Community Care of Wake & Johnston Counties

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1 Community Care of Wake & Johnston Counties Motivational Interviewing Primer-CCWJC MI Champions Anne Morton, Provider Services Manager, Christy Street, MSW, CCM, Social Work Care Manager, Erika Wagner, QI Specialist Why is Change so Hard? Feelings Thoughts Practical Barriers Motivational Interviewing Defined Motivational Interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change. What about Behavior Change and MI? 80% to 90% of healthcare issues are attributed to patient non-adherence and poor lifestyle and behavior choices. Uses skills and strategies to help people think differently about what they are doing Evidenced based health coaching Focus is on ambivalence and resistance- we explore how people make sense of life and the information they ve been given about their condition That desire to FIX patients is the quickest killer of motivation for change and it s what we have the most control over What do we know about behavior change? People Either Resist Change or Straddle the Fence for Good Reasons Significant life distractions or other pressing priorities Does not experience or understand the problem or unable to appreciate the benefits associated with change Cost, inconvenience and undesired trade offs (ex. side effects) Confidence levels informed by past failure Lack of support by others No immediate payoff Why Motivational Interviewing? Provides an alternative approach to the traditional medical model where the professional interacts in a non-collaborative, confrontational style, as the expert whose knowledge is the cure with little regard for the patient s level of motivation or readiness for change. 1

2 What is Motivation? The state or condition of having a strong reason to act or accomplish something o A state of mind, not a character flaw o Multidimensional, dynamic and fluctuating o Interactive and modifiable by the clinician MI is. Effective in many areas of behavior change Learnable and specific interventions A way of being with clients/patients One of many useful interventions The Righting Reflex Spirit of Motivational Interviewing People in the Helping Professions have Natural Tendency to want to FIX what s wrong with patients. This is called The Righting Reflex When you want to jump in and tell them what to do, try asking permission first May I share some information with you? Would it be okay if I shared some information with you? Partnership Confrontation) Acceptance Disapproval) MI is a collaborative partnering with patients Ask for permission See the patient as the expert on themselves Client is responsible for change which arises from within Respect patient autonomy whether or not they change Inform and encourage choices without judgment Spirit of Motivational Interviewing MI Communication Principles Compassion Judging) Evocation Education) Genuine care and concern Understand and validate the struggle Evoking the patient s own motivation and resources for change Trust the patient to be motivated for something Asking versus telling Avoid expert trap Roll with Resistance Express empathy Avoid Argumentation Develop discrepancy Support self-efficacy 2

3 Roll with Resistance/Avoid Argumentation Example Roll with Resistance/Avoid Argumentation Roll with Resistance not responding with persuasion or direct confrontation, but to side step an argument and encourage conversation Avoid arguing for change Emphasize personal choice Ignore antagonistic statements Resistance is a signal that we need to respond differently Patient: I just don t think I can quit smoking I ve tried before but it s how I relax especially when I get off work in the afternoon. Provider: It sounds like smoking is a big part of how you relax and the idea of stopping seems too hard. Express Empathy Expressing Empathy Express empathy..to understand the client s world Empathy reflects an accurate understanding Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal Leads to & patient outcomes - Patient feels understood - Reduces anxiety - Improves adherence Patient: I just don t know if I can take this medication twice a day every day. Provider: Sally, it sounds like this would be a big change for you and you re worried you won t be able to take this medication as prescribed. To help the patient see the contrast between what they want and what they do A discrepancy between present behavior and important personal goals or values will motivate change Developing discrepancy creates dissonance (that uncomfortable feeling you get from continuing the current behavior) Techniques/strategies for helping to develop discrepancy: Repeat back Pros and Cons stated by patient 3

4 Support Self-Efficacy Ask questions about behaviors that don t support goals set by the patient. To foster hope in the patient that he/she can achieve desired changes. Mr. Jones, I am concerned that your Advair refill has been ready for about two weeks. You told me last time that you didn t want to end up back in the hospital with an asthma flair. What are your thoughts about how this might affect that goal? A person s belief in the possibility of change is an important motivator Notice, support and encourage patient attempts or even thoughts about change Praise the behavior, not the person The patient, not the practitioner, is responsible for choosing and carrying out change Example (Support Self-efficacy) Summing up the Principles I really believe you are on your way to better health since you are thinking about using your inhalers for asthma. People experience ambivalence the conflicting thoughts and feelings about a particular behavior or change that holds pros and cons for them It s great that Joey hasn t had an emergency room visit for an asthma flair in 3 months! Tell me what you re doing to keep Joey s asthma better controlled. You were able to decrease smoking before, I m confident you can do it again. What worked for you last time? When a person experiences a discrepancy between how things are and how they want them to be they tend to be motivated to reduce that discrepancy if it seems possible to do so Person (patient) has to argue for change MI Principles MI Methods MI Processes Express Empathy Roll with Resistance Avoid Argumentation Support Self-Efficacy Open-Ended Questions Reflective Listening Summaries Elicit Change Talk Engaging-empathic listening Build Rapport Using OARS Focusing-targeting change Agenda mapping Elicit-Provide-Elicit Evoking-patients ideas Pro and cons Agenda Mapping Planning-setting up structured change Stages of Change Often, the processes overlap, so use what works with a given patient at a given time. Where a patient is on the continuum determines what processes and what interventions make the most sense. Change is a process not an event. There are different stages along the change continuum. 4

5 - Open Ended Questions Reflective Listening Summary Statements Closed Ended Questions vs. Open Ended Questions Closed ended questions Can be answered with a single word or two word response. Don t leave much room for elaboration, interpretation or opinion. Leave little room for new ideas and they don t spark creativity or imagination which would lead to new questions. Do you take your medications? How often do you eat fast food? Have you been taking your medicines? Closed Ended Questions vs. Open Ended Questions Open ended questions Cannot be answered with one word responses. Invite responders to say what is important to them. (invites relationship) A great tool to promote creative thought & problem-solving skills because it forces a person to spend more time contemplating their response. Examples of open ended questions: How can I help you with your asthma/breathing?. How would you like things to be different? How have you been taking your medicines? What things would you be able to do if you could breathe better? Why Why Questions Don t Work Why questions are open-ended questions but can have unintended overtones or criticism. This may lead patients to defend the status quo. Why don t you want to take your medication? Why can t you stop smoking? Why haven t you filled your prescriptions? are statements or gestures that recognize and acknowledge patient s strengths and behaviors that guide in the direction of positive change. Gestures- Nodding head Leaning forward and appearing engaged 5

6 can be delivered in several different forms. Appreciation: You re a very resourceful person. Thank you for coming in today. Confidence-building: You ve succeeded through some difficult changes in the past Reinforcement: That s a good idea or Good for you Build rapport Understand where the patient is coming from Demonstrates points of relation should be sincere and consistent to be effective. Reinforce the patient s efforts Praise his/her efforts and all accomplishments Always reinforce efforts, no matter if the efforts are big or small! Reflective Listening Reflective Listening is the skill of responding to the other person s comment by saying what you understand him/her to have said. This can be a powerful tool of communication. You simply reflect to the client what you think you heard, making sure to reflect his/her feelings. Purposes of Reflective Listening Encourage Further Disclosure: invites patients to confirm or correct the reflection and say more about themselves Encourage Ownership: only they can know what matters to them Highlight discrepancy: explore discrepancies using the person s own words Summary Statement(s) Summary Statements A summary is essentially reflections of the conversation and points discussed. It is a statement or restatement of main points covered. A good summary will show that you have been listening carefully to and remembering what the patient said. This can strengthen your relationship & build trust with the patient by confirming they were heard. Providing a summary allows you to bring together the pieces of the picture and to see whether you have missed anything important. To do this, you can follow a summary by asking What else? 6

7 Summary Examples. Throughout our conversation you have said you would like to reduce the amount of times Johnny has to go to the emergency room by starting to give him the controller medication twice a day QUESTIONS? Michael, I heard you say you might think more seriously about quitting smoking if you could come up with some alternative ways to de-stress, is that right? MI Resources & References Rollnick S, Miller W, Butler C. (2009). Motivational Interviewing in Health Care, New York: 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, 2 nd Edition: Preparing People for Change, New York, NY: The Guilford Press. Motivational Interviewing: Helping People Change, 3rd Edition (Applications of Motivational Interviewing) 3rd Edition Miller W, Rose G. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6): Kavookjian J, Elswick B, Whetsel T. Interventions for being active among individuals with diabetes. Diabetes Educator 2007; 33(6): Soria R, Legido A, Escolano C, et al. A randomised controlled trial of motivational interviewing for smoking cessation. Br J Gen Prac, 2006;56: Van Wormer JJ, Boucher JL. Motivational interviewing and diet modification: A review of the evidence. Diabetes Educator, 2004; 30(3): Burke BL, Arkowitz H, Menchola M: The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consul Clin Psych 2003; 71: Knight KM, McGowan L, Dickens C, Bundy C. A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology 2006; 11: Rubak S, Sandboek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. B J Gen Prac, 2005; 55: Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral domains: a sstematic review. Addiction 2001; 96: ,. Kavookjian J, et al. Patient decision-making: Strategies for diabetes diet adherence intervention. Res Soc Admin Pharm. 2005;1: Kavookjian J, et al. Helping Patients Change for Diabetes Self Management. Oct Lauren Moyer, L.M., S.W., C.C.D.P.D., C.C.G.C Motivational Interviewing: Preparing People to Change-A Skill Building Training Auburn University Motivational Interviewing Training Institute: 7