05/12/2014
1
McKenzie Institute Mechanical Diagnosis and Therapy
Practitioners (MIMDTP) one day conference.
November 2014
The role of Motivational Interviewing in promoting behaviour
change
Dr Jeff Breckon PhD., C.Psychol., AFBPsS., SFHEA
Reader in Exercise Psychology
Themes
• Issues and myths of [PA] behaviour change
• Behaviour change counselling interventions
• Motivational interviewing
– Relational
– Technical
– Four processes
– Psycholinguistics of change (CT/ST)
• Where next?
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ISSUES OF [PA] BEHAVIOUR
CHANGE
ITS COMPLICATED!
4
www.employeewellnessnetwork.com
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“Over 75% of individuals do not maintain behavior
changes in multiple areas of behavior including
substance use, smoking, physical activity, nutrition, and
management of chronic physical and mental health
conditions”
(Naar-King, Earnshaw & Breckon, 2013)
PHYSICAL ACTIVITY (PA) specifically
• Multiple conditions (e.g. smoking, alcohol, diet)
• Requires significant effort
• It is a 'complex intervention'
• Success is dependant on environmental and social
factors as well as personal 'engagement‘
• ‘Positive contamination’
• Seasonality
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INFORMATION IS NOT ENOUGH:
ITS HOW YOU PRESENT INFORMATION THAT
MATTERS…
60%20%
BEHAVIOUR CHANGE COUNSELLING
INTERVENTIONS
The role of the health professional:
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Client outcomes before and after random
reassignment to a new counsellor
0
5
10
15
20
25
30
35
40
45
50
1 2 3 4
% Positive Urines
35
37
39
41
43
45
47
49
1 2 3 4
Methadone Use
30
35
40
45
50
55
60
1 2 3 4
% Employed
0
1
2
3
4
5
6
1 2 3 4
% Arrested
McLellan et al (1988) Journal of Nervous and Mental Disease, 176, 423-430.
Clinician effects
• Substantial empirical evidence indicates that clinicians account for a significant portion of outcome in behavioural and psychosocial treatments
• In fact, one of the best predictors for how well clients will do after behavioural interventions is which clinician they have
Moyers (2013)
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"We need to move beyond just a brand name"
(Terri Moyers)
MI
BAT
CBT
ACTIVE INGREDIENTS?
SFT
550 named behavioral therapies…
knowing the identification of core
components (that are part of many
successful interventions) is critical
(Fixsen, 2005)
MOTIVATIONAL INTERVIEWING
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A technical definition of MI
“Motivational interviewing is a collaborative, goal
orientated style of communication with particular
attention to the language of change. It is designed
to strengthen personal motivation for and
commitment to a specific goal by eliciting and
exploring the person’s own reasons for change
within an atmosphere of acceptance and
compassion.” (Miller & Rollnick, 2012)
A technical definition of MI
“Motivational interviewing is a collaborative, goal
orientated style of communication with particular
attention to the language of change. It is designed
to strengthen personal motivation for and
commitment to a specific goal by eliciting and
exploring the person’s own reasons for change
within an atmosphere of acceptance and
compassion.” (Miller & Rollnick, 2012)
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OR…
"MI with someone is like entering their home. One
should enter with respect, interest and kindness,
affirm what is good, and refrain from providing
unsolicited advice and rearranging their
furniture. “
(An Alaskan elder reflecting on an MI workshop by Steve Berg-Smith)
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MI
MI Spirit
Change
(and
Sustain)
Talk
MI Processes
MI Micro
skills
(OARS)
The Elements of Motivational Interviewing
Collaboration Acceptance
Compassion Evocation
MI Spirit
Adapted from Miller & Rollnick (2012)
MI
Spirit
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MI Micro skills
(OARS)
– Open ended questions
– Affirmations
– Reflective listening
– Summarising
OQs• Disadvantages of the Status Quo
• Advantages of Change• Optimism for Change• Intention to Change
1. What the client
means
2. Words the client
says
3. Words the practitioner hears
4. What the practitioner
thinks the client means
Four ‘+’ processesMI
Processes
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BENEFITS OF STAYING
THE SAME & COSTS OF
CHANGE
BENEFITS OF CHANGE &
COSTS OF STAYING THE
SAME
Sustain Talk
& (Discord)
Change TalkChange (and
Sustain) Talk
PREDICTOR
PRECURSOR
Sustain vs Change talk
• Desire
• Ability
• Reasons
• Need
• Commitment
• Activation
• Taking steps
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MI in physiotherapy and
rehabilitation?
• Lal & Korner-Bitensky (2013) Motivational
Interviewing: a novel intervention for translating
rehabilitation research into practice.
• Cheing et al (2014) Testing a path-analytic
mediation model of how motivational
enhancement physiotherapy improves physical
functioning in pain patients
• McGrane et al (2014) Addition of motivational
interventions to exercise and traditional
physiotherapy: a review and meta-analysis
WHERE NEXT?
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WHERE NEXT: VALUES MATCHING VS
STAGE MATCHING INTERVENTIONS(HUTCHISON, JOHNSTON & BRECKON, 2011)
Values card sort
1
6
2
7
34
1
09
8
5
1
61
5
1
4
1
3
1
2
1
1
1
91
8
1
7
20 21 22
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WHERE NEXT: IMPLEMENTATION
SCIENCE
SCIENCE TO SERVICE GAP
A key part of 'Implementation Science'
(Fixsen, 2010)
science service
SERVICE GAP
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The Challenge
• What is known is not what is adopted in the health sector
• What is adopted is not used with fidelity and good outcomes
for consumer
• What is used with fidelity is not sustained for a useful period
of time
• What is used with fidelity is not used on a scale sufficient to
impact on societal health problems
(Adapted from Fixsen, 2010)
WHERE NEXT: MI-CBT FOR
MAINTAINING BEHAVIOUR CHANGE
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CBT Maintenance Strategies and MI Integration (Naar-King, Earnshaw & Breckon, 2013)
Maintenance Strategy MI Integration
Managing the Goal Violation
Effect
• Avoid the term relapse
• Empathise with slips
• Elicit change talk about maintenance
• Consider an importance ruler
• Explore discrepancy between values/goals and slips Emphasise adoption of new behaviors
Flexible Goal Setting • Offer menu of options of short-term goals
• Develop a change plan’ for maintenance
• Consider a commitment ruler
Identifying Triggers and
Developing Coping Skills
• Ask for permission before engaging in treatment tasks
• Use Elicit-Provide-Elicit strategy when discussing rationales or providing information/advice
• Consider rulers for treatment tasks.
Supporting Self-Efficacy • Use affirmations instead of praise
• Ask open-ended questions to elicit confidence statements
• Consider an Affirmations Card Sort or a confidence ruler
• Avoid the ‘false-hope syndrome.’
Increasing Social Support • Use MI skills to increase motivation for social skills training or to address ambivalence about
engaging significant others
• Include specific plans for social support in the change plan for maintenance
• Consider addressing social support in each session in relation to specific treatment tasks.
Using Extrinsic Reinforcers • Use of MI skills to elicit the identification of internal reasons for maintenance
• Use Elicit-Provide-Elicit when discussing rationale
• Present reinforcers as a menu of options to support autonomy.
Information SourcesBreckon, J.D. (2014) Motivational Interviewing to promote physical activity and nutrition
behaviour change. In, Doing Exercise Psychology (M. Anderson & S. Hanrahan, Eds.). Human Kinetics, Champaign, Ill.
Breckon, J. D., Johnston, L. H. & Hutchison, A. (2008) Physical activity counseling content and competency: A systematic review. Journal of Physical Activity and Health, 5, 398-417.
Crust, L., Swann, C., Allen-Collinson, J., Breckon, J. & Weinberg, R. (2014) A phenomenological exploration of exercise mental toughness: Perceptions of exercise leaders and regular exercisers. Qualitative Research in Sport, Exercise and Health.
Hutchison, A., Breckon, J. D., & Johnston, L. H. (2009). Physical activity behaviour change interventions based on the transtheoretical model: A systematic review. Health Education & Behavior, 36, 829-845.
Johnston, L. H., Breckon, J. D. & Hutchison, A. (2008) Influencing Health Behaviour: Applying Theory to Practice. In, L. Dugdill, D. Crone and R. Murphy (Eds) Physical Activity and Health Promotion: Evidence-based Approaches to Practice. London: Blackwell
Miller, W.R & Rollnick, S. (2012) Motivational Interviewing: preparing people for change. London: Guilford Press.
Naar-King, S., Earnshaw, P. & Breckon, J. (2013) Towards a Universal Maintenance Intervention: Integrating Motivational Interviewing with Cognitive-Behavioural Strategies for Maintenance of Behaviour Change. Cognitive and Behavioral Practice, 27(2), pp.126-137.
Rollnick, S., Miller, W.R. & Butler, C. (2008) Motivational Interviewing in Health Care: Helping patients change behaviour. London: Guildford.
Rosengren, D. (2009) Building Motivational Interviewing Skills: A practitioner workbook. London: Guilford.
Scott, S., Breckon, J. & Copeland, R. (2014) Determinants and Strategies for Physical Activity Maintenance in Chronic Health Conditions: A Qualitative Study. Journal of Physical Activity and Health.
05/12/2014
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Online MI training programme - For more information
go to emit.zembl.com
Dr. Jeff Breckon
twitter: @jbreckon
THANKS FOR
LISTENING