1 MOTIVATIONAL INTERVIEWINGWELCOME TO MOTIVATIONAL INTERVIEWING Ken Resnicow, PhD Professor University of Michigan School of Public Health Department of Pediatrics Comprehensive Cancer Center Center for Health Communications Research Ann Arbor, MI Please DO NOT reproduce, forward, or otherwise circulate any of these slides. All materials herein are copyrighted to Ken Resnicow and Academic Assistance Inc This slide deck has some suggested talking points and sample answers in the NOTES field. If there are none for a particular slide you can assume that the key points are self evident. To start the workshop, we typically go right to a video clip before we have everyone introduce themselves. It can be a good way to break the ice. So LET’s get right into…show a clip..either CRAZY HEART or TAO of STEVE

2 Rolling with ResistanceCLIENT: I know because I have diabetes, I probably should exercise more, but I am so busy. With the three kids and my new job I don’t see anywhere to fit it in. Plus, I hate the gym. I can’t stand being around all that Lyrca. My husband is useless because he already plays basketball four times a week. NEW SCHOOL: Although part of you knows exercise would be good for you and help you control your diabetes, fitting it in seems almost impossible given how busy you are at home and at work. The gym doesn’t work for you, and your husband doesn’t seem like he can be much help either. OLD SCHOOL: Well you can exercise at home. Maybe ride your bike or walk. Ask your husband to help. Don’t worry about how you look nobody is paying attention to you.

3 Two Elements of Behavior Change CounselingWHY to Change HOW to Change ENERGY STRUCTURE VIGILANCE STRATEGY MI CBT/Behavioral Economics/NUDGE Starting with a strong WHY leads to better outcomes More likely to TRY More likely to PERSIST More likely to SUCCEED

4 Two Elements of Behavior Change CounselingWHY to Change HOW to Change ENERGY Goal VIGILANCE Plan MI CBT/Behavioral Economics/NUDGE Starting with a strong WHY leads to better outcomes More likely to TRY More likely to PERSIST More likely to SUCCEED

5 Essence of Motivational InterviewingComfort the afflicted and Afflict the comfortable An effective MI practitioner is able to strategically balance the need to “comfort the afflicted” and “afflict the comfortable.”; to balance the expression of empathy with the need to build sufficient discrepancy to stimulate change. In MI we build energy for change by tapping into deeper values…discrepancy creates tension which is energy for change Drain the swamp and barriers allowed…that means we want to draw the negative energy (resistance) out from the client to neutralize it. But only talk about it just enough to get it out…don’t embellish it. But benefits are encouraged….we selectively reinforce and build CHANGE talk.

6 Essence of Motivational InterviewingRoll with Resistance Then Find Meaning for Change Acknowledge Dread: Drain the Swamp Link with Role, Goals, and Values Disrupt

7 ENERGIZING CHANGE Fear Feedback Roles Values Meaning

8 Energizing Change Roles Values Meaning Fear Feedback

9 Energy Independence Successful long-term behavior change is the formation of habit with low need for exertion, effort, or impulse control. Energy is needed to start the change process and get back on track when derailed.  However, the goal is energy independence.

10 MI vs. Usual Care Address Feeling Before Fixing Reflect vs. ask2-3 Reflections per Question Roll with resistance vs. counterpunch Elicit change talk vs. inform/advise Affirm effort and commitent > 50% patient talk time

11 Client: We eat at Wendy’s a few times a weekClient: We eat at Wendy’s a few times a week. It’s cheap, fast, my kids like it, and it’s better than those other places. There’s a lot worse we could be eating. Sure there are better foods than that but I don’t have time to cook… AFFIRM Key is to AFFIRM the mother’s concern for her child’s health..even if WENDY’s is NO BETTER than McDonalds (USEFUL FICTION)….she thinks she is doing ok by NOT eating at other fast food places…. Reflection: You care about your child and want to feed her healthy foods. It is just tough now given how little time you have now. So ideally you would prefer not to be eating as much at fast food.

12 Old School You know, Wendy’s is no better than McDonalds so you are not doing your kids any favors by eating there.

13 New School Because you are so busy and exhausted it is hard to find the time to cook healthier meals. But you care about your kids’ health and are want them to eat better than fast food.

14 Married sedentary female“I really need to find someone to exercise with. I can’t do it alone. I just need someone to remind me or do it with me……but there is no one….” Reflect on Omission

15 Old School Why don’t you exercise with your husband?

16 New School So, it’s interesting you have not mentioned your husband..I assume that he would not be helpful in any of this….

17 Rolling with resistance and reframingClient: Look at you…were you ever heavy….how can you really relate to me? Response: You’re concerned that if I have not struggled with my weight that I won’t be able to understand you or won’t be able to help you.

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19 Managing Chronic DiseaseBrand Switch Vaccination Seat Belt Most Screening Tests Smoking Cessation Addiction Obesity Managing Chronic Disease

20 Brand Switch

21 Brand Switch

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23 Autonomous MotivationLow Resistance High Readiness Autonomous Motivation Patient Factors Behavior Factors Simple Change Low effort Complex Change High effort High Resistance Low Readiness Controlled Motivation Amotivation

24 Motivation x Energy Matrix

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27 Autonomous MotivationLow Resistance High Readiness Autonomous Motivation Lower Intensity Tx Incentives Nudge How Messages Efficacy Building Motivational Interviewing Phase III E-Health SMS Tailored Messaging PSA Lower Intensity Tx Incentives Nudge How Messages Efficacy Building Motivational Interviewing Phase III E-Health SMS Tailored Messaging Simple Change Low effort Complex Change High effort Higher Intensity Tx Interpersonal Motivational Interviewing Phase I-II Why Messages Higher Intensity Tx Interpersonal Motivational Interviewing Phase I-II Why Messages High Resistance Low Readiness Controlled Motivation Amotivation

28 Autonomous MotivationLow Resistance High Readiness Autonomous Motivation Seat Belts Dental Behavior Adherence to most Rx Vaccination Most Screening Behaviors Bullying Eating Disorders Addiction/Smoking Obesity/Diet/Activity Diabetes Heart Failure Simple Change Low effort Complex Change High effort Addiction/Smoking Compulsive Behaviors Obesity/Diet/Activity Diabetes, Heart Failure, other chronic disease Seat Belts Dental Behavior Vaccination Adherence to most Rx Most Screening Behaviors High Resistance Low Readiness Controlled Motivation Amotivation

29 Autonomous MotivationLow Resistance High Readiness Autonomous Motivation HOW HOW Patient Factors Behavior Factors Simple Change Low effort Complex Change High effort WHY WHY High Resistance Low Readiness Controlled Motivation Amotivation

30 RESISTANCE DREAD DEPLETION FEARResistance often is just the symptom of deeper issues Dread of change Depletion (not energy) Fear of life without it or how hard it is to change it RESISTANCE DREAD DEPLETION FEAR

31 Can Brief Motivational Interviewing in Practice Reduce Child Body Mass Index? Results of a 2-year Randomized Controlled Trial Good afternoon. I would like to thank all of my co-authors. Funding for this study was supported by the National Heart Lung and Blood Institute, the Health Resources and Services Administration Maternal and Child Health Bureau and the American Academy of Pediatrics Results I am presenting today are from the PROS Brief Motivational Interviewing to Reduce Body Mass Index, or the BMI-Squared, study. Pediatric Research in Office Settings, or PROS, is the American Academy of Pediatrics practice-based research network. Our collaborators include the Dietetics Practice-based Research Network of the Academy of Nutrition and Dietetics Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135: Funding provided by a grant from National Heart Lung and Blood Institute (R01HL085400), PROS core funding from the Health Resources and Services Administration Maternal and Child Health Bureau (R60MC00107) and the American Academy of Pediatrics

32 Methods 2-year national randomized controlled trial in 42 PROS practices Test use of MI vs. usual care among children ages 2-8 with BMI 85th to 97th percentile 3-arm design: Group 1 – Usual care Group 2 – MI delivered by pediatricians (4 sessions) Group 3 – MI delivered by pediatricians (4 sessions) plus registered dietitians (6 sessions) Read after first bullet -- At risk for obesity was defined as 85th to 97th percentile for body mass index. Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:

33 Study Overview Overall Enrollment n= 42 practices n= 645 patientsGroup 1 Usual Care n= 11 practices n= 198 patients Lost to follow-up 1 practice 40 patients Analyzed n=158 patients (80%) Group 2 Pediatricians n= 16 practices n= 212 patients 3 practices 67 patients n=145 patients (68%) Group 3 Pediatricians and RDs n= 15 practices n= 235 patients 81 patients n=154 patients (66%)

34 Hypotheses At 2 year follow-up, children in group 2 (PCP only) will show a 3 point decrease in BMI percentile relative to group 1 At 2 year follow-up, children in group 3 (PCP + RD) will show a 3 point decrease in BMI percentile relative to group 2. Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:

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36 Resnicow K, McMaster F, Bocian A, et alResnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics. Mar ;135(4):

37 Thank you to participating PROS practices!

38 Primary Objective Assess the impact of brief Motivational Interviewing (MI) counseling on child BMI percentile over a 2-year period Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:

39 Intervention ElementsMI training MI delivery MI booster training DVD Parent Behavior Screener Autonomy Supportive Materials Tip Sheets (Optional) Diaries (Optional) Autonomy Supportive Skills (MD to Parent) You Provide They Decide Engagement-Choice

40 What did our providers do?Reflect 2x-3x for every question asked Talk < 50% of the time Support parent and child autonomy Affirm effort Elicit Change Talk Link behavior to role and goals Undersell advice Provide menu of options

41 Baseline Sample Description By Study GroupTotal Control MD MD+RD (n= 198) (n=212) (n=235) (n=645) Mean Child Age (sd)* 4.87 (1.72) 5.08 (1.94) 5.32 (1.78) 5.10 (1.82) Mean Child BMI percentile (sd) 91.50 (3.29) 92.17 (3.26) 92.09 (3.44) 91.93 (3.34) Parent BMI (sd) * 28.43(6.77) 30.13 (7.43) 28.48 (6.43) 29.01 (6.91) Child Gender % Male 47.0 42.9 39.6 % Female 53.0 57.2 60.4 Parent Completing Questionnaire** % Mother 87.2 92.4 91.7 90.5 % Father 12.2 4.3 7.5 7.9 % Other 0.5 3.3 0.9 1.6 Child Race ** % White 67.9 53.6 59.1 60.0 % Black 2.6 11.0 6.1 6.6 % Hispanic 13.3 30.1 20.9 21.6 % Asian 6.63 1.4 8.7 5.7 %Other 9.7 3.8 5.2 Household Income* % < $ 40,000 27.2 38.6 29.8 31.9 % >=$ 40,000 72.8 61.4 70.2 68.1 Parent Education ** % < College 61.8 70.1 52.6 61.2 % College or higher 38.2 29.9 47.4 38.9 Child Insurance Coverage % Any 99.5 98.1 97.3 98.3 % Private* 74.0 59.8 65.9 66.4 % Medicaid ** 17.4 36.4 23.0 25.7 * p < ** p < .01

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43 Results for BMI PercentileYear 2 BMI Percentile and BMI Percentile Change by Study Group Study Group N Year 2 BMI Percentile^ (SE) BMI Percentile Difference#^ (SE) Group 1 – Usual Care 158 90.31 (0.94) 1.82 (0.98) Group 2 –PCP 145 88.1 (0.94) 3.8 (0.96) Group 3 –PCP & RD 154 (0.92) 4.92 (0.99) Read slide. Groups with matching superscripts differ p < .05 # Subtracting post-intervention BMI percentile from baseline BMI percentile. ^ Adjusted for age, race, sex, baseline BMI, household income, parent BMI, provider age, and practice effects (clustering)

44 Results using Raw BMI Year 2 BMI by Study Group Study Group NYear 2 Raw BMI (SE) Group 1 – Usual Care 158 19.751 (0.17) Group 2 –PCP 145 19.33 (0.18) Group 3 –PCP & RD 154 19.171 Read slide. Groups with matching superscripts differ p < .05 ^ Adjusted for age, race, sex, baseline BMI, parent BMI, income, provider age, and practice effects (clustering)

45 BMI2: Behavioral Outcomes^ at 2-year Follow-upStudy Group Fruit & Veg Serving p/day Sweet Beverages Physical Activity Hrs. p/day Screen Time Hrs. p/Day Control 3.8 1 (.12) 2.1 (.05) 1.3 (.11) 2.51 (.10) PCP only 4.1 (.14) 1.9 (.06) 2.42 (.11) PCP + RD 4.31 (.13) 2.1 (.06) 1.0 (.12) 2.21,2(.10) ^ Adjusted for age, race, sex, baseline value, and practice effect

46 Number and Percent of MI Contacts CompletedNumber and Percent of MI Contacts Completed by Intervention Group in BMI2 GROUP Number and Percent of MI Contacts Completed 1 2 3 4 5 6 GROUP 2 PCP (n =145) 2.1% 14 9.7 8 5.% 9.7% 106 73.1% NA GROUP 3 PCP (n =154) 1.9% 18 11.7% 17 11.0% 12 7.8% 104 67.5% GROUP 3 RD 21 13.6% 24 15.6% 29 18.8% 30 19.5% 22 14.3% 9 5.8% 19 12.3% Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:

47 Number and Percent of MI Contacts CompletedNumber and Percent of MI Contacts Completed by Intervention Group in BMI2 GROUP Number and Percent of MI Contacts Completed 1 2 3 4 5 6 GROUP 2 PCP (n =145) 2.1% 14 9.7 8 5.% 9.7% 106 73.1% NA GROUP 3 PCP (n =154) 1.9% 18 11.7% 17 11.0% 12 7.8% 104 67.5% GROUP 3 RD 21 13.6% 24 15.6% 29 18.8% 30 19.5% 22 14.3% 9 5.8% 19 12.3% 32.4% of families received 4 or more RD calls.

48 Baseline to Year 2 BMI Percentile Change by Completed# MI Dose in BMI2, 2009-2013Study Group Dose (n=425) Adherence Adjusted^^ BMI Percentile ∆ Mean (SE) Control 149 1.71,2 Group 2 Low < 3 MI 23 3.2 Group 2 High > =3 MI 112 4.2 Group 3 Low < 8 MI 104 4.61 Group 3 High >= 8 MI 37 5.52 ^ adjusted for age, race, sex ^^ adjusted for sex, age, income, education, race, and psychosocial predictors of adherence. # - High Dose defined as 75% of expected sessions. Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:

49 Even a little MI goes a long Way…these docs were not trained in MI…the study examined naturally occurring small amounts of MI skill

50 Longitudinal, observational study to examine;Physician Communication Techniques and Weight Loss in Adults, Project CHAT Pollak, Kathryn I, et al. Purpose: Longitudinal, observational study to examine; 1) Whether weight was discussed as part of preventive counseling in overweight patients 2) To see if Motivational Interviewing (MI) techniques used during weight discussion predicted weight loss at 3 months after the counseling session.

51 Methods: Forty primary care physicians recruited and told the study was on preventive health (not weight loss specifically), to prevent bias. Patients recruited based on physicians clinic roster review to identify patients scheduled for non acute visits. Each physician counseled overweight or obese patients, totaling to 461 audio recorded sessions. Three primary weight related topics were coded to determine presence of counseling (nutrition, physical activity, BMI/weight).

52 (2) empathy (score >1) (3) open questions Methods: MI assessed with the Motivational Interview Treatment Integrity Scale (MITI). In those patients who DID receive weight loss counseling, researchers looked at the association with each of the 5 MI criteria and weight loss. (1) MI spirit (score >1) (2) empathy (score >1) (3) open questions (4) any simple or complex reflections (5) behaviors consistent and inconsistent with MI. The threshold for competence was moved from a 5 out of 7 to a 2 for MI spirit and any reflections rather than 2 to 1 reflections to questions..

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54 Physicians discussed weight in 69% of encounters Results: Physicians discussed weight in 69% of encounters At baseline, the mean patient weight was 91.7kg A 3 month follow up weight was recorded for 326 patients. After controlling for all patient-, physician-, and visit level covariates, the estimated mean weight change between baseline and 3 months was 0.0 kg (Model 1a). The estimated difference in weight change over 3 months between patients who experienced weight-related discussions and those without was 0.1 kg (Model 1b).

55 Model 2a: Patients whose physician had a high MI-spirit score lost an estimated 1.4 kg (95% CI:2.6, 0.2), while those whose physician had a low MI-spirit score gained an estimated 0.2 kg (95%CI:0.2, 0.6). Model 2b: Patients whose physician used reflective listening in their encounter lost an estimated 0.5 kg (95% CI:1.2, 0.1), while those whose physician did not use reflective listening gained an estimated 0.4 kg (95% CI:0.1, 0.9). Model 2e: the MI–inconsistent proportion was fixed at 0 and 1, respectively. Patients whose physician used only MI–consistent behaviors in their encounter lost an estimated 0.8 kg (95% CI:1.8, 0.1), while those whose physician used only MI–inconsistent behaviors gained an estimated 0.3 kg (95% CI:0.3, 0.3).  The higher the MI–inconsistent proportion, the less weight loss occurred. “lay” version of the findings…. Patients whose physician had at least SOME MI-spirit score (>1) lost 3 lbs while those whose physician had a low MI-spirit score (=1) gained an estimated 0.4 lbs. Patients whose physician used at least on reflective statement in their encounter lost an estimated 1 lb while those whose physician did not use any reflective listening gained 1 lb

56 Manufacturing Change TalkMI Duality STYLE TECHNIQUE Autonomy Support Choice Empathy Collaboration Evoke vs. Persuade Agenda Setting Open Questions Reflective Listening Manufacturing Change Talk Rulers/Values

57 WHY HOW Build Discrepancy Listening Advising Informing Explore GuideThree phases of DM….usually they follow in order..however sometime members can go through in different order. Each phase comprises different skills….more about this found in the next four slides Asking Explore Understanding Guide Deciding Choose Acting WHY HOW

58 Explore Choose Ok to bounce around phases but usually phase III , choosing is toward the later part of the encounter Guide

59 Open ended ?s Can’t be answered yes/no Cast a broad netUse respondent’s own words; Don’t label emotions Not biased Have few assumptions Non-judgmental/"Preachy" Ask one question Closed ended, good for getting Binary Info Did you take the garbage out Did you Lock the door IF Used Close Ended HOW, Why, What Use Open OE, only a starting point. Not the basic of most sessions. RL is Exercise: Find out as much as you can about the person’s childhood. Client don’t respond to Close Ended Questions only no statements.

60 Open Ended Starters Open VS Closed To what extent…. Did You..?How Often.. Will You..? Why…. Can You..? Tell me about… Is it...? Help me understand….. What, if any,….. When, if ever, How, if at all, What else….. Ones on the left of course are Open ended…those on the right force a close ended question

61 Some are like this Others like thisWhere are you? WE call this the LONG FORM..very good for highly sensitive topics..make sure to encourage trainees to use it during the activity ahead SEE ACTIVITY #1 IN TRAINING MANUAL for more instructions… USE ABORTION, HOMOSEXUALITY, or OTHER SENSITIVE TOPICS TO DEMONSTRATE THIS SKILL… Present these issues both with a direct Open ended question and the long form…ask which they prefer Most but NOT ALL will prefer the long form.. Not everyone likes the long form…if you don’t care what I think about you, you might do fine with the short form… Like Rush Limbaugh….he would be happy to answer the short form…. During the practice exercise of fixing questions, try to bring this strategy in several times….

62 Decreased Stayed Same IncreasedWorse No Change Better

63 Effective “generic” StartersTypical day Compared to……. O-10 or 0-100 How’s it going? How’s that been/worked for you? How have things been since we last spoke? Tell me about days when it has gone well/not so well To what extent does this surprise or was this expected…

64 Assessing Adherence/PersistenceIn the past month, how many doses of XXX have you missed? In the past month, on a scale of 0-100, with 0 missing no doses, and 100 misses almost every dose, where would you rate yourself? In the past month, thinking about your medication, would you say 1) You have been taking it less regularly 2) You have been taking it more regularly 3) No change. Taking it the same as always. WE FOCUS ON THE NEGATIVE TO GIVE PATIENT PERMISSION TO NOT BE PERFECT You can add IF ANY into the first question ……… I PREFER THE FIRST ONE TO THE 2ND AND 3RD

65 Are all closed-enders created equal?NEW TYPOLOGY OF CLOSED QUESTIONS Nasty - Preferred + Benign 0

66 Nasty Closed Ended Have you always been this fat?Do you really want to die? Do you not care about your kids? Haven’t you thought about what will happen if you come off the drug? Are you aware how bad this is for you and your family? Do you sleep around? Are you finally ready to quit? Do you watch your salt intake carefully? Does your child take her insulin everyday as we recommend? Do you watch a lot of TV? Do you get enough exercise? Do you think that African Americans are very distrustful of the health care system? Didn’t you know that BEFORE you married him! THESE ARE THE TYPE WE WANT TO DISCOURAGE..you will be fixing these type in a few minutes

67 Sometimes Close-ended is Preferable: WHY?Have you ever eaten a kiwi? Did you vote in last year’s election? Is there a TV in your child’s room? Did you take out the garbage? Do you have a driver’s license? Did you close the garage door? Do you have enough pills for your two weeks away? Did you bring your consent form with you? Do you have your insurance card with you? Are you having any thoughts of harming yourself? Do you have a plan in any way to harm yourself? THESE SHOULD BE CLOSE ENDED BECAUSE THERE ARE ONLY TWO ANSWERS THE INFORMATION IS BINARY Of course Bill Clinton can evade such questions…. Such questions are RARELY appropriate when asking about EMOTION or MOTIVATION

68 BENIGN Close-Ended ?s Are you ok? Is this a good time to talk?Does that make sense? Did things work out with xxxx? You feeling any better since we spoke last? Are you still have problems with XXXX? Did that help at all? Were you able to try any of what we talked about? You ok with that? Are things still difficult at home? You alright talking about this? Are things any better? Can you see how that might affect you? Might it be possible?--- Might that work for you? Are you concerned at all about that? THESE ARE TECHNICALLY CLOSED ENDED BUT FUNCTION PRETTY WELL..ALMOST LIKE OPEN ENDED.. KEY IS TO COMMUNICATE TO TRAINEES THAT THERE IS NO NEED TO WORRY ABOUT THESE TYPES OF CLOSED QUESTIONS…THEY ARE JUST FINE….

69 Reflective Listening Statement, not a question Ends with a down turnHypothesis testing (If I understand you correctly, it sounds like..) Affirms and validates Keeps the client thinking and talking Now we embark on the most important part of the training…building skill of reflective listening…. Note good reflections are really just your BEST GUESS for WHY you said that, or WHERE you are going with this…. Up talk conveys insecurity and comes across like a closed ended question (common among adolescents)

70 Reflective Listening: Value addedInformation PLUS empathy and understanding How well do you think people understand you? vs You’re feeling nobody understands you. Which one conveys EMPATHY? Answer: the REFLECTION Ask group..therefore what is the implication of this?

71 Reflective Listening: Value addedInformation PLUS empathy and understanding How did that make you feel? vs You’re feeling sad about that. Which one conveys empathy again ….the reflection……… but they may wonder…..does it get the same amount of info?…see next slide…yes it does..and more So that is why we seek at least 2:1 QUESTION to REFLECTION ratio

72 Second vs. First Person Praise Reflect vs. CheerleadYou I You seem proud of what you have accomplished I am proud of you You have put a lot of effort into this I am happy to see you have done this You have tried really hard to quit It is great you have tried to quit You are getting more confident that you can do it I know you can do it

73 Rocky Rapport: Intensity MismatchClient Counselor Responds Weak Strong I am a bit upset with my husband Sounds like you hate your husband Strong Weak I am furious with my boss Sounds like you are a little upset with your boss Example 1 knocks the patient out of their chair..too much too soon….(gives them the BENDS) .use the example of the drinker who says he has beer for breakfast, lunch, and dinner and you reflect he is an alcoholic…not ready to hear it… Instead, move emotional intensity up one or two notches at a time… for example, “you sound like you are more than a bit upset” Example 2: minimizes…send message that you cannot handle the emotion ..shuts the patient down… Very common for health care providers to avoid talking about intense emotion… We are going to do an exercise (#2) that specifically addresses this issue.

74 thankful thrilled weak turned on up warm wonderfulHappy Sad Angry Confused alive awful agitated anxious amused bad annoyed awkward blue bitter baffled calm bummed out burned up bewildered cheerful crushed critical bothered content depressed disgusted crazy delighted desperate dismayed dazed ecstatic devastated enraged disorganized elated disappointed envious disoriented energized dissatisfied fed up distracted excited distressed frustrated disturbed fantastic furious embarrassed fortunate down hostile friendly impatient helpless fulfilled gloomy irate hopeless glad glum irritated jolted good hateful livid lost great mad mixed up hopeful hurt outraged panicky lively lonely perturbed paralyzed loving put out perplexed motherly low riled puzzled optimistic miserable resentful shocked overjoyed painful seething stuck peaceful sorry sore stunned pleased terrible ticked off surprised proud turned off uptight tangled refreshed uneasy worked up trapped relaxed unhappy troubled relieved unloved uncertain rested upset uncomfortable satisfied undecided spirited unsure thankful thrilled weak turned on up warm wonderful Remember to PRINT THIS ON LARGE PAPER for trainings..too small to read on the screnn Ask audience to pick 2-4 NEW feeling words to use over the next two days…

75 Reflecting 101: Basic StructureIt sounds like you are feeling…… It sounds like you are not happy with…. In other words……. So you are saying that you are having trouble…….. So you are saying that you are conflicted about …….. I think you may be saying…. Correct me if I’m wrong… I hear you saying… As you improve, you can truncate the reflection…. You’re not ready to…. You’re having a problem with .... You’re feeling that….. It’s been difficult for you…. You’re struggling with…… Eventually we want counselors to be more “pithy” and just start with YOU statements (SHORT FORM) but in the beginning IT SOUNDS LIKE is a good crutch (LONG FORM) It can get redundant to keep saying the LONG FORM

76 Reflection Pronoun HierarchyYOU IT’s I/we

77 Health Behavior Change: The Feeling VocabularyTrapped Torn Hopeless Powerless Alone Overwhelmed Drained At War/Conflicted Struggling

78 Types of Reflections Content Feeling/Meaning Double-SidedRolling with Resistance Amplified Negative Reflection on Omission Action SIMPLE COMPLEX

79 Reflection on Omission: Crossing off the listIt’s interesting that you didn’t mention…so that doesn’t seem to be an issue you didn’t mention xx as an option so I’m assuming that wouldn’t be a great solution for you you didn’t mention xx as an option…. I’m guessing there is probably a reason. Reflection of Exclusion By crossing off the list we show we are listening and it helps to avoid info and advice dump and SKEET shooting

80 Reflection on Omission: ActionWhen X may be an option I suspect you thought about this already and maybe decided against it, however I am curious about…… Although you didn’t mention x, I was wondering how that might work for you…

81 E-P-E Elicit Provide What is your understanding of?PERMISSION 1: Would it be ok if we spend a few minutes talking about XX? What is your understanding of? What have you heard about? REFLECT AND AFFIRM THEIR KNOWLEDGE PERMISSION 2: If it’s okay I’d like to share with you some other (or new) information about xx GIVE CHOICE ABOUT WHAT AND HOW What’s the most important thing you want to know about? What do you want to know? Provide Information Advice “Some of what I say may differ from what you have heard?” What do you make of that? Where does that leave you? How does that compare to what you previously thought/heard? Do you have any other questions about this? What else might you want to know more about? This is a GOLDEN strategy..it reduces information dump and unsolicited advice.. EYEDropper VS. shovel It buys us back time which allows us to reflect… Remember to try and bring EPE into cases that arise…

82 Correcting Misinformation Adding Essential InformationE-P-E Is this normal ? Can I xxx? Correcting Misinformation Adding Essential Information These are the triggers for an EPE

83 Bringing it all togetherX P L O R G U I D C H S Get permission Set agenda Assess current level Discuss History Assess 0-10 importance/confidence  Probe lower/higher/what would it take Assess core values  Link behavior to values Summarize & Spin: Where does that leave you? Build Menu of Choices Ask Client to Pick Option What can you do to make it happen?  This week  Today

84 Autonomy Supportive ChoosingMenu of Options Avoid Advice Skeet Shoot You Provide-They Decide

85 Bringing the Water…. X has not worked for youYou are looking for something other than X Any thoughts about Y Y might be an option

86 We become more committed to that which we voiceChange Talk We become more committed to that which we voice Client Takes the “positive” side of the argument Client “discovers” discrepancy between current behavior with core values/goals Problem Recognition Client states their Pros Client solves own barriers Explore life without the problem How I felt when I used to do it How I would feel if I did do it Change talk is central to MI: your job is to elicit it and reinforce it. Remember the BMW test drive or trying on fancy shoes….thinking about and visualizing “My life without this problem…….” It can be how they USED to feel when the did it How they WOULD feel if they did it Or simply WHY they want to do it

87 Levels of Change Talk Desire: Want, wish, like, etc. Ability: Can could, able, etc. Reasons: Specific reason for change Need: Need, have to, important, must, compelled (w/o specific reason) Commitment: Will, plan to, intend to, going to, willing, ready, etc. This is the DARN-C model We often misinterpret lower levels of change talk as true commitment…desire is low and commitment is high… Next slide give examples of increasing levels of change talk..

88 Change Talk Reflections: Before Change has StartedStarting to feel you want a change xx Something about xx is starting to feel not right for you Starting to feel you no longer want xx in your life.. Starting to think it might be time to change… Starting to feel xx has gotten a little out of control Starting to catch up with you… Starting to bother you a bit more… Starting to worry you a bit more Moving more toward change… Wondering what it might be like with/without Starting to feel a little dependent on xxx (for addictive) ….but you realize that… Xx does not feel sustainable..

89 Fully Motivated Patient Ok to Reflect with EnthusiasmException Fully Motivated Patient Ok to Reflect with Enthusiasm

90 Change talk reflections: When things have startedPutting a lot of energy into this Starting to see the benefits Putting in a lot of effort Really trying to make this work

91 Magnify vs. Manufacturing Change Talk

92 FIND THE BURIED CHANGE TALK

93 Magnify vs. Manufacturing Change Talk

94 I know we need to eat betterI know we need to eat better. But I am not a good cook, and I have NO time to learn how. Sure McDonalds is poison but it’s fast, cheap and all three kids eat it without complaining.

95 Yes, I know all that TV and all those video games are not good for herYes, I know all that TV and all those video games are not good for her. By what can I do? I cannot afford a babysitter and I have to get my work done. I work out of my home.

96 I know we would all be better off if we were more active, but we are so busy and so tired all the time. We did have a great time when we went camping last summer but I’m not sure we can pull that off again.

97 I just love sweets. Cookies, candy, ice cream, you name itI just love sweets. Cookies, candy, ice cream, you name it. And I know it is making me fat. I actually like fruit but my mom never buys any. She says they are really expensive and nobody eats them.

98 Maybe it’s time to quit. I am 55, my dad died of heart disease…and I am coughing up all this junk every morning. Use this to demonstrate Overshot Change Talk: “You are ready to quit” Correctly undershot change talk: “You are starting to think about quitting….”

99 I’ll probably drink less when I am older but for now I am going to party.Overshoot: You will quit when you are 40 Undershoot: It is something that down the line you might want to consider changing but not at this stage of your life. At some point you may start to think that this is too much Right now partying is more important than health

100 I probably should start using condoms with my boyfriend…he slept with someone and gave me and STI. I haven’t brought it up with him..I don’t want him to think I don’t trust him

101 Moving things forward: Using reflections that embed potential solutions

102 Magnify vs. Manufacturing Change Talk

103 Manufacturing Change TalkImportance and Confidence Rulers

104 Importance and ConfidenceEliciting Change Talk Importance and Confidence Importance On a scale of 0 to 10, with 10 being very important, how important is it for you to (quit smoking, eat more F & V, exercise more, take your meds)? Not at all Somewhat Very Confidence On a scale of 0 to 10, with 10 being very confident, assuming you decided to (quit smoking, begin exercising) how confident are you that you could succeed ?

105 Eliciting Change Talk: “The Three Probes”1) Could have been Lower 2) Could have been Higher 3) What would it take If the swamp of negativity has been drained then you might skip probes 2 and 3

106 Can’t and doesn’t want toMotivational Matrix Can but doesn’t want to Can and wants to Confidence Can’t and doesn’t want to Can’t but wants to Ask the group to come up with a case that is low confidence but high importance Ex: smoker who really wants to quit but has failed many times Ex: overweight member who wants to lose weight but has gained all their weight back after each diet Goal for this type of patient is to build confidence by setting realistic short term goal or pulling forward success from somewhere else in their life that can inspire them for this concern Alternatively, ask the group to come up with a case that is high confidence but low importance Ex: I could lose their extra 6 pounds but I don’t see the need Ex: I could get a mammogram, I just don’t think they are helpful Importance Importance Confidence

107 Importance Confidence = MOTIVATION X ImportanceAsk the group to come up with a case that is low confidence but high importance Ex: smoker who really wants to quit but has failed many times Ex: overweight member who wants to lose weight but has gained all their weight back after each diet Goal for this type of patient is to build confidence by setting realistic short term goal or pulling forward success from somewhere else in their life that can inspire them for this concern Alternatively, ask the group to come up with a case that is high confidence but low importance Ex: I could lose their extra 6 pounds but I don’t see the need Ex: I could get a mammogram, I just don’t think they are helpful Importance

108 Roles, Goals, and Values Choose your top 3 or 4Which of the Following Values, Traits, or Characteristics are Important to you? Good Parent Attractive Good Spouse/Partner Disciplined Responsible Environmental Conscious Strong In Control On top of things Respected at work Competent Athletic Spiritual Not hypocritical Respected at home Energetic Considerate Supportive of others Successful Youthful (Older) Popular (Youth) Independent (Older) Tolerance Respect for Others Justice Community/Neighborhood Genuine Authentic Choose your top 3 or 4

109 Values List Choose your top 3 or 4Which of the Following Values, Traits, or Characteristics are Important to you? Good Parent Supportive Good Family Member Attractive Good Spouse/Partner Disciplined Good Community Member Responsible Strong In Control On top of things Respected at work Competent Athletic Spiritual Not hypocritical Respected at home Energetic Good Christian (or Jew, Muslim etc) Considerate Successful Youthful (Older) Popular (Youth) Independent (Older) Good to my Parents Choose your top 3 or 4 The list intentionally contains values and goals that have a high likelihood of being linked to a health behavior List of vales and goals need to be customized to specific demographics and different health behaviors. For example, for teens, the value popular might be useful to include Make sure to reflect Comfort with religion

110 Valores Latinos Buen Padre/Madre Atractivo ConfidenteBuen Esposo/Esposa/Compañero Disciplinado Tolerante Responsable Fuerte Respeto para otros En control Superar las cosas Esperanzado Competente Atlético Haciendo la voluntad de Dios Espiritual Respetado en casa Amistad Energético Considerado Respetado en la comunidad Soportivo de otros Exitoso Ser productivo De espíritu juvenil Independiente Familia Otro

111 Values List: Australian StyleWhich of the Following Values, Traits, or Characteristics are Important to you? Good Parent Attractive Good Spouse/Partner Disciplined Good Community Member Responsible Strong In Control On top of things Respected at work Competent Athletic/Good at Sport Spiritual Not hypocritical Respected at home Energetic Considerate Assertive Successful Youthful (Older) Popular (Youth) Independent (Older) Laid Back/Easy going/Being A good Sport Be a good/loyal mate Environmentally responsible Fare Go/Egalitarian Being able to Take it Honesty/Being Upfront Being able to cope Resilient Privacy Communalism Choose your top 3 or 4

112 Values List: The Dutch ExperienceWhich of the Following Values, Traits, or Characteristics are Important to you? Good Parent Attractive Good Spouse/Partner Disciplined Responsible Environmental Conscious Strong In Control On top of things Respected at work Competent Athletic Spiritual Not hypocritical Respected at home Energetic Considerate Supportive of others Successful Youthful (Older) Popular (Youth) Independent (Older) Tolerant Respect for Other Justice Community/Neighbor Genuine Authentic Choose your top 3 or 4

113 Values List: South African AdultsWhich of the Following Values, Traits, or Characteristics are Important to you? Good Parent Good Spouse/Partner Disciplined Politically Aware Good Community Member Responsible Strong Extended Family At peace with ancestors Responsible Manhood (n”guni) Strong In Control On top of things Respected at work Competent Independent (Older) Spiritual Not hypocritical Respected at home Energetic Considerate Successful Youthful (Older) Popular (Youth) Choose your top 3 or 4

114 Values List: Middle Eastern-Arabic SpeakingGood Parent والد جيد أو والدة جيدة (waled jayed or waledeh jayeda) Good Family Member جزء كبير من العائلة (juz’ kabir min al-a’ela) Honorable محترم (muhtarim) Responsible جدير بالثقة (jadir bil-thikka) Strong قوي (qawi) Successful ناجح (najeh) Well educated/cultured مثقف (muthaqef) Good neighbor جار صالح (jar saleh) Attractive شخص جذاب (shakhs jidhab) Disciplined منضبط (mundabet) Good Community Member عضوا مسؤولا في المجتمع (‘adowa mas’oola fee al-mujtama’a) Respected at work محترم في مكان العمل (muhtarem fi makan al-amal) Pious متدين (mutadayin)‪ Nationalistic وطني، قومي (watani, qawmi) Traditional تقليدي (taqlidi) Popular (Youth) محبوب (mahboob) Charitable كريم (karim)

115 Français Good Family Member Bon membre de la famille Good ParentBon parent Good Spouse/Partner Bonne épouse/époux/compagnon Good Community Member Bon membre de la communauté Strong fort On top of things Organize (Méthodique) Competent compétent Spiritual Spirituel Respected at home Respecté Good Christian (or Jew, Muslim, et cet.) Bon Chrétien, Juif, Musulman Successful Avoir du succès Popular (Youth) Populaire Good to my Parents Bon à mes parents Supportive Apporter du soutien Attractive Attirant Disciplined Discipline Responsible Responsable In Control Avoir le contrôle Respected at Work Respecté au travail Athletic Sportif Not hypocritical Pas hypocrite Energetic Énergique (Dynamique) Considerate Prévenant Compassionate compatissant Youthful (for older individuals) jeune Independent (for older individuals) indépendant

116 Roles, Goals, and Values ListWhich of the following are important to you? Choose your top 3 or 4. Good Parent Communal Good Spouse/Partner Confident Disciplined Tolerant Interconnected Mindful in Word & Deed Connected to my Culture Responsible Strong Respectful of Others In Control On Top of Things Hopeful Competent Honor Land and Water Productive Spiritual Positive Supportive of Others Energetic Considerate Connected to my Ancestors Sharing Learn from Elders Humble Friendly Successful Patient Youthful Respectful of Nature Other: _________________ This list contains values and goals that many people have. Trainer: Demonstrate this activity for the class first. Make sure to reflect. The list intentionally contains values and goals that have a high likelihood of being linked to a health behavior. Why don’t we include HEALTH as a value? (it is a means to an end. We notice when we lose it.) Tell participants to turn to page 9 in the Power of Partners Workbook to see the same values list

117 Values List: Singaporean AdultsWhich of the Following Values, Traits, or Characteristics are Important to you? Good Parent Good Spouse/Partner Disciplined Good Community Member Politically Aware Responsible Respect for elders Freedom Success at work Social Consciousness Strong In Control On top of things Respected at work Competent Independent (Older) Spiritual Not hypocritical Respected at home Energetic Considerate Successful Youthful (Older) Popular (Youth) Wealthy Successful children Not losing out (kiasu) Face saving (ai-mian-zi) Don’t wash your dirty linen/Disgrace (jia-chou-bu-ke-wai-yang) Longevity (kiasi) Filial piety (Xiao Shun) Harmonious Relationships (he xie) Personal Responsibility Individuality Choose your top 3 or 4

118 Health Behavior Core Value

119 How might the values you chose, possibly motivate you to make this change?If you changed your behavior, how might it influence your values?

120 Explore linkages Current Behavior If you Changed the BehaviorIf not raised by client….. Your Health Losing your Health

121 Two ways to values clarityOrganic: What values are important to you? Directive: Which of these values might be related to this behavior……? Two ways to use the values list.. Organic you ask them for values first then ask them to connect to their behavior. Directed you have them look at the values and see if there is anything on the list that might get better if they make the behavior change…

122 Developing Values Discrepancy: ProbesHow, if at all, does your current behavior affect your ability to achieve these goals or live out any or all of these values? How, if at all, would changing this behavior affect your ability to achieve these goals or live out any or all of these values? What connection, if any, do you see between your health and any of these values/goals? How if it all, might losing your health, affect your ability to live out any or all of these values and goals?

123 Values Transition….. We have found that behavior change is often easier when it relates to a person’s values and goals…so for a few minutes I would like to discuss …. When considering behavior change it is often useful for me to get a better understanding of what is important to you as a person…what motivates you….this may help you find motivation (inspiration) for making what can be difficult changes. I would like to switch gears for a second and learn a bit about what is important to you….this might be helpful in finding reasons to change….

124 List of values, attributes, and goals and rates of endorsement in the Healthy Body, Healthy Spirit Project (n=135) Good Parent 49% Attractive 5% Good Spouse/Partner 38% Disciplined 16% Good Community Member 13% Responsible 22% Strong 13% In Control 10% On top of things 7% Respected at work 8% Competent 8% Athletic 2% Spiritual 55% Not hypocritical 7% Respected at home 4% Energetic 10% Good Christian 46% Considerate 18% Successful 13% Youthful 3% Independent 16%

125 Values for AdolescentsGood student Disciplined Healthy & fit Respected at school Strong In control Responsible Good to my parents On top of things Good Sibling Athletic Attractive Competent Confident Spiritual Energetic Respected at Home Mature Successful Independent Popular Good School Member Accepting Diversity Having Good Friends Good at Technology Accepted other__________

126 Values for Parents of Overweight YouthValues For Your Child Values for You Values for Your Family Be Healthy Good Parent Cohesive Be Strong Responsible Healthy Have many friends Disciplined Peaceful Meals Being fit Good Spouse Getting along Not feeling abnormal Respected at Home Spending time together Not being teased On top of things Not feeling left out Spiritual Be able to communicate his/her feelings Fulfill her potential Have high self-esteem

127 Alternative Values ListWhich three are most important to you? ____ Responsibility, to do what I said I would do  ____ Purpose, to have meaning and direction in my life ____ Helpfulness, to reach out to others  ____ Inner peace, to find a sense of quiet/calmness  ____ Justice, to promote fair and equal treatment for all  ____ Hope, to see what happens in life in a positive way  ____ Independence, to be able to meet my own needs  ____ God’s will, to follow God’s plan for me  ____ Loving, to give and receive love   ____ Family, to have a happy, loving family  ____ Spirituality, to grow and mature spiritually  ____ Forgiveness, to be forgiving of others  ____ Strength, to be physically fit and capable  ____ Mental strength, to be mentally alert   ____ Humor, to see the funny side of life  ____ Friendship, to have close, supportive friends  ____ Growth, to keep changing and growing  ____ Health, to be physically well   ____ Other _____________________________

128 RGV Two Ways How do the RGV that you selected possibly influence your motivation to change your target behavior? How if you changed your target behavior, might it influence the RGV you selected?

129 Importance vs. Confidence Values Vs. StrengthsLow IMPORTANCE Low CONFIDENCE VALUES STRENGTHS Values used to build importance whereas the strengths can be used to build Confidence

130 What are you good at. (What is something difficult you have achievedWhat are you good at ? (What is something difficult you have achieved?) (What is something you have overcome? ) SPORTS MUSIC ART COOKING MY JOB MATH SCIENCE LANGUAGES WRITING DISCIPLINE STRONG FIXING THINGS TRUSTWORTHY PARENTING BEING CREATIVE STAYING POSITIVE LEARNING NEW THINGS STAYING COOL UNDER PRESSURE BEING PATIENT HELPING OTHERS FORGIVING APPRECIATING/BEING THANKFUL RESEARCHING THINGS LISTENING TO OTHERS CARING BEING SPONTANEOUS BEAT AN ILLNESS OTHER_____________ Use FORGIVING AND STAYING POSITIVE AS EXAMPLES… To help quit smoking…that might mean…if you have a relapse….being positive and forgiving… Same with something you have overcome…like a disability Comfort with religion Self Affirmation ….

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133 Linking Strengths Your confidence to do XX is low.Think for a minute about some of the other things you are good at, like sports, being a father, and meeting challenges at work. How might your success in these areas help you find the confidence you need to change XX?

134 Bringing it all togetherX P L O R G U I D C H S WHY WHY HOW Get permission Set agenda Assess current level Discuss History Assess 0-10 importance/confidence  Probe lower/higher/what would it take Assess core values  Link behavior to values Summarize & Spin: Where does that leave you? Build Menu of Choices Ask Client to Pick Option What can you do to make it happen?  This week  Today

135 Autonomy Supportive ChoosingAction Reflections Provide Menu of Options for Change Usually client helps populate the list Counselor Undersells Options Provide Choice What to change How much change When How Monitored Contingencies

136 Bringing the Water.. Move from general to specific..….X has not worked for you You are looking for something other than X Any thoughts about Y Y might be an option

137 PHASE 3: CHOOSING Build a Menu of Options1a) List possible ideas mentioned by client during session 1b) Ask patient for other solutions 1c) Offer “other ideas that have worked with people with similar concerns” Ask “which if any of these” might work best for you”. If they choose one… Ask “what might you be able to do to increase your chances of success in the next day or week” Summarize (you or them?) Hope assessment Key is to populate the menu with things from the client, i.e., 1a and 1b Though your expertise can supplement their input (1c) We generally only ask the hope assessment if things ended on an upbeat note

138 Homing in.. Of the things you mentioned, which one or two is the best place for us to start? Which of those do you think you might be able to change?

139 Throughout the session, listen for action talkOften, clients will already have an idea for what they MIGHT try Make a mental note and mention that you may go back to that idea later 1a) Action Item Parking LOT Idea 1 Idea 2 Idea 3 Throughout the encounter listen for the client suggesting what they might actually do… Mention to your client, when they start dropping possible action steps, that “we will get back to this later” It is ok to take notes if you cannot remember them unaided

140 Moving Forward… What might you be able to do in the next few days to move things along (or increase your chances of success?) What might you be able to do in the next few weeks to move things along? Don’t push them to answer Next few days if they seem saturated with doing something in the next week

141 Behavior Change: The core dialecticACT our way into a new way of THINKING Vs. THINK our way into a new way of ACTING