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Creating Conversational Flow With MI Copyright Berger Consulting, LLC 1792 Overton Rd Auburn, AL 36830 334.444.3160 baberger.shutterfly.com.

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Presentation on theme: "Creating Conversational Flow With MI Copyright Berger Consulting, LLC 1792 Overton Rd Auburn, AL 36830 334.444.3160 baberger.shutterfly.com."— Presentation transcript:

1 Creating Conversational Flow With MI Copyright Berger Consulting, LLC 1792 Overton Rd Auburn, AL baberger.shutterfly.com These materials may not be duplicated or used without permission.

2 Creating Conversational Flow Weve 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 patients reasoning Address issue resistance

4 Basic MI Processes (cont.) Developing the relationship with the patient Express empathy Support self-efficacy Engaging the patients reasoning Establishing global premises Assessing patients understanding of disease and treatment Establishing risk and susceptibility Establishing patients long-term goals Addressing the patients 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 patients reasoning Identify the patients 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 patients 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 patients reasoning Allows you to speed up because patient is not defensive and argumentative Saves time by precisely targeting the patients thinking: rifle vs shotgun

9 Example #1 Developing the relationship with the patient Engaging the patients reasoning processes Identify the patients 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: Ive tried to quit smoking for a while. But I always come back to it again. So, I dont 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 youve 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 patients core motivational issues Helps to create early rapport with the patient Helps to initiate the process of engaging the patients reasoning process If the patient feels that you havent heard and havent 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 patients reasoning processes Identify the patients 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 patients reasoning processes Identify the patients 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 Impose your own conclusion on the patient Decreases rapport

15 Example #2 (cont.) HCP: Given that you dont want to have a stroke or heart attack, what are you going to do to lower your blood pressure? Patient: I dont think that I can handle dieting, exercise, or quitting smoking. So, Im going to rely on just taking the medicine. HCP: Its great that you are going to take your medicine. But the medicine alone wont 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, theres no way Im going to diet or exercise or quit smoking! And I really dont 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 patients thinking are global because they are the foundation for many lines of reasoning Assessing patients understanding of disease and treatment Establishing risk and susceptibility Establishing patients 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: Whats your understanding of what can happen if your blood pressure remains high…even if you feel ok? Patient: Im not sure…I just know its bad for you. RPh: Thats 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 Patients Reasoning on a Specific Motivational Issue

21 1.Empathize With the Motivational Issue Reflect back and empathize with the patients 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 patients issues

22 1.Empathize With the Motivational Issue (cont.) Avoid semantic reductions Im shocked Youre concerned Avoid generalized references Im 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: Its really hard to cut back on my smoking when Im stressed out about things. Right now its 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: Its really hard to cut back on my smoking when Im stressed out about things. Right now its 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 its 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: Im shocked that my blood pressure didnt come down a lot more because Ive been really cutting back on my smoking and eating less salty foods. HCP: Its great that youve been cutting back on your smoking. Tell me how youve 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: Im shocked that my blood pressure didnt come down a lot more because Ive been really cutting back on my smoking and eating less salty foods. HCP: Because youve 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 didnt 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 dont 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 patients core motivational issue, HCPs often move too quickly to perform clinical steps required to address the patients issue HCPs assume patients will understand why they are asking these questions Patients can easily misunderstand the HCPs questions as accusatory in nature

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

31 3. Create an Explicit Transition to Exploring and Informing (cont.) Patient: Im shocked that my blood pressure didnt come down a lot more because Ive been really cutting back on my smoking and eating less salty foods. HCP: Youre 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 Patients Line of Reasoning Explore and reflect back the patients line of reasoning Identify potential points of influence in the line of reasoning What parts of the patients reasoning can be targeted precisely? Wheres the weakness in the reasoning? How can you address the line of reasoning?

34 5.Address the Patients 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 patients line of reasoning, many HCPs put the pressure on the patient by Implying that there is a correct conclusion: Thats 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 arent 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 patients line of reasoning Express the desire to assist in reaching the patients goal Affirm self-efficacy of any change proposed by the patient Look forward to future interaction with the patient

39 Questions? Comments?


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