Unlocking the Secrets to Motivational Interviewing for Chronic Disease Prevention and Treatment

Rhonda DiNovo, LMSWClinical Assistant Professor, COSW

Today’s Learning Objectives

Intro to Motivational Interviewing: Brief History Theoretical Framework Definition Style Spirit Process and Techniques

The Basic Facts of Motivational Interviewing

• Founders: Dr. Miller & Stephen Rollnick, 1991• MI evolved from the addiction field, and now applies to numerous behavior

changes (ie. Mental health, co-occurring disorders, weight change and nutrition, HIV, medication adherence, gambling, smoking cessation, and non-clinical settings such as schools, universities, etc.

• MI is evidence-based, that is has been shown through research methodologies to be successful and replicable

• MI is designed to work fairly quickly, often requiring just 2 to 4 sessions, which makes it relatively fast acting and inexpensive.

• MI is NOT a form of cognitive-behavioral therapy, but rather a tool for addressing a problem and motivating change

• MI is NOT a therapeutic technique, but rather a conversational style(copyright, K. Sciacca, 2009)

New Material:Constructing a Theoretical Framework for MI

MI practice aligns with four foundational social work theories: • Person-Centered Approach: non-directive, empathic

approach that empowers and motivates • Self Determination Theory: examination of psychological

needs and continuum of motivation• Trans-theoretical Model of Change: understanding

fluctuations in and incremental stages of changes• Mindfulness: A state of active, open awareness and attention

on the present moment

Person-Centered Approach• Carl Rogers, American psychologist

and founder of humanistic theory (person-centered care)

• Miller and Rollnick’s Principles of Person Centered Care: The needs of our clients have

priority. Change is self change. Our

service is one of facilitation. People are their own experts. We don’t make change happen.

Change requires partnership. Motivation for change is not

installed, rather evoked. Clients make their own decisions.

• https://www.youtube.com/watch?v=XvO8tvrtOms

• https://www.youtube.com/watch?v=X6fidphMX38

• https://www.youtube.com/watch?v=xi76tmxEJig

Self Determination TheoryPeople have natural or intrinsic tendencies to behave in healthy & effective ways. Three psychological needs must be met:

• The need to be effective in dealing with environment

Competence

• The need to control the course of their lives

Autonomy

• The need to have close, affectionate relationships with others

Relatedness

SelfDeterminationTheory.org

The Self-Determination Continuum

A-Motivation Nonintentional, incompetence, lack of control

Ex-External Compliance, external rewards/punishment

Ex-Somewhat external Self-control, ego, internal rewards/ punishment

Ex-Somewhat internal Personal importance, conscious valuing

Ex-Internal Congruence, awareness, synthesis with self

In-Internal Interest, enjoyment, inherent satisfaction

Based on Ryan, R.M. & Deci, E.L. (2000). Self-Determination Theory & the Facilitation of Intrinsic Motivation, Social Development, and Well-Being. American Psychologist. 55(1), 68-78.

What regulates MOTIVATION?What’s the source?

Trans theoretical Model: Theory of Change

Pre-contemplatio

n

Contemplation

Preparation

Action

Maintenance

Go Back (Relapse)

No intention of changing behavior

Aware a problem exists, but no

commitment to action

Intent upon taking action

Actively modifying behavior

Sustained change –new behaviorreplaces old

Fall back into old patterns of behavior

Stable, safer lifestyle

Mindfulness Theory

Definition: A state of active, open

awareness and attention on the present moment.

Observation of thoughts and feelings from a distance, without judging them as good or bad.

We have thoughts, but we are not our thoughts.

Mindfulness Principles Live in the present, here-and-now moment. Engage fully in what you are doing rather than “getting lost” in your thoughts Consciously set intentions. They set the stage for what is possible and directly determine

outcomes. Experience awareness of here-and-now moments with openness, interest and receptiveness.

(In this way, even painful thoughts, feelings, sensations and memories can seem less threatening or unbearable)

Facilitate “being”, rather than “doing”. Be still and observe in a non-judging, non-striving way.

Allow your feelings to be as they are, let them come and go rather than trying to control them.

Become aware in four main areas: body (breath), feelings, mind (awareness, concentration), mind-object (what we think about).

Definition of Motivational Interviewing

• A collaborative conversation style for the primary purpose of strengthening a person’s own motivation and commitment to change

The Style of MI

• Not just techniques• A way of being present

with a person• A way of guiding

through communication• Approach the

relationship with exploration and wonder

The Spirit of MIHabits of the HeartWe are a privileged

witness to changeFour key elements• Partnership• Acceptance• Compassion• Evocation

PartnershipHow do you achieve this?- Practice self-awareness- Ask, don’t tell- Keep your “righting

reflex” in check

isWorking together

Showing interest and support

*Client centered

A waltz

is notDone by someone,

to someone

Persuasion and argument

About you (the facilitator)

A wrestling match

Motivational Interviewing, Miller & Rollnick

Acceptance

How do you achieve this?Demonstrate: Absolute Worth Accurate Empathy Autonomy Affirmation

is about

worth

autonomy

empathy

affirmation

is not about

approval of actions

acquiescence to status quo

Motivational Interviewing, Miller & Rollnick

CompassionWhat:• Seek and value the well being of another• Deserve the trust you been given

How do you achieve this? Actively promoting and

committing to the pursuit of another’s welfare

Giving priority to their needs

Evocation

How do you achieve this?Drawing out Evoking and

strengthening change motivations that are already within

isStrengths-

focused

Trusting the *client

Drawing water from the well

is notDeficit-focused

Believing you know best

Watering from a garden hose

Motivational Interviewing, Miller & Rollnick

The MI Process

Two phases:

• Engaging• Focusing1. Building motivation

• Evoking• Planning

2. Strengthening commitment to change

The four processes flow, overlap, and recur.

Process Step #1: Engagement

Establishment of mutual trust and respect

Agreement on treatment goals

Collaboration on mutually negotiated tasks to reach the goals

Technique for Engaging:Four Basic Listening Skills

OARS:• Open-ended questions• Affirming• Reflective Statements• Summarizing

Technique for Engaging: Utilizing OARS to Explore Values and Goals

Exploring client’s top 5-10 values is important/key to: Appreciating client’s internal frame of reference Knowing/utilizing what motivates client Promoting engagement Focusing and guiding their actions Reflecting on discrepancies and inconsistencies

Process Step #2: Focusing

• Clarifying, developing and maintaining a specific direction in the conversation about change

• Goals may/may not involve behavior change.

• Change can also occur in attitude, thoughts, acceptance of not change

Three Sources of Focus

• The client (presenting problem and concerns)

• The setting (agency is funded to address specific issues and provide certain services)

• The SW (own perceptions of the issues to address)

Technique for Focusing: Agenda Mapping

Agenda mapping involves a sequence of actions: Structuring Statement: “Would you mind if we

consider…”, “Can we take a moment to discuss…” Considering Options: list the options we might focus on

together Allow client to reflect on options, include affirmations,

invite new ideas, reflect, and include your opinions Zooming In: Consider priorities, urgent attention items,

limits to focus, negotiate best option Summarize: Wrap up by mentioning the big picture of

what you’ve considered together, then pinpoint one or two top priorities, remind client that we can return to the map when needed, and finish by asking for client’s response “what else?”

Technique for Focusing: Exchanging Information Utilizing Elicit-Provide-Elicit

• It’s unhelpful to provide info the client already has considered or tried

• EPE: the information is sandwiched between two questions of permission

• Respectful way to provide information that prevents you from telling client what they already know, which increases client’s willingness to listen

• Allows you to use the time wisely by providing them with info they do need/want to know, and allows client to decide

Technique for Focusing: Information Exchange Utilizing Elicit-Provide-Elicit

Elicit (Ask):• Ask permission, allow them to choose what to do or think, agree or disagree• Explore client’s prior knowledge, clarify information needs and gaps• Ask about their interest in whatever information you may be able to provide• Ask: May I….?, Would you like to know….?, Is there any info I can offer?, What

do you know about…..?

Provide (Tell):• Prioritize what information to provide• Give clear, manageable doses, Use every day language• Use autonomy-supportive language, Acknowledge freedom to disagree or ignore

Elicit (Ask):• Checking back in to inquire about their understanding, interpretation or

response to the info• Ask open-ended questions: What do you think about the information?, What do

you think you will do with the information?, How does this information relate to your situation?

• Reflect reactions: You seem surprised……, You look resolved……, You are thinking about something……

Process Step #3: Evoking

• Social worker elicits motivation for change through OARS

• Clients respond, and their own talk moves them into change

Evoking Part #1: Preparatory Change Talk

• Acronym: DARN• None of these, alone or together,

indicate that change in going to happen

D- Desire Statements• I want to make my life better.

A-Ability Statements• I can do it.

R-Reason Statements• Here are the reasons I have to

quit.N-Need Statements

• I need to do this.

Evoking Part #2: Mobilizing Change Talk

• Acronym: CAT• Committing language signals

likelihood of actionC-Commitment

• I will, I promise, I intend to, I guarantee

A-Activation• Language that describes

when and how the change will occur

T-Taking Steps• Speech that indicates

steps have been taken in the direction of change

Technique for Evoking: Decisional Balance • Ambivalence (mixed feelings

about change) is normal and necessary

• Ambivalence can be uncomfortable and complex

• Solution: Neutrality (not encouraging movement in a particular direction)

• Rather, explore both pros/cons of options in a balanced way

• https://www.youtube.com/watch?v=7vJ8jBqzVqU

Technique for Evoking: Decisional Balance

Process Step #4: Planning

• Developing commitment to change and formulating a plan for action by elicitingthe client’s own solutions, promoting autonomy and strengthening change talk

Technique for Planning: Development

• With several clear options, task is to prioritize and choose

• Steps: (Path mapping/similar to agenda mapping)

• Confirm the goal• Itemize the options (ask

permission)• Elicit the client’s preferences

(explore pros/cons) • Summarize the plan• Troubleshoot

Technique for Planning: Implementation

• The plan is not a final step, but rather a beginning step

• Implementation (doing the plan) requires: – specificity (ready, willingness,

and ability to do)– intention (what, when, and

how is the reasonable next step?)

– Commitment (how will monitoring and support happen?

Technique for Planning: Supporting Change

• Assume: – Change is not linear, takes

time– Motivation and persistence

fluctuates– Setbacks occur

• Support persistence with MI spirit and style

• Flexible Revisiting– Re-planning– Reminding (re-evoking)– Re-focusing– Re-engaging

Five Questions for MI BeginnersWhy would you

want to make this change?

How might you go about it in order to

succeed?

What are the three best reasons for

you to do it?

How important is it for you to make this change, and

why?

So what do you think you’ll do?

… and your *client will feelEngaged. Empowered. Comfortable. Understood.

Motivational Interviewing, Miller & Rollnick

What changes might our clients consider?

If they want to keep smoking

If (or how) to break the news of their diagnosis to a

loved one

How much they drink on a nightly

basis

How to address tension with a family member

The amount of time or money they spend on

AOD

How many hours they dedicate to

exercise

Whether they want to go

through the treatment process

Addressing their weight issue

Whether or not they’re going to

take their medicine

Still yearning for more?

Wrap Up: Questions & Answers

Rhonda DiNovo, LMSWPhone- (803)-777-9374dinovo@mailbox.sc.edu