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FOLLOW GUIDE DIRECT MOVING FROM WHY TO HOW Barcelona, 2009 Ken Resnicow, PhD University of Michigan School of Public Health Ann Arbor, MI

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Presentation on theme: "FOLLOW GUIDE DIRECT MOVING FROM WHY TO HOW Barcelona, 2009 Ken Resnicow, PhD University of Michigan School of Public Health Ann Arbor, MI"— Presentation transcript:

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2 FOLLOW GUIDE DIRECT MOVING FROM WHY TO HOW Barcelona, 2009 Ken Resnicow, PhD University of Michigan School of Public Health Ann Arbor, MI 1

3 What they tell us…. “Ok, I got the reflection thing. I got the change talk thing. But where do I go from there. How do I bring this all together. ” 2

4 Perceived Barriers in the Treatment of Overweight Children and Adolescents Percentage Responding “Most of the Time” and “Often” RDs PNPs Pediatricians Barrier (n= 441) (n = 293) (n = 201) Lack of patient motivation Lack of parent involvement Lack of clinician time Lack of reimbursement Lack of clinician knowledge Lack of treatment skills Lack of support services Treatment futility Eating disorder concerns Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.

5 Barriers to Treatment of Pediatric Obesity % Report Encountering FPs PDs (n=74)(n=213) Lack of patient motivation99% 97% Poor patient compliance 96%95% Lack of effective therapy 83%78% No insurance for referrals 74%67% Lack of availability of referral services 65% 64% No insurance for in-office counseling 60%51% No time for frequent follow-up 56% 49% Kolagotla L, Adams W. Ambulatory management of childhood obesity. Obesity Research 2004;12(2):

6 Attitudes toward pediatric obesity counseling Family PracticePeds (n=74)(n=213) Personal ability to counsel Poor 11% 6% Fair 30% 17% Average44% 47% Good15%27% Excellent 0%3% Efficacy of obesity counseling Poor 11%23% Fair 48% 33% Average 36% 35% Good 5% 9% Excellent 0% 0.5% Kolagotla L, Adams W. Ambulatory management of childhood obesity. Obesity Research 2004;12(2):

7 Perceived Skill Level in Pediatric Obesity Management Among Practitioners % Low Proficiency Level RDs PNPs Pediatricians Use of behavioral management strategies Modification of eating practices Modification of physical activity Modification of sedentary behavior Guidance in parenting techniques Addressing family conflicts Assessment of the degree of overweight Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.

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12 11 Study Design: Ahluwalia, J. S., Okuyemi, K., Nollen, N., Choi, W. S., Kaur, H., Pulvers, K., et al. (2006). The effects of nicotine gum and counseling among African American light smokers: a 2 x 2 factorial design. Addiction, 101(6),  Six counseling sessions –three in-person (at randomization, week 1, week 8) –three by telephone (week 3, week 6 and week 16).  Health education (HE) focused on providing information and advice. Review the addictive nature of nicotine, health consequences of smoking and benefits of quitting, and concrete strategies for a quit plan.  MI explored the pros and cons of smoking/quitting;motivation and confidence to quit and values clarification.  Both HE and MI counselors participated in weekly supervision

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15 14 MI not indicated in highly motivated? Baseline motivation to quit on a 1-10 scale was 9.1 AND Must be willing to set a quit date in the next 14 days and use nicotine gum for 8 weeks

16  Health care professionals want closing skills.  They want to integrate MI with other Behavior Change skills  For highly motivated clients, MI might be contraindicated. 15

17 6. MI is not a form of cognitive-behavior therapy Cognitive-behavior therapies generally involve providing clients with something that they are presumed to lack. The missing piece might be new coping skills, conceptual education about how behavior is learned, counterconditioning, environmental contingencies, or the restructuring of faulty cognitions toward more adaptive ones. The expertise of CBT providers rests on their knowledge of and technical skill in applying principles of learning. The typically brief course of MI in one or two sessions does not involve teaching new skills, re-educating, counterconditioning, changing the environment, or installing more rational and adaptive beliefs. It is…. about eliciting from people that which is already there. It is not the communication of an expert who assumes that “I have what you need”, but rather the facilitative style of a companion whose manner says, “You have what you need, and together we’ll find it.” 16

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19 The Contradiction “ In cognitive and behavioral therapies …. the therapist is there to teach the client strategies for change such as exposure, social skills, contingency management, and cognitive strategies for changing distorted thoughts or beliefs. ….Either implicitly or explicitly, when we do CBT we often take the role of teacher and advocate for change. In doing MI the decisions about whether to change and how to change are left primarily to the client.” 18

20 Reconciliation “ MI can be viewed as a creative synthesis between Client- Centered Therapy and the action orientation of CBT. In CBT we do not formally address ambivalence about change, but in MI there are specific strategies for understanding and addressing this ambivalence to help the client become more ready for change. Since …MI does not assume readiness to change, but works to increase and maintain motivation for change, it may be a useful complement for CBT. ” 19

21 Integrative Approach “The therapist moves naturally and smoothly to examining and working with ambivalence in an MI style as it arises in the course of therapy. ” Arkowitz & Westra,

22 Autonomy Supportive Closing (MI-Consistent Directing)  Action Reflections  Provide Menu of Options for Change –Usually client helps populate the list  Counselor Undersells Options  Provide Choice – What to change – How much change – When – How Monitored – Contingencies 21

23 Two Phase Model MIBehavior Therapy Why to Change How to Change Low Readiness High Readiness (Resistant/Angry/Ambivalent)(Convinced) 22

24 MOVING FROM WHY TO HOW MI CONSISTENT DIRECTING AUTONOMY SUPPORTIVE CLOSING WHY Change HOW to Change MI Background Platform Building MotivationBuilding an Action Plan Handling ResistanceSelf-Monitoring Resolving AmbivalenceShaping Contract Contingency Management Cognitive Restructuring 23 MI Primary Modality

25 24 DIRECTING  Manage Prescribe  Lead Govern  Take ChargeAuthorize  RuleReign  SteerTake Command

26 25 Directing Acting Asking Listening Informing Advising Following Understanding Guiding Deciding Closing Acting Structure

27 Three Phases of Consultation  Following (WHAT/WHY/WHY NOT) –COMFORT THE AFFLICTED –Build Initial rapport & Express Empathy –Obtain a history –Collaborative agenda setting –Explore pros, cons, hopes and fears (Reasons)  Guiding (IF) –AFFLICT THE COMFORTBLE –Build Motivation & Discrepancy –Elicit change talk 0-10 Readiness Rulers Importance (Reasons/Desire/Need) Confidence (Ability) Values Clarification (Desire & Need) –SPIN THE BALLS Where does that leave you? –Obtain COMMITMENT –Move toward a behavior decision  Directing (if a decision/commitment has been made) (WHEN/HOW) –Taking STEPS –Establish a Goal –Provide Menu of Options –Set an Action Plan –Overcome/anticipate barriers –Make a contract & Discuss follow up 26

28 Phase I: Following –COMFORT THE AFFLICTED –Build Initial rapport & Express Empathy –Obtain a history  How long, how often, how much –Collaborative agenda setting –Explore pros, cons, hopes and fears (Reasons)  Guiding (IF) 27

29 Phase II: Guiding –AFFLICT THE COMFORTBLE –Build Motivation & Discrepancy –Elicit change talk 0-10 Readiness Rulers Importance (Reasons/Desire/Need) Confidence (Ability) Energy (Effort) Values Clarification (Desire & Need) –SPIN THE BALLS Where does that leave you? –Obtain COMMITMENT –Move toward a behavior decision  Directing ( if a decision/commitment has been made) 28

30 Phase III: What should we call it? MI-CONSISTENT DIRECTING AUTONOMY SUPPORTIVE CLOSING –ACTION REFLECTIONS –Provide Menu of Options –Establish a Goal –Set an Action Plan –Overcome/anticipate barriers –Make contract –Monitoring Plan –Discuss follow up 29

31 Types of Reflections  Content  Feeling/Meaning  Double-Sided  Rolling with Resistance  Amplified Negative  Reflection on Omission  Action 30

32 Moving things forward: Using reflections that embed potential solutions 31

33 Advanced Reflections  Imbed Solutions to Barriers  Imbed Action Plans  Undersell –You might want to… –You might want to consider… –Sounds like…..might be an option… –If we are to move forward you might need to address…. 32

34 Bringing the Water….  X has not worked for you  You are looking for something other than X  Any thoughts about Y  Y might be an option 33

35 Action Reflections  1) Invert Barrier –Sounds like we will need to address barrier a,b,c  2) General Behavior Fix –Sounds like doing something like x,y,z  3) Specific Behavior Fix –Sounds like doing x may be a possibility  4) Cognitive Fix –Sounds like you may have to think about x differently (make peace, no all or nothing thinking) 34

36 Maybe it’s time to quit. I am 55, my dad died of heart disease…and I am coughing up all this junk every morning. But I am dreading it. I cannot deal with the withdrawal…the cravings, the edginess, and the hunger..plus it is annoying having everyone commenting to me about how proud they are of me……… 35

37  So if you could find a way to reduce the withdrawal symptoms, you might be more willing to quit  Something to reduce cravings, edginess, and hunger might be of interest to you 36

38 Action Reflections  So if you could find a way to reduce the withdrawal symptoms, you might be more willing to quit (invert barrier)  Something to reduce cravings, edginess, and hunger might be of interest to you (general fix)  A medicine to reduce craving might be something for us to talk about (general fix)  Your might be interested in learning about a new drug called Chantix that helps with craving (specific fix)  You might want to quit without telling others, to avoid being under the microscope (specific fix)  If you could make peace with your fears, or realize you in fact CAN handle, that might make quitting easier (cognitive fix) 37

39 We tried to reduce the amount of TV she watches but it didn’t go so well. In the morning I need to get dressed, take a shower, make some breakfast and I usually end up letting her watch the Wiggles or Dexter’s Laboratory just to give me some free time. In the afternoon I feel it might be easier…since maybe I could get her involved in an art project or playing outside. 38

40  So it might be more realistic to work on the afternoon TV first.  Getting her involved in something more creative might help her fulfill her potential.  Art is the way to go 39

41 I tried giving my kids fruit for snack, if they don’t have their cookies they make a huge fuss… they expect sweets after school and I can’t stand the sound of their whining when they don’t get what they want. Plus, I kind of like baking homemade treats…. 40

42  So baking something that has some fruit in it, or is a little more healthy might satisfy both you and your kids 41

43 I've tried everything to help my child lose weight. I always have carrot sticks available and don’t let him eat any fried food. I tell him exactly what he can have, and watch what he eats very closely. I also make him exercise every day. I’m constantly on him, and yet he hasn’t lost a pound! 42

44  So trying to control what your child does hasn’t worked very well.  Telling your child what to eat isn’t helping him lose weight. 43

45  So far you have not involved your son in the decisions  Involving your son might help him buy into the changes better than setting new rules for him 44

46 I really want to lose weight..so this week I decided to be really good and tried to cut out all sweets from my diet. However, I felt miserable by the end of the day and finally broke down and ate a whole box of chocolates.. 45

47  So cutting out all sweets entirely doesn’t work for you.  Finding a way to lose weight might need to include having a few sweets. 46

48 Bringing it all together Get permission Set agenda Assess current level Discuss History Assess 0-10 importance/confidence  Probe lower/higher/what would it take A ssess core values  Link behavior to values Summarize & Spin: Where does that leave you? Build Menu of Choices Ask Client to Pick Option What can you do to make it happen?  This week  Today 47 FOLLOWGUIDEDIRECTFOLLOWGUIDEDIRECT

49 48 Action Item Parking LOT Idea 1 Idea 2 Idea 3 Throughout the session, listen for action talk Often, clients will already have an idea for what they MIGHT try Make a mental note and mention that you may go back to that idea later

50 Three Steps Toward Change… MI DIRECTING 101 1) Build a Menu of Options  List possible ideas mentioned by client during session  Ask patient for other solutions  Offer “other ideas that have worked with people with similar concerns” 2) Ask “which if any of these” might work best for you”. If they choose one… 3) Ask “what might you be able to do to increase your chances of success in the next day or week” 49

51 Cognitive Options for Change  Abstinence violation syndrome/Not All or Nothing  Craving/discomfort will pass  You can in fact deal with it  The withdrawal/side effect is normal  Focusing on the benefits  Making peace with the fact that the benefit is difficult to observe  Taking actions gives you a sense of control 50

52 Options for Change: BMI 2 Cognitive  Making peace with the transition phase. It may suck initially  Small changes still count  Healthy eating is not an ALL or NOTHING game  Once in a while it’s ok  It might take some time  Your child will eventually eat it  You PROVIDE they DECIDE Behavioral  Order Salad at Wendy’s  Limit TV to 1 hr a day  Order apple fries  Walk with your child  Talk to your husband about his ice cream  Have F & V around  Meditate or take Yoga  Provide choice 51

53 What else are those Public Health MINTies doing? 52

54 Human Motivation: Corresponding Intervention Models RationalEmotiveSpiritual/Metaphysical KnowledgeAttitudeMeaning PlannedEpiphany ConsciousUnconscious Left BrainRight Brain LinearChaotic Health Belief ModelSelf Determination Theory Social Cognitive TheoryChaos Theory Transtheoretical ModelMotivational Interviewing Theory of Reasoned Action 53

55 Self Determination Theory: Essential Human Needs  Competence  Autonomy  Relatedness 54

56 Intrinsic-Extrinsic Continuum 55 External IntrojectedIdentifiedIntegrated RegulationRegulationRegulationRegulation ComplianceEgoPersonal ImportanceCongruent RewardsGuilt/ShameConscious ValueMeaning Competence/Autonomy/Relatedness Amotivation Extrinsic MotivationIntrinsic Motivation NOT SELF-DETERMINEDCOMPLETELY SELF-DETERMINED Novelty Challenge Pleasure

57 Reflect on Omission  It’s interesting that you didn’t mention…  I suspect you thought about this already and maybe decided against it, however I am curious about……  You didn’t seem to respond to……  Reflect on silence 56

58 Married sedentary female  I really need to find someone to exercise with. I can’t do it alone. I just need someone to remind me or do it with me……but there is no one…. 57

59  So, it is interesting you have not mentioned your husband..I assume that he would no be helpful in any of this…. 58

60 59 Metaphors & Similes: Health/Patient Education is to MI as…  Engine/Fuel/Helm vs. Rudder –OHMMMM; be the rudder  Seeds in the wind vs. Strategic Planting –Measure twice; cut once Who Paints: You or the client?

61 60 Standardized Patients: Overweight case

62 REPEAT AFTER ME CRACK ROCKS!  Handling our own resistance 61

63  I eat at McDonalds a few times a week. There’s nothing better than a Big Mac, fries, and a shake. 62

64  When I am really down, a bowl of ice cream is sometimes the only thing that makes me feel better 63

65  You sound scared that we were going to ask you to give it up entirely (rolling with resistance)  This sounds like something we might have to work in once in a while (action) 64

66  Have you ever had Krispy Kreme glazed donuts…oh my god….you have to try them. 65

67  On weekends I love having a few joints and chilling.. 66

68 Eliciting Change Talk Stage 1: Diagnosis Strategy 1: Importance and Confidence Willingness/Importance On a scale of 0 to 10, with 10 being very important, how important is it for your (and/or your child) to change XXX ? Not at all SomewhatVery Confidence On a scale of 0 to 10, with 10 being very confident, assuming you decided to change XXX….how confident are you that you could succeed ? Not at all SomewhatVery 67

69 Energy & Dread 68 How much energy do you think it will take to change XXX? Very LittleModerate AmountTons

70 Why Values Clarification?  0-10, Pros & Cons, and other strategies often fail to tap deeper levels of motivation  Builds discrepancy  Link health behavior to person’s bottom line  Elicits new and different change talk 69

71 Values List 70 Which of the Following Values, Traits, or Characteristics are Important to you? Good ParentSupportive Good Family MemberAttractive Good Spouse/PartnerDisciplined Good Community MemberResponsible StrongIn Control On top of thingsRespected at work CompetentAthletic SpiritualNot hypocritical Respected at homeEnergetic Good Christian (or Jew, Muslim etc)Considerate SuccessfulYouthful (Older) Popular (Youth)Independent (Older) Choose your top 3 or 4

72 Values for Adolescents Good student Disciplined Healthy & fit Respected at school Strong In control ResponsibleGood to my parents On top of thingsAthletic Competent Confident Spiritual Energetic Respected at Home Mature Successful Independent Popular Other__________ Attractive 71

73 Values for Parents of Overweight Youth Values For Your ChildValues for YouValues for Your Family Be HealthyGood ParentCohesive Be Strong ResponsibleHealthy Have many friends DisciplinedPeaceful Meals Being fitGood SpouseGetting along Not feeling abnormal Respected at HomeSpending time together Not being teasedOn top of things Not feeling left outSpiritual Be able to communicate his/her feelings Fulfill her potential Have high self-esteem 72

74 Values List: Australian Style 73 Which of the Following Values, Traits, or Characteristics are Important to you? Good ParentAttractive Good Spouse/PartnerDisciplined Good Community MemberResponsible StrongIn Control On top of thingsRespected at work CompetentAthletic/Good at Sport SpiritualNot hypocritical Respected at homeEnergetic ConsiderateAssertive SuccessfulYouthful (Older) Popular (Youth)Independent (Older) Laid Back/Easy going/Being A good SportBe a good/loyal mate Environmentally responsibleFare Go/Egalitarian Being able to Take itHonesty/Being Upfront Being able to copeResilient PrivacyCommunalism Choose your top 3 or 4

75 Values List: The Dutch Experience 74 Which of the Following Values, Traits, or Characteristics are Important to you? Good ParentAttractive Good Spouse/PartnerDisciplined ResponsibleEnvironmental Conscious StrongIn Control On top of thingsRespected at work CompetentAthletic SpiritualNot hypocritical Respected at homeEnergetic ConsiderateSupportive of others SuccessfulYouthful (Older) Popular (Youth)Independent (Older) TolerantRespect for Other JusticeCommunity/Neighbor Choose your top 3 or 4

76 Values List: South African Adults 75 Which of the Following Values, Traits, or Characteristics are Important to you? Good ParentGood Spouse/Partner DisciplinedPolitically Aware Good Community MemberResponsible Strong Extended FamilyAt peace with ancestors Responsible Manhood (n”guni) StrongIn Control On top of thingsRespected at work CompetentIndependent (Older) SpiritualNot hypocritical Respected at homeEnergetic ConsiderateSuccessful Youthful (Older)Popular (Youth) Choose your top 3 or 4

77 Values List: Singaporean Adults 76 Which of the Following Values, Traits, or Characteristics are Important to you? Good ParentGood Spouse/Partner DisciplinedGood Community Member Politically Aware Responsible Respect for eldersFreedom Success at work Social Consciousness StrongIn Control On top of thingsRespected at work CompetentIndependent (Older) SpiritualNot hypocritical Respected at homeEnergetic ConsiderateSuccessful Youthful (Older)Popular (Youth) WealthySuccessful children Not losing out (kiasu)Face saving (ai-mian-zi) Don’t wash your dirty linen/Disgrace (jia-chou-bu-ke-wai-wang) Choose your top 3 or 4

78 Buying Back Time –Reduce Unsolicited Information Use E-P-E vs. Information Dump –Reduce Unsolicited Advice Use Action Reflections Provide Choices vs. Skeet Shooting 77

79 The 10 Epiphanies of MI Training  Reflections elicit more information than questions  You only need to get the bat on the ball: Reflections don’t have to be perfect  Deeper level reflections are worth the risk  Health behaviors relate to deeper issues  The counselor’s role is to help clients explore their ambivalence and the possibility of change, not to ensure change  Behavior change is driven by more by motivation than information  Motivated clients solve their own barriers (or ask for help)  Most of the advice you might offer has already been thought about, and rejected by your patients  Clients will share a lot, quickly with empathetic, attentive listeners  Much can be covered in a 10-minute encounter 78

80 Health Behavior Change: The Feeling Vocabulary  Trapped  Torn  Hopeless  Powerless  Alone  Overwhelmed  Drained 79

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83 BMI² Brief Motivational Interviewing to Reduce Child BMI R01 HL A2 INVESTIGATORS University of Michigan AAP K. ResnicowE. Slora M. DavisM. Wasserman (UVM) S. WoolfordA. Bocian F. McMasterD. Harris J. Gotlieb American Dietetics AssociationWake Forest S of M E. MyersR. Schwartz J.Foster NHLBIUniversity of Iowa C. PrattL. Snetselaar

84 BMI 2 Study Overview Group 1 (Usual Care) 10 practice/200 subjects Group 2 (PED) 10 practice/200 subjects Group 3 (PED+RD) 10 practice/200 subjects Baseline BMI % ½ day study orientation 2 day MI/CBT training MI-DVD 2 day MI/CBT training MI-DVD Educational Materials+ 4 MD MI sessions (3 sessions in year 1; 1 session in year 2) + 4 MD MI & 6 RD MI (in person and by phone) Sessions 2 Yr FU BMI % 2-day MI/CBT training & MI-DVD NA

85 Key Study Parameters Study Sample –Children, ages 2-8, with BMI > 85th & < 97th percentile –Intervene with parents Study Setting –33-39 PROS offices nationally –20 Children per office (600 total) –Randomize Practices Primary Outcome –Child BMI Percentile Change at 2-year FU –Powered to detect 3%ntile difference between groups

86 Primary Hypotheses HO1: At 2-year follow-up, children in the moderate intensity intervention (PED only) group will show a 3 point (absolute) decrease in BMI percentile relative to usual care group (UC). HO2: At 2-year follow-up, children in the high intensity intervention (PED + RD) group will show a 3 point (absolute) decrease in BMI percentile relative to children in the moderate intensity group (PED only).

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89 A PEER SUPPORT PROGRAM FOR VETERANS OF THE MICHIGAN NATIONAL GUARD Ken Resnicow, PhD University of Michigan School of Public Health Ann Arbor, MI Phone (734) Buddy to Buddy Communication Skills

90 I drink a bit…..and smoke a little weed… sure it ain’t good for me…..but I don’t see how I can make it through the day without it….I am edgy all the time and have these nightmare images in my head that are..I am not a drug addict..this is just a short term thing to get through the first few months back 89

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105  I really don’t like thinking about it. My husband makes my appointment. He orders my drugs. I just show up at the clinic for my infusion. With adjusting to this disease I don’t think at this point I can handle taking care of all those logistics. 104

106 E-P-E  Empathize/Elicit –Reflect –What is your understanding? –What have you heard about? –What do you want to know?  Provide –Info –Advice –Choice –Some of what I say may differ from what you have heard?  Elicit –What do you make of that? –Where does that leave you? 105

107 106 Closing Acting Asking Listening Informing Advising Following Understanding Guiding Deciding

108 Moving Forward…  What might you be able to do in the next few days to move things along (or increase your chances of success?)  What might you be able to do in the next few weeks to move things along? 107

109 What goes on the MENU 1) Solutions listed by counselor suggested or implied by the client 2) Other ideas generated by the client Which of these do you think might work best for you? Which of these might you be willing to try? 108

110 Five Steps Toward Change… 1) List possible ideas mentioned during session 2) Ask patient to offer other solutions 3) Offer “other ways” to think about it and “possible” tips to help deal with the problem (talking points) 4) Ask “which if any of these” might work best for you”. If they choose one… 5) Ask “what might you be able to do to increase your chances of success in the next day or week” 109


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