motivational interviewing the basics - · pdf filemotivational interviewing the basics funded...
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Funded by: www.sbirtonline.org
Alan Lyme, LCSW
Sylvia Shellenberger, PhD
Southeastern Consortium for Substance Abuse Training – Advanced Practice Registered Nurses
Funded by Grant 1U79T1025372-01
Substance Abuse and Mental Health Services Administration (SAMHSA)
Last revised: March 31, 2014
Motivational InterviewingThe Basics
Funded
by:
SECSAT-APRNSoutheastern Consortium for Substance Abuse Training -
Advanced Practice Registered Nurses
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Key Contributors &SECSAT – APRN Site Coordinators
Mercer University, School of MedicineJ. Paul Seale, MD
Principal Investigator
Annie Biers, LPC, Project Coordinator
Sylvia Shellenberger, PhD
Mercer University, Georgia Baptist College of NursingDr. Frieda Fuller Dr. Laura K. Baraona
Armstrong Atlantic University
Dr. Anita NivensDr. Linda Tuck
Emory University, Nell Hodgson Woodson
School of Nursing Dr. Carolyn Clevenger
Dr. Ursula KellyDr. Phyllis Wright
University of North Georgia Dr. Sharon Chalmers
South UniversityDr. Doris Parrish
Johns Hopkins University
Dr. Christine SavageDr. Deborah Finnell
Georgia College & State University
Dr. Deborah MacMillanDr. Sallie Coke
University of Alabama, Birmingham
Dr. Susanne Fogger
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Why Should We Be Interested in
Patients’ Motivation for Behavior
Change?
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Motivation Pretest
Let’s find out what you think about motivation.
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Beliefs About Motivation
1. Until a person is motivated to change, there is not much we can do.a. True
b. False
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Beliefs About Motivation
2. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change.a. Trueb. False
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Beliefs About Motivation
3. Motivation is influenced by interpersonal relationships.a. Trueb. False
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Beliefs About Motivation
4. Creating motivation for change usually requires confrontation.
a. Trueb. False
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Southeastern Consortium on Substance Abuse Training
- APRN © 2014
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Why Do People Change?1. ?
2. ?
3. ?
4. ?
5. ?
6. ?
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Why Don’t People Change?1. ?
2. ?
3. ?
4. ?
5. ?
6. ?
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At the end of the session, you will be able to—1. Define motivational interviewing (MI).
2. Identify the tasks of MI.
3. Describe the spirit of MI.
4. Define the principles of MI.
5. Identify MI intervention to explore potential change.
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Learning Objectives
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Definition of Motivational Interviewing
“Motivational interviewing is a patient-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”
Miller & Rollnick, Motivational Interviewing: Helping People Change, 3rd edition, 2013
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Motivational Interviewing
The tasks of MI are to—
Engage, through having sensitive conversations with patients.
Focus on what’s important to the patient regarding behavior, health, and welfare.
Evoke the patient’s personal reasons and means for change.
Plan, collaborating with patient and exploring options.
Motivation often results from helping the patient resolve conflicting and ambivalent feelings and thoughts.
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Discussion of video
What were the strengths of this doctor’s approach?
What was his goal?
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How willing do you think this patient
will be to change his drinking or
reduce his risk as a result of this
conversation?
Not willing Very willing
______________________________________
0 1 2 3 4 5 6 7 8 9 10
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Discussion of video
What were the strengths of this doctor’s approach?
What was his goal?
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How willing do you think this patient
will be to change his drinking or
reduce his risk as a result of this
conversation?
Not willing Very willing
______________________________________
0 1 2 3 4 5 6 7 8 9 10
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Motivational Interviewing Spirit
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“People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others.”
—Blaise Pascal
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Spirit of MI
A way of communicating with patients that is…
Collaborative
Evocative
Respectful of autonomy
Compassionate
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Spirit of MI
Collaboration (not confrontation) Developing a partnership in
which the patient’s expertise, perspectives, and input are central to the consultation.
Fostering and encouraging power sharing in the interaction.
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Spirit of MI
Evocation (not education)
Motivation for change resides within the patient.
Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals.
Ask key open-ended questions.
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Spirit of MIAutonomy (not authority) Respecting the patient’s right to make
informed choices facilitates change.
The patient is in charge of his/her choices and thus is responsible for the outcomes.
Emphasizing patient control and choice. Patients are experts in their own needs, experience, and what worked in the past.
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Spirit of MI
Compassion
Empathy (not sympathy) for the experience of others.
Desire to promote the wellbeing of others.
Belief and commitment to act in the best interests of the patient.
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Collaboration
Acceptance
Evocation
CompassionMI
Spirit
MI Core Skills 2013
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Motivational Interviewing Principles
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MI Principles
MI is founded on four basic principles:
Express empathy
Develop discrepancy
Dance with discord
Support self-efficacy
Resisting the “Righting Reflex”
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MI Principles
Express empathy
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Express Empathy
What is empathy?
Reflects an accurate understanding
– Assumes the person’s perspectives are understandable, comprehensible, and valid.
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Express Empathy Empathy is:
– The ability to accurately understand the patient’s meaning
– The ability to reflect that accurate understanding back to the patient
– Seeking to understand the patient’s feelings and perspectives without judging
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Express Empathy
Why is empathy important in MI?
Encourages a collaborative alliance, which also promotes change.
Leads to an understanding of each person’s unique perspective, feelings, and values, which make up the material we need to facilitate change.
Communicates acceptance, which facilitates change.
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What do we mean by communicating acceptance?
Not acceptance of unhealthy behaviors or high risk lifestyle, but acceptance of the person who is struggling with competing needs, feelings and concerns.
Empathy is the ability to see that to struggle with shortcomings is to be human.
Empathy is also the ability to recognize that everyone has strengths, and small strengths can pull us through bad times.
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Express EmpathyTips…
Good eye contact
Responsive facial expression
Body orientation
Verbal and nonverbal “encouragers”
Reflective listening/asking clarifying questions
Avoid expressing doubt/passing judgment
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Listen actively
• Pair up in twos
• Speaker (Partner A) share something about yourself – where you are from, what kind of work you do, what you like about your life (home, family, work).
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Partner B will listen actively with:
Presence – undividedattention
Patience Eyes, ears, heart Acceptance & non-judgment Curiosity Delight No interruptions Encouragers (uh-huh, wow,
tell me more)
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Speaker (Partner A) Ask for permission saying, “May I share with you
some positive feedback?”
Tell the listener/Partner B: what made it easy to share your story?
20 seconds
Reverse roles
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The Bottom Line on Empathy
An opportunity to understand the patient
Our acceptance facilitates change.
Skillful reflective listening is fundamental to expressing empathy.
Miller, W. R. & Rollnick, S. (2013)
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MI PrinciplesDevelop discrepancy.
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Make transparent and amplify the patient’s own ambivalence:
– Decisional balance “Good” vs. “Not-so-good”
Develop Discrepancy
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Develop Discrepancy
Current behavior versus future goals
Example: “You enjoy your work, and doing well in your job is very important to you, and sometimes when you drink during the week, you can’t get out of bed to get to work. Last month, you said you missed 5 days.”
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MI Principles Dance with Discord
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Dance with Discord So as to avoid patients thinking…
When will
this be
over?You’re wrong
Yes, but...
If I just play along…45
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Traditionally viewed as patient denial or resistance
– “I don’t think my drinking is that bad.”
Now thought to be a product of a practitioner who utilizes a confrontational interviewing style –creating discord
– “Can’t you see that your drinking is seriously damaging your liver?”
Motivational Interviewing in Health Care Settings: Opportunities and Limitations. Karen M. Emmons, PhD, Stephen Rollnick, PhD. Am J Prev Med 2001;20(1) 68-74
Dance with Discord
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Dance with Discord Confrontation may have a deleterious impact on
patient self-efficacy
– The more practitioners confront patients about their drinking, the more patients drink at follow-up
An empathic approach builds self-efficacy
Practitioners are more effective if they elicit arguments for change from the patients themselves
Motivational Interviewing in Health Care Settings: Opportunities and Limitations. Karen M. Emmons, PhD, Stephen Rollnick, PhD. Am J Prev Med 2001;20(1), 68-74
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Dance with DiscordPatient: You can’t make me quit drinking.
Clinician: You don’t think that abstinence would work for you right now.
Patient: Look, I’m just fine. I can take care of
myself, OK? Can I go now?
Clinician: It sounds like you are tired of dealing with this issue and want to move on.
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MI PrinciplesSupport self-efficacy.
“Can-do”
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Support Self-Efficacy
Patients are responsible
for choosing and carrying
out actions to change.
We help them build
confidence and have a
“can-do” attitude.
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MI Principles: Resist Righting Reflex
Resist the righting reflex (urge to fix) If a patient is ambivalent
about change, and the clinician champions the side of change…
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Conclusion of MI Basics The Four Principles: Engage, Focus, Evoke, and
Plan provide structure to the consultation
Collaboration, evocation, autonomy and compassion are the foundation of the model
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QUESTIONS?
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What’s Next?
In the next session, you will learn the steps and core skills of MI.
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