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Motivational Interviewing: Motivational Interviewing: Some Basic Tools Some Basic Tools Ana Moseley, LISW, ACSW Ana Moseley, LISW, ACSW Thomas Peterson, Ph.D. Thomas Peterson, Ph.D. , Sponsored by: Sponsored by: Sangre de Cristo Sangre de Cristo Sangre de Cristo Sangre de Cristo Community Health Partnership Community Health Partnership Substance Abuse and Mental Health Substance Abuse and Mental Health Services Administration Services Administration Services Administration Services Administration Tennessee Primary Care Association Tennessee Primary Care Association 1

Goals Goals • Brief intro to MI: Brief intro to MI: • Focus on some specific MI skills: Focus on some specific MI skills: • Using reflections Using reflections • Rolling with resistance Rolling with resistance g • Giving information or advice Giving information or advice When working with a client, would you rather be or 2

What is MI What is MI A person centered goal orientated approach for A person centered goal orientated approach for facilitating change by exploring & resolving facilitating change by exploring & resolving g g g g y y p p g g g g ambivalence ambivalence ( ( Miller 2006) Miller 2006) …a method of communication rather than a set …a method of communication rather than a set of techniques. It is not a bag of tricks for getting of techniques. It is not a bag of tricks for getting p p people to do what they don’t want to do; rather, it people to do what they don’t want to do; rather, it p p y y ; ; , , is a fundamental way of being with & for people is a fundamental way of being with & for people – a facilitative approach to communication that a facilitative approach to communication that evokes change” evokes change” (Miller & Rollnick 2002) (Miller & Rollnick 2002) The Spirit of MI vs. Its The Spirit of MI vs. Its Mirror Image Mirror Image COLLABORATION VS. CONFRONTATION EVOCATION VS. EDUCATING AUTONOMY VS. AUTHORITY 3

Ambivalence Ambivalence The Dilemma of Change The Dilemma of Change • “I want to, and I don’t want to” “I want to, and I don’t want to” • Ambivalence is a normal aspect of Ambivalence is a normal aspect of human nature. human nature. • Passing through ambivalence is a Passing through ambivalence is a natural phase in the process of natural phase in the process of change. change. • Ambivalence is a reasonable place to Ambivalence is a reasonable place to visit but you wouldn’t want to live visit but you wouldn’t want to live there. there. Typical Strategies Typical Strategies  Give them Give them Insight Insight - if you can just make if you can just make people see people l l see , then they will change , then they will change th th th th ill h ill h  Give them Give them Knowledge Knowledge - if people just if people just know know enough, then they will change enough, then they will change  Give them Give them Skills Skills - if you can just teach if you can just teach people people how people people how how to change then they will do it how to change, then they will do it to change then they will do it to change, then they will do it  Give them Give them Hell Hell - if you can just make if you can just make people feel people feel bad bad or afraid or afraid enough, they will enough, they will change change 4

Stages of Change Stages of Change Permanent exit Relapse Precontemplation Maintenance Contemplation Action Preparation Precontemplation Precontemplation  Keyword: Doesn’t know or not ready Keyword: Doesn’t know or not ready  Task: Increase recognition and  Task: Increase recognition and Task: Increase recognition and Task: Increase recognition and concern about behavior concern about behavior Contemplation Contemplation  Keyword: Ambivalence Keyword: Ambivalence  Task: Tip the balance Task: Tip the balance 5

Preparation Preparation  Keyword: Threshold Keyword: Threshold  Task: Negotiate a change plan Task: Negotiate a change plan Action Action  Keyword: Movement Keyword: Movement  Task: Help person implement change Task: Help person implement change plan plan 6

Maintenance Maintenance  Keyword: Balance Keyword: Balance  Task: Help person continue change Task: Help person continue change Relapse/Repeat Relapse/Repeat  Keyword: Guilt and Shame Keyword: Guilt and Shame  Assist return to change behavior, Get Assist return to change behavior, Get back on track back on track 7

Traditional Health Care Approach Traditional Health Care Approach • Explain why the person Explain why the person should should change change • Give benefits that would result from Give benefits that would result from Give benefits that would result from Give benefits that would result from making the change making the change • Tell the person how they could make the Tell the person how they could make the change change • Persuade the person to do it Persuade the person to do it • If you meet resistance, repeat the above. If you meet resistance, repeat the above. If you meet resistance, repeat the above. If you meet resistance, repeat the above. • Warn the speaker what may happen if Warn the speaker what may happen if change is not made. change is not made. • P.S. This is P.S. This is NOT NOT motivational Interviewing motivational Interviewing 8

The Righting Reflex The Righting Reflex • The desire to set things right. The desire to set things right. • Acting on the inclination to advise, Acting on the inclination to advise, teach, persuade, counsel or argue for teach, persuade, counsel or argue for a particular resolution to a clients a particular resolution to a clients ambivalence. ambivalence ambivalence ambivalence. Reactions to Righting Reflex Reactions to Righting Reflex  Angry, agitated Angry, agitated  Helpless Helpless   Oppositional  Oppositional Oppositional Oppositional  Overwhelmed  Overwhelmed Overwhelmed Overwhelmed    Discounting Discounting  Ashamed Ashamed   Defensive Defensive  Trapped Trapped   Justifying Justifying  Disengaged Disengaged   Not understood Not understood  Not come back Not come back- -  avoid avoid avoid avoid  Not heard N t h N t h Not heard d d  Uncomfortable Uncomfortable   Procrastination Procrastination  Afraid Afraid 9

In Motivational Interviewing: In Motivational Interviewing:  Direct persuasion is not very useful for Direct persuasion is not very useful for resolving ambivalence resolving ambivalence  Motivation is elicited from the patient and Motivation is elicited from the patient and not imposed from without not imposed from without  The patient is supported in identifying The patient is supported in identifying and resolving ambivalence and resolving ambivalence  Patient values and autonomy respected Patient values and autonomy respected  “Change talk” recognized & responded to “Change talk” recognized & responded to  Resistance is treated constructively Resistance is treated constructively Four General Principles of MI Four General Principles of MI  1. Express empathy 1. Express empathy  2. Develop discrepancy 2. Develop discrepancy  3. Support self 3. Support self- -efficacy efficacy  4. Roll with resistance 4. Roll with resistance 10

Principle 1: Express Empathy Principle 1: Express Empathy  Listen actively with the goal of Listen actively with the goal of understanding understanding understanding understanding  Skillful reflective listening is Skillful reflective listening is fundamental. fundamental.  Acceptance facilitates change. Acceptance facilitates change.  Ambivalence is normal. Ambivalence is normal. Principle 2: Develop Discrepancy Principle 2: Develop Discrepancy  Motivation for change occurs when Motivation for change occurs when people perceive a discrepancy between people perceive a discrepancy between people perceive a discrepancy between people perceive a discrepancy between where they are and where they want to where they are and where they want to be be  Values and beliefs are key factors Values and beliefs are key factors  The person rather than the practitioner The person rather than the practitioner should make the arguments for change should make the arguments for change 11