“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)
- 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 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:
- Ready: a matter of priorities
- Willing: importance of change
- Able: confidence to change
The ABCs of Motivation and change
- Accept: Patient must accept that the behavior is a problem
- Believe: Patient must believe that they will be better off if they change
- Confidence: Patient must have confidence in their ability to change
6 Stages of Change
- Precontemplation: No way. (Denial)
- Contemplation: Maybe I can do this. (Ambivalence)
- Determination/Preparation: Let’s do this! (Motivated)
- Action: Doing it.
- Maintenance: Living it
- 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:
- Express Empathy
- Develop Discrepancy
- Roll with Resistance
- 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?”