Linda Ehrlich-Jones, PhD, RN March 15, 2017 Practical Applications for Motivational Interviewing to Encourage People with Osteoarthritis to Make Behavior Changes Linda Ehrlich-Jones, PhD, RN March 15, 2017

Disclosures Grant from the National Institute on Disability, Independent Living, and Rehabilitation Research Consulting on a grant from NIH and NIDILRR

Agenda Introduction to MI and MI Spirit Four Key MI Processes Five Key Communication Skills Readiness ruler Brief overview of what MI is and how it is done. If you are interested in learning MI, I would suggest that you participate in a workshop where you can actually practice the skills with a trainer. MI NOT myocardial infarction!

Clinical Situations to Use MI Increasing physical activity Weight loss Medication adherence Dietary changes (diabetes, heart disease, renal disease) Quitting smoking or drinking alcohol Uses of MI: not a fix for everything; used for conversations centering on behavior change.

Motivational Interviewing (MI) A refined form of the process of guiding Skillful practitioner shifts from directing, guiding and following styles in response to patients’ needs MI does not displace, but complements the communication skills you’ve already developed We learn MI from our patients Directing: HCP takes charge at the time; tells other what to do Guiding: Patient decides where to go and hires a guide to help get there Following: Listening predominates; follow the other’s lead We all know that change is difficult. MI is an opportunity to help our patients make a change in their behavior.

Transtheoretical Model of Health Behavior Change Precontemplation Contemplation Preparation Taking action Maintenance Background: Stages of change has played an important role in the development of MI Motivation provides the push to move through the process of change Precontemplation: unaware of problem behavior or unwilling to change Contemplation: person acknowledges they have a problem and begins to think seriously about solving it. May be far from acting on it. Preparation: ready to change in the near future; on the verge of taking action Taking action: modify behavior Maintenance: sustaining behavior change can be difficult; struggles to prevent relapse

Stages of Change and MI MI with precontemplators is difficult because they do not want to be lectured or given action techniques when they are not ready to change MI with contemplators helps them examine their own situation considering the pros and cons in a nonthreatening and supportive manner encouraging them to take responsibility for their situation

Stages of Change and MI MI with patients who are preparing for action, taking action and maintaining change provides “coaching”, helping to increase self-efficacy and reinforcement of accomplishments in an empathic, caring style

Ingredients of Motivation Importance Confidence Readiness Three critical components of motivation: readiness, willingness and ability.

Ambivalence Ambivalence is normal and precedes change Decisional balance-weighing the costs and benefits Cost and benefits of making change and not making a change

Definition of MI A counseling style used to strengthen personal motivation and commitment to a specific goal by exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. Not a technique for tricking people into doing what they do not want to do. Skillful clinical style for eliciting from the patient their own good motivations for making behavior changes

MI Spirit Interpersonal style characterized by the absence of confrontation or persuasion and by the acceptance of the person, expressed by empathy, respect and support Atmosphere in which to conduct MI.

Four Key MI Processes Engaging Focusing Evoking Planning These processes are both sequential and recursive Represent as stair steps Engaging: Both parties establish a helpful connection and working relationship. There is an agreement on treatment goals and Good listening. Focusing: Focus on a particular agenda. In MI, focusing is a collaborative process of finding mutually agreeable direction. Evoking: Elicit the patient’s own motivations for change and have the person voice the arguments for change. Planning: Encompasses both developing commitment to change and formulating a concrete plan of action. People are more likely to follow through with a change when they have a specific plan and express that plan to another person.

Five Key Communication Skills Open-ended questions Affirmations Reflective listening Summarizing Providing information and advice with permission Open-ended Questions: A question that cannot be answered with a “yes” or “no”; Are non-judgmental; Allows for the person to do most of the talking, using their own words; Let’s them know the conversation is about them. Affirmations: Statements of appreciation and understanding; Supports the person’s sense of efficacy and indicates value for their point of view. For example: “You’re clearly a resourceful person to cope with such difficulties for such a long time”.

Starters for Open-Ended Questions Tell me about… What else… What, if any… Help me understand… How did you…

Five Key Communication Skills Open-ended questions Affirmations Reflective listening Summarizing Providing information and advice with permission Affirmations: Statements of appreciation and understanding; Supports the person’s sense of efficacy and indicates value for their point of view. For example: “You’re clearly a resourceful person to cope with such difficulties for such a long time”.

Reflective listening One of the most important and most challenging skills required for MI It is active listening; listening both to the words spoken and the emotions behind the words Keeps people talking Forces you to listen carefully Lets you check that you understand what the person is saying

“Silence is Golden” Don’t be afraid of silence No one likes silence and if you can hold out someone else will speak Count slowly to 10 before jumping in with another question You want to wait for the patient to speak, don’t jump in with another question or reflection. You want the patient to talk most of the time, 80/20 rule.

Summarizing A brief statement that links together and reinforces key parts of the conversation, such as: Thoughts Concerns Plans Reflections

Providing information and advice with permission It is ok to provide the patient information and advice, but ask first if this is what they want you to do. Example: “Would you like me to give you some ideas about how to change your behavior?” 5th Communication style You want the patient to come up with the ideas for change and you affirm and reinforce them.

Reduce Discord By: Using reflective listening Using empathetic statements Focusing on building the relationship rather than on change Engaging people by first discussing issues that are important to them Emphasizing that the issue of whether or not to change is their decision

Clinician Behaviors Characteristic of MI Seeks to understand the person’s frame of reference, particularly via reflective listening Expresses acceptance and affirmation Elicits and selectively reinforces the patient’s own self-motivational statements Monitors the patient’s degree of readiness to change Affirms the patient’s freedom of choice and self-direction

Motivation is a combination of importance and confidence.

Importance How important the person feels changing their behavior is Level of importance is based on the individual’s benefits that they see from changing their behavior The person may see the benefit but have other priorities in their life

Confidence How confident or sure the person is about their ability to change their behavior Person may have barriers to making a change Small steps to change can help increase confidence for further change It is important to discuss both importance and confidence in order to develop a realistic plan of action for change.

Importance Important component of intrinsic motivation for change. Use a ruler with gradations from 0 to 10 “How important would you say it is for you to ________? On a scale from 0 to 10 where 0 is not at all important and 10 is extremely important, where would you say you are? Readiness ruler: 2 parts- importance and confidence. Not necessary to show client a ruler, but you can.

Importance After the person gives you a number, ask, “Why did you choose _____, and not a lower number like 1 or 2?” (If they choose 0 or 1, ask, “Why did you choose such a low number?”) Their answer will tell you what benefits they see to changing their behavior. Reflect on their reasons Why are you at a 3 and not a 0? What would it take for you to move from a 3 to a 4 (or a higher number)? Do not reverse and ask why are you at 3 and not 10? To answer that question is to argue against change.

Importance Then ask, “What would it take to move your number a little higher?” Their answers will tell you what would motivate them to change their behavior Reflect on their response.

Confidence Important component of intrinsic motivation for change. Use a ruler with gradations from 0 to 10 “How confident would you say you are that if you decided to ________, you could do it? On a scale from 0 to 10 where 0 is not at all confident and 10 is extremely confident, where would you say you are? Confidence question is phrased such that you could make this change; this allows confidence to be somewhat detached from importance.

Confidence After the person gives you a number, ask, “Why did you choose _____, and not a lower number like 1 or 2?” (If they choose 0 or 1, ask, “Why did you choose such a low number?”) Their answer will tell you what helps them feel confident to change their behavior Reflect on their reasons Why are you at a 3 and not a 0? What would it take for you to move from a 3 to a 4 (or a higher number)? Do not reverse and ask why are you at 3 and not 10? To answer that question is to argue against change.

Confidence Then ask, “What would it take to move your number a little higher?” Their answer will tell you what would increase their confidence to change their behavior. Reflect on their response.

Decisional Balance Person experiences competing motivations because there are benefits and costs associated with both sides of the conflict Benefits for making a change; Costs for making a change Benefits for not making a change; Costs for not making a change

Decisional Balance This was a very brief, quick overview of MI. If you are interested in MI, I would encourage you to take a course so you can practice these skills. These are skills that need practice.

Resources www.motivationalinterviewing.org Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York: The Guilford Press. Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York: The Guilford Press.

Questions?

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