Health Behavior Coordinator, Psychologist “Practical Strategies in Medication Adherence in Patients with Cardiovascular Disease” MOTIVATIONAL INTERVIEWING: What is it? Does it work? Julie Culligan, PhD Health Behavior Coordinator, Psychologist Mountain Home VAMC

MI Philosophy "People are generally better persuaded by the reasons which they have themselves discovered than by those which have come in to the mind of others.”  ~ Blaise Pascal, French mathematician, physicist and religious philosopher

Learning Objectives Specify and discuss 3 elements of the “spirit” of Motivational Interviewing Identify the 4 principles of Motivational Interviewing Identify basic use of the following core MI skills: open-ended inquiry, affirmation, reflective listening and summaries

Facilitating Behavior Change What makes behavior change so hard? It works for us “Habit” It often involves multiple behaviors Knowledge about how to change isn’t always enough People are creatures of habit Health consequences are often delayed Busy lifestyles require us to make time for self care

Motivational Interviewing “A person-centered, goal-oriented approach for facilitating change through exploring and resolving ambivalence.“ (Miller & Rollnick, 2006) A clinical “style;” a “way of being with people” (Miller & Rollnick, 2002; Rollnick & Miller, 1995)

Motivational Interviewing: Based on Theory Conceptualized according to stage model of change (Prochaska & DiClemente, 1982) Not everyone engages in treatment at the same stage of readiness Different type of approach may be utilized for individuals at different stages

Transtheoretical Model: Stages of Change A STAGE MODEL OF THE PROCESS OF CHANGE Pre-Contemplation Determination Contemplation Relapse Action Maintenance Permanent Exit

Not to change behavior….. The Goal of MI The goal of MI is to facilitate: Fully informed, Deeply thought out, Internally motivated choices, Not to change behavior….. Resnicow, et al., 2002

Traditional vs. Motivational The “Doctor”: The “patient”: Places the importance on the behavior change Controls the interaction May direct/select the goals the patient should achieve Determines the importance of the behavior change Is listened to, shares concerns and needs Is supported in decisions about change and goals

Empathic Style of MI and Brief Interventions The key element in brief interventions is empathy Research on empathy and clinical outcomes: Strongest predictor of outcomes Not accounted for by demographics Not accounted for by treatment type

Patient Focus MI supports the patient in articulating How personally important this change (e.g., dietary) is, as opposed to how important we think it is What stands in the way of making this change (time, money, cultural factors, emotions, etc.) Changes that might work in their life How to increase the chances of success

Learning MI Techniques Listening Skills Spirit

Spirit of Motivational Interviewing Evocative (vs. Educational) – patient is responsible for change. (“What would you gain if you changed your drinking?”) vs. implanting the right idea (“You really need to stop drinking.”) Honoring Autonomy (vs. Authority) – Allow the freedom not to change. (“How ready are you to change?) vs. push for commitment (“If you delay getting sober, you could die.”) Collaborative (vs. Confrontational) – Work in Partnership. (“How about we discuss some options together” vs. “I would urge you to quit drinking.”) Honoring patient autonomy – requires a certain degree of detachment from the outcomes, though not an absence of caring. Clinicians may inform, advice, even warn – but ultimately it is up the patient to decide what to do. Humans resist coercion and being told what to do. Ironically, it is the acknowledging the other’s right and freedom not to change that sometimes makes change possible. Collaborative – a cooperative and collaborative partnership between patient and clinician. Challenges typical uneven power differential, and encourages active collaborative conversations and joint decision-making.

The Spirit of MI Motivation for change is elicited from within the patient, not imposed from outside The patient must articulate reasons for change The patient is the one responsible to decide Direct persuasion is ineffective The clinician should steer the conversation to focus on change

Ambivalence Interesting, natural, human, understandable Not unique to characterological problems Not indicative of defense (denial) “I want to but I don’t want to” Unhelpful to think of people as “unmotivated”

SPIRIT OF MI Ambivalence APPRECIATE AMBIVALENCE HONOR, EMBRACE, EXPLORE AMBIVALENCE. It’s the core. Many brief (and single session) therapies work by focusing on this ambivalence, not on skills (people frequently have the skills)

The RIGHTING Reflex “This person SHOULD want to change.” NOW is the right time to change. A TOUGH/clear/honest approach is best. Patient should follow my EXPERT ADVICE. If patient doesn’t change, the session FAILED. There’s nothing we can do for the “unmotivated.” OKAY if suicidal, but NOT IN RESPONSE TO AMBIVALENCE!!!

Rather than the Righting Reflex, Understand Ambivalence Reflective listening Helps patients to feel understood Provides comfort to patient (makes change easier) Acceptance; non-judgmental; no blaming Acceptance ≠ Agreement Ambivalence = normal (not pathological)

Communication is a Dance

Not a Tug of War

Evaluate the Pros and Cons Reducing/Giving up Tobacco Pros (Good Things) Cons (Downsides) Smoking the Same I can still smoke with I friends It helps me deal with my stress It’s hard to breathe It’s a fire hazard It’s bad for my health It’s expensive Making Changes in Smoking Feel better Have more energy Have more money I wouldn’t be able to hang out with my friends who smoke I wouldn’t have a way to deal with my problems Fill in any behavior change

Evaluate the Pros and Cons Increasing Medication Adherence Pros (Good Things) Cons (Downsides) Stay the Same, i.e., Non-Adherent I can still smoke with I friends It helps me deal with my stress It’s hard to breathe It’s a fire hazard It’s bad for my health It’s expensive Making Changes, i.e., Adherent Feel better Have more energy Have more money I wouldn’t be able to hang out with my friends who smoke I wouldn’t have a way to deal with my problems Fill in any behavior change

Four Key Principles of MI Express empathy Develop discrepancy Roll with resistance Support self-efficacy

(1) Express Empathy Reflective listening Helps patients to feel understood Provides comfort to patient (makes change easier) Acceptance; non-judgmental; no blaming Acceptance ≠ Agreement Ambivalence = normal (not pathological)

(2) Develop Discrepancy Change is motivated by perceived discrepancy between present behavior and personal goals/values Discrepancy = importance of change for patient Amplify the discrepancy to move patient from the status quo Elicit discrepancy from the patient – they should make the argument for change

(3) Roll with Resistance Argument often pushes person in the opposite direction Resistance is a call for the clinician to change, not the patient Questions and problems should be reflected back to the patient, not “solved” by the clinician

(4) Support Self-Efficacy Be aware of your own beliefs about a patient’s ability to change (self-fulfilling prophecy) Enhance patient’s self-belief about his or her capability to make a change Be genuine

Motivational Interviewing December, 2007 What People say about Change predicts Behavior Change Self-perception theory Gary S. Rose, Ph.D. gary@miinstitute.com. Copyright (c) 2007. Please do not reproduce without permission.

Core MI Strategies Four Early Strategies; OARS Open Questions Affirming Reflective Listening Summarizing Elicit Positive “Change Talk” There are 5 early strategies that can help you deliver messages in a motivational style: Asking open questions – these are questions that can’t be answered with a simple “yes” or “no” and encourage the person to tell you more Affirming – Validating the patient’s perspective, even when you don’t necessarily agree Reflective Listening – Selectively reflecting back patient statements that highlight discrepancies, clarify patient’s desires and help them determine the best course of action. Summarizing – Offer periodic summaries that pull together different parts of the conversation to be sure the health worker accurately understands the patient, and that the patient understands the agreed upon plan. These strategies, when used together strategically, can elicit positive change talk from patients.

Open-Ended Questions Disarms resistance Creates momentum Avoids arguments You want them engaged and exploring – with you gently steering

Open Questions to Promote Change Disadvantages of the Status Quo How do you feel about your weight? Advantages of Change What would the benefits be for you, if you were to quit smoking ? Optimism for Change What makes you feel that now is a good time to try something different? Intention to Change What would you like to see happen? How might things be different for you, if you did make a change?

Affirmation Genuinely highlight patients’ strengths Antidotes to demoralization Appreciative of partial success (ex. Focus on success with quitting smoking for 2 years in past) Appreciates their honesty regarding ambivalence Support: form of compliments, statement of appreciation & understanding

Reflective Listening – The Foundation of MI “MINI-SUMMARIES” used strategically to lower resistance Used to highlight patient statements favoring change (“Change Talk”) A way of thinking, Difficult to learn Powerful for increasing readiness Expert ratio 2 reflections for every question vs. Novice ratio .5 reflections for every question

Handy Reflections Double-Sided (reflects both sides of ambivalence) – takes the clinician out of the equation – puts the ambivalence in their own lap So on the one hand, you like how alcohol makes you feel and at the same time, you worry about your Hepatitis. Amplified – can go in either direction Undershoots so patient might elaborate, “You’re a LITTLE confused…” Overshoots so patient can back down, “So you don’t EVER intend to cut down…”

Handy Reflections Shifting Focus – shift patient’s concern away from a potential stumbling block – around barriers rather than over them c: “Okay, maybe I’ve got some problems with drinking, but I’m not alcoholic.” Argument with a Twist – offer initial agreement, but with a slight twist or change of direction

Summarizing Helps the other person: Recall and reflect upon the conversation Think of new ideas Understand the importance of these issues Plan next steps Feel more confident, instill hope

Importance and Confidence Importance: lets you know how important this issue(s) is to the patient, in the grand scheme of other important values in their life Confidence: lets you know how able the patient feels he/she is to make specific changes towards his/her goal(s)

Readiness Indicators Assessing Importance and Confidence Importance How important is it to you to ____________? On a scale of 0 to 10, with 0 being not important at all & 10 being very important… 0 1 2 3 4 5 6 7 8 9 10 Not a all Somewhat Very Confidence How confident are you that you could _____________, if you decided to? On a scale of 0 to 10, with 0 being not confident at all & 10 being very confident? 0 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very

Evaluating Importance/Confidence “What made you answer with a (number patient gave) and not a zero?” “What would it take for you to move from a (number patient gave) to a (slightly higher number)?”

Setting Goals Specific Measurable Achievable Realistic Timely Rather than: “I will exercise regularly”, Aim for “I will walk for 15-20 minutes 4 days/week starting today”

Let’s see how we pull this together…

Resources www.motivationalinterview.org Clinical issues The Library Background Special Populations Group Approaches The Library Abstracts Bibliography MINUET Newsletter Links Training Upcoming Training MINT Trainers Training Videos

MI Books Miller, WR & Rollnick, S (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press. Miller, WR & Rollnick, S (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Arkowitz, H, Westra, HA, Miller, WR, Rollnick, S (Eds.) (2008). Motivational interviewing in the treatment of psychological problems. New York: Guilford Press. Rollnick, S, Miller, WR & Butler, CC (2008). Motivational interviewing in health care. New York: Guilford Press.

MI Articles Britt, E, Hudson, SM, & Blampied, NM. (2004). Motivational interviewing in health care settings. Education and Counseling, 53, 147-155. Emmons, KM, & Rollnick, S. (2001). Motivational interviewing in health care settings. American Journal of Preventive Medicine, 20, 68-74. Greaves C, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Steele A, Gale T, Hammerton F, Daly M (2008). Motivational interviewing for modifying diabetes risk: a randomized controlled trial. British Journal of General Practice, 58(553), 535-40. Hecht, J, et al. (2005). Motivational Interviewing in community-based research: Experiences from the field. Annals of Behavioral Medicine, 29 Special Supplement, 29-34. Resnicow, K, et al. (2001). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21, 444-451.

Soria R, Legido A, Escolano C, and Yeste A (2006) Soria R, Legido A, Escolano C, and Yeste A (2006). A randomized controlled trial of motivational interviewing for smoking cessation. Br J Gen Prac, 56(531), 768-774. Moyers T, Martino S (2006). “What’s important in my life” The personal goals and values card sorting task for individuals with schizophrenia. Zygmunt A, Olfson M, Boyer A, Mechanic d (2002). Interventions to improve medication adherence in schizophrenia. American Journal of Psychiatry. Possidente C, Bucci K, McClain W (2005). Motivational interviewing: A tool to improve medication adherence? American Journal of Health-System Pharmacy, 62(12) 1311-1314. Swaminath G (2007). You can lead a horse to water… Indian Journal of Psychiatry, 49(4), 228-230. Cole S, Bogenschutz M, Hungerford D (2011). Motivational Interviewing and Psychiatry: Use in addiction treatment, risky drinking and routine practice. FOCUS, 9:42-54. www.ComprehensiveMI.com