Motivational Interviewing for Promoting Physical Activity Kenneth Brummel-Smith, MD Charlotte Edwards Maguire Professor of Geriatrics Florida State University College of Medicine

The “Spirit” of MI Collaborative Evocative Honors autonomy Partnership with patients Joint decision-making Evocative Activates their own motivation We don’t “motivate” patients Honors autonomy People resist when they are told what to do Some detachment required Try to get someone to buy something example in class MI deals with precontemplation and contemplation

Guiding The guide doesn’t decide where you want to go A guide helps you find your way “I can help you solve this for yourself” Not, “I’ll solve this for you.” Explores options Synonyms – encourage, support, take along, accompany, elicit, enlighten Letting go of control doesn’t mean lack of influence

Ambivalence There are always disadvantages to change Some healthy behaviors are seen as unpleasant, hard, or distasteful Many people enjoy the status quo How to recognize ambivalence? – look for the “but” in the middle Status quo Pros (toward change) Cons (no change)

Ambivalence People Have Big “Buts” I know I need to lose weight, but I hate exercising. I’d like to start walking, but I just don’t have any time to do it. I used to love swimming, but all those young women in their bathing suits make me feel self-conscious.

Exploring Ambivalence Starts the process of change Patients review all their reasons surrounding a behavior Reasons to change Reasons to not change In talking about reasons, the patient decides what is really important to them Beware of stopping exploration TOO SOON

Listening For Change Talk “I don’t know, I might be able to do it.” “I wish I could.” “I’ll try to do it.” “I’ll think about it.” Often culture specific You’re on the right track when you hear this!

Themes of Change - DARN Desire – want to, like to, wish Ability – can, could, able Reasons – specific outcomes Need – need, have to, should, ought to Ambivalence involves conflict in the four themes

Listening Interventions Reflect change talk “Ahh, so you think you need to change.” (Single sided reflection) Reflect resistance or ambivalence “So, you’d like to quit smoking, and know the risks, and you’re not sure you’ll be able to do it.” Downward inflection of your voice at the end (Double sided reflection) Use their change words Following

Using a Ruler (or Scale) How strongly do you feel about starting an exercise program? 0 – not at all interested, 10 – totally committed How important do you think it is for you to stop smoking? The answer to this question is change talk. Another way to ask, if, for instance, a 5 was given, is, “What would it take to move to a 6?” Not important at all Really, really important Then ask why she didn’t give a lower number…. Guiding

Two Important Questions How important is it for you to _____? 0 – not important at all 10 – extremely important How confident are you that you could do it? 0 – not at all confident 10 – I’m certain I can do it What would it take to move from a 3 to a 4? Guiding

Ways to Ask Permission Simple question First choice Prefacing “Would you like to know some things that you could do?” First choice “Which of these options would you like to talk about first?” Prefacing “This may or may not worry you, but…” Can combine them too Informing

Summary Guiding Principles Listen for Themes of Change Resist trying to fix them – you can’t motivate them! Help the patient discover their motivation Listen for Themes of Change DARN – desire, ability, reasons, need Explore (don’t negate) ambivalence – celebrate it! Guide more than you inform People who are ambivalent have opened the door to change.

Evidence Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005 Apr;55(513):305-12. (Level B) Knight KM, McGowan L, Dickens C, & Bundy C. (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11, 319-32. Schroeder, K., Fahey, T., & Ebrahim, S. (2004). How Can We Improve Adherence to Blood Pressure-Lowering Medication in Ambulatory Care? Systematic Review of Randomized Controlled Trials. Archives of Internal Medicine, 164(7), 722-732.

Learning More Motivation Interviewing in Health Care, Rollnick S, Miller WR, Butler CC, 2008, Guilford Press, NY www.motivationalinterview.org Trainings Trainers Videos