1. MI, Complexity and Chaos
Ken Resnicow, PhD
University of Michigan
School of Public Health
Department of Pediatrics
Comprehensive Cancer Center
Center for Health Communications Research
Ann Arbor, MI
Kresnic@umich.edu
http://chcr.umich.edu

2. What do these concepts mean for MI ?
 Sudden/Unplanned Change
 Chaos Theory
 Energy and Depletion
 Autonomy Preferences
– MI not for everyone?
 Why to How transition
2

3. Newtonian Principles
Linearity— simple relationship between inputs and
outputs. Small inputs have small effects, large
inputs have large effects.
Reductionism— systems can be understood by breaking
them down into their component parts.
Determinism—a system can be predicted.
Rationalism---- Behavior can be formulated as the making
of a rational choices between alternative means of
achieving a known end. More information leads to
more rational choices.
Are these principles inherent to MI?

4. Transtheoretical Model: Stage of Change
(Prochaska)
Source: http://www.prochange.com/ttm

6. Implications for MI
 Sudden/Unplanned Change
 Chaos
 Energy and Depletion
 Autonomy Preferences
 Why to How
6

7. Random selection:
900 current smokers
800 ex-smokers quit > 4 weeks but < 10 years

8. Which of these statements best describes how your
most recent quit attempt started?
 I did not plan the quit attempt in advance, I just did it
 I planned the quit attempt for later the same day
 I planned the quit attempt the day beforehand
 I planned the quit attempt a few days beforehand
 I planned the quit attempt a few weeks beforehand
 I planned the quit attempt a few months beforehand

9.  UNPLANNED
I did not plan the quit attempt in advance, I just did it
 PLANNED
I planned the quit attempt for later the same day
I planned the quit attempt the day beforehand
I planned the quit attempt a few days beforehand
I planned the quit attempt a few weeks beforehand
I planned the quit attempt a few months beforehand

11. Odds of 6-month success

12. West, R. and T. Sohal (2006). "Catastrophic" pathways
to smoking cessation: findings from a national survey.
BMJ 332(7539): 458-60.

13. Sudden Gains: enduring reductions
in symptoms from one session to
the next.

15. Study Overview
 60 moderately-to-severely depressed adult
outpatients who scored at least 20 on the 17-item
modified HRSD.
 16 weeks of CT
 A full course of CT usually produces about 12–
15 points of improvements in mean BDI scores

16. Sudden Gains
 7 BDI points (Beck Depression Inventory), between
Session n and Session n+1, and
 At least 25% of the pre-gain session’s BDI score
(relative magnitude), and
 Difference between the mean BDI score of the three
sessions before the gain (n 2, n 1, and n) and the
three sessions after the gain (n 1, n 2, and n 3) was at
least 2.78 times greater than the pooled standard
deviations of these sessions’ BDI scores

17. Response & Relapse
 Responders: (a) 16-week HRSD <= 12 and either 14-week
HRSD <=14 or 10-week and 12-week HRSD < = 12 or (b)
12-, 14-, and 18-week HRSD < = 12.3
 Relapse: Responder (a) scored > = 14 on HRSD for 2
consecutive weeks or (b) met the diagnostic criteria for
major depressive disorder for 2 consecutive weeks.

18. RESULTS
 24 of the 60 patients (40%) experienced
sudden gains (SG) during treatment.
 8 patients experienced more than one
sudden gain.
 Sudden gains averaged 11 BDI points
 Median SG was Session 5.

19. RESULTS
35 Responders
Sudden Gain No Sudden Gain
19/24 16/36
(79%) (44%)

20. Non Relapse by Sudden-Gain Status
Responders only (n=35)
73%
34%

21. Quantum Change
Quantum Change: When Epiphanies and Sudden Insights Transform
Ordinary Lives. William R. Miller and Janet C’de Baca, 2001
“Quantum Change is a vivid, surprising, benevolent,
and enduring personal transformation. Some
quantum changes are insightful, an "aha!" that
leaves a person breathless and confident of a new
truth and a new way of thinking. Other quantum
changes are mystical, like Saint Paul’s on the road
to Damascus. Both kinds tend to impart a
mysterious and enduring sense of peacefulness.
Both mark the beginning of lasting and often
pervasive changes in a person’s life. Both usually
involve a significant alteration in how one perceives
other people, the world, oneself, and the
relationships among them. What differentiates the
mystical type is the sense of being acted upon by
something outside and greater than oneself. ”
21

22. “Buried in the statement “I just decided”,
however can be another kind of experience
that has been confused with ordinary
decision making…..When people talk about
such experiences….., they may say “it just
happened” or “I just decided”.
Inquire a little more closely, however, and it
becomes apparent that the process is
somewhat more complex.” (page37)
Quantum Change: When Epiphanies and Sudden Insights Transform
Ordinary Lives. William R. Miller and Janet C’de Baca, 2001

23. So what?
 Is sudden, unplanned change simply a
curiosity, or can we elicit “epiphany”
clinically?
23

24. Some new/other concepts to
incorporate into MI
 Sudden/Unplanned Change
 Chaos
 Energy and Depletion
 Autonomy Preferences
 Why to How
24

25. Chaotic and Complex Systems
 Sensitive to Initial Conditions
 Outcomes are non-random, but difficult to
predict
 Often non-linear pattern
 Exact patterns rarely repeat
 Greater than sum of their parts
 Multiple interactions

26. Chaotic and Complex Systems
 Sensitive to Initial Conditions
 Outcomes are non-random, but difficult to
predict
 Often non-linear pattern
 Exact patterns rarely repeat
 Greater than sum of their parts
 Multiple interactions

27. Sensitivity to Initial Conditions
Edward Lorenz accidental discovery, in 1961, through his work on
weather prediction.
Lorenz was running computer simulations to predict weather. He
wanted to repeat a prediction. To save time he started the simulation
in the middle. He did so by beginning in the middle of the run, using
output from the prior calculation.
To his surprise the weather predicted was completely different than the
weather calculated before.
He discovered that he had rounded some variables off to a 3-digit
number, but the computer originally worked with 5-digit numbers.
This tiny difference produced large changes in the long, complex
calculation which greatly altered the outcome.
We call this the BUTTERFLY EFFECT.

28. The Butterfly Effect
The flapping of a butterfly's wings in Malaysia can
create a tornado in Kansas.
The butterfly flapping its wings represents a "small"
change in the initial condition of the system which
causes a chain of events leading to large-scale
phenomena like tornadoes. Had the butterfly not
flapped its wings, the trajectory of the system might
have been vastly different.

30. Sensitivity to initial conditions
Person 2
Person 1
Success Failure

31. Chaos, Complexity, and
Behavior Change
 Behavior change is sensitive to initial conditions.
 Behavior change is highly variable and difficult to predict. (non-
deterministic).
 Behavior change is a complex dynamic system that involves multiple
component parts that interact.
 Behavior change is often a quantum leap rather than a gradual linear
event. (small input large output).
• Many health decisions are transformational, not rational. Knowledge necessary but
insufficient.
5) Motivation may be greater than the sum of it parts (non-reductionistic).
6) Chaos can be positive.

32. Healthy Variability (chaos)
Ary L. Goldberger. Proc Am Thorac . Vol 3. pp 467–472, 2006

33. A little Chaos is good/Correlated Variability
Too Little Optimal Too Much
CHF Healthy V-fib
Sleep
Gait
Epilepsy
Breathing
OCD
Behavior Change?
Grant Review?

34. Chaos and Complexity
Intervention and
Assessment Implications
Moderators
Mediators
Tailoring Variables

35. Chaos and Complexity
Intervention Implications
Moderators
Mediators
Tailoring Variables

36. Creating a Butterfly Effect
 We help create the atmospheric conditions for a
perfect storm, although it is outside our ability to
cause.
 MI provides opportunities for epiphanies and
sudden change.
– Directive interventions inhibit them.
 Jump in change talk.
– Motivational Orgasm.
 Accept linear change; strive for quantum change

37. Creating a Butterfly Effect
 Provide multiple opportunities for change
 Vary Initial Conditions……
– How you counsel
– When you counsel
 Client Mood
– Where you counsel
– What you recommend

38. Chaos and Complexity
Assessment Implications
Moderators
Mediators
Tailoring Variables

39. Assessing quantum vs.
planned change
How would you describe the process you used to change your (weight, eating,
exercise)?
1 2 3 4 5 6 7 8 9
10
I planned it I just did it
Intellectual Emotional
Weighed Pros and Cons Just Decided
Thought it through It just hit me

40. DESCISION-MAKING: TRAIT
When you make an important life decision, are you more likely to plan or to just do it?
PLAN JUST DO IT
When you make an important life decision, are you more likely to weigh the pros and
cons or to just decide?
WEIGH THE PROS AND CONS JUST DECIDE
When you make an important life decision, are you more likely to think it through or to
just let it hit you?
THINK IT THROUGH LET IT HIT YOU

41. Some new/other concepts to
incorporate into MI
 Sudden/Unplanned Change
 Chaos
 Energy and Depletion
 Autonomy Preferences
– MI not for everyone?
 Why to How
41

42. WHEN MI MAY NOT BE THE
PREFERRED METHOD
State:
 Fully motivated clients
 Some clinical situations warrant a more directive style, e.g.,
acute conditions, recent Dx
Trait:
 Some individuals prefer a directive style
42

45. WHEN MI MAY NOT BE THE
PREFERRED METHOD
State:
 Fully motivated clients
 Some clinical situations warrant a more directive style, e.g.,
acute conditions, recent Dx
Trait:
 Some individuals prefer a directive style
45

46. Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision
making. A national study of public preferences. J Gen Intern Med 2005;20(6):531-5.

47. Methods:
US Population-based survey of adults conducted in
In 2002 General Social Survey (N = 2,765).
GSS conducted by the National Opinion Research
Center (NORC).
Largest sociology project funded since 1973 by the
National Science Foundation.
In-home interview, 90 minutes

48. Methods:
Respondents rated preferences ranging from patient-
directed to physician directed styles on each of 3
aspects of decision making:
1) seeking information
2) discussing options
3) making the final decision

49. ITEMS
‘‘I prefer to rely on my doctor’s knowledge and not try to find out
about my condition on my own’’ (Knowledge)
‘‘I prefer that my doctor offers me choices and asks my opinion’’
(Options) ITEM REVERSE CODED FOR MULTIVARIATE
‘‘I prefer to leave decisions about my medical care up to my doctor’’
(Decision).
Responses: 6-point scale ranging from ‘‘strongly agree’’ (l) to ‘‘strongly
disagree’’ (6).

50. Results:

51. • HIGHER SCORES = HIGHER PATIENT CENTERED
PREFERENCE

52. PATIENT COMMUNICATION
PREFERENCES
See Also
• Miller S, Khensani N, Beech B. Perceptions of Physical Activity and
Motivational Interviewing Among Rural African-American Women
with Type 2 Diabetes. Women's health issues 2009: 1–7.
• Miller ST, Beech BM. Rural healthcare providers question the
practicality of motivational interviewing and report varied physical
activity counseling experience. Patient Education and Counseling
2009;76(2):279-282.

53. The role of AUTONOMY in patient counseling
High State/
Trait
Need
Autonomy Autonomy
Support Style Support Style
Acute Condition Chronic Condition
More
Directive Style Autonomy
Support Style
Low
State/Trait
Need
Low State need, e.g., high arousal, anxiety or fear state or recent diagnosis
Low Trait need, e.g., preference for expert recommendation, personality-culture

54. Some new/other concepts to
incorporate into MI
 Sudden/Unplanned Change
 Chaos
 Energy and Depletion
 Autonomy Preferences
– MI not for everyone?
 Why to How
54

55. There is no improvement, Henry. Are
you sure you’ve given up everything
you enjoy?
55

56. Depletion: Self-Regulation as Limited
Resource
• Self-regulation requires energy
• A single, domain-general resource from which
individuals draw every time they exert self-
control (Muraven et al., 1998)
• Ego-depletion: Each exertion can affect
subsequent self-regulation
• Resisting temptations, delaying gratification,
monitoring impressions, controlling emotion

57. Depletion:
Self-Regulation as Limited Resource
• Meta-analysis of 83 studies
• Significant ego depletion effects:
– Task performance, effort, perceived difficulty,
subjective fatigue, & blood glucose levels
• Moderators of ego depletion effects:
– Task duration & complexity
– Motivation & self-control training
(Hagger, Wood, Stiff, & Chatzisarantis, 2010)

58. RESISTANCE ENERGY CONSERVATION DREAD
DEPLETION
58

59. Some new/other concepts to
incorporate into MI
 Sudden/Unplanned Change
 Chaos
 Energy and Depletion
 Autonomy Preferences
– MI not for everyone?
 Why to How
59

60. MOVING FROM WHY TO HOW
AUTONOMY SUPPORTIVE CHOOSING
WHY Change HOW to Change
MI Background Platform
MI Primary Modality
Building Motivation Building an Action Plan
Self-Monitoring
Shaping
Contract
Contingency Management
Cognitive Restructuring
60

61. Build Discrepancy
Listening
Advising
Informing
Asking
Explore Guide
Choose
Understanding Deciding
Acting
61

62. Explore
Choose
Guide
62

63. 4 Processes
1-Engage
2-Guide
3-Evoke
4-Plan
63

64. Build Discrepancy
Listening
Advising
Informing
Asking
Explore Guide Choose
Understanding Deciding Acting
1-Engage 2-Guide 3-Evoke 4-Plan

65. Three Phases of Consultation
 Explore (WHAT/WHY/WHY NOT)
– COMFORT THE AFFLICTED
– Build Initial rapport & Express Empathy
– Drain the swamp of negativity
– Obtain a history
– Collaborative agenda setting
– Explore pros, cons, hopes and fears (Reasons)
 Guide (IF)
– AFFLICT THE COMFORTBLE
– Build Motivation & Discrepancy
– Elicit change talk
• 0-10 Readiness Rulers
• Importance (Reasons/Desire/Need)
• Confidence (Ability)
• Values Clarification (Desire & Need)
– SPIN THE BALLS
• Where does that leave you?
– Obtain COMMITMENT
– Move toward a behavior decision
 Choose (if a decision/commitment has been made) (WHEN/HOW)
– Taking STEPS
– Establish a Goal
– Provide Menu of Options
– Set an Action Plan
– Overcome/anticipate barriers
– Make a contract & Discuss follow up
65

66. Autonomy Supportive Choosing
 Action Reflections
 Elicit-Provide-Elicit
 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
66
– Contingencies

67. Action Reflections
• Imbed Solutions to Barriers
• Imbed Action Plans
• Undersell
– You might want to…
– You might want to consider…
– Sounds like…..might be an option…
– If we are to move forward you might want to
address….
67

68. Action Reflections:
Soft Sell CBT
• 1) Invert Barrier
– Sounds like we might want to address barrier a,b,c
• 2) General Behavior Fix
– Sounds like doing something like x,y,z
• 3) Specific Behavior Fix
– Sounds like doing x may be a possibility
• 4) Cognitive Fix
– Sounds like you may have to think about x differently
(make peace, no all or nothing thinking, giving credit)
EXTENSION OF REFLECTING ON DARN CAT (Taking Steps)
68

69. Action Reflections
69

70. E-P-E
 Elicit
– What is your understanding of?
– What have you heard about?
– What do you want to know?
– What’s the most important thing you want to know about?
 REFLECT AND AFFIRM THEIR KNOWLEDGE
 ASK PERMISSION TO PROVIDE
 GIVE CHOICE ABOUT WHAT AND HOW
 Provide
– Information
– Advice
“Some of what I say may differ from what you have heard?”
 Elicit
– What do you make of that?
– Where does that leave you?
– How does that compare to what you previously thought/heard?
70

71. E-P-E
 Is this normal ?
 Can I xxx?
71

72. PAD
54 year old female with PAD, diabetes mellitus,
hypertension, and difficulty walking.
“I used to walk to the park with my nephews, but
now I avoid walking more than a block
because of the cramping in my right calf. I
miss spending time with them. But I’m worried
that the pain will make my leg worse. Is that
true? ”
E-P-E 72

73. A 12 year old went to WIC clinic, she
was asked about breastfeeding and
answered,
 “Can I? I heard teenagers can’t
breastfeed.”
E-P-E

74.  “Moms should stop
breastfeeding around 6 Months,
because breast milk is not good any
longer.”
E-P-E

75. EPIPHANY ANYONE ?
75

76. The RANDOM WALK

77. Random Walk
 Stock prices (Health Behaviors)
tend to follow a random walk, i.e,
the best forecast of tomorrow’s
price (Behavior) is today’s price
(Behavior/Intention) plus a random
component (Our Interventions)

79. METHODS
Overweight adults (N=104) were randomly assigned to nondirective, directive, or
minimal support.
All received weekly lessons and feedback graphs via email.
Participants in the nondirective and directive support conditions received individualized
nondirective or directive weight loss support.
Participants attended an in-person baseline assessment, completed on-line
assessments at 4 and 8 weeks, and attended an in-person 12-week follow-up
assessment