K A T H E R I N E F O R T E N B E R R Y P H DA S S I S T A N T P R O F E S S O R

D E P A R T M E N T O F F A M I L Y A N D P R E V E N T I V E M E D I C I N E

Motivational Interviewingand

Brief Negotiated Interviewin Practice

SBIRT Training Course

Learning Objectives

Apply the Stages of Change Model to patients

List Motivational Interviewing (MI) guiding principles and foundational skills (OARS)

Recognize and elicit Change Talk in your patient

List steps of Brief Negotiated Interview (BNI)

Use MI and BNI to develop an effective patient plan

Stages of Change

Transtheoretical Model of Behavior ChangeProchaska & DiClemente

Stages of Change

Pre-contemplation

Do not intend to change within 6 months May be resistant to discussion of behavior change May not recognize consequences of behavior

Contemplation

Inclined to change in next 6 months Very ambivalent about change

Preparation

Intends to take steps to change within the month Patient has a plan of action or is ready for one

Action

Specific behavioral modifications have begun (within past 6 months)

The action is observable

Maintenance

Has engaged in behavior over the last 6 months Taking steps to avoid temptations Stabilizing behavior change and preventing relapse.

Relapse

Can occur at any of the stages Can move back to any prior stage

Y O U A L W A Y S A S K M E A B O U T D R I N K I N G . C A N W E P L E A S E S K I P T H A T T O D A Y ?

What’s My Stage?

I F I N A L L Y W E N T T O A N A A M E E T I N G ! !

What’s My Stage?

E V E R Y T I M E I ’ V E T R I E D T O Q U I T , M Y B O Y F R I E N D J U S T M A K E S I T S O H A R D .

What’s My Stage?

N O B O O Z E F O R T H R E E M O N T H S ! ! !

What’s My Stage?

W E L L , C R A P .

What’s My Stage?

Motivational Interviewing

Definition:

A person-centered counseling method for addressing the common problem of ambivalence about change

Miller, 2009

What your patient hears

What your patient cares about

What Not to Do

Underlying Assumptions

Ambivalence is normal – but must be resolved Change Talk is Golden People change when they discuss their ambivalence

STUCK!

Cons of ChangePros of the

Status Quo

Pros of ChangeCons of the

Status Quo

Guiding Principles

Resist the Righting Reflex Understand Your Patient’s Motivations Listen to Your Patient Empower Your Patient

Skill Set - OARS

Open Ended Questions Affirmations Reflective Statements Summary

Practice OARS

Open Ended Questions

Screening indicates your patient is drinking a six pack every day after work.

Practice OARS

Affirmations

He’s drinking a six pack per day, missing work, and has had the police called for domestic violence.

Practice OARS

Reflections

“Of course I’ve tried to cut back. But you had as much stress as I do, you’d be drinking too.”

Practice OARS

Summarize: Let me make sure I understand how this all fits together….

The summary: Show you have been listening Draw together pieces of the picture Re-emphasize aspects of what the patient has said Change direction if needed

Let’s Practice!

Brief Negotiated Interview

Tying It Together

Build Rapport Provide Feedback

Build Readiness to Change

Negotiate Plan for Change

OARS

1. Building Rapport

1. Begin with a general conversation

1. Ask for permission

1. Roll with resistance

2. Presenting Feedback

1. Ask for permission

1. Discuss screening findings

1. Link findings to any known health concerns

3. Building Readiness to Change

Readiness Ruler

“On a scale of 1-10, how READY are you to make changes in your alcohol use?”

1 5 10Not Ready at all Very Ready

“WHY”before

“HOW”

Change Rulers

“On a scale of 1-10, how IMPORTANT is it for you to cut back on drinking?”

1 5 10Not important Important

“On a scale of 1-10, how CONFIDENT are you that you could cut back on drinking if you decided to?”

1 5 10Not Confident Confident

Change Rulers: Importance

“On a scale of 1-10, how IMPORTANT is it for you to stop drinking?”

Patient says “2”

Increase Importance

Why a 2, and not a 0? (Move DOWN the scale!) Elicit change talk

Tools to Increase Importance

Decisional Balance Good stuff first

What are some of the benefits of drinking? Bad stuff second

Any not-so-good stuff in your life because of drinking? If you never cut back on drinking, what do you see happening 5

years from now?

Magical Questions If you were able to cut back on drinking, how might your life

change?

Change Rulers: Importance

On a scale of 1-10, how IMPORTANT is it for you to quit smoking?

Patient says “8” (a high number) You say: “Great! Why an 8, and not a 5?”

Importance before confidence!

Change Rulers: Confidence

On a scale of 1-10, how confident are you that you could stop drinking?

Patient says “3” (a low number) You say: “Why did you pick 3 and not 1?” Elicit past success

You say: “What would it take to get you to 5?” (higher number) Assess patient barriers

“WHY”before

“HOW”

B E H A V I O R C H A N G EO R

R E F E R R A L T O S P E C I A L I S T

4. Negotiate a Plan for Change

Summary

Build Rapport Provide Feedback

Build Readiness to Change

Negotiate Plan for Change

Motivational Interviewing Principles

OARS

Read this book!

A Taste of MI Exercise

Ask!1. Why do you want to make this change?2. If you did decide to make this change now, how

would you go about it in order to succeed?3. What are the 3 best reasons to make this change?4. On a scale from 1-10, how important is it for you to

make this change?

Summarize!