1. Linda Carter Sobell, Ph.D., ABPP Nova Southeastern University
Using Motivational Interviewing Techniques to Help Patients to Change Risky/Problem Behaviours
Linda Carter Sobell, Ph.D., ABPP
Nova Southeastern University

2. Objectives
Learn how to construct a conversation with patients to influence their receptiveness to consider changing problematicor risky behaviours while not evoking resistance using Motivational Interviewing techniques

3. Constructing a Conversation with Patients
WHY USE MI TECHNIQUES? So patients feel comfortable discussing their risky problematic behaviours with you
HOW DO YOU APPROACH THEM?
Present information in non judgmental, neutral context about risks of continuing the behaviour vs. benefits of changing
INTENT: Increase a patient’s commitment to consider changing

4. Motivational Interviewing New Interviewing Style
FOR WHOM? Patients ambivalent about changing
WHY? To build rapport 
GOAL: Help patients explore and resolve ambivalence about changing
HOW: In a manner likely to increase a patient’s motivation to change
AIM: Elicit reasons for changing from patients vs. confronting or telling them to change

5. Motivational Interviewing
Patient-centered, directive method for eliciting intrinsic motivation to change, by exploring and resolving a patient’s ambivalence to change using reflective listening

6. Focus of Motivational Interviewing
Patient’s concerns and beliefs
Explore ambivalence about changing in manner that increases motivation to changing without invoking resistance
MI gives patients sense of empowerment

7. Motivational Interviewing
Developed early 1980s
Bill Miller (US) and Steve Rollnick (UK)
Initially for substance abusers
Why did it develop?
High dropout, high relapse rates, and poor outcomes

8. Motivational Interviewing: Common Currency
Over past 20 years, MI has had wide application to variety behavioural domains and patient populations
Today practitioners use MI with all types of patients and problems (e.g., dietary and medication compliance problems-- hypertension, asthma, insulin dependent diabetes to eating disorders to schizophrenia to flossing)
> 150 clinical studies
Today MI “COMMON CURRENCY” among Health Care Practitioners
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9. New View of Motivation Conceptualized As
STATE of Readiness to Change
Can vary from situation to situation
Dynamic, fluctuating and a modifiable state
Importantly, can be influenced by Practitioner’s interaction style

10. EMPATHY KEY MI FEATURE
WHY? High levels of empathy associated with positive patient outcomes
Key to expressing empathy through Reflective Listening
Listening in a reflective manner demonstrates an understanding of patients and validates their concerns
“It sounds like you are ambivalent about changing (insert behaviour)”

11. Focus: Eliciting Change Talk
HOW: Arguments for changing elicited from patients
You are (insert problem or concern), what will happen if you don’t change (insert behaviour) in (use time frame if you want)
Example 1: “You’re 55 & seem to be having difficulty breathing. What will happen in 5 years if you continue to smoke.
Example 2:“I sounds like you are not happy with having to take you insulin. What do you know about what might happen if you don’t take it regularly?

12. Tone of Motivational Interviewing
Nonjudgmental, nonconfrontational, empathic, supportive climate where patients can discuss good and less good things related to changing (insert behaviour).
Inquisitive Tone allows you to address discrepancies between what patients say and do without engendering defensiveness
“Help me to understand on the one hand you’re coughing, having trouble breathing and on the other hand you say cigarettes are not causing you any problems.”
RESPECTFUL APPROACH

13. Motivational Interviewing Two Key Components
STYLE: How you say it
CONTENT: What you say
Critical Components for influencing receptiveness to consider changing

14. STYLE: How You Say It
Use an Empathic, Nonjudgmental, Nonconfrontational, Supportive Manner

15. CONTENT: What You Say
“Do you floss?” vs. “What are the good and less good things about flossing?”
“Why are you still smoking?” vs. “It sounds like you are ambivalent about quitting.”

16. MI and Non-MI Comparison Exercise
Short Role Play Exercise: Compare and contrast effectiveness of talking with a smoker about quitting smoking using two interviewing approaches: Non MI and MI

17. 1st Role Play
90 seconds
Role Play #1: Divide into pairs; one person is Health Care Provider (HCP) and one is Patient (PT)
HCP: Read questions as they appear
PT: Answer in any way
Then we will evaluate how it felt
DO NOT GO TO ROLE PLAY #2

18. Therapist/ Health Care Practitioner
Patient seeing you for a routine visit and you noticed that on the medical history form they indicated they currently smoke cigarettes

19. Patient 25 years old and married Smoked for 10 years
Smokes about 1 pack a day
Eventually plans to quit, but currently not worried about smoking and it is not causing any problems

20. How Did It Feel? In One Word
Non-MI Scenario
Patient HCP

21. 2nd Role Play
90 seconds
Role Play #2: Keep same PT & HCP roles as 1st role play
HCP: Again read questions as they appear
PT: Answer in any way
Then we will evaluate how it felt

22. How Did It Feel? In One Word
MI Scenario
Patient TH/HCP

23. Health Care Practitioner Patient
MI Views Health Care Practitioner and Patient’s Relationship as Collaborative
Recognize patients’ ambivalence; Give patients advice so they can make better informed decisions; but ultimately the patients are responsible for changing
Health Care Practitioner
Patient

24. Simulated Patient Scenarios
First 2 scenarios with same patient
1st demonstrates non-MI interview
2nd demonstrates MI interview
After viewing both compare & contrast 2 interview styles

25. NON MI SCENARIO

27. MI SCENARIO

29. Which skit is more likely to result in the patient quitting smoking?
Why?

30. Workshop Focus Key MI Techniques
ASKING PERMISSION to discuss target change behaviour or for providing information about it
REFLECTING what patients say
NORMALIZING
Using DECISIONAL BALANCING
Using READINESS RULERS to assess readiness to change
Patients GIVE VOICE to changing

31. Asking Permission
“Do you mind if we talk about your (insert behaviour)”
Communicates respect for patients; more likely to get them talking about quitting
“Tell me a bit about your alcohol use, any quit attempts, how has it affected your health?”
“Would you be interested in learning more about how how alcohol can affect your hypertension?”

32. VALUE OF ASKING PERMISSION
Major MI technique with patients
Provides opportunity to discuss patient’s behaviour when not presenting problem (e.g., coming for physical or blood pressure check) and you want to talk about how exercise, diet, smoking can affect their overall health
Allows conversation to continue even if patient not thinking of changing
Respectful

33. Motivational Interviewing Creates an Understanding
of Why People
Do What They Do

34. Often Difficult to Understand Why Patients Continue to Engage In Problematic/Risky Behaviours
Practitioners mostly see negatives — death, health problems, divorces
Rarely, do we SEE or TALK about good things about the behaviour from patient’s perspective
MI recognizes that MOST behaviour has GOOD and LESS GOOD THINGS that maintain it

35. What Can be Done to Help Patients Consider Changing?
Get patients to explore their emotional attachment to their behaviour — to look at the good things they get from it and then the less good things
Remember they’re ambivalent!

36. Most People, Not Just Patients, Ambivalent About Changing
AMBIVALENCE critical concept in MI
Working with ambivalence is working with HEART of the problem
Ambivalence normal everyday occurrence
How many of you have ever made New Year’s Resolution?

37. AMBIVALENCE IS NOT Reluctance to do something
Heightened psychological conflict about choosing between two courses of action
Continue Behaviour vs. Changing Behaviour
Ambivalence difficult to resolve each side has costs & benefits

39. Ambivalence is a Powerful Emotion!
From the movie “Girl Interrupted”
Vanessa Redgrave (Psychiatrist): “How do you feel about your behaviour….?”
Winona Ryder (Client): “Ambivalent”
Redgrave: “That’s a pretty powerful emotion, let’s explore that together.”

40. Decisional Balancing
Helping Patients to
Consider Changing

41. Decisional Balancing
Can discuss problem risky behaviours without suggesting its a problem
Asking about good things creates SAFE context to then talk about “less good things”
Allows Practitioners to sound credible as they VALIDATE a patient’s behaviour (good things)
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42. Asking About Good and Less Good Things About Smoking
“Tell me some of the good things about insert behaviour.”
“Tell me some of the less good or not so good things about insert behaviour.”
“What will your life be like if you continue engaging in insert behaviour for the next 5 years?”
“How would your life be different if you did change?”

43. VALUE OF DECISIONAL BALANCING
Explores good things and less good things related to the problematic/risky behaviour
Addresses patient’s ambivalence about changing
Goal: Tip scale in favor of changing

44. READINESS RULERS Assessing Readiness to CHANGE
Definitely NOT Ready Definitely Ready To Change To Change

45. Using Readiness Rulers
On a scale from 1 to 10, where 1 is Definitely Not Ready to Change & 10 is Definitely Ready to Change, what # best reflects how READY you area at the PRESENT TIME to change? Patient says 5
On this same scale, where were you 6 months ago? Patient says 2
How did you go from 2 to 5 (# 6 mo-NOW)?
What would it take for you to change?
What would be best outcome if you change?

46. VALUE OF USING READINESS RULERS
Patients at different levels of readiness to change
Assess patient’s readiness to change
Helps Practitioners recognize and deal with a patient’s ambivalence
Allows patients to give voice to changing: “Where are you now. Where were you 6 months ago.”

47. Motivational Interviewing
Requires a Special
Type of Listening
of the Kind We Don’t Normally Do

48. REFLECTIVE LISTENING Primary way of responding to patients
After patient speaks Practitioner paraphrases the patient’s comments
“I get the sense that you are wanting to change, but are concerned about gaining weight”
“It seems there is a lot of pressure for you to change, but you are not sure you can do it because you have tried before. What have you tried before?”

49. REFLECTIVE LISTENING More Examples
“What I hear you saying is that insert behaviour is not causing you any problems now. What might it take for you to change?”
“So what I hear you saying is that you know that insert behaviour is not good for you, but you are not experiencing any serious consequences that you are aware of. What do you know about the long-term consequences of insert behaviour over the next 5 years?”

50. Normalizing
Communicates to patients that difficulty in changing is not uncommon — others have had similar experiences
“Many women report feeling like you, they want to quit for the health of their baby, but find it difficult.”
“That is not unusual, many people report making several attempts.”
“A lot of people are concerned about gaining weight when quitting.”

51. VALUE OF REFLECTIONS AND NORMALIZING
REFLECTIONS validate what patients are feeling
REFLECTING back what patients say indicates you understood what they said
NORMALIZING communicates that difficulty changing is not uncommon

52. Key MI Strategy Advice Giving
Often patients have little or misinformation about their behaviours
Advice or information presented in neutral, nonjudgmental manner can help patients make better more informed decisions about changing
Focus on positives if possible

53. Simple Advice “Being Told” vs. MI Advice Strategies
Traditionally, Practitioners encourage changing using Simple Advice
“If you don’t stop….. this will happen……health consequences”
Research shows effectiveness of simple advice very limited — only 5% to 10% people likely to change
WHY? Most people don’t like being “told what to do”
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54. MI Alternatives to Simple Advice
Offer relevant new information in neutral, nonjudgmental, sensitive manner
Ask Permission: “Do you mind if we spend a few minutes talking about your insert behaviour?
Ask: “What do you know about how behaviour affects your health?”
……your unborn child?”
……your teeth and gums?”

55. Focus on Benefits of Quitting

56. VALUE OF PROVIDING INFORMATION TO PATIENTS
Often patients have little or no information about changing
Can help patients make better informed decisions about changing
How information is presented can affect how it is received
Examples: “What do you know about….?” “Are you interested in learning more about…..?”

57. Research Shows
Effective and empathetic communication between Practitioners and patients leads to
Greater patient satisfaction
Greater compliance with medication and treatment and attendance
Reduced health care costs, and
Significantly improved clinical outcomes
Decreased malpractice litigation

58. MI Scenario Skills To Be Demonstrated
Asking permission to discuss risky or problematic behaviour(s)
Reflecting what the patient said
Normalizing
Using Decisional Balancing
Using Readiness Ruler to assess readiness to change
Asking patient to give voice to new goals
Asking permission to provide information

60. Your Turn
You will now have the opportunity to practice ALL the MI techniques you have seen today
Break into pairs
Each person will practice a brief negotiated interview using the MI Card and Readiness Ruler

61. What Stood Out Today?