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AASE ODE MI Workshop 5.23.12

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  • 1. Motivational Interviewing “A work in progress…” AADE/ODE MI Workshop Series Michael Fulop, Psy.D. Clinical & Consulting Psychology FORSTER FULOP Rewarding Diabetes
  • 2.  What’s one specific MI take-away you might use in your practice?michael@rewardingdiabetes.com
  • 3. 79michael@rewardingdiabetes.com
  • 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. 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. MI Publications  Last Count was ~754, RCT’s > 180michael@rewardingdiabetes.com
  • 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. 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. What MI is not…michael@rewardingdiabetes.com
  • 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. 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. 16michael@rewardingdiabetes.com Ph.D. Building Motivational Interviewing Skills From David Rosengren,
  • 13. 78michael@rewardingdiabetes.com
  • 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.  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. 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.  Miller Conversation Encountering Ambivalencemichael@rewardingdiabetes.com
  • 18. michael@rewardingdiabetes.com
  • 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.  Miller Conversation on the Spirit of MI  Interview for Psych1michael@rewardingdiabetes.com
  • 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. 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. • 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. Four Fundamental Processes Planning Evoking Focusing Engagingmichael@rewardingdiabetes.com
  • 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. . . . . 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. 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. michael@rewardingdiabetes.com
  • 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. Readiness to Changemichael@rewardingdiabetes.com
  • 31. •Dental hygienist storymichael@rewardingdiabetes.com
  • 32. Ambivalence under pressure…  Leads to discord  Tends to elicit push back  Predicts worse outcomes  Is something we avoid in MImichael@rewardingdiabetes.com
  • 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. 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. 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. 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. 16michael@rewardingdiabetes.com Ph.D. Building Motivational Interviewing Skills From David Rosengren,
  • 38. OARS  Open Ended questions  Strength based questions  Affirmations  Reflective Listening  Summarizingmichael@rewardingdiabetes.com
  • 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. 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. 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. michael@rewardingdiabetes.com
  • 43. MI GOAL  Change Talkmichael@rewardingdiabetes.com
  • 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. 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. Mobilizing Change Talk Reflects resolution of ambivalence  COMMITMENT (intention, decision, promise)  ACTIVATION (willing, ready, preparing)  TAKING STEPS 55michael@rewardingdiabetes.com
  • 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. 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. 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. 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.  Miller Conversation Rolling With Resistancemichael@rewardingdiabetes.com
  • 52. Righting Reflex Video  Arg Clin Starts at 1:15 & Ends at 3:40  http://www.youtube.com/watch?v=kQFKtI6gn9Ymichael@rewardingdiabetes.com
  • 53. Avoiding Troublemichael@rewardingdiabetes.com
  • 54. michael@rewardingdiabetes.com
  • 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. 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. 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. 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. Foundational Skills – Simple, Not Necessarily Easy • Open Questions • Affirmations • Reflective Listening • Summaries • Offering Informationmichael@rewardingdiabetes.com
  • 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. 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. 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. Effective Listening:  Is not asking  More than paying attention  Is not just silence  More than repeating words  Way of thinkingmichael@rewardingdiabetes.com
  • 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. Reflective Listening  Vary your depth  Timing is important  Typically undershootmichael@rewardingdiabetes.com
  • 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. 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. 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. 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. 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. Informing  Successful communication requires:  Transmission of technical information  Interpersonal skills  Therefore, a relationship is key to good informingmichael@rewardingdiabetes.com
  • 72. Useful Informing  Ask permission  Offer choices  Use other client examples  Chunk-Check-Chunk  Elicit-Provide-Elicitmichael@rewardingdiabetes.com
  • 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.  What’s one specific MI take-away you might use in your practice?michael@rewardingdiabetes.com
  • 75. michael@rewardingdiabetes.com
  • 76. Reflections  View hettama tape disc 1 –michael@rewardingdiabetes.com
  • 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. 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. 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.  “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. 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.  “My friends say I should just stop smoking pot, but I am not sure I can anymore.”michael@rewardingdiabetes.com
  • 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. Practice  “Since my accident, I don’t care if I live or die, and I wonder if anyone else cares?”michael@rewardingdiabetes.com
  • 85. Reflection Practice  “Do you mean” practicemichael@rewardingdiabetes.com
  • 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. 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. Contact Information Michael J Fulop, Psy.D. michael@rewardingdiabetes.com www.rewardingdiabetes.com 503.539.4932 74michael@rewardingdiabetes.com

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