Presentation on theme: "Health Behavior Coordinator, Psychologist"— Presentation transcript:
1Health Behavior Coordinator, Psychologist “Practical Strategies in Medication Adherence in Patients with Cardiovascular Disease” MOTIVATIONAL INTERVIEWING: What is it? Does it work?Julie Culligan, PhDHealth Behavior Coordinator, PsychologistMountain Home VAMC
2MI Philosophy"People are generally better persuaded by the reasons which they have themselves discovered than by those which have come in to the mind of others.” ~ Blaise Pascal, French mathematician, physicist and religious philosopher
3Learning ObjectivesSpecify and discuss 3 elements of the “spirit” of Motivational InterviewingIdentify the 4 principles of Motivational InterviewingIdentify basic use of the following core MI skills: open-ended inquiry, affirmation, reflective listening and summaries
4Facilitating Behavior Change What makes behavior change so hard?It works for us“Habit”It often involves multiple behaviorsKnowledge about how to change isn’t always enoughPeople are creatures of habitHealth consequences are often delayedBusy lifestyles require us to make time for self care
5Motivational Interviewing “A person-centered, goal-oriented approach for facilitating change through exploring and resolving ambivalence.“ (Miller & Rollnick, 2006)A clinical “style;” a “way of being with people” (Miller & Rollnick, 2002; Rollnick & Miller, 1995)
6Motivational Interviewing: Based on Theory Conceptualized according to stage model of change (Prochaska & DiClemente, 1982)Not everyone engages in treatment at the same stage of readinessDifferent type of approach may be utilized for individuals at different stages
7Transtheoretical Model: Stages of Change A STAGE MODEL OF THE PROCESS OF CHANGEPre-ContemplationDeterminationContemplationRelapseActionMaintenancePermanent Exit
8Not to change behavior….. The Goal of MIThe goal of MI is to facilitate:Fully informed,Deeply thought out,Internally motivated choices,Not to change behavior…..Resnicow, et al., 2002
9Traditional vs. Motivational The “Doctor”:The “patient”:Places the importance on the behavior changeControls the interactionMay direct/select the goals the patient should achieveDetermines the importance of the behavior changeIs listened to, shares concerns and needsIs supported in decisions about change and goals
10Empathic Style of MI and Brief Interventions The key element in brief interventions is empathyResearch on empathy and clinical outcomes:Strongest predictor of outcomesNot accounted for by demographicsNot accounted for by treatment type
11Patient Focus MI supports the patient in articulating How personally important this change (e.g., dietary) is, as opposed to how important we think it isWhat stands in the way of making this change (time, money, cultural factors, emotions, etc.)Changes that might work in their lifeHow to increase the chances of success
13Spirit of Motivational Interviewing Evocative (vs. Educational) – patient is responsible for change. (“What would you gain if you changed your drinking?”) vs. implanting the right idea (“You really need to stop drinking.”)Honoring Autonomy (vs. Authority) – Allow the freedom not to change. (“How ready are you to change?) vs. push for commitment (“If you delay getting sober, you could die.”)Collaborative (vs. Confrontational) – Work in Partnership. (“How about we discuss some options together” vs. “I would urge you to quit drinking.”)Honoring patient autonomy – requires a certain degree of detachment from the outcomes, though not an absence of caring. Clinicians may inform, advice, even warn – but ultimately it is up the patient to decide what to do. Humans resist coercion and being told what to do. Ironically, it is the acknowledging the other’s right and freedom not to change that sometimes makes change possible.Collaborative – a cooperative and collaborative partnership between patient and clinician. Challenges typical uneven power differential, and encourages active collaborative conversations and joint decision-making.
14The Spirit of MIMotivation for change is elicited from within the patient, not imposed from outsideThe patient must articulate reasons for changeThe patient is the one responsible to decideDirect persuasion is ineffectiveThe clinician should steer the conversation to focus on change
15Ambivalence Interesting, natural, human, understandable Not unique to characterological problemsNot indicative of defense (denial)“I want to but I don’t want to”Unhelpful to think of people as “unmotivated”
16SPIRIT OF MI Ambivalence APPRECIATE AMBIVALENCEHONOR, EMBRACE, EXPLORE AMBIVALENCE. It’s the core.Many brief (and single session) therapies work by focusing on this ambivalence, not on skills (people frequently have the skills)
17The RIGHTING Reflex “This person SHOULD want to change.” NOW is the right time to change.A TOUGH/clear/honest approach is best.Patient should follow my EXPERT ADVICE.If patient doesn’t change, the session FAILED.There’s nothing we can do for the “unmotivated.”OKAY if suicidal, but NOT IN RESPONSE TO AMBIVALENCE!!!
18Rather than the Righting Reflex, Understand Ambivalence Reflective listeningHelps patients to feel understoodProvides comfort to patient (makes change easier)Acceptance; non-judgmental; no blamingAcceptance ≠ AgreementAmbivalence = normal (not pathological)
21Evaluate the Pros and Cons Reducing/Giving up TobaccoPros (Good Things)Cons (Downsides)Smoking the SameI can still smoke with I friendsIt helps me deal with my stressIt’s hard to breatheIt’s a fire hazardIt’s bad for my healthIt’s expensiveMaking Changes in SmokingFeel betterHave more energyHave more moneyI wouldn’t be able to hang out with my friends who smokeI wouldn’t have a way to deal with my problemsFill in any behavior change
22Evaluate the Pros and Cons Increasing Medication AdherencePros (Good Things)Cons (Downsides)Stay the Same, i.e., Non-AdherentI can still smoke with I friendsIt helps me deal with my stressIt’s hard to breatheIt’s a fire hazardIt’s bad for my healthIt’s expensiveMaking Changes,i.e., AdherentFeel betterHave more energyHave more moneyI wouldn’t be able to hang out with my friends who smokeI wouldn’t have a way to deal with my problemsFill in any behavior change
23Four Key Principles of MI Express empathyDevelop discrepancyRoll with resistanceSupport self-efficacy
24(1) Express Empathy Reflective listening Helps patients to feel understoodProvides comfort to patient (makes change easier)Acceptance; non-judgmental; no blamingAcceptance ≠ AgreementAmbivalence = normal (not pathological)
25(2) Develop Discrepancy Change is motivated by perceived discrepancy between present behavior and personal goals/valuesDiscrepancy = importance of change for patientAmplify the discrepancy to move patient from the status quoElicit discrepancy from the patient – they should make the argument for change
26(3) Roll with Resistance Argument often pushes person in the opposite directionResistance is a call for the clinician to change, not the patientQuestions and problems should be reflected back to the patient, not “solved” by the clinician
27(4) Support Self-Efficacy Be aware of your own beliefs about a patient’s ability to change (self-fulfilling prophecy)Enhance patient’s self-belief about his or her capability to make a changeBe genuine
28Motivational Interviewing December, 2007 What People say about Change predicts Behavior ChangeSelf-perception theoryGary S. Rose, Ph.D. Copyright (c) Please do not reproduce without permission.
29Core MI Strategies Four Early Strategies; OARS Open Questions AffirmingReflective ListeningSummarizingElicit Positive “Change Talk”There are 5 early strategies that can help you deliver messages in a motivational style:Asking open questions – these are questions that can’t be answered with a simple “yes” or “no” and encourage the person to tell you moreAffirming – Validating the patient’s perspective, even when you don’t necessarily agreeReflective Listening – Selectively reflecting back patient statements that highlight discrepancies, clarify patient’s desires and help them determine the best course of action.Summarizing – Offer periodic summaries that pull together different parts of the conversation to be sure the health worker accurately understands the patient, and that the patient understands the agreed upon plan.These strategies, when used together strategically, can elicit positive change talk from patients.
30Open-Ended Questions Disarms resistance Creates momentum Avoids argumentsYou want them engaged and exploring – with you gently steering
31Open Questions to Promote Change Disadvantages of the Status QuoHow do you feel about your weight?Advantages of ChangeWhat would the benefits be for you, if you were to quit smoking ?Optimism for ChangeWhat makes you feel that now is a good time to try something different?Intention to ChangeWhat would you like to see happen?How might things be different for you, if you did make a change?
32Affirmation Genuinely highlight patients’ strengths Antidotes to demoralizationAppreciative of partial success (ex. Focus on success with quitting smoking for 2 years in past)Appreciates their honesty regarding ambivalenceSupport: form of compliments, statement of appreciation & understanding
33Reflective Listening – The Foundation of MI “MINI-SUMMARIES” used strategically to lower resistanceUsed to highlight patient statements favoring change (“Change Talk”)A way of thinking, Difficult to learnPowerful for increasing readinessExpert ratio 2 reflections for every question vs. Novice ratio .5 reflections for every question
34Handy ReflectionsDouble-Sided (reflects both sides of ambivalence) – takes the clinician out of the equation – puts the ambivalence in their own lapSo on the one hand, you like how alcohol makes you feel and at the same time, you worry about your Hepatitis.Amplified – can go in either directionUndershoots so patient might elaborate, “You’re a LITTLE confused…”Overshoots so patient can back down, “So you don’t EVER intend to cut down…”
35Handy ReflectionsShifting Focus – shift patient’s concern away from a potential stumbling block – around barriers rather than over themc: “Okay, maybe I’ve got some problems with drinking, but I’m not alcoholic.”Argument with a Twist – offer initial agreement, but with a slight twist or change of direction
36Summarizing Helps the other person: Recall and reflect upon the conversationThink of new ideasUnderstand the importance of these issuesPlan next stepsFeel more confident, instill hope
37Importance and Confidence Importance: lets you know how important this issue(s) is to the patient, in the grand scheme of other important values in their lifeConfidence: lets you know how able the patient feels he/she is to make specific changes towards his/her goal(s)
38Readiness Indicators Assessing Importance and Confidence Importance How important is it to you to ____________?On a scale of 0 to 10, with 0 being not important at all & 10 being very important…Not a all Somewhat VeryConfidenceHow confident are you that you could _____________, if you decided to? On a scale of 0 to 10, with 0 being not confident at all & 10 being very confident?Not at all Somewhat Very
39Evaluating Importance/Confidence “What made you answer with a (number patient gave) and not a zero?”“What would it take for you to move from a (number patient gave) to a (slightly higher number)?”
40Setting Goals Specific Measurable Achievable Realistic Timely Rather than: “I will exercise regularly”, Aim for “I will walk for minutes 4 days/week starting today”
43MI BooksMiller, WR & Rollnick, S (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.Miller, WR & Rollnick, S (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.Arkowitz, H, Westra, HA, Miller, WR, Rollnick, S (Eds.) (2008). Motivational interviewing in the treatment of psychological problems. New York: Guilford Press.Rollnick, S, Miller, WR & Butler, CC (2008). Motivational interviewing in health care. New York: Guilford Press.
44MI ArticlesBritt, E, Hudson, SM, & Blampied, NM. (2004). Motivational interviewing in health care settings. Education and Counseling, 53,Emmons, KM, & Rollnick, S. (2001). Motivational interviewing in health care settings. American Journal of Preventive Medicine, 20,Greaves C, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Steele A, Gale T, Hammerton F, Daly M (2008). Motivational interviewing for modifying diabetes risk: a randomized controlled trial. British Journal of General Practice, 58(553),Hecht, J, et al. (2005). Motivational Interviewing in community-based research: Experiences from the field. Annals of Behavioral Medicine, 29 Special Supplement,Resnicow, K, et al. (2001). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21,
45Soria R, Legido A, Escolano C, and Yeste A (2006) Soria R, Legido A, Escolano C, and Yeste A (2006). A randomized controlled trial of motivational interviewing for smoking cessation. Br J Gen Prac, 56(531),Moyers T, Martino S (2006). “What’s important in my life” The personal goals and values card sorting task for individuals with schizophrenia.Zygmunt A, Olfson M, Boyer A, Mechanic d (2002). Interventions to improve medication adherence in schizophrenia. American Journal of Psychiatry.Possidente C, Bucci K, McClain W (2005). Motivational interviewing: A tool to improve medication adherence? American Journal of Health-System Pharmacy, 62(12)Swaminath G (2007). You can lead a horse to water… Indian Journal of Psychiatry, 49(4),Cole S, Bogenschutz M, Hungerford D (2011). Motivational Interviewing and Psychiatry: Use in addiction treatment, risky drinking and routine practice. FOCUS, 9:42-54.