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Evan Williams, PharmD Assistant Professor of Pharmacy Practice Husson University School of Pharmacy.

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Presentation on theme: "Evan Williams, PharmD Assistant Professor of Pharmacy Practice Husson University School of Pharmacy."— Presentation transcript:

1 Evan Williams, PharmD Assistant Professor of Pharmacy Practice Husson University School of Pharmacy

2  I have no financial disclosures 2

3  Clinicians can only provide patients with clinical knowledge and education  Patients make the ultimate decision to change  What can clinicians do to influence patient change? ◦ Scare tactics ◦ Lecture and educate ◦ Motivate the patient to change 3

4  Describe Motivational Interviewing (MI) and its components  Identify tools pharmacists and pharmacy technicians can use to help implement Motivational Interviewing in their practice setting  Review literature that supports the effectiveness of Motivational Interviewing 4

5  MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change. MI is a style of communication, not a technique. True or False? 5

6  OARS in MI stands for A. Open Communication, Active listening, Reasoning with the patient, and Seeking change B. Oral arguments, Active listening, Rolling with Resistance, and Summaries C. Open-Ended Questions, Affirmations, Reflective Responses, and Summaries D. Ongoing dialogue, Affirmations, Resisting the Righting Reflex, and Seeking change 6

7  Developing discrepancy involves: A. The patient discovering how current behaviors conflict with personal values or goals B. Telling the patient the negative results of current behaviors C. Allowing the patient to choose between two treatment options D. None of the above 7

8  Think of a “bad” habit you have tried to change ◦ Dietary habits ◦ Exercise habits ◦ Workplace habits ◦ Relationship habits  How long did it take to realize that this habit had a negative impact on you or others? ◦ Months? Years?  Were you successful? Did you relapse? 8

9  “Motivational Interviewing (MI) is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change.”  Defined by the identification, examination, and resolution of ambivalence about changing behavior – Ambivalence: Feeling two ways about behavior change 9 0V4% pdf

10  Method of communication ◦ Not a technique ◦ Increases mutual understanding  Collaborative ◦ Honors patient autonomy  Strengthens a person’s own motivation for and commitment to change ◦ Patient-centered 10 0V4% pdf

11  William R. Miller ◦ Motivational Interviewing with Problem Drinkers  Behavioral Psychotherapy  Stephen Rollnick and William R. Miller ◦ 1991 article ◦ Outlines clinical procedures  Has been revised and applied to many settings Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press. Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy. 1983, 11 (2); pp

12  Key Elements of MI ◦ Collaboration ◦ Evocation ◦ Autonomy  Principles of MI ◦ Express Empathy ◦ Support Self Efficacy ◦ Develop Discrepancy ◦ Roll with Resistance 12 0V4% pdf

13  Collaboration ◦ Dismisses hierarchy ◦ Builds rapport ◦ Non-confrontational ◦ Focus is mutual understanding 13 0V4% pdf

14  RG is a 57 year old male with hypertension and hyperlipidemia. On questioning it is revealed that he smokes about 1 pack of cigarettes daily. You would like him to quit smoking.  Which of the following shows the spirit of collaboration consistent with MI? ◦ A. You need to stop smoking now. ◦ B. What reasons do you have to stop smoking? ◦ C. If you continue to smoke, you are increasing your risk for having a heart attack or stroke. ◦ D. Let me help you to stop smoking. 14

15  Evocation ◦ Patients discover their own motivation and skills for change ◦ Draw out the patients own thoughts and ideas ◦ “..lasting change is more likely to occur when the client discovers their own reasons and determination to change” 15 0V4% pdf

16  Pharmacist: “I’ve noticed you have been late filling these medications the last 2 months.”  Patient: “Yeah, I’ve been having a hard time keeping up with things as I am moving to a new home across town in a few weeks. I know taking my medications is important but I’ve been so busy lately that I forget sometimes.”  Pharmacist: “It sounds like you would like to take your medications but it has been a tough time dealing with the move.” 16

17  Autonomy ◦ Ultimately it is the patient’s decision to change ◦ Empowers the patient and gives them responsibility ◦ As clinicians, we can encourage patients to develop their own “SMART” goals  Specific, Measurable, Achievable, Relevant, Timely 17 0V4% pdf

18  DK is a 44 year old patient newly diagnosed with diabetes. After discussion, it is revealed that he eats desserts for relaxation. When asked how he thinks this impacts his diabetes, he states he does not know.  The response that best exemplifies autonomy consistent with MI is: ◦ A. “May I tell you some information about how sweet foods impact your blood sugars?” ◦ B. “Sugary dessert foods increase your blood sugar and negatively impact your diabetes.” ◦ C. “Here is a pamphlet about how foods impact blood sugar.” 18

19  Express Empathy ◦ See the situation from the patient’s perspective ◦ Gain perspective on what the patient’s motivation may be  “It sounds like this has been tough for you”  “It seems like this situation has been difficult for you to accept” 19 0V4% pdf

20  Support Self Efficacy ◦ Focus on strengths and skills patient already has ◦ Highlight previous successes ◦ Patient needs to believe that change is possible 0V4% pdf 20

21  Develop Discrepancy ◦ Patients identify their values and goals ◦ Patients evaluate their current behaviors ◦ Ambivalence is discovered when conflict between values/goals and behaviors is identified ◦ Change is more likely when patients realize their behaviors are in conflict with their self‐identified values or accomplishment of goals ◦ “On the one side, you feel unhappy that you cannot keep up with your grandkids because of your COPD, but on the other hand, you feel that smoking is one of the only ways you can relax.” 21 0V4% pdf

22  Roll with Resistance ◦ Do not challenge resistant statements  Confronting resistance promotes defensiveness and diminishes the likelihood of a patient finding their own reasons to change ◦ Use the resistance as an opportunity to further explore the patient’s views ◦ Be aware of when a patient is becoming frustrated  Closed body language  Negative verbal responses  Shortened verbal responses 22 0V4% pdf

23  BG is an overweight veteran recently discharged from the Air Force. He has gained much of this weight since his discharge 14 months ago. The pharmacist suggested that BG enroll in clinic sponsored program for weight loss. BG declines enrollment. BG states that he is just not willing to exercise for 30 minutes 5 days a week because he is just too exhausted after work.  Which response best exemplifies the spirit of MI? ◦ A. If you don’t lose weight, you are putting yourself at risk for other serious problems. ◦ B. Could you try to exercise just a few days a week? ◦ C. How much are you willing to exercise? ◦ D. Why don’t you want to be healthy? 23

24  OARS ◦ Open-Ended Questions ◦ Affirmations ◦ Reflective Responses ◦ Summaries  RULES of Motivational Interviewing ◦ Resist the righting reflex ◦ Understand the patient’s motivation ◦ Listen with empathy ◦ Empower the patient Brief Motivational Interviewing for Veterans. TMS. VALU system. 24

25  Elicit better responses from patients  Make a conversation less one-sided  Are not answerable with a simple yes or no Open-Ended Question WordsClosed-Ended Question Words How? Why? Tell me more about... When? What kinds of… Do you? Have you? Can you? Will you? Brief Motivational Interviewing for Veterans. TMS. VALU system. 25

26  Statements that recognize a patient’s strengths  Help support self efficacy ◦ Tries to help patient believe change is possible despite past failures 26 0V4% pdf

27 Words the patient uses Words clinician hears What the clinician thinks the patient meant What the patient meant  Restate how the provider perceives the patient  Allows for increased clarity  Allows the listener to affirm the patient’s feelings  Patient feels understood Brief Motivational Interviewing for Veterans. TMS. VALU system. 27

28  Reflection that recaps visit and highlights important areas  Can clarify ambivalence and discrepancies 28 0V4% pdf

29  “I know what is best” ◦ Removes autonomy from the patient by insinuating the patient does not know what is best for themselves ◦ Re-establishes hierarchy ◦ Can undermine the patient’s motivation for change ◦ Can create conflict Brief Motivational Interviewing for Veterans. TMS. VALU system. 29

30  Patient’s reason for change is more important than the clinician’s  Explore importance of changing ◦ Ask for a scaled answer ◦ Why is it that number and not another? Brief Motivational Interviewing for Veterans. TMS. VALU system. 30

31  Use reflective responses ◦ Allows patient to tell you more ◦ Clarifies patient’s concerns ◦ Confirms mutual understanding  Be aware of body language ◦ Eye Contact ◦ Nodding ◦ Posture  Do not “understand” Brief Motivational Interviewing for Veterans. TMS. VALU system. 31

32  Patients must believe change is possible  Failures can be demoralizing  Focus on previous successes ◦ Even small victories can be uplifting  Encourage the patient  Let the patient know that they are in control of the change Brief Motivational Interviewing for Veterans. TMS. VALU system. 32

33  DARN-CAT ◦ Desire (I want to change) ◦ Ability (I can change) ◦ Reason (It is important to change) ◦ Need (I need to change) ◦ Commitment (I will make changes) ◦ Activation (I’m ready and prepared to change) ◦ Taking steps (I am doing specific things to change) 33 0V4% pdf

34  Ask questions that will elicit answers that are consistent with DARN-CAT ◦ Developing discrepancy  Desire  Reason  Need ◦ Change ruler  Ability  Activation ◦ SMART Goal Setting  Ability  Activation  Taking steps 34

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37  What went wrong?  What could the pharmacist have done instead? 37

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40  What principles of MI were used by this pharmacist?  How well did the change ruler work?  What else could the pharmacist have done? 40

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42  What went right?  What examples of change talk did the patient give?  What could the pharmacist have done to improve? 42

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44  Growing body of evidence ◦ 6 references ◦ 78 references ◦ 707 references  Most studies show MI to be beneficial ◦ Publication bias?  Most studies have limitations ◦ Small sample size ◦ Weak comparator groups ◦ Various providers offering MI ◦ Providers have differing levels of training in MI ◦ Difficult to assess the manner in which MI is used 44 Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)

45  Effectiveness of MI on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study  N=109 officers ◦ 67 officers completed the program ( 13 women, 54 men) ◦ Previously completed a “high performance training seminar”  10-week program ◦ Goal to improve fitness, nutrition, and lipids ◦ Weekly meetings with health coach  MI included to help the officers identify and achieve goals  10-week endpoints were compared to baseline Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare :48 45

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47  Significant improvements in physical fitness, blood pressure, and lipids for those who completed the 10-week course ◦ Baseline values already at BP/Lipid goals  Unknown cardiovascular/diabetes risks ◦ Changes in lipids comparable to low dose statin ◦ Changes in BP comparable to addition low dose ACEi Average Adherence to fitness regimen: 80% for cardiovascular activity 75% for strength training 47

48  Limitations ◦ large drop out rate (42%) ◦ Selection Bias  Those who completed study were likely more motivated and active prior to study ◦ Results likely only reflective of increased exercise ◦ Short follow-up  Were benefits maintained  Is MI beneficial for long term lifestyle changes? 48

49  Pattern of results show MI is likely ◦ To confer at least a 10% advantage in success rates versus weak comparators ◦ To be as good or better than established treatments ◦ To take less time and resources  Best outcomes may be using MI pre- treatment 49 Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)

50  Effective regardless of gender or age  Training level does not significantly impact effectiveness ◦ Versatile  In what areas is MI most effective? 50 Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)

51 51 Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)

52 52 Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)

53 53 Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice April, pp

54  Limitations Interventions ranged from min (60 min most common) Variable follow up periods  Usefulness Provides evidence that MI can elicit significant change Overall about 75% of studies show there was an effect 54 Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice April, pp

55  Online resources or live classes  Begin small ◦ Try only adding one component at a time ◦ Reflective responses are a great starting point  Keep working at it ◦ It may feel uncomfortable the first few times  Add components as you become more adept 55

56  MI is a useful technique to help people change  It is useful in combination with other techniques for eliciting change  MI should not replace your method of patient interaction, but enhance it 56

57  Motivational interviewing is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change.  Key Elements ◦ Collaboration ◦ Evocation ◦ Autonomy 57

58  Principles ◦ Express Empathy ◦ Support Self Efficacy ◦ Develop Discrepancy ◦ Roll with Resistance 58

59  Strategies for implementation ◦ OARS  Open-Ended Questions  Affirmations  Reflective Responses  Summaries ◦ RULE  Resist the righting reflex  Understand the patient’s motivation  Listen with empathy  Empower the patient 59

60  MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change. MI is a style of communication, not a technique. True or False? 60

61  OARS in MI stands for A. Open Communication, Active listening, Reasoning with the patient, and Seeking change B. Oral arguments, Active listening, Rolling with Resistance, and Summaries C. Open-Ended Questions, Affirmations, Reflective Responses, and Summaries D. Ongoing dialogue, Affirmations, Resisting the Righting Reflex, and Seeking change 61

62  Developing discrepancy involves: A. The patient discovering how current behaviors conflict with personal values or goals B. Telling the patient the negative results of current behaviors C. Allowing the patient to choose between two treatment options D. None of the above 62

63 63

64  Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare :48  Brief Motivational Interviewing for Veterans. TMS. VALU system.  Burke B, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology 2003; 71,  Hettema J, Steele J, Miller W. Motivational Interviewing. Annual Review of Clinical Psychology 2005;  pproach%20V4% pdf  Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11)  Lundahl B, Tollefson D, Kunz C et al. Meta analysis of motivational interviewing: twenty five years of research. Research on Social Work Practice 2009  Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983; 11(2),  Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.  Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice 2005; April,  Vasilaki E, Hosier S, Cox W. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta analytic review. Alcohol and Alcoholism 2006; 41,


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