1. Motivational Interviewing in the Primary Care Setting Presented by: Jonathan Betlinski, MD Date: 02/26/2015

2. Disclosures and Learning Objectives Learning Objectives: Know the 6 Stages of Change Know the 1 goal of Motivational Interviewing Know the 3 parts of the Spirit of MI Know the 4 principles of MI Know the 4 core communication skills of MI Disclosures: Dr. Jonathan Betlinski has nothing to disclose except his profound gratitude to the late Jon Emerson, LCSW, for his mentoring in teaching this topic. Some of these slides are from a lecture of his.

3. Motivational Interviewing in Primary Care Review the history of MI Review the basic elements of MI Discuss the impact of MI in the Primary Care Setting Discuss clinical scenarios in which MI may be helpful Reveal next week’s topic

4. Motivational Interviewing: History Originally developed for use in Addiction First described in 1983 article Miller and Rollnick published 2 nd Edition in 2002 By 2013, more than 3,000 formally trained More than 3 million clients in 47 languages Number of studies doubles every 3 years Now listed in SAMHSA’s NREPP http://nrepp.samhsa.gov/ViewIntervention.aspx?id=346 http://www.a-healthcoaching.com/docs/motivational-interviewing-in-primary-care.pdf

5. Motivational Interviewing: Current Uses Sexual Health Dietary Change Weight Loss Voice Therapy Gambling Promote Physical Activity Medication Adherence Fibromyalgia http://www.a-healthcoaching.com/docs/motivational-interviewing-in-primary-care.pdf Diabetes Chronic Leg Ulceration Criminal Justice Stroke Rehabilitation Chronic Pain Self-Care Domestic Violence Mental Health

6. Stages of Change The Transtheoretical Model posits a series of steps to adopting healthy behaviors 1.Precontemplation 2.Contemplation 3.Preparation 4.Action 5.Maintenance 6.Relapse www.cpe.vt.edu/gttc/presentations/8eStagesofChange.pdf http://www.socialwork.career/2013/02/motivational-interviewing-client_20.html

7. Stages of Change http://www.socialwork.career/2013/02/motivational- interviewing-client_20.html

8. Motivational Interviewing: Definition Motivational interviewing is “a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” --Rollnick & Miller (1995) Emerson

9. Motivational Interviewing: Definition Motivational interviewing is “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” --Miller and Rollnick (2002) http://www.a-healthcoaching.com/docs/motivational-interviewing-in-primary-care.pdf

10. Motivational Interviewing: Definition Motivational interviewing is “a person-centered method of guiding to elicit and strengthen personal motivation for change.” --Miller and Rollnick (2009) http://www.a-healthcoaching.com/docs/motivational-interviewing-in-primary-care.pdf

11. Motivational Interviewing: Goal The Goal of MI is simple: Behavior Change Commitment Not Capitulation http://www.a-healthcoaching.com/docs/motivational-interviewing-in-primary-care.pdf

12. Motivational Interviewing: The Spirit Collaboration (not confrontation) Counselor is a partner, not an authority Motivation for change is elicited, not imposed Task is to help client articulate and resolve ambivalence Evocation (not imposition) Draw knowledge out rather than imparting it The patient is the expert in their own lives Autonomy (not authority) Responsibility for change belongs to client The client presents the arguments for change http://www.ytporegon.org/content/spirit-motivational-interviewing

13. Motivational Interviewing: The Principles Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy http://www.a-healthcoaching.com/docs/motivational-interviewing-in-primary-care.pdf

14. Express Empathy Accepting the person, their situation, their point of view Respecting their explanations Reflective, nonjudgmental listening Avoiding criticism and blaming Support self-esteem Emerson

15. Develop Discrepancy Identify problematic behavior Remind of goals and values Ask for help in understanding – Columbo Be sincerely curious Use “so”, “if” reflectively Let client make the argument for change Emerson

16. Roll with Resistance Argument breeds defensiveness Go with the direction of the client’s argument Suggest new perspectives, but don’t insist on them “Take what you want, leave the rest” Emerson

17. Roll with Resistance Argument breeds defensiveness Go with the direction of the client’s argument Suggest new perspectives, but don’t insist on them “Take what you want, leave the rest” “Yes….and” Emerson

18. Support Self-Efficacy Believe in the client’s capability Explore strengths Highlight positive exceptions Emphasize small steps – realistic hope Maintain confidence and optimism Anticipate a different future Emerson

19. Motivational Interviewing: Core Skills Core MI Communication Skills – OARS Asking Open-ended Questions Making well-timed Affirmations Making frequent Reflective Listening Statements Using Summaries to communicate understanding http://www.ytporegon.org/sites/default/files/fileattachments/HelpDocForOARSYTPWebPage_0.pdf http://www.a-healthcoaching.com/docs/motivational-interviewing-in-primary-care.pdf

20. Motivational Interviewing: Inconsistent Items MI Inconsistent Items Unsolicited Advice, Direction-Giving or Feedback Emphasis on Abstinence Direct Confrontation of Client Emphasis on Powerlessness and Loss of Control Asserting Authority http://www.drugabuse.gov/blending-initiative/motivational-interviewing-assessment

21. Summary Motivational Interviewing is an effective way to elicit healthy behavior change The Spirit of MI is one of Collaboration, Evocation and Autonomy The Principles of MI include Expressing Empathy, Developing Discrepancy, Rolling with Resistance, and Supporting Self-Efficacy Remember to use your OARS skills

22. The End! Psychosis in the Primary Care Setting 03/06/15 http://proof.nationalgeographic.com/2015/02/04/photo-of-the-day-best-of-january-2/?source=photosite