Motivating Patients to Make Change Ann Landes, Ph.D. alandes@zoho.com

Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.

Objectives Introduce the model of Motivational Interviewing (MI) Provide an overview of the concept of "Stages of Change" and its application to patient self-management Explain how MI can be employed by medical providers to encourage collaboration between the patient and the medical provider, as they work toward positive behavior change and improved quality-of-life

Support for Motivational Interviewing

Hettema, Steele, and Miller (2005) Found significant support for the efficacy of MI across 75 randomized controlled trials (RCTs). Adding MI to the beginning of treatment led to sustained outcome improvements. Outcomes were better when no manual was used. *(e.g., focus more on the alliance/relationship between provider and patient) Conducted a systematic meta-analysis of 72 RCT (randomized controlled trials): and found the following

Applications Alcohol abuse HIV risk reduction Illicit drug use Smoking Treatment adherence Diet/exercise Gambling Intimate relationships Eating disorders Water purification to promote health

Beach, Keruly, & Moore, 2005; Schneider, et al., 2004 Patient-Centered Communication from Provider Effective Patient-Physician Relationship & Communications = Greater patient satisfaction in medical care Greater improvements in general medical condition Increased adherence to medical treatments

What is mi?

Motivational Interviewing is a… method that has been found to be successful in increasing intrinsic motivation to change by exploring and resolving ambivalence collaborative effort between the provider and patient (Miller & Rollnick, 2002)

Motivational Interviewing … helps patients identify and address roadblocks to change (i.e., fears, lack of skills/information, needed supports, etc.) focuses on the way we as providers can inspire positive change in the lives of patients (Miller & Rollnick, 2002)

The Spirit of MI Autonomy Collaboration Evocation Appreciation of Focusing on patient choice Asking “permission” to provide assistance , info. Collaboration Coming along side; nonjudgmental Viewing the patient as the “expert” Evocation Exploring what motivates the patient Making no assumptions Appreciation of Ambivalence

Notes about Ambivalence When an individual feels two ways about something Normal to the process of change Trap If we argue for change, the patient may argue for the status quo, leading to decreased likelihood for change. MI focuses on the individual and our dance with that individual. It is not a wrestling match.

Motivational Interviewing is a method that … works to create collaboration between the provider and the patient focuses on patient choice/autonomy sees ambivalence as pathological Answers “1” and “2” None of the above

The Individual and Change Change can be frightening for many. They may not see themselves as capable … so, our job is to help them feel empowered to begin the change – to be “different” from what they are used to. The Individual and Change

Patients with HIV/AIDs and Change Adherence to current medication schedule Maintaining regular medical appointments Making healthy choices about use of alcohol, tobacco, illicit drugs Attending to self-care needs, such as diet and exercise Practice consistent precautionary behaviors to reduce transmission (prevention) Enlisting social support(s) Here is a short list of issues that may need to be addressed with our patient population with HIV and AIDs

Prochaska and DiClemente’s Stages of Change Model Pre-contemplation Contemplation Preparation Action Maintenance Relapse When we think about change, it is important to consider where the individual is with respect to wanting to change. That way, we can tailor our efforts in the correct manner and in the most useful way to increase likelihood for progress. According to Prochaska and DiCliemente, individuals present at different stages of change. People rarely ever come to us ready for change, so we need to consider where they are.

Pre-contemplation “I see no problem(s) to address at this time.” “I know there’s a need for change, but I don’t want to right now.” (… has not given much thought to change) Provider Role Bring awareness to the issue Encourage engagement of the patient Stage: Patient has not made the choice to even consider changing.

Tell-Tale Signs – “I’m not ready” Argues/disagrees with the provider’s diagnosis or suggestions Resists offers of assistance Expresses denial of problems/concerns Communicates a sense of hopelessness about the situation

Contemplation “Yeah, I’ve thought about my health needs, but I’m just not ready yet to change.” (ambivalence) Provider Role Increase awareness about the options for and benefits of change * Keep the patient thinking about positive change.

Preparation/Determination “OK, I’m prepared to make some changes, but, I’m not really sure I can or know how to do it.” Provider Role Decrease barriers to change by providing resources, information & offering assistance Address issues of self-efficacy Self-efficacy: Relating belief in the individual’s ability to make positive change

Action/Will Power “I know I need to make some changes; I have had to make changes before and did it.” Provider Role Encourage movement by helping to develop realistic goals and a plan-of-action Offer resources and support

Maintenance “Wow! I have made some impressive changes! How can I continue on this path?” Provider Role Help maintain positive focus and reduce opportunities for relapse At this stage, the patient has been able to change and maintain the changes and growth for about 6 mths

Relapse “I was doing really well, I thought, but then I got tired of having to focus so much energy on caring for my health. So, I just quit.” Provider Role Normalize that relapse is “OK” (reduce shame) Encourage honest discussion about what led to relapse Assist in re-exploration of personal goals Help develop strategies for re-engagement Remember: We need to suppress our own desire to express our disappointment, fear, worries. This is about the patient, not us.

Tips To Remember It is not about us. Responsibility lies with the individual patient and what they feel they need in their life. Our role is to be active, caring observers who are present to help the patient. Because individual behaviors can change over time, we need to remain vigilant about checking-in at each encounter (Metsch, et al., 2004).

The Health Care Provider Motivational Interviewing & Motivational Interviewing Instruments of change

Provider Stance Guiding or coaching (versus directing) and supporting Respecting individual autonomy & empowerment Expressing belief in the patient’s ability to make decisions Resisting the reflex to make it “right” or to label actions as “good versus bad” Being a committed and dedicated provider is not the same as taking “ownership” for the patient’s decisions. Not good versus bad, but “what worked for you and what didn’t” – look at the patients goals and values and seeing if their actions worked or not to keep them focused on their goals.

MI is about choosing the type of instrument and who you want to be as a provider ….

Four Processes of MI Engaging: listening to understand – “OARS” Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, offering information and advice Evoking: selective eliciting, responding, summaries toward change talk Planning: moving toward commitment and change These 4 processes help to bring about or eliciting change talk!

Change Speak – DARN-C Desire: I want to get healthier. Ability: I can do this if I set my mind to it. Reasons: My heavy drinking is causing me many health problems. Need: My family worries about me too much; it is not fair to them. Commitment: I will start getting more regular health check-ups. DARN-C is an acronym that can help us be more cognizant of change talk from the patient, as well as ways that we can pose questions to elicit change talk. Exploring ambivalence also allows us to selectively listen for “the language of change” or DARN – C . Asking about Desire, Ability, Reasons and Need help us and the Veteran to fill in the benefit side of change, as well as the down side of sustaining…. Here is what we mean by each of these aspects of change talk….

Engaging: Building a therapeutic alliance Step 1 OARS Open ended questions Affirmations Reflective Listening Summaries Nonjudgmental stance Listening to the patient and learning about their values and their reality/understanding about their condition and needs. OARS is an acronym for the 4 skills/strategies central to Engaging. These are THE core skills of Motivational Interviewing. http://motivationalinterview.org/clinical/interaction.html www.mpaetc.org/downloads/motiv_interv_09.pdf

O-A-R-S Open ended questions to elicit change talk: “What are some of your reasons for decreasing your alcohol intake?” (desire) “How might you go about decreasing your drug usage?” (ability) “What do you see as some benefits to lowering your alcohol usage?” (reasons)

O-A-R-S Open ended questions to elicit change talk: “How important is it for you to decrease your usage?” (need) “What might you do to start reducing your alcohol consumption?” (commitment) understanding Veteran’s perspective and motivation, agenda setting, eliciting change talk

“I’m really glad you decided to come in to see me today.” O-A-R-S Affirmations: Use to encourage people to see their “resources” Make them personal and genuine Explore partial successes and attempts and intentions Highlight patient attributes, effort “I’m really glad you decided to come in to see me today.” understanding Veteran’s perspective and motivation, agenda setting, eliciting change talk

Summaries (restating patient’s main points): O-A-R-S Reflective Listening (paraphrasing pt comments): “It sounds as if you are a bit concerned about how to make healthier choices in your life.” Summaries (restating patient’s main points): “Let me make sure I heard you correctly. You do want to address your drug usage and you want information about how to take more precautions in your sex life.” Reflection: Is not a time to question. These are statements only. It relays that you are listening to the patient and their needs and concerns YOU ARE PRESENT YOU SEE THEM as an individual Way to express EMPATHY -------------------------------------------------------------------------------------------------------------------- Summaries are a form of reflective listening – a way of combining multiple reflections in one intervention. It is often quite helpful to summarize the conversation at various points. Doing so checks again on your understanding of the patient’s position, allows an opportunity for correction, and assures the patient that he/she has been heard and understood. It is also a way to begin to shift the interaction – increasing focus and/or planning. Using an open question at the end has this effect (e.g., “So, where would you like to go from here?” )

O.A.R.S. is an acronym for the skills that can be used to engage patients in treatment; it stands for O-offer assistance; A-ask questions; R-refer out; S-summarize O-operationalize; A-attend; R-request tests; S-start goals O-open ended questions; A-affirmations; R-reflective listening; S-summaries O-open up discussion; A-attend to; R-reflect; S-shorten session

Focusing: Target one area step 2 Identify a strategic focus (agenda setting) Explore patient’s motivation, while listening for change talk Offer and share information - ask permission, Elicit-Provide-Elicit The second MI process that we would like to share and work on with you is Focusing, helping to move beyond engaging to finding a strategic focus. Agenda setting: The goal of the agenda-setting technique is to provide patients with the opportunity to discuss that which they are most ready to change and practitioners with the opportunity to deliver a dose of more tailored education to interested individuals This doesn’t mean we stop engaging, or that there is a discrete start (or end) to focusing; each process blends with the others, and we often need to circle back, especially to engaging. However, to be efficient, especially in primary care, where time is limited, we need to shift to working on a specific area or behavior. Sometimes the Veteran will be clear about what they want to focus on, at other times, the clinician will have to start the process; often times, there will be some negotiation… Here are the goals of Focusing: we will cover the skills and strategies associated with

Example Target behavior: use of condoms Agenda setting: “Hello, Sandy, it’s nice to see you. The last time we met, we spoke about your goal to begin using condoms more regularly. I’d like to start with that topic, unless you have something more pressing to discuss.” Sandy: “I didn’t do too well - I do want to do better.” Possible Reflections: “You found it more difficult than you thought.” “You’re still committed to change and you found it challenging.” Sandy, a 24 yo single female came to the clinic for treatment of gonorrhea.

Example (cont.) Sandy: “My partner doesn’t like using condoms. He won’t even talk to me about it.” Reflections: “It’s been difficult to make the change, especially since your partner doesn’t agree with the change.” Sandy: “Yeah, I guess; I don’t really see the need either, since I am monogamous.” “You have questions about the importance of using condoms, since you are having sex with just your partner.

(cont.) Sandy: “Yeah, it’s such a big change; I’m not sure it’s worth it.” Reflection: “You feel a bit unprepared for making this change and uncertain about whether using condoms is what you want to do.” Sandy: “Yeah. I do and I don’t’ want to make the change.” “You have some motivation to change. We can work on this together. I have some ideas and information. Can I share them with you?” Sandy: “Okay.”

Conversation continues Transitional Summary: “Alright, if I can summarize what we have spoken about: You are confused about the reasons for using a condom, it’s been difficult to make the change since your partner does not agree with it, and you feel unprepared. So, you would like more information and some ideas that may work for you.” Key Question: “Where do you want to begin – with information about condom use, ways to make the change, or how to approach your partner?” (autonomy)

“Elicit, Provide, Elicit” (information sharing process) ELICIT readiness and interest “What do you know about the effects of …” “What concerns do you have about…?” PROVIDE clear information or feedback “What happens to some people is that…” “The results of your tests suggest that…” “As your doctor/counselor/nurse, I strongly urge you to…” ELICIT the interpretation or reaction “What do you think?” “How do you think you might…?” Here is another specific format for thinking about the Information Sharing Process: EPE In this format, the patient is first asked to describe what they know about a particular health behavior, or what concerns or questions they have (Elicit). Next, the counselor gives clear, nonjudgmental advice (Provide), using specific examples if available. Finally, the patient is asked what he or she would like to do about the behavior (Elicit). E-P-E reverses the usual advice hierarchy by allowing the patient to do most of the talking—It is patient centered. The typical (and I think less effective) method is to start by providing information, allow the patient to react, and then attempt to correct the patient’s viewpoint or make additional suggestions on the way out of the conversation. In contrast, the E-P-E format allows the patient to voice potential concerns and encourages better synthesis of the material.

Evoking – pulling for change talk step 3 Encouraging, nurturing, reinforcing change talk Guiding towards change – finding alignment (and discrepancy) between current behavior and goals and values Rolling with resistance Summarizing where you are The clinician moves from exploring to selectively evoking Change Talk (Darn, Ability Reasons Need) and eliciting and reinforcing Commitment Language. This is the part of the process we are focusing on here Eventually, we move into Process IV - Taking Steps and planning for successful behavior change. Again, there is research evidence that evoking change talk and particularly commitment language is highly correlated to positive behavior change.

Approaches for Evoking Change Talk Ruler for importance Querying extremes Goals and Values Typical day Looking forward Coming alongside How do we evoke more and stronger change talk? Here are some specific strategies that we can use to address this goal…

Importance Ruler “On a scale of 0 to 10, how important is it to you to _________?” “What is the reason it’s (x) and not (a lower number)?” (If number is less than 8), “What would it take to move it up in importance just one number?” {Listen, reflect} …“What do you think you might do next?” The importance ruler is one of the most useful tools for eliciting change talk, especially when motivation is low. Here is how this works. The patient is asked, in a nonjudgmental tone of voice, how important, on a scale of 0 to 10, with 1 being not at all important and 10 being extremely important, is it to you to feel better about yourself by losing some weight (or insert other potential change)? When the patient responds with a number above zero, then ask, for example, why did you give that a 4 instead of a 1 or 2? This is an open ended questions that asks for elaboration and for reasons. It gives additional insight into the patient’s thoughts and feelings. Next, ask “what would it take to raise that 4 to a 6 or 7?” This gives insight into reasons or plans the patient may have had in the back of his/her mind, or at least stimulates the patient to think about the issue. It stimulates change talk. Later, we will apply the ruler to assessing and responding to confidence….or ability. However, it is useful, especially when change talk is low, to start with importance

Querying Extremes “What are the worst things that could happen if you don’t make this change?” “What’s the best thing that could happen if you make this change?”

Goals and Values “Let’s, for a moment, move away from this ____ issue and focus on the things that are most important to you, your life dreams, goals, and values. Tell me the most important areas for you.” Listen, then say: “So being here, healthy, is important. How does your (behavior) fit in with that?” Relate to values, bigger issues. May be useful to prompt or have visual aides that reflect common values and goals (family, work, country, spirituality, community) (Miller and C’deBaca, 2001) Discussed in Bill Miller’s book on sudden change: Quantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives (2001), Guilford Press William R. Miller Phd (Author), Janet C'deBaca Phd (Author)

Rolling with Resistance Affirm and accept patient’s fears, concerns: “I can understand your worries about the side effects of all you medications. Let’s spend some time discussing this.” Reflect other’s concerns: “I hear you saying that you don’t care about maintaining a healthy diet; but, how does this impact your partner?” Reframing patient concerns to positive movement “So what you’re saying is that you desire to quit smoking and (instead of BUT) you realize this may be hard to do.” Offer assistance “How can I help you move towards making positive change? What is needed?” [Consider asking audience to read silently or aloud]

Assessment and Planning step 4 Summarizing where the patient is with regard to making change Developing a goal and action plan Exploring, building patient’s confidence/self-efficacy (affirmations) Addressing real and perceived barriers, challenges Scheduling follow-up Here are the goals of Planning [Read] We strive to develop a plan that is not only desirable, but also achievable, and we want to assist the Veteran to prepare and plan so that they are likely to meet their goal. Planning includes assessing and building confidence (also known as self-efficacy), identifying and overcoming barriers, and arranging follow-up so that we can assess progress and help the Veteran to stay, or get back, on track. [May want to foreshadow that any plan, no matter how thorough, is likely to be only partially successful. Even if fully successful initially, maintenance of change is challenging, and relapse is the rule, rather than the exception.]

Assess Stage of Change “How confident/ready are you in making changes to your lifestyle?” “How do you feel about the requirements of maintaining your health?” “ What do you hope with regard to your health diagnosis for the future?” “What concerns do you have about your risk-reduction practices?”

Pre-contemplation Listen and help address any patient concerns “It sounds as if you want to reduce your alcohol intake, but your partner does not want to change his/her lifestyle. Maybe we can brainstorm ways that you can address this with your partner.” Encourage information sharing from patient “What is your opinion or belief about using condoms?” “Tell me how you have been able to manage your medication requirements.” Express interest and empathy “The decisions you have to make are very difficult. I know you can make the decision on your own, but I would like to assist you in learning more about your options.”

Planning for Change (Contemplation Stage) Attend to ambivalence “I hear that part of you wants to make some positive changes, but a part of you is also hesitant.” – reflect intention Foster Self-efficacy and Autonomy Elicit current knowledge: “What do you know about __?” Provide information: “If I may, let me provide some information.” Elicit Pt reaction: “What are your reactions to this information?” “Ultimately, it is your decision to make about ___.”

Movement Towards Change (Preparation and Action) “What do you think would be a ‘do-able’ first step towards your goal that you can do today?” “What do you plan to do between now and next week?” “ When do you think you will be able to start?” “What strategies have you employed in the past to achieve goals?” “What will we be looking for that indicates success?”

Addressing Barriers to Change & Enlisting Support “What can I do to assist you?” “Can I provide you some resources?” “Who can you ask to be a support for you during this time?”

Maintaining Positive Change Normalize any possible set-backs (reduce shame) “It’s OK if you don’t always meet your goals of ___”. Help patient develop a plan to ensure success “What other things can you do to encourage your progress towards ____.” “What might be some barriers or temptations that hinder you?” Provide Continued Support “I would you like to meet again to check-in and see how you are doing. How does that sound?”

When Relapse Happens Normalize relapse “Relapsing is a normal part of any change process.” Assist patient in remaining engaged “I believe you are quite capable of continuing on toward your goals – you did it before and you can do it again!” “What lessons can be learned from this relapse to help you remain focused on ___. What might you do differently?” “Where do you think we should go from here?”

Case Study H.A., a 42-year-old, Caucasian, divorced male is referred to your care after he was found to be HIV-seropositive. H.A. is currently unemployed and homeless and though he has a long history of abusing drugs and alcohol he states that he is trying to “get clean”. H.A. states that he is really concerned about his deteriorating physical and mental health. When asked about social supports, HA replies that he has a brother and a sister who live close by. He adds that he also receives great support from his case manager, a social worker at the community-based recovery program for homeless persons with addictions.

What is the patient’s stage of change and how would you nurture his change talk? Precontemplation Stage; provider would express empathy and encourage info. sharing Contemplation Stage; provider would attend to patient’s ambivalence and foster his self-efficacy and autonomy Preparation Stage; provider would help patient set goals and develop action plan Maintenance Stage; provider would normalize relapse

Remind yourself that even if the patient does not choose to change, the intervention is not a failure. Any discussion or talk about change is planting a seed.

References Beach, M., Keruly, J., & Moore, R. D. (2005). Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV? Journal of General Internal Medicine, 21, 661. Metsch, L. R, Pereyra, M., del Rio, C., Gardner, L., Duffus, W. A., Dickinson, G., et al. (2004). Delivery of HIV prevention counseling by physicians at HIV medical care settings in 4 US cities. American Journal of Public Health, 94(7), 1186. Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York: Guilford. Discussed in Bill Miller’s book on sudden change: Quantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives (2001), Guilford Press William R. Miller Phd (Author), Janet C'deBaca Phd (Author)

References Miller, W. R., & C’deBaca, J. (2001). Quantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives. New York: Guilford Press. Schneider, J., Kaplan, S. H., Greenfield, S., Li, W., & Wilson, I. B. (2004). Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. Journal of General Internal Medicine, 19, 1096.

References Cook, P. F., Bradley-Springer, L., & Corwin, M. A. (2009, August). Motivational interviewing and HIV: Reducing risk, inspiring change. Retrieved July 2, 2010, from www.mpaetc.org/downloads/motiv_interv_09.pdf Motivational interviewing [resources for clinicians, researchers, and trainers.](n.d.) Retrieved July 2, 2010, from http://motivationalinterview.org/clinical/interaction.html Family Health International. (2007). Nursing care of patients with HIV/AIDS. Retrieved August 19, 2010, from http://www.fhi.org/NR/rdonlyres/erwyyfde6xm6oxea3vg46q5fpg7lottczgkru5ymvykflcipkasb3jkqkfomo3ybedwpeis5z6sxlp/NursesCarePatientsParticipantsGuideHV.pdf

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Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.