Motivational Interviewing: An Introduction by Constance Brooks, Ph.D., PMHCNS- BC, PHCNS-BC Slides are based work of Miller and Rollnick and Tammy Day ( 2013) last modified (February,2014)

MOTIVATION: Early Concepts People are either motivated or not. If not, there is not much we can do about it. Motivated means agreeing with the helper. Confrontation is the best way to bring about change.

“Compliant” Agree with healthcare professional. Purchase health care insurance Expresses need for assistance and to make changes. Show distress about the situation. Compliant with treatment plan. Changes are made. Really careful to take good care of themselves.

“Non-Compliant” Disagreeing with the provider. Resisting a diagnosis/label. Refusing or declining help. Stating no need for assistance or change. Doesn’t follow treatment plan. Doesn’t make changes. Doesn’t care. No effort to obtain access to care

Discussion: 16 y/o F student who has come to you seeking help with losing weight Explain why the student should make the change. Give at least 3 specific benefits that would result from the change. Tell the student how to change. Emphasize how important it is to change. Emphasize what will happen if no change is made. Direct the student to do it.

How Did That Feel? Student perspective School Nurse perspective

Basic Human Nature It is basic human nature to resist direction, especially about something you are ambivalent about. It is also basic human nature to believe what we hear ourselves say.

The Spirit of MI Starts with Acceptance – Absolute worth – Affirmation – Autonomy – Accurate empathy Compassion : to have your heart in the right place so that trust you establish is deserved.

The Spirit of MI Collaboration vs. Prescription Evocation vs. Installation Requires a willingness to no longer operate from the authoritative role and begin to look at the person’s capacity vs. incapacity, with a genuine interest in his or her experience and perspective.

Stages of Change Contemplation Preparation We usually jump in here Action Pre-contemplationMaintenance

Four Basic Skills OARS Ask Open-ended questions-not short-answer, yes- no, or rhetorical questions. Affirm the person—comment positively on strengths, effort and intention. Reflect what the person says—active listening. Summarize—draw together the person’s own perspective on change.

Ambivalence If you argue for one side, an ambivalent person is likely to defend the other side. As a person defends the status quo, the likelihood of change decreases. Resist the urge to only take up the “good” side of ambivalence. Resist the reflex to provide a “fix” or solution.

Responding to sustain talk Sustain talk is the persons own motivation and verbalization to maintain the status quo. Don’t argue: pushing against what is important to the per son only gives fuel to the status quo. Strategic response of reflection, emphasizing autonomy and reframing.

Responding to sustain talk Some effective responses that tend to defuse resistance and refocus on change: – Reflection—acknowledge by reflecting back. – Amplified reflection—overstating a bit. – Double-sided reflection—on the one hand…and on the other… – Emphasize personal choice, ability to control and maintain autonomy.

Looking Forward If you don’t make any change, what do you think will happen? Where would you like to be in _____years? – What do you hope will be different? – An how does _____________ fit into that?

Giving Advice The person is more likely to hear and heed your advice if you have permission to give it. – Three forms of Permission: 1.The person asks for advice. 2.You ask permission to give it. – There’s something that concerns me here. Would it be all right if I….? – Would you like to know….? – I could tell you some things other persons have tried that worked… 3.You preface your advice with permission to disagree/disregard. – This may or may not be of interest to you…. – I don’t know how you’ll feel about this…. – Tell me what you think of this... It is better to offer several options, rather than suggesting only one.

Stages of Change: Using an MI Approach Preparation Contemplation Action Pre-contemplation Maintenance Explore Concerns Explore Ambivalence Explore Goals Explore Strategies Provide support & encouragement Support/Encourage Anticipate Relapse

Change Talk Counsel in a way that invites the person to make the arguments for change. Common dimensions to ask about (DARN-C) – Desire—want, prefer, wish. – Ability-able, can, could, possible. – Reasons-specific arguments for change—why do it? What would be good? – Need-important, have to, need to, it matters. – Commitment Language (the goal/action plan): this predicts actual change.

Eliciting Change Talk The simplest way: Ask for it, in open-ended questions to elicit desire, ability, reasons, need. – In what ways would it be good for you to? – If you decide to……., how would you do it? – What would be the good things about….? – Why would you want to…….? The balance: What are the good things about ____ and what are the not so good things?

Responding to Change Talk When you hear change talk, don’t just sit there!!! – Reflect it—Restate it back to the patient. – Ask for examples/elaboration: when was the last time, in what ways, – Ask for more: What else? What other reasons? – Affirm change talk-reinforce, encourage, support it. – Summarize—”collecting flowers into a bouquet”

TIME TO TAKE ACTION Time to elicit patient/person commitment. Setting a specific goal will help patient/person stay on track and accountable. Be specific: what, when, who, where & how? Set a confidence level. TAKE NOTES AND FOLLOW-UP! If the patient/person knows you are concerned enough to follow-up, their motivation will be propelled!

Practice A 16 year old girl has come to you for help in losing weight. She opens the conversation with the following statement: I hate being fat. Everybody makes fun of me. Engage this student in conversation applying principles of MI

Four Basic Skills OARS Ask Open-ended questions-not short-answer, yes- no, or rhetorical questions. Affirm the person—comment positively on strengths, effort and intention. Reflect what the person says—active listening. Summarize—draw together the person’s own perspective on change.

DISCUSSION