended Questions – Action-Reaction Observation guide Action-Reaction Observation guide – Rolling With Resistance Rolling With Resistance – Knowledge and Skills Checklist Knowledge and Skills Checklist Info on Continuing Education Credit for RD's MI Skills Evaluation Tools Training Packet for RD's (sample) – Goals Checklist Goals Checklist – Peer Review Documentation Form Peer Review Documentation Form MI Tip of the Week

Thank you!!