Mi queen's 2013 pub

Motivational Interviewing

Marilyn Herie PhD RSW

Health, Counselling and Disability Services Queen’s University September 4, 2013

marilyn.herie@utoronto.ca @MarilynHerie www.educateria.com

• Dr. Marilyn Herie is the Academic Chair, Community Services at Centennial College in Toronto, Canada, and Assistant Professor (Status Only), University of Toronto Factor-Inwentash Faculty of Social Work. She is a member of the international Motivational Interviewing Network of Trainers (MINT), and has published numerous books, chapters and journal articles on addiction, professional education and evidence-based practice, including Substance Abuse in Canada with Oxford University Press. Dr. Herie’s areas of interest and focus include e-learning and classroom teaching, motivational interviewing and health behaviour change, education research and evaluation, social media and interprofessional education. She blogs about education and teaching-related topics at www.educateria.com.

First, empty your cup

A scientist went to visit a famous Zen master. While the master quietly served tea, the scientist talked about Zen. The master poured the visitor's cup to the brim, and then kept pouring. The scientist watched the overflowing cup until he could no longer restrain himself. "It's overfull! No more will go in!" the scientist blurted. "You are like this cup," the master replied, "How can I show you Zen unless you first empty your cup?" http://users.rider.edu/~suler/zenstory/emptycup.html

Confidence Ruler

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No Way I am Bill Miller

http://www.williamrmiller.net/

Learning Objectives At the end of this session, you will be able to: 1. Frame MI as a way of being with your client

– evocation versus installation 2. Review and practice the five key MI

strategies 3. Troubleshoot challenging practice

issues/cases 4. Identify barriers and enablers to

implementing MI skills with clients 5. Set concrete implementation objectives for

clinical practice

Motivational Interviewing Three Definitions

1. What is it for? Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for, and commitment to, change

Spirit of MI

Who was your favourite teacher?

The “Spirit” of Motivational Interviewing

• Partnership • Acceptance • Compassion • Evocation

• Absolute worth • Accurate empathy • Autonomy support • Affirmation

12 Miller & Rollnick 2013

Partnership

“You are the best judge of what is going to work for you.”

Acceptance

“I am here to help whatever you decide to do.”

Compassion

Guide me to be a patient companion, to listen with a heart as open as the sky. Grant me vision to see through his eyes, and eager ears to hear his story…Let me honour and respect his choosing of his own path.

Adapted from Miller, 2013, “A Meditative Preparation” (p.24)

Evocation

“What were you hoping for by coming here today?”

Common Human Reactions to Being Listened to

• Understood • Want to talk more • Liking the counselor • Open • Accepted • Respected • Engaged • Able to change

• Safe • Empowered • Hopeful • Comfortable • Interested • Want to come back • Cooperative

17 Slide from Bill Miller

2. Why would I use it? Motivational interviewing is a person-centered counseling method for addressing the common problem of ambivalence about change

Miller & Rollnick 2013

The “Righting Reflex” http://tinyurl.com/lyk4gqo

http://tinyurl.com/lbcvo76

Practitioner to the rescue!

Yes, but…

“Unsolicited advice is the junk mail of life.” (Bern Williams, in Miller & Rollnick 2013)

Common Reactions to Righting Reflex

• Angry, agitated • Oppositional • Discounting • Defensive • Justifying • Not understood • Not heard • Procrastinate

• Afraid • Helpless, overwhelmed • Ashamed • Trapped • Disengaged • Not come back – avoid • Uncomfortable

Common Human Reactions to Being Listened to

• Understood • Want to talk more • Liking the counselor • Open • Accepted • Respected • Engaged • Able to change

• Safe • Empowered • Hopeful • Comfortable • Interested • Want to come back • Cooperative

But what if the person refuses to change?

A 'No' uttered from the deepest conviction is better than a 'Yes' merely uttered to please, or worse, to avoid trouble.

Mahatma Gandhi

“He that complies against his will is of the same opinion still.”

Samuel Butler 1612-1680 English Poet

Motivational Interviewing in Dental Practice How NOT to do it: Emily’s Oral Piercing

http://tinyurl.com/c2kh3z9

The Righting Reflex

Motivational Interviewing in Dental Practice Emily’s Oral Piercing

http://tinyurl.com/bojtj92

A Better Way

Quick Reflection: How confident are you feeling?

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“Spirit” of MI – Resist the Righting Reflex

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“Spirit” of MI – Directional (versus directive)

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“Spirit” of MI – Evoke (versus educate)

The Evidence Base for Motivational Interviewing

Research publications evaluating MI effectiveness have been doubling every three years.

www.motivationalinterview.org

MI Applications • Public health &

workplace • Sexual health • Dietary change • Weight management • Voice therapy • Gambling • Physical activity • Stroke rehab • Chronic pain

• Medication adherence • Diabetes • Mental health • Addictions • Fibromyalgia • Chronic leg ulceration • Self-care • Criminal justice • Vascular risk • Domestic violence

Anstiss, 2009

A Causal Chain for MI

Therapist MI-consistent speech

Increased client change talk

Improved treatment outcomes

Moyers et al., 2009

“What [practitioners] reflect, they will hear more of.”

Moyers et al., 2009

2002 2009

2012 2013

2008 2011

Engaging

Focusing Evoking

Planning

Four Processes in MI

Adapted from Miller and Rollnick, 2013, p. 26

Engaging

Focusing

Evoking

Planning

3. How does it work? Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

Change Talk

Change Talk and Sustain Talk

Opposite Sides of a Coin

Sustain Talk and Resistance

• Sustain Talk is about the target behavior • Discord is about your relationship • Both are highly responsive to counsellor

style • We respond to both in the same way

DARN CAT • Desire • Ability • Reasons • Need

• Commitment • Activation • Taking Steps

Yet another metaphor MI Hill

Contemplation Preparation Action (Pre-)

Slide from Bill Miller, 2010

DARN CAT

• Desire • Ability • Reasons • Need

• Commitment • Action • Taking Steps

Snap fingers = DARN

Clap = CAT

Silence = No change talk Motivational Interviewing Network of Trainers (MINT)

Listening for Change Talk

“Things are getting totally messed up with my courses.”

“My parents are the ones who are worried about my grades.”

“I am not addicted to smoking pot. I can quit anytime I want.”

“I want to get well again, but this whole situation is totally unfair.”

“I have started working out, quit smoking and drinking, have joined Varsity basketball and am attending all of my classes.”

When you are not sure where to go next…

“Tell me more…Tell me more…”

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Recognizing Change Talk

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Evoking Change Talk

Foundation Skills:

O A R S

FOUR KEY STRATEGIES – OARS OPEN questions (to elicit client change talk)

AFFIRM the client appropriately (support, emphasize personal control)

REFLECT (try for complex reflections)

SUMMARIZE ambivalence, offer double-sided reflection

Open Questions

Open versus Closed Questions • CLOSED questions invite a “yes/no”,

one- word or very limited answer • OPEN questions encourage elaboration –

they evoke the client’s ideas, opinions, hopes, concerns, etc.

Affirmations

Affirmations: • Go beyond “giving a good grade” • Are not about the practitioner’s approval

of the client • Acknowledge the client’s experience,

struggle, expertise, efforts, etc.

Example of Praising:

You are such a wonderful group - I have really enjoyed our session.

Example of Affirming The group has worked hard today in exploring some tough issues, and we have come closer as a result of that.

Choose one of your most challenging patients – and come up with an affirmation that you could offer

http://www.gems.tv/

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Open-ended Questions

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Affirmations (versus praise)

Reflections

UNDIVIDED ATTENTION

“To Listen”

IMPERIAL

Simple Reflection

Complex Reflection

Simple Reflection

Complex Reflection

They are really on your case about your cannabis use.

It wasn’t your idea to come, and you’re not sure this is going to be at all helpful to you.

“I’m only coming to see you because my parents and my boyfriend are all pressuring me about smoking pot.”

Simple Reflection

Complex Reflection

How you see it is, they are the ones who have a problem with it, and that is frustrating.

Simple Reflection

Complex Reflection

It would feel a lot better if they respected that what you do or not do is your choice and decision.

Simple Reflection

Complex Reflection

Even if you did have any concerns, all this pressure makes it hard to want to change.

Video Demonstration: A tough question…

http://tinyurl.com/kxomabp

Practicing Reflective Listening

Individually, take a moment to write down an example of a simple and a complex reflection for the following statement (coming up – next slide).

Then compare what you wrote with others at your table. As a group, choose the best examples to share with the larger group.

Practicing Reflective Listening (1)

“How I live my life is no one else’s business, and certainly not yours!”

Simple Reflection:

___________________________________

Complex (Enhanced) Reflection:

___________________________________

“How I live my life is my own business and certainly not yours.”

Simple Reflection:

You are the only one to decide how to live your life.

You’re being told you have to make all these changes, and that doesn’t feel very respectful of your choice and autonomy.

“How I live my life is my own business and certainly not yours.”

Practicing Reflective Listening (2)

“I know you mean well, but I don’t need this medication any more.”

Simple Reflection:

___________________________________

Simple Reflection:

You see that I am concerned, but you are ready to stop taking the medication.

You feel like I am pushing for you to take this medication, and not really appreciating where you are at.

More Reflections • I am not going to call a crisis line. • I was too busy to do that homework

you gave me. • I am a perfectionist – I don’t stop until I

get something perfect. • How am I supposed to improve my self-

esteem? • I don’t have time to eat. • Anxiety motivates me.

Reflecting Panel

Motivational Interviewing Network of Trainers (MINT)

1. Four volunteers: Counsellors

2. One volunteer: Client Something you are considering

changing/struggling with

3. One volunteer: Coach A sounding board for the “client”

Reflecting Panel Instructions

1. Client: Share a paragraph with the Reflecting Panel about your struggle/experience

2. Panel: Take turns offering a single reflection 3. Client: After ALL Panel members are done,

talk to your coach about which reflection resonates most for you and why

4. Client: Offer this feedback to the panel, and continue the paragraph

Motivational Interviewing Network of Trainers (MINT)

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Simple Reflections

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Complex Reflections

Summary Statements

Why use summary statements?

• To check your understanding of the person’s situation as a whole

• To reflect back key components of what the person has discussed

• To signal a transition to another topic or the end of the session/consultation

• To highlight change talk

Example of OARS (including Summary Statement)

“Angry Bob” http://www.youtube.com/user/teachproject#p/u/5/79YTuZUFRIc

Partner A: Something you are considering changing

Partner B:

• Start with an open question

• Follow up with two reflective statements

• Offer an affirmation

• End with a summary statement

Hands-on Practice: O A R S

The 5th Foundation Skill:

Providing Information in a Motivational Way

“Advice is what we ask for when we already know the answer but wish we didn’t.” (Erica Jong, in Miller & Rollnick 2013)

Agenda-Mapping

Agenda Mapping • A brief discussion with the client, where

he/she has the most decision-making freedom possible

• The client chooses what area toward better health they want to discuss

• No topic is off limits – success in one area can lead to success in another

• Start with understanding the patient’s perspectives and preferences

• Try not to ‘trap’ the person by suggesting a lifestyle change (or focusing too soon on change) once the person raises a lifestyle area

Tips for Agenda Mapping

• Consider providing the patient with a finite list of topics to choose from, and asking them if any of the areas they want to discuss are included in that list

• After the patient responds, feel free to mention topics that you want to talk about

Tips for Agenda Mapping

Strategies Include… • Asking for elaboration • Reflective listening • Emphasizing personal choice and

control • Asking permission before making

suggestions • Summary statements

Agenda-Mapping Worksheet Priorities

Priorities Diagnosis Treatment

Symptoms

Agenda-Mapping Worksheet

Symptoms

Grades

Stress

Relationship

“Given these possible areas to focus, what would you like to talk about in our time together today?”

Symptoms

Grades

Stress

Relationship

Agenda Mapping conversation with "Sal“ http://www.youtube.com/watch?v=klnHJ4coG8o

Agenda Mapping

“Readiness Ruler”

• How important is it to change this behaviour?

• How confident are you that you could make this change?

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People usually have several things they would like to change in their lives – this may be only one of those things. Answer the following two questions with respect to your goal for this week.

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Agenda-mapping

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Readiness Ruler

Putting it all together

“A Psychological Law”

I learn what I believe as I hear myself speak.

Bill Miller (Based on D. Bem, 1967, “Self-Perception: An alternative interpretation of cognitive dissonance phenomena”)

…or put another way…

The word you keep between your lips is your slave. The word you speak is your master. - Arabic proverb

Motivational Interviewing Coding Sheet

• Number of closed questions: __________ • Number of open questions: __________ • Number of simple reflections: _________ • Number of complex reflections: _______ • Change statements by client: _______ • Sustain statements by client: __________ • Therapist talk time (approx.): __________ %

Targets: Twice as many reflections as questions At least 50% complex reflections No more than 50% therapist talk time

MI “Spirit” (low) (high)

Partnership 1 2 3 4 5

Acceptance 1 2 3 4 5

Compassion 1 2 3 4 5

Evocation 1 2 3 4 5 Herie & Skinner 2013, adapted from Moyers et al. MITI coding guide

How Not to Do It

A conversation with Sal about his asthma http://www.youtube.com/watch?v=kN7T-cmb_l0

A Better Way

A conversation with Sal about his asthma http://www.youtube.com/watch?v=-RXy8Li3ZaE

Ineffective Practitioner

Effective Practitioner

Closed Questions 2 0

Open Questions 0 3

Simple Reflections 0 1

Complex Reflections 1 6

Change Statements 1 7

Sustain Statements 8 8

Therapist Talk Time 70% 50%

Let’s Compare

Hands-on Practice • In groups of three, take three roles:

– Person “A” describe a change you are thinking of making in the next 6 months – 1 year

– Person “B” respond using motivational strategies – Person “C” observe and give feedback

Each “Real Play” will take 5 minutes. After each turn, rotate the roles so that everyone has a chance to practice and receive feedback. Please HOLD your feedback until everyone has had a chance to practice – you will have an opportunity to debrief as a small group at the end of this exercise

In groups of three, take three roles: – Person “A” describe a change you are thinking

of making in the next 6 months – 1 year – Person “B” respond using motivational

strategies – Person “C” observe and give feedback

Re-write this challenging case:

• From the client’s perspective • From the client's parents’ or

partner’s perspective • From the faculty’s perspective

Here’s how we see the case from our perspective:

Let’s re-imagine this case in a different way

The goal is to find a way in

Bridging the learning-practice gap

What are the MI skills that you will commit to using?

• MI Spirit • Identify and evoke change talk • OARS • Using Elicit/Provide/Elicit to provide

information • Agenda-mapping • Other?

Engaging

Focusing

Evoking Planning

Motivational Interviewing: Practice Tips MI Spirit: The Essential Foundation

Partnership: You and the client are equal experts

Acceptance: Absolute worth, accurate empathy, autonomy support, affirmation

Compassion: Beneficence, caring, focus on the other

Evocation: The client’s wisdom is most important

OARS: Key Skills

Open Questions: What are your reasons for change? How might you go about it in order to succeed?

Affirmation: You have worked hard to make this happen. I can see that you’ve given this a lot of thought.

Reflections: You wish that… You would like to…

Summary Statements: Let me make sure I understand how this all fits together…

Diagnosis Treatment Plan

Symptoms

Benefits

Finances

Stress

Relationship

Agenda-Mapping Can we take a few minutes to talk about the different issues or concerns that you or others have? Just to get a “big picture” view of what you are coping with right now…

Given all of these possible areas for change, what are your priorities? Where would be the most helpful place for us to start?

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People usually have multiple or competing priorities. On a scale of zero-to-ten, how important is it to change…? How confident are you that you could make this change?

Readiness Ruler

Why did you say [lower number] and not [higher number]?

What would it take to go from [lower number] to [higher number]?

Elicit: What do you already know about…?

Provide information: Be brief!

Elicit: How does that fit for you? What do you make of that?

Listen for Change Talk: DARN CAT

Desire, Ability, Reasons, Need

Commitment, Activation, Taking Steps

Four MI Processes

Recommended Resources Martino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C.,

Hamilton, J., and Hausotter, W. (2006). Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA STEP). Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University.

http://www.motivationalinterview.org/Documents//MIA-STEP.pdf Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change

(Third Edition). New York: Guilford. Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not.

Behavioural and Cognitive Psychotherapy, 37, 129-140. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416

Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: The Guildford Press.

First chapter and table of contents available at www.motivationalinterview.org Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner

Workbook. New York: Guilford. Wagner, C.C. & Ingersoll, K.S. (2013). Motivational Interviewing in Groups. New

York: Guilford Useful Websites Motivational Interviewing Website http://www.motivationalinterview.net/ Motivational Interviewing Network of Trainers (MINT) Website www.motivationalinterviewing.org Examples of Motivational Interviewing Videos on YouTube http://www.youtube.com/user/teachproject#p/u

Motivational Interviewing Glossary of Acronyms Compiled by Marilyn Herie, PhD, RSW November, 2012 ACE (Spirit of MI from Miller and Rollnick 2002 edition) Autonomy / Collaboration / Evocation versus Authority / Coercion / Education OARS (Fundamental strategies of MI) Open questions / Affirmations / Reflections / Summary statements EARS (Strategies for eliciting change talk) Evocation / Affirmation / Reflective listening / Summary statements RULE (Fundamental strategies in MI v.2) Resist the righting reflex / Understand reasons for change (motivation) / Listen empathically / Empower

the client to use own resources DARN CAT (Types of preparatory change talk and commitment language) Desire / Ability / Reasons / Need / Commitment / Action / Taking steps FRAMES (Ingredients of brief, motivational interventions) Feedback / Responsibility / Advice / Menu (of strategies)/ Empathy / Self-efficacy RAISE (How to give advice) Relationship / Advice to change / “I” statements (affirmation) / Support autonomy / Empathy READS (Principles of MI) Roll with resistance / Express empathy / Avoid argumentation / Develop discrepancy / Support self-

efficacy PACE (Spirit of MI from Miller and Rollnick 2013 edition) Partnership / Acceptance / Compassion / Evocation MIST (Coding form) Motivational Interviewing Supervision and Training Scale MITI (Coding form) Motivational Interviewing Treatment Integrity Coding Form MET (Manual-based motivational intervention) Motivational Enhancement Therapy MIA (Coding abbreviation, used in the MITI) Motivational Interviewing Adherent MINA (Coding abbreviation, used in the MITI) Motivational Interviewing Non-Adherent MIA-STEP (MI supervision manual and coding resource) Motivational Interviewing Assessment – Supervisory Tools for Enhancing Proficiency AMI Adaptations of Motivational Interviewing

Additional Reflections and Next Steps

Confidence Ruler

0 1 2 3 4 5 6 7 8 9 10

No Way I am Bill Miller

http://www.williamrmiller.net/

“When people are ready to, they change. They never do it before then, and sometimes they die before they get around to it. You can't make them change if they don't want to, just like when they do want to, you can't stop them.” ― Andy Warhol, Andy Warhol in His Own Words

http://en.wikipedia.org/wiki/File:Warhol-Campbell Soup-1-screenprint-1968.jpg

Thank you

marilyn.herie@utoronto.ca

www.educateria.com

@MarilynHerie

Life can only be understood backwards, but it must be lived forwards. -Kierkegaard

Mi queen's 2013 pub

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