Motivational Interviewing in Motivational Interviewing in NeuropsychologyNeuropsychology

Basic Principles and MethodsBasic Principles and MethodsNovember 23, 2012 – 1:30pm – 5:00pmNovember 23, 2012 – 1:30pm – 5:00pm

Tad Gorske, Ph.D.Tad Gorske, Ph.D.Clinical Assistant ProfessorClinical Assistant ProfessorDirector, Outpatient NeuropsychologyDirector, Outpatient NeuropsychologyDivision of Neuropsychology and Rehabilitation PsychologyDivision of Neuropsychology and Rehabilitation PsychologyUniversity of Pittsburgh School of Medicine, Pittsburgh Pennsylvania, USAUniversity of Pittsburgh School of Medicine, Pittsburgh Pennsylvania, USA

The Challenge of ChangeThe Challenge of Change 42 year old male who suffers a TBI after an ATV accident 42 year old male who suffers a TBI after an ATV accident

where he is intoxicated. Makes a reasonably good where he is intoxicated. Makes a reasonably good recovery. History of extensive alcohol use. 6 months after recovery. History of extensive alcohol use. 6 months after inpatient TBI rehab has resumed drinking. inpatient TBI rehab has resumed drinking.

24 year old female, mild concussion, having PCS 24 year old female, mild concussion, having PCS symptoms one year later. Significant psychiatric history but symptoms one year later. Significant psychiatric history but doesn’t believe symptoms are related. doesn’t believe symptoms are related.

56 year old male, suffers a stroke, continues to have mild 56 year old male, suffers a stroke, continues to have mild to moderate cognitive deficits that are likely permanent. to moderate cognitive deficits that are likely permanent. Doesn’t see need to reduce workload at a high stress, fast Doesn’t see need to reduce workload at a high stress, fast paced profession. paced profession.

The Challenge of ChangeThe Challenge of Change

Community based rehabilitation is an effective Community based rehabilitation is an effective strategy for increasing opportunities for people strategy for increasing opportunities for people with disabilities to maximize their physical and with disabilities to maximize their physical and mental functioning (World Health Organization). mental functioning (World Health Organization).

However, the benefits that might be accrued are However, the benefits that might be accrued are all too often disrupted by individuals’ lack of all too often disrupted by individuals’ lack of participation in the rehabilitation process participation in the rehabilitation process (Lequerica et al., 2006)(Lequerica et al., 2006)

Motivation – Whose Job is it? Motivation – Whose Job is it?

The unmotivated client:The unmotivated client:– ““When the client’s goals do not match those of When the client’s goals do not match those of

the counselor” (Lane and Barry, 1970). the counselor” (Lane and Barry, 1970). – Others may hinder independence by Others may hinder independence by

inadvertently reinforcing dependence over self inadvertently reinforcing dependence over self reliance (Wright, 1980). reliance (Wright, 1980).

3 Key elements underlying client motivation 3 Key elements underlying client motivation (Roessler, 1980/89):(Roessler, 1980/89):

1. The client’s perception of the value of the outcome 1. The client’s perception of the value of the outcome of a change plan, including both benefits and of a change plan, including both benefits and costs;costs;

2. The client’s perception of the probability of 2. The client’s perception of the probability of achieving a successful outcome;achieving a successful outcome;

3. The presence of environmental barriers and 3. The presence of environmental barriers and supports that inhibit or promote change.supports that inhibit or promote change.

Importance of Working AllianceImportance of Working Alliance

There are strong links between patient-There are strong links between patient-therapist collaboration and goal consensus therapist collaboration and goal consensus in psychotherapy outcomes (Shick Tryon in psychotherapy outcomes (Shick Tryon and Winograd, 2011). and Winograd, 2011).

Working alliance and collaboration in Working alliance and collaboration in rehabilitation is viewed as important but less rehabilitation is viewed as important but less well studied. well studied.

Working Alliance in RehabilitationWorking Alliance in Rehabilitation

A positive relationship between working A positive relationship between working alliance and outcomes has been found. alliance and outcomes has been found. Working alliance defined as Working alliance defined as

(a) the agreement between client and therapist on (a) the agreement between client and therapist on goals, goals,

(b) their agreement on how to achieve these goals (b) their agreement on how to achieve these goals (common work on tasks) and,(common work on tasks) and,

(c) the development of a personal bond between (c) the development of a personal bond between client and therapist. (Shönberger et al. 2006). client and therapist. (Shönberger et al. 2006).

Working Alliance in RehabilitationWorking Alliance in Rehabilitation

A good working alliance can be created with both A good working alliance can be created with both clients who experience many problems and clients clients who experience many problems and clients who experience comparatively few problems, as who experience comparatively few problems, as long as they are aware of the consequences of long as they are aware of the consequences of their brain injury.their brain injury.

Therapist’s experience of a good working alliance Therapist’s experience of a good working alliance was influenced by the client’s experience of was influenced by the client’s experience of success. (Shönberger, et al., 2006). success. (Shönberger, et al., 2006).

Working Alliance in RehabilitationWorking Alliance in Rehabilitation

Clients’ and therapists’ overall success ratings at Clients’ and therapists’ overall success ratings at program end were related to their emotional bond program end were related to their emotional bond at program end.at program end.

Early-therapy compliance and the average amount Early-therapy compliance and the average amount of compliance are predictive of subjective of compliance are predictive of subjective improvement. (Shönberger, et al., 2006). improvement. (Shönberger, et al., 2006).

Working Alliance: Some evidenceWorking Alliance: Some evidence

Bieman-Copelan and Dywan (2000). Brain and Bieman-Copelan and Dywan (2000). Brain and Cognition, 44, 1-5. Cognition, 44, 1-5.

Behavioral therapy in context of a Behavioral therapy in context of a supportive/collaborative therapeutic alliance for supportive/collaborative therapeutic alliance for anosognosia. anosognosia.

Collaborative negotiation and trusting therapeutic Collaborative negotiation and trusting therapeutic relationship for behavioral goal setting. relationship for behavioral goal setting.

Results indicated a significant reduction in Results indicated a significant reduction in problematic behaviors despite no increase in insight problematic behaviors despite no increase in insight or awareness of injury. or awareness of injury.

Pegg et al., 2005Pegg et al., 2005 Evaluated the role of interpersonal relationship factors on Evaluated the role of interpersonal relationship factors on

patient outcomes with 28 patients with moderate to severe patient outcomes with 28 patients with moderate to severe TBI admitted to an inpatient unit at a VAMC. TBI admitted to an inpatient unit at a VAMC.

Personalized information-provision intervention. Personalized information-provision intervention. Results:Results:

– Patients exerted greater effort in therapiesPatients exerted greater effort in therapies– Patients increased satisfaction with rehabilitation Patients increased satisfaction with rehabilitation

treatment. treatment. – Significantly more improvement in cognitive FIM scores. Significantly more improvement in cognitive FIM scores.

Interdisciplinary team working Interdisciplinary team working alliance (Evans, et al., 2008). alliance (Evans, et al., 2008).

Importance of therapeutic alliance in post acute brain injury Importance of therapeutic alliance in post acute brain injury rehabilitation (PABIR). rehabilitation (PABIR).

Sherer et al., 2007 - poor working alliance was associated with Sherer et al., 2007 - poor working alliance was associated with high levels of family discord, greater discrepancy between high levels of family discord, greater discrepancy between family and clinician ratings of client functioning, and poor client family and clinician ratings of client functioning, and poor client participation in therapies.participation in therapies.

Treatment team members attended in-services that emphasized Treatment team members attended in-services that emphasized motivational interviewing philosophy and techniques, building motivational interviewing philosophy and techniques, building rapport, reflective listening, dealing with patient resistance, rapport, reflective listening, dealing with patient resistance, making behavioral changes, stages of change, dealing with making behavioral changes, stages of change, dealing with challenging clients, and assessment and treatment issues with challenging clients, and assessment and treatment issues with depressed and/or suicidal patients (pg. 332).depressed and/or suicidal patients (pg. 332).

Interdisciplinary team working Interdisciplinary team working alliance (Evans, et al., 2008). alliance (Evans, et al., 2008).

Treatment group had higher functional status and were Treatment group had higher functional status and were more productive and had less dropouts, although the more productive and had less dropouts, although the differences were not statistically significant. differences were not statistically significant.

Lane-Brown and Tate, 2010.Lane-Brown and Tate, 2010. Single case study that evaluated an Single case study that evaluated an

intervention utilizing external compensation intervention utilizing external compensation and motivational interviewing to initiate and and motivational interviewing to initiate and sustain goal directed activity with a TBI patient. sustain goal directed activity with a TBI patient.

Demonstrated that treating specific and Demonstrated that treating specific and operationally defined goals through external operationally defined goals through external compensation and motivational interviewing compensation and motivational interviewing successfully decreased apathy.successfully decreased apathy.

Health Behavior Change (HBC) Health Behavior Change (HBC) ModelModel

A method of dialogue based on Motivational A method of dialogue based on Motivational Interviewing Principles to enhance clients Interviewing Principles to enhance clients internal motivation for change versus trying internal motivation for change versus trying to persuade them to change. to persuade them to change.

Behavior Change: Whose Behavior Change: Whose Problem Is It?Problem Is It?

The outcome of a consultation can be The outcome of a consultation can be affected by providers consulting behavior. affected by providers consulting behavior.

Behavior change, or lack of it, is not Behavior change, or lack of it, is not justjust a a patient problem. patient problem.

Practitioner style can make matters better Practitioner style can make matters better or worse. or worse. – (Rollnick, Mason, and Butler, 1999). (Rollnick, Mason, and Butler, 1999).

Foundations of HBC ModelFoundations of HBC Model

Motivational InterviewingMotivational Interviewing

Counseling style Counseling style (Miller, 1983)(Miller, 1983)– Client-centered, directive method for enhancing Client-centered, directive method for enhancing

intrinsic motivation to change by exploring and intrinsic motivation to change by exploring and resolving ambivalence. resolving ambivalence.

An evolution of the client centered An evolution of the client centered approach.approach.

Intentionally resolves ambivalence in the Intentionally resolves ambivalence in the direction of change. direction of change.

Four Motivational Interviewing Four Motivational Interviewing PrinciplesPrinciples

1.1. Express EmpathyExpress Empathy

2.2. Develop DiscrepancyDevelop Discrepancy

3.3. Roll with ResistanceRoll with Resistance

4.4. Support Self EfficacySupport Self Efficacy

What Motivates Change?What Motivates Change?

Interpersonal StyleInterpersonal Style Readiness, willingness, abilityReadiness, willingness, ability Intrinsic versus extrinsic factorsIntrinsic versus extrinsic factors Change TalkChange Talk Commitment LanguageCommitment Language

Change TalkChange Talk

Categories of Change TalkCategories of Change Talk– Desire: “I want to…”Desire: “I want to…”– Ability: “I can..”Ability: “I can..”– Reason: “There are good reasons for me to..”Reason: “There are good reasons for me to..”– Need: “I really need to…”Need: “I really need to…”

– Commitment: “I am going to…”Commitment: “I am going to…”

How MI theoretically worksHow MI theoretically works

1.1. MI approach leads to; MI approach leads to; 2.2. An increase in Desire, Ability, Reason, An increase in Desire, Ability, Reason,

Need, which leads to; Need, which leads to; 3.3. An increased intensity of commitment An increased intensity of commitment

which leads to; which leads to; 4.4. Behavior ChangeBehavior Change

Core Communication SkillsCore Communication Skills

1.1. Open Ended QuestionsOpen Ended Questions2.2. Affirmations Affirmations 3.3. Reflective ListeningReflective Listening4.4. SummarizingSummarizing

Maintaining a Patient Centered Maintaining a Patient Centered ApproachApproach

Active – Reflective listeningActive – Reflective listening Encourage an expression of concernsEncourage an expression of concerns Allow them to articulate what they needAllow them to articulate what they need All them greater control over decision All them greater control over decision

makingmaking Reach joint decisionsReach joint decisions

What is (The Spirit) of HBCWhat is (The Spirit) of HBC

Collaboration: Collaboration: Two parties working Two parties working together, listening, responding, progressing, together, listening, responding, progressing, and cooperating toward a common goal.and cooperating toward a common goal.

Coercion: Coercion: Using force to cause Using force to cause something to occur; trying to persuade something to occur; trying to persuade through debate or to have their points be through debate or to have their points be heardheard

The likelihood of change is highly The likelihood of change is highly influenced by interpersonal interactionsinfluenced by interpersonal interactions

Empathic StyleEmpathic Style Less Empathic Less Empathic StyleStyle

An increased likelihood An increased likelihood Decreased likelihood Decreased likelihood of changeof change of changeof change

Collaborative Agenda SettingCollaborative Agenda Setting

Presenting agenda setting chart;Presenting agenda setting chart; Transition to focus on problem areasTransition to focus on problem areas Raising clinician concernsRaising clinician concerns Summarize outcome – next step(s)Summarize outcome – next step(s)

Agenda Setting Chart

Single vs Multiple BehaviorsSingle vs Multiple Behaviors Elicit – Personal views and feelings about Elicit – Personal views and feelings about

factors related to illness/injury/recovery;factors related to illness/injury/recovery;– ““ie. You are about 4 months out of your traumatic brain injury, ie. You are about 4 months out of your traumatic brain injury,

what are your major concerns about ongoing recovery?”what are your major concerns about ongoing recovery?”

Provide – Information about what is known Provide – Information about what is known about the issue presentedabout the issue presented– ie. “What we know is that most recovery happens in the first ie. “What we know is that most recovery happens in the first

year to 18 months. There is no good way to predict what type year to 18 months. There is no good way to predict what type of recovery will be made but there are some things that can of recovery will be made but there are some things that can help or hinder one’s recovery.”help or hinder one’s recovery.”

Single vs Multiple BehaviorsSingle vs Multiple Behaviors Elicit – Patient reactions to the information Elicit – Patient reactions to the information

given . given . – ie. “How to you feel about your recovery so far and what ie. “How to you feel about your recovery so far and what

things have been positive versus what has not gone so things have been positive versus what has not gone so well?”well?”

ReadinessReadiness

Stages of ChangeStages of Change– PrecontemplationPrecontemplation– ContemplationContemplation– PreparationPreparation– ActionAction– MaintenanceMaintenance

Readiness on a continuumReadiness on a continuum

ReadinessReadiness

IMPORTANCE CONFIDENCE

Why should I change?Exploration of personal values and expectations about the importance of change.

How will I do it?Explorations of self efficacy.

StrategyStrategy

1.1. Identify behavior to discuss (Agenda Identify behavior to discuss (Agenda setting, prioritize, identify behavior);setting, prioritize, identify behavior);

2.2. Assess readiness to change behavior;Assess readiness to change behavior;a)a) Introduce readiness ruler (formal or informal);Introduce readiness ruler (formal or informal);b)b) Use OARS to clarify stage of change, level of Use OARS to clarify stage of change, level of

readiness;readiness;c)c) Identify and explore issues of Identify and explore issues of

importance/confidence.importance/confidence.

Exploring Importance/ConfidenceExploring Importance/Confidence Introducing the Discussion Introducing the Discussion

““I‟m not really sure exactly how you feel about I‟m not really sure exactly how you feel about ____________________. Can you help me by answering two simple ____________________. Can you help me by answering two simple questions, and then we can see where to go from there?” questions, and then we can see where to go from there?”

Assessing Importance and Confidence Assessing Importance and Confidence ““How do you feel How do you feel right now about _______________________? How right now about _______________________? How

important is it to you personally to ________________________? If 0 important is it to you personally to ________________________? If 0 was „not important at all‟ and 10 „very important‟, what number would was „not important at all‟ and 10 „very important‟, what number would you give yourself?” you give yourself?”

““If you decided If you decided right now to _____________________, how confident right now to _____________________, how confident do you feel that you would succeed? If 0 was „not at all confident‟ and do you feel that you would succeed? If 0 was „not at all confident‟ and 10 was „very confident‟, what number would you give yourself?” 10 was „very confident‟, what number would you give yourself?”

Summarize the answers Summarize the answers

Exploring Importance/ConfidenceExploring Importance/Confidence

Selecting the Focus Selecting the Focus If importance is low (<5), focus on If importance is low (<5), focus on importance first importance first If both are about the same, focus on If both are about the same, focus on importance first importance first If one number is distinctly lower than the other, focus on the If one number is distinctly lower than the other, focus on the lower lower

number first number first If both are very low (<3), explore feelings about participating in If both are very low (<3), explore feelings about participating in

discussion of the issue (discussion of the issue (‘‘all of this’) all of this’)

EXAMINING PROS AND CONSEXAMINING PROS AND CONS

The Dilemma of AmbivalenceThe Dilemma of Ambivalence Most people are Most people are

ambivalent about ambivalent about making changes. making changes.

Ambivalence is normal Ambivalence is normal but is typically seen as but is typically seen as pathological pathological

Exploring and resolving Exploring and resolving ambivalence is the core ambivalence is the core of MI and HBC. of MI and HBC.

Examine Pros and ConsExamine Pros and ConsNo Change ChangeCosts Costs

Benefits Benefits

Examine Pros and ConsExamine Pros and Cons

1.1. Introduce the strategy: Ask the patient;Introduce the strategy: Ask the patient;2.2. Review pros and cons of the behavior Review pros and cons of the behavior

usually beginning with the side that usually beginning with the side that supports the status quo (no change);supports the status quo (no change);

3.3. Throughout the interview use client Throughout the interview use client centered/directive strategies, ie. OARS. centered/directive strategies, ie. OARS.

4.4. Summarize and look ahead to the next Summarize and look ahead to the next step. step.

Evocative QuestionsEvocative Questions

Problem recognitionProblem recognition ConcernConcern IntentionIntention OptimismOptimism

Information ExchangeInformation Exchange Step 1:Step 1:

– Ask “does the patient want or need information?”Ask “does the patient want or need information?”– Distinguish between fact and personal opinion. Distinguish between fact and personal opinion. – Present information in a neutral manner.Present information in a neutral manner.

Step 2:Step 2:– Elicit – Readiness and interest in information;Elicit – Readiness and interest in information;– Provide - Feedback in a neutral manner;Provide - Feedback in a neutral manner;– Elicit – Patient reactions and interpretations of Elicit – Patient reactions and interpretations of

information. information.

Information ExchangeInformation Exchange Step 3: Review and summarize.Step 3: Review and summarize. Step 4:Step 4: Ask about the next step.Ask about the next step.

Resistance in HBC ModelResistance in HBC Model

Rolling with ResistanceRolling with Resistance

Resistance is not met head on or challenged Resistance is not met head on or challenged directly. directly.

Resistance met with empathy and Resistance met with empathy and understanding where alternative viewpoints understanding where alternative viewpoints are invited but not imposed. are invited but not imposed.

True Victory is Victory Over OneselfOne must first learn to control oneself before attempting to harmonize and control others.

Seidokan Aikido World Headquarters

Change/ResistanceChange/Resistance

Causes of Resistance:Causes of Resistance:– Patient brings conflict into the session;Patient brings conflict into the session;– Practitioner elicits it;Practitioner elicits it;– Combination of the twoCombination of the two

Three Traps/Three StrategiesThree Traps/Three StrategiesTrapsTraps

Take control awayTake control away

Misjudge Misjudge importance/confidenceimportance/confidence/readiness/readiness

Meet force with forceMeet force with force

StrategyStrategy Emphasize personal Emphasize personal

choice and controlchoice and control Assess Assess

readiness/importance/readiness/importance/confidenceconfidence

Back off – come Back off – come alongsidealongside

Negotiating a Change PlanNegotiating a Change Plan

Setting GoalsSetting Goals Considering Change OptionsConsidering Change Options Arriving at a PlanArriving at a Plan Eliciting CommitmentEliciting Commitment

““The commitment to a change plan completes the The commitment to a change plan completes the formal cycle of motivational interviewing. formal cycle of motivational interviewing. Sometimes people proceed with change on their Sometimes people proceed with change on their own from here. It can also work well, however, to own from here. It can also work well, however, to transition from this initial motivational consultation transition from this initial motivational consultation into action-focused counseling if the person so into action-focused counseling if the person so chooses….MI can be used to facilitate change chooses….MI can be used to facilitate change throughout the process of counseling. throughout the process of counseling. Ambivalence…rarely disappears on the first step Ambivalence…rarely disappears on the first step of a journey.” (Miller and Rollnick, 2002, p.139)of a journey.” (Miller and Rollnick, 2002, p.139)

My thanks to all the participants, Dr. Fiona My thanks to all the participants, Dr. Fiona Bardenhagen and the Australian Bardenhagen and the Australian Psychological Society for inviting me to your Psychological Society for inviting me to your conference. conference.

My contact informationMy contact informationTad T. Gorske, Ph.DTad T. Gorske, Ph.DClinical Assistant Professor Clinical Assistant Professor Division of Neuropsychology and Rehabilitation PsychologyDivision of Neuropsychology and Rehabilitation PsychologyUPMC MercyUPMC Mercy1400 Locust Street, Suite G1381400 Locust Street, Suite G138Pittsburgh, PA USA 15219Pittsburgh, PA USA 15219Gorskett@upmc. eduGorskett@upmc. edu