Motivational Interviewing Flashcards
Transtheoretical Model of Behavior Change (TTM)
Biopsychosocial model
Integrates multiple theories of behavior change
Diverse applications
Four constructs of the TTM:
Stages of Change
Processes of Change
Decisional Balance
Self-efficacy
Stages of Change
the progression of stages through which individuals pass as they modify their behavior
Processes of Change
strategies to help individuals make and maintain change — the “how” of change
Decisional Balance
a growing awareness that the advantages (the “pros”) of adopting/changing a behavior outweigh the disadvantages (the “cons”)
Self-efficacy
confidence that one can make and maintain changes in situations that could trigger a return to previous unhealthy behaviors
TTM limitations
The model assumes that individuals make coherent and logical plans in their decision-making process when this is not always true
Consciousness Raising -
Increasing awareness about the healthy behavior.
Dramatic Relief -
Emotional arousal about the health behavior, whether positive or negative arousal.
Self-Reevaluation -
Self reappraisal to realize the healthy behavior is part of who they want to be.
Environmental Reevaluation -
Social reappraisal to realize how their unhealthy behavior affects others.
Social Liberation -
Environmental opportunities that exist to show society is supportive of the healthy behavior.
Self-Liberation -
Commitment to change behavior based on the belief that achievement of the healthy behavior is possible.
Helping Relationships -
Finding supportive relationships that encourage the desired change.
Counter-Conditioning -
Substituting healthy behaviors and thoughts for unhealthy behaviors and thoughts.
Reinforcement Management -
Rewarding the positive behavior and reducing the rewards that come from negative behavior.
Stimulus Control -
Re-engineering the environment to have reminders and cues that support and encourage the healthy behavior and remove those that encourage the unhealthy behavior.
TTM: Stages of Change
precontemplation
contemplation
preparation
action
maintenance
Precontemplation:
no current intention to change a problematic/unhealthy behavior or adopt a healthy one (not in the next 6 months)
unaware of the problem
Contemplation:
desire to change a certain behavior, aware of pros and cons
unresolved ambivalence, feel immobilized
aware of the problem and desired behavior
Preparation:
pros outweigh cons
intention to change is clearer
action plan (next 30 days) but shaky commitment
Action:
begins actual change of targeted behavior
requires sufficient prep and commitment
tipping point for relapse and regression
Maintenance:
successful maintenance of behavior change for at least 6 months
solidifying new behavior, less effort
Contemplation:Skillful approaches
empathize
validate
encourage
help patient tip decisional balance
acknowledge cons
ask client to expand on self-identified problems
explore positive past change experiences
Preparation: Skillful Strategies
Motivational Interviewing Skills: 3 key elements
1) Collaborative (vs confrontational)
2) Evocative (vs coercive)
3) Honoring of patient autonomy (vs authoritarian)
Motivational Interviewing Strategy = 1st Elicit
Elicit – ASK what the patient knows or would like to know or if it’s okay if you offer them information:
> “What do you know about…”
> “Do you mind if I express my concerns?”
> “Can I share some information with you?”
> “Is it okay with you if I tell you what we know?”
Motivational Interviewing Strategy = Provide
Provide – Information in a neutral, nonjudgmental fashion.
Avoid “I…” and “You…”
“Research suggests…”
“Studies have shown…”
“Others have benefited from…” “Folks have found…”“What we know is…”
Motivational Interviewing Strategy = 2nd Elicit
Elicit – The patient’s interpretation
“What does this mean to you?”
“How can I help?”
“Where does this leave you?”
How does this information relate to your situation?
Clinical Application: CASE 1 – Candidate for surgery who smokes )+(MI) =
ELICIT:“What do you know about how smoking affects the healing process after surgery?”Vs.“If I performed surgery on you, I’d be afraid your wound would never heal because you smoke.”
PROVIDE:“What we know is that tobacco can impair wound healing after surgery, leaving folks vulnerable to infections.”
ELICIT:“Tell me what your thoughts are about that.”Vs.“So, you obviously need to quit before I’ll do surgery.”
Motivational InterviewingDARN-CAT
Change Talk –personal arguments for change: (vs Resistance Talk)
DARN
Desire for Change (preference) –”I wish I could start running again.”
Ability for Change (capability) –”I might be able to…”, “I can…I could…”
Reasons for Change (personal argument) –”I want to have more energy to play with my kids.”
Need for Change -based on values and sense of obligation –”If I can’t build my strength then I likely won’t be able to go on the backpacking trip with my family.”
CAT
Willingness and action for change
Commitment - “I will make changes” “I am going to…I intend to..”
Actuation/activation = “I’m prepared to make changes” “I am ready to…I will start tonight”
Taking steps to change - “what have they already done” “this week I started…”
Action:Skillful Approaches
SMART goals
S = specific - state exactly what you want to accomplish
M = measurable - use smaller, mini-goals to measure progress
A = achievable - make your goal reasonable
R = realistic - state a goal that is relevant to your life
T = timely - give yourself time, but set a deadline
Maintenance:
Skillful Approaches
What supports do they need to maintain progress?
Reinforce skills they have developed/learned that will help in the face of set-backs?
What’s next? Forward thinking…
When might they need to return to PT?
TTM:Bandura’s 4. Self-Efficacy Theory
“Self-Efficacy is a person’s particular set of beliefs that determine how well one can execute a plan of action in prospective situations”
Reflects disparity between self-efficacy and temptation
a person’s degree of confidence in maintaining their desired behavioral change in situations that often trigger relapse
the degree to which a person feels tempted to return to their unhealthy behavior in high-risk situations/environments
Value ofMotivational Interviewing
growing long-term condition management (chronic illness)
requires richer understanding and skilled approaches to health behavior change
evidence-based and patient/person-centered
explores and resolves ambivalence
uses language of change; creates collaborative, counseling-style conversations
designed to strengthen sense of self-efficacy, intrinsic motivation
MI: Four Guiding PrinciplesRULE(for the clinician)
Resist = Resist the righting reflex- strong urge to fix; roll with resistance
Understand and Explore = Understand and explore the patient’s own motivations and ambivalence
Listen = Listen with empathy
Empower = Empower the patient, encouraging hope and optimism…SELF-EFFICACY
Understand =
Be interested in the patient’s own concerns, values, and motivations
Listen =
Look for answers from your patient
Empower =
Patient’s own ideas and resources are key
Patients are your best consultants on their own lives and on how best to accomplish behavior change.
OARS
Open Questions
Affirmation
Reflection
Summary
Open Questions
How and Why and When?
Allows client to say what is important to them
“Mrs. Marks, have you been doing the home exercise I prescribed last visit?”
VS
“Mrs. Marks, how have your exercises been working for you since the last visit?”
Affirmations
Statements from the clinician that affirm values, strengths, efforts, attention
Congruent with behaviors, not effusive
A way to help derail self-sabotaging and negative thinking
Reflections(Reflective listening)
Helps the patient feel that the provider is listening/empathizing
Allows for greater clarity
Match the patient’s emotional intensity when appropriate
Basic reflection = repeating what the patient said…
Guide the person towards change
Need to find your authentic voice rather than simply parroting the patient, otherwise can feel insincere
Summaries
Paraphrasing what you hear without your own interpretation or biases (or at least be aware of them)
used to redirect a very talkative patient
when closing a session with a patient
when the patient makes several important yet distinct points
communicates interest and understanding
