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University of Massachusetts Medical School Center for Integrated

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1 University of Massachusetts Medical School Center for Integrated Primary Care An Introduction to Guiding Patient Health Behavior Change with Motivational Interviewing Daniel Mullin, PsyD Center for Integrated Primary Care Department of Family Medicine and Community Health September 25, 2013

2 Overview Brief discussion of Health Behavior Change
Introduction to Motivational Interviewing (MI) Review of Evidence for MI and health behavior change Discussion of the Spirit of MI Introduction to Guiding, Ambivalence, Resisting the Righting Reflex, and Empathy Explanation of OARS A Brief Video Demonstration Introduction to Change Talk Summary of Elicit, Provide, Elicit approach to discussing change Review of Project CHAT Next steps for learning MI

3 You should be flossing your teeth more often than you do.

4 Why don’t you floss more?
Do you need more education regarding the benefits? Is it difficult to acquire floss? What is really missing?

5 What are some reasons that people change their behavior?

6 A Definition of MI Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. Last month you were introduced to patient centered counseling with the 5As. Motivational Interviewing will provide you with the specific skills you need to deliver patient centered care

7 The Origins of MI MI was discovered accidentally as part of research into what worked for counseling for problem drinking. Strong evidence for MI with drug and ETOH problems (Burke, 2003) Researchers found that the use of empathy accounted for a large proportion of the sustained change. A guiding principle of MI was to have the patient, rather than the clinician, voice the arguments for change.

8 MI is often an adjunct For some conditions MI alone may be insufficient to improve health outcomes MI can be more effective when paired with other interventions For example, MI session preceding a 12 step drug treatment program Or MI to improve participation in diabetes education

9 Evidence for MI in Healthcare
Strong evidence (RCT) for use of MI to facilitate dietary changes and weight loss (Spahn, 2010;Greaves, 2008) Evidence to recommend use in smoking cessation (Cochrane, 2010; Hettema, 2010; Lindqvist, 2013) When paired with stage of change counseling can be effective with patients with HTN (Woollard, 1995) Chronic disease management programs with clinicians trained in MI outperform traditional approaches (Linden, 2009)

10 Evidence for MI in Healthcare
Meta-analysis from Rubak, 2005 concluded that MI outperforms “advice giving” in 80% of studies “We can therefore argue that motivational interviewing is not limited in any way to counseling of a small group of selected patients, but can be used in the treatment of a broader area of diseases that to some extent are influenced by behaviour.” (Rubak, 2005)

11 Fundamental approach of motivational interviewing
Mirror-image opposite approach to counseling Collaboration involves a partnership that honors the patient’s expertise and perspectives. The clinician provides an atmosphere that is conducive rather than coercive to change. Confrontation involves overriding the patient’s impaired perspectives by imposing awareness and acceptance of “reality” that the patient cannot see or will not admit. Evocation The resources and motivation for change are presumed to reside within the patient. Intrinsic motivation for change is enhanced by drawing on the patient’s own perceptions, goals, and values. Education The patient is presumed to lack key knowledge, insight, and/or skills that are necessary for change to occur. The clinician seeks to address these deficits by providing the requisite enlightenment. Autonomy affirms the patient’s right and capacity for self-direction and facilitates informed choice. Authority tells the patient what he or she must do. Miller, William R. ( ). Motivational Interviewing, Second Edition. Guilford Press.

12 Spirit of Motivational Interviewing
Partnership Acceptance Compassion Evocation


14 MI Perspective on Expertise
People possess substantial personal expertise and wisdom regarding themselves and tend to develop in a positive direction if given proper conditions of support. Clinicians are faced with the difficult responsibility of moving between tasks in which their expertise is essential to their patient’s welfare and other tasks in which their expertise has the potential to interfere with promoting health. Expert knowledge alone is insufficient. Knowing when to share that expertise and when to patiently withhold it is critical to facilitating health behavior change.

15 Adapted from Miller and Rollnick
When patients are viewed primarily from a deficit perspective (e.g., being in denial; lacking insight, knowledge, and skills), it makes little sense to spend time eliciting their own wisdom. Instead, the clinician would be inclined to confront denial, explain reality, provide information, and teach skills. Within this perspective, consultation is clinician-centered, and it revolves around the clinician providing what the patient lacks: “I have what you need.” It can be quite a cognitive jump from this expert stance to MI, wherein the clinician instead communicates a respect for the patient’s own perspectives and autonomy. The MI clinician seeks to evoke the patient’s own motivations for change (“You have what you need”) rather than installing them. A willingness to entertain this patient-centered perspective is a starting point in learning MI. Adapted from Miller and Rollnick

16 Rollnick, Miller, and Butler (2008)
There is something in human nature that resists being coerced and told what to do. Ironically, it is acknowledging the other’s right and freedom not to change that sometimes makes change possible. Why is it important for children to do what their told? Why is it important for adolescents to be defiant? Rollnick, Miller, and Butler (2008)

17 Non-Compliance Is non-adherence a better term?
Both terms overstate the importance of the clinician’s role in guiding patient behavior Non-compliance is NOT a personality trait We are all non-compliant with regards to some health behaviors What did you think of the last driver who cut in front of you? What was the reason you recently cut in front of another driver?

18 Fundamental Attribution Error
When explaining the behavior of others, we tend to overestimate personal factors and underestimate environmental factors. When explaining our own behavior, we tend to underestimate personal factors and overestimate environmental factors. What did you think of the last driver who cut in front of you? What was the reason you recently cut in front of another driver? * Fundamental Attribution Error is not an MI Concept

19 3 Styles of Communication
FOLLOWING DIRECTING GUIDING Guiding includes asking, listening, and informing about options

20 Ambivalence It is normal to have contradictory feelings about making behavior change MI is a method of communication for exploring and resolving ambivalence. When using MI we explore the patient’s ambivalence,

21 Resist Righting Reflex
Tolerate incorrect information that is irrelevant or useful Ask permission before educating or informing Be strategic about when to educate, first find out what the patient already knows Remember that many people already know which behaviors are healthy and which are not Many of us became healthcare professionals to fix things that were broken Example, includes anti-depressant The patient who exercises once a week for 15 minutes, doesn’t need to be immediately corrected

22 Demonstrate Empathy Empathy = understanding the patient’s thoughts and feelings It does not necessarily mean you feel what the patient feels or think what the patient thinks A clinician’s empathy is only useful if it is experienced by the patient To demonstrate empathy you must verbalize your understanding of the patient’s thoughts/feelings

23 Empathy (Adapted from MITI 3.1)
High Low 5 Clinician shows evidence of deep understanding of patient’s point of view, not just for what has been explicitly stated but what the patient means but has not yet said. 4 Clinician shows evidence of accurate understanding of patient’s worldview. Makes active and repeated efforts to understand patient’s point of view. Understanding mostly limited to explicit content. 3 Clinician is actively trying to understand the patient’ s perspective, with modest success. 2 Clinician makes sporadic efforts to explore the patient’s perspective. Clinician’s understanding may be inaccurate or may detract from the patient’s true meaning. 1 Clinician has no apparent interest in patient’s worldview. Gives little or no attention to the patient’ s perspective.

24 Reflecting statements Summarizing statements
MI Skills Open questions Affirming statements Reflecting statements Summarizing statements Many of us became healthcare professionals to fix things that were broken Example, includes anti-depressant Diabetes examples

25 Reflecting statements Summarizing statements
MI Skills Open questions Affirming statements Reflecting statements Summarizing statements Many of us became healthcare professionals to fix things that were broken Example, includes anti-depressant Diabetes examples

26 Reflecting Simple Complex
Repeating - The simplest reflection simply repeats an element of what the speaker has said. Rephrasing - Here the listener stays close to what the speaker said, but substitutes synonyms or slightly rephrases what was offered. Paraphrasing - This is a more major restatement, in which the listener infers the meaning in what was said and reflects this back in new words. This adds to and extends what was actually said. In artful form, this is like continuing the paragraph that the speaker has been developing saying the next sentence rather than repeating the last one. Reflection of feeling - Often regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimension through feeling statements, metaphor, etc. Complex

27 A Video Demonstration

The more patients verbalize the disadvantages of change, the more committed they become to sustaining the status quo The opposite is true, the more patients express their commitment to change the more likely they are to make and sustain change

29 Change Talk Patients are more likely to change health behaviors when the clinician elicits the patient’s own reasons for changing Clinicians are successful when patients talk themselves into change When patients are talking about their own reasons for changing this is called Change Talk

30 Change Talk When practicing MI the goal is to evoke and reinforce change talk The goal is not to make them change You are responsible for the intervention not the outcome


32 Reasons for change which originate with the clinician are not associated with patient health behavior change

33 Reasons for change which originate with the patient
are associated with patient health behavior change

34 Elicit Provide

35 Elicit Provide Begin by eliciting the patient’s thoughts and feelings about the topic in question Examples: “I’d like to shift the conversation to talking about mammograms. Tell me a bit about your thoughts about mammograms.” “I’d like to spend a few minutes talking about a few options that are available to you. Perhaps we could start by having you share your thoughts about smoking.” “Before we jump into deciding whether or not you should change your drinking please take a minute to tell me what you know or have heard about how drinking relates to your blood pressure.”

36 Elicit Provide After assessing the patients thoughts/feelings/knowledge you may begin to shift to offering the patient information. However, before providing information, first assess the patient’s interest in hearing what you have to say.

37 Elicit Provide Asking permission to educate about behavior change:
- promotes collaboration - communicates respect for the patient’s expertise - encourages patient to voice his or her perspective - focuses the patient’s attention on what you say Examples of asking permission: “I have an idea here that may or may not be relevant. Do you want to hear it?” “I think I understand your perspective on this. I wonder if it would be OK for me to tell you a few things that occur to me as I listen to you.”

38 Elicit Provide If after asking the patient’s interest in hearing your advice, the patient declines, do not proceed with education. If some patients decline to hear your advice you know you are building strong relationships with your patients. They are comfortable being honest with you. Telling someone what to do when they don’t want to hear your thoughts will damage your relationship with them. Telling someone what to do when they don’t want to hear your thoughts has almost no chance of changing their behavior.

39 Elicit Provide After sharing your advice and thoughts follow up with the patient to confirm you were understood and elicit reactions Examples: “Now that I have shared some of my thoughts I wonder how you they strike you.” “Tell me a bit about how what I have shared fits with your thoughts and feelings about smoking.” “Now that you have shared your thoughts, and I have shared mine, I wonder where we should go from here.”

40 Listen/ Reflect Elicit Provide Communicate listening, non-verbally:
Eye contact, head nods, hands off keyboard Confirm understanding by repeating back, or reflecting what you have heard: “Let me make sure I understand, you said...” “I can tell that you have given this some thought. Your understanding is that...”

41 Elicit Listen/Reflect Provide

42 Project CHAT - design 426 Adult patients with BMI > 25 were enrolled and followed for 3 months Patients attend non-acute visit with their PCP Neither MDs or patients knew study was focused on weight PCPs were not trained in Motivational Interviewing - any use of MI spirit or techniques was incidental Pollak, K. I., Alexander, S. C., Coffman, C. J., Tulsky, J. A., Lyna, P., Dolor, R. J., et al. (2010). Physician Communication Techniques and Weight Loss in Adults. American Journal of Preventive Medicine, 39(4), 321–328.

43 Project CHAT - general findings
320 or 461 patient encounters included discussions of weight When physicians discussed a patient’s weight they spent an average of 3.3 minutes discussing weight There were no differences in outcomes (weight at 3 months) between those patients who discussed their weight with physicians and those that didn’t

44 Project CHAT - MI findings
Patients whose physician demonstrated MI Spirit lost more weight than those that did not (1.4kg lost vs. 0.2kg gained, p = 0.02) Patients whose physician use reflective statements lost more weight than those that did not (0.5kg lost vs. 0.4kg gained, p = 0.03)

45 The more MI inconsistent behaviors, such as giving
unsolicited advice, the more weight gain.

46 Evocation (Adapted from MITI 3.1)
High Low 5 Clinician works proactively to evoke patient’s own reasons for change and ideas about how change should happen. 4 Clinician is accepting of patient’s own reasons for change and ideas about how change should happen when they are offered in interaction. Does not attempt to educate or direct if patient resists. 3 Clinician shows no particular interest in, or awareness of, patient’s own reasons for change and how change should occur. May provide information or education without tailoring to patient circumstances. 2 Clinician relies on education and information giving at the expense of exploring patient’s personal motivations and ideas. 1 Clinician actively provides reasons for change, or education about change, in the absence of exploring patient’s knowledge, efforts or motivation.

47 Collaboration (Adapted from MITI 3.1)
High Low 5 Clinician actively fosters and encourages power sharing in the interaction in such a way that patient’s ideas substantially influence the nature of the session. 4 Clinician fosters collaboration and power sharing so that patient’s ideas impact the session in ways that they otherwise would not. 3 Clinician incorporates patient’s goals, ideas and values but does so in a lukewarm or erratic fashion. May not perceive or may ignore opportunities to deepen patient’s contribution to the interview. 2 Clinician responds to opportunities to collaborate superficially. 1 Clinician actively assumes the expert role for the majority of the interaction with the patient. Collaboration is absent.

48 Autonomy/Support (Adapted from MITI 3.1)
High Low 5 Clinician adds significantly to the feeling and meaning of patient’s expression of autonomy, in such a way as to markedly expand patient’ s experience of own control and choice. 4 Clinician is accepting and supportive of patient autonomy. 3 Clinician is neutral relative to patient autonomy and choice. 2 Clinician discourages patient’s perception of choice or responds to it superficially. 1 Clinician actively detracts from or denies patient’s perception of choice or control.

49 Learning MI An online 20 hour course in Motivational Interviewing available at: University of Massachusetts Medical School Center for Integrated Primary Care


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