Motivational Interviewing: A Patient Centered Strategy that Builds Provider Awareness and Patient Reflection

Transcription

1 Motivational Interviewing: A Patient Centered Strategy that Builds Provider Awareness and Patient Reflection Gwen Alexander, PhD Henry Ford Health System Department of Public Health Sciences 1R24HS (JOHNSON-CENTER DIRECTOR) PERSONALIZING CARE FOR OBESE PATIENTS IN AN URBAN HEALTH SYSTEM Patient Centered Outcomes Research Group R24 Webinar August 22, 2014

2 Helping People Change Most interactions in health care are Provider to Patient In many cases, a behavior change is needed by the Patient Teaching or informing is involved, although most patients know what they need to do, or how to do it Some providers are more effective than others Some patients are not ready to or convinced that or capable of change that is requested This can lead to ineffective communication, resentment, lost opportunity to start reversing a health problem. Question: What is missing? Do we keep saying the same things or make a change?

3 Outline Introduction to practical applications of Motivational Interviewing Being stuck and uncovering ambivalence Examples of coaching components Motivations, confidence Change talk Affirm Reflections Goal setting Role of the coach

4

5 Motivational Interviewing Preparing People for Change ----Title and subtitle for the 2nd edition book by William Miller Stephen Rollnick MI is a person-centered, collaborative process that elicits and strengthens motivation for change Ambivalence is usually behind slow or no change (do/don t) Uncover ambivalence -> awareness of what blocks desired change Interview - questions to identify and build motivation, and build commitment to reach desired change MI discussions about change require a lot of active listening and squashing the reflex to fix it. and

6 Motivational Interviewing MI is consistent with the Self-determination Theory (Deci and Ryan, 1985*) that explores the range of motivation from internal (intrinsic based on deeply held values) to external (extrinsic based on opinion/threat from others) MI has its roots in addiction counseling in face to face interactions. MI makes use of client-centered counseling skills and includes goal-oriented components, guided by the coach/provider. MI aims to elicit internal motivations and strengths when ambivalence is impeding behavior change. MI takes a while to learn. Similarities to an athletic person learning a new sport. Proficiency requires learning, practicing and receiving feedback. ** *(Deci and Ryan 1985) **Naar-King S, Suarez M. pg 6.

7 Motivational Interviewing, con t Most MI coaching used in the moment as face to face or conversations by phone, recently I helped create an format Full blown motivational interviewing for complicated behaviors (i.e., addiction) may take a number of sessions Brief adaptations are designed and used. Use in many health-related domains Smoking adherence sexual risk eating disorders chronic illness management obesity health promotion used with individuals, couples, adolescents, adults Not Used: if the person is fully motivated and ready to start making a change.

8 Discovering Ambivalence I want to.. competing motivations And I don t want to Cost of status quo (benefits of change) Cost of change (benefits of status quo) Decisional balance weighing costs and benefits * Discovering and understanding an individual s motivations is an important first step toward change. ** Miller and Rollnick 2 nd Edit *p 15, ** p 18

9 Provider Advice vs. Eliciting Health professionals (physicians, nurses, dietitians), who may have been trained traditionally, may go beyond giving expert advice to present instructions in a prescriptive way - steps people should take to change a health behavior. Challenge is to move to a collaborative, facilitator approach which can be a big challenge for providers... Traditional MI eliciting It is very important to your How, if at all, can you see health to stop smoking because that smoking might affect your ability to spend time with your grandkids [personal value]?

10 Best Practices: Listening and Reflection Provider needs to learn (interview) what is going on Reflection to show he/she is listening You wish the teasing would stop. Reflection to display the emotions/conflict: patient s dilemma You are furious that your boss recommended therapy to you. Patient can untangle the complex motivations that creates feeling stuck Hearing a complex reflection helps untangle issues Example: On one hand, you always feel winded and worry that smoking is making your throat always feel irritated. On the other hand, your best way to relax is to smoke.

11 MI Themes Autonomy - identify person s decision to change, not provider s direction Collaboration partnership and guiding, rather than prescriptive Evoke and elicit - allow person to discover his ambivalence, and present his own reasons for change, rather than provider fixing it Express empathy in reflection, let person know provider accepts his position, hears concerns Roll with resistance provider expresses understanding of person s point of view, avoids arguing for change: Sounds like this diet journal is not going to work for you. Support Self-Efficacy (confidence that I can do it ) the key element and good predictor of the outcome If you think you can do a thing, or if you think you can t, you are always right. (Henry Ford)

12 Phase 1 Building Motivation for Change Key to understanding ambivalence is to know person s perception of importance and confidence - Open Ended Questions How important would you say it is for you to eat the recommended servings of fruit and vegetables? (motivations to change) Response: 1=not at all 10 = extremely important If 8-9: That is a high number. What makes it such a high number for you? (identify motivations/values) Reflecting: Sounds like your nutrition course put you on a good track, and you especially love fruit. Do I have that right? (check impression for accuracy) Guiding: What would it take to move your importance rating to a 10? (by saying what they need to do solve some issues)

13 Phase 1 Building Motivation for Change, con t Next, assess confidence (self-efficacy): How confident are you that you could eat the recommended servings of fruit and vegetables? If lower, 5 or 6: 1=not at all 10 = extremely confident Why that number rather than something lower, like a 3 or 4? This reveals the ability they believe they have. What would it take to move your confidence to a 7 or 8? This gives ways to solve some barriers.

14 Values key to linking intrinsic motivations to actions Exploring values and incongruities between actions and values can elicit change talk Coach: I am going to switch gears for a minute and ask you this question. What are some things that are very important to you in your life right now.* You already mentioned you want to be a good example for your children. What else? *Can show a list or bring up something previously mentioned.

15 Phase II: Keys to Guiding Change Goal - move the person to identify and/or take the first steps of change. Change talk reveals the crack in the resistance - may include statements that include: Disadvantages of status quo - If I don t change, I ll probably get worse Coach: So you have some ideas about cutting down on salt so you won t have to worry so much about Tell me more about that. Advantage for change I was hoping to fit into my bride s maid dress for the wedding. Coach: Tell me more about the wedding. You ve picked out the dresses already? How much time would you have to work on fitting into that dress? Intention to change/opportunity to change I wish I could start walking with my neighbors. They have asked me Optimism about change I need to try something, I suppose I could cut back on my soda pop habit. It would be good for my kids to see me drink less pop, and get my wife off my back about it. Coach: You think starting with soda might work for you. What ideas do you have?.... (Affirm) That sounds like a good idea.

16 Affirm You made this happen Include personal strengths/empower in reflections: You are dedicated to your health to make these changes, and have overcome the challenges of your very busy schedule to include more fruit in your lunches at work. Kudos on your ability to make this happen. (Rather than kudos alone.) good job rather than great You care enough about keeping on an even keel, and you feel confident/happy about how it is going with keeping to the plan you worked out for your insulin schedule.

17 More on Change Talk - coach initiates questions Coach: I wonder if you would be willing to tell me what you see for yourself, say in the next year or so? How do you imagine life to be? How would you like for things to be different? If you could [make this change] immediately, what advantages would you see? Patient: I want to apply for nursing school and get some clinical experience, but this diabetes... I would really need to have my insulin levels in good control for that. Coach: What would concern you most about managing your diabetes and getting your insulin levels evened out, if you were in this demanding training program? (Ask about extremes)

18 Reflection stretch to find emotion, expect corrections Coach: Sounds like you are really upset about the way people tease you when you try to eat the right way. Patient: I m not upset, I just worry that I will buckle under and not keep my promise to myself. My friends can be so annoying sometimes. Coach: Oh, you worry about keeping to your goals when you are having fun around some of your friends it can really be a work out for you to follow your own choices [empower] What ideas do you have to give you strength in these situations? Patient: I don t know, can you help me? Coach: Let s take a minute to come up with ideas you might have, and then, if it is OK with you, I can add some ideas that have worked for others. (Ask permission before offering)

19 Setting Goals with Patient s Choice Once agreement that change is possible, ask: There are many possibilities that people have used. What do you prefer? What do you think will work for you? What specifically do you plan to do? We can Write it out on this form Talk more about details Talk more about what support you have at home to help you, if you need it. Talk more about challenges once you get started.

20 Summarizing and Eliciting Commitment Coach: Let me see if I can summarize where you are. You have a couple of ideas on how to add more fruit and vegetables- take a small bag of fruit to work on Mondays, shop on Thursdays to be ready for the weekend, and set up a schedule on the calendar each week to help bring in variety. Do I have that right? Have I forgotten anything? Elicit Commitment. And let me check with you is this what you want to do?. If you are not quite sure or if you want to try it out first, take a day or two and think about it. We can talk about it more next time.

21 MI Tools for Teacher/Coach/Provider to guide CHANGE Identify challenge/conflict/ambivalence Facilitate patient s self-understanding Offer the chance for decisional balance sheet (+ column, - column) Encourage and model reflection say out loud what you might be thinking, check accuracy Identify values that can be linked with behavior change.. This all requires a lot of listening.

22 Strength of this Approach For providers building awareness: You now know what is delaying change, motivating change For patients reflect on ambivalence and personal strengths, choices: They know more about their own motivations, what might work for them, what will strengthen commitment.

23 MI Research Examples Diabetes Medication Adherence workshop for pharmacists and diabetes nurse educators, monitoring and assessing coaching sessions over two 6-month follow up visits. coaching for Dietary Improvement MENU GenY (21-30 yr olds) for 4 month online intervention with 12 month follow-up. Coaches are women with no experience in nutrition/heath education. New project Coaching providers to talk to teens about the complications on a chronic health condition due to weight

24 Thank you References: Motivational Interviewing: Preparing People for Change. 2 nd Edit. Miller WR, Rollnick S. (Eds). Guilford Press:New York Motivational Interviewing with Adolescents and Young Adults. Naar-King S, Suarez M galexan2@hfhs.org

25

26

27

28