1. Motivational Interviewing Scott McIntosh, PhD University of Rochester Medical Center Copyright 2015: University of Rochester Medical Center; Columbia University / Children’s Hospital of New York

2. Unhealthy Behaviors  There are costs, as well as “benefits”, to every behavior - including unhealthy lifestyle behaviors  Junk Food: Satisfying; tastes good; need fulfillment  Smoking: Relieves stress, appetite suppressant, reduces withdrawal symptoms  People engage in and persist with behaviors based on an “assessment” (conscious or unconscious) of these costs and benefits

3. Unhealthy Behaviors  Ambivalence results from the unresolved conflict between these costs and benefits, which leads to the behavior being sustained  Ongoing ambivalence is a barrier to change  People may not be fully aware of this ambivalence - or of their own costs and benefits

4. Prochaska & Di Clemente: Transtheoretical Model of Behavior Change

5. Stages Involved In Behavior Change - Identify / acknowledge the behavior - Recognize (validate) the perceived rewards or benefits - Identify problems and consequences - Fostering a desire to change - Feeling confident about a change (Self Efficacy) - Making the change - Maintaining the change

6. Behavior Change Examples - Starting a Behavior -Exercise - Changing a Behavior -Diet - Stopping a Behavior -Smoking All of these behavioral changes go through the “Stages of Change”, and are amenable to Motivational Interviewing.

7. Motivational Interviewing (MI)  Developed in the 1980’s by William Miller and Stephen Rollnick, psychologists experienced in treating alcoholism (their seminal book is now in its 3rd Edition - 2012)  The spirit or philosophy of MI and behavior change is considered central to the approach - the techniques follow accordingly  Person centered, not directive or authoritative  Empowering the patient, or “client”  Rolling with resistance  Etc.

8. Goal of Motivational Interviewing  Finding out which stage the client is at, and addressing the concerns specific to their stage  Have the client articulate their own costs and benefits (“pros” and “cons”) so they can better process and ultimately resolve the conflict between them  Empathizing and empowering the client to take steps towards change by affirming their strengths as well as the centrality of their initiative in lasting change

9. MI and evidence  Systematic reviews and meta-analyses have shown some beneficial effect of MI interviewing techniques compared to traditional advice giving in various contexts outside of the addictions, such as with diet, exercise and adherence to medications.  Some reviews have even shown statistically significant change in direct measures such as blood pressure, cholesterol, and body mass index (Rubal, Sandbaek, et al. Motivational Interviewing: A Systematic Review and Meta-Analysis. British Journal of General Practice 2005; 55: 305-312).

10. Effect measure n Estimate of effect P-value (95% CI) Body mass index 11400.72 0.0001 (0.33 to 1.11) HbA1c (%GHb) 2430.43 0.155 (-0.16 to 1.01) Total blood cholesterol (mmol/l) 13580.27 0.0001 (0.20 to 0.34) Systolic blood pressure (mmHg) 3164.22 0.038 (0.23 to 8.99) Number of cigarettes/day 1901.32 0.099 (-0.25 to 2.88) Blood alcohol content (mg%) 27872.92 0.0001 (46.80 to 99.04) Standard ethanol content (units) 64814.64 0.0001 (13.73 to 15.55)

11. Case presentation You are seeing a 4 year old boy with poorly controlled asthma in clinic. He has been admitted three times in the past 6 months for acute exacerbations. During your interview with the mother, a pack of cigarettes falls from her coat. She quickly states that she does not smoke “around her son.”

12. What stage is the client at? (Hint: Do we know at this point?)

13. You get more history… The mother says she has been feeling very stressed recently, especially with her child’s recent hospitalizations. She has been smoking since she was a teenager (she is in her mid-20’s) and she says that smoking relaxes her. She does think that quitting would help her child’s asthma, and several people have told her that she should stop smoking in the interest of her child’s health. When asked about quitting, she frowns and says she has tried to quit smoking several times in the past without success.

14. Use of Scales  A common way of assessing as well as cultivating confidence or importance is the use of scales. Scales can help clients/patients to verbalize and process their ambivalence further. In this case,  “On a scale of 1 to 10, how important do you think it is for you to quit smoking?” (Patient says 9 out of 10)  “On a scale of 1 to 10, how confident are you that you can quit smoking?” (Patient says 4 out of 10)

15. So, now what do we do? Affirmations: recognizing client strengths and countering a defeatist attitude Affirmations: recognizing client strengths and countering a defeatist attitude “ Why did you give yourself a 4 instead of a 2?” “I am impressed that you have been trying to quit despite all the stress you are going through” Reflecting the pros and cons Reflecting the pros and cons “So, it is important for you to smoke in order to deal with the stress in your life, but you also wish you could quit in the interest of your child’s health” Look for client driven strengths Look for client driven strengths “What would make you go up to a 6 or 7?” “What would make you go up to a 6 or 7?”

16. Consider this history: The mother, who is 35 years old, smokes with her girlfriends who come and visit her in her apartment. She feels a sense of community with them, and smoking is a shared pastime they enjoy. The mother does not think her child’s asthma has worsened because of her smoking – “I’ve been smoking since he was born and his asthma wasn’t this bad before” When asked about quitting, she says – “Yes, I’m sure it would be better for my health, but so would moving out of New York City!”

17. On a scale of 1 to 10…  “How important do you think quitting smoking is for your child?” (Patient says 3 out of 10)  “How important is it for your own health?” (Patient says 4 out of 10)  What about confidence?

18. NEXT STEPS:  Reflecting and empathizing with the “pros” and “cons” “It seems that smoking is an important social activity for you, but you also would like to quit because it would be better for your health.” “Yes, New York City can certainly be hazardous to your health!”  “Roll” with resistance “Yes, it does seem that you’ve been smoking for quite some time and your child’s asthma has only recently been flaring up.”  Emphasize the significance of this patient’s level “Why did you give it a 3 and not a 1?”

19. Case Presentation #2 You are seeing a 7 year old girl with poorly controlled asthma in your clinic. She has been coughing 1 to 2 times a week at nighttime, interfering with her sleep. The mother is rightly concerned and would like some treatment. You prescribe an inhaled corticosteroid for twice daily use to be continued even when her symptoms resolve.

20. Case Presentation #2 (con’t) Four weeks later, during a follow-up visit, the mother tells you that she stopped the inhaled steroid medication because her child’s symptoms resolved. How would you proceed at this point?

21. Find out where the client is at: “What do you remember about the instructions for the medication prescribed for your daughter’s cough?” “Do you have any concerns about the medication?” “Are there people you know who have taken steroids for asthma?” “Tell me what you feel [or know] about steroids”

22. You get more history… The mother does remember that she was instructed to continue the medication even after her child’s cough resolved, but she stopped giving the medication because she “doesn’t like giving medications” to her daughter. When asked why, she simply repeats herself – “I just don’t like it!”

23. What’s going on here?

24. Resistance!  In motivational interviewing philosophy, resistance is elicited when we try to push clients farther than they are ready to go.  Resistance also occurs when clients have not been given sufficient opportunity to direct their actions and have simply been given instructions from their providers.

25. How to deal with resistance:  Empathize with the client “It sounds like many of us have been telling you what you should do and we’re not listening to what you would like to do for your child.”  EMPOWER the client “You know, it’s up to you what you would like to do with your daughter’s medication – after all, you are her mother.”

26. Case Presentation #3  You are seeing a 13 year old girl in clinic because she is here for the 2 nd dose of HPV vaccine  She is sexually active with one male partner, but he does not use condoms.  You have a discussion with her about the importance of using latex barriers to prevent sexually transmitted infections.  She seems to understand, but is hesitant about using condoms.

27. How would you approach this case?  Find out the stage the client is at  “Do you feel using condoms are important?”  “Are you afraid of bringing up condom use with your partner?” or “Have you talked with your partner about using condoms?”  “Do you or your partner not like using condoms?”  “Do you feel safe/happy in this relationship?”  One manifestation of confidence here is asserting oneself in a partnership

28. You get this history:  She hasn’t spoken with her partner about using condoms, but he often talks about how great the sex is.  She says that he does not have sex with other people, but she is not sure.  What other questions would you ask?

29. Try using a Decisional Matrix Status Quo or Staying in the Habit (i.e., staying in this relationship with current sexual habits) Change or Breaking from the habit (i.e., breaking from this relationship or beginning to use protection) PROS CONS

30. Try using a Decisional Matrix Status Quo or Staying in the Habit (i.e., staying in this relationship with current sexual habits) Change or Breaking from the habit (i.e., breaking from this relationship or beginning to use protection) PROS“Having unprotected sex with him makes him happy, and I like it when he’s happy” “I don’t know. I guess I won’t feel like a fool calling him all the time” CONS“I don’t get any pleasure out of sex” “I’m the one who calls him all the time just to hang out – he never calls me” “I might be lonely” “All of my friends have boyfriends, so I worry if I’ll be left out”

31. EXERCISE: WHAT ABOUT YOUR OWN EXPERIENCE? Are there any cases in which behavior change was a prominent issue that you would like to discuss?

32. EXERCISE  Break out into pairs  One person will describe a habit or behavior that they, a family member, or friend have struggled with  The other person will assess what stage his/her partner is at as well as their “pros” and “cons”  Use the Scales and the Decisional Matrix  Reverse roles!

33. TAKE HOME MESSAGES  MI is a client-centered philosophy  A non-judgmental tone and attitude helps clients be more open about their “pros” and “cons”  Focus on the stage the client is at – e.g., don’t address confidence issues if the client is not yet interested in changing their behavior  It’s a process: Don’t assume that we have failed if clients don’t make decisions toward change at each visit

34. Resources / References   YouTube Primer (17 minutes): https://www.youtube.com/watch?v=s3MCJZ7OG Rk https://www.youtube.com/watch?v=s3MCJZ7OG Rk   Miller WR & Rollnick S (2012). Motivational Interviewing (Third Edition) Helping People Change