Motivational Interviewing for the Health Care Professionals How to engage your patients, overcome resistance and promote behavior change Amy Walters, PhD Licensed Clinical Psychologist Director of Behavioral Health Services St. Luke’s Humphreys Diabetes Center
Transcript
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Amy Walters, PhD Licensed Clinical Psychologist Director of
Behavioral Health Services St. Lukes Humphreys Diabetes Center
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Objectives Attendees will be able to do the following: Define
Motivational Interviewing Identify at least 3 core elements to MI
style List the 3 guiding principles of MI Identify ways to address
patient resistance Practice the basic elements of an MI
intervention
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Definition (Miller & Rollnick) Motivational Interviewing
is.. A client-centered, directive method for enhancing intrinsic
motivation for change by exploring and resolving ambivalence
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MI is... A collaborative, evocative, conversation about change
Accepting Compassionate Directional A Partnership... promotes the
interest of other person
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Motivational Interviewing Roots are in substance abuse
intervention First published in early 90s by Miller & Rollnick
Expanded to other health conditions Hundreds of randomized clinical
trials and publications Activate patients motivation for
change
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Developments in MI: 2003 - 2011 Over 200 randomized trials
Total publications tripled to >1200 > 40 books 2011 over
30,000 Google Scholar articles Meta-analyses of MI research New
research on MI processes theory Rapid diffusion into health care,
corrections Newer diffusion into mental health, education,
dentistry, social work Areas of study : alcohol, drugs, dual dx,
gambling, offenders, eating, smoking, HIV, cardiac, diabetes,
psychiatric, health promotion, family violence, asthma, dental,
cancer (listed by freq) (Miller, 2013)
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Motivational Interviewing Basic premise: How we speak with
people about behavior change matters Shift from expert role: I know
what is best to guide role : You tell me what is best and let me
guide you Tour guide in the land of health behavior change MI is
not a method, it is a style
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Key Elements of MI Collaboration Person Centered Guidance
encourages self-based problem solving Empathy relationship is the
foundation Elicit and strengthen motivation for change
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Partnership Compassion Acceptance Evocation MI Spirit
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Developing proficiency in MI is like learning to play a musical
instrument. Some initial instruction is helpful, but real skill
develops over time with practice, ideally with feedback and
consultation from knowledgeable others. As with other complex
skills, gaining proficiency in MI is a lifelong process.- William
Miller, 2008
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Adapted from Steve Berg-Smith 2011 Strategy Skills Style
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Interpersonal Style Empathic Warm & friendly Collaborative
Accepting Respectful Optimistic Eliciting & Listening Honoring
of autonomy & choice * Adapted from Steve Berg-Smith 2011
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Common Communication Styles 3 common styles of communication
for practitioners Directing advice giving Guiding empathetic
listening and encouraging ideas Following listening only Guiding
style provides the best outcome and most likely to lead to behavior
change
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Dancing not Wrestling
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3 Guiding Principles of MI Collaboration/partnership Guiding
rather than directing and dancing rather than wrestling
Collaborative conversations and joint decisions Evocation: elicit
hows and whys from the patient Rather than giving advice, we evoke
motivation and resources for change Autonomy Respect and support
patient autonomy for decisions directing and coercing leads to
resistance
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Paradox of change when people feel accepted for who they are
and what they do (regardless of how unhealthy) it allows them the
freedom to consider change, rather than needing to defend against
it (Miller and Rollinick, 2010) Studies suggest empathy is the best
predictor of patient behavior change
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4 fundamental processes Engaging - form the relationship
Focusing what is our goal, where are we going Evoking calling forth
desires Planning how will we get there Not a checklist; rather a
process you revisit over and over; dancing around the floor
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Interaction Style REAL Principle Respect Empathy Active
collaboration Listen
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Importance of Empathy Empathy is a key ingredient Evidence
based element of treatment Predicts outcomes (e.g. drinking change)
Empathy alone is a significant intervention low level empathy
associated with poor outcomes Relationship is the vehicle for
change... building it for brief encounters is even more
important
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Reflective Listening A core skill Eye contactEngagement
PaceWord choice Inquisitive Content FeelingMessage Reflect general
content and emotion the core message, not a mirror
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Basic Flow Listen and identify the issue Ask/Evoke: Why make
the change? How could go about it to succeed? What are 3 best
reasons to do it? How important is to make change 1-10 (why )
Summarize Confirm: What do you think you will do?
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Taste of MI Best way to learn MI is to experience MI Choose a
partner - not with your boss or supervisor One will be the speaker
and the other will be the listener 2 part exercise
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Exercise Reflection/Persuasion Exercise Speaker: Choose a topic
- something thinking about changing Listener 1) Choose a side and
try to persuade accordingly 2) Practice reflective listening &
evoking Ex Qs: Why make change? 3 best reasons? How important is
the change? Summary? What do you think you will do?
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You Tube Video Effective Physician
http://www.youtube.com/watch?v=URiKA7CKtfc Diabetes Educator
http://www.youtube.com/watch?v=5h0i-b0xrnI
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Adapted from Steve Berg-Smith 2011 Strategy Skills Style
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Core Skills - OARS OARS Open questions Affirm Reflective
listening Summarize Gather the pearls of the conversation and
present them with a string that summarizes it and highlights change
talk
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Core Skill Change Talk Change talk Any statements that favor
changing the target behavior Goal: clarify ambivalence & elicit
change talk Encourage change talk identify, reinforce, respond The
goal is for the patient to talk him/herself into changing Reflect:
desire, ability, reasons, need, commitment, steps to action Ex: I
want to, I could, I need to, I will
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Importance of Intention Multiple studies highlight the
importance of intension Intension is greatest predictor of future
behavior (25-30% of variance) Stable Based on personal factors (vs
social norms) Specific and detailed (Bruin et al, 2012)
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Types of Change Talk DARNS Desire Ability Reasons Need
Steps
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Questions to Promote Change Talk Desire Ability Reason Need
Steps What do you want, wish, hope? What? How? Why ? Benefits? How
important is it? What might be a next step?
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Strategies to Encourage Change Talk All EARS: E: evoke &
ask for elaboration (be curious) A: affirm R: reflect S: collect
bouquet of change talk flowers and offer in summary
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Core Skill - Evoking Evoking: recognize, elicit & respond
to change talk Reasons we miss change talk - dont listen, other
agenda, expert role Set the stage so patient is one that brings it
up Differential response: Reinforce change talk Ignore sustain
talk
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Evoking Questions Ask evocative, open ended Qs Use importance
ruler & confidence ruler Query extremes best thing, worst thing
Look back and forward Explore goals and values- what matters to
you, care about most, guides decisions Qs: How will that happen for
you; what would help you be successful
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Core Skills EOE Rhythm EOE Rhythm Explore Offer Explore Painter
analogy good outcomes are all about the prep work
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Sharing Information Ask permission Slow down Be clear and
concise: Small nuggets! Avoid information overload: Less is more!
Use visual support Avoid technical terms and jargon Offer choices
Explore Offer Explore Education, feedback, skills, referrals *
Adapted from Steve Berg 2011
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Clinician:"Jackie, tell me a little about what you know about
anti- depressants.[Explore] Patient:"Well, I know that lots of
women are told they have depression and then take these pills that
lowers their sex drive and makes them fatter. How can that be
helpful? Clinician:"You're absolutely right! These side effects can
and do happen for many women. Could I tell you some other things
about anti-depressants that we know as well?[Ask permission to
Offer] Patient:"Well, I suppose." Clinician:"Great; thanks! There
are many newer anti-depressants that don't seem to have the same
side effects for most women; they seem to lessen the depression
only and not the sex drive. And your sex life sounds important to
you.[Offer] What do you think about that?[Explore] Patient:"Well, I
guess I could try one of those other ones if you really think it
might help -and that I won't gain more weight!"
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Resistance Resistance is a by-product of communicative style
and approach Its a sign we are dancing to a different song STOP
listen to the beat try to join the patients rhythm Being heard can
be the most healing response Resistance signals ambivalence and a
need to step back, listen and help the patient explore the
options
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Resistance Traps The question-answer trap The taking sides trap
The expert trap The scare tactics trap The cheerleading trap The
pouncing trap The information over-load trap The premature action
planning trap
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Dealing with Resistance/Discord Signs: interrupting, arguing,
challenging, discounting, hostility, withdrawal, ignoring, changing
the topic Responsive to style Not dancing together well Step back,
listen and evoke concerns
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Addressing Ambivalence and Resistance Back away from the
problem Move to exploration and guidance Explore why and how change
might occur Ambivalence is a normal phenomenon when considering
change resist the righting response (advice)
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The RULE Principle Resist the righting response Roll with
resistance, invite perceptions, listen and reflect Understand
motivation Explore values for change, listen for core values &
motivation Listen with empathy Warmth & acceptance, reflection,
safe connection Empower ability to change Affirmation, evidence of
ability to solve problems
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Open the Conversation Negotiate the Agenda Build Motivation
*Ask Open Ended Questions Assess Readiness avoid premature plan
Explore Ambivalence Close the Conversation The Next Step Adapted
from Steve Berg Smith 2011
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Readiness for Change How important is health behavior change to
you? How confident are you in your ability to change your behavior?
How committed are you to changing your behavior? 0 1 2 3 4 5 6 7 8
9 10
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Specific Techniques and Strategies Ruler ratings Gather pearls
(selectively reinforce change talk) Choices for direction Circle
chart Decision Square
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Final Points Behavior change is a key element of healthy living
and wellness Many patients struggle to achieve behavior change,
despite good intentions Traditional methods of advice giving may
increase resistance to change MI is a research-based technique that
may assist health care professionals to support patients in their
behavior change efforts
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Final Points Health behavior change is not a by-product of
education, medication or provider instruction - behavior change is
always the result of patient motivation Release the responsibility
to fix - Patients hold responsibility for their own health choices
and behaviors
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Research indicates the most effective providers: Focus on
patient goals and priorities Follow the patients pace Communicate
high levels of empathy Provide guidance to reach health goals
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References Miller, W & Rollnick (2013) Motivational
Interviewing: Helping People Change (3 rd Edition). Guilford Press,
New York Miller, W & Moyers, T (2013) Advanced Workshop in
Motivational Interviewing, Albuquerque, NM September 2013 Rollnick,
S., Miller, W., & Butler, C. (2008). Motivational Interviewing
in Health Care: Helping Patients Change Behavior. Guilford Press,
London. Arkowitz et al. (2008). Motivational Interviewing in the
Treatment of Psychological Problems. Guildford Press, London. Berg
Smith, S. (2011). Intensive Introduction to Motivational
Interviewing : 3 day training, San Fransisco, CA, December 2011.
Bruin et al. (2012) Self regulatory processes mediate the intention
behavior relation of adherence and exercise behavior; Health
Psychology,31 (6), 695-703. Groot et al. Depression Among Adults
with Diabetes: Prevalence, Impact and Treatment.(2010) Diabetes
Spectrum 23: 15-18. Welch, G., et. al. (2006). Motivational
Interviewing and Diabetes: What is it? How is it used? Does it
work? Diabetes Spectrum 19: 5-11.
www.motivationalinterview.org