1. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Integrating Motivational Interviewing and Narrative Medicine to Teach Behavior Change Gene Combs MD Lauren Oshman MD MPH University of Chicago (Northshore) Family Medicine Residency Program

2. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Disclosures We have no actual or potential conflict of interest in relation to this topic.

3. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Objectives: Understand how Narrative Medicine and Motivational Interviewing can be combined to enhance doctor- patient communications skills. Be able to describe how one program has implemented and obtained faculty buy-in for a program-wide, integrated curriculum in the Narrative/MI approach. Experience the effects of using the Narrative/MI approach in a “real play” exercise.

4. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Our Motivation for Change Measurement of counseling behaviors Need for direct observation tools Milestones Avoiding “stuck” feeling with patients Helping patients who don’t “fit the algorithm” Complex patient management initiative Need for disease self management program Lifestyle management and goals PCMH Transformation MI NT

5. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Our Barriers to Change Milestones Complex Care PCMH Transformation Time and energy Shared faculty model Resident buy-in

6. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin MilestoneObservable MI Behavior C1: Develops meaningful, therapeutic relationships with patients and families. Respects patient autonomy in decisions. Clarifies patient goals to provide care c/w values. C-1, 3Assess readiness, summary and closure. Use of MI ruler, reflection, summary and planning. Connects with patients … including the ability to manage conflict. C-1, 4Assess readiness (allow for ambivalence), use reflections. Establishes rapport and patient-centered information exchange C-2, 1Session agenda, OARS skills, use of open-ended questions. C2: Communicates effectively with patients, families and the public. Negotiates agenda, uses active and reflective listening. C-2, 3Session agenda, OARS skills, use of open-ended questions and reflections. Engages patients’ perspectives in SDM.C-2, 3Use of MI ruler, reflection, summary. PC-2: Cares for patient with chronic conditions. Engages the patient in self management.PC-2, 3Feedback,/advice, assess readiness.

7. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Curriculum Development June 2014: Clerkship Workshop Feb 2015: Faculty Development May 2015: Resident workshop June 2015: Intern workshop July 2015: Intern OSCE and Clerkship OSCE

8. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin MI / NT Intern Workshop Objectives: Recognize patient-doctor communication c/w the spirit of motivational interviewing (MI). Respond to patients using open-ended statements, affirmations, reflections, and summaries (OARS). Respond to patient’s arguments against change without amplifying resistance. Listen for and amplify change talk using reflection, open questions, and importance/confidence scales. Know when and how to give advice or information.

9. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Activities Interactive OARS activities Worse / better physician video and debrief Fishbowl exercise: smoking cessation, antibiotics Real play and debrief Topics Understanding human behavior change Spirit of MI OARS tools Resistance, Ambivalence, and the Righting Reflex Importance/ confidence Advice and planning MI / NT Intern Workshop

10. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin What is Motivational Interviewing? Motivational interviewing (MI) is a guiding conversational style of helping people to change by uncovering and strengthening a person’s own motivation and commitment to change. MI addresses the common problem of ambivalence about change by respecting a person’s own autonomy, reasons, and motivations. Miller, Willam R and Stephen Rollnick. Motivational Interviewing: Helping People Change, 3 rd ed. New York: Guilford Publ, 2012. Print.

11. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Spirit of MI Collaboration Compassion Evocation Acceptance MI Spirit “I bring physician expertise. You are an “expert” in your story and how to change.” “My heart is in the right place. I am in this for your best interests, not my own.” ‘’You have what you need, and together we will find it. My job is to evoke reasons for change from you.’” “I am invested in understanding what it is to walk in your shoes. I accept you where you are in your process.”

12. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Exercise: Rating Samples for MI Spirit Review and rate the client statements and practitioner responses as “thumbs up” or “thumbs down.”

13. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Exercise: Video Review Good and Bad Videos Group debriefing What went well? What didn’t? #63504. University of Florida Department of Psychiatry. Funded by Flight Attendant Medical Research Institute Grant. Co-Pis: Gold & Merlo.

14. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin MOTIVATIONAL INTERVIEWING FEEDBACK SHEET BEHAVIOR COUNTS Giving Information Count the # of times you notice this behavior and write down examples. MI Adherent (advising, confronting, directing) MI Non-Adherent (asks permission, affirming, supporting) Asking Questions Closed Ended Open Ended Reflective Listening Simple reflections Complex reflections GLOBAL RATINGS Evocation – elicits patient’s own motivation 1 2 3 4 5 low high Collaboration – approaches issues from the patient’s perspective. 1 2 3 4 5 low high Autonomy / support - let’s the patient decide if now is the right time to change. 1 2 3 4 5 low high Direction – focuses the conversation toward change. 1 2 3 4 5 low high Empathy – shows the patient they are listening by using reflective listening. 1 2 3 4 5 low high Exercise: Video Review

15. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Righting reflex – You need to be convincing. If you are persuasive enough, the patient will do what you say. – If you provide the right information / risks / benefits, the patient will do what you say.

16. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Ambivalence When you argue for a change, your patient (the person ambivalent about changing), may take the opposite stance (decide not to change). If you can get the patient to identify and verbalize reasons for change, people most often believe what they say.

17. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Change Talk & Commitment Talk DESIRE: I want to ABILITY: I can REASONS: It’s important NEED: I should COMMITMENT: I will ACTIVATION: I am ready TAKING STEPS: I am doing it Change Talk Commitment Talk

18. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin MI Tools: “OARS” Open ended questions Affirmations Reflections Summaries Ruler (Confidence / Importance)

19. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Confidence and Importance Rulers “How important is it to you to make change …” “How confident are you that you could make this change?” – Why a XXX and not a XXX? – What would it take to get you to a XXX? “Imagine if” scenario – “Imagine if you were going to make a change. What would you do?”

20. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Fishbowl Exercise: Rolling with Resistance “Doc, you don’t get it. I tried all of those meds for smoking, and none of them worked. I tried Zyban and Chantix, and I went back to smoking each time. “ Reflection You feel like I don’t understand what you’re going through. Shift focus I’m sorry … I’m focusing on meds. Maybe there’s a way to do it without meds? Reframing What I see is how hard you worked – it was important and you kept trying. Agree with a twist You feel like giving up, but a part of you is still committed to this. Emphasize personal choice and control Well, you’re the only one who can decide if you want to try something else. Come alongside / siding with the negative You’re better off continuing smoking. The meds didn’t work.

21. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Real Play Exercise Patient: pick something about yourself that: You want to change You need to change You have been told you should change You have been trying to change BUT you haven’t changed yet

22. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Narrative Therapy

23. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Narrative Curriculum Our two OSCE’s emphasize MI skills Narrative is covered – In exercises and mini-lectures at our monthly Intern Hour – In a few lectures in the Wed afternoon lecture series. – During the month-long Psych rotation – With complex patients throughout each resident’s training

24. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Life is full of experiences. Each dot here reperesents a life experience.

25. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin When people come for help, they are usually focused on a problematic story that connects certain experiences while leaving others “off the map.”

26. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin We can listen for things they say that hint at other experiences, ones that wouldn’t be predicted by the problem story.

27. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin We can then ask questions about the non- problem event, and bring forth a vivid story of that event and its meaning.

28. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Over time we can help people remember and value a whole other thread of life history that stands outside of the problematic story, so that the problems don’t dominate the person’s life.

29. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin In a continuity relationship, the story of a chronic problem can be viewed as only one thread in a broader tapestry of life.

30. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin PHYSICIAN ASTHMATIC Pathology focused view of the Problem

31. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Externalized view of the Problem PHYSICIAN PERSON ASTHMA

32. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin What Narrative and MI Share Both strongly emphasize meeting people where they are Shared responsibility Respect for the knowledge and skills of people in the patient position Small manageable steps

33. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin What Does Narrative Therapy add to MI? Narrative empathy, putting yourself in their viewpoint as a character in a novel Externalization: developing a story of working together to manage the problem (HTN, DM) and the problems it is causing in the person’s life Placing sessions in a past, present, future context “Coherence” “meaning making” (When “fix it” doesn’t work, try to “understand it.”)

34. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin What Does MI add to Narrative Therapy? Adds clarity and simple rules Mastery: Importance and Confidence Ruler Helpful for many patients a good bit of the time (more often than “full on narrative”) A way to talk about something that maybe not on the patient’s agenda. “Comfort the afflicted and afflict the comfortable.”

35. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Curriculum evaluation: OSCE

36. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Obj. 123 Session Agenda Did not ask permission at opening of session. Partially involved client in setting agenda of the session. Fully involve client in setting agenda and asked permission to discuss behavior change issue. OARS Skills Frequent use of closed ended questions. Use of “nasty” or “judgmental” closed ended questions. Frequent use of questions when reflections are possible. Some use of open ended questions. Closed ended questions are benign and non-judgmental Some use of questions when reflections are possible. >70% open ended questions. Reflection: question ratio 2:1. Reflections are complex and move toward change talk. Summaries reflect understanding of patient statements. Feedback Advice Frequently gives unsolicited advice or feedback, lectures, or tells patient what to do. Does not ask permission prior to advice or information giving. Does not seek explore thoughts, feelings, or perspective of patient. Occasionally gives unsolicited advice. Sometimes asks permission to give advice or information. Sometimes explores what the patient thinks/feels about advice. Sometimes explores what the patient knows or wants to know and offers concise advice or info. Does not give unsolicited advice. Always asks permission. Uses “Elicit/Provide/Elicit” framework. Explores what the patient thinks/feels about advice. Explores what the patient knows or wants to know and offers concise advice or info. Shows insight and understanding (attunement). Assess readiness Conventional/paternalistic approach. “Wrestles,” struggles, or argues with patient. Engages with resistance statements instead of rolling. Allows for ambivalence. Does not consistently explore reasons against change (siding with the negative). Does not “wrestle” with resistant statements. Allows for ambivalence. Consistently encourages reasons against change / reasons to not change. Respects autonomy. Sets goals that are congruent with patient’s readiness, expresses confidence. Curriculum evaluation: OSCE

37. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin 123 Summary and Closure Does not summarize or ask client to edit summary Does not transition or fails to create an action plan. Does not involve client in discussion of plan and follow-up Partially summarizes and seeks some feedback from patient. Provides some transition to next steps. Some collaboration in discussion of action plan and follow-up Skilled transition to summary. Attentiveness to patient affect. Seeks feedback about summary Highly collaborative discussion of action plan and follow-up. Rating Scale adapted from 1-PASS (kresnic@umich.edu) andkresnic@umich.edu Rubric for Core Competencies in Behavioral Medicine (Olson and Triana). Curriculum evaluation: OSCE

38. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Curriculum evaluation: OSCE Debrief: What feedback would you give this resident?

39. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Your Turn: Real Play Exercise Patient: pick something about yourself that: You want to change You need to change You have been told you should change You have been trying to change BUT you haven’t changed yet

40. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Real Play Doctor: ask the following questions: 1.Why might you want to ____? 2.What are the most important reasons for you to _____? 3.How important is it to make this change? 4.How confident are you that you can make this change? 5.If you did decide to _______, how would you do it? 6.Summarize the patient’s motivation for change and then ask: “So what do you think you’ll do?”

41. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Real Play Observer: use the feedback sheet to make notes Take 5 minutes to role play Take 5 minutes to discuss as a trio Switch roles and repeat X2 (if time permits…)

42. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Real Play Debriefing: -what went well? -what should the “learner” work on

43. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Future plans Direct observation Faculty buy in and help Include residents in teaching, student OSCE review

44. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin What We’ve Learned Each resident must decide whether to try MI / NT Praise effort … points for trying When you can’t change ‘em, come alongside

45. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin References Combs, G & Freedman J. Narrative Therapy: The Social Construction of Preferred Realities. First edition. Norton. 1996. Miller, W. & Rollnick, S. Motivational Interviewing. Third Edition. Guilford Press. 2012. Olson, M. & Triana, C. Development of a Rubric for Core Competencies in Behavioral Medicine: Implications for the FM Milestones Project. (STFM website). Rosengren, David. Building Motivational Interviewing Skills: a practitioner workbook. Guildford Press, 2009. White, M. & Epston, D. Narrative Means to Therapeutic Ends. Norton. 1990.

46. The 36th Forum for Behavioral Science in Family Medicine Sponsored by The Medical College of Wisconsin Our MI student and resident lecture and our OSCE scripts are available to share via email: loshman@northshore.org