Motivational Interviewingfor Health Behavior ChangePaul F. Cook, PhD & Laurra M. Aagaard, MS,

MAUniversity of Colorado College of Nursing

DISCLOSURES (past 12 months)

• Grant Funding: National Institutes of Health, HRSA (Federal), SAMHSA (Federal), CDC (Federal), Merck & Co. Inc., Colorado Health Foundation

• Speaking: University of Colorado Hospital, Children’s Hospital of Colorado, National Food Program Sponsors’ Association, Colorado Dept. of Workers’ Comp.

• Consulting: Takeda Inc., Covance Market Access Inc., Medical Simulation Corp., Academic Impressions Inc., Competency & Credentialing Institute Inc.

• Health is getting worse over time. From 1994 to 2000, the U.S. obesity rate rose by 1/3

• Patients don’t follow medical recommendations: 50% for medication adherence, lower for diet, exercise, recommended screening & prevention

• Behaviors are independent of each other• Patients aren’t always honest about

behavior Abid, et al., 2005; Goldstein, Whitlock, & DePue, 2004; Polivy & Herman, 2002; WHO, 2002

The Problem

OUR OBJECTIVES FOR YOU• Use the spirit of MI to guide your work with clients

and avoid unproductive interactions• Describe the research basis for MI as a best

practice• Identify key MI principles: rolling with resistance,

expressing empathy, developing discrepancy, an supporting self-efficacy

• Recognize MI "micro-skills" like reflection, open-ended questions, and the elicit- provide-elicit method of patient education

• Recognize change talk and sustain talk, and apply strategies for responding to each

Behavior Change is Difficult!• Individuals and systems tend to resist

change• 50% of meds abandoned by 12 mos.• Exercise has even lower adherence• Diet changes are hard to sustain• Environmental pressures and habits

affect behavior outside awareness

• Some barriers are legitimate concerns: cost, time, weather, transportation, pain

• Change in one area does not generalize to changes in other areasGlasgow, McCaul, & Schafer, 1987 ; Meichenbaum

& Turk, 1987; NCPIE, 1994; Polivy & Herman, 2002

Help, I really want to change!

Everyone is Ambivalent• The nonadherent person

– Argues or interrupts: yeah, but …– Denies or ignores problems:

it’s not a big deal …– Still has a part of them that values health– Still has a part of them that wants to change

• The adherent person– Is (probably) telling you the truth– Is doing fine for now– Still has a part of them that resents/resists

change

Beliefs

PARISIN THE

THE SPRING

POPGOES THE

THE WEASEL

12 Roadblocks• Ordering• Threatening• Persuading• Lecturing• Moralizing• Criticizing

• Shaming

Psychoanalyzing

• Sympathizing• Praising• Questioning• Changing the

SubjectTry it!

Gordon, 1970

A Way Through Resistance• Listen carefully• Understand people’s

motivations• Resist the urge to “fix it”• Empower the client

Marla Corwin, CU School of Medicine, 2013 (adapted from Rollnick, Miller, & Butler, 2008)

Motivational Interviewing “SPIRIT”• MI is not primarily a set of techniques; it is

an attitude or a different way of being with people

• MI is at the same time …– Empathic (caring) and– Guiding (directive)

• Some characteristics of MI (ACCE):– Accepting – Collaborative / Person-Centered– Compassionate– Evoking and Strengthening Motivation to

Change Miller et al., 2013, Motivational Interviewing, 3rd Ed.

What Works?What Works?• Acceptance• Attention• Choice• Support• Reminders• Experimentation• Reinforcement

MI Principles

Develop Discrepancy

Express Empathy

Support Self-Efficacy

Roll with Resistance

Motivational Interviewing• Developed for substance abuse• Intended to motivate “resistant” clients• Based on social psychology principles

– Social influence/persuasion– People resist your efforts to change them– Person-centered counseling techniques

• “A method for exploring and resolving ambivalence”– NOT: teaching, changing, controlling

• “MI is like dancing”

Miller & Rollnick. (2002). Motivational Interviewing, 2nd Ed.

Four Principles of MI• Roll with resistance

– Listen and try to understand – Avoid arguing – don’t try to “fix it”

• Develop discrepancy– Clients present arguments for change

• Express empathy– Reflection, acceptance, collaboration

• Support self-efficacy– Ask for the client’s perspective– Facilitate hope for change

Rollnick, Miller, & Butler. (2007). Motivational Interviewing in Health Care.

Try it!

How MI Works

http://youtu.be/9il0RgO5fGM

Avoid the Traps• Expert Trap• Educator Trap• Premature Focus

Trap• 20-Questions Trap• Fear Trap• Advice Trap

• Client is the expert• Clients choose to

learn• Negotiate an

agenda• Open-ended

questions• Reduce fear &

denial• Clients make

choicesMiller et al., 2013, Motivational Interviewing, 3rd Ed.

The Evidence for MI• Review of 30 studies with 5541

participants, most with 3-12 month follow-up data

• Total amount of MI provided: 30 min to 4 hrs

• Moderate changes in alcohol use, drug use, diet & exercise, treatment adherence (similar to longer-term counseling methods)

• Smaller but still significant changes for smoking (about half as strong), based on 16 studies

• Smaller effects for safer sex (2 studies), eating disorders (1 study)

Burke, et al. (2003). J Consult Clin Psych, 71(5), 843-861; Hettema & Hendricks. (2010). J Consult Clin Psych, 78(6),

868-884.

MI Across the Lifespan• Adolescents

– Transitions in care / chronic disease management

– Preventing depression in at-risk adolescents

• Children– Oral health– Diet– Exercise– Chronic disease managementBerg-Smith et al. (1999). Health Educ Res, 14, 339-410; Gueldner & Merrell (2011). J Educ Psychol

Consult, 21, 1-27; Resnicow et al. (2006). J Am Dietetic Assoc, 106, 2024-2033; Schwartz et al. (2007). Arch Pediatr Adolesc Med, 161, 495-501; Suarez & Mullins. (2008). J Devel Behav Pediatr, 29, 417-428; Weinstein et al. (2006). J Am Dent Assoc, 137, 789-793.

MI “Micro-Techniques”: OARS• Open-Ended Questions

– Problem recognition– Concern about the problem / pros and cons– Optimism about change– Intention to change

• Affirm• Restate

– Reflect content– Reflect emotion (worry, concern, upset)– Reflect intention– Reflect meaning (go one step further)

• Summarize (“what else?”)

Miller & Rollnick, 2002

• “What I hear you saying is …”• “It sounds like …”• “You’re feeling like …”• “It seems like …”• “You wish …”• “You want …”• “You think …”• “From your perspective …”

Examples of Reflective Listening

Summary Statements Combine Several Previous

Reflections• Reflection #1: You want to help your child

eat a healthy diet• Reflection #2: You’ve talked to her, but

she doesn’t listen• Reflection #3: You’re frustrated with the

situation• Summary Statement: I hear that you

really want to help your child, but you aren’t sure how. The things you have tried don’t seem to work, which is frustrating.

Change These to Open Questions

• “Did your moods feel out of control last night?”• “Did you use meditation or Biofeedback

strategies?”• “You really want to impact your patients don’t

you?”• “Did you use Reflective Listening techniques?”

• “Is the patient ready to work on change goals?”• “Are you being relational?”

Affirmation• Affirming self-determination

– You’re in charge– This is your decision

• Affirming strengths– You have made big changes in the past– You’re sure you could do it if you decided to

• Affirming competence– You know what’s best for your family– You’re the expert in what will work for you

Directing the Conversation

Reflect to communicate understanding• “You don’t brush your children’s teeth very

often”Use open-ended questions to raise new

topics• “How have you tried to gain their

cooperation?”Use summary statements to close topics• “I’m hearing that your dentist lectures,

and that’s frustrating, so your kids resist going there”

Follow with open-ended questions about change

• “How can I help?”

The Relationship Matters Most• Client commitment language is the best

predictor of behavior change in MI– The more time the client spends talking, vs. you– The amount of time talking about change (desire,

ability, recognition, need, commitment, activation, taking steps)

• Helper’s interpersonal skill predicts outcome better than specific techniques– Experience matters, but not specific knowledge– Do whatever works to strengthen the relationship

When Can I Educate?The Traditional Model in Education:

Tell — Ask — Tell

The Motivational Interviewing Model:

Elicit — Provide — Elicit

Rollnick, Mason, & Butler. (1999). Health Behavior Change.

Possible Benefits• Cut to the chase – a lengthy spiel takes

time• Deliver information in focused chunks• Increase the odds the patient will

remember

• Get to the most important issues more quickly

• Check off boxes in your EMR as the patient talks

Whole pie:What you sayto patients

This half: What patients hear

This quarter: What they understand

This eighth is what they rememberWell enough to use the information!

Recognizing ReadinessShowing Resistance• Seeing benefits of current behavior• Seeing costs of new behavior Strategy: back off, build motivation (the “strong principle of change”: increase

benefits)

Ready for Change• Seeing benefits of new behavior• Seeing costs of current behavior

Strategy: support efforts for change (the “weak principle of change”: decrease

barriers)Prochaska et al. (1995). Changing for Good

Early Stages: Use FRAMES

• Feedback about personal risks• Responsibility for change is the

client’s• Advice is given in a nonjudgmental

way• Menus of options are suggested• Empathic counseling style (OARS)• Self-efficacy of the client is

encouragedMiller & Rollnick, 2002

Getting Stuck:Some “Resistance” is only Sustain

Talk

“To fly, we have to have resistance” – Maya Lin

Some “resistance” is a natural expression ofthe process that moves us toward change.

Roll with resistance; don’t fight against it.

Pushing back against resistance only gets you more of it.

It is often helpful to hear from both sides of the ambivalence:• Why do you want to make this change? And also …• What do you not like about the idea of making this change

Roll With Resistance

• Use reflection to communicate empathy– I hear that this is difficult for you.

• Find out what the client already knows– Wait to offer new information until you are invited– Ask the client her opinion about the new information

• Summarize to communicate understanding– You see three barriers to moving forward: … .– What causes problems doesn’t matter as much as what

you decide to do about them.• Use open-ended questions to refocus on change

– What would you be doing if the situation were different?

When people resist, you might be pushing too hard for change!

RESISTANCEis futile

Change TalkListen for DARN CATs in the conversation:

• Desire for change

• Ability to change

• Reasons for change

• Need to change

• Commitment to change

• Activation for change

• Taking steps already for a change

Miller & Rollnick, 2007

Contemplation Stage

ActionStage

EARS for Change Talk

• Elaboration – what? why? how? tell me …• Affirmation – that sounds like a good

idea. I can see that you’ve considered this carefully.

• Reflection – you think … you want … you need … you intend … you think you can …

• Summary – you have considered … and at this point your plan is …

Questions to Elicit Change Talk

• Advantages of Change (Desire, Reasons) – What makes you think you would like a change?

• Disadvantages of the Status Quo (Need)– What concerns you about the current situation?

• Optimism about Change (Ability)– What do you think would work, if you did want a

change?• Intention to Change (Commitment, Taking Steps)

– What would you like to do at this point?

Miller & Rollnick, 2002

Find the Change Talk …a. I like it when I’m out drinking with friends, but

the next day I usually feel awful.b. If I’m late to work again because of my drinking,

I will get fired.c. My wife keeps nagging me to give up cigarettes.d. The doctor told me to cut down on drinking.e. I don’t like the idea of taking so many pain

meds, but the pain just won’t go away.f. I’m not sure I can quit smoking pot – it helps me

cope.

Use Naturally Occurring Solutions• Problems are struggles, failures are efforts

– What worked before?– How have you overcome other challenges?– What would you change from past attempts?

• Look for solutions that already exist– What is working already?– When isn’t the problem quite as bad?

• Access support from others– Who in the network is supportive?– Who haven’t you asked, and can they help?– What do others say that you might like to try?

• What do you think is the best plan from here?

Red Light / Green Light

• SUSTAIN TALK– LURE: listen, understand, resist the

urge to “fix it,” empathize• AMBIVALENCE

– OARS: open-ended questions, affirm, reflect, summarize

– Use elicit-provide-elicit to educate• CHANGE TALK

– EARS: explore, affirm, reflect, summarize

– Challenge the changeDart, M.A. (2011). Motivational

Interviewing in Nursing Practice

Next Steps in Using MI

• Active listening (OARS)• Use reflections more than questions• Roll with resistance• Use elicit-provide-elicit to educate• Assess readiness for change• Use FRAMES to motivate change• Listen for change talk (DARN CAT)• Problem-solve using natural supports

Developing the “Spirit” of MI

• The heart of MI is a spirit of …– empathy– acceptance– respect– honesty– caring

• Hope & faith in the client• Interest in others’ well-being and growth• Empathy: 2 reflections per 1 question

(Moyers, Miller, & Hendrickson, 2005)

Learn More about MI• Miller & Rollnick (2013). Motivational Interviewing,

3rd Ed.• Rollnick, Miller, & Butler (2007). Motivational

Interviewing in Health Care• Rollnick, et al. (1999). Health Behavior Change• MI home page: www.motivationalinterview.org • Prochaska, Norcross, & DiClemente (1995).

Changing for Good• Stages of change home page:

www.uri.edu/research/cprc/transtheoretical.htm • Bothello (2004). Motivate Healthy Habits• Seminars: professional.development@ucdenver.edu