Motivational Interviewing in Health Care: Application to a Geriatric Patient
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1 Motivational Interviewing in Health Care: Application to a Geriatric Patient Presented by Brett Engle, PhD, LCSW Sponsored by Miami Area Geriatric Education Center
2 Rationale and evidence-base Target behaviors/change goals Spirit of MI Collaboration, acceptance, evocation Processes of MI and application Engaging, focusing, evoking, and planning Techniques of MI OARS Exchanging information using elicit-provide-elicit DARN-CAT change and sustain talk
3
4 Rationale for MI Brief and cost effective (Dennis et al., 2004) Versatile-intensity/duration, professions, combined treatments, settings (Lundahl et al., in press; Miller & Rose, 2009) Humanistic-facilitates relationships, rapport and disclosure (Miller & Rose, 2009) Consistent with SW ethics and values (Hohman, 2012) May be more effective with minorities (Hettema, Steele, & Miller, 2005) Established training tools and practices (Moyers et al., 2005; Madson & Lane, 2008)
5 Evidence-Base for MI About 200 clinical trials and 1000 peer reviewed articles involving MI (Miller & Rose, 2009) Average dose: 2 sessions/2 hours Effect size is often maintained or even increases through 1 year follow up when MI is added to beginning of treatment (Miller, 2005)
6 Evidence-Base for MI: Target Behaviors/Outcomes More likely to enter, stay in and complete treatment Participate in follow-up visits Adhere to glucose monitoring and improve glycemic control Increase exercise and fruit and vegetable intake Reduce stress and sodium intake Keep food diaries Weight loss Reduce unprotected sex and needle sharing Improve medication adherence Decrease alcohol and illicit drug use Quit smoking Fewer subsequent injuries and hospitalizations Rollnick, Miller, & Butler (2008)
7 Collaboration/Partnership Acceptance Compassion Evocation
8 Interviewer functions as a partner or companion, collaborating with the client s own expertise Dancing versus wrestling Avoiding the expert trap Non-judgmental Active collaborative conversation Joint decision-making process
9 Absolute worth Affirmation Accurate empathy Autonomy support
10 Unconditional positive regard (Rogers) Dignity and worth of the person (NASW Code of Ethics)
11 Seek and acknowledge strengths, including change talk, resources, and values Building blocks
12 to sense the person s inner world of private personal meanings (Rogers, 1989, pp ) Anticipating Experiencing Communicating
13 Responsibility : Resistance trade off People can and will make own decision Paradoxical nature of behavior change Support both self-determination and selfefficacy Detachment from outcomes
14 To benevolently seek and value the wellbeing of others To give priority to the person s needs Never exploit Not necessarily to suffer with.
15 Elicit and activate person s own resources, rationale and motivation for behavior change The person s side of ambivalence that favors change Includes their goals, values, and aspirations that relate to target behavior
16 Engaging Focusing Evoking Planning
17 Meet where patient is Discord and sustain talk be prevalent Empathize Establish trust and rapport Verbally and non-verbally
18 Lives with wife of 46 years and daughter Quit smoking in 1994 History of low fat diet and credits it for no chest pain Regular exercise History of checking blood sugar regularly (but not currently) Checks blood pressure daily (but does not record) Apparently take medications regularly
19 Focus and structure conversation on an identified target behavior Redirect discourse toward target behavior when necessary Discuss possible change rather than history
20 Checking blood sugar 2/daily like before and recording Record blood pressure (in addition to checking, which he currently does) Give self injections Return to more consistent low fat diet (although apparently no chest pains still) Return to regular exercise (osteoarthritis and gout may be barriers) Driving Referral to cardiologist Two drinks daily (contraindications?) Advanced directive
21 Patient s own ideas about change Change talk side of ambivalence
22 Difficulty sleeping and frequent urination Possible depression (denies) Anxiety (not self report) Grief (loss of adult child 2 years ago) Low energy Low sex drive Forgetfulness (according to wife but he denies)
23 Decision making Action steps and target behaviors prioritized Implementation intentions (Gollwitzer)
24 Open questions Affirmations Reflections: Simple and complex Summaries
25 Elicit Ask permission Clarify information needs and gaps May I ask what you already know about Provide Prioritize Support autonomy Don t prescribe the person s response Elicit Ask for person s interpretation, understanding, or response
26 Preparatory Change (and Sustain) Talk Four Kinds DARN DESIRE to change (want, like, wish.. ) ABILITY to change (can, could.. ) REASONS to change (if.. then) NEED to change (need, have to, got to..) 26
27 Mobilizing Change (and Sustain) Talk reflects resolution of ambivalence COMMITMENT (intention, decision) ACTIVATION (ready, prepared, willing) TAKING STEPS 27
28 Commitment-Behavior Change Model in Groups: Participant Desire, Ability, Reasons, and Need (DARN) change talk mediate Commitment Language, which in turn mediates their impact on health behavior. Desire Ability (Self-efficacy) Reasons Commitment Activation Taking Steps Health behavior Need From How Does Motivational Interviewing Work? What Client Talk Reveals, by P. C. Amrhein, 2004, Journal of Cognitive Psychotherapy: An International Quarterly, 18, 4, p Copyright 2004 by the Springer Publishing Company. Adapted with permission.
29 Supplemental Slides
30 12 Tasks in Learning MI 1. Understanding the spirit of MI 2. Developing skill and comfort with reflective listening and the client-centered OARS skills 3. Identifying change goals/target behaviors 4. Giving information in an MI adherent manner 5. Recognizing change and sustain talk 6. Evoking and reinforcing change talk 7. Responding to, reinforcing, and strengthening change talk 8. Responding to sustain talk and discord so as to not amplify it 9. Developing hope and confidence 10. Timing and negotiating a change plan 11. Strengthening commitment 12. Flexibly integrating MI with other skills and practices (Miller & Moyers, 2006; Miller & Rollnick, 2013)
31 Discord Interpersonal behavior that reflects dissonance in the working relationship: Arguing, interrupting, discounting, or ignoring 31
32 Lay Definition: A collaborative conversation style for strengthening a person s own motivation and commitment to change Used in many contexts by many different professional or paraprofessional people
33 Clinical Definition: A person-centered counseling style for addressing the common problem of ambivalence about change Why should I as a clinician learn MI? How would I use it?
34 Technical Definition: A collaborative, goal-oriented style of communication with particular attention to the language of change, designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion How does it work?
35 Directing Guiding Following
36 Parameters of the working relationship Exceptions to confidentiality The nonnegotiables Providing information
37 Understanding and taking an interest in the other person Being curious and showing respect Super listening
38 Focus and structure conversation on an identified target behavior Redirect discourse toward target behavior when necessary Discuss possible change rather than history Elicit/emphasize/reinforce change talk
39 What Good Listening Is Not * (Roadblocks: Thomas Gordon) Asking questions Agreeing, approving, or praising Advising, suggesting, providing solutions Arguing, persuading with logic, lecturing Analyzing or interpreting Assuring, sympathizing, or consoling 39
40 What Good Listening is Not (Roadblocks, from Thomas Gordon) Ordering, directing, or commanding Warning, cautioning, or threatening Moralizing, telling what they should do Disagreeing, judging, criticizing, or blaming Shaming, ridiculing, or labeling Withdrawing, distracting, humoring, or changing the subject 40
41 Hypothesized Relationship Among Process and Outcome Variables in MI Training in MI Therapist Empathy & MI Spirit Client Preparatory Change Talk & Diminished Resistance Behavior Change Therapist Use of MI- Consistent Methods Commitment to Behavior Change From Miller and Rose (2009) Toward a Theory of Motivational Interviewing., 64, p American Psychologist
42 Ten Things that MI is Not (Miller & Rollnick, 2008) 1. Based on the transtheoretical model of change 2. A way of tricking people into doing what you want them to do 3. A specific technique (MI is a counseling method; no specific technique is essential) 4. Decisional balance, equally exploring pros and cons of change 5. Assessment feedback 6. A form of cognitive-behavior therapy 7. Just client-centered therapy 8. Easy to learn 9. What you were already doing 10. A panacea for every clinical challenge
43 Evidence-Base for MI: Effects across Samples 25% no effect 50% small but meaningful effect 25% moderate to strong effect Average MI intervention: 99 minutes (Lundahl et al., in press) Brief MI in health care: 5-15 minutes (Martino et al., 2007)
44 Forming Reflections Reflections * Are statements rather than questions Make a guess about the client s meaning (rather than asking) Yield more information and better understanding Often a question can be turned into a reflection 44
45 Forming Reflections A reflection states an hypothesis, makes a guess about what the person means Form a statement, not a question Think of your question: X Do X you X mean X that you...? Cut the question words Do you mean that You.. Inflect your voice down at the end There s no penalty for missing In general, a reflection should not be longer 45
46 59 Collaboration: Giving Information/Educating Neutral language Folks have found Others have benefited from Doctors recommend Conditional words Might consider vs. ought to, should Avoid the I and Y words I think You should Gary S. Rose, Ph.D. grosephd@erols.com
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