motivational interviewing: a client-centered approach to ... · and the “righting reflex” lack...

Motivational Interviewing:

A client-centered approach to health care

behavior change

Pamela J. Myhre APNP, CDEpmyhre@swtc.edu608-412-1751

Objectives

At the end of this session, the participant will:

Describe principles of motivational interviewingIdentify two interventions to use when counseling clients for health behavior changeFormulate MI adherent responses in guiding a client in decisions for health behavior change

And, can we use it in health care?

Evidence based

Used extensively:Alcohol treatmentSubstance abuse treatmentDiabetes behavior change

Inpatient & outpatientPrimary medical practice for exercise behaviorsInpatient women with bulemia

Across the age spectrum

Adolescents and polysubstance useCollege student drinkingAdults with hyperlipidemia– dietetic dept.

Disjointed?A Disclaimer!

Motivational Interviewing A Definition

“A client centered, directive method for enhancing intrinsic motivation to change by

exploring and resolving ambivalence”

Client-centered“A client centered, directive method for enhancing intrinsic motivation to

change by exploring and resolving ambivalence”

It’s all about me…“A client centered, directive method for enhancing intrinsic motivation to

change by exploring and resolving ambivalence”

So what is it NOT about? Why isn’t this person motivated?

For what is this person motivated?

So, as the interviewer:

Shup up and fishBe quietHold your tongueBite your tongueListenListenNodAffirmHmmmUh-huhOh…WAIT for them to say more

So….

Be quietHold your tongueListen – Listen - LISTEN

NodAffirm

WAIT for them to say more

YOU CAN SAY:

HmmmUh-huhOh…I seeAnd then,Tell me more…

A gal meets a guy on the road…

PIG!!!Witch!

A man is driving down a road. A woman is driving down the same road from the opposite direction. As they pass each other, the woman leans out the window and yells "PIG!!". The man immediately leans out his window and yells, "BITCH!!". They each continue on their way, and as the man rounds a curve he crashes into a huge pig in the middle of the road and dies . . . If men would only listen.

“Directive, but….” “A client centered, directive method for enhancing intrinsic motivation to

change by exploring and resolving ambivalence”

Guide Dance

Wrestle

Example:

Like a dance… but not like this…

“You should…”“You could…”“I want you to…”“You have to…”“Why don’t you…”“These are the things…”“Here is your medication…”“Take 2 in the morning…”“Test every day…”

It is crucial that we avoid the authoritarian role

Motivation“A client centered, directive method for enhancing intrinsic motivation to

change by exploring and resolving ambivalence”

Enhancing INTRINSIC motivation

What’s in it for them?How’s that working for you?

Listen for…

CHANGE TALK!“I want to…”“I should…”“I will…”“I’m going to do it for the kids…”

Exploring & Resolving Ambivalence“A client centered, directive method for enhancing intrinsic motivation to change

by exploring and resolving ambivalence”

Enhance & Amplify Ambivalenceand the “Righting Reflex”

Lack of motivation is often ambivalenceBoth sides are already within the personIf you argue for one side, an ambivalent person will likely _____________________________As the person defends the status quo, the likelihood of change____________RESIST the “righting reflex” – to take up the “good side” of the ambivalence

Enhance & Amplify Their Ambivalence!

So, on the one hand you…And on the other hand you…

Tell ‘em, time ‘em, introduce the topic

Motivational Interviewing Tools(You can pull these out to start… or when you’re stuck)

Circles

Motivational Interviewing Tools

RulersImportance RulerConfidence Ruler

On a scale of 0 to 10, with 0 being not at all important, and 10 being

extremely important….

On a scale of 0 to 10, with 0 being not at all confident, and 10 being 100%

sure of your ability…. How confident do you feel that you can…

Basic MI principles: O-A-R-S

Open-ended questionsAffirmReflective listeningSummarize

O-A-R-S Principle 1:

Open ended questions (start with):

What ….?When….?Who….?Where…?

Steer clear of:why… do… are…

I’m Curious...

O-A-R-S Principle 1:

Open-ended questionsGoal: Put the person in charge

“Tell me…“How would you like things to be different?”“What is it that you want to change?”“Let’s take things one step at a time. What do you think is the first step?”“How would your life be different if you pursued this goal and reached it?”“So that’s your goal. What can you think of that might go wrong with this plan?”“What do you make of that?”

O-A-R-S Principle 1: Practice

“Did you eat 5 fruits and vegetables this week?” (MI non-adherent)

“How many fruits and vegetables did you eat this week?” (Is this any better?)

O-A-R-S: Open-ended questions practice

O-A-R-S Principle 2:

AffirmGoal: Support strengths & efforts. Provide HOPE.

“Thank you so much for meeting with me today”

O-A-R-S Principle 2: Practice

C: “Well, I make sure the kids eat all the Krispy Kremes so I’m not tempted.”

I: “You think that is any way to raise your children?” (MI non-adherent)

O-A-R-S Principle 2:

Affirm with EmpathyGoal: Support person’s self confidence & self-efficacy

Remembering…If this is so good for us, why aren’t we all doing it?

If we empathize,we think about the barriers

So, what gets in your way?So, what might keep you from….?

O-A-R-S Principle 3:

Roll with resistance

WHEN YOU HEAR…I can’tI don’t knowSilenceI won’tIF onlyI just…

You’ve got resistance….

TAKE CARE not to respond with:

O-A-R-S Principle 3:

Roll with resistance

TAKE CARE not to respond with:

Arguing, disagreeing, challengingJudging, criticizing, blamingWarning of negative consequencesSeeking to persuide with logic or evidenceConfronting with authoritySarcasm or incredulityInterpreting or analyzing the “reasons” for resistance

O-A-R-S Principle 3:

“How can you help me? You don’t even know what it’s like to be fat?”

“Yes, I do. I went to weight watchers and lost 50 pounds.”

“This is about you, not me.”

“Trusting that I can help you is something you think about a lot.”

Doesn’t work

Raising resistance

Rolling with resistance!

O-A-R-S Principle 3: Roll with Resistance

Resist the urge to fix it! (righting reflex)

a. If you have an idea and they are quiet WAIT!b. If you have an idea - they seem ready - and ask

you…. Ask them back. c. If you have an idea – they seem ready – reflect

on their strength, decision, anything (affirm) d. If you have an idea… ASK a question to get to

that idea.e. If you have an idea… and it’s really time….

ASK permission!

O-A-R-S Principle 3: Practice

C: “But I really like Mountain Dew”I: “What about trying Crystal Light?”

(MI non-adherent – DON’T FIX IT)

O-A-R-S Principle 3: Roll with Resistance

C: “What should I do? I don’t know where to begin to stop smoking”

I: “Chantix is a good way to start”(MI non-adherent – DON’T FIX IT)

O-A-R-S Principle 4:

Listen reflectivelyGoal: Provide them with a mirror of what they are saying

Reflect the feelingEXAMPLE:

Reflect with metaphorEXAMPLE:

Practice responding reflectively…

“I just don’t know how I can lose weight again! I just… I know the Lord is with me as I’m trying… but the cost of food is just so much… to eat good is really expensive. And the kids need shoes and all the stuff for school. I have to buy backpacks and notebooks. And you know, the chips and cereal – well, it’s cheaper, and my fiancee just got out of the hospital, and I keep having these migraines….”

O-A-R-S: SummarizeGoal: Tie together SUCCINCTLY the pearls in the thread of

the conversation.

So, you’re feeling …. And you want to…. And you get stuck sometimes….

Have I got it all? ORAm I missing anything?

Summarize“Exactly! Once at a meeting we had a focus/research

group that was looking at our experiences with the bereavement process at the hospital. As this is a very sensitive topic, I thought it would be difficult to share my feelings. However, the leader of the group was so respectful and truly listened --it was honestly very therapeutic. After we finished our "story," she would say something like "So what I'm hearing you say is.....is this what you're trying to express?" That way she wasn't making an interpretation of what she THOUGHT we said. She summarized it, asked for clarity, and mirrored the info back to us. I felt completely supported and truly felt like I was heard. ”

To Summarize (for me…)

“I’m curious”SHUT UPAsk for permissionProvide HOPE

Confidence andImportance Rulers

________________________________0 – 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10

And thank them…

For comingFor tryingFor something!

“It might not be as bad as you think. People will try to help if you give

them a chance.” (MI non-adherent)

This person is trying… and attempting to provide hope… BUT

C: “I was in the store and feeling strong – I wasn’t going to get any junk food. Then I saw my old boyfriend and…”I: “So, you bought the Fritos and dip anyway” (MI non-adherent)

“Solving this at home – on your own hasn’t worked, so you’re finally

willing to ask for help?” (MI non-adherent)

“Yes, you are obese. You might not think so, but right here on the chart –

the statistics say so.” (MI non-adherent)

“Wait a minute. It says right here that your A1c is 12. I’m sorry, but

there is no way you could have been counting your carbohydrates like you

said if it’s that high.” (MI non-adherent)

“Don’t do that.” (MI non-adherent)

“Do… this….”

“Bring back this logbook next week.” (MI non-adherent)

How many Ds in…..