Motivational Interviewing

“A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” – Miller & Rollnick, 2002

 

Basic Concept/Idea behind motivational interviewing: “Helping people talk themselves into changing”

 

Basics of Motivational Interviewing (MI):

 

  • A model to describe how people change
  • Identifies a client’s own fears and difficulties about change and helps to resolve the issues
  • Not just a series of techniques for doing therapy but instead is a way of being with patients.
  • Not a technique for tricking your patients into doing something that they do not want to do
  • Skillful clinical style for eliciting from patients their own good motivation for making changes and identifying patients’ ambivalence about change and helping to resolve it
  • Guiding more than directing, eliciting more than imparting and listening at least as much as telling

 

Theoretical Foundations of MI

 

  • Client-centered therapy (Carl Rogers)
  • Self-efficacy (Albert Bandura)
  • Transtheoretical model (Prochaska & DiClemente)

 

Guiding Principles

 

  • Resist the “righting” reflex
  • Understand and explore the patients own motivation
  • Listen with empathy
  • Empower and instill hope and optimism

 

Why use MI?

 

  • Evidence-based – it works!
  • Effective across populations and cultures
  • Improves adherence and retention in care by actively involving individuals in their own care
  • Reduces clinician burnout: Promotes healthy “helping” role for clinicians

 

Motivation

 

  • Motivation is multidimensional, dynamic, has external and internal factors, and is the Key to change
  • Motivation can be elicited and enhanced and assess the state of readiness
  • Two important dimensions of Motivation:
    • Importance: the “why” of change
    • Confidence: the “how” of change

 

Components of Motivation:

 

  1. Ready: a matter of priorities
  2. Willing: importance of change
  3. Able: confidence to change

 

The ABCs of Motivation and change

 

  1. Accept: Patient must accept that the behavior is a problem
  2. Believe: Patient must believe that they will be better off if they change
  3. Confidence: Patient must have confidence in their ability to change

 

6 Stages of Change

 

  1. Precontemplation: No way. (Denial)
  2. Contemplation: Maybe I can do this. (Ambivalence)
  3. Determination/Preparation: Let’s do this! (Motivated)
  4. Action: Doing it.
  5. Maintenance: Living it
  6. Relapse/Recycle: Ugh!! Back to 1…

 

Basic Tool: OARS

 

O: Open-ended Questions: Encourages patient to talk more and for provider to learn more about patient’s concerns

 

  • What makes you feel it might be time for a change?
  • Can you tell me more about that?
  • What have you noticed about your ____?
  • What concerns you most?
  • How would you like things to be different?
  • What will you lose if you give up drinking?
  • What have you tried before?
  • What do you want to do next?

 

A: Affirmations: Statements that show recognition of patient’s strengths

 

  • “So you’ve started walking this past week!”
  • “You didn’t want to come today, but you did!”

 

R: Reflective Listening: Listening and trying to understand the patient’s point of view even if you disagree with it

 

  • Communicating (to the patient) your understanding of his/her experience, behavior and/or feelings from their point of view.
  • The following are not congruent with reflective listening:
    • Ordering, directing or commanding
    • Warning, cautioning or threatening
    • Giving advice, making suggestions or providing solutions or providing solutions
    • Persuading with logic, arguing, lecturing
    • Telling people what they should do Telling
    • Disagreeing, judging, criticizing or blaming

 

S: Summarizing: Special form of reflective listening

 

  • Ensures clear communication
  • Use at transitions in conversation
  • Be concise
  • Reflect ambivalence
  • Accentuate “change talk”
  • “Let me see if I understand thus far…”

 

Principles of Motivational Interviewing:

 

  1. Express Empathy
  2. Develop Discrepancy
  3. Roll with Resistance
  4. Support Self-efficacy

 

Examples of questions used in MI to encourage patient (not provider), explore ambivalence, and minimize resistance:

 

  • What are some of the good things about X behavior?
  • People usually do X because they feel it helps in some way. How has it helped you?
  • What do you like about the effects of X?
  • What would you miss if you weren’t doing X?
  • Can you tell me about the down side?
  • What are some aspects you are not so happy about?
  • What are the things you wouldn’t miss?
  • If you continued as before, how do you see yourself in a couple of years from now if you don’t change?
  • On a scale of 1-10, how important is it to you to change X behavior?
  • Why did you give it a higher # and not a (lower #) ?”
  • What would have to happen to raise that score from # to #
  • “How might I help you with that?”

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