1. Helping People Who Live with TBI to Make Positive Behavior Changes
29th Annual BIAMD Conference
March 23 – 24, 2017
Christine Higgins, M.A.
Member of MINT, Master Trainer

2. Learning Objectives - Understand how people make a behavior change.
- Learn new ways to engage people who are reluctant to make a change.
- Learn about three techniques that are known to be helpful in identifying barriers and increasing motivation: Open-ended Questions, Readiness Ruler & Value Card Sort.

3. A New Template: Person Centered Treatment
We consider a person’s “recovery capital.” What internal and external support does the person already possess that we can build on. We elicit and weigh pros and cons of current behaviors. We examine the patients personal values in relation to change. We elicit self-motivational statements of intent and commitment to change.

4. Show of Hands 1. Some knowledge of MI?
Familiar with Prochaska & DiClemente’s
Stages of Change?
You have an agenda when you meet with patients. You are providing a rehabilitative service.

5. They Wrote the Book
Bill Miller, the father of Motivational Interviewing
Authors of Motivational Interviewing: Helping People Change, Guilford Press, 2013
Steve Rollnick

6. The Basics of MI
MI is a client-centered, non-confrontational, directional method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. A counselor using an MI style expresses empathy, develops discrepancy, reduces resistance and supports client self-esteem. 6

7. The Advantages of MI
It’s more than a counseling technique, it’s a way of being.
We refer to MI as a dance. Moving with the client as the client moves, rather than creating an opposing force.
It’s nicely tailored to a brief intervention.
MI is being used by pastoral counselors, nutritionists, ER docs, probation officers, physical therapists.
It’s hopeful.
Clinicians at Thresholds in Georgetown, Del most frustrated by clients who are court-ordered have 3 DUIs, but say my problem is driving, not drinking. 7

8. How Do People Change?

9. The Paradox of Change
When a person feels accepted for who they are & what they do, no matter how unhealthy, it allows them the freedom to consider change rather than needing to defend against it.

10. Stages of Change Model Prochaska & Di Clemente, 1992
Now we’re thinking:
recurrence
Something moves that person into Contemplation. Think about people who come to see you. Where are they?
Prochaska & Di Clemente, 1992 10

11. The Stages of Change
Developed to help people stop smoking by Prochaska & Di Clemente, 1992
Precontemplation (raise awareness)
Contemplation (explore ambivalence)
Preparation (create a change plan)
Action (see if the change plan is working)
Maintenance (remain consistent/affirmation)
Recurrence (somewhat expected with chronic disease)
Originally designed for smokers. The average times people try to quit before they are successful? 7x 11

12. So let’s talk about what used to be called resistance…
What does it look like? Maybe… Raised voice Cursing Folded arms Scowling Hiding face with cap, hoodie, sunglasses Arriving late Monosyllabic Not showing up at all
…and now the term is “discord”

13. Dischord The new term to replace “resistance is discord”.
It means you and the patient are not in agreement. It is not one-sided. The discord comes from the two of you not agreeing.
In music, the term “dissonance” is used to define lack of harmony among musical notes.

14. Discord: It Takes Two
Maybe hang the image up in your office?

15. What do you hear? How long is this going to take?
My ride is waiting for me.
You don’t know what it’s like.
I don’t want to take medicine.
This is a waste of my time.

16. Is It Rejection?
A 'No' uttered from the deepest conviction is better than a 'Yes' merely uttered to please, or worse, to avoid trouble. Mahatma Gandhi

17. Ambivalence is normal!
What are some of the things you feel two ways about?
Which one of these activities is “better”. OR

18. MI Techniques:
An alternative to finger wagging, admonishment, negative consequences.
A way to handle patients who
are afraid to make a change.
Will they be better off or worse?
What else will be expected?

19. The Beauty of Open-ended questions
They can help when you’re stumped.
They invite exploration.
They help you avoid being the problem solver.
Consider:
Why are you so upset?
What’s one thing you can do today to….
If you could wave a magic wand, what would you want to
to be different?
Picture yourself a year from now, where would you like to be?

20. Eliciting Change Talk – Readiness Ruler
People tell us about their reasons for change, their desire for change, their need for change, their ability to change.
It not only helps us to assess readiness, it can also assess
importance, and confidence.
“How important is it for you to start an exercise program?
“How confident are you that you can quit drinking?” 1 2 3 4 5 6 7 8 9 10
Not at all
Moderately
Extremely 20

21. Guidelines for the Readiness Ruler10
Reflect the response: “So 6, somewhat strong.
Open-ended question: How come you didn’t say 4 or 5? Go down the scale first.
Look for opportunity to make an affirmation, “That’s smart thinking..
Go up the number scale, open-ended question: What would it take for you to be at a 7 or an 8?
Reflect the response, “So, in order for you to be at an 8, you would…”

22. Let’s See It in Action

23. What Did You Notice? “Why didn’t you say 5 or 6?”
You query by going down the number scale to elicit what the person has going for them, level of motivation, needs or abilities.
“What would take you to an 8 or 9?”
Then you go up the number scale to elicit what the person still needs to make the change.
Not pushing, person is doing the talking,

24. Value Card Sort 1.Get some index cards (15-30)
2.Write a subject on each card ( a value or a desire): Faith, Family, My children,
Free from drugs, No more headaches
On 3 cards: Very Important,
Important, Not Important
4. Two blank cards for patient
to include other priorities

25. Please Play Along Does everyone have an index card?
Write down a word (or a few words) that accurately represent what some of the needs or desires or values of the people you are trying to help.

26. Ask the person to sort the cards into the 3 piles
Ask the person to sort the cards into the 3 piles. There should be no more than 10 cards in the Very Important pile.
Ask the person to sort the Very Important
pile in order of importance 1-10.

27. Value Card Sort Very Important Important Not Important Live
Independently
Faith
Look Good
Friendship
Find meaningful
Work
Reliable
Transportation
Find medicines
that work for me
Good sex life
Be in Control
Family
Respect
Have people understand me
Money
Keep my benefits
Find a hobby

28. Dimensions of Wellness

29. If you found interest in these MI techniques, here are some add’l resources:
I have taught a 3 day class on Intro to MI