Workshop powerpoints on MI in Neuropsychology presented in Tasmania for the Australian Neuropsychological Society.

1. Motivational Interviewing in
Neuropsychology
Basic Principles and Methods
November 23, 2012 – 1:30pm – 5:00pm
Tad Gorske, Ph.D.
Clinical Assistant Professor
Director, Outpatient Neuropsychology
Division of Neuropsychology and Rehabilitation Psychology
University of Pittsburgh School of Medicine, Pittsburgh Pennsylvania, USA

6. The Challenge of Change
 42 year old male who suffers a TBI after an ATV accident
where he is intoxicated. Makes a reasonably good
recovery. History of extensive alcohol use. 6 months after
inpatient TBI rehab has resumed drinking.
 24 year old female, mild concussion, having PCS
symptoms one year later. Significant psychiatric history but
doesn’t believe symptoms are related.
 56 year old male, suffers a stroke, continues to have mild
to moderate cognitive deficits that are likely permanent.
Doesn’t see need to reduce workload at a high stress, fast
paced profession.

7. The Challenge of Change
 Community based rehabilitation is an effective
strategy for increasing opportunities for people
with disabilities to maximize their physical and
mental functioning (World Health Organization).
 However, the benefits that might be accrued are
all too often disrupted by individuals’ lack of
participation in the rehabilitation process
(Lequerica et al., 2006)

8. Motivation – Whose Job is it?
 The unmotivated client:
– “When the client’s goals do not match those of
the counselor” (Lane and Barry, 1970).
– Others may hinder independence by
inadvertently reinforcing dependence over self
reliance (Wright, 1980).

9. 3 Key elements underlying client motivation
(Roessler, 1980/89):
1. The client’s perception of the value of the
outcome of a change plan, including both benefits
and costs;
2. The client’s perception of the probability of
achieving a successful outcome;
3. The presence of environmental barriers and
supports that inhibit or promote change.

10. Importance of Working Alliance
 There are strong links between patient-
therapist collaboration and goal consensus
in psychotherapy outcomes (Shick Tryon
and Winograd, 2011).
 Working alliance and collaboration in
rehabilitation is viewed as important but less
well studied.

11. Working Alliance in Rehabilitation
 A positive relationship between working
alliance and outcomes has been found.
Working alliance defined as
 (a) the agreement between client and therapist on
goals,
 (b) their agreement on how to achieve these goals
(common work on tasks) and,
 (c) the development of a personal bond between
client and therapist. (Shönberger et al. 2006).

12. Working Alliance in Rehabilitation
 A good working alliance can be created with both
clients who experience many problems and clients
who experience comparatively few problems, as
long as they are aware of the consequences of
their brain injury.
 Therapist’s experience of a good working alliance
was influenced by the client’s experience of
success. (Shönberger, et al., 2006).

13. Working Alliance in Rehabilitation
 Clients’ and therapists’ overall success ratings at
program end were related to their emotional bond
at program end.
 Early-therapy compliance and the average amount
of compliance are predictive of subjective
improvement. (Shönberger, et al., 2006).

14. Working Alliance: Some evidence
Bieman-Copelan and Dywan (2000). Brain and
Cognition, 44, 1-5.
 Behavioral therapy in context of a
supportive/collaborative therapeutic alliance for
anosognosia.
 Collaborative negotiation and trusting therapeutic
relationship for behavioral goal setting.
 Results indicated a significant reduction in
problematic behaviors despite no increase in
insight or awareness of injury.

15. Pegg et al., 2005
 Evaluated the role of interpersonal relationship factors on
patient outcomes with 28 patients with moderate to severe
TBI admitted to an inpatient unit at a VAMC.
 Personalized information-provision intervention.
 Results:
– Patients exerted greater effort in therapies
– Patients increased satisfaction with rehabilitation
treatment.
– Significantly more improvement in cognitive FIM scores.

16. Interdisciplinary team working
alliance (Evans, et al., 2008).
 Importance of therapeutic alliance in post acute brain injury
rehabilitation (PABIR).
 Sherer et al., 2007 - poor working alliance was associated
with high levels of family discord, greater discrepancy
between family and clinician ratings of client functioning,
and poor client participation in therapies.
 Treatment team members attended in-services that
emphasized motivational interviewing philosophy and
techniques, building rapport, reflective listening, dealing
with patient resistance, making behavioral changes, stages
of change, dealing with challenging clients, and
assessment and treatment issues with depressed and/or
suicidal patients (pg. 332).

17. Interdisciplinary team working
alliance (Evans, et al., 2008).
 Treatment group had higher functional status and were
more productive and had less dropouts, although the
differences were not statistically significant.

18. Lane-Brown and Tate, 2010.
 Single case study that evaluated an
intervention utilizing external
compensation and motivational
interviewing to initiate and sustain goal
directed activity with a TBI patient.
 Demonstrated that treating specific and
operationally defined goals through
external compensation and motivational
interviewing successfully decreased
apathy.

19. Health Behavior Change (HBC)
Model
 A method of dialogue based on Motivational
Interviewing Principles to enhance clients
internal motivation for change versus trying
to persuade them to change.

20. Behavior Change: Whose
Problem Is It?

21.  The outcome of a consultation can be
affected by providers consulting behavior.
 Behavior change, or lack of it, is not just a
patient problem.
 Practitioner style can make matters better
or worse.
– (Rollnick, Mason, and Butler, 1999).

22. Foundations of HBC Model

23. Motivational Interviewing
 Counseling style (Miller, 1983)
– Client-centered, directive method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence.
 An evolution of the client centered
approach.
 Intentionally resolves ambivalence in the
direction of change.

24. Four Motivational Interviewing
Principles
1. Express Empathy
2. Develop Discrepancy
3. Roll with Resistance
4. Support Self Efficacy

25. What Motivates Change?
 Interpersonal Style
 Readiness, willingness, ability
 Intrinsic versus extrinsic factors
 Change Talk
 Commitment Language

26. Change Talk
 Categories of Change Talk
– Desire: “I want to…”
– Ability: “I can..”
– Reason: “There are good reasons for me to..”
– Need: “I really need to…”
– Commitment: “I am going to…”

27. How MI theoretically works
1. MI approach leads to;
2. An increase in Desire, Ability, Reason,
Need, which leads to;
3. An increased intensity of commitment
which leads to;
4. Behavior Change

28. Core Communication Skills
1. Open Ended Questions
2. Affirmations
3. Reflective Listening
4. Summarizing

30. Maintaining a Patient Centered
Approach
 Active – Reflective listening
 Encourage an expression of concerns
 Allow them to articulate what they need
 All them greater control over decision
making
 Reach joint decisions

31. What is (The Spirit) of HBC
 Collaboration: Two parties working
together, listening, responding, progressing,
and cooperating toward a common goal.
 Coercion: Using force to cause
something to occur; trying to persuade
through debate or to have their points be
heard

32. The likelihood of change is highly
influenced by interpersonal interactions
Empathic Style Less Empathic Style
An increased likelihood Decreased likelihood
of change of change

33. Collaborative Agenda Setting
 Presenting agenda setting chart;
 Transition to focus on problem areas
 Raising clinician concerns
 Summarize outcome – next step(s)

34. Agenda Setting Chart

35. Single vs Multiple Behaviors
 Elicit – Personal views and feelings about
factors related to illness/injury/recovery;
– “ie. You are about 4 months out of your traumatic brain
injury, what are your major concerns about ongoing
recovery?”
 Provide – Information about what is known
about the issue presented
– ie. “What we know is that most recovery happens in the
first year to 18 months. There is no good way to predict
what type of recovery will be made but there are some
things that can help or hinder one’s recovery.”

36. Single vs Multiple Behaviors
 Elicit – Patient reactions to the information
given .
– ie. “How to you feel about your recovery so far and what
things have been positive versus what has not gone so
well?”

37. Readiness
 Stages of Change
– Precontemplation
– Contemplation
– Preparation
– Action
– Maintenance

38. Readiness on a continuum

39. Readiness
IMPORTANCE CONFIDENCE
Why should I change? How will I do it?
Exploration of personal Explorations of self
values and expectations efficacy.
about the importance of
change.

40. Strategy
1. Identify behavior to discuss (Agenda
setting, prioritize, identify behavior);
2. Assess readiness to change behavior;
a) Introduce readiness ruler (formal or informal);
b) Use OARS to clarify stage of change, level of
readiness;
c) Identify and explore issues of
importance/confidence.

41. Exploring Importance/Confidence
 Introducing the Discussion
“I‟m not really sure exactly how you feel about
____________________. Can you help me by answering two simple
questions, and then we can see where to go from there?”
 Assessing Importance and Confidence
 “How do you feel right now about _______________________? How
important is it to you personally to ________________________? If 0
was „not important at all‟ and 10 „very important‟, what number would
you give yourself?”
 “If you decided right now to _____________________, how confident
do you feel that you would succeed? If 0 was „not at all confident‟ and
10 was „very confident‟, what number would you give yourself?”
 Summarize the answers

42. Exploring Importance/Confidence
 Selecting the Focus
 If importance is low (<5), focus on importance first
 If both are about the same, focus on importance first
 If one number is distinctly lower than the other, focus on the lower
number first
 If both are very low (<3), explore feelings about participating in
discussion of the issue (‘all of this’)

43. EXAMINING PROS AND CONS

44. The Dilemma of Ambivalence
 Most people are
ambivalent about
making changes.
 Ambivalence is normal
but is typically seen as
pathological
 Exploring and resolving
ambivalence is the core
of MI and HBC.

45. Examine Pros and Cons
No Change Change
Costs Costs
Benefits Benefits

46. Examine Pros and Cons
1. Introduce the strategy: Ask the patient;
2. Review pros and cons of the behavior
usually beginning with the side that
supports the status quo (no change);
3. Throughout the interview use client
centered/directive strategies, ie. OARS.
4. Summarize and look ahead to the next
step.

47. Evocative Questions
 Problem recognition
 Concern
 Intention
 Optimism

48. Information Exchange
 Step 1:
– Ask “does the patient want or need
information?”
– Distinguish between fact and personal opinion.
– Present information in a neutral manner.
 Step 2:
– Elicit – Readiness and interest in information;
– Provide - Feedback in a neutral manner;
– Elicit – Patient reactions and interpretations of
information.

49. Information Exchange
 Step 3: Review and summarize.
 Step 4: Ask about the next step.

50. Resistance in HBC Model

51. Rolling with Resistance
 Resistance is not met head on or
challenged directly.
 Resistance met with empathy and
understanding where alternative viewpoints
are invited but not imposed.

53. True Victory is Victory Over Oneself
One must first learn to control oneself
before attempting to harmonize and
control others.
Seidokan Aikido World Headquarters

54. Change/Resistance
 Causes of Resistance:
– Patient brings conflict into the session;
– Practitioner elicits it;
– Combination of the two

55. Three Traps/Three Strategies
Traps Strategy
 Take control away  Emphasize personal
choice and control
 Misjudge  Assess
importance/confidence readiness/importance/
/readiness confidence
 Meet force with force  Back off – come
alongside

56. Negotiating a Change Plan
 Setting Goals
 Considering Change Options
 Arriving at a Plan
 Eliciting Commitment

57. “The commitment to a change plan completes the
formal cycle of motivational interviewing.
Sometimes people proceed with change on their
own from here. It can also work well, however, to
transition from this initial motivational consultation
into action-focused counseling if the person so
chooses….MI can be used to facilitate change
throughout the process of counseling.
Ambivalence…rarely disappears on the first step
of a journey.” (Miller and Rollnick, 2002, p.139)

58.  My thanks to all the participants, Dr. Fiona
Bardenhagen and the Australian
Psychological Society for inviting me to your
conference.
My contact information
Tad T. Gorske, Ph.D
Clinical Assistant Professor
Division of Neuropsychology and Rehabilitation Psychology
UPMC Mercy
1400 Locust Street, Suite G138
Pittsburgh, PA USA 15219
Gorskett@upmc. edu