In This Issue:
BHWP Spotlight
A Study in Wellness
Wellness in Practice:
BHWP Spotlight
With our upcoming Advanced Motivational Interviewing (MI) training in the summer, the time seems right to dedicate this quarterly newsletter to how we think about and utilize our MI skill-sets. At the Behavioral Health & Wellness Program, we believe in a parallel process of behavior change for providers as well as among the individuals with whom we work. Motivational Interviewing can often be empty buzz words in much the same way “wellness” is a popular, often questionably operationalized term. But when I truly practice MI, it is a cornerstone of my professional development. A renewed attention to the fundamentals of MI assists tremendously to quiet my mind, be in the moment, sharpen focus on the journey to the healthy change I hope to reach in my own internal conversation and in my conversations with others. Unlike many therapeutic or medical interventions, the risk-benefit analysis is clear. A non-judgmental evaluation of self may suggest contradictions in thoughts and behaviors as well as a path toward meaning, belonging, and acceptance. In this newsletter, we celebrate the diversity of authentic life journeys.
Registration is open for two upcoming BHWP Trainings!
Click below to learn more.
Motivational Interviewing for Behavior Change – Level II: July 31 – August 1, 2018
Rocky Mountain Tobacco Treatment Specialist Training Program: October 15 – 18, 2018
A Study in Wellness
Motivational Interviewing
In the fall of 2016, I had the honor of traveling to the pink and purple desert land of Albuquerque, NM to take an advanced training course in Motivational Interviewing (MI) with none other than Dr. William R. Miller. Bill Miller’s trainings are a blend of graduate school in psychology, counseling workshop, spiritual retreat, and music camp. Yes, music camp. On the second day of training, Bill took out his guitar, donned his cowboy hat, and sang a 6-verse song about behavior change interspersed with puns and humor. Bill is a philosopher, an analyst, a humanist, a gentle soul and has succeeded in improving the lives of millions of people.
Initially, Bill Miller helped clients address their alcohol use. Some 30 years ago, the traditional approach to substance use was “confrontation of denial.” Denial of addiction was seen as a personality trait to confront with arguments and corrections. Clients were labeled “alcoholics” and told they had a disease and were helpless over it. This left people feeling devoid of personal choice and agency over their behaviors.
Rather than confronting denial, Bill simply had conversations with his clients about their alcohol use. He emphasized personal choice and control regarding behaviors and solicited clients’ own concerns about their decisions. He used his philosophical, analytical, humanistic approach with his clients and started seeing individuals change.
Bill simply being Bill is one way of explaining how and why MI works, but for all the scientists reading this article, this explanation is lacking data. Bill’s first written description of MI was in 1983 in the British journal, Behavioural Psychotherapy.1 The article was solicited by his friend, Ray J. Hodgson, PhD, who thought the depiction of MI would be of use to clinicians. For those interested, Dr. Hodgson’s letter to Bill is published in the MINT Bulletin along with Bill’s original MI manuscript written on an IBM Selectric typewriter.2
Since then, Bill Miller and Stephen Rollnick, PhD went on to develop the practice of Motivational Interviewing. Several meta-analyses have shown MI to be an effective intervention for producing changes in both maladaptive behaviors
(e.g., alcohol and drug use, gambling, smoking) as well as adaptive ones (e.g., exercise, diet, medication adherence, diabetes management).3 Not only is MI effective, but it is flexible and demonstrates favorable outcomes in behavior change in a variety of formats.4 MI can be delivered in one or multiple sessions, as a stand-alone intervention, or in conjunction with other therapies (e.g., cognitive behavioral therapy),3 and depending on the amount of time healthcare providers are able to spend with individuals, MI can be delivered during brief encounters or longer full-length sessions. Research has shown that a variety of healthcare providers were able to learn and implement MI with their patients and clients resulting in behavior change that endured post-treatment.5-8
We know MI works, but researchers are only starting to examine how. The theoretical model of MI, first proposed by Bill Miller and his colleague, Dr. Gary Rose, in 2009, involves two active components, relational and technical, that lead to client behavior change.9 Therapist global relational skills such as empathy and exhibiting the spirit of MI, including partnership, acceptance, compassion, and evocation, as well as therapist specific technical behaviors that evoke and reinforce client change talk both influence client behavior change and, thus, client outcomes. The theory involves an interplay of both therapist and client behaviors. Therapists engage with clients in a non-confrontational manner that supports autonomy and personal choice rather than forcing change. In turn, clients feel more comfortable to explore ambivalence about change and formulate their own reasons, desires, needs and commitment to change. Collectively, this client language that indicates movement toward behavior change is called change talk. Change talk is the variable that predicts actual behavior change.3
Meta-analytic research has demonstrated support for Miller and Rose’s theory. Therapists who are more empathetic and encompass the MI spirit also use more reflections, affirmations, and open-ended questions which leads to more client change talk.3,10-11 When further examining the mechanisms, a higher ratio of reflections to questions and use of affirmations led to positive client outcomes more consistently in the research.3 In particular, change talk involving ability language, or confidence in their capability to change, more regularly predicted actual behavioral change.3
While we are still exploring exactly how the processes involved in MI lead to client behavior change, we know that both the relational and technical aspects of the MI approach are essential. And given the right support, people have the ability to make healthful choices. This is the leverage point for healthcare providers to make a real difference and cultivate a supportive environment in which people feel comfortable enough to explore change talk. While MI is a valuable and effective skill, it is experiential and takes time to learn, usually via multi-day workshops, practice, and informal or formal coaching. We invite you to seek such opportunities and become part of a legacy that improves the lives of millions.
References:
- Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11, 147–172.
- Miller, W. R. (2008). The first description of Motivational Interviewing. MINT Bulletin, 14(2), 1-38.
- Romano, M. & Peters, L. (2016). Understanding the process of motivational interviewing: A review of the relational and technical hypotheses. Psychotherapy Research, 26(2), 220-240.
- Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
- Miller, W., Yahne, C., Moyers, T., Martinez., J., & Pirritano, M. A. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72(6), 1050-1062.
- Keeley, R., Brody, D., & Burke, B. (2012). Cluster-randomized trial of teaching primary care clinicians motivational interviewing to improve depression treatment. Anschutz Medical Campus, Aurora, Colorado, USA. University of Colorado (Unpublished manuscript).
- Lundahl B., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20, 137-160.
- Lundahl, B. & Burke, B. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245.
- Miller, W. R. & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527-537.
- Magill, M., Gaume, J., Apodaca, T. R., Walthers, J., Mastroleo, N. R., Borsari, B., & Longabaugh, R. (2014). The technical hypothesis of motivational interviewing: A meta-analysis of MI’s key causal model. Journal of Consulting and Clinical Psychology, 82(6), 973-83.
- Pace, B. T., Dembe, A., Soma, C. S., Baldwin, S. A., Atkins, D. C., & Imel, Z. E. (2017). A multivariate meta-analysis of motivational interviewing process and outcome. Psychology of Addictive Behaviors, 31(5), 524-533.
Wellness in Practice
Awake!
I often hear from my clients, “I want to change ________ (fill in the blank).” The blank can be filled in with any number of behaviors – health and lifestyle, relationship, communication, professional development, self-care, among others. Whether the person feels a strong desire for change or is ambivalent, the fear, uncertainty, and unknown around change can be immobilizing. To an outsider looking in, this can look like apathy and a lack of motivation or even resistance and opposition. However, through experience, I know that what is going on inside a person can be very different from how they appear to others.
For healthcare providers with limited resources, especially time, it can seem easier to tell people what to do rather than elicit what motivates them, looking beyond the presenting problem. You may want to say—”It is so simple, just go do it.” Whatever it may be. But then it doesn’t get done. 
What we know is most people don’t work that way. For some individuals, they can easily set a plan and achieve it. For many others, it takes focus, guidance, and exploration of values, beliefs, and desire to elicit the motivation to change their behavior.
This is why the practice of Motivational Interviewing (MI) is so powerful. When you take away advice-giving and problem-solving, which is typically talking at someone rather than with someone, we open a creative space in which we more clearly see a person who wants to change. Through simple and complex reflections, people gain a new perspective about themselves, evoking meaning in their experience while feeling seen and heard by the listener. Thoughtful open-ended questions demonstrate curiosity and often elicit unanticipated responses. Affirmations recognize and acknowledge an individual’s strengths and communicate an approach of unconditional positive regard. While summaries organize the conversation, creating focus and movement towards transition and closure.
It is not an overstatement to say that working from a MI approach completely transforms our conversations about change. What may once have been an uphill battle or an impasse becomes a dynamic flow of ideas and information. More gets accomplished in a shorter amount of time. There are few missed opportunities and misunderstandings. Everyone leaves the conversation feeling energized and excited about what is to come. As a MI practitioner, I am privileged to witness the transformation a simple conversation style can evoke. Not only do people achieve the goals they set for themselves, we are both transformed by our co-created experience. Something I hold sacred and honor with a deep sense of appreciation.
In the Flow
I completed my first MI training in 1995, and, like many newly trained MI practitioners, my first goal was to temper my “righting reflex” or that burning desire to correct my client’s “wrong thinking” with education and persuasion and replace it with a stance of expectancy. A few days after the training, I had the opportunity to try this new approach. I found myself counseling Becca (not her real name), a young breast cancer patient. Like me, Becca was in her 30’s, a writer, and the mother of an adolescent. I learned from her that she had recently been diagnosed with high grade, stage III breast cancer and was refusing conventional medical treatment. She was amazingly resolute in her conviction. The words, “poison, toxic, and deadly,” scurried off her tongue in what sounded like a well-practiced and comfortable monologue.
Although I honestly attempted to be curious, within minutes, my righting reflex was fully activated. I found myself thinking of all the reasons why Becca needed to pursue treatment accompanied by my certainty of illness progression and death if she did not. My judgment arose in part from my knowledge of the aggressive nature of breast cancer in younger women and my belief in evidence-based cancer treatment, but it was also energized by my identification with Becca. In fact, when I looked at her, it was hard to not see myself, my eleven-year-old son, and my own mortality.
I was less than gentle in my persuasion and I most definitely tried to convince her to take an alternate path. However, my righting reflex did not open Becca’s mind to the possibility of conventional treatment. It only caused her to further dig in her heels and argue fervently against my ideas. She told me that she had watched her mother suffer through chemotherapy and radiation only to die and that she would not walk in her mother’s shoes. I empathized and affirmed but then I proceeded to inform Becca of major breakthroughs and improvements to conventional treatments, and the blending of complementary and traditional western medicine in new models of integrative cancer care. I talked about genetic tests that could assist in treatment decisions and also benefit her daughter down the line. I talked passionately and profusely. By the end, I was exhausted, and Becca was gone.
A couple of years later, I crossed paths with Becca at a local Breast Cancer Survivor event. I was amazed that she remembered me from our one counseling session and was even more surprised that she recalled our conversation kindly. She thanked me for telling her about the new genetic tests. She had undergone testing and was found to be positive for two genetic mutations. This allowed her to provide guidance to her daughter in early monitoring, healthy lifestyle, and cancer prevention. She also told me that she had eventually decided to have a double mastectomy, primarily to ease the symptoms of growing tumors in both breasts, but by then the cancer had further spread to her bones. She was doing well though, teaching yoga, and feeling thankful for each good day spent with her daughter. “My daughter’s story will be very different from mom’s and, hopefully, from mine as well,” she said. “It’s a story filled with possibility and one with a fresh new ending.”
My encounters with Becca and the veracity of my judgement at our first meeting brings to mind the classic Taoist story of a farmer as told here by the philosopher, Allen Watts.
There was a farmer whose horse ran away. That evening the neighbors gathered to commiserate with him since this was such bad luck. He said, “Maybe.” The next day the horse returned, but brought with it six wild horses, and the neighbors came exclaiming at his good fortune. He said, “Maybe.” And then, the following day, his son tried to saddle and ride one of the wild horses, was thrown, and broke his leg. Again, the neighbors came to offer their sympathy for the misfortune. He said, “Maybe.” The day after that, conscription officers came to the village to seize young men for the army, but because of the broken leg the farmer’s son was rejected. When the neighbors came in to say how fortunately everything had turned out, he said, “Maybe.”
Would Becca have lived longer or better had she followed a more conventional course of cancer treatment? Maybe. Would she have suffered through harsh treatments only to die like her mother? Maybe. Did things unfold for Becca as they did so that her daughter and those who follow might carry a story of promise and hope? Maybe.
It can be humbling and liberating to recognize that often we don’t know whether a decision or a path is the right one and it can even be a relief to let go of our judgements periodically. I thought I understood how to recognize and soften my righting reflex at the end of my first MI training, but I didn’t. Real learning, deep learning, comes from experience and teachers like Becca.