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Camh ipe 2013 pub

  1. 1. Motivational InterviewingCAMH Interprofessional Student EducationFebruary 6, 2013Marilyn Herie PhD, RSW
  2. 2. Confidence RulerNo Way I am 0 1 2 3 4 5 6 7 8 9 10 Bill Miller http://www.williamrmiller.net/
  3. 3. First, empty your cup
  4. 4. A scientist went to visit a famous Zen master. While the master quietly served tea, the scientist talked about Zen. The master poured the visitors cup to the brim, and then kept pouring. The scientist watched the overflowing cup until he could no longer restrain himself. "Its overfull! No more will go in!" the scientist blurted. "You are like this cup," the master replied, "How can I show you Zen unless you first empty your cup?"http://users.rider.edu/~suler/zenstory/emptycup.html
  5. 5. A hypothetical scenario…
  6. 6. How are you feeling?
  7. 7. http://www.lifehack.org/articles/lifestyle/sentences-that-can-change-your-life.html
  8. 8. Learning Objectives1. Identify practical strategies to motivate change2. Reflect on how you can adapt these strategies with your clients3. Set concrete objectives for clinical practice
  9. 9. Persuasion Exercise• Choose one person near you to have a conversation with, and work together• One will be the speaker, the other will be a counsellorMiller & Rollnick, 2013 14
  10. 10. Speaker’s Topic • Something about yourself that you want to change need to change should change have been thinking about changing but you haven’t changed yet …in other words – something you’re ambivalent aboutMiller & Rollnick, 2013 15
  11. 11. Counsellor: Find out what change the person is considering making, and then:• Explain why the person should make this change• Give at least three specific benefits that would result from making the change• Tell the person how they could make the change• Emphasize how important it is to change• If you meet resistance, repeat the above.P.S. This is NOT motivational interviewing Miller & Rollnick, 2013 16
  12. 12. Listeners: What were you thinking or feeling during this conversation?Miller & Rollnick, 2013
  13. 13. Common Reactions to Righting Reflex• Angry, agitated • Afraid• Oppositional • Helpless, overwhelmed• Discounting • Ashamed• Defensive • Trapped• Justifying • Disengaged• Not understood • Not come back – avoid• Not heard • Uncomfortable• Procrastinate Miller & Rollnick, 2013 18
  14. 14. “Unsolicited advice is the junkmail of life.” (Bern Williams)
  15. 15. “Advice is what we ask for whenwe already know the answer butwish we didn’t.” (Erica Jong)
  16. 16. A taste of Motivational Interviewing 21
  17. 17. A Taste of Motivational Interviewing: Conversation with one speaker and one listener. Speaker’s Topic:• Something about yourself that you want to change need to change should change have been thinking about changing but you haven’t changed yeti.e. – something you’re ambivalent about Miller & Rollnick, 2013 22
  18. 18. Listener• Listen carefully with a goal of understanding the dilemma• Give no advice.• Ask these four open questions and listen with interest: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?4. On a scale from 0 to 10, how important would you say it is for you to make this change?Follow-up: And why are you at __ and not zero?• 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 Miller & Rollnick, 2013 23
  19. 19. Speakers: What were you thinking or feeling during this conversation?Miller & Rollnick, 2013
  20. 20. Common Human Reactions to Being Listened to• Understood • Safe• Want to talk more • Empowered• Liking the counselor • Hopeful• Open • Comfortable• Accepted • Interested• Respected • Want to come back• Engaged • Cooperative• Able to changeWould you rather work with these people… Miller & Rollnick, 2013 25
  21. 21. …or these?Common Reactions to Righting Reflex• Angry, agitated • Afraid• Oppositional • Helpless, overwhelmed• Discounting • Ashamed• Defensive • Trapped• Justifying • Disengaged• Not understood • Not come back – avoid• Not heard • Uncomfortable• Procrastinate Miller & Rollnick, 2013 26
  22. 22. What is it for?Motivational interviewing is acollaborative conversation tostrengthen a person’s ownmotivation for and commitment tochangeMiller & Rollnick, 2013
  23. 23. Spirit of MI
  24. 24. The “Righting Reflex”
  25. 25. “I try to get my daughter to eathealthy, but that food isexpensive and she doesn’t likeit anyway.”
  26. 26. “Injecting Oxycodone isn’t sogreat for my veins, but it’sbetter than a lot of other crapout there.”
  27. 27. “I only have unprotected sexwith my boyfriend, and I knowhe wouldn’t cheat on me.”
  28. 28. Practitioner to the rescue!
  29. 29. It is your choice But giving your kidswhether to make healthy food is verythis change… important in preventing future problems
  30. 30. You are the one But if you keepwho has to injecting, your veinsdecide… aren’t the only serious thing to worry about
  31. 31. Regardless of what But even people weyou do, I will be trust make mistakeshere to support sometimes, and thatyou… includes your boyfriend
  32. 32. It is your choice But giving your kidswhether to make healthy food is verythis change… important in preventing future problemsYou are the one But if you keepwho has to injecting, your veinsdecide… aren’t the only serious thing to worry aboutRegardless of whatyou do, I will be But even people wehere to support trust make mistakesyou… sometimes, and that includes your boyfriend
  33. 33. • “It is your choice whether to make this change.”• “You are the one who has to decide.”• “Regardless of what you do, I will be here to support you.”
  34. 34. “People are most able tochange when they feelfree not to.” - Carl Rogers
  35. 35. The “Spirit” of Motivational Interviewing• Partnership • Absolute worth • Accurate empathy• Acceptance • Autonomy support• Compassion • Affirmation• Evocation Miller & Rollnick, 2013 41
  36. 36. Partnership“You are the best judge of what is going to work for you.”
  37. 37. Acceptance“I am here to help whatever you decide to do.”
  38. 38. Compassion Guide me to be a patient companion, to listen with a heart as open as the sky. Grant me vision to see through his eyes, and eager ears to hear his story…Let me honour and respect his choosing of his own path.Adapted from Miller, 2013, “A Meditative Preparation” (p.24)
  39. 39. Evocation“What were you hoping for by coming here today?”
  40. 40. Why would I use it?Motivational interviewing is a person-centered counseling method foraddressing the common problem ofambivalence about change.Miller & Rollnick, 2013
  41. 41. http://tinyurl.com/c5gamll
  42. 42. Where am I in MI?“Spirit” of MI – Resist the Righting Reflex 0 1 2 3 4 5 6 7 8 9 10“Spirit” of MI – Directional (versus directive) 0 1 2 3 4 5 6 7 8 9 10 “Spirit” of MI – Evoke (versus educate) 0 1 2 3 4 5 6 7 8 9 10
  43. 43. The Evidence Base forMotivational Interviewing
  44. 44. Research publications evaluating MIeffectiveness have been doubling everythree years.www.motivationalinterview.org
  45. 45. MI Outcome Studies by Era 100 80 60 40 20 0 1988-94 1995-99 2000-02 2003-06 Alcohol Drugs Dual Dx Gambling Offenders Eating Dis Adh/Retention Smoking HIV Risk Cardiac Diabetes Psychiatric Health Prom Family Violence Asthma DentalSlide from Bill Miller, 2010 55
  46. 46. MI Applications • Public health & • Medication adherence workplace • Diabetes • Sexual health • Mental health • Dietary change • Addictions • Weight management • Fibromyalgia • Voice therapy • Chronic leg ulceration • Gambling • Self-care • Physical activity • Criminal justice • Stroke rehab • Vascular risk • Chronic pain • Domestic violenceAnstiss, 2009
  47. 47. A Causal Chain for MI Therapist MI- consistent speech Increased client change talk Improved treatment outcomesMoyers et al., 2009
  48. 48. “What [practitioners] reflect, they will hear more of.” Moyers et al., 2009
  49. 49. “Miller and Mount, 2001 havesuggested that learning MI involvesat least two processes, one ofadding preferred behaviors, andanother of suppression of non-preferred behaviors.” (Baer, 2004)
  50. 50. “There is some evidence thateliminating those responses such asconfrontations, advice withoutpermission, directing, threatening,and raising concern withoutpermission is more important thanjust adding MI-consistent responses.” (Moyers and Ernst, 2001)
  51. 51. 20022012 2009 61
  52. 52. 2008 2011 62
  53. 53. 2012 2013
  54. 54. But what if the person refuses to change?
  55. 55. A No uttered from the deepestconviction is better than a Yesmerely uttered to please, orworse, to avoid trouble. Mahatma Gandhi
  56. 56. “He that complies against his will is of the same opinion still.” Samuel Butler 1612-1680 English Poet
  57. 57. The Ineffective Practitioner “Sal”http://www.youtube.com/watch?v=kN7T-cmb_l0&feature=related
  58. 58. Four Processes in MI 1. Engaging: The relational foundation 2. Focusing: Clarify directions: What is the horizon? 3. Evoking: The person’s own arguments for change 4. Planning: Developing commitment to change + formulating a plan of action “Planning is the clutch that engages the engine of change talk” (p.30)Miller and Rollnick, 2013
  59. 59. Four Processes in MI Planning Evoking Focusing EngagingAdapted from Miller and Rollnick, 2013, p. 26
  60. 60. Engaging
  61. 61. Focusing
  62. 62. Agenda-Mapping Worksheet PrioritiesDiagnosis Treatment PlanBenefitsSymptoms
  63. 63. Agenda-Mapping Worksheet PrioritiesDiagnosis Finances Treatment PlanBenefits StressSymptoms Relationship
  64. 64. Agenda-Mapping Worksheet PrioritiesDiagnosis Finances Treatment PlanBenefits StressSymptoms Relationship
  65. 65. Video Demonstration Agenda Mapping conversation with "Sal"http://www.youtube.com/watch?v=klnHJ4coG8o
  66. 66. “Readiness Ruler”People usually have several things they would like to change in their lives – this may be only one of thosethings. Answer the following two questions with respect to your goal for this week. • How important is it to change this behaviour? 0 1 2 3 4 5 6 7 8 9 10 • How confident are you that you could make this change? 0 1 2 3 4 5 6 7 8 9 10
  67. 67. Evoking
  68. 68. The Effective Practitioner “Sal”http://www.youtube.com/watch?v=-RXy8Li3ZaE&feature=related
  69. 69. Planning
  70. 70. Change Talk
  71. 71. Change Talk and Sustain Talk Opposite Sides of a Coin
  72. 72. Sustain Talk and Resistance• Sustain Talk is about the target behavior• Resistance is about your relationship• Both are highly responsive to counsellor style• We respond to both in the same way
  73. 73. Change Talk: Sustain Talk:I should But beer isreally cut good!back on thedrinking…
  74. 74. Change Talk: Sustain Talk:Smoking is But it is partunhealthy… of who we are
  75. 75. Change Talk: Sustain Talk:I should But I ampractice this booked back-motivational to-back withinterviewing clients andstuff… there is no time!
  76. 76. DARN CAT• Desire • Commitment• Ability • Action• Reasons • Taking Steps• Need
  77. 77. Yet another metaphor MI Hill k M al ob Nange T ili C R Ch zin g A Aory Ch an T D rat ge Ta e pa lkPr (Pre-) Contemplation Preparation Action Slide from Bill Miller, 2010
  78. 78. DARN CAT• Desire • Commitment• Ability • Action• Reasons • Taking Steps• Need Snap fingers = DARN Clap = CAT Silence = No change talk
  79. 79. Listening for Change Talk“I am getting too old for this lifestyle.” • Desire • Commitment • Ability • Action • Reasons • Taking Steps • Need
  80. 80. “My probation order is the only reason I am coming here.”• Desire • Commitment• Ability • Action• Reasons • Taking Steps• Need
  81. 81. “I am not addicted. I can quit anytime I want.”• Desire • Commitment• Ability • Action• Reasons • Taking Steps• Need
  82. 82. “I want to get well again, but my pain is still really bad.”• Desire • Commitment• Ability • Action• Reasons • Taking Steps• Need
  83. 83. “I have started a modified exercise program, quit smoking and drinking, am practicing mindfulness meditation for one hour daily and will do whatever else I need to return to work.”• Desire • Commitment• Ability • Action• Reasons • Taking Steps• Need
  84. 84. When you are not sure where to go next…
  85. 85. “Tell me more…Tell me more…”
  86. 86. Where am I in MI? Recognizing Change Talk0 1 2 3 4 5 6 7 8 9 10 Evoking Change Talk0 1 2 3 4 5 6 7 8 9 10
  87. 87. Foundation Skills: OARS
  88. 88. FOUR KEY STRATEGIES – OARS OPEN questions (to elicit client change talk) AFFIRM the client appropriately (support, emphasize personal control) REFLECT (try for complex reflections) SUMMARIZE ambivalence, offer double-sided reflectionMiller & Rollnick, 2013 
  89. 89. Mylopoulos, M, Lohfeld, L, Norman, GR, Dhaliwell, G, Eva, KW (2012). Renowned physicians perceptions ofexpert diagnostic practice, Acad Med. 87(10):1413-7.
  90. 90. Mylopoulos, M, Lohfeld, L, Norman, GR, Dhaliwell, G, Eva, KW (2012). Renownedphysicians perceptions of expert diagnostic practice, Acad Med. 87(10):1413-7.
  91. 91. “To Listen” EAR EYES UNDIVIDED ATTENTIONIMPERIAL HEART
  92. 92. Simple ReflectionComplex Reflection
  93. 93. http://tinyurl.com/ara93vh
  94. 94. “I’m only coming to group today because my doctor and my probation officer are both pressuring me.” Simple Reflection They are really on your case  about coming to a support  group. It wasn’t your idea to come  to group, and you’re not  sure this is going to be at all  helpful to you. Complex Reflection
  95. 95. Practicing Reflective ListeningIndividually, take a moment to writedown an example of a simple and acomplex reflection for the followingstatement (coming up – next slide).Then compare what you wrote withothers at your table. As a group,choose the best examples to share withthe larger group.
  96. 96. Practicing Reflective Listening (1) “How I live my life is no one else’s business, and certainly not yours!”
  97. 97. “How I live my life is my own business andcertainly not yours.”Simple Reflection:______________________________________________________________________Complex (Enhanced) Reflection:______________________________________________________________________
  98. 98. “How I live my life is my own business andcertainly not yours.”Simple Reflection:You are the only one to decide how tolive your life.Complex (Enhanced) Reflection:You’re being told you have to make allthese changes, and that doesn’t feel veryrespectful of your choice and autonomy.
  99. 99. Practicing Reflective Listening (2) “I know you mean well, but I don’t need this medication any more.”
  100. 100. “I know you mean well, but I don’t need thismedication any more.”Simple Reflection:______________________________________________________________________Complex (Enhanced) Reflection:______________________________________________________________________
  101. 101. “I know you mean well, but I don’t need thismedication any more.”Simple Reflection:You see that I am concerned, but you areready to stop taking the medication.Complex (Enhanced) Reflection:You feel like I am pushing for you to takethis medication, and not reallyappreciating where you are at.
  102. 102. Reflecting Panel
  103. 103. 1. Four volunteers: Counsellors
  104. 104. 2. One volunteer: Client Something you are considering changing and struggling with
  105. 105. 3. One volunteer: Coach A sounding board for the client
  106. 106. Reflecting Panel Instructions1. Client: Share a paragraph with the Reflecting Panel about your struggle/experience2. Panel: Take turns offering a single reflection3. Client: After ALL Panel members are done, talk to your coach about which reflection resonates most for you and why4. Client: Offer this feedback to the panel, and continue the paragraph
  107. 107. “A Psychological Law” I learn what I believe as I hear myself speak.Bill Miller (Based on D. Bem, 1967, “Self-Perception: Analternative interpretation of cognitive dissonancephenomena”)
  108. 108. …or put another way…The word you keep betweenyour lips is your slave. Theword you speak is yourmaster. - Arabic proverb
  109. 109. Where am I in MI? Simple Reflections0 1 2 3 4 5 6 7 8 9 10 Complex Reflections0 1 2 3 4 5 6 7 8 9 10
  110. 110. Additional Reflectionsand Next Steps
  111. 111. Confidence RulerNo Way I am 0 1 2 3 4 5 6 7 8 9 10 Bill Miller http://www.williamrmiller.net/
  112. 112. Castles in the air?If you have built castles in the air, yourwork need not be lost. That is wherethey should be. Now put thefoundation under them. Henry David Thoreau
  113. 113. Motivational Interviewing: Practice TipsMI Spirit: The Essential Foundation Four MI ProcessesPartnership: You and the client are equal experts PlanningAcceptance: Absolute worth, accurate  Evokingempathy, autonomy support, affirmationCompassion: Beneficence, caring, focus on the  FocusingotherEvocation: The client’s wisdom is most  Engagingimportant  Agenda‐Mapping OARS: Key Skills Can we take a few minutes to talk about the different issues or  Listen for Change Talk: DARN CAT Open  Questions: What are your reasons for  concerns that you or others have? Just to get a “big picture” view  of  change? How might you go about it in order to  Desire, Ability, Reasons, Need what you are coping with right now… succeed? Commitment, Activation, Taking Steps Affirmation: You have worked hard to make this  Treatment happen. I can see that you’ve given this a lot of  Diagnosis Finances thought.  Plan Readiness Ruler Reflections: You wish that… You would like to… Summary Statements: Let me make sure I  People usually have multiple or competing priorities. On a  understand how this all fits together… scale of zero‐to‐ten, how important is it to change…? How  confident are you that you could make this change? Benefits Stress Elicit: What do you already know about…? Provide information: Be brief! 0 1 2 3 4 5 6 7 8 9 10 Symptoms Relationship Elicit: How does that fit for you? What do  you make of that? Why did you say [lower number] and not [higher number]? What would it take to go from [lower number] to [higher number]? Given  all of these possible areas for change, what are your priorities?  Where would be the most helpful place for us to start? © 2013 Marilyn Herie, PhD RSW       marilyn.herie@utoronto.ca Reference: Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd Edition). New York: Guilford.
  114. 114. Life can only be understood backwards, but it must be lived forwards. ‐Kierkegaard
  115. 115. Recommended ResourcesMartino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C., Hamilton, J., and Hausotter, W. (2006). Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA STEP). Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University.http://www.motivationalinterview.org/Documents//MIA-STEP.pdfMiller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (Third Edition). New York: Guilford.Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129-140. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: The Guildford Press.First chapter and table of contents available at www.motivationalinterview.orgRosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. New York: Guilford.Wagner, C.C. & Ingersoll, K.S. (2013). Motivational Interviewing in Groups. New York: GuilfordUseful WebsitesMotivational Interviewing Websitehttp://www.motivationalinterview.net/Motivational Interviewing Network of Trainers (MINT) Websitewww.motivationalinterviewing.orgExamples of Motivational Interviewing Videos on YouTubehttp://www.youtube.com/user/teachproject#p/u
  116. 116. Motivational Interviewing Glossary of AcronymsCompiled by Marilyn Herie, PhD, RSW November, 2012ACE (Spirit of MI from Miller and Rollnick 2002 edition)Autonomy / Collaboration / Evocation versusAuthority / Coercion / EducationOARS (Fundamental strategies of MI)Open questions / Affirmations / Reflections / Summary statementsEARS (Strategies for eliciting change talk)Evocation / Affirmation / Reflective listening / Summary statementsRULE (Fundamental strategies in MI v.2)Resist the righting reflex / Understand reasons for change (motivation) / Listen empathically / Empower the client to use own resourcesDARN CAT (Types of preparatory change talk and commitment language)Desire / Ability / Reasons / Need / Commitment / Action / Taking stepsFRAMES (Ingredients of brief, motivational interventions)Feedback / Responsibility / Advice / Menu (of strategies)/ Empathy / Self-efficacyRAISE (How to give advice)Relationship / Advice to change / “I” statements (affirmation) / Support autonomy / EmpathyREADS (Principles of MI)Roll with resistance / Express empathy / Avoid argumentation / Develop discrepancy / Support self- efficacyPACE (Spirit of MI from Miller and Rollnick 2013 edition)Partnership / Acceptance / Compassion / EvocationMIST (Coding form)Motivational Interviewing Supervision and Training ScaleMITI (Coding form)Motivational Interviewing Treatment Integrity Coding FormMET (Manual-based motivational intervention)Motivational Enhancement TherapyMIA (Coding abbreviation, used in the MITI)Motivational Interviewing AdherentMINA (Coding abbreviation, used in the MITI)Motivational Interviewing Non-AdherentMIA-STEP (MI supervision manual and coding resource)Motivational Interviewing Assessment – Supervisory Tools for Enhancing ProficiencyAMIAdaptations of Motivational Interviewing
  117. 117. Thank  youmarilyn.herie@utoronto.cawww.educateria.com@MarilynHerie

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