AASE ODE MI Workshop 5.23.12


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AASE ODE MI Workshop 5.23.12

  1. 1. Motivational Interviewing “A work in progress…” AADE/ODE MI Workshop Series Michael Fulop, Psy.D. Clinical & Consulting Psychology FORSTER FULOP Rewarding Diabetes
  2. 2.  What’s one specific MI take-away you might use in your practice?michael@rewardingdiabetes.com
  3. 3. 79michael@rewardingdiabetes.com
  4. 4. My Agenda  Provide ongoing training to AADE/ODE providers to improve MI skills  Discuss evidence for MI in psychotherapy  Show examples of MI in practice  Have you practice MI – in your setting  How comfortable role/real playing? 0-10  How comfortable taping self in practice? 0-10  Humble + Curious 4michael@rewardingdiabetes.com
  5. 5. What would like to accomplish today? •30 seconds •Your Name •Where do you practice? •What’s one specific take- away from today, imagine what it might be. •Write down as we go alongmichael@rewardingdiabetes.com
  6. 6. MI Publications  Last Count was ~754, RCT’s > 180michael@rewardingdiabetes.com
  7. 7. Some Things MI is Not  MI not Transtheoretical Model - MI not intended as a comprehensive theory of change  MI does not trick people into doing what don’t want to do ★ Not an end run for outwitting people ★ MI is “with” or “for” someone, not “to” or “on”  MI is not what you already are doing ★ Near zero-correlation for perceived competence in MI – ★ Attending 1 workshop doesn’t improve outcomes for clients ★ Practice is needed, being coded, being observed and practice 6michael@rewardingdiabetes.com
  8. 8. Some Things MI is Not  MI is simple, but not easy  Not easy to integrate complex skills  Like learning to play a musical instrument!  MI is not a Panacea  It’s a specific way to address the need to make behavioral changes when someone is ambivalent ★ People ready for change do not need MI  Mi is not stand-alone therapy – adds effectiveness w/other treatments w/1- 4 sessions 8michael@rewardingdiabetes.com
  9. 9. What MI is not…michael@rewardingdiabetes.com
  10. 10. What MI is…  After 30 years of research we have a treatment approach that is evidence-based [over 200 RCT’s published], relatively brief [typically 1-3 sessions], that can be specified, grounded in testable theory, with identifiable methods of action, verifiable as to when it is being delivered competently, generalizable across a wide range of problem areas, complimentary to other treatment methods, and learnable by a wide range of providers – WR Miller, Ph.D.michael@rewardingdiabetes.com
  11. 11. Recent definition of MI - MI-3  MI is a collaborative, goal-oriented style of communication with particular attention to the language of change, designed to strengthen personal motivation for & commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. Miller & Rollnick, 2011michael@rewardingdiabetes.com
  12. 12. 16michael@rewardingdiabetes.com Ph.D. Building Motivational Interviewing Skills From David Rosengren,
  13. 13. 78michael@rewardingdiabetes.com
  14. 14. Does MI Work? Meta-analyses & reviews  Britt, Hudson & Blampied, 2004  Burke et al., 2003  Dunn, Deroo & Rivara, 2001  Hettema, Steele & Miller, 2005  Moyer, Finney, Swearingen & Vergun, 2002  Rubak, Sandbaek, Lauritzen & Christensen, 2005  Cochrane Review 2011michael@rewardingdiabetes.com
  15. 15.  Evidence For MI efficacy  Dunn, C, Deroo, L, Rivara, F (2001) The Use of brief interventions adapted from MI across behavioral domains. Addiction, 96; 1725-42.  Burke B, Arkowitz H, Dunn C (2002) The efficacy of MI and it’s adaptations: What we know so far. In Miller & Rollnick [eds] Motivational Interviewing, 2nd [2002]  Burke B, Arkowitz H, Menchola M (2003) The efficacy of MI: A meta-analysis of controlled clinical trials. Journal of Consulting & Clinical Psych, 71 843-61.  Britt, E, Hudson S, Blampied N (2004) MI in health care settings: A review. Patient Education and Counseling, 52, 147-55.  Rubak, S, Sandboek A, Lauritzen T, Christensen B (2005) MI: A systematic review and meta-analysis. British Journal of General Practice, 55, 305-12.  Hettema J, Steele J, Miller W (2005) Motivational Interviewing. Annual Review of Clinical Psychology, 1 91-111. 73michael@rewardingdiabetes.com
  16. 16. Further Study - Resources  Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner’s Workbook. New York: Guilford Press.  Arkowitz, H. Westra, H. Miller, W.R., & Rollnick, S. (2008). Motivational Interviewing in the Treatment of Psychological Problems. Guilford: New York.  Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. Guilford:.  Training Tapes: MI Series  MI Website: www.motivationalinterview.orgmichael@rewardingdiabetes.com
  17. 17.  Miller Conversation Encountering Ambivalencemichael@rewardingdiabetes.com
  18. 18. michael@rewardingdiabetes.com
  19. 19. MI Spirit  Collaborative  Honors client expertise and perspective  Creates an environment that supports change  Evocative  Resources lie within client  Enhance their intrinsic motivation  less about external pressure  Promotes Client Autonomy  “Patient is right” they have capacity for self change  Facilitate informed choice  Compassion - MI-3 [Miller & Rollnick, 2012]michael@rewardingdiabetes.com
  20. 20.  Miller Conversation on the Spirit of MI  Interview for Psych1michael@rewardingdiabetes.com
  21. 21. What is MI Spirit? 1-5 Ranking  Evocation  Collaboration  Autonomy/Support  Spirit = [EV] + __ [CL] + __ [A/S]/3 = ___ Evocation + Collaboration + Autonomy/Support/3]  Direction  Empathymichael@rewardingdiabetes.com
  22. 22. A Continuum of Styles Directing <=> Guiding <=> Following Behavior therapy Cognitive therapy Reality therapy Dr. Phil Motivational interviewing Solution-focused therapy Psychodynamic Psychotherapy Client Centered Psychotherapy 31michael@rewardingdiabetes.com
  23. 23. • It’s MI when…• The communication style involves person- centered, empathic listening (engaging), and• There is a target of change and that is the focus of conversation (focusing), and• The interviewer evokes a person’s own motivation & reasons for change (evoking), but• It may or may not include planning.michael@rewardingdiabetes.com
  24. 24. Four Fundamental Processes Planning Evoking Focusing Engagingmichael@rewardingdiabetes.com
  25. 25. These 4 processes are somewhat linear ….  Engaging necessarily comes first  Focusing (identifying a change goal) is a prerequisite for Evoking  Planning is logically a later step Engage Focus Evoke Plan 67michael@rewardingdiabetes.com
  26. 26. . . . . and yet also recursive  Engaging skills [& re-engaging] continue throughout MI  Focusing is not just a one-time event;  re-focusing often needed; focus may change  Evoking begins very early in encounters  “Testing waters” with planning may indicate a need for more of the above 68michael@rewardingdiabetes.com
  27. 27. Ambivalence  Feeling 2 ways about change is common & normal  MI accepts ambivalence; patient gets time to explore & consider both sides of their dilemma  Telling people why they should change evokes the “righting reflex” & increases resistance 14michael@rewardingdiabetes.com
  28. 28. michael@rewardingdiabetes.com
  29. 29. Ambivalence Occurs throughout the change process Reflects costs and benefits of change and status quo Is uncomfortable & may become chronic Resolved by client – Bem’s Self-Perception Theory  What people say to themselves, is what they believemichael@rewardingdiabetes.com
  30. 30. Readiness to Changemichael@rewardingdiabetes.com
  31. 31. •Dental hygienist storymichael@rewardingdiabetes.com
  32. 32. Ambivalence under pressure…  Leads to discord  Tends to elicit push back  Predicts worse outcomes  Is something we avoid in MImichael@rewardingdiabetes.com
  33. 33. Reinforcing Change Statements  Be attentive  Don’t have to respond immediately  May collect like a bouquet of flowers  Warning – be attentive to ambivalencemichael@rewardingdiabetes.com
  34. 34. Pair Up - 1 speaker & 1 listener• Speaker talks about a change they are ambivalent about – they want to change, but have not started yet [real play, or role play patient]. Speaker begins, describes change they want.• Listener your job is to convince your speaker about why they should change – list your reasons, why you think they should change• 4 minutes – then we debrief• What happened to you as the person who wants a change? What’s it like?• What happens to you, the listener/”convincer” What’s it like?michael@rewardingdiabetes.com
  35. 35. Installing Motivation? • Speaker discuss a change you want to make – or play a client, patient • Listener – Your task is to help this person come hell or high water • Instead of listening, please: • Explain why s/he should make this change • Give 3 specific benefits of making the change • Tell him/her how to change • Emphasize importance of the change • Tell the participant to do it! • Don’t use MI!michael@rewardingdiabetes.com
  36. 36. Evoking Motivation? • Speaker continue discussing change • Listen carefully - goal to understand their dilemma • Ask these four questions: • Why would you want to make this change? • How might you go about it, in order to succeed? • What are the 3 best reasons to do it? • On a scale of 0-10, how important would you say it is to make this change? • And why are you a ? and not zero?michael@rewardingdiabetes.com
  37. 37. 16michael@rewardingdiabetes.com Ph.D. Building Motivational Interviewing Skills From David Rosengren,
  38. 38. OARS  Open Ended questions  Strength based questions  Affirmations  Reflective Listening  Summarizingmichael@rewardingdiabetes.com
  39. 39. Engaging a real individual • Remember, you are not their 1st provider • May need to overcome some barriers – • My 1st Q -“Have you seen any other mh providers?” • Relationship building is needed • Accepting ambivalence is particularly important • Don’t insist on diagnosis acceptance • Target problems and client goals – not diagnosesmichael@rewardingdiabetes.com
  40. 40. Exercise: On the Nature of Helpfulness Imagine a major pressing dilemma in your life  Professional or Personal  Debating this with yourself Imagine  Your thinking is moving in ever tightening circles  You’re in a state of perplexity  It’s affecting all aspects of your life  You’re making little progress on your own So… you decide to seek out help Activity from Jeff Allisonmichael@rewardingdiabetes.com
  41. 41. Exercise: The Nature of Helpfulness  Who should you discuss this with?  Don’t want to make a mistake - Choosing wrong person leads you in wrong way  Go to Powell’s, grab some coffee and sort this out  What are desirable qualities & skills of such a person? How would you want them to behave?  Make two lists by yourself  Most desirable qualities & skills  What will make you feel antagonistic and or disappointed?  This Exercise is from Jeff Allisonmichael@rewardingdiabetes.com
  42. 42. michael@rewardingdiabetes.com
  43. 43. MI GOAL  Change Talkmichael@rewardingdiabetes.com
  44. 44. Change Talk  Change talk is any client speech that favors movement in the direction of change  Previously called “self-motivational statements” (Miller & Rollnick, 1991)  Change talk is by definition linked to a particular behavior change goal  DARN CATs 53michael@rewardingdiabetes.com
  45. 45. Preparatory Change Talk DARN Examples DESIRE to change (want, like to, wish.,) ABILITYto change (can, could . . ) REASONS to change (if . . then) NEED to change (need, have to, got to . .) 54michael@rewardingdiabetes.com
  46. 46. Mobilizing Change Talk Reflects resolution of ambivalence  COMMITMENT (intention, decision, promise)  ACTIVATION (willing, ready, preparing)  TAKING STEPS 55michael@rewardingdiabetes.com
  47. 47. Mobilizing Language  Three Types: Commitment, Activation & Taking Steps  I an done with being depressed.  I am ready to do something different.  My boyfriend said I didn’t need my meds, but I told him I did.michael@rewardingdiabetes.com
  48. 48. Is mobilizing language enough?  Some Answers…  I wish I could…  I’d like to…  I think I should…  I could if I really wanted to…  I have good reasons to…  For some questions...  Do you swear to tell the truth, whole truth and…?  Do you take this person to have and to hold in sickness in health…?michael@rewardingdiabetes.com
  49. 49. Responding to Change Talk All EARS  E: Elaborating: Asking for elaboration, more detail, in what ways, an example, etc.  A: Affirming – commenting positively on the person’s statement  R: Reflecting, continuing the paragraph, etc.  S: Summarizing – collecting bouquets of change talk 58michael@rewardingdiabetes.com
  50. 50. Sustain Talk The other side of ambivalence  I really like marijuana (Desire)  I don’t see how I could give up pot (Ability)  I have to smoke to be creative (Reason)  I don’t think I need to quit (Need)  I’m gonnna keep smoking (Committment)  I’m not ready to quit (Activation)  I went back to smoking this week (Taking Steps) 61michael@rewardingdiabetes.com
  51. 51.  Miller Conversation Rolling With Resistancemichael@rewardingdiabetes.com
  52. 52. Righting Reflex Video  Arg Clin Starts at 1:15 & Ends at 3:40  http://www.youtube.com/watch?v=kQFKtI6gn9Ymichael@rewardingdiabetes.com
  53. 53. Avoiding Troublemichael@rewardingdiabetes.com
  54. 54. michael@rewardingdiabetes.com
  55. 55. What is Resistance?  Behavior  Interpersonal (It takes two to resist)  A signal of dissonance  Predictive of (non)change  The Righting Reflex - Reactance 62michael@rewardingdiabetes.com
  56. 56. Handling Resistance• Already in skills repertoire• May not eliminate, but can reduce “heat”• Three reflective types: • Simple • Amplified • Double-sided• Two Strategies • Shifting focus • Emphasize personal choicemichael@rewardingdiabetes.com
  57. 57. Handling Resistance - Reflection • I thought a little red wine was supposed to be good for your heart. • I know the meds are good for me, but they make me too drowsy. • I think you are blowing this way out of proportion, I only got a little messed up, why are you such a prude? • You don’t understand what it’s like for me, you’ve got a job and career; all I got is these memories. • Meds don’t help much anymore, but something’s got to, or I am out of here. • I’ve tried everything you’ve asked. None of that shit works. Why don’t you get it?michael@rewardingdiabetes.com
  58. 58. Sustain Talk and Resistance  Sustain Talk is about the target behavior  I really don’t want to stop smoking  I have to take pills to make it through the day  Resistance is about your relationship  You can’t make me quit  You don’t understand how hard it is for me  Both are highly responsive to counselor style 63michael@rewardingdiabetes.com
  59. 59. Foundational Skills – Simple, Not Necessarily Easy • Open Questions • Affirmations • Reflective Listening • Summaries • Offering Informationmichael@rewardingdiabetes.com
  60. 60. Asking  Develop an understanding of client’s situation  Allows you to:  Follow a decision tree  Arrive at a diagnosis  Complete forms  Closed questions can be:  Efficient way to gather specific information  May create or reinforce the expert-trapmichael@rewardingdiabetes.com
  61. 61. Open-ended Questions  These sets the tone for MI work  Communicates interest and caring  Allows client room to respond  Makes client more a more active partner  You receive information otherwise unavailable  Creates momentummichael@rewardingdiabetes.com
  62. 62. Listening  MI is built on this skill  Directive use of listening  Attend to some things and not others  Create awareness of gaps  Reinforce change talkmichael@rewardingdiabetes.com
  63. 63. Effective Listening:  Is not asking  More than paying attention  Is not just silence  More than repeating words  Way of thinkingmichael@rewardingdiabetes.com
  64. 64. Reflective Listening  2 levels of reflection  Simple - content stays close  Repeating  Rephrasing  Complex – guesses at unexpressed, affect, anticipates, and metaphors  Paraphrasing Meaning or Intent  Reflecting Feelingmichael@rewardingdiabetes.com
  65. 65. Reflective Listening  Vary your depth  Timing is important  Typically undershootmichael@rewardingdiabetes.com
  66. 66. Exercise – Two Levels of Reflections  Form groups of 4  Choose a representative to record answers  Record Simple & Depth Reflections for each sentence stemmichael@rewardingdiabetes.com
  67. 67. Being Directional  Not telling client what to do  Choosing to attend to different elements  Usually multiple elements in a statement  Focus will determine pathmichael@rewardingdiabetes.com
  68. 68. Examples of being directional  I’m tired and it feels impossible right now.  You’re worn out.  It feels really hard to do.  Right now is a problem, but maybe later won’t be.michael@rewardingdiabetes.com
  69. 69. Summaries  Special form of reflective listening  Different kinds:  Collecting – short, continue flow (change talk)  Linking – add recent material to prior info (ambivalence)  Transitional – announces a shift in focus (change direction)michael@rewardingdiabetes.com
  70. 70. Affirmations• Some clients are demoralized• Orients people to their resources• Be genuine• Probe partial successes• Reframe resistance into an affirmation• What and how questions are helpful• Use “you” statements, not “I”michael@rewardingdiabetes.com
  71. 71. Informing  Successful communication requires:  Transmission of technical information  Interpersonal skills  Therefore, a relationship is key to good informingmichael@rewardingdiabetes.com
  72. 72. Useful Informing  Ask permission  Offer choices  Use other client examples  Chunk-Check-Chunk  Elicit-Provide-Elicitmichael@rewardingdiabetes.com
  73. 73. Useful Informing  Slow down and progress may be quicker  It’s a person not an information receptacle  Consider the client context & priorities  Amount matters and depends on the client  Best method? The individualized one  Beware of righting reflexmichael@rewardingdiabetes.com
  74. 74.  What’s one specific MI take-away you might use in your practice?michael@rewardingdiabetes.com
  75. 75. michael@rewardingdiabetes.com
  76. 76. Reflections  View hettama tape disc 1 –michael@rewardingdiabetes.com
  77. 77. Reflections  Reflections are a way of hypothesis testing without the questions  They are a way to attune to the person  They are choosing where you think someone might be going  Heart of MImichael@rewardingdiabetes.com
  78. 78. Reflective Responses  Three levels of Reflections  Repeats - or parrots  Rephrases - with simple word changes  Paraphrasing – infers a meaning  Reflection – of feeling, value, or attitude  Simple  Complexmichael@rewardingdiabetes.com
  79. 79. Intensity of Reflections  Understated or attenuating a reflection  “You a slightly annoyed”  Which direction will the client go?  Overstating or Amplified Reflections  You are outraged  Which direction will the client go?michael@rewardingdiabetes.com
  80. 80.  “I really hate my boss telling me I have to pick up those boxes over and over again.”  Understated reflection  Which direction will the client go?  Amplified Reflection  Which direction will the client go?michael@rewardingdiabetes.com
  81. 81. Double Sided  On the one hand you want to … On the other hand you don’t want to.  You’ve told me some good reasons to stop smoking, and in some ways you love it a lotmichael@rewardingdiabetes.com
  82. 82.  “My friends say I should just stop smoking pot, but I am not sure I can anymore.”michael@rewardingdiabetes.com
  83. 83.  “My diabetes used to be easy to control, but I’m not sure I can get it under control any more.”michael@rewardingdiabetes.com
  84. 84. Practice  “Since my accident, I don’t care if I live or die, and I wonder if anyone else cares?”michael@rewardingdiabetes.com
  85. 85. Reflection Practice  “Do you mean” practicemichael@rewardingdiabetes.com
  86. 86. Reflection Practice  “It’s fun, but something has to give. I can’t go on like this anymore.”  “I know I can do some things differently., but if she would just back off, the this situations would be a lot less tense. These things wouldn’t happen.  I’ve been depressed lately. I keep trying to get back to using exercising more, but my back always hurts, it is so frustrating. A couple of drinks would help.michael@rewardingdiabetes.com
  87. 87. Reflection Practice  “So I’m not too worried, it’s been over a year, and I can still walk with that knee pain.”  “I know I should lose some weight, everybody tells me that, but nobody knows how hard it is for me. I wish I was on the biggest loser.”  My daughter thinks it’s her body, and so she should be able to do what she wants. Hooking up is no big deal to her. She doesn’t get why I won’t back off.”michael@rewardingdiabetes.com
  88. 88. Contact Information Michael J Fulop, Psy.D. michael@rewardingdiabetes.com www.rewardingdiabetes.com 503.539.4932 74michael@rewardingdiabetes.com
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