INTRODUCTION TO MOTIVATIONAL INTERVIEWING Lynn S. Massey, LMSW Department of Psychiatry Department of Emergency Medicine University of Michigan

 Client centered approach is necessary but not sufficient for behavior change  Client centeredness – the relational component- based on the Spirit of MI (collaboration, evocation, autonomy, respect) and empathy  “It is not a goal unless it is a goal for the patient”  Change talk – the technical component – gives a voice to the person’s inner motivation based on what they value most The Basics of MI

We’ll practice the skills to listen so people can talk, and to talk so people can listen

 MI is not a set of methods to learn, but a therapeutic way of being and interacting with a person – not everyone will be able to do it  Spirit of MI is necessary for expert use, but not to begin to learn MI – spirit of MI can emerge from therapist-client interactions using the method  The extent of initial curiosity and willingness to learn MI seems to be a good predictor for speed and ease of acquiring MI skills SPIRIT OF MI

 Empathy – genuine curiosity about client’s perspective (understanding)  MI Spirit:  Collaboration – fostering power sharing in the interaction  Evocation – elicitation / acceptance / understanding of client’s own ideas about change  Respect Autonomy – active fostering of client perception of choice RELATIONAL COMPONENTS OF MI

 Motivation  “the probability that a person will enter into, continue, and adhere to a specific change strategy” or plan  Motivation is a dynamic state (of readiness to change)  Part of the clinician’s job  Occurs in an interpersonal context  “Noncompliance”, “resistance”, and “lack of motivation” are all partially due to therapists strategies ASSUMPTIONS OF MI

 Ambivalence  Is normal, acceptable and understandable  Helps clinician to appreciate the complexity of the individual and their situation  Is at the heart of motivation  Usually mistaken for resistance (yes, but…) ASSUMPTIONS OF MI

1.) Express empathy – acceptance of people as they are frees them to change whereas non-acceptance immobilizes the change process 2.) Develop discrepancy – between present behavior and broader goals and values; helping people get un- stuck 3.) Roll with resistance – avoid arguing for change; new ideas/goals/options are not imposed; used as a signal 4.) Support self-efficacy – belief in ability to change is a powerful predictor of change; counselor self-fulfilling prophesy 4 PRINCIPLES OF MI

 Open Ended Questions: “are you concerned about your health?” vs “to you, what are important reasons to cut down on your drinking?”  Affirmations: “It really sounds like you have been committed to being the best father you can.”  Reflective listening  Summary EARLY STRATEGIES: OARS

Learning Motivational Interviewing: Is a process of learning about and using strategies to boost problem recognition, motivation and strengthen commitment to change.

 Practitioners want to help! Leads to strong urge to correct behavior that is harmful – Righting reflex. But it is a natural human tendency to resist persuasion – Resist  The patients own reasons for change are much more powerful than ours – Understand  The answers regarding behavior change come from the patient – Listen  Outcomes are better when patient takes and active role in deciding on outcomes - Empower BASIC PRINCIPLES

Styles Guiding – “I can help you solve this for yourself” Directing – “I know how you can solve this problem, I know what you should do” Following – “I won’t push or change you, I trust your wisdom to do what is best for you” Skills Asking Listening Informing Styles and Skills may be mixed and matched COMMUNICATION SKILLS WITHIN A HELPING CONTEXT

 Behavior change is at the heart of most modern health care concerns (heart disease, obesity, depression, cancers, diabetes, liver disease, respiratory problems)  Most health care practitioners have conversations / encounters regarding behavior change in daily work  More attention has been on information vs how to approach (style) behavior change with the person MI INTEGRATION IN BEHAVIOR CHANGE COUNSELING

Brief Interventions in the ED

PRIMARY CARE

Key elements of brief interventions using motivational enhancement techniques (FRAMES): MI emphasizes: Developing a discrepancy between current behavior and future goals, Increase problem recognition, motivation and self efficacy A menu of possible options ADAPTED MOTIVATIONAL INTERVIEWING

1a. MI will increase client change talk 1b. MI will diminish client resistance 2a. The extent to which clients verbally defend status quo (resistance) will be inversely related to behavior change 2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change Are these propositions supported by data? YES IMPLICIT THEORY OF MI POSITS

SUMMARY OF RESEARCH LITERATURE  100’s of outcome studies meeting meta-analysis criteria have been conducted  Alcohol use, smoking, HIV, drugs, treatment compliance, gambling, diet and exercise  Strongest support found for substance use outcomes  Strong effects found for additive effect on MI to adherence, retention and outcome  Synergistic effect over time when used as a prelude to treatment

 In-person MI have been shown effective in primary care (reducing drinking by 20-30%) up to 12-months (Saunders et al., 2004; Moyer et al., 2002)  MI has been demonstrated to be effective across genders; effectiveness across ethnic groups is yet to be established (Poikolainen, 1999; Dunn et al., 2001)  Brief interventions among adolescents and adults in the ED setting show changes in consequences (Monti et al., 1999; 2001; Longabaugh et al., 2001) EFFECTIVENESS OF MI ALCOHOL PREVENTION

Contact information Lynn Massey, LMSW