Introduction to Motivational Interviewing Nimi Singh, MD, MPH Division of Adolescent Health and Medicine University of Minnesota Amplatz Children’s Hospital

Introduction to Introduction to Motivational InterviewingMotivational Interviewing

Nimi Singh, MD, MPHNimi Singh, MD, MPHDivision of Adolescent Health and MedicineDivision of Adolescent Health and MedicineUniversity of Minnesota Amplatz Children’s University of Minnesota Amplatz Children’s

HospitalHospital(adapted from Kelly Lundberg, Ph.D. University of Utah)(adapted from Kelly Lundberg, Ph.D. University of Utah)

DisclosureDisclosure

I have no financial relationships to discloseI have no financial relationships to disclose

I will not be discussing off-label use of any I will not be discussing off-label use of any medicationsmedications

OUTLINEOUTLINE

What is Motivational Interviewing?What is Motivational Interviewing? Stages of ChangeStages of Change Impact of the counselor/ health care providerImpact of the counselor/ health care provider Principles of motivational interviewingPrinciples of motivational interviewing Philosophical approachPhilosophical approach Specific methodsSpecific methods Resources/ ReferencesResources/ References

Motivational InterviewingMotivational Interviewing

Empathetic, patient-focused directive counseling Empathetic, patient-focused directive counseling stylestyle

Seeks to create conditions for positive Seeks to create conditions for positive behavioral changebehavioral change

Well-suited for brief clinical encountersWell-suited for brief clinical encounters Evidence-based (>200 clinical trials, both adults Evidence-based (>200 clinical trials, both adults

and adolescents)and adolescents)(grounded in theory, verifiable, generalizable, delivered (grounded in theory, verifiable, generalizable, delivered

by wide range of health care practitioners)by wide range of health care practitioners)

Two Assumptions:Two Assumptions:

1. Motivation: due to 1. Motivation: due to interpersonal interactioninterpersonal interaction (not just innate character trait)(not just innate character trait)

• • Confrontation leads to resistanceConfrontation leads to resistance

•• Empathy and understanding lead to changeEmpathy and understanding lead to change

2. Ambivalence to change: normal and natural2. Ambivalence to change: normal and natural

•• CCompeting positive and negative feelingsompeting positive and negative feelings

• • Decision balance: pros and consDecision balance: pros and cons

Motivational Interviewing (con’t)Motivational Interviewing (con’t)

Counselor/ Health care provider: facilitatorCounselor/ Health care provider: facilitator ““Client/ Patient: presents arguments for changeClient/ Patient: presents arguments for change

Counselor:Counselor: Listens for ambivalence in patient’s own wordsListens for ambivalence in patient’s own words Reflects back negative and positive aspects of Reflects back negative and positive aspects of

behavior AND of changing behaviorbehavior AND of changing behavior Supports client self-efficacy: Supports client self-efficacy:

• Points out strengthsPoints out strengths• Points out previous successesPoints out previous successes• Acknowledges difficulties of making behavioral changeAcknowledges difficulties of making behavioral change• Avoids resistance by avoiding lecturing and arguing with Avoids resistance by avoiding lecturing and arguing with

patientpatient

Stage of Change TheoryStage of Change Theory

Prochaska and DiClemente (1992)Prochaska and DiClemente (1992) Pre-contemplationPre-contemplation ContemplationContemplation ActionAction MaintenanceMaintenance RelapseRelapse

PRE-CONTEMPLATIONPRE-CONTEMPLATION

Not even thinking about changeNot even thinking about change

CONTEMPLATIONCONTEMPLATION

Wax and wane toward the idea of changeWax and wane toward the idea of change Often influenced by emotionally salient Often influenced by emotionally salient

evensevens IsIs the stage of ambivalence the stage of ambivalence

ACTIONACTION

Ambivalence is goneAmbivalence is gone Actual working on the changeActual working on the change

MAINTENANCEMAINTENANCE

““Losing weight is easy. I’ve done it Losing weight is easy. I’ve done it hundreds of times.”hundreds of times.”

Behavior change takes repeated Behavior change takes repeated implementation of new life skillsimplementation of new life skills

Changes in the physiology of our brain Changes in the physiology of our brain takes even longertakes even longer

This is often when services/ support are This is often when services/ support are withdrawnwithdrawn

RELAPSERELAPSE

Return to the previous behaviorReturn to the previous behavior Once there has been a lapse or relapse, Once there has been a lapse or relapse,

the individual re-enters at either:the individual re-enters at either: Pre-contemplationPre-contemplation ContemplationContemplation ActionAction

Counselor plays KEY role in Counselor plays KEY role in influencing re-entry point!influencing re-entry point!

Clients will experience shame even when there Clients will experience shame even when there is no one blaming themis no one blaming them

Have the conversation about how you, as a Have the conversation about how you, as a health care provider, would respond to a relapse health care provider, would respond to a relapse prior to it happeningprior to it happening

Call your clients when they don’t show for their Call your clients when they don’t show for their appointmentappointment

Why we like working with patients in Why we like working with patients in Action stageAction stage

Our tools fit well with their stage of Our tools fit well with their stage of changechange

They cooperate and typically do what we They cooperate and typically do what we suggestsuggest

We tend not to experience anger, We tend not to experience anger, frustration and impatiencefrustration and impatience

We tend to feel disappointment when they We tend to feel disappointment when they don’t show for their appointmentdon’t show for their appointment

Why we DON’T like working with clients Why we DON’T like working with clients in Precontemplation or Contemplationin Precontemplation or Contemplation

Our tools don’t work with their stage of Our tools don’t work with their stage of changechange

They don’t do what we suggestThey don’t do what we suggest We tend to experience anger, frustration We tend to experience anger, frustration

and/or impatienceand/or impatience We tend to feel relieved when they don’t We tend to feel relieved when they don’t

show for their appointmentshow for their appointment We feel impotentWe feel impotent

So what do we tend to do?So what do we tend to do?

Spend more time with clients who are in the action stage Spend more time with clients who are in the action stage then those who are notthen those who are not

Use derogatory labels for those who are in the pre-Use derogatory labels for those who are in the pre-contemplation or contemplation stagecontemplation or contemplation stage

Forget that ambivalence is normalForget that ambivalence is normal Train clients to lie to usTrain clients to lie to us Shrug our shoulders and say, “I can’t help someone who Shrug our shoulders and say, “I can’t help someone who

doesn’t want to be helped.”doesn’t want to be helped.” Shrug our shoulders and say, “I can’t help someone who Shrug our shoulders and say, “I can’t help someone who

doesn’t admit to having a problem.”doesn’t admit to having a problem.”

Who are our clients?Who are our clients?

Most of the conventional health care tools we have Most of the conventional health care tools we have are for individuals who are in the Action stageare for individuals who are in the Action stage

It is estimated that 30% of patients who present to It is estimated that 30% of patients who present to clinic for care are in the Action stage (varies clinic for care are in the Action stage (varies depending on type of clinic)depending on type of clinic)

We tend to overestimate the motivation of those We tend to overestimate the motivation of those who say they’re ready to change and who say they’re ready to change and underestimate the motivation of those who underestimate the motivation of those who indicate no interest in change.indicate no interest in change.

Motivational Interviewing is Motivational Interviewing is the treatment of choice for the treatment of choice for

AMBIVALENCEAMBIVALENCE

PRINCIPLES OF MOTIVATIONAL PRINCIPLES OF MOTIVATIONAL INTERVIEWINGINTERVIEWING

Express empathyExpress empathy Develop discrepancyDevelop discrepancy Roll with resistanceRoll with resistance

Don’t argue against itDon’t argue against it Encourage elaboration of resistanceEncourage elaboration of resistance

• What makes it so hard?What makes it so hard?• What would help?What would help?

Allow silenceAllow silence Support self-efficacySupport self-efficacy

PHILOSOPHICAL APPROACH OF PHILOSOPHICAL APPROACH OF MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWING

RespectfulRespectful NonjudgmentalNonjudgmental ReflectiveReflective Encourages “Change” talk from clientEncourages “Change” talk from client

One of the biggest difference One of the biggest difference between MI techniques and other between MI techniques and other techniques is that the CLIENT is techniques is that the CLIENT is the one who verbalizes the need the one who verbalizes the need

for change rather than the for change rather than the counselorcounselor

EIGHT METHODS OF EIGHT METHODS OF EVOKING CHANGE TALKEVOKING CHANGE TALK

ElaboratingElaborating Asking evocative questionsAsking evocative questions Using the “Importance ruler”Using the “Importance ruler” Querying extremesQuerying extremes Exploring decisional balanceExploring decisional balance Looking backLooking back Looking forwardLooking forward Exploring goals and valuesExploring goals and values

ELABORATINGELABORATING Understand your client’s world viewUnderstand your client’s world view

Tell me about your (behavior). When did it start? When did it Tell me about your (behavior). When did it start? When did it become a problem for you/ for others?become a problem for you/ for others?

““How do you feel about it?”How do you feel about it?”• ““What do you get out of (problem behavior)?What do you get out of (problem behavior)?• ““How do you think it causes difficulties for you?How do you think it causes difficulties for you?

Express empathyExpress empathy• ““I can see why this must be hard for you…”I can see why this must be hard for you…”

Summarize ambivalenceSummarize ambivalence Begin to develop discrepancy between the polarized Begin to develop discrepancy between the polarized

urgesurges ExamplesExamples

• So on one hand…and on the other…So on one hand…and on the other…• Part of your wants…And the other part…Part of your wants…And the other part…

ASKING EVOCATIVE ASKING EVOCATIVE QUESTIONSQUESTIONS

Evoking an emotionally “charged”/ evocative Evoking an emotionally “charged”/ evocative response is important for change to take placeresponse is important for change to take place

You know your question is evocative if the client You know your question is evocative if the client has to think about his or her responsehas to think about his or her response

Tone of voice is exploratory, not criticalTone of voice is exploratory, not critical ExamplesExamples

What if you choose to continue _____?What if you choose to continue _____? What if you choose to decrease/ stop _____?What if you choose to decrease/ stop _____?

USING THE “IMPORTANCE USING THE “IMPORTANCE RULER”RULER”

Three parts:Three parts:

First Part:First Part:• On a scale of 1 to 10, 10 being “absolutely On a scale of 1 to 10, 10 being “absolutely

yes” and 1 being “no way”, how motivated yes” and 1 being “no way”, how motivated are you to ______?are you to ______?

• Ten is always direction you want the change to goTen is always direction you want the change to go• Sometimes it’s necessary to exaggerate the Sometimes it’s necessary to exaggerate the

extremesextremes

USING THE IMPORTANCE USING THE IMPORTANCE RULLERRULLER

Second Part:Second Part: Whatever number they give you, select one or two Whatever number they give you, select one or two

numbers BELOW and ask: Why a 6 instead of a 4?numbers BELOW and ask: Why a 6 instead of a 4?

By choosing a number below, you are eliciting By choosing a number below, you are eliciting change talk from the clientchange talk from the client

USING THE IMPORTANCE USING THE IMPORTANCE RULERRULER

Third Part:Third Part: Take a number or two above what they gave you and Take a number or two above what they gave you and

ask: What would it take to move you to a 7, not ask: What would it take to move you to a 7, not actually (changing the behavior), but a little more actually (changing the behavior), but a little more comfortable with the idea?comfortable with the idea?

Be sure to elicit something the client has Be sure to elicit something the client has control overcontrol over

Whatever the client tells you becomes the Whatever the client tells you becomes the treatment plan.treatment plan.


Make sure the plan is something the client can Make sure the plan is something the client can actually accomplishactually accomplish

Work with the client exploring potential barriers Work with the client exploring potential barriers to the plan and appropriate solutionsto the plan and appropriate solutions

Set an appropriate time line for implementing the Set an appropriate time line for implementing the plan (client-directed, if at all possible)plan (client-directed, if at all possible)

Sometimes an appropriate plan is that the client Sometimes an appropriate plan is that the client will think about the issue.will think about the issue.


Sometimes the issue is not importance or Sometimes the issue is not importance or motivation, but confidencemotivation, but confidence

This is often obvious when the client provides an This is often obvious when the client provides an 8 or 9 on the Importance Ruler and yet remains 8 or 9 on the Importance Ruler and yet remains stuckstuck


If you believe motivation has increased during a If you believe motivation has increased during a session, use the ruler againsession, use the ruler again

Group Application:Group Application: Clients identify where they are on the rulerClients identify where they are on the ruler Have the clients with low numbers ask the clients with higher Have the clients with low numbers ask the clients with higher

numbers to reflect on how they got therenumbers to reflect on how they got there Have the clients with high numbers ask the clients with low Have the clients with high numbers ask the clients with low

numbers how they intend to movenumbers how they intend to move

QUERYING EXTREMESQUERYING EXTREMES

Always target CURRENT behaviorAlways target CURRENT behavior

ExampleExample What’s the worst thing about it?What’s the worst thing about it? What’s the best thing about it?What’s the best thing about it?

EXPLORING DECISIONAL EXPLORING DECISIONAL BALANCEBALANCE

Always target CURRENT behaviorAlways target CURRENT behavior

Elicit pros and consElicit pros and cons ““What do you get out of (behavior)?”What do you get out of (behavior)?” ““What problems does it cause?”What problems does it cause?”

LOOKING BACKLOOKING BACK

Always target CURRENT behaviorAlways target CURRENT behavior Example:Example:

When was the last time _____ really made you feel good/ better/ worked for you?When was the last time _____ really made you feel good/ better/ worked for you?

The phrase “really worked for you” refers to all aspects The phrase “really worked for you” refers to all aspects of lifeof life

If this elicits a poignant reply, your best response is If this elicits a poignant reply, your best response is SILENCESILENCE

HARD, for us health care providersHARD, for us health care providers We’re TRAINED to fix and intervene…silence often feels like We’re TRAINED to fix and intervene…silence often feels like

failure or inactionfailure or inaction Often can be a powerful therapeutic tool in that it can powerfully Often can be a powerful therapeutic tool in that it can powerfully

deepen the client’s insight into the issues at hand)deepen the client’s insight into the issues at hand)

EXPLORING GOALS (LOOKING EXPLORING GOALS (LOOKING FORWARD) AND VALUESFORWARD) AND VALUES

Three Parts:Three Parts: First Part:First Part:

• What do you see yourself doing ___ months/ years What do you see yourself doing ___ months/ years from now ( or next year)? from now ( or next year)?

Do not use with individuals who :Do not use with individuals who : You suspect are potentially suicidalYou suspect are potentially suicidal Terminal Terminal


Second Part:Second Part: What are your top three values and why?What are your top three values and why?

Define a value if necessaryDefine a value if necessary

Always get three (never settle for “I don’t Always get three (never settle for “I don’t know” from clients)know” from clients)


Third Part:Third Part: How do you think (current behavior) fits with How do you think (current behavior) fits with

these values?these values? Tone of Voice is Tone of Voice is exploratoryexploratory, NOT critical, NOT critical Best used following some discussion Best used following some discussion

about the key issue to be changedabout the key issue to be changed This technique alone has been correlated This technique alone has been correlated

with changewith change

It is CRITICAL to engage clients It is CRITICAL to engage clients in treatment planin treatment plan

(especially adolescents!!!)(especially adolescents!!!)

Giving information and adviceGiving information and advice

Ask for permissionAsk for permission Qualify honoring autonomyQualify honoring autonomy

““Of course, while I can only suggest, you’re ultimately Of course, while I can only suggest, you’re ultimately the one to decide…”the one to decide…”

Ask – Provide – AskAsk – Provide – Ask “…“….what do you think of that? Do you think that .what do you think of that? Do you think that

would work for you? Why? Why not?”would work for you? Why? Why not?”

For suggestions, offer several, not one For suggestions, offer several, not one (otherwise it looks like the “right” answer)(otherwise it looks like the “right” answer)

RememberRemember

Stress physiology is often driving “problem Stress physiology is often driving “problem behavior”behavior”

Make sure you/ someone on health care team is Make sure you/ someone on health care team is exploring stress reduction techniques with clientexploring stress reduction techniques with client

When stress is managed in a more healthy, pro-When stress is managed in a more healthy, pro-social way, need for problem behavior social way, need for problem behavior diminishesdiminishes

ResourcesResources

www.motivationalinterview.orgwww.motivationalinterview.org TIPS Manual (SAMHSA)TIPS Manual (SAMHSA) Project Match (NIAAA)Project Match (NIAAA) Motivational Interviewing (Miller and Motivational Interviewing (Miller and

Rollnick)Rollnick)

ReferencesReferences Lundberg, KJ. “Introduction to motivational interviewing”; on-line Lundberg, KJ. “Introduction to motivational interviewing”; on-line

Powerpoint presentation at: Powerpoint presentation at: http://humanservices.slco.org/pdf/Long_MI_without_ASAM.pdfhttp://humanservices.slco.org/pdf/Long_MI_without_ASAM.pdf

Miller WR, Rollnick S. Motivational Interviewing: preparing people for Miller WR, Rollnick S. Motivational Interviewing: preparing people for change, 2change, 2ndnd ed. New York, NY: Guilford Press; 2002. ed. New York, NY: Guilford Press; 2002.

Miller WR, Rollnick S. What’s new since MI-2? Presentation in Stockholm, Miller WR, Rollnick S. What’s new since MI-2? Presentation in Stockholm, Sweden, June 2010 (at www.motivationalinterview.orgSweden, June 2010 (at www.motivationalinterview.org

Prochaska, JO, DiClemente CC. Stages of change in the modification of Prochaska, JO, DiClemente CC. Stages of change in the modification of problem behaviors. problem behaviors. Prog Behav ModifProg Behav Modif 1992;28:183. 1992;28:183.

Levy S, Knight JR. “Office-based management of adolescent substance Levy S, Knight JR. “Office-based management of adolescent substance use and abuse”, in Adolescent Health Care: a practical guide, 5use and abuse”, in Adolescent Health Care: a practical guide, 5thth ed. ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2008.Philadelphia, PA: Lippincott, Williams and Wilkins; 2008.

Documents

Introduction to Motivational Interviewing Nimi Singh, MD, MPH Division of Adolescent Health and Medicine University of Minnesota Amplatz Children’s Hospital