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
Discuss 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 / caregiver
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 A’s”), 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 don’t people change?
procrastination
reactance
behavioral economics
reject labels
avoidance
self-affirmation biases
habit-driven
biases toward downward comparison

7. How do people change? Style & Spirit Commitment/ Behavior Change
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:
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 reflections
Poor 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 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 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 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 Johnny’s ………. 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. Hypothesis Testing Model of Listening
Role of Reflections
What and how the patient says
What the clinician hears and sees
What the
patient means
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
I’m 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 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 encouragement
Offer statements of compassion or sympathy
Emphasize choice, autonomy, or control
Be explicit about your respect for the patient’s choice
It 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 match
Advising (without permission)
Language usually includes words such as: should, why don’t you, consider, try, how about, etc.
Over-directing
Commands, orders, imperatives
You should, you must, etc.

24. Comparison of usual practice vs. MI
Motivational interviewing
Clinician sets agenda
Tell patient what’s important
Clinician decides when to
move ahead w/goals
Clinician is responsible for
patient making changes
Clinician is instructor
Success measured by
clinician definition
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 patient’s own values and goals