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DESCRIPTIONMotivational Interviewing: Helping People Change Problem Behaviors Using Smoking Cessation as the Model . Andrée Aubrey , MSW, LCSW, CTTS Director, Area Health Education Center FSU College of Medicine Department of Family Medicine and Health Affairs [email protected] 850-645-6439. - PowerPoint PPT Presentation
Motivational Interviewing:Helping People Change Problem Behaviors
Using Smoking Cessation as the Model
Andrée Aubrey, MSW, LCSW, CTTS
Director, Area Health Education CenterFSU College of Medicine
Department of Family Medicine and Health Affairs
At the end of this training, learners will be able to:
• Articulate the key components of MI interventions; • Demonstrate competence in an evidence based and
practical approach to behavior change counseling;• Focus the assessment interview on identifying and/or
enhancing the client’s own reasons for wanting to quit tobacco or make other health related changes;
• Use reflective listening skills to more fully understand clients’ perspectives about “the problem” and potential strategies to address those problems;
• Enhance client self-efficacy for making a change.
What would you say to this patient?
• Video slide here
Typical Tobacco Cessation Counseling
• Video slide here
Problems with Traditional Approach
• Focuses on “fixing” the problem • Assumes knowledge and information are keys
to motivating behavior change • “Teaches” patients how to make the desired
• Often leads to a “Yes, but…” tug of war
Motivational Interviewing is NOT a treatment for tobacco dependency. It is an evidence-
based intervention for tobacco users WHO ARE NOT YET READY TO QUIT.
You can lead a horse to water but you cannot make
The most effective treatment for tobacco dependency is a combination of ….
1. Practical Counseling2. Pharmacotherapy3. Systems level interventions
MI “salts the oats”
TX for Tobacco Dependency• Problem Solving: compulsions to use, triggers to smoke,
changes in lifestyle• Coping Skills: developing or enhancing other coping mechanisms
• ASKING every client at every visit about tobacco use – paper screening like a vital sign OR electronic health record (EHR) prompt
• ADVISING about the benefits of quitting• REFERRING for treatment if not able to provide on-site
• Reminder systems which prompt clinicians to do the 2A/R intervention
• Nicotine Replacement Therapy: Patch, gum, lozenge, nasal spray, inhaler
• Bupropion: Wellbutrin SR• Verenicline: Chantix
What is Motivational Interviewing?
• A collaborative, person-centered form of guiding to elicit and strengthen motivation for change
• Empirically validated approach for helping people change addictive or other problematic behaviors
MI• A consumer-centered, yet guiding style of
counseling that is shaped by a guiding philosophy and understanding of what triggers change.
• Involves the conscious and disciplined use of specific communication strategies to evoke the person’s own motivations for change.
Three Essential Elements of MI
• MI is a particular conversation about change
• MI is collaborative (person-centered, not expert-recipient; partnership; honors autonomy and self-determination)
• MI is evocative – seeks to call forth the person’s own motivation and commitment
Persuasion Exercise: Part 1• SPEAKER: Talk about something you’d like to
change. May be a behavior, attitude, or habit but something it would be good to change.
• COUNSELOR #1: – Explain why he/she should make this change– Give at least 3 benefits of making the change– Tell him/her how to do it– Emphasize how important it is to make the change
Persuasion Exercise: Part 2COUNSELOR #1• Why would you want to make this change?• If you do decide to make this change, how
might you go about it in order to succeed?• What are your three best reasons to do it?• On a scale of 0 to 10, how important is it for
you to make the change? *Why are you at___ and not 0?
Persuasion Exercise: Part 3
COUNSELOR #2• Give a short summary of the speaker’s
motivation for change:– Summarize desire, ability, reasons, need for
change– Then, ask “So what do you think you will do?”– Affirm strengths of the speaker
TO BE DOING MI THERE MUST BE…• a Target such as a health related behavioral
change; attitude; decision (forgiveness); habit
• Change Talk
• Without these, there may be great rapport building and patient-centered listening, but not MI
Underlying Theory of MI
• People are ambivalent about making changes• When the clinician advocates for change, it
will evoke resistance from the person• Resistance predicts lack of change• Getting the person to talk about making the
change makes it more likely that he/she will do it
Refuses to take care of herself
Unwilling to change
Doesn’t understand Waste of
Where do we start?• Understanding basic principles of MI• MI skills:
– Open ended questions– Affirmations – Reflective listening– Summaries and
• Informing/ Advising
Open Ended Questions • Open questions
– Encourages patient speech– More efficient for gathering information– Builds relationship – patients perceive clinician as caring
and showing personal interest• Closed questions
– Effective for gathering information, if you ask the right questions!
• Question-answer trap– A series of questions (lends itself to quantification focus)
Video Example of MI in action!
Video slide here
• Statement of appreciation and understanding – Builds rapport and conveys respect for their
struggles, feelings, achievements, humanity – Reinforces open exploration– Promotes self-efficacy for change
• The point is to notice and appropriately affirm the person’s strengths and efforts
Affirmations• “I am sure that when you do decide to quit,
you will figure out a way that works for you.”
• “You are clearly a resourceful person, to cope with so many difficulties for so long.”
• “If I were in your position, I would have a hard time dealing with so much stress.”
• “I know this is not easy to hear.”
Clinician • Keep the person
talking and thinking
• Avoid a premature focus on solutions
• Improve “adherence”
• Enjoy your interactions more
Person• Listen to one’s
own reasons • Hear how the
behavior fits into one’s life
• Freedom to explore the desire or reasons for change in a safe environment
• Use a down-turn in inflection• Make statements, rather than asking
• Focus on change talk
• ROLL with RESISTANCE
Practice Simple Reflections• Tobacco user: “All my friends smoke, and I feel like I
wouldn’t belong anymore if I quit.”– Instead of: “Would you rather die from lung cancer?”– Try: “Smoking helps you fit in.”
• Tobacco user: “I know I need to quit, but I don’t know how I would deal w/ my depression without smoking.” – Instead of: “We’ve got a great medication that will help you
quit and help w/ your depression at the same time. Let’s get you a prescription and I’ll sign you up for one of our Quit Smoking now classes.”
– Try: “You have had some thoughts about quitting.”– Try: “You’ve been using smoking as a coping mechanism for
a long time.”– Try: “It’s kind of scary to think about quitting.”
Janine has been at the detox program for three days and has an appointment with you this morning, before being discharged.
“Well, I’ve ben wearing the patch since I got
admitted and haven’t really been craving
cigarettes. But I am just not sure what is going to happen once I get
• You were not expecting to give up smoking when you got admitted for alcohol detox.
• It’s surprising to you that the cravings have been pretty manageable.
• Your experience with the NRT patch has been positive.
• Not smoking or drinking while at detox has been a positive experience and you are wondering how your home environment is going to influence your sobriety.
Double-sided Reflections • May be used to highlight ambivalence
• “On one hand, there are some things about smoking that you really enjoy like socializing with your friends, and yet you are worried about the health effects of continuing to smoke and the impact it has on your children.”
Yes….but • People usually are ambivalent about change • Comfortable w/ status quo and disadvantages
to change • Arguments on either side of the ….but… cancel
each other out.
“You would like to cut down on your drinking and you are concerned about fitting in with your friends.”
Reflective Listening Skills
TALKER: • Discuss something you’ve been
thinking about changing
LISTENER: • Respond with reflective
Remember, you don’t have to hit a home run, just put a little wood on it!
Summaries: Putting it all together
• Effective transitions when moving from the “building motivation” phase to the “goal-setting” stage
• Useful if the person starts to get off track
• Focus on the person’s own motivations for change
Help Get Person Back On-track
• "So far you've listed three reasons to keep smoking; and three reasons to quit. And you found that quitting for your daughter's sake was the most important of all these reasons."
• Video slide here
Video slide here
• Video slide here
Is it change talk?
• I want to quit smoking so I’ll be here for my grandchildren.
• My boss told me I had to join this QSN class or my insurance costs will double.
• No one can tell me what to do!• I wish my life was different. • It took me 12 years to get off cocaine. I am
not using any drug, not even NRT!