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Motivational Interviewing: Helping People Change Problem Behaviors Using Smoking Cessation as the Model . Andrée Aubrey , MSW, LCSW, CTTS Director, Area Health Education Center FSU College of Medicine Department of Family Medicine and Health Affairs 850-645-6439. - PowerPoint PPT Presentation



Motivational Interviewing:Helping People Change Problem Behaviors Using Smoking Cessation as the Model

Andre Aubrey, MSW, LCSW, CTTS

Director, Area Health Education CenterFSU College of MedicineDepartment of Family Medicine and Health Affairs


2At the end of this training, learners will be able to: Articulate the key components of MI interventions; Demonstrate competence in an evidence based and practical approach to behavior change counseling;Focus the assessment interview on identifying and/or enhancing the clients own reasons for wanting to quit tobacco or make other health related changes;Use reflective listening skills to more fully understand clients perspectives about the problem and potential strategies to address those problems;Enhance client self-efficacy for making a change.

What would you say to this patient?Video slide here Too much stress to quit4Typical Tobacco Cessation CounselingVideo slide here The way in which we communicate with people SIGNIFICANTLY influences their motivation about change.

5Problems with Traditional ApproachFocuses on fixing the problem Assumes knowledge and information are keys to motivating behavior change Teaches patients how to make the desired change

Often leads to a Yes, but tug of warKnowledge weakly correlated with behavior changeThe traditional approach is: ID problem; evaluate risk of behavior; advise pt. to change I am going to teach you./ provider is expert and pt. should follow his advice.

If pt. does not change, the counseling/ interaction has been a failure.

The way in which you talk w/ pts. about their health can substantially influence their personal motivation for behavior change. 6Motivational Interviewing is NOT a treatment for tobacco dependency. It is an evidence-based intervention for tobacco users WHO ARE NOT YET READY TO QUIT.

You can lead a horse to water but you cannot make him drink.7The most effective treatment for tobacco dependency is a combination of .Practical CounselingPharmacotherapySystems level interventions

MI salts the oats 8TX for Tobacco DependencyProblem Solving: compulsions to use, triggers to smoke, changes in lifestyleCoping Skills: developing or enhancing other coping mechanisms

ASKING every client at every visit about tobacco use paper screening like a vital sign OR electronic health record (EHR) promptADVISING about the benefits of quittingREFERRING for treatment if not able to provide on-site

Reminder systems which prompt clinicians to do the 2A/R interventionNicotine Replacement Therapy: Patch, gum, lozenge, nasal spray, inhalerBupropion: Wellbutrin SRVerenicline: Chantix Practical Counseling Pharmaco-therapySystems InterventionsWhat is Motivational Interviewing?A collaborative, person-centered form of guiding to elicit and strengthen motivation for change

Empirically validated approach for helping people change addictive or other problematic behaviors Spirit and style more than specific techniques shaped by a guiding philosophy and understanding of what triggers change. It involves the conscious and disciplined use of specific communication principles and strategies to evoke the persons own motivations for change 10MIA consumer-centered, yet guiding style of counseling that is shaped by a guiding philosophy and understanding of what triggers change.Involves the conscious and disciplined use of specific communication strategies to evoke the persons own motivations for change. Three Essential Elements of MIMI is a particular conversation about change MI is collaborative (person-centered, not expert-recipient; partnership; honors autonomy and self-determination)MI is evocative seeks to call forth the persons own motivation and commitment Takes place in context of interpersonal relationsip. 12Persuasion Exercise: Part 1SPEAKER: Talk about something youd like to change. May be a behavior, attitude, or habit but something it would be good to change.

COUNSELOR #1: Explain why he/she should make this changeGive at least 3 benefits of making the changeTell him/her how to do itEmphasize how important it is to make the change

13Persuasion Exercise: Part 2COUNSELOR #1Why would you want to make this change?If you do decide to make this change, how might you go about it in order to succeed?What are your three best reasons to do it?On a scale of 0 to 10, how important is it for you to make the change? *Why are you at___ and not 0?14Persuasion Exercise: Part 3COUNSELOR #2Give a short summary of the speakers motivation for change:Summarize desire, ability, reasons, need for changeThen, ask So what do you think you will do?Affirm strengths of the speaker 15TO BE DOING MI THERE MUST BEa Target such as a health related behavioral change; attitude; decision (forgiveness); habit

Change Talk

Without these, there may be great rapport building and patient-centered listening, but not MI Underlying Theory of MIPeople are ambivalent about making changesWhen the clinician advocates for change, it will evoke resistance from the personResistance predicts lack of changeGetting the person to talk about making the change makes it more likely that he/she will do it 17

Change Talk An argument FOR change

-There is good evidence to suggest that people can literally talk themselves in and out of change (Walters, et al., 2003). For instance, there are linguistic studies that suggest that the speech of the provider sets the tone for the speech of the client, which in turn, influences the ultimate outcome (Amrhein, et. al., 2003).

-In short, certain statements and questionsand especially a certain provider styleseem to predict whether people decide to change during brief conversations. -Community members may come in with a certain range of readiness, but what the organizer said from that point on makes a difference in how the community member speaks and thinks, and ultimately in how they choose to behave when deciding if they wanted to register to vote.


ResistantNon-compliantRefuses to take care of herselfUnwilling to changeNon-adherentDifficult personDoesnt understand Waste of my timeLost Cause!

Sustain Talk Argues for the status quoArgues against change

Change Talk and Sustain Talk are opposite sides of the same coin both sides of ambivalence

Resistance Now framed as SUSTAIN TALK + DISCORDOnly resistance when the person has something to push against The individuals sustain talk is causing discord in the relationship (thats our reaction!)

Recognizing Change TalkCategories of Change Talk:Desire to changeI would really like to quit smoking. Ability to changeI think I could start cutting back.Reasons for changeMy relationship w/ my wife would be better if I quit drinking. 22Recognizing Change TalkCategories of Change Talk:Need to changeI have to lose weight or my breathing is just going to get worse. Commitment to changeIve decided Im going to start an exercise program this week. Taking stepsIve stopped smoking in my car and cleaned out all the cigarette packs in the glove compartment. Notes on 6: usually when see pts over timePt taken some steps, baby stepsI tried a couple of days w/o drinking this weekI got some condoms from the CHDDO NOT OFFER SKEPTICISM condoms only work when you use themAAFIRMATIONS/ encouragement 23

DARN- CT How change talk fits together24Where do we start?Understanding basic principles of MIMI skills:Open ended questionsAffirmations Reflective listeningSummaries andInforming/ Advising

Emphasize SPIRIT AND STYLE OF COUNSELING. EARLY METHODS: we dont call them early methods because we use at the beginning and then abandon; it is important to use them right from the startInforming/ Advising: Just dont give the info. Ask how the person wants to obtain info.25

Open Ended Questions Open questionsEncourages patient speechMore efficient for gathering informationBuilds relationship patients perceive clinician as caring and showing personal interestClosed questionsEffective for gathering information, if you ask the right questions! Question-answer trapA series of questions (lends itself to quantification focus) Questions that do not invite brief answers. Establishes an atmosphere of acceptance and trust so clients will be able to explore their concerns. Client should do most of the talking w/ counselor listening carefully and encouraging expression. Important for client to do more than 50% of talking- process of MI involves eliciting and shaping certain kinds of client speech. 26

Open-ended Questions Video Example of MI in action!

27Video slide hereHelp them talk more about the problem area. Dont just note the info. 28Open ended questions to evoke change talkDisadvantages of the status quoWhat worries you about your current situation?What do you think will happen if you do not change anything?How has this stopped you from doing what you want in life?What hassles or difficulties have you had in relation to your __________?What makes you think you need to do something about_________?Open ended questions to evoke change talkAdvantages of changeHow would you like for things to be different?If you could make this change immediately, by magic, how might things be better for you?What would be the good things about ________?What would you like your life to be like in five years?The fact that you are here indicates at least part of you thinks its time to do something. What are the main reasons you see for making a change?

Open ended questions to evoke change talkOptimism about changeWhat makes you think that if you did decide to change, you could do it?What encourages you to think that you can cha

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