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Unit 3: Putting Motivational Interviewing Into Action

Motivational Interviewing - A Training Resource
By Jim Messina

A Helping Truism:

How many helpers does it take to change a light bulb?

Just one, but the light bulb has to want to be changed.

What does a Motivational Interviewing Session look like?

 

Engage:

  • I’m not here to preach to you or tell you what you “should” do; how would I know, it’s your life and not mine! I believe people know what’s best for them.
  • I don’t have an agenda, just a goal: to see if there is anything about the way you take care of your health that you would like to change, and if so, to see if I can help you get there.
  • How does that sound to you?

 

Focus:

Begin with a general question regarding their health and health-related behavior. For example: “I’m curious - how happy are you with how well you take care of your health?”

 

Evoke:

Follow up by using all your best MI skills: reflections, open-ended questions, affirmations, and eliciting change talk: (e.g., “You said you feel you could be doing better. In what way?”). The overall goal here is to communicate a genuine desire to understand, not a desire to push them into anything.

 

ASK (Elicit):

Try to stay focused on health-related behavior. This part should take 5–10 minutes, but could be more or less depending on the client.

 

TELL (Provide):

Next, mention that you have some information to share, if it’s OK with them. “I’ve got some information here that’s related to you and your health. Is it OK with you if we go over this a minute?”

 

ASK (Elicit):

Remember the keys to good feedback: Be completely objective (you are providing them with information that they can take or leave, you are NOT evaluating them). Never argue, and ask a simple question:

“What do you make of all this?”

 

Planning Phase (Using CAT)

 

C - Commitment

Follow up with reflections, etc. Be sure to use the Pros and Cons exercise and at least one other strategy to elicit change talk, usually the Readiness Ruler (“On a 0–10 scale, if 0 is not in the least bit ready to see the doctor at least once every 3 months and 10 is as fired up as you can be, where are you?) Remember with the Readiness Ruler to ask, “Why a 3 and not a 0?” if they give you a low number, and “Why such a high number?” if they give a high number (7 or higher).

 

A - Activation:

Remember, never argue, never push, just be curious and accepting. There’s no hurry. Remember also, the goal here is to maximize change talk by using questions that elicit change talk, by asking for explanation (if they give a little, ask for more details), and by using exercises like Pros and Cons or the Readiness Ruler.

 

T – Taking Steps

Do a good summary of everything that’s been said so far. “Let me see if I understand where you’re at with your health right now. . . .”

 

Summarize the things they feel good about and the positive health behaviors you have noticed, starting with general health stuff and ending with specific stuff about their attending doctor’s appointments.

 

Summarize the things that concern them in general, and things that concern them about appointments in particular.

 

Finally: Ask if your summary is about right. If not, correct it.

Case Studies for Putting Motivational Interviewing Into Action

Larry the Smoker

Larry: I know smoking is bad for me. I know I should quit.

Helper: Then why don’t you? (Righting Reflex Response – Not a MI response)

Possible MI Responses

Permission:  “May I tell you what concerns me about your continuing to smoke?”

Evoking: “You are certainly right about smoking being bad for you. Tell me more

about that.”

Double-Sided Reflection: “Earlier you told me that you have a goal of reducing your risk of stroke and heart attack. On the other hand smoking increases those risks. What are your thoughts about that?”

Rolling with Resistance: “It has been hard to quit smoking even though you are concerned about its impact on your health.”

 

Maria, Mother of 4 year old with Asthma

Your team is seeing a 4 year old boy Larry with poorly controlled asthma in clinic. He has been admitted three times in the hospital in the past 6 months for acute exacerbations. During your interview with the mother, Maria a pack of cigarettes falls from her coat. She quickly states that she does not smoke “around her son.”

 

Maria says she has been feeling very stressed recently, especially with her Larry’s recent hospitalizations.  She has been smoking since she was a teenager (she is in her mid-20’s) and she says that smoking relaxes her.  She does think that quitting would help her child’s asthma, and several people have told her that she should stop smoking in the interest of her child’s health.  When asked about quitting, she frowns and says she has tried to quit smoking several times in the past without success.

 

We then use a scales with Maria to assess as well as cultivateconfidence or importance is the use of scales. Hopefully the scales can help Maria to verbalize and process her ambivalence further. In this case, “On a scale of 1 to 10, how important do you think it is for you to quit smoking?” (Maria says 9 out of 10).

“On a scale of 1 to 10, how confident are you that you can quit smoking?” (Maria says 4 out of 10)

 

So, now do we use Affirmations: recognizing Maria’s strengths and countering a defeatist attitude: “Why did you give yourself a 4 instead of a 2?”

“I am impressed that you have been trying to quit despite all the stress you are going through”

 

We also use reflecting the pros and cons: “So, it is important for you to smoke in order to deal with the stress in your life, but you also wish you could quit in the interest of your child’s health”

 

We look Maria driven strengths: “What would make you go up to a 6 or 7?”

 

We then continue to get more history: Maria, who is 35 years old, smokes with her girlfriends who come and visit her in her apartment. She feels a sense of community with them, and smoking is a shared pastime they enjoy.

 

Maria does not think her child Larry’s asthma has worsened because of her smoking: “I’ve been smoking since he was born and his asthma wasn’t this bad before”

When asked about quitting, she says: “Yes, I’m sure it would be better for my health, but so would moving out of New York City!”

 

Maria is then asked  on a scale of 1 to 10: “How important do you think quitting smoking is for your child?” (Maria says 3 out of 10)

“How important is it for your own health?” (Maria says 4 out of 10)

 

We then begin reflecting and empathizing with the “pros” and “cons:” “It seems that smoking is an important social activity for you, but you also would like to quit because it would be better for your health.”

“Yes, New York City can certainly be hazardous to your health!”

 

We then Roll with Maria’s Resistance: “Yes, it does seem that you’ve been smoking for quite some time and your child’s asthma has only recently been flaring up.”

Emphasize the significance of this Maria’s level on this: “Why did you give it a 3 and not a 1?”


Gladys Mother of 7 year old Susanna with Asthma

Your team is seeing a 7 year old girl Susanna, with poorly controlled asthma in your clinic. She has been coughing 1 to 2 times a week at nighttime, interfering with her sleep. Gladys her mother is rightly concerned and would like some treatment. You prescribe an inhaled corticosteroid for twice daily use to be continued even when her symptoms resolve. 

 

Four weeks later, during a follow-up visit, the Gladys tells you that she stopped the inhaled steroid medication because her Susanna’s symptoms resolved. How would you proceed at this point?

Find out where the Gladys is at: “What do you remember about the instructions for the medication prescribed for your daughter’s cough?”

“Do you have any concerns about the medication?”

“Are there people you know who have taken steroids for asthma?”

“Tell me what you feel [or know] about steroids”

 

You get more history: Gladys does remember that she was instructed to continue the medication even after Susanna’s cough resolved, but she stopped giving the medication because she “doesn’t like giving medications” to her daughter. When asked why, she simply repeats herself “I just don’t like it!”


All right…what’s going on here? Your are right: Resistance!

In motivational interviewing philosophy, resistance is elicited when we try to push clients farther than they are ready to go.. Resistance also occurs when clients have not been given sufficient opportunity to direct their actions and have simply been given instructions from their helpers.

 

How do you deal with Gladys’ resistance?

Empathize with the client: “It sounds like many of us have been telling you what you should do and we’re not listening to what you would like to do for your child”

Empower the client: “You know, it’s up to you what you would like to do with your daughter’s medication – after all, you are her mother.”

Rosanna a Sexually Active Teen

You are seeing Rosanna a 13 year old girl in the team’s clinic because she is here for the 2nd dose of HPV vaccine. She is sexually active with one male partner, but he does not use condoms. You have a discussion with her about the importance of using latex barriers to prevent sexually transmitted infections. She seems to understand, but is hesitant about using condoms. 

 

Find out Rosanna’s readiness for change:

“Do you feel using condoms are important?”

“Are you afraid of bringing up condom use with your partner?” or “Have you talked with your partner about using condoms?”

“Do you or your partner not like using condoms?”

“Do you feel safe/happy in this relationship?”

One manifestation of confidence here is asserting oneself in a partnership with Rosanna

So, you get this history…She hasn’t spoken with her partner about using condoms, but he often talks about how great the sex is. She says that he does not have sex with other people, but she is not sure.

What other questions would you ask? Try using a Decisional Matrix:

 

 

Status Quo or Staying in the Habit (i.e., staying in this relationship with current sexual habits)

Change or Breaking from the habit

(i.e., breaking from this relationship or beginning to use protection)

Pros

 

 

 

 

Cons

 

 

 

 

 

Rosanna’s Response to the Decision Matrix

 

Status Quo or Staying in the Habit (i.e., staying in this relationship with current sexual habits)

Change or Breaking from the habit

(i.e., breaking from this relationship or beginning to use protection)

Pros

 

 

Having unprotected sex with him makes him happy, and I like it when he’s happy”

“I don’t know. I guess I won’t feel like a fool calling him all the time”

Cons

 

 

“I don’t get any pleasure out of sex”

“I’m the one who calls him all the time just to hang out – he never calls me”

“I might be lonely”

“All of my friends have boyfriends, so I worry if I’ll be left out”

 

We now have something to work with, don’t we!

3 Eamples of Clients at Different Stages of Readiness

 

Example 1: Steps to take in dealing with a client with Obesity who is not ready for change

This is a client who is not considering change, He immediately says to you: “Weight is not a concern for me”

 

1. Your MI goals with this client would be to:

  1. Help client develop a reason for changing
  2. Validate the client’s experience
  3. Encourage further self-exploration
  4. Leave the door open for future conversations
  5. Validate the client’s experience: “I can understand why you feel that way”

 

2. Acknowledge the client’s control of the decision: “It’s up to you to decide if and when you are ready to make lifestyle changes.”

 

3. Repeat a simple, direct statement about your stand on the medical benefits of weight

loss for this patient: “I believe that your extra weight is putting you at risk for heart disease. Making some lifestyle changes could help you lose weight, and improve your health substantially.”

 

4. Explore potential concerns: “Has your weight created difficulties in your life?” “Can you imagine how your weight might cause problems in the future?”

 

5. Acknowledge possible feelings of being pressured: “It can be hard to initiate changes in your life when you feel pressured by others. I want to thank you for talking with me about this today.”

 

6. Validate that they are not ready: “I hear you saying that you are not ready to lose weight right now.”

 

7. Restate your position that it is up to them: “It’s totally up to you to decide if this is right for you right now.”

 

8. Encourage reframing of current state of change–the potential beginning of a change

rather than a decision never to change: “Everyone who’s ever lost weight starts right where you are now; they start by seeing the reasons where they might want to lose weight. And that’s what I’ve been talking to you about.”

 

Example 2: Steps to take in dealing with a client who is ambivalent about change

This is a client who is ambivalent about change. She says: "Yes my weight is a concern for me, but I’m not willing or able to begin losing weight within the next month."

 

1. Your MI goals with this client would be to:

  1. Validate the client’s experience
  2. Clarify the client’s perceptions of the pros and cons of attempted weight loss
  3. Encourage further self-exploration
  4. Leave the door open for moving to preparation
  5. Validate the client’s experience: “I’m hearing that you are thinking about losing weight but you’re definitely not ready to take action right now.”

 

2. Acknowledge client’s control of the decision: “It’s up to you to decide if and when you are ready to make lifestyle changes.”

 

3. Clarify client’s perceptions of the pros and cons of attempted weight loss: “Using this worksheet, what is one benefit of losing weight? What is one drawback of losing

weight?”

 

4. Encourage further self-exploration: “These questions are very important to beginning a successful weight loss program. Would you be willing to finish this at home and talk to me about it at our next visit?”

 

5. Restate your position that it is up to them: “It’s totally up to you to decide if this is right for you right now. Whatever you choose, I’m here to support you.”

 

6. Leave the door open for moving to preparation: “After talking about this, and doing the exercise, if you feel you would like to make some changes, the next step won’t be jumping into action - we can begin with some preparation work.”

 

Example 3: Steps to take in dealing with a client who is preparing to change and begins small changes

This is a client who is preparing to change and begins making small changes to prepare for a larger life change – “My weight is a concern for me; I’m clear that the benefits of attempting weight loss outweigh the drawbacks, and I’m planning to start within the next month.”

1. Your MI goals with this client are:

  1. Reinforce the decision to change behavior
  2. Prioritize behavior change opportunities
  3. Identify and assist in problem solving re: obstacles
  4. Encourage small initial steps
  5. Encourage identification of social supports
  6. Reinforce the decision to change behavior: “It’s great that you feel good about your decision to make some lifestyle changes; you are taking important steps to improve your health.”

 

2. Prioritize behavior change opportunities: “Looking at your eating habits, I think the biggest benefits would come from switching from whole milk dairy products to fat-free dairy products. What do you think?”

 

3. Identify and assist in problem solving re: obstacles: “Have you ever attempted weight loss before? What was helpful? What kinds of problems would you expect in making those changes now? How do you think you could deal with them?”

 

4. Encourage small, initial steps: “So, the initial goal is to try nonfat milk instead of whole milk every time you have cereal this week.”

 

5. Assist client  in identifying social support: “Which family members or friends could support you as you make this change? How could they support you? Is there anything else I can do to help?”

Now You Try MI on these Case

 

Directions: For each of the following cases, read the case first. Then write down your responses for each of the stimulus questions that follow the case description. You can do this alone, with a partner or in a small group.

 

Case 1: Jim

Jim is a 68-year old, Hispanic male with type-2 diabetes that lives independently and is retired. He is divorced with two adult children and has had recent difficulty monitoring his health and diabetes routine, including his medication management. He reports a lack of energy, increased fluid intake and more frequent urination. His Primary Care Physician (PCP) advised Jim to frequently check his blood pressure at home, eat more low-fat foods and increase his physical activity.

 

Jim voiced concerns about his ability to be able to maintain and follow these recommendations and asked for a referral to speak to a counselor, therapist, or social worker who could help motivate him to maintain his diabetes better. During intake with social worker, Jim voiced ambivalence regarding changing his behaviors using statements such as, “I know I need to change and I want to change, but it’s so difficult to take that first step,” and “I am already so old, why do I need to change?”

 

How would you say Asking Permission lines with him?

How would Elicit or Evoke Change Talk with him?

What Open-ended Questions would you ask him?

Why type of Reflective Listening would you use with him?

What Affirmations would you offer him?

How would you use the Ready to change Ruler with him?

What Advice/Feedback would you want to offer him?

What Summary Statements could you use with him?

 

Case 2: Victoria

Victoria is a 37 year old Latina female. She’s 5’4” and 187lbs and a smoker. She is seeking your services because she wants to lose weight for her wedding in 6 months. She tells you that she’s been trying to lose weight for at least 10 years through various diets and cleanses but nothing seems to “stick” and she ends up gaining the weight back, and more. She says that she is unable to exercise or quit smoking because of her very busy and stressful job as a film executive so wants to lose weight through diet alone. However, she also notes that she often eats sweets at night as a reward for a long day.

 

How would you say Asking Permission lines with her?

How would Elicit or Evoke Change Talk with her?

What Open-ended Questions would you ask her?

Why type of Reflective Listening would you use with her?

What Affirmations would you offer her?

How would you use the Ready to change Ruler with her?

What Advice/Feedback would you want to offer her?

What Summary Statements could you use with her?

 

Case 3: Michael

Michael is a 49 year old White male. He’s 5’10” and 220lbs and a non-smoker. He walks about 2 miles daily as a mail carrier but doesn’t do any other exercise.Michael came in reluctantly upon referral from his doctor who recently diagnosed him with prediabetes

and high cholesterol. He says his “wife made him come” and that he doesn’t think he has a problem as he eats “fine” and walks 5 times week for work. He notes that he’s “always been a burger and fries guy” and drinks 3-4 beers nightly. Tom admits that his dad died of a heart attack at 57 but thinks this is unrelated to his current situation since dad smoked.

 

How would you say Asking Permission lines with him?

How would Elicit or Evoke Change Talk with him?

What Open-ended Questions would you ask him?

Why type of Reflective Listening would you use with him?

What Affirmations would you offer him?

How would you use the Ready to change Ruler with him?

What Advice/Feedback would you want to offer him?

What Summary Statements could you use with him?