Motivational Interviewing

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Communication & Counseling

Does your communication with clients inspire motivation to change their lives? Change requires more than: Knowledge Competent skills The client needs to want to change behavior AND the motivation to change.
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Paula Ackerman, MS, RD, CDE UPDON www.diabetesinmichigan.org

Motivation
The mental process, function, or instinct that produces and sustains incentive or drive in human and animal behavior. Components Willing: degree of discrepancy between current behavior and future values Able: Ready: confidence for change setting priorities
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Counter-Motivation
Characteristics
Resistance Hopelessness Low self-efficacy

Signs
Interrupting Ignoring Arguing Denying Changing subject Talking off subject Daydreaming
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Motivational Interviewing
Introduced by William Miller and Stephen Rollnick in early 1990s (drug and alcohol addiction). Revised in 2008 with Christopher Butler for health care. New definition (2008) A skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.
Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior, 2007.
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Spirit of MI
Collaboration
Partnership, shared decision making between client and hcp

Evocative
Understand client goals Connecting behavior change with what client cares about (beliefs, values, concerns) Use these to evoke arguments for change

Honor Client Autonomy

Client ultimately decides what to do
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Motivational Interviewing
Style
A refined form of guiding (vs directing or following) Helps the client make his or her own decisions about behavior change

Principles of MI
Resisting the Righting Reflex
Health care providers (hcp) have a powerful desire to fix things
Becomes automatic or like a reflex

Problem: human tendency is to resist persuasion

(especially when they are ambivalent)

Principles of MI
Resist the Righting Reflex Understand Client Motivations Listen to Client Empower the Client
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Its not that badI feel fine; I know I should exercise more, BUT. The more a client hears themselves talk of the disadvantages of changing, the more committed they are to status quo.
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Principles of MI
Resisting the Righting Reflex Client s Role:
argue and provide reasons for change

Principles of MI
Understand Client Motivations
Be interested in the clients own concerns, values and motivations.

Ask Why they want to make a change and how they might do it. Listen to your Client
Should listen as much as you inform Use empathy

HCPs Role:
Guide them through ambivalence. Understand their motivations

Empower the Client

Helping the client explore how they can make a difference in their own health
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3 Communication Styles
Following: follows clients lead; willing and able to listen
I wont push you. Ill let you work it out on your own time

Core Skills of MI
Asking: to understand clients problems Listening: to understand the meaning of their problem correctly Informing: educating the client Must balance these skills; be flexible
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Directing: take charge; tell client what to do

I know what you should do

Guiding: tutor, resource, supporter, motivator

I can help you solve this for yourself.

3 styles often intermixed, shifting styles as appropriate to client and situation

MI Goals: Components of SelfManagement Support (SMS)

Emphasize client role Build relationships Include family Share info Collaborate on goals and action plans Problem solving Follow up on progress
www.newhealthpartnerships.org
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Emphasize Client Role

Client to take more responsibility/initiative in their health and self-management skills
I look forward to helping you do a better job in dealing with your DM. Just remember, we dont have to do this all at once.

Set expectations: how have client and hcp expectations changed over the yrs
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Client Roles
OLD Roles NEW Roles

Client Roles
OLD Roles Rely on hcp to solve problems Learn about condition from hcp Respond to hcp questions on progress during appointments Dont worry about meds
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Defer to hcp authority Share responsibility for own health Be passive. Be fixed Be active. Self-manage health by the hcp and condition. (HCP role is to coach, support and sometimes provide direction) Share history when Be assertive: share goals, history, asked values, beliefs and preferences Follow hcp orders Decide on tx plan with provider

NEW Roles Seek provider support in solving problems Learn from provider; inform self also. Seek new info Track own progress between hcp visits. Share info during visits Share responsibility for keeping med list up to date
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Set Expectations
You are in a position to do more to improve your diabetes than anyone else. My job, as your educator, is to provide you with the latest information on diabetes; to guide and support you. You will be doing most of the work. It may be difficult and challenging, at times. But we will work together to improve your condition and quality of life.
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Building Relationships
Ask open ended questions
Requires more than a one word answer Allows client to share their story or express concerns and feelings so the clinician can understand where theyre coming from. Use Tell me, What How as lead ins; avoid using Why
Tell me how you feel about having diabetes. What is the most difficult part of managing your diabetes
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Building Relationships
Reflective listening
Listen, express interest and understand the meaning of what client is saying (even if you disagree with it) Repeat back to the client your understanding of his/her experience or feelings from their point of view (using a short summary) So, you are saying. It sounds like. What Im hearing you say is Allow time for client to verify, correct, add or refine
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Building Relationships
Affirmations
Identify and acknowledge clients strengths. Believe in your client and their ability to change: promote self-esteem. Be genuine. Their attitudes are shaped by our words. Examples:
So youve started walking this past week! You didnt want to come today, but you did! Remember, most who need to make change have tried and are failed self-changers
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Roadblocks to Reflective Listening

Order, direct or command Give advice, make suggestions or provide solutions Warn, caution or threaten Persuade with logic, argue, lecture Disagree, judge, criticize or blame Question or probe Distraction, humor or changing the subject
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Building Relationships
Expressing empathy
Strive to understand the clients emotions, thoughts, values, fears Sounds like you feel pretty
overwhelmed with managing your diabetes. or So, you are worried about walking safely outside in the winter months.

Express understanding
Normalize Many people have higher blood sugar
readings in the morning.

Self-disclose (when appropriate) I also struggle

with finding time to get my physical therapy exercises in.
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Building Relationships
Expressing empathy
Use nonverbal communication
Face client Keep an open posture (do not fold arms) Lean toward client at times Maintain good eye contact Be relaxed.
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In communication, which of the following has the biggest influence on message delivery?
A. Words we use (7%) B. Tone of voice (38%) C. Body language (55%)

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Include Family
Family support is a major factor in self-mgt outcomes (positive support = positive outcomes; negative or no support = poorer outcomes) Ask client if they want family involved in appts (include in materials sent home to client) Dont want the family member to speak for the client, but you do want their input Encourage family to eat healthy also, be active, help with med adherence, goal achievement Monitor for self-care police
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Info Sharing
Encourage clients to share
Feelings What do they find hard Record keeping (BG, bp, wt, food, activity, steps)

Sharing what you know

What do you want to learn about eating? Would you rather I talk about meal planning or would you rather just ask me questions? How do you like to learnreading, seeing, doing, video; groups, 1:1?
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Collaborate on Goals
Success dependent on 2 kinds of motivation
Positive expectation or hope (the belief that change will do some good) Confidence or self efficacy (the belief that they can successfully make the change, even with some slip ups)

Goal Setting
Specific activity that you will do. It must be something:
You WANT to do. You reasonably CAN do. Behavior-specific What, where, how often, when, with who? The more specific the better You have a level of confidence
7 or higher on a scale of 1 to 10
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Problem Solving
Identify a problem or barrier to achieving goal Brainstorm with client options that may help to overcome the problem/barrier Select one of the options and try it Assess results.
If works, great If not, brainstorm other options. Concerns with ambivalence
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Ambivalence
Feeling 2 or more ways about something Not committed to change, undecided Values not aligned with change: not important enough Dont have sufficient DARN
Desire (Values, Emotions) Ability (Confidence, Self-Efficacy) Reasons (Pros/Cons) Needs (Importance, Priorities)
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Resolving Ambivalence
Key to behavior change
First goal: increase the discrepancy between current status and desired goal Second goal: Elicit, Listen and Respond to Change Talk (client needs to be the one voicing the
argument for change).

Reinforce Change Talk

Desire for change: I want to Ability to change: I know I can Reasons to change: It will help me to... Need to change: I have to because Commitment Language Terms:
Vow, promise, will, plan to, consider, may

Desire Ability Reasons Need

Commitment Language (Change Talk)

Behavior Change

Taking Steps
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Eliciting Change Talk

Ask evocative questions
How do you feel about checking your BG? (D, R) What is most important to you right now about your health?(R, N) What have you done to successfully lose weight in the past? (A) What would need to happen for you to begin an exercise program? (D, N) If you could see a future with your DM better controlled, what would that look like? (D, R)

(Tool for exploring ambivalence)

Cons Negatives about Changing changing behavior behavior? Not changing behavior
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Decisional Balance

Explore decisional balance Use readiness to change scale

Pros Positives about changing behaviors? Positives about Negatives status quo? about status quo?
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Quitting Concerns with smoking smoking Mother died of cancer Father died of emphysema Personal illness My children will smoke Cost Smell Cough Still Benefits of Smoking smoking Relaxation Wakes me up I enjoy it Helps me think

Benefits of quitting Breathe and feel better Please my family Have more money Not embarrassed of smell Concerns with quitting Wt gain Fail at quitting Life not as fun More stressed
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Exploring Readiness to Change

Use readiness scale
Readiness = importance X confidence

How important is it to the client to change. How confident is the client about making the change.
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Readiness Scale
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Readiness Scale
How important is it for you to make the change? 3 4 5 6 7 8 9 10

1
Pre-c ontem platio n

3
Unsure
tion Con temp la

5
tion

10

Not ready

Somewhat Ready
Prep aratio n
emp la

Very Ready

Not important

Very Important

_____________________________________________________________

How confident are you that you can make the change?
Actio n

C ont

10

Not confident

Very Confident

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Building Motivation and Confidence for Change

Group A: Group B: Group C: Group D: Low importance, low confidence Low importance, high confidence High importance, low confidence High importance, high confidence

Follow Up
Designate someone to do follow-up
How, when, where

Check on goal progress Identify new or ongoing problems Need for exams/labs Reminder of upcoming appts Document follow-up
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Questions to elicit change talk:

Why are you at a ____ and not a zero? What would it take for you to go from ___ to a (higher number)? What might help you overcome that barrier?

Collaborative Goal Setting

Must agree on a goal and work with hcp to develop a plan Offer options
What behavior would you like to change? What appeals to you the most? Barriers: Goal: Describe:

Action Plan
How What When Plans to overcome barriers: Conviction and Confidence rating (1-10): Follow-up
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Where Frequency

HCP must support clients choice of a goal Accept small steps toward change

Action Plan
Goal: become more active Describe: How: walk What: 20 min Where: home on treadmill Frequency: 3 X/week

General Guidelines
Talk less than your client. Listen more. Offer 2-3 reflections for every question you ask Ask twice as many open-ended questions as closed Overall goal of MI is help client to argue for behavior change.
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When: after I wake in the morning Barriers: not waking up in time Plans to overcome barriers: set alarm, get to be early Conviction and Confidence rating (1-10): 8 Follow-up: keep activity log

Motivational Interviewing

References
www.motivationalinterviewing.org: Motivational Interviewing, Resources for Trainers www.newheatlhpartnerships.org and click on health care providers for info on self management support Rollnick, Miller and Butler (2007). Motivational Interviewing in Health Care.

What technique will you try in the next week?

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Maurer, L., Mesznik, s. (2005) Counseling Strategies to Promote Behavior Change, On the Cutting Edge, 26(2):17-21.
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