introduction to motivational interviewing lynn s. massey, lmsw department of psychiatry department...
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INTRODUCTION TO MOTIVATIONAL INTERVIEWING
Lynn S. Massey, LMSWDepartment of Psychiatry
Department of Emergency MedicineUniversity of Michigan
Client centered approach is necessary but not sufficient for behavior change
Client centeredness – the relational component- based on the Spirit of MI (collaboration, evocation, autonomy, respect) and empathy
“It is not a goal unless it is a goal for the patient” Change talk – the technical component – gives a
voice to the person’s inner motivation based on what they value most
The Basics of MI
We’ll practice the skills to listen so people can talk, and to talk so people can
listen
MI is not a set of methods to learn, but a therapeutic way of being and interacting with a person – not everyone will be able to do it
Spirit of MI is necessary for expert use, but not to begin to learn MI – spirit of MI can emerge from therapist-client interactions using the method
The extent of initial curiosity and willingness to learn MI seems to be a good predictor for speed and ease of acquiring MI skills
SPIRIT OF MI
Empathy – genuine curiosity about client’s perspective (understanding)
MI Spirit: Collaboration – fostering power sharing
in the interaction Evocation – elicitation / acceptance /
understanding of client’s own ideas about change
Respect Autonomy – active fostering of client perception of choice
RELATIONAL COMPONENTS OF MI
Motivation “the probability that a person will enter
into, continue, and adhere to a specific change strategy” or plan
Motivation is a dynamic state (of readiness to change)
Part of the clinician’s job Occurs in an interpersonal context “Noncompliance”, “resistance”, and “lack
of motivation” are all partially due to therapists strategies
ASSUMPTIONS OF MI
Ambivalence Is normal, acceptable and understandable
Helps clinician to appreciate the complexity of the individual and their situation
Is at the heart of motivation
Usually mistaken for resistance (yes, but…)
ASSUMPTIONS OF MI
1.) Express empathy – acceptance of people as they are frees them to change whereas non-acceptance immobilizes the change process2.) Develop discrepancy – between present behavior and broader goals and values; helping people get un-stuck3.) Roll with resistance – avoid arguing for change; new ideas/goals/options are not imposed; used as a signal4.) Support self-efficacy – belief in ability to change is a powerful predictor of change; counselor self-fulfilling prophesy
4 PRINCIPLES OF MI
Open Ended Questions: “are you concerned about your health?” vs “to you, what are important reasons to cut down on your drinking?”
Affirmations: “It really sounds like you have been committed to being the best father you can.”
Reflective listening Summary
EARLY STRATEGIES: OARS
Learning Motivational Interviewing: Is a process of learning about and using strategies to boost problem
recognition, motivation and strengthen commitment to
change.
Practitioners want to help! Leads to strong urge to correct behavior that is harmful – Righting reflex. But it is a natural human tendency to resist persuasion – Resist
The patients own reasons for change are much more powerful than ours – Understand
The answers regarding behavior change come from the patient – Listen
Outcomes are better when patient takes and active role in deciding on outcomes - Empower
BASIC PRINCIPLES
StylesGuiding – “I can help you solve this for yourself”Directing – “I know how you can solve this problem, I know what you should do”Following – “I won’t push or change you, I trust your wisdom to do what is best for you”
SkillsAsking Listening Informing
Styles and Skills may be mixed and matched
COMMUNICATION SKILLS WITHIN A HELPING CONTEXT
Behavior change is at the heart of most modern health care concerns (heart disease, obesity, depression, cancers, diabetes, liver disease, respiratory problems)
Most health care practitioners have conversations / encounters regarding behavior change in daily work
More attention has been on information vs how to approach (style) behavior change with the person
MI INTEGRATION IN BEHAVIOR CHANGE COUNSELING
Brief Interventions in the ED
PRIMARY CARE
Key elements of brief interventions using motivational enhancement techniques (FRAMES):
MI emphasizes:Developing a discrepancy between current
behavior and future goals,Increase problem recognition, motivation
and self efficacyA menu of possible options
ADAPTED MOTIVATIONAL INTERVIEWING
1a. MI will increase client change talk 1b. MI will diminish client resistance 2a. The extent to which clients verbally defend
status quo (resistance) will be inversely related to behavior change
2b. The extent to which clients verbally argue for change (change talk) will be directly related to behavior change
Are these propositions supported by data? YES
IMPLICIT THEORY OF MI POSITS
SUMMARY OF RESEARCH LITERATURE
100’s of outcome studies meeting meta-analysis criteria have been conducted
Alcohol use, smoking, HIV, drugs, treatment compliance, gambling, diet and exercise
Strongest support found for substance use outcomes
Strong effects found for additive effect on MI to adherence, retention and outcome
Synergistic effect over time when used as a prelude to treatment
In-person MI have been shown effective in primary care (reducing drinking by 20-30%) up to 12-months (Saunders et al., 2004; Moyer et al., 2002)
MI has been demonstrated to be effective across genders; effectiveness across ethnic groups is yet to be established (Poikolainen, 1999; Dunn et al., 2001)
Brief interventions among adolescents and adults in the ED setting show changes in consequences (Monti et al., 1999; 2001; Longabaugh et al., 2001)
EFFECTIVENESS OF MI ALCOHOL PREVENTION
