Motivational Interviewing: moving from why to how with autonomy support

Motivational Interviewing (MI), a counseling style initially used to treat addictions, increasingly has been used in health care and public health settings. This manuscript provides an overview of MI, including its theoretical origins and core clinical strategies. We also address similarities and differences with Self-Determination Theory. MI has been defined as person-centered method of guiding to elicit and strengthen personal motivation for change. Core clinical strategies include, e.g., reflective listening and eliciting change talk. MI encourages individuals to work through their ambivalence about behavior change and to explore discrepancy between their current behavior and broader life goals and values. A key challenge for MI practitioners is deciding when and how to transition from building motivation to the goal setting and planning phases of counseling. To address this, we present a new three-phase model that provides a framework for moving from WHY to HOW; from building motivation to more action oriented counseling, within a patient centered framework

Toward systematic integration between self-determination theory and motivational interviewing as examples of top-down and bottom-up intervention development: autonomy or volition as a fundamental theoretical principle

Clinical interventions can be developed through two distinct pathways. In the first, which we call top-down, a well-articulated theory drives the development of the intervention, whereas in the case of a bottom-up approach, clinical experience, more so than a dedicated theoretical perspective, drives the intervention. Using this dialectic, this paper discusses Self-Determination Theory (SDT) [1,2] and Motivational Interviewing (MI) [3] as prototypical examples of a top-down and bottom-up approaches, respectively. We sketch the different starting points, foci and developmental processes of SDT and MI, but equally note the complementary character and the potential for systematic integration between both approaches. Nevertheless, for a deeper integration to take place, we contend that MI researchers might want to embrace autonomy as a fundamental basic process underlying therapeutic change and we discuss the advantages of doing so

A chaotic view of behavior change: a quantum leap for health promotion

Background: The study of health behavior change, including nutrition and physical activity behaviors, has been rooted in a cognitive-rational paradigm. Change is conceptualized as a linear, deterministic process where individuals weigh pros and cons, and at the point at which the benefits outweigh the cost change occurs. Consistent with this paradigm, the associated statistical models have almost exclusively assumed a linear relationship between psychosocial predictors and behavior. Such a perspective however, fails to account for non-linear, quantum influences on human thought and action. Consider why after years of false starts and failed attempts, a person succeeds at increasing their physical activity, eating healthier or losing weight. Or, why after years of success a person relapses. This paper discusses a competing view of health behavior change that was presented at the 2006 annual ISBNPA meeting in Boston. Discussion: Rather than viewing behavior change from a linear perspective it can be viewed as a quantum event that can be understood through the lens of Chaos Theory and Complex Dynamic Systems. Key principles of Chaos Theory and Complex Dynamic Systems relevant to understanding health behavior change include: 1) Chaotic systems can be mathematically modeled but are nearly impossible to predict; 2) Chaotic systems are sensitive to initial conditions; 3) Complex Systems involve multiple component parts that interact in a nonlinear fashion; and 4) The results of Complex Systems are often greater than the sum of their parts. Accordingly, small changes in knowledge, attitude, efficacy, etc may dramatically alter motivation and behavioral outcomes. And the interaction of such variables can yield almost infinite potential patterns of motivation and behavior change. In the linear paradigm unaccounted for variance is generally relegated to the catch all "error" term, when in fact such "error" may represent the chaotic component of the process. The linear and chaotic paradigms are however, not mutually exclusive, as behavior change may include both chaotic and cognitive processes. Studies of addiction suggest that many decisions to change are quantum rather than planned events; motivation arrives as opposed to being planned. Moreover, changes made through quantum processes appear more enduring than those that involve more rational, planned processes. How such processes may apply to nutrition and physical activity behavior and related interventions merits examination

Pilot Trial of an Emergency Department–based Intervention to Promote Child Passenger Safety Best Practices

BackgroundDespite demonstrated effectiveness of child restraint systems (CRSs), use remains suboptimal. In this randomized pilot trial, we sought to determine the feasibility, acceptability, and potential efficacy of “Tiny Cargo, Big Deal” an ED‐based intervention to promote guideline‐concordant size‐appropriate CRS use.MethodsParents of children < 11 years old were recruited in two EDs and randomized in a 2 × 2 factorial design to four conditions: 1) generic information sheet, 2) tailored brochure mailed after the ED visit, 3) a single motivational interviewing‐based counseling session in the ED, and 4) full intervention (counseling session plus tailored brochure). We assessed feasibility (recruitment, completion, follow‐up rates) and acceptability (parent attitudes, uptake of information) in the ED, at 1 month and at 6 months. We obtained preliminary estimates of effect sizes of the intervention components on appropriate CRS use at 6‐month follow‐up.ResultsOf the 514 parents assessed for eligibility, 456 met inclusion criteria and 347 consented to participate. Enrolled parents were mostly mothers (88.1%); 48.7% were 18 to 29 years old; 52.5% were non‐Hispanic, white; and 65.2% reported size‐appropriate CRS use. Completion rates were 97.7% for baseline survey, 81.6% for counseling, 51.9% for 1‐month follow‐up, and 59.3% for 6‐month follow‐up. In the ED, 70.5% rated thinking about child passenger safety in the ED as very helpful. At 1 month, 70.0% expressed positive attitudes toward the study. Of 132 parents who reported receiving study mailings, 78.9% reviewed the information. Parents randomized to the full intervention demonstrated an increase (+6.12 percentage points) and other groups a decrease (–1.69 to –9.3 percentage points) in the proportion of children reported to use a size‐appropriate CRS at 6‐month follow‐up.ConclusionsSuboptimal CRS use can be identified and intervened upon during a child’s ED visit. A combined approach with ED‐based counseling and mailed tailored brochures shows promise to improve size‐appropriate CRS use.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150596/1/acem13687_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150596/2/acem13687.pd

Action reflections: a client-centered technique to bridge the WHY-HOW transition in motivational interviewing

Background: When using Motivational Interviewing (MI), once resistance or ambivalence are resolved and motivation is solidified, many practitioners struggle with how best to transition the discussion toward action planning, while still retaining the spirit and style of client centeredness, i.e., moving from the WHY phase to the HOW phase of counseling in a style that is MI-consistent. For many, there is a perception that the counseling style, skills, and strategies used to build motivation are distinct from those used in the action planning phase. The WHY to HOW transition does not, however, necessitate abandoning a client-centered style for a more overtly educational or directive style. Goal setting, action planning, provision of advice, and relapse prevention can be implemented from an autonomy supportive, MI consistent framework. Method: To this end, this article will present a new class of reflection, which we have termed “action reflections”, that can be used to help bridge the WHY-HOW gap. Action reflections (AR) allow the clinician to maintain a tone and orientation that are consistent with MI, i.e. autonomy support; guiding versus directing, during the action phase of counseling. They differ from reflecting change talk as they focus not on the WHY of change, but the HOW, WHEN, or WHERE. Action Reflections (ARs) also differ from the more common type of reflections such as those that focus on client feelings, rolling with resistance, or acknowledging ambivalence as ARs usually contain a potential concrete step that the client has directly or obliquely mentioned. Like any type of reflection, ARs represent the clinician's best guess for what the client has said or, more apropos here, where the conversation might be heading. Conclusion: This article describes the various types of ARs and provides examples of each to help clinicians incorporate them into their behavior change counseling

A Pilot Study of the Effects of a Tailored Web-Based Intervention on Promoting Fruit and Vegetable Intake in African American Families

Background: The current study examined the effects of a Web-based tailored parenting intervention on increasing fruit and vegetable intake in African American families. Methods: Forty-seven African American parents (mean age, 41.32±7.30; 93.6% female) with an adolescent (mean age, 13.32±1.46; 59.6% female) participated in a Web-based autonomy-support parenting tailored intervention session to increase both parent and youth fruit and vegetable (F a Web-based information phase, and a goal-setting and action plan phase. Self-reported measures of parenting skills [based on autonomy (choice), support, and communication] and FandV intake (assessed as average daily intake) were assessed at baseline and at a 1-week follow-up session. Results: There was a significant increase in parents' self-reports of daily fruit intake from pretest to the 1-week follow-up. Parent and adolescent combined FandV intake also significantly increased from pretest to 1-week follow-up. Overall, parents reported that the program was easy to navigate and that they enjoyed participating in the Web-based online program. Conclusions: Current findings provide preliminary support for an autonomy-support parent tailored Web-based program for improving dietary intake in African American families.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140334/1/chi.2013.0070.pd

Racial and Ethnic Differences in Directâ toâ Consumer Genetic Tests Awareness in HINTS 2007: Sociodemographic and Numeracy Correlates

To examine the association of 1) race/ethnicity and 2) numeracy with awareness of DTC genetic tests. Secondary analysis of 6,754 Hispanic, black, and white adult respondents to the National Cancer Institute’s 2007 Health Information National Trends Survey (HINTS). Logistic regression was used to examine sociodemographic predictors of DTC genetic tests awareness including race/ethnicity, income, education, and gender. Next, two numeracy variables were added to the model. After controlling for sociodemographic variables, black respondents were significantly less likely to have heard of DTC genetic tests compared to white respondents (ORâ =â 0.79; CI: 0.65â 0.97). When numeracy variables were added to the model, the effect of black race was no longer significant (ORâ =â 0.84; CI: 0.69â 1.04). Hispanic respondents did not significantly differ from white respondents in awareness of DTC genetic tests. Other significant correlates of DTC genetic tests awareness in the full model included education, income, age, and numeracy variables including degree to which people use medical statistics and numbers to make health decisions, and preference for words or numbers when discussing â the chance of something happening.â Although black respondents were generally less aware of DTC genetic tests than white respondents, this relationship appears to be partially mediated by numeracy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146912/1/jgc40440.pd

Enhancing the Evidence for Behavioral Counseling A Perspective From the Society of Behavioral Medicine

U.S. Preventive Services Task Force (USPSTF) clinical guidelines at present rarely assign the highest grade recommendation to behavioral counseling interventions for chronic disease prevention or risk reduction because of concerns about the certainty and quality of the evidence base. As a result, the broad integration of behavioral counseling interventions in primary care remains elusive. Thus, there is an urgent need for novel perspectives on how to generate the highest-quality and -certainty evidence for primary care–focused behavioral counseling interventions. As members of the Society of Behavioral Medicine (SBM)—a multidisciplinary scientific organization committed to improving population health through behavior change—we review the USPSTF mandate and current recommendations for behavioral counseling interventions and provide a perspective for the future that calls for concerted and coordinated efforts among SBM, USPSTF, and other organizations invested in the rapid and wider uptake of beneficial, feasible, and referable primary care–focused behavioral counseling interventions. This perspective highlights five areas for further development, including (1) behavioral counseling–focused practice-based research networks; (2) promotion of USPSTF evidence standards and the increased use of pragmatic RCT design; (3) quality control and improvement procedures for behavioral counseling training; (4) systematic research on effective primary care–based collaborative care models; and (5) methodologic innovations that capitalize on disruptive technologies and healthcare transformation. Collective efforts to improve the health of all Americans in the 21st century and beyond must ensure that effective, feasible, and referable behavioral counseling interventions are embedded in modern primary care practice

Response to Letter Written by Shelly Cummings, MS, CGC of Myriad Genetics Laboratories, Inc. Regarding the Paper, â Racial and Ethnic Differences in Directâ toâ Consumer Genetic Tests Awareness in HINTS 2007: Sociodemographic and Numeracy Correlates.â J Genet Counsel (2012) 21:440â 447

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/147095/1/jgc40154.pd

Smoking Characteristics of a Homeless Population

When addressing tobacco control and smoking cessation measures, the homeless have been perceived as a difficult to reach population. The purpose of this study was to examine the smoking characteristics of a homeless population. Data were derived from a larger study that examined smoking among inner-city residents. Homeless smokers (n=107) were compared with non-homeless smokers (n=491) on socio-demographics, smoking characteristics, motivation to quit, and smoking cessation experiences. Results showed that homeless smokers were more likely to be white, smoke more cigarettes per day, initiate smoking at a younger age, and have a longer smoking history. Knowledge about the risks of smoking and the benefits of quitting was equally high in both groups. Homeless smokers were less likely to be preparing to quit smoking compared to non-homeless smokers. These factors place homeless smokers at increased risk of tobacco-related diseases. Programs are needed to design and test effective cessation interventions for homeless smokers