Presentation on theme: "Motivational Interviewing for Health Behavior Change"— Presentation transcript:
1 Motivational Interviewing for Health Behavior Change Paul F. Cook, PhD & Laurra M. Aagaard, MS, MAUniversity of Colorado College of Nursing
2 DISCLOSURES (past 12 months) Grant Funding: National Institutes of Health, HRSA (Federal), SAMHSA (Federal), CDC (Federal), Merck & Co. Inc., Colorado Health FoundationSpeaking: University of Colorado Hospital, Children’s Hospital of Colorado, National Food Program Sponsors’ Association, Colorado Dept. of Workers’ Comp.Consulting: Takeda Inc., Covance Market Access Inc., Medical Simulation Corp., Academic Impressions Inc., Competency & Credentialing Institute Inc.
3 The ProblemHealth is getting worse over time. From 1994 to 2000, the U.S. obesity rate rose by 1/3Patients don’t follow medical recommendations: 50% for medication adherence, lower for diet, exercise, recommended screening & preventionBehaviors are independent of each otherPatients aren’t always honest about behaviorAbid, et al., 2005; Goldstein, Whitlock, & DePue, 2004; Polivy & Herman, 2002; WHO, 2002
4 OUR OBJECTIVES FOR YOUUse the spirit of MI to guide your work with clients and avoid unproductive interactionsDescribe the research basis for MI as a best practiceIdentify key MI principles: rolling with resistance, expressing empathy, developing discrepancy, an supporting self-efficacyRecognize MI "micro-skills" like reflection, open-ended questions, and the elicit provide-elicit method of patient educationRecognize change talk and sustain talk, andapply strategies for responding to each
5 Behavior Change is Difficult! Individuals and systems tend to resist change50% of meds abandoned by 12 mos.Exercise has even lower adherenceDiet changes are hard to sustainEnvironmental pressures and habits affect behavior outside awarenessSome barriers are legitimate concerns: cost, time, weather, transportation, painChange in one area does not generalize to changes in other areasGlasgow, McCaul, & Schafer, 1987 ; Meichenbaum & Turk, 1987; NCPIE, 1994; Polivy & Herman, 2002
7 Everyone is Ambivalent The nonadherent personArgues or interrupts: yeah, but …Denies or ignores problems: it’s not a big deal …Still has a part of them that values healthStill has a part of them that wants to changeThe adherent personIs (probably) telling you the truthIs doing fine for nowStill has a part of them that resents/resists change
9 12 Roadblocks Ordering Shaming Threatening Psychoanalyzing Persuading LecturingMoralizingCriticizingShamingPsychoanalyzingSympathizingPraisingQuestioningChanging the SubjectExercise: MI script for Head Start dental issues, or MI script for adolescent obesity programTry it!Gordon, 1970
10 A Way Through Resistance Listen carefullyUnderstand people’s motivationsResist the urge to “fix it”Empower the clientSee if we can locate a story for this one – your answer is right for you, someone else’s answer is right for themMarla Corwin, CU School of Medicine, 2013 (adapted from Rollnick, Miller, & Butler, 2008)
11 Motivational Interviewing “SPIRIT” MI is not primarily a set of techniques; it is an attitude or a different way of being with peopleMI is at the same time …Empathic (caring) andGuiding (directive)Some characteristics of MI (ACCE):AcceptingCollaborative / Person-CenteredCompassionateEvoking and Strengthening Motivation to ChangeMiller et al., 2013, Motivational Interviewing, 3rd Ed.
12 What Works? What Works? Acceptance Attention Choice Support Reminders ExperimentationReinforcementMI PrinciplesRoll with ResistanceDevelop DiscrepancyExpress EmpathySupport Self-EfficacyExercise: stand up, etc.
13 Motivational Interviewing Developed for substance abuseIntended to motivate “resistant” clientsBased on social psychology principlesSocial influence/persuasionPeople resist your efforts to change themPerson-centered counseling techniques“A method for exploring and resolving ambivalence”NOT: teaching, changing, controlling“MI is like dancing”“drinker’s check-up” story – MI is designed for people who aren’t interested in change and don’t think they have a problemMiller & Rollnick. (2002). Motivational Interviewing, 2nd Ed.
14 Four Principles of MI Try it! Roll with resistance Develop discrepancy Listen and try to understandAvoid arguing – don’t try to “fix it”Develop discrepancyClients present arguments for changeExpress empathyReflection, acceptance, collaborationSupport self-efficacyAsk for the client’s perspectiveFacilitate hope for changeTry it!Rollnick, Miller, & Butler. (2007). Motivational Interviewing in Health Care.
16 Avoid the Traps Expert Trap Educator Trap Premature Focus Trap 20-Questions TrapFear TrapAdvice TrapClient is the expertClients choose to learnNegotiate an agendaOpen-ended questionsReduce fear & denialClients make choicesMiller et al., 2013, Motivational Interviewing, 3rd Ed.
17 The Evidence for MIReview of 30 studies with 5541 participants, most with 3-12 month follow-up dataTotal amount of MI provided: 30 min to 4 hrsModerate changes in alcohol use, drug use, diet & exercise, treatment adherence (similar to longer-term counseling methods)Smaller but still significant changes for smoking (about half as strong), based on 16 studiesSmaller effects for safer sex (2 studies), eating disorders (1 study)Burke, et al. (2003). J Consult Clin Psych, 71(5), ; Hettema & Hendricks. (2010). J Consult Clin Psych, 78(6),
18 MI Across the Lifespan Adolescents Children Transitions in care / chronic disease managementPreventing depression in at-risk adolescentsChildrenOral healthDietExerciseChronic disease managementBerg-Smith et al. (1999). Health Educ Res, 14, ; Gueldner & Merrell (2011). J Educ Psychol Consult, 21, 1-27; Resnicow et al. (2006). J Am Dietetic Assoc, 106, ; Schwartz et al. (2007). Arch Pediatr Adolesc Med, 161, ; Suarez & Mullins. (2008). J Devel Behav Pediatr, 29, ; Weinstein et al. (2006). J Am Dent Assoc, 137,
19 MI “Micro-Techniques”: OARS Open-Ended QuestionsProblem recognitionConcern about the problem / pros and consOptimism about changeIntention to changeAffirmRestateReflect contentReflect emotion (worry, concern, upset)Reflect intentionReflect meaning (go one step further)Summarize (“what else?”)Miller & Rollnick, 2002
20 Examples of Reflective Listening “What I hear you saying is …”“It sounds like …”“You’re feeling like …”“It seems like …”“You wish …”“You want …”“You think …”“From your perspective …”Exercise: best teacher
21 Summary Statements Combine Several Previous Reflections Reflection #1: You want to help your child eat a healthy dietReflection #2: You’ve talked to her, but she doesn’t listenReflection #3: You’re frustrated with the situationSummary Statement: I hear that you really want to help your child, but you aren’t sure how. The things you have tried don’t seem to work, which is frustrating.
22 Change These to Open Questions “Did your moods feel out of control last night?”“Did you use meditation or Biofeedback strategies?”“You really want to impact your patients don’t you?”“Did you use Reflective Listening techniques?”“Is the patient ready to work on change goals?”“Are you being relational?”GROUP EXERCISE
23 Affirmation Affirming self-determination Affirming strengths You’re in chargeThis is your decisionAffirming strengthsYou have made big changes in the pastYou’re sure you could do it if you decided toAffirming competenceYou know what’s best for your familyYou’re the expert in what will work for youEXERCISE: affirm 3 things about your neighbor (take turns)
24 Directing the Conversation Reflect to communicate understanding“You don’t brush your children’s teeth very often”Use open-ended questions to raise new topics“How have you tried to gain their cooperation?”Use summary statements to close topics“I’m hearing that your dentist lectures, and that’s frustrating, so your kids resist going there”Follow with open-ended questions about change“How can I help?”
25 The Relationship Matters Most Client commitment language is the best predictor of behavior change in MIThe more time the client spends talking, vs. youThe amount of time talking about change (desire, ability, recognition, need, commitment, activation, taking steps)Helper’s interpersonal skill predicts outcome better than specific techniquesExperience matters, but not specific knowledgeDo whatever works to strengthen the relationship
26 When Can I Educate?The Traditional Model in Education: Tell — Ask — Tell The Motivational Interviewing Model: Elicit — Provide — ElicitRollnick, Mason, & Butler. (1999).Health Behavior Change.
27 Possible Benefits Cut to the chase – a lengthy spiel takes time Deliver information in focused chunksIncrease the odds the patient will rememberGet to the most important issues more quicklyCheck off boxes in your EMR as the patient talksThis half: What patients hearWhole pie:What you sayto patientsThis quarter: What they understandThis eighth is what they rememberWell enough to use the information!
28 Recognizing Readiness Showing ResistanceSeeing benefits of current behaviorSeeing costs of new behaviorStrategy: back off, build motivation(the “strong principle of change”: increase benefits)Ready for ChangeSeeing benefits of new behaviorSeeing costs of current behaviorStrategy: support efforts for change(the “weak principle of change”: decrease barriers)Prochaska et al. (1995). Changing for Good
29 Early Stages: Use FRAMES Feedback about personal risksResponsibility for change is the client’sAdvice is given in a nonjudgmental wayMenus of options are suggestedEmpathic counseling style (OARS)Self-efficacy of the client is encouragedMiller & Rollnick, 2002
30 Getting Stuck: Some “Resistance” is only Sustain Talk Roll with resistance; don’t fight against it.Pushing back against resistance only gets you more of it.Some “resistance” is a natural expression ofthe process that moves us toward change.Sustain talk is a normal part of the processIt is often helpful to hear from both sides of the ambivalence:Why do you want to make this change? And also …What do you not like about the idea of making this change“To fly, we have to have resistance” – Maya Lin
31 Roll With Resistance Use reflection to communicate empathy When people resist,you might be pushing too hard for change!Use reflection to communicate empathyI hear that this is difficult for you.Find out what the client already knowsWait to offer new information until you are invitedAsk the client her opinion about the new informationSummarize to communicate understandingYou see three barriers to moving forward: … .What causes problems doesn’t matter as much as what you decide to do about them.Use open-ended questions to refocus on changeWhat would you be doing if the situation were different?RESISTANCEis futile
32 Change Talk Listen for DARN CATs in the conversation: Desire for changeAbility to changeReasons for changeNeed to changeCommitment to changeActivation for changeTaking steps already for a changeContemplation StageActionStageMiller & Rollnick, 2007
33 EARS for Change Talk Elaboration – what? why? how? tell me … Affirmation – that sounds like a good idea. I can see that you’ve considered this carefully.Reflection – you think … you want … you need … you intend … you think you can …Summary – you have considered … and at this point your plan is …
34 Questions to Elicit Change Talk Advantages of Change (Desire, Reasons)What makes you think you would like a change?Disadvantages of the Status Quo (Need)What concerns you about the current situation?Optimism about Change (Ability)What do you think would work, if you did want a change?Intention to Change (Commitment, Taking Steps)What would you like to do at this point?Handout of questions from Miller & Rollnick (2002) bookMiller & Rollnick, 2002
35 Find the Change Talk …I like it when I’m out drinking with friends, but the next day I usually feel awful.If I’m late to work again because of my drinking, I will get fired.My wife keeps nagging me to give up cigarettes.The doctor told me to cut down on drinking.I don’t like the idea of taking so many pain meds, but the pain just won’t go away.I’m not sure I can quit smoking pot – it helps me cope.Exercise – identify DARN CATs in each statement (as a group)
36 Use Naturally Occurring Solutions Problems are struggles, failures are effortsWhat worked before?How have you overcome other challenges?What would you change from past attempts?Look for solutions that already existWhat is working already?When isn’t the problem quite as bad?Access support from othersWho in the network is supportive?Who haven’t you asked, and can they help?What do others say that you might like to try?What do you think is the best plan from here?
37 Red Light / Green Light SUSTAIN TALK AMBIVALENCE CHANGE TALK LURE: listen, understand, resist the urge to “fix it,” empathizeAMBIVALENCEOARS: open-ended questions, affirm, reflect, summarizeUse elicit-provide-elicit to educateCHANGE TALKEARS: explore, affirm, reflect, summarizeChallenge the changeDart, M.A. (2011). Motivational Interviewing in Nursing Practice
38 Next Steps in Using MI Active listening (OARS) Use reflections more than questionsRoll with resistanceUse elicit-provide-elicit to educateAssess readiness for changeUse FRAMES to motivate changeListen for change talk (DARN CAT)Problem-solve using natural supports
39 Developing the “Spirit” of MI The heart of MI is a spirit of …empathyacceptancerespecthonestycaringHope & faith in the clientInterest in others’well-being and growthEmpathy: 2 reflections per 1 question(Moyers, Miller, & Hendrickson, 2005)
40 Learn More about MIMiller & Rollnick (2013). Motivational Interviewing, 3rd Ed.Rollnick, Miller, & Butler (2007). Motivational Interviewing in Health CareRollnick, et al. (1999). Health Behavior ChangeMI home page:Prochaska, Norcross, & DiClemente (1995). Changing for GoodStages of change home page:Bothello (2004). Motivate Healthy HabitsSeminars: