1. Hertfordshire Diabetes Conference 2016
Behaviour change: a motivational interviewing approach to consultations
Hertfordshire Diabetes Conference 2016

2. Aims of the session
To gain a greater appreciation of the practical potential for Motivational Interviewing within routine clinical care
To reflect on current practice around supporting behaviour change
To practice core MI skills in relation to a patient consultation
To find out about options for further skill development

3. What is motivational interviewing?
MI is a collaborative, goal-orientated style of communication which pays particular attention to the language of change. It’s aim is to strengthen personal motivation and commitment to a specific goal (like increasing physical activity) by exploring the person’s own reasons for change in an atmosphere of acceptance and compassion.
Features of MI
MIs style is conversational and pays particular attention to language
It’s a shared decision making conversation
It’s collaborative and solution focused
EQUALITY- They are the expert in their own behaviour but you have the skills and knowledge to help them!

4. Motivational interviewing in action
2 video clips:
How not to do it: Prescriptive Approach to Sharing Risk Message “Health Profession has the Solution” (2.5mins)
How to do it:Using MI to share risk message (3.5 mins)
These video clips demonstrate a prescriptive approach to the consultation and then an MI approach, we can discuss the differences and then we will have a look at the skills involved in MI in more detail.

5. THE PRINCIPLES OF MI
RESIST THE RIGHTING REFLEX UNDERSTAND / EXPLORE CLIENTS’ MOTIVATIONS LISTEN WITH EMPATHY EMPOWER THE CLIENT, ENCOURAGE OPTIMISM SUPPORT SELF EFFICACY
Righting reflex –
how easy is it to tell someone the benefits of change and why it’s important?
Give advice on what will happen if they don’t change, the risks?
What results do you get from this?
It is natural for those in a ‘helping’ role to want to make things right – to help - but we must resist to avoid resistance
 If your approach is confrontational, too persuasive or argumentative:
 i.e. “Why don’t you do this…” or “”Have you tried doing that…”
 And you side strongly with the behaviour change
 Changing diet/being more active/losing weight
Client is forced to take the opposite side of their ambivalence (i.e. to defend their current behaviour) to avoid cognitive discomfort and gain cognitive balance
In MI we want to maximise motivation and empower the client to change.

6. Ambivalence Unsure……in two minds
Passing through ambivalence is a natural state
People get stuck – sometimes for years!
Identify when behaviour is inconsistent with the client’s goals or ambitions.
With MI we don’t necessarily wait for the client to be ready for change
Focus where there is a discrepancy between their values i.e. I don’t want to smoke and their current behaviour i.e. smoking.
It’s very hard to be resistant to someone who is trying hard to understand you.
Eliciting Change is like climbing a mountain where our client is the climber and we are the guide.
A guide can’t take you up the mountain, he/she can’t make those steps for the client.
The guide can only suggest when to rest, what to eat, what to wear, what has helped others climb.
Most importantly, the practitioner holds the confidence the client will ultimately succeed

7. Core Skills
Open ended questions Affirmations Reflections Summaries

8. Open ended questions Examples:
What would be your best reason for making this Change?
What might you hope to gain from making this change?
How confident are you in making this change?
What could help with your confidence?
What specifically will you do?
What might get in the way of you making this change?
When do you think you might start?
Opened ended questions are something that I am sure you have come across before, they are questions that do not require an yes/no answer and offer the opportunity to gain more information from your clients. It is helpful just to touch on this as a refresher as it is one of the key skills in MI:
Some examples of other open ended questions:
How might you best go about that?
What would that be like for you?
What are your thoughts?
What strengths do you have?
Looking forward 1-2 years, how would you like your life to be?
Where should the focus of our conversation be today, to make it as helpful as possible for you?

9. Exercise – Open ended questions
“The wise man doesn’t give the right answers, he poses the right questions.” - Claude Levi-Strauss
In your groups of three conduct a short consultation on a health related issue. Take turns in the role of practitioner, client and observer
Imagine this is the first time you have met the client and use open ended questions to illicit information.
Observer to note how many open/closed questions asked.

10. Affirmations Noticing what is right about someone
A recognition of strengths, values, effort…
Look for change talk!
Examples:
I can see you are really trying to stop smoking even though you are finding it challenging….
You are someone who can stop smoking – you managed to quit for three weeks…..
You are the kind of person who cares a lot for other people….
It can be easy to miss the positive things that people tell us and focus on the negatives e.g.. I tried to lose weigh before but put it back on again….
By noticing the positives we have the opportunity to build people confidence and self-esteem in relation to behaviour change. E.g. so you lost weight before, that’s fantastic and you clearly done well, tell me more about that…..
It is really important that as professionals we believe that the client can be successful. If we believe it then so will they…..

11. Reflections Key element of empathic listening – requires practice
Aims to check your understanding
Make the person feel heard and understood.
Encourages them to keep talking.
Simple reflections – changing one or two words
Complex reflections – paraphrasing, metaphor
This is one of the more challenging MI skills and it requires a bit of practice as we are not generally used to reflecting what people say.
So the aim is to use the clients words or sentiments to check our understanding and get the client to share more information.
We are going to practice with a few simple reflections

12. Exercise - Reflections
In threes take it in turns:
Client - read out the statements
Practitioner – create a simple or complex reflection
1) “But I can't quit smoking. I mean, all of my friends smoke!”
2) “I feel like it’s so difficult to avoid eating snacks at work”
3) “I know I should exercise, it’s just that I can’t seem to start”
4) “I only drink alcohol in the evenings, it helps me relax”
5) “I don’t see the point of doing more exercise”
6) “My husband is always nagging me about my drinking, always calling me an alcoholic. It really bugs me.”
Example answers:
So when you are out with your friends you find it difficult not to smoke….
When you’re at work you find it difficult not to snack…
You are finding it difficult to start exercising…
You find having a drink in the evenings relaxing….
You feel that you are doing enough exercise already….
You find it upsetting when your husband raises the subject of alcohol….
Ask each table to feed back on one reflection.

13. Summaries Use periodically to provide feedback and check understanding
Helpful before changing direction/topic
Helps people hear what they have said
Can help people feel listened to and understood
At key points in the consultation it is helpful to check your understanding with the client. Summaries should be brief and give the client the opportunity to add more information or correct any misunderstandings.
An example might be: So if I understand correctly, you would like to lose weight, you lost 2 stone successfully before and maintained this for 9 months. You have put the weight on again and are concerned about your health and would like some support to lose weight again, is that right?

14. Exercise
Bob is a 54 year old factory worker with type 2 diabetes. He is overweight, has a poor diet, and struggles to manage his blood sugars. He is concerned that his health is deteriorating. He has tried to lose weight before with limited success. He is married with two children; his daughter is getting married in three months and he wants to lose weight before the wedding.
In groups of three take it in turns to conduct a consultation:
Client – take the role of Bob
Practitioner – conduct a 5 min consultation with Bob using MI skills
Observer – use RULES and OARS checklist
Put responses on flipchart.

15. Discussion How did you find using the MI core skills?
What are you going to take back into your own practice?
Action Plans
Note responses on flipchart

16. Next steps? Consider using MI in your consultations
Think about the skill mix in your team
Consider further training needs
Communication is key to success
Health Psychology in Public Health Network
Commit to your action plan

17. References
Miller, W. R., & Rollnick, S., (2013). Motivational interviewing: Helping people change. New York: Guilford Press.
BMJ online MI module:
Motivational Interviewing Network of Trainers (MINT)
Health Psychology in Public Health Network

18. Thank you!