Associate Professor, Harrison School of Pharmacy Motivational Interviewing (MI): Righting Reflex, Resistant Patients, Micro Skills Jan Kavookjian, MBA, PhD Associate Professor, Harrison School of Pharmacy Auburn University

Overview Background MI Assumptions Righting Reflex Research Training MI Assumptions Righting Reflex MI Communication Principles Micro Skills

Provider-Centered Patient-Centered Information giving “Save” the patient Dictate behavior Compliance Authoritarian Motivate the patient Persuade, manipulate Resistance is bad Argue Respect expected Literacy level of communication may be high Information exchange Patient “saves” self Negotiate behavior Adherence Servant Assess motivation Understand, accept Resistance is information Confront Respect earned Literacy level of communication at patient level

Motivational Interviewing (MI) Major Assumption: Patient-centered “SPIRIT of MI” Major Assumption: Building ongoing relationship/ trust Major Assumption: Not motivating the patient; helping patient get to his/her existing internal motivation Major Assumption: Patient should doing most of talking Major Assumption: Tool box with communication strategy choices Major Assumption: Addresses ambivalence and resistance Rollnick, Miller & Butler (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior, New York, NY: The Guilford Press. Rollnick S, Mason P, Butler C. (2000). Health Behavior Change: A Guide for Practitioners, London: Churchill Livingstone. Miller WR, Rollnick S. (2002). Motivational Interviewing, 2nd Edition: Preparing People for Change, New York, NY: The Guilford Press.

Ambivalent: Jane Smith, 34 yo, T2D, Obese “Yeah, I know I need to lose weight and I know it will help my numbers. I don’t feel like I can do it. I AM worried that my A1C is 10%; I should start an exercise routine because I feel better when I do, and my doctor will quit bugging me about it if I lose some weight, and I like my smaller size clothes, but it’s hard to fit exercise into my day and it hurts… and I don’t like people to see me exercising – it’s embarrassing. And, I just really feel comfort in the foods I eat- they’re what I have always eaten. Besides, it seems like every time I try to do anything, it’s not enough to make a real difference; I don’t know what I could do that would change things.”

Resistant: John Jones 58 yo,T2D, HTN “I know you’re going to try to make me feel bad about myself like everyone else did, so you may as well quit now. I just don’t see why it’s a big deal – my numbers aren’t that far out of range and I feel fine. I work hard and I am not giving up my after-work drinks and cigarettes, nor am I giving up my all-you-can eat buffet lunches with my buddies at work. And, I take my medicine most of the time anyway so I should be able to eat what I want – okay, so I miss it a few days a week, but don’t make a big deal out of it – I feel fine.”

“Yes, but……” A very common reactive response Assumes ‘I know better than you’ (violates face) Forces patient defensiveness When patient defends, it reinforces why not to change Resistance is now justified in mind of patient

Patients must have their own internal motivation for change. Bottom Line: Patients must have their own internal motivation for change.

Most interventions try to push or pull patients to temporary change when they are not ready (external motivation).

The ‘Righting Reflex’ People in the Helping Professions have a Natural Tendency to want to FIX what’s ‘wrong’ with patients.

MI Communication Principles Expressing empathy (early and often) Supporting self-efficacy Rolling with resistance/Avoiding arguments Developing discrepancy

Expressing Empathy Feeling or identifying affectively with another 1. Careful listening 2. Reflecting understanding 3. Patient feels understood 4. Reduces anxiety 5. Improves adherence & patient outcomes

Expressing Empathy Example Patient: “I just cannot endure this diabetes diet! I’ve had to give up too many of the things I like and the small portion sizes leave me hungry!” Provider: “Mr. Johnson, you sound angry. The idea of having to limit yourself with a diet you didn’t get to choose is frustrating.” (c) Jan Kavookjian, MBA, PhD Auburn University 24

Empathic Responses “You seem_____” “In other words…” “You feel ___ because ___” “It seems to you…” “As I understand it, you seem to be saying…” “I sense that…” “You sound…..” AVOID: “I understand how you feel.”

Support Self-Efficacy Notice, support, encourage patient attempts or even thoughts about change. Praise the behavior, not the person. Look for opportunities to support the change efforts of your patients. Caution: over-praising sounds insincere.

Support Self-Efficacy Examples “Mr. Richards, it’s great that you take your diabetes medicine every day the way you planned. Keep it up!” “You were able to lose weight before, I am confident that you can do it again. What worked for you last time?” “That’s great that your A1C has come down since last time! Tell me about the things you’re doing that are helping you succeed!”

Roll with Resistance/Avoid Arguments Ignore antagonistic statements. Don’t add to patient’s resistance by forcing mutual defensiveness. Shift focus away from resistance; stay focused on the purpose of the encounter and important issues. Emphasize personal choice.

Rolling with Resistance Example Patient: “I don’t like the idea of blood pressure medicine. I hear it can have bad side effects.” Provider: “And it really is your decision. All I can do is tell you the advantages and disadvantages and give you my opinion. It really is up to you.”

Rolling with Resistance Example Patient: “I just don’t think I can quit eating my nightly bowl of ice cream- that’s how I relax before I go to bed.” Provider: “May I tell you what concerns me?” Insurance Card strategy

Develop Discrepancy Strategy 1. Repeat back Pros (benefits) and Cons (barriers) stated by the patient.

Strategy 1 Example “So, on the one hand, you want to reduce your risk of ending up on dialysis by lowering your blood sugar, but on the other hand you don’t like to take medication and you feel fine.” “I am concerned that if …. This worries me…. What are your thoughts?”

Develop Discrepancy Strategy 2. Ask questions about behaviors that don’t support goals set by the patient.

Strategy 2 Example “Mr. Jones, I am concerned that your diabetes medicine refill has been ready for about two weeks. What are your thoughts about how this might affect the goal you told me last time about reducing your risk of the diabetes complications your mother had?”

Develop Discrepancy Strategy 3. Thought-Provoking Questions OR “If I were to give you an envelope, what would the message inside have to say for you to think about quitting smoking?” OR “What would have to happen for you to think about getting more activity into your daily routine?” “What will life be like for you when you lose the 30 pounds [you have set as your goal this year]?”

MI Micro Skills FIRST establish patient understanding about diagnosis & risks/susceptibility Maintain patient autonomy by using open-ended questions, agenda setting, and asking permission to give information/advice Engage the patient in ‘change talk’: the patient talking about the change, benefits/pros, prior successes Self-efficacy building & incremental goals

Establishing Risk/ Susceptibility Patient has to make the link to WHY change is needed Patient may have forgotten Patient may be avoiding Health beliefs Early in the conversation, useful later

Establishing Risk/ Susceptibility Dialog Mrs. Smith, tell me what you know about what this blood sugar number (A1C) puts you at risk for? [I don’t know, or knows minimal or incorrect information] May I share with you some [additional] information about that? [yes] [provider gives information, citing evidence/CPGs] What do you think about that? I don’t want those things to happen to me. I don’t want those to happen to you either. If it’s okay with you, I’d like to talk with you about some things you can do to help prevent those from happening to you.

Patient Autonomy: Agenda-Setting Maintains autonomy/choice Organizes the conversation structure -‘We can talk about taking medication, small changes you can make in the foods you eat, and getting more activity into your daily routine. Which of these would you like to talk about first?’ [medication taking] ‘ Now that we’ve talked about the medicine, which of the other two topics would you like to talk about next?’

Patient-Autonomy: Open-ended vs. Yes/No Questions To explore (‘Tell me what you know…’ vs ‘Do you know?’) (What are your thoughts about walking to get activity in your routine?) To get patient input (‘What are some things you can do to remind yourself to take this medication?’) Prevents patient feeling judged or interrogated (vs. ‘Did you try this?’ ‘Have you thought about trying walking?’)

Patient Autonomy: Asking Permission to Give Information* To avoid a sense of advising and ‘fixing’ Ask permission if you need to give information (“May I share with you some things you can do to help prevent being readmitted to the hospital?”) *Treatment for the Righting Reflex Avoid arguing the patient’s point of view (when they argue their barriers, they are reinforcing why not to change)

Process for Asking Permission to Give Information 1. Ask what they know 2. Affirm what they do know (if they do) 3. Ask permission to fill in the blanks 4. Give the information/advice about disease and/or treatment and/or changes needed ‘Mrs. Smith, what are some things you can think of to do to remember to take your medicine?’ [don’t know or knows minimal] ‘May I share with you some things other patients have said help them to remember?’ [yes] [customizing a plan that fits patient’s routine]

Change Talk What do you see as the benefits of changing? What would your life be like if you changed? What would you like about your life if you changed? When you were successful at this target behavior before, what were the things you were doing that got you there? How ready are you to change? How important is the change to you? How confident are you that you can change?

Change Talk: Readiness Ruler (OR, Importance, Confidence) “On a scale of 1 to 10, with 1 being not at all and 10 being completely, how ready are you to cut down on salt to reduce your blood pressure?” [ 7 ] 1. “Okay, a 7, that’s great! Why a 7 and not a 1?” (Identify motivators and support SE that it’s a 7 and not a 1) 2. “What would have to happen for it to be a 8 or 9?” Change Talk, motivators, incremental expectations

Incremental Goals Self-efficacy building via small successes Success in small things can progressively build confidence towards bigger change Avoiding use of BIG words like ‘diet’ and ‘exercise’ and ‘quitting’ (smoking) Instead: ‘small changes in some of the foods you eat,’ ‘getting more activity into your routine,’’ cutting back on the number of cigarettes per day’, ‘cutting one soda out of your daily routine for the next week and see how that goes’

Strategies for Those Most Resistant Patients Maintain ‘Spirit of MI’ & relationship Early and frequent Empathy ‘It sounds like you’re not ready to quit smoking.’ Roll with it – stick to topic at hand EXPLORE the resistance (e.g., using the rulers) Develop discrepancy Emphasize personal choice-unexpected Use the ‘insurance card’ (“May I tell you what concerns me?”)

Associate Professor of Pharmacy Care Systems Contact Information Jan Kavookjian, MBA, PhD Associate Professor of Pharmacy Care Systems Harrison School of Pharmacy 212 Dunstan Hall Auburn University, AL 36849-5506 Phone: 334-844-8301 E-mail: kavooja@auburn.edu