1. Motivational Interviewing: Tools for Helping with Behavior Change WA AAP Population Health Forum – June 8, 2019
Alicia Dixon Docter, MS, RDN
University of Washington
Division of Adolescent Medicine/UW LEAH

2. Introductions
Introduce yourself to someone in the room you don’t know really well. Form teams of 3 – you will be working together during the session.
Name
Role
Where from
Pick one topic that you want to work on (personal or work); this will be used throughout
Reflect on topics, choose something you actually want to fix. Ex. organizing my schedule, improving communication on the team, morning routine.

3. Objectives
Discuss how motivational interviewing can be used to address ambivalence in patient care
Demonstrate at least one method to elicit change talk
Increase your ability to confidently use motivational interviewing techniques in your practice
Experiential

4. Case
Maria is a 16 year old coming to see you because parents are concerned about weight loss
You excuse parents from the room
Emphasize confidentiality when speaking with Maria alone
You begin to ask Maria questions. The responses are…
‘I don’t know’
Shoulder shrug
Now what?

5. MI: Helps Address Ambivalence
Feeling two ways about a thing
Common prior to and during habit change
For example:
Difficulty scheduling appointments
Missed appointments
Intervention plans not being followed
Goals of family have little substance
Treatment progress uneven
Family members not forthcoming

6. Transtheoretical Model of Change
Precontemplative
Learner sees no problem
Contemplative
Learner weighs the pros and cons
Preparation
To carry on as before or to change
Action
Put decision into practice
Maintenance
Actively maintaining change
Relapse
Returns to previous behavior
Transtheoretical Model of Change
Adapted from Prochasksa (1997)

7. What’s in a Successful Change Plan?
Communication – 7x 7ways
What’s in a Successful Change Plan?
Vision
Skills
Benefits
Resources
Action Plan =
Success
Missing
False Starts
Frustration
Resistance
Anxiety
Confusion
Adapted from Knoster, T. (1991)
RainbowSlide-Planning for Success.pptx AD

8. Principles of Motivational Interviewing
Collaborative
Evocative
Honor Autonomy
Instead of the expert clinician directing, there is an active collaborative conversation and joint decision-making process
Evoke from patients what they already have; activate their own motivation
Requires an acceptance that people can and do make decisions about the course of their lives

9. O.A.R.S. Build rapport Open ended question Summary statement
Affirmations Reflective listening
Summary statement
Throughout:
Ask permission
O.A.R.S is the cornerstone of Motivational Interviewing. (BTW way, all of this is in your notes)
Skills you likely already have
Essential for good rapport development
Backbone of MI
Before beginning – always ask permission
Example: is it OK if we take a few minutes to talk about your activity level today? Many other examples in your job aid that we are providing today.

10. O.A.R.S. Open-ended Questions
Invites person to reflect and elaborate
Helps to understand their internal frame of reference
Creates impetus for forward movement to help the person explore change
3 minutes
Cannot answer yes or no…
Instead of, “Are you making sure your child is physically active every day?” ask: “what activities do you enjoy with your child?”
Instead of, “Do you fix your child breakfast every morning?” ask: “what do you like to have for breakfast?”

11. Closed-ended vs Open-ended Questions
Did you…
Can you…
Will you…
Is it…
Open-ended
To what extent…
How often…
Tell me about…
What, if any,…
More examples

12. #1 Practice Open-ended Questions
Speaker: Describe what you are working on
Listener: Goal of understanding the dilemma. Give no advice.
Why might you want to make this change?
How might you go about it, in order to succeed?
What are three reasons to do it?
Observer: Reflect on interaction and provide feedback using worksheet as a guide.
How did it go?
What did you notice (body language, tone, likelihood of change)?
How did the speaker feel? How did the listener feel?
2-3 minutes each
How did this feel different? 12

13. O.A.R.S.: Affirmations Statements of recognition about strengths
Helps person feel change is possible
Point out strengths where only failure is perceived by individual
Consider partial successes
Use resistance
Examples:
I see you had breakfast once this week
Although you didn’t succeed, I saw how hard you worked
I see your struggling with this, but it’s shows you are interested in changing because you’re here
3 minutes
This is important to you vs. that is great that you are here.
I see that this is a difficult thing to talk about for you. A bit of struggle with how to answer my question shows that you are thinking about it! In fact, this is better than last week when you refused to talk with me.

14. #2 Practice Affirmations
Speaker: describe what you have tried so far even if it’s just one or two small things
Listener: Ask open-ended questions in order to uncover something positive & then affirm it. Listener needs to really focus.
Observer: Reflect on interaction and provide feedback using worksheet as a guide.
How did it go?
What did you notice (body language, tone, likelihood of change)?
How did the speaker feel? How did the listener feel?
3 minutes each
Talk about looking for something positive regardless of magnitude… i.e: showing up for the visit, having something for breakfast (vs. not having anything before), or even having a plan without even starting to change the behavior (walking after school with change of school schedule)

15. O.A.R.S.: Reflective Listening
Helps you understand what’s working or not
Statement, not question
Trust and rapport will deepen even if you don’t get it “right”
Ex.: “I hear you are making progress and taking a walk a couple of times per week”.
ALSO: If wrong or individual not ready to deal with, he/she corrects you and the conversation moves forward

16. Reflective Listening Starts with:
So…
Sounds like…
You…
So, one hand…But on the other…
Use 2-3 reflections before moving on to next question
Can be a skill to use when “stuck”
If you are right, emotional intensity of session will deepen.
If wrong or person not ready to deal with, they’ll correct you and the conversation moves forward

17. #3 Practice Reflective Listening
Speaker: Share with your group the reasons for the changes you want to make.
Listener: Each try a reflective response.
Observer: Reflect on interaction and provide feedback using worksheet as a guide.
How did it go?
What did you notice (body language, tone, likelihood of change)?
How did the speaker feel? How did the listener feel?
3 minutes each

18. O.A.R.S. Summaries
Communicates interest in the person and helps develop rapport
Can shift direction if necessary
How to do this:
Begin with announcement that you are about to summarize
Be selective and concise
Note ambivalence
Invitation to correct anything
End with an open–ended question
So you were nervous about coming here but you decided to try to have breakfast. Come up with good example -

19. #4 Practice OARS #3 Speaker: Describe what you are working on
Listener: Goal of understanding the dilemma using open-ended questions, affirmations, reflective listening and summaries. Refer to handout.
Observer: Reflect on interaction and provide feedback using worksheet as a guide.
How did it go?
What did you notice (body language, tone, likelihood of change)?
How did the speaker feel? How did the listener feel?
2-3 minutes each

20. Change Talk If you hear anything close to: Desire (want, like, wish)
Ability (could, can, might be able to)
Reasons (argue for change)
Need (ought to, have to, really should)
This will open the door to talk about commitment and possible plan/goals.
Listening for change talk:
Desire: I would like to keep up with my friends; I want to buy some fun clothes;
Ability: I could set my alarm 5 minutes earlier; Mom: I could set some breakfast items right when I get up; I might be able to walk to the bus
Reasons: I need to have more energy to stay up late; I would probably feel better if I ate lunch
Need: I must get some sleep; I really need to get some exercise
I really should eat breakfast (need) but I can’t get up (ability) = ambivalence
So it sounds like you are thinking about having breakfast, but you are wondering how to make that happen. Could we talk about this a bit more?

21. Elicit-Provide-Elicit (EPE)
Ask permission prior to beginning
Elicit - what the patient already knows and wants to know.
Provide - information in a neutral manner.
Elicit - the patient’s response to, interpretation of the information
Another tool: to be used when sharing information is the only option.

22. Case – an update You begin by engaging Maria using OARS
Weekly visits over the next few months have lead to…
Eating breakfast as well as more regular meals
Decrease in rate of BMI increase
Spending more time with friends
Significantly reduced household stress!

23. Reflections on patient care
MI takes practice
It’s easy to go back to ‘old habits’
Patient engagement is a good indicator of effective MI

24. How to engage in culturally appropriate care?
What aspects of MI fit with your patient population?
What things might not work?
How might the cultural background of your patients shape the clinical encounter?

25. Discussion/Questions
What was hard or easy about this session?
How can you see applying these skills?
Or changes that impact your team?

26. References References
Miller, WR and S Rollnick, Motivational Interviewing, 3rd edition, Guildford Press, 2013.
Prochaska, JO and Velicer, WF, The Transtheroretical Model of Health Behavior Change. Am J Health Promot, 1997, 12(1)38-48.
Questions until 4:00