Deborah L. Drew, Ed. D., LCPC and Evan Williams, PharmD Husson
University HICHEP Presentation August 24, 2013
Slide 3
Welcome and Introductions Hour 1: What is Motivational
Interviewing? Hour 2: Components of Motivational Interviewing Hour
3: Tools and Practice Hour 4: Action Plan: Implementing Change in
Your Practice Summary and Evaluations 2
Slide 4
3
Slide 5
Slide 6
Clinicians can only provide patients with clinical knowledge
and education Patients make the ultimate decision to change What
can clinicians do to influence patient change? Scare tactics
Lecture and educate Motivate the patient to change 5
Slide 7
Describe the development and evidence for the use of
motivational interviewing Implement components of the model for
motivational interviewing Develop an action plan to implement the
elements and principles of motivational interviewing in practice
6
Slide 8
Think of a bad habit you have tried to change Dietary habits
Exercise habits Workplace habits Relationship habits How long did
it take to realize that this habit had a negative impact on you or
others? Months? Years? Were you successful? Did you relapse? 7
Slide 9
Think about patients who have difficulty making change 8
Slide 10
Slide 11
10 Precontemplation No intention of changing their behavior for
the foreseeable future Not thinking about changing their behavior
May not see the behavior as a problem Contemplation Aware a problem
exists Seriously considers action Not yet made a commitment to an
action Preparation Intent upon taking action soon Often report some
steps in that direction Action Aware a problem exists Actively
modifies their behavior, experiences and environment in order to
overcome the problem Commitment is clear Great deal of effort to
change Maintenance Sustained change New pattern of behavior has
replaced the old Behavior is firmly established Threat of relapse
becomes less intense Prochaska, J. O., & DiClemente, C. C.
Slide 12
Stages of Change
Slide 13
Motivational Interviewing (MI) is a collaborative,
personcentered form of guiding to elicit and strengthen motivation
for change. Defined by the identification, examination, and
resolution of ambivalence about changing behavior Ambivalence:
Feeling two ways about behavior change 12
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles
%20&%20Approach%20V4%20012911.pdf
Slide 14
Method of communication Not a technique Increases mutual
understanding Collaborative Honors patient autonomy Strengthens a
persons own motivation for and commitment to change
Patient-centered 13
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 15
William R. Miller Motivational Interviewing with Problem
Drinkers Behavioral Psychotherapy - 1983 Stephen Rollnick and
William R. Miller 1991 article Outlines clinical procedures Has
been revised and applied to many settings Miller, W. R., &
Rollnick, S. (1991). Motivational interviewing: Preparing people
for change. New York: Guilford Press. Miller WR. Motivational
Interviewing with Problem Drinkers. Behavioural Psychotherapy.
1983, 11 (2); pp 147-172 14
Slide 16
Growing body of evidence 6 references 1980-1989 78 references
1990-1999 707 references 2000-2009 Most studies show MI to be
beneficial Publication bias? Most studies have limitations Small
sample size Weak comparator groups Various providers offering MI
Providers have differing levels of training in MI Difficult to
assess the manner in which MI is used 15 Lundahl B, Burke B. The
effectiveness and applicability of motivational interviewing. J
Clin Psych 2009;65(11) 1232-45
Slide 17
Pattern of results show MI is likely To confer at least a 10%
advantage in success rates versus weak comparators To be as good or
better than established treatments To take less time and resources
Best outcomes may be using MI pre- treatment 16 Lundahl B, Burke B.
The effectiveness and applicability of motivational interviewing. J
Clin Psych 2009;65(11) 1232-45
Slide 18
Effective regardless of gender or age Training level does not
significantly impact effectiveness Versatile In what areas is MI
most effective? 17 Lundahl B, Burke B. The effectiveness and
applicability of motivational interviewing. J Clin Psych
2009;65(11) 1232-45
Slide 19
18 Lundahl B, Burke B. The effectiveness and applicability of
motivational interviewing. J Clin Psych 2009;65(11) 1232-45
Slide 20
19 Lundahl B, Burke B. The effectiveness and applicability of
motivational interviewing. J Clin Psych 2009;65(11) 1232-45
Slide 21
20 Rubak S, Sandboek a, Lauritzen C et al. The efficacy of
motivational interviewing: A meta- analysis of controlled clinical
trials. Brit J General Practice. 2005 April, pp 305-312
Slide 22
Limitations Interventions ranged from 10-120 min (60 min most
common) Variable follow up periods Usefulness Provides evidence
that MI can elicit significant change Overall about 75% of studies
show there was an effect 21 Lundahl B, Burke B. The effectiveness
and applicability of motivational interviewing. J Clin Psych
2009;65(11) 1232-45 Rubak S, Sandboek a, Lauritzen C et al. The
efficacy of motivational interviewing: A meta-analysis of
controlled clinical trials. Brit J General Practice. 2005 April, pp
305-312
Slide 23
22
Slide 24
Key Elements of MI Collaboration Evocation Autonomy Principles
of MI Express Empathy Support Self Efficacy Develop Discrepancy
Roll with Resistance 23
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20P
rinciples%20&%20Approach%20V4%20012911.pdf
Slide 25
Collaboration Dismisses hierarchy Builds rapport
Non-confrontational Focus is mutual understanding 24
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 26
RG is a 57 year old male with hypertension and hyperlipidemia.
On questioning it is revealed that he smokes about 1 pack of
cigarettes daily. You would like him to quit smoking. 25
Slide 27
Evocation Patients discover their own motivation and skills for
change Draw out the patients own thoughts and ideas ..lasting
change is more likely to occur when the client discovers their own
reasons and determination to change 26
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 28
Pharmacist: Ive noticed you have been late filling these
medications the last 2 months. Patient: Yeah, Ive been having a
hard time keeping up with things as I am moving to a new home
across town in a few weeks. I know taking my medications is
important but Ive been so busy lately that I forget sometimes.
Pharmacist: It sounds like you would like to take your medications
but it has been a tough time dealing with the move. 27
Slide 29
Autonomy Ultimately it is the patients decision to change
Empowers the patient and gives them responsibility As clinicians,
we can encourage patients to develop their own SMART goals
Specific, Measurable, Achievable, Relevant, Timely 28
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 30
DK is a 44 year old patient newly diagnosed with diabetes.
After discussion, it is revealed that he eats desserts for
relaxation. When asked how he thinks this impacts his diabetes, he
states he does not know. 29
Slide 31
Express Empathy See the situation from the patients perspective
Gain perspective on what the patients motivation may be It sounds
like this has been tough for you It seems like this situation has
been difficult for you to accept 30
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 32
Support Self Efficacy Focus on strengths and skills patient
already has Highlight previous successes Patient needs to believe
that change is possible
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf 31
Slide 33
Develop Discrepancy Patients identify their values and goals
Patients evaluate their current behaviors Ambivalence is discovered
when conflict between values/goals and behaviors is identified
Change is more likely when patients realize their behaviors are in
conflict with their selfidentified values or accomplishment of
goals On the one side, you feel unhappy that you cannot keep up
with your grandkids because of your COPD, but on the other hand,
you feel that smoking is one of the only ways you can relax. 32
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 34
Roll with Resistance Do not challenge resistant statements
Confronting resistance promotes defensiveness and diminishes the
likelihood of a patient finding their own reasons to change Use the
resistance as an opportunity to further explore the patients views
Be aware of when a patient is becoming frustrated Closed body
language Negative verbal responses Shortened verbal responses 33
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 35
BG is an overweight veteran recently discharged from the Air
Force. He has gained much of this weight since his discharge 14
months ago. The clinician suggested that BG enroll in clinic
sponsored program for weight loss. BG declines enrollment. BG
states that he is just not willing to exercise for 30 minutes 5
days a week because he is just too exhausted after work. 34
Slide 36
35
Slide 37
OARS Open-Ended Questions Affirmations Reflective Responses
Summaries RULES of Motivational Interviewing Resist the righting
reflex Understand the patients motivation Listen with empathy
Empower the patient Brief Motivational Interviewing for Veterans.
TMS. VALU system. www.tms.va.govwww.tms.va.gov 36
Slide 38
Elicit better responses from patients Make a conversation less
one-sided Are not answerable with a simple yes or no Open-Ended
Question WordsClosed-Ended Question Words How? Why? Tell me more
about... When? What kinds of Do you? Have you? Can you? Will you?
Brief Motivational Interviewing for Veterans. TMS. VALU system.
www.tms.va.govwww.tms.va.gov 37
Slide 39
Slide 40
Statements that recognize a patients strengths Help support
self efficacy Tries to help patient believe change is possible
despite past failures 39
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 41
Words the patient uses Words clinician hears What the clinician
thinks the patient meant What the patient meant Restate how the
provider perceives the patient Allows for increased clarity Allows
the listener to affirm the patients feelings Patient feels
understood Brief Motivational Interviewing for Veterans. TMS. VALU
system. www.tms.va.govwww.tms.va.gov 40
Slide 42
Slide 43
Reflection that recaps visit and highlights important areas Can
clarify ambivalence and discrepancies 42
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
I know what is best Removes autonomy from the patient by
insinuating the patient does not know what is best for themselves
Re-establishes hierarchy Can undermine the patients motivation for
change Can create conflict Brief Motivational Interviewing for
Veterans. TMS. VALU system. www.tms.va.govwww.tms.va.gov 46
Slide 48
Patients reason for change is more important than the
clinicians Explore importance of changing Ask for a scaled answer
Why is it that number and not another? Brief Motivational
Interviewing for Veterans. TMS. VALU system.
www.tms.va.govwww.tms.va.gov 47
Slide 49
On a scale from zero to ten how important is it for you to?
Tell me why you chose that number? What could happen that would
move you to higher number? On a scale from zero to 10, how
confident are you that you can make this change? Tell me more why
you chose that number for your confidence level? What do you think
might help become more confident in making a change?
Slide 50
Use reflective responses Allows patient to tell you more
Clarifies patients concerns Confirms mutual understanding Be aware
of body language Eye Contact Nodding Posture Do not understand
Brief Motivational Interviewing for Veterans. TMS. VALU system.
www.tms.va.govwww.tms.va.gov 49
Patients must believe change is possible Failures can be
demoralizing Focus on previous successes Even small victories can
be uplifting Encourage the patient Let the patient know that they
are in control of the change Brief Motivational Interviewing for
Veterans. TMS. VALU system. www.tms.va.govwww.tms.va.gov 51
Slide 53
Think again about those patients you identified earlier who are
resisting change 52
Slide 54
53 Roll with Resistance Affirmation Open Ended Question
Collaboration Respected patients autonomy Reflective Response
Listening with Empathy Collaboration Open Ended Question
Elaboration Listening with Empathy
Slide 55
What went right? How well did the pharmacist do using
reflective responses? What could the pharmacist have done to
improve? 54
Slide 56
Slide 57
56
Slide 58
DARN-CAT Desire (I want to change) Ability (I can change)
Reason (It is important to change) Need (I need to change)
Commitment (I will make changes) Activation (Im ready and prepared
to change) Taking steps (I am doing specific things to change) 57
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
Slide 59
Ask questions that will elicit answers that are consistent with
DARN-CAT Developing discrepancy Desire Reason Need Change ruler
Ability Activation SMART Goal Setting Ability Activation Taking
steps 58
Slide 60
What concerns you about your current situation? What makes you
think you need to do something about your weight? What concerns you
about not checking your blood glucose on a regular basis? What do
you think might happen if you dont change your diet?
Slide 61
How would life be different for you if? If you could wake up
tomorrow and things changed by magic, how would things be better
for you? What are the main reasons you see for ..? What would be
the benefits of for you?
Slide 62
You mentioned how important it is for you to be able to play
with your grandchildren and how your current weight interferes with
that You said you would really like to be able to hike with your
friends on vacation and how your current energy level keeps you
from doing that
Slide 63
What do you think would work if you decided to change? How
confident are you that you can make this change? What kind of
support would be helpful in making this change? What encourages you
to change if you want to do it?
Slide 64
I can see you are feeling stuck right now. What is going to
have to change? How important is it for you to .? What do you
intend to do? What do you think you might be able to do?
Online resources or live classes Begin small Try only adding
one component at a time Reflective responses are a great starting
point Keep working at it It may feel uncomfortable the first few
times Add components as you become more adept 66
Slide 68
MI is a useful technique to help people change It is useful in
combination with other techniques for eliciting change MI should
not replace your method of patient interaction, but enhance it
67
Slide 69
Motivational interviewing is a collaborative, personcentered
form of guiding to elicit and strengthen motivation for change. Key
Elements Collaboration Evocation Autonomy 68
Slide 70
Principles Express Empathy Support Self Efficacy Develop
Discrepancy Roll with Resistance 69
Slide 71
Strategies for implementation OARS Open-Ended Questions
Affirmations Reflective Responses Summaries RULE Resist the
righting reflex Understand the patients motivation Listen with
empathy Empower the patient 70
Slide 72
Group by profession. Discuss how you would implement MI in your
work setting. 71
Slide 73
72
Slide 74
Anshel MH, Kang M. Effectiveness of motivational interviewing
on changes in fitness, blood lipids, and exercise adherence of
police officers: an outcome-based action study. Journal of
Correctional Healthcare. 2008 14:48 Brief Motivational Interviewing
for Veterans. TMS. VALU system. www.tms.va.gov Burke B, Arkowitz H,
Menchola M. The efficacy of motivational interviewing: a meta
analysis of controlled clinical trials. Journal of Consulting and
Clinical Psychology 2003; 71, 843-861 (Egan, 2010) D&E Hettema
J, Steele J, Miller W. Motivational Interviewing. Annual Review of
Clinical Psychology 2005; 91-111
http://counselingvideos.blogspot.com/2013/06/its-not-about-nail.html
http://counselingvideos.blogspot.com/2013/06/its-not-about-nail.html
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%
20V4%20012911.pdf
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%
20V4%20012911.pdf http://www.youtube.com/watch?v=sWc0g2K9LAI
http://www.youtube.com/watch?v=sWc0g2K9LAI Lundahl B, Burke B. The
effectiveness and applicability of motivational interviewing. J
Clin Psych 2009;65(11) 1232-45 Lundahl B, Tollefson D, Kunz C et
al. Meta analysis of motivational interviewing: twenty five years
of research. Research on Social Work Practice 2009 Maslows
Hierarchy en.wikipedia.org Miller WR. Motivational Interviewing
with Problem Drinkers. Behavioural Psychotherapy 1983;
11(2),147-172 Miller, W. R., & Rollnick, S. (1991).
Motivational interviewing: Preparing people for change. New York:
Guilford Press. Miller, W. R. & Rollnick, S. (2002).
Motivational Interviewing: Preparing People for Change, 2 nd Ed.
New York: Guilford Press. Prochaska, J. O., & DiClemente, C. C.
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of
motivational interviewing: A meta-analysis of controlled clinical
trials. Brit J General Practice 2005; April, 305-312 Vasilaki E,
Hosier S, Cox W. The efficacy of motivational interviewing as a
brief intervention for excessive drinking: a meta analytic review.
Alcohol and Alcoholism 2006; 41, 328-35 73
