Motivational Interviewing in Neuropsychology Basic Principles and MethodsNovember 23, 2012 – 1:30pm – 5:00pmTad Gorske, Ph.D.Clinical Assistant ProfessorDirector, Outpatient NeuropsychologyDivision of Neuropsychology and Rehabilitation PsychologyUniversity of Pittsburgh School of Medicine, Pittsburgh Pennsylvania, USA
The Challenge of Change 42 year old male who suffers a TBI after an ATV accident where he is intoxicated. Makes a reasonably good recovery. History of extensive alcohol use. 6 months after inpatient TBI rehab has resumed drinking. 24 year old female, mild concussion, having PCS symptoms one year later. Significant psychiatric history but doesn’t believe symptoms are related. 56 year old male, suffers a stroke, continues to have mild to moderate cognitive deficits that are likely permanent. Doesn’t see need to reduce workload at a high stress, fast paced profession.
The Challenge of Change Community based rehabilitation is an effective strategy for increasing opportunities for people with disabilities to maximize their physical and mental functioning (World Health Organization). However, the benefits that might be accrued are all too often disrupted by individuals’ lack of participation in the rehabilitation process (Lequerica et al., 2006)
Motivation – Whose Job is it? The unmotivated client: – “When the client’s goals do not match those of the counselor” (Lane and Barry, 1970). – Others may hinder independence by inadvertently reinforcing dependence over self reliance (Wright, 1980).
3 Key elements underlying client motivation (Roessler, 1980/89):1. The client’s perception of the value of the outcome of a change plan, including both benefits and costs;2. The client’s perception of the probability of achieving a successful outcome;3. The presence of environmental barriers and supports that inhibit or promote change.
Importance of Working Alliance There are strong links between patient- therapist collaboration and goal consensus in psychotherapy outcomes (Shick Tryon and Winograd, 2011). Working alliance and collaboration in rehabilitation is viewed as important but less well studied.
Working Alliance in Rehabilitation A positive relationship between working alliance and outcomes has been found. Working alliance defined as (a) the agreement between client and therapist on goals, (b) their agreement on how to achieve these goals (common work on tasks) and, (c) the development of a personal bond between client and therapist. (Shönberger et al. 2006).
Working Alliance in Rehabilitation A good working alliance can be created with both clients who experience many problems and clients who experience comparatively few problems, as long as they are aware of the consequences of their brain injury. Therapist’s experience of a good working alliance was influenced by the client’s experience of success. (Shönberger, et al., 2006).
Working Alliance in Rehabilitation Clients’ and therapists’ overall success ratings at program end were related to their emotional bond at program end. Early-therapy compliance and the average amount of compliance are predictive of subjective improvement. (Shönberger, et al., 2006).
Working Alliance: Some evidence Bieman-Copelan and Dywan (2000). Brain and Cognition, 44, 1-5. Behavioral therapy in context of a supportive/collaborative therapeutic alliance for anosognosia. Collaborative negotiation and trusting therapeutic relationship for behavioral goal setting. Results indicated a significant reduction in problematic behaviors despite no increase in insight or awareness of injury.
Pegg et al., 2005 Evaluated the role of interpersonal relationship factors on patient outcomes with 28 patients with moderate to severe TBI admitted to an inpatient unit at a VAMC. Personalized information-provision intervention. Results: – Patients exerted greater effort in therapies – Patients increased satisfaction with rehabilitation treatment. – Significantly more improvement in cognitive FIM scores.
Interdisciplinary team working alliance (Evans, et al., 2008). Importance of therapeutic alliance in post acute brain injury rehabilitation (PABIR). Sherer et al., 2007 - poor working alliance was associated with high levels of family discord, greater discrepancy between family and clinician ratings of client functioning, and poor client participation in therapies. Treatment team members attended in-services that emphasized motivational interviewing philosophy and techniques, building rapport, reflective listening, dealing with patient resistance, making behavioral changes, stages of change, dealing with challenging clients, and assessment and treatment issues with depressed and/or suicidal patients (pg. 332).
Interdisciplinary team working alliance (Evans, et al., 2008). Treatment group had higher functional status and were more productive and had less dropouts, although the differences were not statistically significant.
Lane-Brown and Tate, 2010. Single case study that evaluated an intervention utilizing external compensation and motivational interviewing to initiate and sustain goal directed activity with a TBI patient. Demonstrated that treating specific and operationally defined goals through external compensation and motivational interviewing successfully decreased apathy.
Health Behavior Change (HBC) Model A method of dialogue based on Motivational Interviewing Principles to enhance clients internal motivation for change versus trying to persuade them to change.
The outcome of a consultation can be affected by providers consulting behavior. Behavior change, or lack of it, is not just a patient problem. Practitioner style can make matters better or worse. – (Rollnick, Mason, and Butler, 1999).
Motivational Interviewing Counseling style (Miller, 1983) – Client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. An evolution of the client centered approach. Intentionally resolves ambivalence in the direction of change.
Four Motivational Interviewing Principles1. Express Empathy2. Develop Discrepancy3. Roll with Resistance4. Support Self Efficacy
What Motivates Change? Interpersonal Style Readiness, willingness, ability Intrinsic versus extrinsic factors Change Talk Commitment Language
Change Talk Categories of Change Talk – Desire: “I want to…” – Ability: “I can..” – Reason: “There are good reasons for me to..” – Need: “I really need to…” – Commitment: “I am going to…”
How MI theoretically works1. MI approach leads to;2. An increase in Desire, Ability, Reason, Need, which leads to;3. An increased intensity of commitment which leads to;4. Behavior Change
Core Communication Skills1. Open Ended Questions2. Affirmations3. Reflective Listening4. Summarizing
Maintaining a Patient Centered Approach Active – Reflective listening Encourage an expression of concerns Allow them to articulate what they need All them greater control over decision making Reach joint decisions
What is (The Spirit) of HBC Collaboration: Two parties working together, listening, responding, progressing, and cooperating toward a common goal. Coercion: Using force to cause something to occur; trying to persuade through debate or to have their points be heard
The likelihood of change is highlyinfluenced by interpersonal interactionsEmpathic Style Less Empathic StyleAn increased likelihood Decreased likelihoodof change of change
Collaborative Agenda Setting Presenting agenda setting chart; Transition to focus on problem areas Raising clinician concerns Summarize outcome – next step(s)
Single vs Multiple Behaviors Elicit – Personal views and feelings about factors related to illness/injury/recovery; – “ie. You are about 4 months out of your traumatic brain injury, what are your major concerns about ongoing recovery?” Provide – Information about what is known about the issue presented – ie. “What we know is that most recovery happens in the first year to 18 months. There is no good way to predict what type of recovery will be made but there are some things that can help or hinder one’s recovery.”
Single vs Multiple Behaviors Elicit – Patient reactions to the information given . – ie. “How to you feel about your recovery so far and what things have been positive versus what has not gone so well?”
ReadinessIMPORTANCE CONFIDENCEWhy should I change? How will I do it?Exploration of personal Explorations of selfvalues and expectations efficacy.about the importance ofchange.
Strategy1. Identify behavior to discuss (Agenda setting, prioritize, identify behavior);2. Assess readiness to change behavior; a) Introduce readiness ruler (formal or informal); b) Use OARS to clarify stage of change, level of readiness; c) Identify and explore issues of importance/confidence.
Exploring Importance/Confidence Introducing the Discussion “I‟m not really sure exactly how you feel about ____________________. Can you help me by answering two simple questions, and then we can see where to go from there?” Assessing Importance and Confidence “How do you feel right now about _______________________? How important is it to you personally to ________________________? If 0 was „not important at all‟ and 10 „very important‟, what number would you give yourself?” “If you decided right now to _____________________, how confident do you feel that you would succeed? If 0 was „not at all confident‟ and 10 was „very confident‟, what number would you give yourself?” Summarize the answers
Exploring Importance/Confidence Selecting the Focus If importance is low (<5), focus on importance first If both are about the same, focus on importance first If one number is distinctly lower than the other, focus on the lower number first If both are very low (<3), explore feelings about participating in discussion of the issue (‘all of this’)
The Dilemma of Ambivalence Most people are ambivalent about making changes. Ambivalence is normal but is typically seen as pathological Exploring and resolving ambivalence is the core of MI and HBC.
Examine Pros and ConsNo Change ChangeCosts CostsBenefits Benefits
Examine Pros and Cons1. Introduce the strategy: Ask the patient;2. Review pros and cons of the behavior usually beginning with the side that supports the status quo (no change);3. Throughout the interview use client centered/directive strategies, ie. OARS.4. Summarize and look ahead to the next step.
Evocative Questions Problem recognition Concern Intention Optimism
Information Exchange Step 1: – Ask “does the patient want or need information?” – Distinguish between fact and personal opinion. – Present information in a neutral manner. Step 2: – Elicit – Readiness and interest in information; – Provide - Feedback in a neutral manner; – Elicit – Patient reactions and interpretations of information.
Information Exchange Step 3: Review and summarize. Step 4: Ask about the next step.
Rolling with Resistance Resistance is not met head on or challenged directly. Resistance met with empathy and understanding where alternative viewpoints are invited but not imposed.
True Victory is Victory Over OneselfOne must first learn to control oneselfbefore attempting to harmonize andcontrol others. Seidokan Aikido World Headquarters
Change/Resistance Causes of Resistance: – Patient brings conflict into the session; – Practitioner elicits it; – Combination of the two
Three Traps/Three Strategies Traps Strategy Take control away Emphasize personal choice and control Misjudge Assess importance/confidence readiness/importance/ /readiness confidence Meet force with force Back off – come alongside
Negotiating a Change Plan Setting Goals Considering Change Options Arriving at a Plan Eliciting Commitment
“The commitment to a change plan completes theformal cycle of motivational interviewing.Sometimes people proceed with change on theirown from here. It can also work well, however, totransition from this initial motivational consultationinto action-focused counseling if the person sochooses….MI can be used to facilitate changethroughout the process of counseling.Ambivalence…rarely disappears on the first stepof a journey.” (Miller and Rollnick, 2002, p.139)
My thanks to all the participants, Dr. Fiona Bardenhagen and the Australian Psychological Society for inviting me to your conference.My contact information Tad T. Gorske, Ph.D Clinical Assistant Professor Division of Neuropsychology and Rehabilitation Psychology UPMC Mercy 1400 Locust Street, Suite G138 Pittsburgh, PA USA 15219 Gorskett@upmc. edu