Building Confidence, Competence and Composure in the Dietetic MI Practitioner

Size: px

Start display at page:

Download "Building Confidence, Competence and Composure in the Dietetic MI Practitioner"

Antony Goodwin
7 years ago
Views:

1 Building Confidence, Competence and Composure in the Dietetic MI Practitioner Motivational Interviewing (MI)and Chronic Kidney Disease (CKD) John Coumbe-Lilley PhD, CC-AASP MINT Network 1

2 Learning Outcomes: At the end of this presentation participants should be able to: Identify what is/is not motivational interviewing Recognize how confident, competent and composed dietetic professionals are trained Relate MI training to improved dietetic counseling and better medical outcomes 10/27/2014 2

3 Research Findings Rapoport & Nicholson Perry (2000) Main Finding: Dietitians (N= 4202) reported inadequate training in counseling, behavior change and motivational approaches. 3

4 Research Findings Horacek et al (2007). Main Finding: Dietitians could be trained in lifestyle behavior change to effect client behavior change. Lu & Dollahite (2010). Main Finding: Discrepancy between dietitians self-perceived counseling skill and actual counseling skill use 4

5 Research Findings Marley et al (2011). Main Finding: Dietitians acquiring MI skill use efficacy could increase WIC program effectiveness 5

6 One of Many Approaches Hollis et al. (2014). Main Finding: Assessment of the scope of practice guidelines in USA, Canada, Australia and Europe found alignment with the practice of MI. However RDN s are largely practicing with an insufficient, knowledge and competency base. Engaging in ongoing training and research participation to become proficient over years is recommended for enhanced consulting effectiveness. 10/27/2014 6

7 Context for renal disease Dietitian role: Educate & advise; support through treatment; work as part of an MDT; support non-renal staff Aims of diet therapy: maintain biochemistry levels; minimize symptoms; prevent malnutrition and unintentional weight loss Factors influencing consultations: stage of condition; lifestyle behaviors; comorbid conditions; types of treatments; medications; biochemistry trends Angela Haslam, Specialist Renal Dietitian 10/27/2014 7

8 Rule In the population at large, for any behavioral problem, 40% are in precontemplation 40% are in contemplation 20% are in preparation or action *Prochaska and DiClemente,

9 What MI is Not Transtheoretical Model A technique Assessment feedback Client-centered therapy Practice as usual Way of tricking people Decisional balance Cognitive-behavior therapy Easy to learn A panacea Miller & Rollnick (2009) 10/27/2014 MI-D. Version 1. Education Tools. 9

10 Stages of Change 10

11 A Way of Tricking People 11

12 Feedback Assessment 12

13 Practice As Usual 13

14 Client Centered Therapy 14

15 Counseling Technique 15

16 The Goddess of Universal Remedy 16

17 Easy To Learn 17

18 Decisional Balance The good things about. The not-so-good things about. The good things about changing. The not-so-good things about changing. 18

19 Cognitive Behavioral Therapy 19

20 What is MI then? MI Layperson: Motivational interviewing is a collaborative conversation style for strengthening a person s own motivation and commitment to change MI Practitioner: Motivational interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change Technical: Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for commitment to a specific goal by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion 20

21 The Four Phases Process Engaging the relational foundation Guiding the strategic focus Evoking the transition to MI Planning the bridge to change Typical activities Relate; explore values; use OARS; listen to the clients dilemma Directional focus; finding a goal; agenda setting; giving information/advice Clear change goal; distinct from decision-balance; OARS (selective eliciting) Negotiating change goals, plans & plans; strengthening commitment; implementing & adjusting 10/27/2014 MI-D. Version 1. Education Tools. 21

22 MI: Spirit Collaboration -Partnerships Evocation Listening & Eliciting Autonomy The ability to choose 22

23 Goal of MI To create and amplify discrepancy between present behavior and broader goals. How? Create cognitive dissonance between where one is and where one wants to be. 23

24 Ambivalence Ambivalence is normal. Feeling two ways about something. Want to Change Don t Want to Change 24

25 Change Process Action Awareness Miller & Rollnick (2002) Commitment 25

26 Addressing Motivation The result of the interaction between the individual and the situation. The processes that account for an individual s intensity, direction, and persistence of effort toward attaining a goal specifically, an organizational goal. Three key elements: Intensity how hard a person tries Direction effort that is channeled toward, and consistent with, organizational goals Persistence how long a person can maintain effort 26

27 Reinforcing relationships Ryan & Deci (2000) Competence Autonomy Relatedness 27

28 Sources of Self-Efficacy Bandura (1987) 28

29 Ambivalence A state of mind in which a person has coexisting but conflicting feelings, thoughts, and actions about something The I do but I don t dilemma 29

30 Develop Discrepancy Amplify cognitive dissonance. Difference between where one is and where one wants to be. Awareness of consequences is important. Encourage client to present reasons for change. Elicit selfmotivational statements. 30

31 Dancing Not Wrestling 31

32 MI III Miller & Rollnick (2012) Old Way Resistance New Way Sustain Talk Dischord 32

33 When is a client considered motivated? Agrees with the therapist s view Accepts the counselor s diagnosis States a desire for help Shows distress, depends on therapist Complies with treatment Has a successful outcome 33

34 Motivation is influenced by Coaching/Counselor Style Miller, Benefield and Tonigan, 1993 Counselor Expectancies Leake & King, 1977 Biases toward clients Client Expectancies Self change literature 34

35 MICRO-SKILLS (OARS) Open Ended Questions Affirm The Person Reflect What the Person Says Summarize Perspectives on Change 35

36 Change Talk aka self motivational statements Types: DARN C D = desire statements A = ability statements R = reasons statements N = need statements C = commitment language 36

37 Commitment language Less strong Somewhat strong Strong I might I can. I will Maybe I Perhaps I I ought to I m not sure I sometimes I always Yes, but Yes, well Yes, and No Possibly Yes You have to be present when listening for commitment language It could be signaled so quick you ll miss it! 10/27/ /27/2014 NSCA Midwest

38 Traps/ Pitfalls Question-Answer Confrontation-Denial Expert Trap Labeling Trap Premature Focus Blaming Trap 38

39 Dietetic Training 39

40 Research Findings Brug et al (2007). Main Finding: MI trained dietitians counseled patients to achieve lower saturated fat intake Jackson et al (2007). Main Finding: MI trained dietitians implemented an effective TTM stage matched diabetic intervention 40

41 Rulers Use to help clarify participants perception of the level of importance Use to help clarify participants perception of the level of confidence they can change 41

42 Importance Desire HI Capability Need Commitment Reasons LO On the following scale, which point best reflects how important it is to you at the present time to change? 42

43 RULE to Operate By Resist the righting reflex Understand the patients motivation Listen with empathy Empower the patient 43

44 Summary Learn, acquire, practice Principles and values lead MI work MI is a counseling approach rather than a set of techniques. Multiple models, theories underpin MI Addressing ambivalence is key MI is a process oriented approach 44

These core elements are included in three increasingly detailed levels of definition:

These core elements are included in three increasingly detailed levels of definition: A Definition of Motivational Interviewing The definition of Motivational Interviewing (MI) has evolved and been refined since the original publications on its utility as an approach to behavior change.