Motivational Interviewing Yolanda N. Evans MD MPH Seattle Children’s Hospital

Case Tory is a 16 year old coming to see you because parents are concerned about depression You excuse parents from the room Emphasize confidentiality when speaking with Tory alone You begin to ask Tory questions. The responses are… ‘I don’t know’ Shoulder shrug Now what? Over this hour, we’ll plan to help give ideas and tools on how to engage teens in conversation. We’ll go through some Motivational Interviewing skills, but really want this to be a discussion amongst all of us. We’d like to hear your experiences and share our own on what’s worked and what hasn’t when engaging teens in conversation.

Addressing Ambivalence Feeling two ways about a thing Common prior to and during habit change Examples: Difficulty scheduling appointments Missed appointments Intervention plans not being followed Goals of family have little substance Treatment progress uneven Family members not forthcoming about important issues

Principles of Motivational Interviewing Collaborative Evocative Honor Autonomy Instead of the expert clinician directing, there is an active collaborative conversation and joint decision-making process Evoke from patients what they already have; activate their own motivation Requires an acceptance that people can and do make decisions about the course of their lives Erik

O.A.R.S. Build rapport Open ended question Summary statement Affirmations Reflective listening Summary statement Before beginning: ask permission O.A.R.S is the cornerstone of Motivational Interviewing. (BTW way, all of this is in your notes) Skills you likely already have Essential for good rapport development Backbone of MI Before beginning – always ask permission Example: is it OK if we take a few minutes to talk about your activity level today? Many other examples in your job aid that we are providing today.

O.A.R.S. Open-ended Questions Invites person to reflect and elaborate Helps to understand their internal frame of reference Creates impetus for forward movement to help the person explore change 3 minutes Cannot answer yes or no… Instead of, “Are you making sure your child is physically active every day?” ask: “what activities do you enjoy with your child?” Instead of, “Do you fix your child breakfast every morning?” ask: “what do you like to have for breakfast?”

Closed-ended vs Open-ended Questions Did you… Can you… Will you… Is it… Open-ended To what extent… How often… Tell me about… What, if any,… More examples

#2 Practice Open-ended Questions Speaker: Describe what you are working on Listener: Goal of understanding the dilemma. Give no advice. Why might you want to make this change? How might you go about it, in order to succeed? What are three reasons to do it? Observer: Reflect on interaction and provide feedback using worksheet as a guide. How did it go? What did you notice (body language, tone, likelihood of change)? How did the speaker feel? How did the listener feel? 2-3 minutes each How did this feel different? 8

O.A.R.S.: Affirmations Statements of recognition about strengths Helps person feel change is possible Point out strengths where only failure is perceived by individual Consider partial successes Use resistance Examples: I see you had breakfast once this week Although you didn’t succeed, I saw how hard you worked I see your struggling with this, but it’s shows you are interested in changing because you’re here 3 minutes This is important to you vs. that is great that you are here. I see that this is a difficult thing to talk about for you. A bit of struggle with how to answer my question shows that you are thinking about it! In fact, this is better than last week when you refused to talk with me.

O.A.R.S.: Reflective Listening Helps you understand what’s working or not Statement, not question Trust and rapport will deepen even if you don’t get it “right” Ex.: “I hear you are making progress and taking a walk a couple of times per week”. ALSO: If wrong or individual not ready to deal with, he/she corrects you and the conversation moves forward

Reflective Listening Starts with: So… Sounds like… You… So, one hand…But on the other… Use 2-3 reflections before moving on to next question Can be a skill to use when “stuck” If you are right, emotional intensity of session will deepen. If wrong or person not ready to deal with, they’ll correct you and the conversation moves forward

O.A.R.S. Summaries Communicates interest in the person and helps develop rapport Can shift direction if necessary How to do this: Begin with announcement that you are about to summarize Be selective and concise Note ambivalence Invitation to correct anything End with an open–ended question So you were nervous about coming here but you decided to try to have breakfast. Come up with good example -

#5 Practice OARS #3 Speaker: Describe what you are working on Listener: Goal of understanding the dilemma using open-ended questions, affirmations, reflective listening and summaries. Refer to handout. Observer: Reflect on interaction and provide feedback using worksheet as a guide. How did it go? What did you notice (body language, tone, likelihood of change)? How did the speaker feel? How did the listener feel? 2-3 minutes each

Change Talk If you hear anything close to: Desire (want, like, wish) Ability (could, can, might be able to) Reasons (argue for change) Need (ought to, have to, really should) This will open the door to talk about commitment and possible plan/goals. Desire: I would like to keep up with my friends; I want to buy some fun clothes; Ability: I could set my alarm 5 minutes earlier; Mom: I could set some breakfast items right when I get up; I might be able to walk to the bus Reasons: I need to have more energy to stay up late; I would probably feel better if I ate lunch Need: I must get some sleep; I really need to get some exercise I really should eat breakfast (need) but I can’t get up (ability) = ambivalence So it sounds like you are thinking about having breakfast, but you are wondering how to make that happen. Could we talk about this a bit more?

Case – an update You begin by engaging Tory using OARS Weekly visits over the next few months have lead to… Attending school with accommodations Playing soccer Significantly reduced household stress!

Reflections on patient care MI takes practice It’s easy to go back to ‘old habits’ Patient engagement is a good indicator of effective MI

How to engage in culturally appropriate care? What aspects of MI fit with your patient population? What things might not work? How might the cultural background of your patients shape the clinical encounter?

Discussion/Questions