BRADLEY SAMUEL, PHD DIRECTOR OF BEHAVIORAL HEALTH EDUCATION UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE DEPARTMENT OF FAMILY & COMMUNITY MEDICINE MOTIVATIONAL INTERVIEWING IN PRIMARY CARE

ASSUMPTIONS ABOUT MOTIVATION MOTIVATION IS MALLEABLE SUBJECT TO CHANGE IN CONTEXT OF PATIENT- PROVIDER RELATIONSHIP THE WAYS IN WHICH ONE TALKS WITH PATIENTS CAN INFLUENCE PERSONAL MOTIVATION FOR BEHAVIOR CHANGE

SPIRIT OF MOTIVATIONAL INTERVIEWING COLLABORATIVE – Active collaborative conversation and joint decision making process. EVOCATIVE – Access & activate motivation and resources for change. HONORS PATIENT AUTONOMY – Requires some detachment from outcomes. Recognition that ultimately it is patients who decide what to do.

STYLES OF COMMUNICATION DIRECTING FOLLOWING GUIDING (All three are valid…Guiding is best tool for behavior change and motivation) (Helping professionals typically rely on Directing) (Following is best after giving information)

GUIDING LISTENING CAREFULLY & EMPATHICALLY ASKING ABOUT OPTIONS CONSIDERED OFFERING WHAT YOU KNOW ABOUT DECISION MAKING, RELATIONSHIPS, ETC. RECOGNIZING & HONORING THAT “IT IS YOUR DECISION TO MAKE.”

GUIDING IN MI MOTIVATIONAL INTERVIEWING: 1) Is specifically goal directed wherein practitioner has a behavior change goal in mind and gently guides patient in ways that he/she may pursue that goal. 2) Pays particular attention to specific aspects of patient language and actively seeks to evoke patients own arguments for change. 3) Involves competent use of well defined set of clinical skills to evoke patient behavior change…

AGENDA SETTING GUIDING MEANS FINDING OUT WHERE PERSON WANTS TO GO… BRIEF DISCUSSION IN WHICH PATIENT IS GIVEN AS MUCH DECISION MAKING FREEDOM AS POSSIBLE. QUESTIONS LIKE “WHAT CONCERNS YOU MOST?” OR “WHAT WOULD YOU LIKE TO FOCUS ON FIRST?” PROGRESS OR BEHAVIOR CHANGE IN ONE AREA OFTEN GENERALIZES…DO IT IS OK FOR PATIENT TO CHOOSE EASIEST OPTION FIRST.

THREE CORE COMMUNICATION SKILLS ASKING LISTENING INFORMING  MOST PRACTIONERS REPORT UTILIZING ASKING & INFORMING IN THE SERVICE OF A DIRECTING STYLE.  MI PROPOSES THAT PRACTIONERS CONSIDER AN ASKING, LISTENING, INFORMING APPROACH THAT IS IN THE SERVICE OF GUIDING.

AMBIVALENCE “I need to lose weight, but I hate exercise…” “I should quit smoking, but I can’t seem to do it.” “I mean to take my medicine, but I keep forgetting.”  HALLMARK OF AMBIVALENCE IS USE OF THE TERM BUT

RESOLVING AMBIVALENCE ACKNOWLEDGE AND REFLECT BOTH SIDES OF AMBIVALENCE i.e. “You want to lose weight and hate exercising…” COLLABORATIVE EXPLORATION *NOTE THAT REFLECTION SHIFTS FROM “BUT” TO “AND.” HOLD OFF ON TRYING TO FIX THIS NOW. LISTEN FOR, AND ELICIT, CHANGE TALK. WE WANT THE PATIENT TO VOICE REASONS FOR CHANGE.

LISTENING FOR CHANGE TALK RECOGNITION OF, AND ATTUNEMENT TO, CHANGE TALK. LEARNING TO ELICIT CHANGE TALK… EXAMPLES OF CHANGE TALK…  “ YES I WILL…”  “I MIGHT BE ABLE TO…”  “I WISH I COULD…”  “I’LL TRY…”

LEVELS OF CHANGE TALK DESIRE – “I want to…” ABILITY – “I can…” REASONS – “I would probably feel better if…” NEED – “I should…” COMMITMENT – “I will…” TAKING STEPS – “I started…”

PRE-COMMITMENT LEVELS OF CHANGE DESIRE ABILITY REASONS NEED  KEY IS TO LISTEN, REFLECT, AND AFFIRM AT THESE LEVELS.  SKILLED USE OF LISTENING AND COMMUNICATION AT THESE LEVELS INCREASE LIKLIHOOD OF COMMITED CHANGE.

COMMITMENT LEVELS OF CHANGE TALK COMMITMENT TAKING STEPS

ZERO TO TEN ASSESSMENTS “HOW IMPORTANT IS IT FOR YOU TO QUIT SMOKING (MAKE THIS CHANGE)? scale FOCUS DISCUSSION ON “WHY NOT LOWER” RATHER THAN “WHY NOT HIGHER.” e.g. “WHY DID YOU CHOOSE FIVE INSTEAD OF THREE?” THIS FACILITATES CHANGE TALK INSTEAD OF AMBIVALENCE OR RESISTANCE.

GUIDING THROUGH CHANGE TALK TASK IS TO ELICIT CHANGE TALK RATHER THAN RESISTANCE FROM PATIENTS. THE ‘HOW OF IT’ IS TO ASK OPEN ENDED QUESTIONS THAT REFLECT CURRENT LEVEL OF CHANGE TALK & THEN LISTEN. EXAMPLES:  “WHY WOULD YOU WANT TO QUIT SMOKING?”  “HOW WOULD YOU DO IT, IF YOU DECIDED TO?”  “WHAT AR E THE REASONS YOU WOULD QUIT IF YOU DECIDED TO?”

MOVING FROM TALK TO BEHAVIOR CHANGE EXPLORING AMBIVALENCE GATHERING CHANGE TALK MEASURING MOTIV., CONFIDENCE, HOPEFULNESS, IMPORTANCE LISTENING, GUIDING, INFORMING SUMMARIZING MOTIVATION FOR CHANGE TIMING MOSTLY OPEN ENDED QUESTIONS ASKING FOR WILLINGNESS TO CHANGE DEVELOPING PLAN

THREE PRACTICAL RECOMMENDATIONS ABOUT ASKING & LISTENING 1) USE OPEN RATHER THAN CLOSED ENDED QUESTIONS. 2) TRY NOT TO ASK TWO QUESTIONS IN A ROW. 3) TRY TO OFFER AT LEAT TWO REFLECTIIONS FOR EVERY QUESTION.

SUMMARIZING IN MI MOSTLY SUMMARIZING WHAT PATIENT, NOT PROVIDER, HAS SAID. REFLECTIONS ARE MINI-SUMMARIES AS YOU GO. SUMMARIZING CAN BE USED AS A SEGWAY FOR CHANGING DIRECTION. SUMMARIZING HELPS BUILD AND MAINTAIN RAPPORT & CONVEYS UNDERSTANDING. A GOOD SUMMATION DEMONSTRATES THAT YOU HAVE BEEN LISTENING & REMEMBERING WHAT PATIENTS HAVE SAID.

BIBLIOGRAPHY AND RESOURCES MOTIVATIONAL INTERVIEWING IN HEALTH CARE: HELPING PATIENTS CHANGE BEHAVIOR STEPHEN ROLLNICK WILLIAM R. MILLER CHRISTOPHER BUTLER GUILFORD PRESS