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Motivational Interviewing Kristin S. Vickers Douglas, Ph.D., ABPP, L.P. Professor of Psychology Mayo Clinic Department of Psychiatry and Psychology

DISCLOSURE

Relevant Financial Relationship(s) None

Off Label Usage None

Industry Acknowledgment

None

Learning Objectives 1. To normalize provider frustration or lack of

confidence in communicating with patients about behavior change.

2. To describe applications of motivational interviewing to brief encounters.

3. To review specific communication strategies for expressing a concern, providing education, and enhancing patient motivation.

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What I really want to say • “Change now or you could die”

• “You aren’t going to do anything I tell you anyway”

• “Those are lame excuses”

• “Why did you come here today if you are unwilling to change anything?”

• “Arggggghhh”

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But I don’t say it, because • Compassion

• Concern

• Fear of consequences

• Hope

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Motivational Interviewing: Essential Elements and Definition • MI is a particular kind of conversation about

change

• MI is collaborative (person-centered, partnership, honors autonomy, not expert - recipient)

• MI is evocative, seeks to call forth the person’s own motivation and commitment

What is MI for? • MI is a collaborative conversation to strengthen

motivation and commitment for behavior change

Why would I use it? MI is a person-centered counseling method for

addressing the common problem of ambivalence about behavior change

How does it work? • MI is a collaborative, goal-oriented method of

communication with particular attention to the language of change.

• It is intended to strengthen personal motivation for and commitment to a target behavior change by eliciting and exploring an individual’s arguments for change (change talk)

Is Motivational Interviewing Effective? • Systematic review of 72 studies (Rubak et al., 2005)

• Motivational interviewing outperformed traditional advice giving in 80% of studies.

• Meta-analysis of 119 studies from last 25 years (Lundahl et al., 2010) • MI produced statistically significant, durable results when

compared to control conditions. • Achieved comparable results (not significantly different) to other

active treatments.

Motivational Interviewing Key Principles

• R—Resist the righting reflex (resist fixing)

• U—Understand client’s motivation (ambivalence)

• L—Listen to your client (reflect)

• E—Empower your client (engage)

Rollnick (2008)

Collaboration

Acceptance

Evocation

Compassion MI

Spirit

Motivational Interviewing Spirit

Planning

Evoking

Focusing

Engaging

Foundational MI skills: OARS • Open-ended questions

• Affirmations

• Reflective listening

• Summarizing

Change Talk • Desire to change

• Ability to change (optimism, I can do it)

• Reasons for change (benefits of change)

• Needs (problems with the status quo)

Commitment statements and taking steps • I am going to…

• I will…

• I plan to…

• I intend to…

• I have already started to…

Eliciting Change Talk • Look back

• Is there a time that this was working? What has changed?

• Look forward • What are your hopes for the future with this?

• Explore goals • What do you want to accomplish with this?

When Providing Information or Options • Elicit

• What do you already know about…? • May I share a little with you about…?

• Provide • Provide information, feedback, options in

nonjudgmental manner

• Elicit • What are your thoughts on that? • How might that apply to you?

Expressing a concern Clinicians should feel empowered to offer concerns about a patient’s decisions or positions, but should be thoughtful about how they approach this communication.

1.Direct report of concerns without judgment. Use client statement’s when possible.

2.Statement about client’s responsibility for choice and change.

3.Patient’s view is solicited.

Smoking • Express concern

• MI questions: • If you look out 10 years from now, what do you want

to have happen with your smoking? Why? • What matters most to you about your smoking? • What are the good things about smoking these

days? What are the not so good things?

• Listen for change talk

• Reflect, affirm

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Medication Nonadherence • Melissa and her medication calendar

• Nonjudgmental feedback

• Express concern

• Honor autonomy

• Questions: • What are you willing to try? • What could work? • What would be good about trying that? • Why would now be a good time? ©2011 MFMER | slide-21

Diet • Weight bias research, sensitivity needed

• MI questions; open-ended, gauge willingness to engage in the conversation

• You have put a lot of time and effort into weight loss over the years, you being the expert in what works for you, what do you think is the very best approach?

• What would be a good next step? • What makes sense to try? • No weight loss lectures here. Instead, let’s have a

conversation about how I can best help you when you are ready for some support.

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Exercise • E-P-E framework and OARS

• What do you already know? • What are you most interested in? • What could work? • What are you willing to try

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What if I say all the right things in the right way and the patient still doesn’t change • Acceptance within the MI model

• Patient autonomy/right

• Change is process, motivation can shift

• How are you explaining/attributing this? My fault? Patient fault? Change is hard? • Impacts burn-out/compassion fatigue

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But what if I say it and it sounds awful and I want to run and hide? • Be transparent

• Own it and apologize

• Explain your values/concerns driving your decision to speak up.

• Work on the relationship • Engagement is the first step • How can I do this better?

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What can I do during a quick visit? • Resist the quick fix, especially when patient is

ambivalent about change

• Listen for change talk

• Use your OARS

• Elicit Provide Elicit when giving information

• Express a concern in MI framework

• Honor patient autonomy and responsibility for change

• Reinforce all progress!

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Motivational Interviewing Top 10 useful questions • What changes would you

most like to talk about? • What have you noticed

about . . .? • How important is it for

you to change . . .? • How confident do you

feel about changing . . .? • How do you see the

benefits of . . .?

• How do you see the drawback of . . .?

• What will make the most sense to you?

• How might things be different if you . . .?

• In what way . . .? • Where does this leave

you now?

BMJ 2010;340:c1900

Recommended Resources:

• www.motivationalinterview.org

• Miller, W.R. and Rollnick, S. (2013). Motivational Interviewing, Third Edition: Helping People Change. The Guilford Press: New York.

• Rosengren (2009). Building Motivational Interviewing Skills: A Practitioner Workbook (Applications of Motivational Interviewing Series).

• Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. BMJ. 2010 Apr 27;340:c1900. doi: 10.1136/bmj.c1900.