Motivational Interviewing: Enhancing communications to improve health outcomes Celeste Hunter, MS,...

1Celeste A. Hunter; MS, CRC 9/15/11

Motivational Interviewing:Enhancing communications to improve health outcomes

Celeste Hunter, MS, CRCDoctoral Candidate

Department of Rehabilitation PsychologyUniversity of Wisconsin-Madison

2011 Wisconsin Health Improvement and Research Partnership Forum

Celeste A. Hunter; MS, CRC 9/15/11

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Overview• Introduction to Motivational Interviewing

• Basic Tenants of MI

• Motivational Interviewing (MI) is designed specifically to alter patient motivation

• Use of MI in primary care settings can increase successful patient care

• Applications of MI across: o Patient populationso primary care clinic implementation (time permitting).

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Just wondering….

• What do we know about MI so far?

• What are our assumptions about how people change?

• To whom does this apply?



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Rehabilitation is hard work!

oAdhere to self-care, medication, & therapy• i.e. OT,PT, Speech

oExercise & eat righto Show up to all appointments on timeo Stop or curb substance useoUse “appropriate” behavior

In PC or other rehabilitation, we often ask patients to make significant changes in their behavior:

“Challenges” to pursuing “well” behaviorsPeople without acute/chronic health issues: No immediacy & importance to putting forth effort of:

Exercising Eating right Stop drinking, etc…

People with acute/chronic health issues:

-May wonder… “why bother”

-Already struggling w/ challenges of illness (Lynch, in press)

Celeste A. Hunter; MS, CRC 9/15/11 5

Motivation & Health Care Outcomes

“

• How successful people are towards rehab goals = what they do

• Clients are often > ready, willing, and able to make change

• Most clients seeking treatment or change are ambivalent about it:.

• They want it…and they don’t

Client motivational problems are a primary barrier to successful

rehabilitation outcomes” Thoreson, et., al 1968.


Easy to say… But hard to do…

Arising from people's: internal cognitions significant others environment

Convenience or lack of: Facilities transportation

lack of information (Stuifbergen et al., 1990)


Barriers to Health Promo: Patient perceptions of the: unavailability,

inconvenience or difficulty of a particular health-promoting option

Motivation:

Traditional Clinicians Perspective• Motivation is the

patients problem• The patient “just isn’t

ready to change• The patient is getting

“something”out of status quo: i.e.; social security, attention, relaxed lifestyle, etc.

orCeleste A. Hunter; MS, CRC 9/15/11

Introspective Exercise #1

• Think of a behavior you have tried to change and write it down.

• Think about how long it took you to make an earnest attempt at change after noticing the behavior.

• Who was helpful in that process and why?


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Motivational Interviewing: A Definition

Motivational Interviewing is a collaborative, person

centered form of guiding to elicit and strengthen

motivation for change.

Motivation: MI’s Perspective• Motivation is the

probability that a person will change*

• Motivation is influenced by clinician responses

• Low patient motivation can be thought of as a clinician deficit

*Miller & Rollnick, Motivational Interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.


Assumptions About Behavior Change

• Attitude is everything: Impart belief in the possibility of change

• Empathy: Create an atmosphere in which the client safely explores


MI is Theoretically Sound

MI strategies are theoretically & empirically basedo Substance abuse (Miller & Rollnick, 2002)o Chronic pain treatment (Jensen, 2002)o Exercise and MS (Bombardier et al, in

progress)

Focus on Ambivalence: Feeling 2 ways about something: o Wanting to change, but not wanting to

Theoretical Basis of MI

Cognitive Dissonance Theory (Festinger):

-‘If I say it and no one has forced me to say, I must believe it.’

Client-Centered Therapy (Rogers): • Accurate empathy, warmth, and

genuineness promote change.

Belief System Theory (Rokeach): • Awareness of a discrepancy between

behavior and core values creates change.

Theoretical Basis of MI (continued)

Learned Optimism (Seligman): • Optimism and hope facilitate change.

Importance of Choice (Sanchez-Craig): • Choice enhances adherence.

Reactance Theory (Brehm): • Threats to freedom elicit resistance.

Stages of Change:

Transtheoretical Model of Change Prochaska & Velicer, 1997

Transtheoretical model of change:• Explains or predicts a person's success or failure in

achieving a proposed behavior change, such as developing different habits.

• It attempts to answer why the change "stuck" or alternatively why the change was not made.Celeste A. Hunter; MS, CRC 9/15/11

http://en.wikipedia.org/wiki/Behavior_change

Motivational Interviewing: 2 Phases

Phase #1

Increase Motivation to Change

Counselor evokes client’s:

• Desire

• Ability

• Reasons

• Need for change

By responding with reflective listening

Phase #2

Consolidating Commitment

• Strength of language (not frequency) = change

• Low level = “I’ll try" or “I’ll think about it”

• High Level = “I promise” or “I will!”

• Final min of session = strongest predictor of behavior change (Amrhein et al. 2003)

“I will do it!”

SKILLS

SPIRIT

STRATEGIES


“Spirit” is the foundation of MI practice

Research Shows…

General practitioners trained in MI can positively affect patients’ attitude to change behavior: Tend to open up and talk more in telling

their stories Tend to view professionals more positively

and express greater satisfaction with care received

Tend to follow treatment recommendations


Rubak at el, 2009

The Spirit of Motivational Interviewing

3 main concepts:oCollaborationoEvocationoAutonomy

Spirit: Underlying Assumption:

oClients can and will develop direction of health and adaptive behavior

Essential for the full and effective use of MI

MI: Four General Principals

#1: Express empathy: (using short reflections)

• Acceptance facilitates change• Judgment change• Ambivalence is normal

#2 Develop discrepancy: (good things/not so good things)

o Client (rather than counselor) argues for changeo Change when perceived discrepancies in present behavior

important personal goals & values

MI: Four General Principals

#3: Roll with Resistance:• giving advice change and resistance• New perspective are invited-- with permission• Resistance = Signal

- DO SOMETHING DIFFERENT!

#4: Support Self-Efficacy:• Person’s belief in possibility of increases

initiation & persistence of adaptive behavior

Collaborative

Dancing Wrestlingvs.

We’ve all done it…, but…

Lecturing provides little in the way of motivation

Usual response = Annoyance or guilt Jensen, 2005

Information is to behavior change

as wet noodles are to bricks -Wilbert Fordyce


Accepting & Non-judgmental

The paradox of change:when people feel accepted for who they are and what they do - no matter what…

- it allows them the freedom to consider change rather than needing to defend against it.


Spirit… Facilitative CommunicationNothing ‘magical’ about the MI SPIRIT… …it’s just good communication skills that:

Honors Autonomy: Respects the other person’s freedom of

choice, personal control, perspective, and ability to make decisions

Elicits:Encourages the other person to do most of the talking Celeste A. Hunter; MS, CRC

9/15/11 27

Please remember......

• Just because MI seems SIMPLE, that doesn’t mean it is EASY

• Just because it seems like COMMON SENSE, that doesn’t mean it is COMMON PRACTICE!

Spirit Summary

Underlying assumption that clients can develop in the direction of health and adaptive behaviorEssential for the full and effective use of MICan learn if curious and willing to entertain possibility of…

• Evocation• Autonomy• Collaboration


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Applications to Rehabilitation Settings

There are many things you can do to increase motivation…

#1= LISTEN!


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What to listen for…

Is this person ready to change? Identifying stage of change

What does this person value? Link rehabilitation outcomes to the person’s own goals

Why would this person want to participate?

Use the person’s own arguments for change


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Change-talk is client speech that favors movement in the direction of change

What do we know about change talk?

Change talk...

Predicts behavior change

Is suppressed by confrontation

Is enhanced by listening

Is under the control of the counselor

Change Talk Defined

Change talk is client speech that favors movement in the direction of change towards a specific target behavior.

Before we can EVOKE change talk… We need to learn to RECOGNIZE it.Celeste A. Hunter; MS, CRC

9/15/11 34

Preparatory Change Talk:DARN!

DESIRE to change (want, like, wish . . )

ABILITY to change (can, could . . )

REASONS to change (if . . Then)

NEED to change (need, have to, got to .

.)

Ask for DARN to get DARN!• Why would you want to make this change?

(Desire)

• How might you go about making this

change? (Ability)

• What are the three best reasons to do it? (Reasons)

• On a scale of 0-10, how important would you say it is for your to make this change? And why aren‘t you at a _____ (2 points lower)? (Need)

Two Kinds of DARN

It may reveal itself as:

-Attraction to change

“I want to change because I want to look great in a swimsuit.”

or

as avoidance of the status quo“I want to change because I don’t want to

have low energy.”


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Desire

They want or wish to change: “ I wish I could remember to test my blood

sugars everyday.”

“I want to get off of disability.”

“I like the idea of eating better.”


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Ability

They can or have change in the

past…“ I think I can lower my pain meds.”

“I used to exercise at least 3 times per week…”

“I might be able to fit in more fruits and vegetables

…”

“I can imagine quitting smoking…”Celeste A. Hunter; MS, CRC 9/15/11

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ReasonsThey have good reasons to change:

“I’m sure I would feel better about myself if

exercised more.”

“I want to healthy so I can have enough energy to

keep my job.”

“Eating more fruits and veggies would help me

help me feel healthier…. And I’d set a good role

model for my kids.”


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NeedThey need to (have to, got to, should,

ought to, must) change…

“ I must stop smoking...”

“I’ve really got to loose weight… I don’t want a

knee replacement.”

“Cutting down on my drinking will help me keep

my kids …”


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C A T

• Commitment: What do you intend to do?

• Activating: What are you ready or willing to do?

• Taking steps: What have you already done?

Recognizing & Attending to Commitment

STRONG Commitment Talk Medium Commitment Talk

I willI definitely will

I promiseI swear

I guaranteeI know I will

I intend toI am ready toI am going to

I plan toI think I willI expect to

*Given more time, we would excavate this further… Celeste A. Hunter; MS, CRC 9/15/11

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When in doubt, just remember…


Listening Practice to get DARN!

OARS

Key MI Skills: OARS

• Open-ended questions

• Affirmations

• Reflective listening

• Summarize

OARS

We use OARS to give our interactions..

Movement

&

DirectionCeleste A. Hunter; MS, CRC 9/15/11

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Open-Ended Questions

Questions can’t be answered yes or no

Questions that can’t be answered with

one or two words

Questions that are not rhetorical


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Open-Ended Questions

Probe widely for information

Help uncover patients’ priorities and values

Avoid socially desirable responses

Draw people out


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Open or closed? What do you like about drinking?

Where did you grow up?

Isn’t it important for you to take your insulin regularly?

What brings you here today?

Do you want to continue receiving services?

Have you ever thought about how alcohol might effect

your memory?


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Example 1:

“Would you like to come back for your follow-up appointment?

A more open-ended question?

Open-ended questions (continued)


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Example 2:

“How much pot do you smoke?”

A more open-ended question?

Open-ended questions (continued)


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Open ended questions

Using only open ended questions, find out what

your partner will be doing this weekend


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Reflective listening says:

“I hear you.”

“I’m accepting, not judging you.”

“This is important.”

“Please tell me more.”

“ I want to be sure I have this right.”

Reflective Listening


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ReflectionsRemembering to reflect is easier said than

done…

After a long client narrative, the most

important things to reflect are:

Client experience

Client’s reaction to the

experienceCeleste A. Hunter; MS, CRC 9/15/11

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Types of Reflections - Simple

Repeating (repeats an element of the what the speaker said) Rephrasing (uses new words)

Note: Inflection turns D O W N ……at the end

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Types of Reflections: Complex

Paraphrase: (makes an educated stab at

unspoken meaning)

Accurate reflections of deeper

meaning: (deeper, succinct reflections

are ventured as understanding increases)


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Example 1:

“I really want to stop eating junk food, but no one in my family will stop bringing it into the house. I’m tired of trying.”

Reflective response?

Reflective Listening (continued)


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Exercise #2• Choose a behavior you are

interested in changing and willing to share with a partner in this room

• Review the “DARN” principles as they relate to this change

• Role play with a partner as “counselor” and “client”


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Persuasion Exercise: Debrief

- Did the clinician observe movement in the direction of positive change?

- Did the speaker feel like making positive change?

- What are the underlying messages conveyed by advice giving and lecturing?

SummaryConveys to the patient/client:

“What you’ve said is important.”

“I value what you say.”

“Here are the salient points.”

“Did I hear you correctly?”

“We covered that well. Now let's talk

about ...”


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When do you know it is working?- You are speaking slowly

- The patient keeps talking

- The patient is talking more than you

- You are following and understanding

- The patient is working hard and

seeming to come to new realizations

- The patient is asking for information or

advice62

Benefits of Motivational Strategies

• Makes our job easier

• More rewarding

• More effective


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In Conclusion…• Motivational issues are central to

effective Rehabilitation

• We cannot make patients change behavior

• We can help to motivate patients in the direction of positive changes by: Listening rather than lecturing Identifying the stage of change Matching our response to stages to encourage

movement to the next stageCeleste A. Hunter; MS, CRC 9/15/11

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