1. Creating Conversational Flow With MI
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2. Creating Conversational Flow
We’ve presented the MI “toolbox”
What do you do with these tools?
Frustrating to be told, “Go build a house!”
Awkward lack of direction; hesitation
We want to provide a sense of how these MI tools work together to form a smooth conversational flow
What prominent problems to avoid
What strategies work well

3. Basic MI Processes Developing the relationship with the patient
Reduce relational resistance
Engaging the patient’s reasoning
Address issue resistance

4. Basic MI Processes (cont.)
Developing the relationship with the patient
Express empathy
Support self-efficacy
Engaging the patient’s reasoning
Establishing global premises
Assessing patient’s understanding of disease and treatment
Establishing risk and susceptibility
Establishing patient’s long-term goals
Addressing the patient’s specific lines of reasoning

5. Basic MI Processes (cont.)
Developing the relationship with the patient
Objective is to develop rapport
Patients should not feel a need to defend themselves
Patients are willing to talk openly and honestly because they are not losing face and they are being given choices
Consequently, patients are willing to “push the envelope” of their thinking

6. Basic MI Processes (cont.)
Engaging the patient’s reasoning
Identify the patient’s core motivational issues
Reflect and empathize with these issues
Explore the line of reasoning for each issue
Address the weak point of each line of reasoning
Invite the patient to draw a new conclusion

7. Basic MI Processes (cont.)
Developing the relationship with the patient
Engaging the patient’s reasoning processes
Both processes occur simultaneously and are thoroughly interdependent!

8. Typical MI Progression
Early emphasis on developing a solid relationship with the patient
Less relational work required later
Later emphasis on engaging the patient’s reasoning
Allows you to speed up because patient is not defensive and argumentative
Saves time by precisely targeting the patient’s thinking: rifle vs shotgun

9. Example #1 Developing the relationship with the patient
Engaging the patient’s reasoning processes
Identify the patient’s core motivational issues
Reflect and empathize with these issues
Explore the line of reasoning for each issue
Address the weak point of each line of reasoning
Invite the patient to draw a new conclusion
Creates rapport

10. Example #1 (cont.)
Patient: I’ve tried to quit smoking for a while. But I always come back to it again. So, I don’t see the point in trying any more.
HCP: It feels pointless to try to quit one more time if you are just going to smoke again anyway.
Patient: You got it!
HCP: Now, you said that you’ve been successful in quitting previously, but then you start back again. When you quit initially, what worked for you?

11. Example #1 (cont.)
Reflecting and empathizing with the patient’s core motivational issues
Helps to create early rapport with the patient
Helps to initiate the process of engaging the patient’s reasoning process
If the patient feels that you haven’t heard and haven’t respected their issues, the patient will become defensive and/or aggressive
The patient is no longer listening to you

12. Rapport Phone Audio

13. Example #2 Developing the relationship with the patient
Engaging the patient’s reasoning processes
Identify the patient’s core motivational issues
Reflect and empathize with these issues
Explore the line of reasoning for each issue
Address the weak point of each line of reasoning
Invite the patient to draw a new conclusion

14. Example #2 (cont.) Developing the relationship with the patient
Engaging the patient’s reasoning processes
Identify the patient’s core motivational issues
Reflect and empathize with these issues
Explore the line of reasoning for each issue
Address the weak point of each line of reasoning
Decreases rapport
Impose your own conclusion on the patient

15. Example #2 (cont.)
HCP: Given that you don’t want to have a stroke or heart attack, what are you going to do to lower your blood pressure?
Patient: I don’t think that I can handle dieting, exercise, or quitting smoking. So, I’m going to rely on just taking the medicine.
HCP: It’s great that you are going to take your medicine. But the medicine alone won’t get your blood pressure down to a safe level without diet and exercise and quitting smoking. Your blood pressure is just too high.
Patient: Look, there’s no way I’m going to diet or exercise or quit smoking! And I really don’t like the idea of taking the medicine.

16. Example #2 (cont.)
If you make the argument for why you think the patient needs to change, the patient loses face and becomes resistant
READS: Avoid argumentation
MI is a facilitated reasoning process whereby the HCP assists the patient in making the argument for change
Must avoid reasoning steps that lose face for the patient

17. Establishing Global Premises
Some aspects of the patient’s thinking are global because they are the foundation for many lines of reasoning
Assessing patient’s understanding of disease and treatment
Establishing risk and susceptibility
Establishing patient’s long-term goals

18. Example #3 Patient: I had no idea my blood pressure was that high.
RPh: You were surprised to find out you had high blood pressure?
Patient: Yeah…I feel fine.
RPh: What’s your understanding of what can happen if your blood pressure remains high…even if you feel ok?
Patient: I’m not sure…I just know it’s bad for you.
RPh: That’s right..may I share with you some of the risks of it remaining high?
Patient: Ok.
RPh: If it remains elevated, you greatly increase your risk of stroke or heart attack. What are your thoughts about that?

19. Example #3
Sometimes a patient may not process the implications of generalized concepts such as “stroke” or “heart attack”
If you push the patient, you create relational resistance
One option is to personalize the consequences

20. Engaging the Patient’s Reasoning on a Specific Motivational Issue

21. 1. Empathize With the Motivational Issue
Reflect back and empathize with the patient’s motivational issues
Feeling + content + reasons
Empathize fully and explicitly
Create a solid mutually acknowledged foundation that all subsequent reasoning is built upon
Give clear explicit evidence that you have heard the patient’s issues

22. 1. Empathize With the Motivational Issue (cont.)
Avoid semantic reductions
“I’m shocked”  “You’re concerned”
Avoid generalized references
“I’m shocked that my blood pressure is still so high.”  “That would be disturbing.”
Avoid pronouncing “understanding”
“I understand that…”
Instead, use “I sense that…,” “I hear that…,” “I get the impression that…”

23. 1. Empathize With the Motivational Issue (cont.)
Empathize with the central motivational issue
Not with a superficial detail
Patient: It’s really hard to cut back on my smoking when I’m stressed out about things. Right now it’s the holidays…trying to get everything done before Christmas.
HCP: Preparing for the Christmas season is very difficult for you.

24. 1. Empathize With the Motivational Issue (cont.)
Empathize with the central motivational issue
Not with a superficial detail
Patient: It’s really hard to cut back on my smoking when I’m stressed out about things. Right now it’s the holidays…trying to get everything done before Christmas.
HCP: Christmas is really stressing you out. And when you get really stressed, you find that it’s harder to cut back on your smoking.

25. 1. Empathize With the Motivational Issue (cont.)
Combine supporting self-efficacy with empathy
Supporting self-efficacy and ignoring the motivational issue often leads to a dead end
Patient: I’m shocked that my blood pressure didn’t come down a lot more because I’ve been really cutting back on my smoking and eating less salty foods.
HCP: It’s great that you’ve been cutting back on your smoking. Tell me how you’ve managed to accomplish that.

26. 1. Empathize With the Motivational Issue (cont.)
Combine supporting self-efficacy with empathy
Supporting self-efficacy and ignoring the motivational issue often leads to a dead end
Patient: I’m shocked that my blood pressure didn’t come down a lot more because I’ve been really cutting back on my smoking and eating less salty foods.
HCP: Because you’ve worked hard to cut back on your smoking and decreased the salt in your diet, you were shocked and disappointed to find out that your blood pressure didn’t come down as much as you had expected.

27. 2. Frame the Motivational Issue
Framing can make explicit what is implied by the patient
Framing can subtly introduce new possibilities that patients are inclined to accept because
They feel understood
The new possibilities are attributed to them
Framing can help generate a verbal commitment from a negative expression of doubt and concern

28. 2. Frame the Motivational Issue (cont.)
Patient: I don’t see myself quitting smoking with all this stress in my life.
HCP: You seem to be saying that if you were less stressed or had less stress in your life, you would be much more likely to consider quitting.

29. 3. Create an Explicit Transition to Exploring and Informing
Failing to set the context for clinical inquiry
After empathizing with patient’s core motivational issue, HCPs often move too quickly to perform clinical steps required to address the patient’s issue
HCPs assume patients will understand why they are asking these questions
Patients can easily misunderstand the HCP’s questions as accusatory in nature

30. 3. Create an Explicit Transition to Exploring and Informing (cont.)
HCP needs to affirm desire to address the patient’s concern
Then, HCP needs to create explicit connection back to shared understanding of the patient’s issue

31. 3. Create an Explicit Transition to Exploring and Informing (cont.)
Patient: I’m shocked that my blood pressure didn’t come down a lot more because I’ve been really cutting back on my smoking and eating less salty foods.
HCP: You’re surprised that your blood pressure did not come down more especially since you have worked so hard on making lifestyle changes. In order for me to address your concern about your blood pressure, I need to ask you some questions. Would that be ok?
Patient: Sure.

32. Summary Empathize with the motivational issue
Frame the motivational issue
Create explicit transition to exploring and informing

33. 4. Explore the Patient’s Line of Reasoning
Explore and reflect back the patient’s line of reasoning
Identify potential points of influence in the line of reasoning
What parts of the patient’s reasoning can be targeted precisely?
Where’s the weakness in the reasoning?
How can you address the line of reasoning?

34. 5. Address the Patient’s Line of Reasoning
Add new information
Correct mistaken information
Surface unstated assumptions: “I feel fine.”
Personalize abstract benefits/losses
Create discrepancy
Share what other patients have done
The insurance card: “May I share with you my concern?”

35. 6. Invite the Patient to Draw the Conclusion
After addressing the patient’s line of reasoning, many HCPs put the pressure on the patient by
Implying that there is a correct conclusion: “That’s why we want you to…”
Reverting to a yes/no question: “Would you be willing to try…?”
“How do you feel about this information?”
“What are your thoughts about how this information applies to your situation?”

36. 6. Invite the Patient to Draw the Conclusion (cont.)
Crucial objective is to avoid creating new relational resistance by your drawing the conclusion
Intent is to assist patients in making their own argument for change
If they aren’t ready to draw a new conclusion, back off

37. 7. Assess Changes in Willingness, Readiness, and Confidence
Reinforce any change talk and especially any changed conclusions
Explore what the patient is willing and ready to do
HCP: “Cutting back on your smoking will help to reduce your asthma attacks. How do you think you can go about cutting back on your smoking?”

38. 8. Close the Deal
Provide a final summary of the patient’s line of reasoning
Express the desire to assist in reaching the patient’s goal
Affirm self-efficacy of any change proposed by the patient
Look forward to future interaction with the patient

39. Questions? Comments?