Motivational Interviewing Steps and Core Skills Interviewing Steps and Core Skills Funded by: SECSAT-APRN Southeastern Consortium for Substance Abuse Training - Advanced Practice Registered

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: April 5, 2014

Motivational InterviewingSteps and Core Skills

Funded

by:

SECSAT-APRNSoutheastern Consortium for Substance Abuse Training -

Advanced Practice Registered Nurses

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

At the end of the session, you will be able to—

1. Identify MI basic steps.

2. Identify MI core skills.

3. Demonstrate and practice MI using core skills.

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Learning Objectives

SECSAT – APRN © 2014

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Motivational Interviewing Steps


1. ENGAGE

Express empathy

Ask questions

Use affirmations

Support autonomy

5SECSAT – APRN © 2014

2. FOCUS

Reflect

Summarize

Develop discrepancies


3. EVOKE

Motivation

Concerns


4. PLAN

Raise the subject

Support self-efficacy

Address elements of change


Video Demonstration


Play video: The Effective Physician

Motivational Interviewing: Core skills for

understanding values


Core MI skills for exploring values

Open-ended questions

Affirmations

Reflections

Summaries


Open-Ended Questions

Using open-ended questions—

Enables the patient to convey more information

Encourages engagement

Opens the door for exploration



What are open-ended questions?

Gather broad descriptive information

Require more of a response than a simple yes/no or fill in the blank

Often start with words such as— “How…”

“What…” “Tell me about…”

Usually go from general to specific



Why open-ended questions?

Avoid the question-answer trap which:

• Puts patient in a passive role

• Allows no opportunity for patient to explore ambivalence



Why open-ended questions?

Opportunity to explore and make transparent the patient’s own ambivalence


Closed-Ended QuestionsCreate Conversational Dead Ends

Closed-ended questions typically—

Are for gathering very specific information

Tend to solicit yes-or-no answers

Convey impression that the agenda is not focused on the patient


Exercise

Turning closed-ended questions into open-ended questions


Closed QuestionsSo, you are here because you are concerned about alcohol, correct?

Do you feel depressed or anxious?

How many children do you have?

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Open Questions• What is it that brings

you here today?

• How have you been feeling?

• Tell me about your family.


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Closed• Can you tell me about

your marijuana use? Do you like to smoke?

• When do you plan to quit drinking?

• Do you agree it would be a good idea for you to go for treatment?

Open-Ended• Tell me about your

marijuana use. What are some of the things you like about smoking?

• So, what, if anything, do you think you want to do about your drinking?

• What do you think about the possibility of going for treatment?


Affirmations

What is an affirmation?

Statement of appreciation, recognition, or understanding

How do they help?

Recognize positive behaviors

Support the person as they describe difficult situations


Affirmations May Include: Commenting positively on an attribute

─ “You are determined to get your health back.”

A statement of appreciation─ “I appreciate your efforts despite the discomfort

you’re in.”

A supportive statement

─ “You worked hard today.”


Affirmation example

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Patient: I’ve tried to quit drinking and get my job back. I really liked the work I was doing, and I want to earn my own living.

Clinician: You are a person with a strong sense of ethics that includes working and earning your own living.


Affirmation Example

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Patient: No one ever cared whether I went to school or not. Everyone at home was drinking or using drugs. I had to get there myself.

Clinician: You’ve come a long way thanks to your determination and persistence.


Reflective Listening

“Good reflective listening tends to keep the person talking, exploring, and considering.”

(Miller and Rollnick, 2013)



Involves listening and understanding the meaning of what the patient says

Has the effect of encouraging the patient to elaborate, amplify, confirm or correct.



Why listen reflectively?

─ Demonstrates that you have accurately heard & understood the patient

─ Strengthens the empathic relationship

─ Encourages further exploration of problems & feelings


Levels of reflection

REPEAT

REPHRASE

INFER or ADD NEW MEANING

SUMMARIZE

De

pth

of

em

pa

thy

SECSAT – APRN © 2014 27

Levels of reflection

REPEAT - restate what client has said

REPHRASE – offer a synonym

INFER or ADD NEW MEANING –empathic, double-sided, reflections of feelings

SUMMARIZE – gather client utterances


Simple Reflections

Stay close to the content spoken by patient by

Repeating

Rephrasing (substitutes synonyms)

Example

Patient: I hear what you are saying about my drinking, but I don’t think it’s such a big deal.

Clinician: So, at this moment you are not too concerned about your drinking.


Exercise: Reflect by repeating, or substituting a synonym

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Patient: You just don’t know how hard this is.

Clinician: ?

Patient: My boss complains about my being

late.

Clinician: ?


Complex ReflectionsMake a guess or paraphrase becoming a major restatement, infer meaning

Patient: Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint!Clinician: It’s hard to imagine how I could possibly understand.

Patient: I just don’t want to take pills. I ought to be able to handle this on my own.Clinician: You don’t want to rely on a drug. It seems to you like a crutch.


Complex – Reflection of feeling

Reflection of feeling is the deepest form of empathic

reflection

Patient: My wife decided not to come today. She says this is my problem, and I need to solve it or find a new wife. After all these years of my using around her, now she wants immediate change and doesn’t want to help me!

Clinician: Her choosing not to attend today’s meeting

was a big disappointment for you.


Exercise: Reflection of feeling

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Patient: They said this wouldn’t take long, but here it is an hour later. How much longer will I be?

Clinician: ?


Complex – Reflection that is Double-Sided

Attempts to reflect back both sides of the ambivalence the patient experiences.

Patient: But I can't quit smoking. I mean, maybe I should, but all my friends smoke!

Clinician: You can't imagine how you could not smoke with your friends, and at the same time you're worried about how it's affecting you.


The summary is like a bouquet of flowers (change talk) that we collect

and give to the patient


Effective summaries

• Facilitate and guide

• Are selective and concise

• Reflect ambivalence

• Accentuate “change talk”

• Affirm and reinforce motivation to change


Summaries

Periodically summarize the discussion.

Summary usages

─ Begin an appointment

─ End an appointment

─ Transitions

Advantages

─ Enhances collaboration

─ Assures patient and clinician are in sync


Summaries

Strategic summary—select what information should be included and what can be minimized or left out.

Additional information can also be incorporated into summaries—for example, past conversations, assessment results, collateral reports, etc.


Summaries

Examples

─ “So, let me see if I’ve got this right…”

─ “So, you’re saying… is that correct”

─ “I’d like to make sure I’m understanding exactly what you’ve been trying to tell me…”

Double sided reflections are often highly effective as summaries to illustrate ambivalence.


Learning Exercise


http://www.freeimages.com/browse.phtml?f=download&id=1038128&redirect=photo

http://www.freeimages.com/browse.phtml?f=download&id=1038128&redirect=photo

Exercise

OARS in

practice


A taste of MIDivide into pairs. Speaker:

In a minute you will have the opportunity to talk aboutsomething that you have been thinking of changing; something you either want to change, need to change, or should change, but haven't changed yet (i.e., something you're ambivalent about.)

**For group consideration: How advantageous/fun might it be to use the goal of implementing SBIRT into your practice for this role play?


APRN:Listen carefully with a goal of understanding the dilemma. Give no advice. Ask these three questions and reflect the answers: 1. Why would you want to make this change? 2. How might you go about it, in order to succeed? 3. What are the three best reasons to do it?

Give a short summary/reflection of the speaker's motivations for change.

Then ask, "So what do you think you'll do?" and just listen with interest.

A taste of MI - cont’d



DEBRIEF:

Speaker: What was your experience of talking about your potential change goal?

APRN: What was your experience? How was this difficult? Easy? What might you try again?

Conclusion

In this session, you have learned the steps and core motivational interviewing skills.

In the next session, you will use these core skills plus selected tools that help patients better understand their competing priorities and ambivalence to change—to resolve their ambivalence and increase motivation for behavior change.



QUESTIONS?

Documents

Motivational Interviewing Steps and Core Skills Interviewing Steps and Core Skills Funded by: SECSAT-APRN Southeastern Consortium for Substance Abuse Training - Advanced Practice Registered