The only way to keep your health is to eat what you don t want, drink what you don t like, and do what you d rather not

(1)

Motivational Interviewing

B. Nierenberg, Phd, ABPP B. Nierenberg, Phd, ABPP University of Miami Miller School of Medicine University of Miami Miller School of Medicine

M. Jensen, PhD M. Jensen, PhD

U of Washington School of Medicine U of Washington School of Medicine

Motivation Interviewing: Rationale Motivation Interviewing: Rationale

How well people manage change depends on what they do

In medical treatment, we often ask patients to make significant changes in their behavior

– Stop harmful medications – Exercise

– Lose weight

– Keep moving appropriately (slow but steady) despite pain – Return to work

Change management is hard work

Motivation is a primary issue

The only way to keep your health is to eat what you don’t want,

drink what you don’t like, and do what you’d rather not

(2)

What is Motivation?

Motivation is the probability that a person Motivation is the probability that a person

will change* will change*

Motivation is influenced by clinician Motivation is influenced by clinician

responses responses

Low patient motivation can be thought of Low patient motivation can be thought of

as a clinician deficit as a clinician deficit

*Miller & Rollnick, Motivational Interviewing: Preparing people to change *Miller & Rollnick, Motivational Interviewing: Preparing people to change

addictive behavior. New York: Guilford Press, 1991 addictive behavior. New York: Guilford Press, 1991..

What is Motivational Interviewing? What is Motivational Interviewing?

MI is a

MI is ageneral approachgeneral approachand aand asetset of therapeutic responses

of therapeutic responsesthat leadthat lead to an increased probability that the to an increased probability that the patient will change

patient will change

MI strategies are theoretically and MI strategies are theoretically and

empirically based empirically based

Applications to Change Management Applications to Change Management

What not to do

(3)

Lecturing (directing, warning, preaching, criticizing, Lecturing (directing, warning, preaching, criticizing, approving, interpreting) provides little in the way of approving, interpreting) provides little in the way of motivation

motivation

Usual response: Annoyance or guilt Usual response: Annoyance or guilt

Information is to behavior change as

wet noodles are to bricks -Wilbert Fordyce

What’s worse than lecturing?

Arguing!

If you find yourself lecturing or arguing, If you find yourself lecturing or arguing,

Stop

(4)

There are many things you

can do to increase

motivation

I will summarize 152 of them

The first 149 things you can do

Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen

Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen Listen

What to listen for

Is this person ready for change? Is this person ready for change?

Identifying readiness to change Identifying readiness to change

What does this person value? What does this person value?

Link behavior change to the person’s own goals Link behavior change to the person’s own goals

Why would

Why wouldthis personthis personwant to change?want to change?

Use the person’s own arguments for change Use the person’s own arguments for change

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Solution

Solution--focused model

focused model



AssumptionsAssumptions

–

–If it ain’t broke, don’t fix itIf it ain’t broke, don’t fix it –

–If it works, do it moreIf it works, do it more –

–If it doesn’t work, do something differentIf it doesn’t work, do something different

Solution

Solution--Focused Model

Focused Model



Key AspectsKey Aspects

–

–Positive focusPositive focus

»

»Highlight what you are doing rightHighlight what you are doing right

–

–Future visionFuture vision

»

»Vision of what’s possible makes it easier to getVision of what’s possible makes it easier to get there

there

–

–Baby stepsBaby steps

»

»What is the next smallest change possible?What is the next smallest change possible?

Is the person ready for change?

DiClemente and Prochaska (1982).

DiClemente and Prochaska (1982). SelfSelf--change andchange and therapy change of smoking behavior: A comparison of processes of change therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133

in cessation and maintenance. Addictive Behaviors, 7, 133--144.144. Change stages: Change stages: – – PrecontemplationPrecontemplation – – ContemplationContemplation – – PreparationPreparation – – ActionAction – – MaintenanceMaintenance – – RelapseRelapse

(6)

Precontemplation

Not considering change at all

Will actively resist change when

they feel coerced into changing

Contemplation

The person sees a need for change

and may be considering making a

change “sometime”

Contemplators are in a constant

state of weighing the pros and

cons of change

Preparation

In the process of deciding to make

a change

Involves both an intention to

change and initial steps towards

change

(7)

Action

The person is taking concrete

behavioral steps that will

lead to the desired change

Maintenance

The person is making efforts

to maintain the changes

made in the action stage

Relapse

The person is unable to

sustain the changes

made in the action stage

(8)

Matching your response

Stage Clinician’s task

Precontemplation Raise doubt Contemplation Tip the balance

Preparation Assist in plan development Action Assist client with plan Maintenance Review progress; Praise

Relapse Review process

Next, match your response to the patient’s readiness stage

Precontemplation: Raise Doubt

Patient: I won’t stop smoking. I can’t stop smoking. I Patient: I won’t stop smoking. I can’t stop smoking. I need to smoke. I have never been able to quit for very need to smoke. I have never been able to quit for very long. Not smoking is for the birds. Not smoking long. Not smoking is for the birds. Not smoking makes me nervous.

makes me nervous.

Strategy: Acknowledge concern, but ask questions that Strategy: Acknowledge concern, but ask questions that

allow for expression of doubt. allow for expression of doubt.

Response: Not smoking makes you nervous. What Response: Not smoking makes you nervous. What

effect do you think smoking already has had on your effect do you think smoking already has had on your body and your muscles? What changes, if any, have body and your muscles? What changes, if any, have you noticed in your body since you have been smoking you noticed in your body since you have been smoking so much?

so much?

Precontemplation: Raise Doubt

Patient: Well, we’ve been over this Patient: Well, we’ve been over this -- I getI get

short of breath on the steps and can’t keep short of breath on the steps and can’t keep up with my son anymore

up with my son anymore

Strategy: Ask questions and respond in ways Strategy: Ask questions and respond in ways

to encourage further discussion about the to encourage further discussion about the “down side” of the problem behavior. “down side” of the problem behavior. Response: How much does this bother you? Response: How much does this bother you?

(9)

Responding to Contemplation: Tip the Balance Responding to Contemplation: Tip the Balance

Listen for: Reasons the patient gives to change Listen for: Reasons the patient gives to change Being able to breathe is something you want, and Being able to breathe is something you want, and

becoming healthier is important to you. But you’ve becoming healthier is important to you. But you’ve told me that it’s been hard for you to stop for more told me that it’s been hard for you to stop for more than a few days in a row. Is this accurate? than a few days in a row. Is this accurate?

It has been stressful to try to stop, but you have also told It has been stressful to try to stop, but you have also told

me that you need to be healthier to attend your me that you need to be healthier to attend your daughter’s wedding. You really want be there and be daughter’s wedding. You really want be there and be healthy enough to dance with her.

healthy enough to dance with her.

Responding to Preparation: Develop and Enhance Plan Responding to Preparation: Develop and Enhance Plan

Listen for: How the person prefers to make the change Listen for: How the person prefers to make the change Communicate free choice: So you want to stop taking Communicate free choice: So you want to stop taking

smoking. How would you like to go about this? smoking. How would you like to go about this? Review consequences for changing: When this works, and Review consequences for changing: When this works, and

you are healthier, how do you think your life will be you are healthier, how do you think your life will be different?

different?

If asked for information and advice: Keep it short and simple If asked for information and advice: Keep it short and simple

(“I think you should try the patch”) and always follow (“I think you should try the patch”) and always follow--upup with questions to gauge the person’s response (“Does this with questions to gauge the person’s response (“Does this make sense to you?”)

make sense to you?”)

Responding to Action and Maintenance Responding to Action and Maintenance

Come unglued with praise! Come unglued with praise!

-- “I’m really impressed!”“I’m really impressed!” -- “Good job!”“Good job!”

-- “You did it!”“You did it!” -- “I’m proud of you!”“I’m proud of you!” -- “Wow!”“Wow!”

Be dramatic and enthusiastic here Be dramatic and enthusiastic here

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Relapse

To cease smoking is the

easiest thing I ever did; I

ought to know because I’ve

done it a thousand times.

- Mark Twain

Responding to Relapse

Normalize the relapse process Normalize the relapse process Praise accomplishments Praise accomplishments

Discuss what can be learned from Discuss what can be learned from

relapse relapse

Reframe relapse as being one step Reframe relapse as being one step

closer to maintenance closer to maintenance

MEDSTAT



MMiracle questioniracle question

 EExceptionsxceptions  DDifferencesifferences  SScalingcaling 

TTimeime--outout



AAccoladesccolades

 TTaskask

(11)

Miracle question



“If a miracle happened and _____ were“If a miracle happened and _____ were suddenly not a problem for you, what suddenly not a problem for you, what would you be doing instead of the problem would you be doing instead of the problem behavior (smoking, drinking, overeating, behavior (smoking, drinking, overeating, being a couch potato)?”

being a couch potato)?”

–

–Write down behaviors that would be differentWrite down behaviors that would be different if this problem were gone. What would you be if this problem were gone. What would you be doing

doing? What would others notice?? What would others notice?

MEDSTAT



MMiracle questioniracle question

 EExceptionsxceptions  DDifferencesifferences  SScalingcaling 

TTimeime--outout

 AAccoladesccolades  TTaskask

Exceptions



“Are there times when you wanted to“Are there times when you wanted to engage in a problem behavior (smoking, engage in a problem behavior (smoking, drinking, overeating, etc.), but didn’t, or drinking, overeating, etc.), but didn’t, or when you did a healthy behavior instead?” when you did a healthy behavior instead?”

»

»Write down examples of times you had the urge toWrite down examples of times you had the urge to … (overeat, smoke, drink or urge to watch TV … (overeat, smoke, drink or urge to watch TV instead of going for a walk, etc.), but you didn’t act instead of going for a walk, etc.), but you didn’t act on the urge.

(12)

MEDSTAT



 EExceptionsxceptions  DDifferencesifferences  SScalingcaling 

TTimeime--outout

 AAccoladesccolades  TTaskask

Difference



“What is the difference that makes the“What is the difference that makes the difference

difference between the times when (between the times when (overeatovereat)) and the times when you don’t (

and the times when you don’t (overeatovereat)?”)?”

Examples of Differences that Make Examples of Differences that Make the Difference

the Difference



Rest, schedule, buddy, geography, positiveRest, schedule, buddy, geography, positive events, etc.

events, etc.



Level of Urge (LOU)Level of Urge (LOU)



Red light, yellow light, green lightRed light, yellow light, green light

–

–Write down the difference that makes theWrite down the difference that makes the difference for your exception

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MEDSTAT



 EExceptionsxceptions  DDifferencesifferences  SScalingcaling 

TTimeime--outout



 TTaskask

Scaling to assess readiness



Current status relative to the miracleCurrent status relative to the miracle



Willingness to workWillingness to work



ConfidenceConfidence

Scaling to assess readiness



Current status?Current status?

–

–“On a scale of 1“On a scale of 1--10, where 10 means the10, where 10 means the miracle and 1 means the worst it has been, miracle and 1 means the worst it has been, what number would you say best describes what number would you say best describes how things are right now?”

(14)

Scaling to assess readiness



Willingness to work?Willingness to work?

–

–10 means willing to work very hard, while 110 means willing to work very hard, while 1 means just waiting to see if anything happens. means just waiting to see if anything happens.

Scaling to assess readiness



Confidence?Confidence?

–

–10 means most; 1 means least10 means most; 1 means least

»

»Write down your ratings forWrite down your ratings for



Current status (CS)Current status (CS)



Willingness to work (WW)Willingness to work (WW)



ConfidenceConfidence

MEDSTAT



TTimeime--outout



 TTaskask

(15)

Time out



Assess your readiness to change (small,Assess your readiness to change (small, medium, large) medium, large) – –WW = 2;WW = 2; – –CS = 2;CS = 2; – –Confidence = 2Confidence = 2 –

–Small, Medium or Large Readiness?Small, Medium or Large Readiness?



Get ready for AccoladesGet ready for Accolades

MEDSTAT



TTimeime--outout



AAccoladesccolades

 TTaskask

Accolades: Compliment Yourself



ExamplesExamples

–

–“I care so much about my baby’s health that I“I care so much about my baby’s health that I am willing to try to cut back on smoking.” am willing to try to cut back on smoking.” –

–“I give myself credit for taking time to attend a“I give myself credit for taking time to attend a workshop to help myself from here to health.” workshop to help myself from here to health.”

»

(16)

MEDSTAT



TTimeime--outout



 TTaskask

Tasks

Tasks –– If you’re ready, what are you going toIf you’re ready, what are you going to do?

do?

 No TaskNo Task

–

–Information needed? Timing issues? Acid Test?Information needed? Timing issues? Acid Test? –

–Readiness RulerReadiness Ruler



Thinking TaskThinking Task

–

–Be a detective, notice exceptions and analyzeBe a detective, notice exceptions and analyze the difference that makes the difference the difference that makes the difference



Action TaskAction Task

–

–Next smallest stepNext smallest step

Readiness Levels



SmallSmall –– go for No Taskgo for No Task

–

–Not ready for task;Not ready for task;



MediumMedium

--–

–Stick to thinking taskStick to thinking task

 LargeLarge

–

(17)

Next Smallest Step



What would be a small enough step to beWhat would be a small enough step to be doable and yet be large enough to make a doable and yet be large enough to make a difference in moving you closer to the next difference in moving you closer to the next level on your Current Status (CS) Scale? level on your Current Status (CS) Scale?

Example



If 10 = miracle; and CS = 4, how will you knowIf 10 = miracle; and CS = 4, how will you know when CS = 5?

when CS = 5?



Answer: I will _____________ .Answer: I will _____________ .

–

–Example: “I will (walk 5000 steps a day instead ofExample: “I will (walk 5000 steps a day instead of 4000 within ten days).”

4000 within ten days).”



Write down the next smallest step you can take toWrite down the next smallest step you can take to get closer to the the next number up from your get closer to the the next number up from your current status rating.

current status rating.

–

–Be sure to include a deadline for a concrete step.Be sure to include a deadline for a concrete step.

Summary



MEDSTAT Your Self from Here toMEDSTAT Your Self from Here to Healthy

Healthy

–

–Now that you have determined your readinessNow that you have determined your readiness to change, and your matching task (or lack to change, and your matching task (or lack thereof), decide who you are going to tell thereof), decide who you are going to tell about it, because if you find someone about it, because if you find someone supportive to tell it increases your chances of supportive to tell it increases your chances of making it happen.

(18)

MEDSTAT



Seven strategies harnessing positive focus, futureSeven strategies harnessing positive focus, future vision, baby steps

vision, baby steps » »MiracleMiracle » »ExceptionsExceptions » »DifferenceDifference » »ScalingScaling » »Time outTime out

» »AccoladesAccolades

» »TaskTask

–

–Mix and match them; use them alone or together. IfMix and match them; use them alone or together. If you remember only one, which will it be? you remember only one, which will it be?

Another Resource



And have you ever encouraged family and friendsAnd have you ever encouraged family and friends toto change their unhealthy habits?....

change their unhealthy habits?....



Do they also know that they should change ….. butDo they also know that they should change ….. but they don't?

they don't?

Do you notice that giving advice rarely works! Do you notice that giving advice rarely works! And nagging may even make things worst. And nagging may even make things worst. Are you left feeling frustrated?

Are you left feeling frustrated?



 Don't give up! Explore a new way.Don't give up! Explore a new way.



http://www.motivatehealthyhabits.com/http://www.motivatehealthyhabits.com/

Problems with Motivational Strategies Problems with Motivational Strategies

Involves encouraging changes in behavior that Involves encouraging changes in behavior that

may not benefit a particular person may not benefit a particular person

-- Another reason to emphasize free choiceAnother reason to emphasize free choice It is ‘manipulative’

It is ‘manipulative’

-- Everything we do influences people’sEverything we do influences people’s motivation

motivation

(19)

Benefits of Motivational Strategies

Makes our job easier

More rewarding

More effective

Efficacy of Motivational Efficacy of Motivational Interviewing: RCTs Interviewing: RCTs Substance abuse Substance abuse

-- Reduced drinking and reReduced drinking and re--injury (Gentilello et al., 1999)injury (Gentilello et al., 1999) -- Reduced use of cigarettes, alcohol and cannabis in youthReduced use of cigarettes, alcohol and cannabis in youth

(McCambrige & Strang, 2004) (McCambrige & Strang, 2004)

-- Lower frequency and problems (Marlatt et al., 1998)Lower frequency and problems (Marlatt et al., 1998) -- Fewer drinks and drinking days (Miller et al., 1993)Fewer drinks and drinking days (Miller et al., 1993) -- Less risky drivingLess risky driving(Monti et al., 1999)(Monti et al., 1999)

Smoking cessation Smoking cessation

-- Percent abstinent past 24 hoursPercent abstinent past 24 hours(Butler et al., 1999)(Butler et al., 1999)

Efficacy of Motivational Efficacy of Motivational Interviewing: RCTs Interviewing: RCTs

HIV risk reduction HIV risk reduction

-- Increased condom useIncreased condom use(Belcher et al., 1998)(Belcher et al., 1998) Diet and exercise

Diet and exercise

-- Increased physical activityIncreased physical activity(Harlan, 1999)(Harlan, 1999) -- Better treatment adherenceBetter treatment adherence(Smith, 1997)(Smith, 1997) Public health

Public health

(20)

Efficacy of Motivational Interviewing: Efficacy of Motivational Interviewing: Alamo et al. (2002)

Alamo et al. (2002)

Random assignment of 20 general

practitioners to:

-- Usual practice

Usual practice

-- Training in patient

Training in patient--centered

centered

practice

Alamo et al. (2002)

Patient-centered practice included:

Listen to patient w/o interrupting at the beginning of the encounter

Ask patients his/her thoughts about the condition Show support/be empathic

Allow and encourage the patient to ask questions Try to reach agreements about the nature of the problem Try to find a common ground about the management plan Name the process (“a kind of muscular pain”,

“fibromyalgia”) and avoid sentences like “there is nothing wrong with you”

Alamo et al. (2002)

Patients with chronic pain who saw the Patients with chronic pain who saw the

patient

patient--centered physicians reported highercentered physicians reported higher scores on questions about:

scores on questions about:

Willingness of the doctor to discuss the Willingness of the doctor to discuss the

problem. problem.

Clarity of explanation of the problem. Clarity of explanation of the problem. The physician’s willingness to take the The physician’s willingness to take the patient’s suggestions into account. patient’s suggestions into account.

(21)

Alamo et al. (2002) At one year follow

At one year follow--up, patients who sawup, patients who saw the patient

the patient--centered physicians reportedcentered physicians reported greater

greaterdecreases indecreases in:: Number of tender points Number of tender points Anxiety Anxiety Pain intensity Pain intensity

Motivational Interviewing:

Conclusions

Motivation is necessary for successful pain self-management

We cannot make patients change behavior, but can help motivate patients in the direction of positive changes

MI strategies can in incorporated into all pain (and rehabilitation) interventions to increase the probability of engagement in treatment and adherence to treatment recommendations

When to use these treatments: