1. Tools that can be used Options Options Play soccer Increase veggies Decreasing TV time Play basketball Decrease candy Walk to school Increase fruits 1

2. Components of Motivational Interviewing Exploring ambivalenceExploring ambivalence –Pros and cons –Develop discrepancy Asking key questions Reflecting witnessed inconsistencies Summarizing 2

3. Components of Motivational Interviewing Assess individual change potential –Personal importance On a scale of 0-10... –Personal confidence On a scale of 0-10... –Personal readiness On a scale of 0-10... Affirming statements are very important! are very important! 3

4. Component s of Motivational Interviewing Assessments may include: –Alternative ways to measure Ruler, probing questions –Scaling questions What would it take to move you higher? Why not lower on the scale? 4

5. Components of Motivational Interviewing Negotiating a plan –Next steps and follow-up –Reaffirming confidence Summary and next steps –Summarize pros and cons of change So what I heard you say is that… –Possible next steps What might be a good first step for you and your child? What might you do in the next week to help move things along? 5

6. Motivational Interviewing Process Establish Rapport ↓ Set an Agenda ↓ Assess Importance Readiness Confidence Explore Importance Build Confidence Miller & Rollnick, 1991. Motivational Interviewing: Preparing people to change addictive behaviors. 6

7. Assess importance & confidence 7

8. Strategies Based upon Readiness to ChangeBased upon Readiness to Change Based upon Importance of ChangeBased upon Importance of Change Based upon Confidence in Ability to ChangeBased upon Confidence in Ability to Change 8

9. Precontemplation Patient does not perceive behavior as a problem Tasks in Precontemplation 1.Establish discrepancy between goals & behavior 2.Increase the perception of risk of behavior As your healthcare provider, I need to tell you that am worried about your blood pressure and weight. With your family history you are at risk for diabetes. 9

10. Precontemplation: Increase perception of risk 10

11. Contemplation Perceives behavior as problem but not ready to change so may defend behavior. Tasks in contemplation: 1.Elicit pros and cons 2.Evoke reasons for change 3.Explore risks of not changing 4.Strengthen self efficacy for change If you decided you were going to change what would that look like? What would be the benefits? What would make it difficult? 11

12. Contemplation: Evoke reasons for change & Strengthen self efficacy 12

13. Preparation for Action Patient perceives problem and is concerned but cannot change on own. Tasks in Preparation for Action: 1.Negotiate alternatives 2.Help determine the best plan What I hear you saying is that if you continue to gain weight your clothes won’t fit and other kids will continue to make fun of you. You would really like to lose some weight before school starts. 13

14. Preparation for Action: Negotiate Alternatives 14

15. Action The patient is ready to try something new to change the problem behavior. Tasks in the Action Stage: 1.Assist the person in changing. 2.Problem solve. 3.Identify road blocks. So you think that it might work for you to cut back on the soda and walk home from school three times a week. 15

16. Action: Identify Barriers 16

17. Maintenance Maintaining change involves building a new, supportive behaviors that “fill the gaps” left by reduction of problem behavior Tasks in the Maintenance Stage: 1.The goal is relapse prevention. 2.Identify risks of relapse. 3.Help client achieve stable change. 17

18. Maintenance: Relapse Prevention 18

19. Relapse A return to old, problem behavior Tasks in Relapse Stage 1.Debrief the client. What went wrong? What was working? 2.Help client refocus on change. 3.Identify, clarify, and resolve ambivalence. 19

20. General Strategies: Open-ended Questions Establish an atmosphere of acceptance 1.Tell me about your eating? 2.Describe a typical day? 3.What concerns you about your current pattern? 20

21. Open–Ended Questions 21

22. General Strategies: Listen Reflectively Summarize what you heardSummarize what you heard Create a hypothesisCreate a hypothesis 3:1 ratio3:1 ratio 3 reflective statements for each open ended question 1.What I hear you saying is… 2.Do you mean? 3.Repeating 4.Rephrasing 5.Paraphrasing 6.Reflection of feelings Any self motivational statement should be reflected! 22

23. General Strategies: Affirm the Patient Without hope little change is likely Emphasize patient has control Exploring self-efficacy can help identify resistance Reflective listening is affirming 23

24. Affirm the Patient 24

25. Strategies: Summary Statements Patient hears their motivation for change againPatient hears their motivation for change again Components of summary statementComponents of summary statement 1.Problem recognition 2.Concerns 3.Reasons for change 4.Optimism about change 5.Ambivalence 6.End with “what have I missed? 25

26. Strategies: Summary Statements 26

27. Strategies: Elicit Motivational Statements Patient presents the argument for changePatient presents the argument for change ComponentsComponents 1.Problem recognition 2.Expression of concern 3.Intent to change 4.Optimism about change 27

28. Strategies: Eliciting Change Talk Ask evocative questionsAsk evocative questions –What else have you noticed? –Why else could you succeed? Assume ambivalenceAssume ambivalence –Elicit pros and cons of change Pull for elaboration once change has been raised.Pull for elaboration once change has been raised. –Give me an example. –How else is this a problem? 28

29. Strategies: Eliciting Change Talk Use extremesUse extremes –What concerns you the most? –What’s the best that could come of this? Change perspectivesChange perspectives –Looking back before the problem emerged… –Looking forward to envision the future… Explore goalsExplore goals –Develop discrepancy Side with the negativeSide with the negative – By suggesting not changing, –the patient has to verbalize reasons for change 29

30. Eliciting change talk 30

31. Resistance Resistance is normalResistance is normal –Degree is determined by counselor style –Problematic when pattern emerges CategoriesCategories –Arguing –Interrupting –Denying –Ignoring 31

32. Resistance 32

33. Strategies for Handling Resistance Simple Reflection Amplified Reflection Double-sided Reflection Agreement with a twist Reframing Shift Focus Emphasize Personal Responsibility & Control Paradox 33

34. Mapping the Change Process If the client is:If the client is: Arguing Interrupting Denying the problem Ignoring the counselor Strategies to Handle ResistanceStrategies to Handle Resistance Reflection Reframe Shift focus Emphasize personal control Paradox If the client is talking aboutIf the client is talking about Problem recognition Concern re. the problem Intent to change Optimism about change Then use strategies to elicit change talkThen use strategies to elicit change talk Evocative questions Pull for elaboration Use extremes Change perspectives Explore goals Side with negative 34