Motivational Interviewing: Changing the Conversation
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1 Motivational Interviewing: Changing the Conversation BC Nephrology Days 2010 October 7, 2010 Vancouver, BC Cristine Urquhart, MSW, RSW Change Talk Associates How ready, willing and able are you to be here today? Not at all Totally Change Talk Associates 1
2 Definition of Motivational Interviewing (MI) MI is a collaborative person-centered form of guiding to elicit and strengthen motivation for change. Miller, W.R. & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37, Communication Styles Guiding Communication style Following Directing Rollnick, S., Miller, W.R., Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behaviour. New York: Guilford Press. Rollnick et al. (2005). Consultations about changing behaviour. British Medical Journal, 331, Change Talk Associates 2
3 1. Research 2. Understanding Change 3. Key components 4. Skills & Strategies 5. System Integration Outline Research Change Talk Associates 3
4 Motivational Interviewing Drs. William Miller and Stephen Rollnick First described by Dr. Miller in 1983 as a brief intervention for problem drinking Over 200 clinical trials Approx publications on the MI website For more research see Clinical Populations & Ongoing MI Research Effective in supporting positive change in a number of health areas including: Nutrition Exercise Mental health Substance use Chronic disease management and prevention Maternal and child health (FASD prevention) Adolescents & high risk behaviours Cardiovascular health Medication adherence Probation Dentistry Rollnick et al., 2008 Change Talk Associates 4
5 Research Indicates that MI is: A brief intervention Effective in supporting patient engagement, retention and completion of treatment Shown to outperform traditional advice giving Learnable Effective cross-culturally Measurable Complimentary to other treatment approaches Rubak et al. (2005). Motivational Interviewing: A systematic review and meta-analysis. British Journal of General Practice, April, Hettema, J., Steele, J., Miller, W.R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1, Review of MI in Promoting Health Behaviours 37 articles reviewed: diet and exercise (24): increased self-efficacy, physical activity, fruit and veggie; decreased caloric intake, BMI diabetes (9): increased control glucose levels, physical activity, self-efficacy; decreased weight dental health(4): increased caries prevention, keeping dental appointments Martins, R. K. & McNeil, D.W. (2009). Review of Motivational Interviewing in promoting health behaviours. Clinical Psychology Review, 29, Change Talk Associates 5
6 Self-Management: Barriers & Facilitators for Patients on CHD Barrier: Lack of motivation noted as most common psychological barrier to fluid restriction adherence for patient on chronic hemodialysis Facilitator: Respect for autonomy and belief that patients are personally responsible for their own fluid intake and capable of self-restriction Smith et. al. (2010). Patient perspectives on fluid management in chronic hemodialysis. Journal of Renal Nutrition, 20(5), Self-Management, MI & CKD RCT to assess improvement in CKD Stage 3 &4 patients self-management using a multifactorial, nurse-driven intervention including MI Emphasis on reducing cardiovascular risk 5 year f/u van Zuilen, A.D. et.al. (2008). MASTERPLAN: study of the role of nurse practitioners in a multifactorial intervention to reduce cardiovascular risk in chronic kidney disease patients. Journal of Nephrology, 21, Change Talk Associates 6
7 Childhood Obesity and MI Dr. Ken Resnicow, University of Michigan School of Public Health Developing evidenced-based intervention models to assist primary care practitioners to treat their overweight pediatric patients. What are the Limits? Everything to everybody and nothing to no one. (Moyers, 2008, MINT Forum, Albuquerque, NM) Not a panacea Those already ready for change Change Talk Associates 7
8 Understanding Change Ambivalence Change Talk Ambivalence Change Talk Associates 8
9 Ambivalence is a wonderful tune to dance to. It has a rhythm all its own. - Erica Jong, 1942 Exercise: What not to do Persuasion Exercise I have not the right to want to change another I if have I am not not the open right to to want be to changed. another if I am not open - Martin to be changed. Buber - Martin Buber Change Talk Associates 9
10 You would think... that knowing you will eventually need a transplant, you would do everything necessary to stay as healthy as possible, for as long as possible that having had a heart attack would be enough to persuade you to quit smoking, change your diet, exercise more and take your medication What do we do to try to make people change? Give them Insight - if you can just make people see, then they will change Give them Knowledge - if people just know enough, then they will change Give them Skills - if you can just teach people how to change, then they will do it Give them Hell - if you can just make people feel bad or afraid enough, they will change Change Talk Associates 10
11 In MI, lack of change is not denial, stubbornness, or stupidity but often Ambivalence. Ambivalence is when you feel two ways about something. Ambivalence Cons Status Quo Pros MI Inconsistent Resistance Sustain Talk Change Talk Change Talk Associates 11
12 Opposite sides of ambivalence Understanding the person s perspective Change Talk Associates 12
13 Decisional Balance Target Behaviour: Limiting Fluid Intake No Change Change Benefits Eat what I want (don t have to worry about salt) Make own decisions Not thirsty Feel normal with friends Benefits Feel better overall Reduce weight gain Dialysis runs are easier and sometimes shorter Able to go back to work Costs Hard to breathe Lectured each time I come for treatment Don t feel well even after treatment Weight gain Costs Constantly reminded of how sick I am Impact on family eat/drink differently Tired of feeling different Exhausted by all of the rules Cost of special diet The Myth of the Unmotivated Person No person is completely unmotivated When we argue one side, the person takes the other Service providers influence motivation for change Resistance happens in relationship Rollnick, S., Miller, W.R., Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behaviour. New York: Guilford Press. Change Talk Associates 13
14 A Shift in Thinking Shift from: Why isn t this person motivated? To: For what is this person motivated? Change Talk Change Talk Associates 14
15 What we say about change influences whether or not it will happen. Who will tell the truth? Do you swear to tell the truth, the whole truth and nothing but the truth? I want to. I could. I have good reason. I need to. I will. Change Talk Associates 15
16 Map of Change Talk Desire Ability Commitment Reason Need Taking Steps Behaviour Change Rollnick, et al., 2008, p41. Research Shows: Commitment language is predictive of behaviour change Clinicians can purposefully influence clients/patients to speak more favourably about the possibility of change Amrhein et al. (2003). Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting & Clinical Psychology, 71, Glynn, L.H. & Moyers, T.B. (2010). Chasing the talk: The clinician s role in evoking client language about change. Journal of Substance Abuse Treatment, 39, Change Talk Associates 16
17 Change Talk or Sustain Talk? Identify the following statements as change talk or sustain talk. 1. I wish I didn t feel so sick all of the time. 2. My friends and I go to McDonald s for lunch a couple times a week. 3. I will be around for my grandchildren. Change Talk Associates 17
18 MI Core Elements Spirit of Motivational Interviewing Evocative (drawing out) Collaborative Respect (honour) Autonomy Spirit Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York, NY: The Guilford Press. Change Talk Associates 18
19 MI Principles Resist the righting reflex Understand the person Principles (RULE) Empower Listen Rollnick, S., Miller, W.R., Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behaviour. New York: Guilford Press. 4 Fundamental Processes in MI Engaging the relational foundation, listening to understand Guiding strategic focusing, finding a goal Evoking with an identified change goal, evoke, respond, and summarize Change Talk Planning the bridge to change Miller & Rollnick. (June 8, 2010). What s new since MI-2? Second International Conference on Motivational Interviewing. Stockholm, Sweden. Change Talk Associates 19
20 Skills & Strategies OARS Agenda Setting Assessing Readiness Skills: OARS Affirm Reflective Listening Open Questions OARS Summary Change Talk Associates 20
21 Strategy: Agenda Setting exercise nutrition medication What have I missed? Where would you like to start? social support DVD Clips Segment 5: Agenda Setting - How not to do it. Segment 7: Agenda Setting - How to do it. Health Behaviour Change. (2001). Cardiff University, Cardiff. To order please see the Jeff Allison Training Consultancy website: Change Talk Associates 21
22 Strategy: Assessing Readiness to Change Importance (Why should I change? Personal values and expectations of the importance of change) Readiness Confidence (How will I do it? Self-efficacy) Rollnick et al. (1999). Health Behaviour Change: A Guide for Practitioners. Edinburgh: Churchill Livingstone. Importance & Confidence Think about something real to you that you want to change, should change, need to change, but haven t done it yet. Now consider the following questions Change Talk Associates 22
23 System Integration Four Levels of MI Training Awareness Building (1-3 hrs) Knowledge-focused training (6-10 hrs) Skills-based training (14-16 hrs) Abilities training (coaching and feedback) Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency. (MIA-STEP) Change Talk Associates 23
24 MI System Integration Model Urquhart & Jasiura, 2010 Level 1 Intro to MI (2 days) N=50 Level 2 Advanced MI (2 days) N=26 Virtual Coaching N=13 MI Communities of Practice Resourced by Level 2 champions. Shared facilitation/leadership. Supported by system. Virtual Coaching N=13 Ripple Effects MI was designed to diffuse by attraction, not coercion Miller, W.R. (2006). MINT Bulletin,13(1) Change Talk Associates 24
25 Supporting Integrated Care Motivational Interviewing can support health systems deliver integrated care: Passive patients Expert Siloed services Active participants Collaborator Integrated care Anstiss, T. (2009). Motivational interviewing in primary care. Journal of Clinical Psychology in Medical Settings. DOI /s x Upcoming UBC MI Courses November 5,6, 2010, Intro to MI in Health Care February 4,5, 2011, Intro to MI in Health Care April 15,16, 2011, Advanced MI in Health Care Change Talk Associates 25
26 A supportive, compassionate, empathic practitioner is the most effective in inspiring change. Rollnick, et al, 2008 Contact Information Change Talk Associates Cristine Urquhart Frances Jasiura Change Talk Associates 26
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