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Communication Skills to Better Pain Management: Motivational Interviewing Stephen R. Gillaspy, Ph.D. Department of Pediatrics.

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Presentation on theme: "Communication Skills to Better Pain Management: Motivational Interviewing 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 Pediatrics University of Oklahoma College of Medicine

2 Learning Objectives 1.Discuss common barriers to pediatric pain management. 2.Describe and discuss fundamentals of Motivational Interviewing (MI). 3.Describe and discuss specific motivational interviewing techniques.

3 What are barriers? 1.Motivation –Patient –Parent / caregiver 2.Communication 3. Expectations

4 Why Motivational Interviewing? Evidence-base – Hundreds of randomized trials – Several meta-analyses – MI > TAU, direct advice alone, education Practice Guidelines – Tobacco: USPHS Guidelines (5 As), American Academy of Pediatrics (2009), AMA – Alcohol Screening, Brief Intervention, Referral to Treatment (SBIRT), American Academy of Pediatrics (2010), AMA

5 Behavior change Stages of change - pre-contemplation - contemplation - preparation - action - maintenance - relapse Match intervention to stage of change Prochaska & DiClemente, 1984

6 Why dont people change? procrastination behavioral economics avoidance self-affirmation biases habit-driven reactance biases toward downward comparison reject labels negative affect

7 How do people change? Style & Spirit Skills & Strategies Change talk Resistance Commitment/ Intrinsic Motivation Behavior 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: 1.observe, respect, and avoid opposing sustain talk and; 2. 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: – Clinician works to proactively evoke patients 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 patients knowledge, ideas, or motivations

11 Collaboration Good 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: – Clinician is accepting and supporting of patient choice and autonomy and works to expand patients experience of control and choice. Poor practice: – Clinician actively detracts from or denies patients perception of choice or control, assumes that client cannot move in appropriate direction without input from clinician

13 Direction Good 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: – Clinician shows evidence of deep and sincere understanding of patients point of view; demonstrates curiosity about patient; accurate reflections Poor practice: – Clinician has no apparent interest or curiosity in patients worldview; may demonstrate indifference or dismissal of patients 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 agenda – Evocative questioning – Empathic reflective listening – Other MI-consistent behaviors

16 Seek permission Demonstrate respect for autonomy and desire for collaboration immediately Ask for permission before transitioning to discussion of target behavior – Do you mind if we spend a few minutes today talking about your childs ……? – If you dont mind, I would like to spend a little time today visiting about Johnnys ……..

17 Evocative Questioning Use more open-ended questions than closed questions – Open-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 recommended Can ask about readiness, importance, or confidence – On 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 Johnnys ………. under control? Most important questions are follow-up questions – Why did you say 3 and not 1? – What would it take to move from 5 to 9 or 10?

19 Role of Reflections What the patient means What and how the patient says What the clinician hears and sees What the clinician understands Hypothesis Testing Model of Listening

20 Empathic, Reflective Listening Respond to patient statement and ideas with reflective statements – Can include restatement, rephrasing, metaphor, summary, etc. – Try to reflect true meaning of patient expression Important for building rapport and enacting spirit of collaboration, empathy, autonomy support, and evocation

21 Other MI-Consistent Behaviors Advise and educate, with permission – Ask for permission explicitly Do you mind if I share with you some information… – Give permission to disregard Im not sure if this would work for you or not, but my advice would be to… Collaborate on potential solutions or plans – Offer a menu of options for addressing the problem – Explore patients ideas for goodness of fit or next steps

22 Other (cont.) Affirm and support the patient – Reinforce good choices, ideas with praise and encouragement – Offer statements of compassion or sympathy Emphasize choice, autonomy, or control – Be explicit about your respect for the patients choice It is up to you, nobody can make this decision for you. You know yourself better than anyone.

23 Proscribed Behaviors Confrontation – Avoid disagreeing, arguing, correcting, shaming, blaming, criticizing, labeling, moralizing, ridiculing, etc. – Often turn conversation into a wrestling match Advising (without permission) – Language usually includes words such as: should, why dont you, consider, try, how about, etc. Over-directing – Commands, orders, imperatives – You should, you must, etc.

24 Comparison of usual practice vs. MI Comparison of usual practice vs. MI Usual Practice Clinician sets agenda Tell patient whats important Clinician decides when to move ahead w/goals Clinician is responsible for patient making changes Clinician is instructor Success measured by clinician definition Motivational interviewing Patient sets the agenda Patient decides what is important, in line w/core values, beliefs and needs Patient sets pace for work Patient is responsible for if, what & when behavior change occurs Clinician is a guide Success is measured by patients own values and goals

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