Presentation on theme: "Stephen R. Gillaspy, Ph.D. Department of Pediatrics"— Presentation transcript:
1 Communication Skills to Better Pain Management: Motivational Interviewing Stephen R. Gillaspy, Ph.D.Department of PediatricsUniversity of Oklahoma College of Medicine
2 Learning ObjectivesDiscuss common barriers to pediatric pain management.Describe and discuss fundamentals of Motivational Interviewing (MI).Describe and discuss specific motivational interviewing techniques.
3 What are barriers? Motivation Communication 3. Expectations Patient Parent / caregiverCommunication3. Expectations
4 Why Motivational Interviewing? Evidence-baseHundreds of randomized trialsSeveral meta-analysesMI > TAU, direct advice alone, educationPractice GuidelinesTobacco:USPHS Guidelines (“5 A’s”), American Academy of Pediatrics (2009), AMAAlcoholScreening, Brief Intervention, Referral to Treatment (SBIRT), American Academy of Pediatrics (2010), AMA
5 Behavior change Stages of change - pre-contemplation - contemplation - preparation- action- maintenance- relapseMatch intervention to stage of changeProchaska & DiClemente, 1984
7 How do people change? Style & Spirit Commitment/ Behavior Change Skills & Strategies Change talk ResistanceCommitment/Intrinsic MotivationBehavior Change
8 What is “Motivational Interviewing” “…a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” (Miller & Rollnick, 2002, p. 25)In MI, we attempt to:observe, respect, and avoid opposing sustain talk and;elicit, amplify, and affirm change talk
9 Style and Spirit of MI Relentlessly, radically patient-centered A way of being with people, characterized by:Collaboration (vs. one-up, authoritarian relationship)Evocation (vs. imparting or inserting knowledge)Autonomy-supportive (vs. controlling)Direction (vs. avoidant, distracted)Empathy (vs. dismissive, disrespectful)
10 Evocation Good practice: Poor practice: Clinician works to proactively evoke patient’s own reasons for change and ideas about if and how changes should happen.Poor practice:Clinician actively provides his or her reasons why the patient should change, or education about change, in the absence of attention or regard for the patient’s knowledge, ideas, or motivations
11 Collaboration Good practice: Poor practice: Clinician actively fosters and encourages power sharing, shows respect for patient ideas, and allows client ideas to substantially influence conversation.Poor practice:Clinician actively assumes expert role for majority of interaction.
12 Autonomy Support Good practice: Poor practice: Clinician is accepting and supporting of patient choice and autonomy and works to expand patient’s experience of control and choice.Poor practice:Clinician actively detracts from or denies patient’s perception of choice or control, assumes that client cannot move in appropriate direction without input from clinician
13 Direction Good practice: Poor practice: Clinician exerts influence on session and maintains focus on topic of target behavior change.Poor practice:Clinician does not influence topic of conversation, and direction is entirely in hands of patient
14 Empathy Good practice: Poor practice: Clinician shows evidence of deep and sincere understanding of patient’s point of view; demonstrates curiosity about patient; accurate reflectionsPoor practice:Clinician has no apparent interest or curiosity in patient’s worldview; may demonstrate indifference or dismissal of patient’s experiences or ideas; reflections, when present, are inaccurate or shallow
15 Specific Behaviors Microskills – operationalize global ratings Prescribed Behaviors:Seek permission to add target behavior to agendaEvocative questioningEmpathic reflective listeningOther MI-consistent behaviors
16 Seek permissionDemonstrate respect for autonomy and desire for collaboration immediatelyAsk for permission before transitioning to discussion of target behaviorDo you mind if we spend a few minutes today talking about your child’s ……?If you don’t mind, I would like to spend a little time today visiting about Johnny’s ……..
17 Evocative Questioning Use more open-ended questions than closed questionsOpen-ended questions require elaboration, not quite sure where answer might lead.Can you tell me more about that?How did you make that decision in the past?Closed-ended questions require a simple answer and leave direction in the hands of the asker.How many times during the week do you ……….?Where does it hurt?
18 Evocative Questioning (cont.) Scaled questions are very useful and highly recommendedCan ask about readiness, importance, or confidenceOn a 1-10 scale, how ready would you say you are today to make changes to your ………..?On a 1-10 scale, how important is it to you today to get Johnny’s ………. under control?Most important questions are follow-up questionsWhy did you say “3” and not “1”?What would it take to move from “5” to “9” or “10”?
19 Hypothesis Testing Model of Listening Role of ReflectionsWhat and how the patient saysWhat the clinician hears and seesWhat thepatient meansWhat the clinician understandsHypothesis Testing Model of Listening
20 Empathic, Reflective Listening Respond to patient statement and ideas with reflective statementsCan include restatement, rephrasing, metaphor, summary, etc.Try to reflect true meaning of patient expressionImportant for building rapport and enacting spirit of collaboration, empathy, autonomy support, and evocation
21 Other MI-Consistent Behaviors Advise and educate, with permissionAsk for permission explicitlyDo you mind if I share with you some information…Give permission to disregardI’m not sure if this would work for you or not, but my advice would be to…Collaborate on potential solutions or plansOffer a menu of options for addressing the problemExplore patient’s ideas for “goodness of fit” or “next steps”
22 Other (cont.) Affirm and support the patient Reinforce good choices, ideas with praise and encouragementOffer statements of compassion or sympathyEmphasize choice, autonomy, or controlBe explicit about your respect for the patient’s choiceIt is up to you, nobody can make this decision for you.You know yourself better than anyone.
23 Proscribed Behaviors Confrontation Advising (without permission) Avoid disagreeing, arguing, correcting, shaming, blaming, criticizing, labeling, moralizing, ridiculing, etc.Often turn conversation into a wrestling matchAdvising (without permission)Language usually includes words such as: should, why don’t you, consider, try, how about, etc.Over-directingCommands, orders, imperativesYou should, you must, etc.
24 Comparison of usual practice vs. MI Motivational interviewingClinician sets agendaTell patient what’s importantClinician decides when tomove ahead w/goalsClinician is responsible forpatient making changesClinician is instructorSuccess measured byclinician definitionPatient sets the agendaPatient decides what isimportant, in line w/corevalues, beliefs and needsPatient sets pace for workPatient is responsible for if, what & when behavior change occursClinician is a guideSuccess is measured by patient’s own values and goals