AASE ODE MI Workshop 5.23.12

AADE/ODE MI Workshop Series

Michael Fulop, Psy.D.Clinical & Consulting Psychology

FORSTER FULOPRewarding Diabetes

Motivational Interviewing “A work in progress…”

What’s one specific MI take-away you might use in your practice?

michael@rewardingdiabetes.com

79michael@rewardingdiabetes.com

My AgendaProvide ongoing training to AADE/ODE

providers to improve MI skills

Discuss evidence for MI in psychotherapy

Show examples of MI in practice

Have you practice MI – in your settingHow comfortable role/real playing? 0-10How comfortable taping self in practice? 0-10

Humble + Curiousmichael@rewardingdiabetes.com

What would like to accomplish today?

• 30 seconds

• Your Name

• Where do you practice?

• What’s one specific take-away from today, imagine what it might be.

• Write down as we go along

MI Publications

Last Count was ~754, RCT’s > 180michael@rewardingdiabetes.com

Some Things MI is Not MI not Transtheoretical Model - MI not intended as a

comprehensive theory of change

MI does not trick people into doing what don’t want to do★ Not an end run for outwitting people★ MI is “with” or “for” someone, not “to” or “on”

MI is not what you already are doing★ Near zero-correlation for perceived competence in MI –

★ Attending 1 workshop doesn’t improve outcomes for clients

★ Practice is needed, being coded, being observed and practice

Some Things MI is Not MI is simple, but not easy

Not easy to integrate complex skills Like learning to play a musical

instrument!

MI is not a Panacea It’s a specific way to address the need to make

behavioral changes when someone is ambivalent

★ People ready for change do not need MI

Mi is not stand-alone therapy – adds effectiveness w/other treatments w/1- 4 sessions

What MI is not…

What MI is…After 30 years of research

we have a treatment approach that is evidence-based [over 200 RCT’s published], relatively brief [typically 1-3 sessions], that can be specified, grounded in testable theory, with identifiable methods of action, verifiable as to when it is being delivered competently, generalizable across a wide range of problem areas, complimentary to other treatment methods, and learnable by a wide range of providers – WR Miller, Ph.D.

Recent definition of MI - MI-3MI is a collaborative, goal-oriented style

of communication with particular attention to the language of change, designed to strengthen personal motivation for & commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

michael@rewardingdiabetes.com Miller & Rollnick, 2011

16michael@rewardingdiabetes.comFrom David Rosengren, Ph.D. Building Motivational Interviewing Skills

78michael@rewardingdiabetes.com

Meta-analyses & reviewsBritt, Hudson & Blampied, 2004Burke et al., 2003Dunn, Deroo & Rivara, 2001Hettema, Steele & Miller, 2005Moyer, Finney, Swearingen & Vergun,

2002Rubak, Sandbaek, Lauritzen &

Christensen, 2005Cochrane Review 2011

Does MI Work?

Evidence For MI efficacy Dunn, C, Deroo, L, Rivara, F (2001) The Use of brief interventions

adapted from MI across behavioral domains. Addiction, 96; 1725-42.

Burke B, Arkowitz H, Dunn C (2002) The efficacy of MI and it’s adaptations: What we know so far. In Miller & Rollnick [eds] Motivational Interviewing, 2nd [2002]

Burke B, Arkowitz H, Menchola M (2003) The efficacy of MI: A meta-analysis of controlled clinical trials. Journal of Consulting & Clinical Psych, 71 843-61.

Britt, E, Hudson S, Blampied N (2004) MI in health care settings: A review. Patient Education and Counseling, 52, 147-55.

Rubak, S, Sandboek A, Lauritzen T, Christensen B (2005) MI: A systematic review and meta-analysis. British Journal of General Practice, 55, 305-12.

Hettema J, Steele J, Miller W (2005) Motivational Interviewing. Annual Review of Clinical Psychology, 1 91-111.

Further Study - Resources

Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner’s Workbook. New York: Guilford Press.

Arkowitz, H. Westra, H. Miller, W.R., & Rollnick, S. (2008). Motivational Interviewing in the Treatment of Psychological Problems. Guilford: New York.

Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. Guilford:.

Training Tapes: MI SeriesMI Website: www.motivationalinterview.org

Miller Conversation Encountering Ambivalence

MI SpiritCollaborative

Honors client expertise and perspective

Creates an environment that supports changeEvocative

Resources lie within clientEnhance their intrinsic motivation

less about external pressure

Promotes Client Autonomy“Patient is right” they have capacity for self

changeFacilitate informed choice

Compassion - MI-3 [Miller & Rollnick, 2012]michael@rewardingdiabetes.com

Miller Conversation on the Spirit of MI

Interview for Psych1

What is MI Spirit? 1-5 RankingEvocation

CollaborationAutonomy/SupportSpirit = [EV] + __ [CL] + __ [A/S]/3 = ___Evocation + Collaboration + Autonomy/Support/3]

DirectionEmpathy

A Continuum of Styles

Directing <=> Guiding <=> Following

Behavior therapyCognitive therapyReality therapyDr. Phil

Motivational interviewing Solution-focused therapy

Psychodynamic

Psychotherapy

Client Centered

Psychotherapy

• It’s MI when…

• The communication style involves person-centered, empathic listening (engaging), and

• There is a target of change and that is the focus of conversation (focusing), and

• The interviewer evokes a person’s own motivation & reasons for change (evoking), but

• It may or may not include planning.

Four Fundamental Processes

Engaging

Focusing

Evoking

Planning

These 4 processes are somewhat linear ….

Engaging necessarily comes first

Focusing (identifying a change goal) is a prerequisite for Evoking

Planning is logically a later step

Engage Focus Evoke Plan

. . . . and yet also recursive

Engaging skills [& re-engaging] continue throughout MI

Focusing is not just a one-time event; re-focusing often needed; focus may

change

Evoking begins very early in encounters

“Testing waters” with planning may indicate a need for more of the above

AmbivalenceFeeling 2 ways about change is

common & normal

MI accepts ambivalence; patient gets time to explore & consider both sides of their dilemma

Telling people why they should change evokes the “righting reflex” & increases resistance

AmbivalenceOccurs throughout the change process

Reflects costs and benefits of change and status quo

Is uncomfortable & may become chronic

Resolved by client – Bem’s Self-Perception Theory What people say to themselves, is what they

believe

Readiness to Change

•Dental hygienist story

Ambivalence under pressure…

Leads to discord

Tends to elicit push back

Predicts worse outcomes

Is something we avoid in MI

Reinforcing Change Statements

Be attentive

Don’t have to respond immediately

May collect like a bouquet of flowers

Warning – be attentive to ambivalence

Pair Up - 1 speaker & 1 listener• Speaker talks about a change they are

ambivalent about – they want to change, but have not started yet [real play, or role play patient]. Speaker begins, describes change they want.

• Listener your job is to convince your speaker about why they should change – list your reasons, why you think they should change

• 4 minutes – then we debrief

• What happened to you as the person who wants a change? What’s it like?

• What happens to you, the listener/”convincer” What’s it like?michael@rewardingdiabetes.com

Installing Motivation?

• Speaker discuss a change you want to make – or play a client, patient

• Listener – Your task is to help this person come hell or high water

• Instead of listening, please:• Explain why s/he should make this change• Give 3 specific benefits of making the change• Tell him/her how to change• Emphasize importance of the change• Tell the participant to do it!

• Don’t use MI!michael@rewardingdiabetes.com

Evoking Motivation?• Speaker continue discussing change

• Listen carefully - goal to understand their dilemma

• Ask these four questions:• Why would you want to make this change?• How might you go about it, in order to succeed?• What are the 3 best reasons to do it?• On a scale of 0-10, how important would you say

it is to make this change? • And why are you a ? and not zero?

16michael@rewardingdiabetes.comFrom David Rosengren, Ph.D. Building Motivational Interviewing Skills

Open Ended questions Strength based questions

Affirmations

Reflective Listening

Summarizing

Engaging a real individual• Remember, you are not their 1st

provider• May need to overcome some barriers –

• My 1st Q -“Have you seen any other mh providers?”

• Relationship building is needed• Accepting ambivalence is particularly

important• Don’t insist on diagnosis acceptance• Target problems and client goals – not

diagnoses

Exercise: On the Nature of Helpfulness

Imagine a major pressing dilemma in your life Professional or Personal Debating this with yourself

Imagine Your thinking is moving in ever tightening circles You’re in a state of perplexity It’s affecting all aspects of your life You’re making little progress on your own

So… you decide to seek out helpActivity from Jeff Allison

Exercise: The Nature of Helpfulness

Who should you discuss this with?Don’t want to make a mistake - Choosing

wrong person leads you in wrong way Go to Powell’s, grab some coffee and sort this

What are desirable qualities & skills of such a person? How would you want them to behave?

Make two lists by yourselfMost desirable qualities & skillsWhat will make you feel antagonistic and or

disappointed? This Exercise is from Jeff Allison

MI GOAL

Change Talk

Change Talk Change talk is any client speech that favors

movement in the direction of change

Previously called “self-motivational statements” (Miller & Rollnick, 1991)

Change talk is by definition linked to a particular behavior change goal

DARN CATs

Preparatory Change TalkDARN Examples

DESIRE to change (want, like to, wish.,)

ABILITYto change (can, could . . )

REASONS to change (if . . then)

NEED to change (need, have to, got to . .)

Mobilizing Change TalkReflects resolution of ambivalence

COMMITMENT (intention, decision, promise)

ACTIVATION (willing, ready, preparing)

TAKING STEPS

Mobilizing Language

Three Types: Commitment, Activation & Taking Steps I an done with being depressed. I am ready to do something different. My boyfriend said I didn’t need my meds, but I

told him I did.

Is mobilizing language enough?

Some Answers… I wish I could… I’d like to… I think I should… I could if I really wanted to… I have good reasons to…

For some questions... Do you swear to tell the truth, whole truth and…? Do you take this person to have and to hold in

sickness in health…?

Responding to Change Talk

All EARSE: Elaborating: Asking for elaboration, more

detail, in what ways, an example, etc.

A: Affirming – commenting positively on the person’s statement

R: Reflecting, continuing the paragraph, etc.

S: Summarizing – collecting bouquets of change talk

Sustain TalkThe other side of ambivalence

I really like marijuana(Desire)

I don’t see how I could give up pot(Ability)

I have to smoke to be creative(Reason)

I don’t think I need to quit (Need)

I’m gonnna keep smoking (Committment)

I’m not ready to quit (Activation)

I went back to smoking this week (Taking Steps)

Miller Conversation Rolling With Resistance

Righting Reflex Video

Arg Clin Starts at 1:15 & Ends at 3:40

http://www.youtube.com/watch?v=kQFKtI6gn9Y

Avoiding Trouble

What is Resistance?

Behavior

Interpersonal (It takes two to resist)

A signal of dissonance

Predictive of (non)change

The Righting Reflex - Reactance

Handling Resistance • Already in skills repertoire

• May not eliminate, but can reduce “heat”

• Three reflective types:• Simple• Amplified• Double-sided

• Two Strategies• Shifting focus• Emphasize personal choice

Handling Resistance - Reflection

• I thought a little red wine was supposed to be good for your heart.

• I know the meds are good for me, but they make me too drowsy.

• I think you are blowing this way out of proportion, I only got a little messed up, why are you such a prude?

• You don’t understand what it’s like for me, you’ve got a job and career; all I got is these memories.

• Meds don’t help much anymore, but something’s got to, or I am out of here.

• I’ve tried everything you’ve asked. None of that shit works. Why don’t you get it?

Sustain Talk and ResistanceSustain Talk is about the target behavior

I really don’t want to stop smoking I have to take pills to make it through the day

Resistance is about your relationship You can’t make me quit You don’t understand how hard it is for me

Both are highly responsive to counselor style

Foundational Skills – Simple, Not Necessarily Easy

• Open Questions

• Affirmations

• Reflective Listening

• Summaries

• Offering Information

Asking Develop an understanding of client’s

situation

Allows you to:Follow a decision treeArrive at a diagnosisComplete forms

Closed questions can be:Efficient way to gather specific informationMay create or reinforce the expert-trap

Open-ended Questions

These sets the tone for MI work

Communicates interest and caring

Allows client room to respond

Makes client more a more active partner

You receive information otherwise unavailable

Creates momentum

ListeningMI is built on this skill

Directive use of listening

Attend to some things and not others

Create awareness of gaps

Reinforce change talk

Effective Listening:

Is not asking

More than paying attention

Is not just silence

More than repeating words

Way of thinking

Reflective Listening2 levels of reflection

Simple - content stays close RepeatingRephrasing

Complex – guesses at unexpressed, affect, anticipates, and metaphors Paraphrasing Meaning or IntentReflecting Feeling

Reflective Listening

Vary your depth

Timing is important

Typically undershoot

Exercise – Two Levels of Reflections

Form groups of 4

Choose a representative to record answers

Record Simple & Depth Reflections for each sentence stem

Being Directional

Not telling client what to do

Choosing to attend to different elements

Usually multiple elements in a statement

Focus will determine path

Examples of being directional

I’m tired and it feels impossible right now.

You’re worn out.

It feels really hard to do.

Right now is a problem, but maybe later won’t be.

Summaries

Special form of reflective listening

Different kinds: Collecting – short, continue flow (change talk) Linking – add recent material to prior info

(ambivalence) Transitional – announces a shift in focus

(change direction)

Affirmations• Some clients are demoralized

• Orients people to their resources

• Be genuine

• Probe partial successes

• Reframe resistance into an affirmation

• What and how questions are helpful

• Use “you” statements, not “I”

Informing Successful communication

requires:Transmission of technical

informationInterpersonal skills

Therefore, a relationship is key to good informing

Useful Informing Ask permission

Offer choices

Use other client examples

Chunk-Check-Chunk

Elicit-Provide-Elicit

Useful Informing Slow down and progress may be quicker

It’s a person not an information receptacle

Consider the client context & priorities

Amount matters and depends on the client

Best method? The individualized one

Beware of righting reflex

What’s one specific MI take-away you might use in your practice?

Reflections

View hettama tape disc 1 –

Reflections

Reflections are a way of hypothesis testing without the questions

They are a way to attune to the person

They are choosing where you think someone might be going

Heart of MI

Reflective Responses

Three levels of Reflections

Repeats - or parrots

Rephrases - with simple word changes

Paraphrasing – infers a meaning

Reflection – of feeling, value, or attitude Simple Complex

Intensity of Reflections

Understated or attenuating a reflection“You a slightly annoyed”

Which direction will the client go?

Overstating or Amplified ReflectionsYou are outraged

Which direction will the client go?

“I really hate my boss telling me I have to pick up those boxes over and over again.”

Understated reflection Which direction will the client go?

Amplified Reflection Which direction will the client go?

Double Sided

On the one hand you want to … On the other hand you don’t want to.

You’ve told me some good reasons to stop smoking, and in some ways you love it a lot

“My friends say I should just stop smoking pot, but I am not sure I can anymore.”

“My diabetes used to be easy to control, but I’m not sure I can get it under control any more.”

Practice

“Since my accident, I don’t care if I live or die, and I wonder if anyone else cares?”

Reflection Practice

“Do you mean” practice

Reflection Practice

“It’s fun, but something has to give. I can’t go on like this anymore.”

“I know I can do some things differently., but if she would just back off, the this situations would be a lot less tense. These things wouldn’t happen.

I’ve been depressed lately. I keep trying to get back to using exercising more, but my back always hurts, it is so frustrating. A couple of drinks would help.

Reflection Practice “So I’m not too worried, it’s been over a year, and I

can still walk with that knee pain.”

“I know I should lose some weight, everybody tells me that, but nobody knows how hard it is for me. I wish I was on the biggest loser.”

My daughter thinks it’s her body, and so she should be able to do what she wants. Hooking up is no big deal to her. She doesn’t get why I won’t back off.”

Contact Information

Michael J Fulop, Psy.D.

www.rewardingdiabetes.com

503.539.4932

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