Utilizing Motivational Interviewing to Navigate

the Rough Waters An Introduction and

Opportunities for PracticeWilliam T. Dalton III, Ph.D.

Licensed Psychologist & Assistant ProfessorAssistant Director of Clinical Training

Elizabeth Conway-Williams, M.A.

Doctoral Student

Department of PsychologyEast Tennessee State

University

Learning Objectives At the conclusion of this presentation you

should be able to… Describe the characteristics of MI Understand the guiding principles of MI Understand the foundational clinical skills of

MI Understand additional clinical tools for

practice of MI Objectives will be met via…

Lecture Video demonstrations Practice via case studies

MI Defined MI is a collaborative, person-centered

form of guiding to elicit and strengthen motivation to change

Number of Hits on PsycINFO for “Motivational Interviewing”

1980-1989 1990-1999 2000-20090

200

400

600

800

1000

1200

Evidence Base for MI Lundahl & Burke (2009) summarized

results of four meta-analyses on effectiveness of MI

Effect sizes (Cohen’s D): Weak comparison groups (e.g., wait-list):

0.28-0.40 Strong comparison group (e.g., CBT or 12-

step program): 0.04- 0.32 Suggest that MI is significantly better

than no treatment and generally equal to other established treatments for a wide range of problems

MI Applications Alcohol-related

problems Marijuana

dependence Tobacco use Other drugs

(e.g., cocaine, heroin)

Engaging clients in treatment

Reducing risky behavior

Increasing healthy behavior

Other MI Applications Asthma/COPD Brain Injury Cardiovascular

Health/Hypertension Dentistry Diabetes Diet/Lipids Domestic Violence Dual Diagnosis Eating Disorders/Obesity Emergency

Department/Trauma/ Injury Prevention

Family/Relationships Gambling Health Promotion

/Exercise/Fitness HIV/AIDS Medical Adherence Mental Health Offenders Pain Parenting Interventions Reproductive Health Sexual Behavior Speech/Vocal Therapy

History Motivational Interviewing Professional

Training DVD (1998) Interview With Founders

William Miller, Ph.D. (Clinical Psychology) Stephen Rollnick, Ph.D. (Clinical Psychology)

History (Cont’d) Motivation was once considered a trait or

ingrained quality MI was first described in 1983 to help

motivate drinkers to change behavior (resistance)

Ambivalence was being considered a normal and defining state and the recognition that change is not usually made without inconvenience

Around the same period the trans-theoretical model of stages of change was being proposed

Stages of Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

How MI Works Recognizes behavior change as a

process Individuals are considered to be in

different stages of behavior change Assists individuals in moving through

stages via a combination of a strong patient-provider relationship and specific techniques that encourage patients to discuss the possibility of behavior change

Check-It!

MI Characteristics Directive Client-centered Honors autonomy Counseling style Resolve ambivalence Evocative Collaborative Minimizes resistance Offers acceptance

MI is “Not” Arguing that a person has a problem

and needs to change Offering advice without the patient’s

permission Doing most of the talking Simply giving a “prescription” A quick trick or simple procedure

MI Video Demonstration

Check-It!

Guiding Principles: RULE Resisting the Righting Reflex

Roll with resistance Understand Your Patients Motivations

Develop discrepancy Listen To Your Patient

Express empathy Empower Your Patient

Support self-efficacy

Check-It!

Foundational Clinical Skills: OARS Open-ended questions Affirmations Reflective listening Summarizing

Foundational Clinical Skills: OARS (Cont’d) Open-ended questions

Questions that encourage patients to elaborate, feel respected, and elicit change talk

Examples “Would you tell me more about ____?” “How does smoking fit with your dreams of

becoming a pro basketball player?” “How does your current weight interfere with the

activities you most enjoy?” “In what ways is your diabetes a problem for you?” “How have you overcome other obstacles in the

past?”

Foundational Clinical Skills: OARS (Cont’d) Open-ended questions

Avoid questions that can be answered yes/no

Examples “Did you ____?” “Will you ____?” “Can you ____?” “How many ____?”

Foundational Clinical Skills: OARS (Cont’d) Affirmations

Statements reinforcing positive choices, strengths, and self-efficacy

Examples “Coming in every week for therapy and doing

homework is really tough. You are handling a difficult treatment protocol really well.”

“I’m impressed with how mature you are.” “Absolutely! It is really tough to do all that you

need to do when you’re not feeling well. And sticking to your diet makes it easier for you to do your chores, complete your homework, and hang out with your friends.”

Foundational Clinical Skills: OARS (Cont’d) Reflective listening

Following along by restating what is said, clarifying, adding meaning, or highlighting emotions

Examples “It sounds like you are feeling ____.” “It appears that you see no real problem with

your current drinking.” “On the one hand your family really enjoys

several hours of television each day and on the other hand you find that it is interfering with your family’s ability to be physically active which you also enjoy and find important.”

Foundational Clinical Skills: OARS (Cont’d) Summarizing

Sum up patients stories, add insight and reinforce statements in favor of change

Examples “It’s important for you to fit in with your friends.

Sometimes adhering to your chest physiotherapy regimen makes that tough.”

“On the other hand, when you don’t adhere to your therapy, you notice that you don’t feel as well. And when you don’t feel as well, it’s even harder for you to keep up with the energy of your friends. Is there anything that you want to add that I may have missed?”

MI Video Demonstration

Check-It!

Additional Clinical Tools Setting an agenda Assessing readiness to change Developing discrepancy

Pros/consValues and current behavior

Setting an Agenda Ask permission to discuss a specific

topic“Would you be willing to spend a few

minutes discussing your drinking?”“Are you interested in discussing ways to

better take your medicine?” Ask patient to name an area of concern

with the help of a menu of options“There are several topics we could discuss

related to your health. For example, taking your medicine, eating patterns, amount of physical activity or time spent watching television, smoking or drinking behavior, sexual activity, or even others. What is of most concern to you?”

Assessing Readiness to Change Use of Rulers and Scaling

Two useful tools for assessing and enhancing patient readiness for health behavior changes are the Importance and Confidence Rulers

Both on a 11-point scale 0 = least importance or confidence 10 = most importance or confidence

Scaling or follow-up questions may be used to facilitate change talk

Assessing Readiness to Change (Cont’d) “On a scale of 0 to 10, with 10 being ‘very

important,’ how important is it for you to decrease your drinking?”

Reflect patient’s answer“You chose _____.”

Ask follow-up questions“Why did you not choose a lower

number?”“Why did you not choose a higher

number?”“What would it take to move to an

_____?”

Assessing Readiness to Change (Cont’d) “On a scale of 0 to 10, with 10 being ‘very

confident,’ assuming you decided to drink less, how confident are you that you could succeed?”

Reflect patient’s answer“You chose _____.”

Ask follow-up questions“Why did you not choose a lower

number?”“Why did you not choose a higher

number?”“What would it take to move to an _____?”

MI Video Demonstration

Developing Discrepancy: Pros/Cons Allows patients to list the pros and cons

of changing or of not changing health-related behaviors , and then to assign subjective weights (of importance) to each

“Tell me some good and not so good things about taking your medicine.”

“Let’s list together and discuss the pros and cons of completing your homework. Afterwards, let’s list together and discuss the pros and cons of not completing your homework.”

Developing Discrepancy: Values and Current Behavior

Values for Your FamilyCohesiveHealthyPeaceful mealsGetting alongSpending time

togetherOthers: ____

Values for YouGood parentResponsibleDisciplinedGood spouseRespected at homeOn top of thingsSpiritualOthers: ____

Developing Discrepancy: Values and Current Behavior (Cont’d) What do you value most? How does

your/your child’s/family’s current lifestyle fit in with that?“On the one hand you value a healthy

family and on the other hand you and your child have excess weight and you report that your diets are poor?”

“So where does that leave you?”

MI Video Demonstration

Review Characteristics Guiding Principles

Resisting the righting reflexUnderstand your patients motivationsListen to your patientEmpower your patient

Foundational Clinical SkillsOpen-ended questionsAffirmationsReflective listeningSummarizing

Additional Clinical Tools

Questions

Practice Application Review case studies

Case 1Case 2

Turn to your neighbor Develop a plan

Stage of change?Goals?What foundational clinical skills would you

emphasize?Which additional clinical tools may you use?

Practice Application (Cont’d) Role-play between group members

Divide into groups of 3 One person patient One person health care provider One person evaluator

Patient reviews script Health care provider practices foundational

clinical skills (OARS) and at least 1 additional clinical tool (i.e., Assessing readiness to change, Pros/cons, or Values and current behavior)

Evaluator monitors progress and provides feedback

References/Resources Barlow, S. E., & the Expert Committee. (2007). Expert Committee

recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics, 120 (Suppl. 4), 164-192.

Erickson, S. J., Gerstle, M., & Feldstein, S. W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings. Archives of Pediatrics and Adolescent Medicine, 159, 1173-1180.

Glynn, L. H., & Levensky, E. R. (2009). Promoting treatment adherence using motivational interviewing: Guidelines and tools. In L. C. James & W. T. O’Donohue (Eds.), The primary care toolkit: Practical resources for the integrated behavioral care provider (pp. 199-231). New York: Springer.

Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245.

Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160.

Resnicow, K., Davis, R., Rollnick, S. (2006). Motivational interviewing for pediatric obesity: Conceptual issues and evidence review. Journal of the American Dietetic Association, 106, 2024-2033.

References/Resources (Cont’d) Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour

change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: The Guilford Press.

Miller, W., & Rose, G. (2009). Towards a theory of motivational interviewing. American Psychologist, 64, 527-537.

Rollnick, S., Miller, W. R., & Butler, C. C. (1999). Health behavior change: A guide for practitioners. New York: Churchill Livingston.

Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: The Guilford Press.

Sindelar, H. A., Abrantes, A. M., Hart, C., Lewander, W., & Spirito, A. (2004). Motivational interviewing in pediatric practice. Current Problems in Pediatric and Adolescent Health Care, 34, 322-339.

Motivational Interviewing: Resources for Clinicians, Researchers, and Trainers http://www.motivationalinterview.org/