Using Motivational Interviewing to Help Your Patients Make Behavioral Changes Jan. 24, 2013 Thomas E. Broffman, PhD, LICSW, LCDP, LCDS, CEAP Broffman Training & Consultation Services P.O. Box 41503, Providence, RI 02940-1503 (401) 338-5605 tbroffman@cox.net 1
Disclosure of Financial Relationships I have no financial relationships to disclose with regard to this presentation. This talk is free of commercial bias. 2
Sound Familiar? I tell them what to do, but they won t do it. It s my job just to give them the facts, and that s all I can do. These people lead very difficult lives, and I understand why they. Some of my patients are in complete denial. Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008. 3
What Should We Do? Explain what patients could do differently in the interest of their health? Advise and persuade them to change their behavior? Warn them what will happen if they don t change their ways? Take time to counsel them about how to change their behavior? Refer them to a specialist? Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008. 4
The Righting Reflex: The Best Intentions Can Backfire Most patients are ambivalent about unhealthy behaviors. When we (providers) see an unhealthy/risky behavior, our natural instinct is to point it out & advise change. The patient s natural response is to defend the opposite (no change) side of the ambivalence coin. 5
Avoid Righting Reflex: Taking Sides Trap PROVIDER You must change You ll be better off You can do it!! You ll die PATIENT I don t want to change Things aren t half bad. No I can t!! Uncle Fred is 89 and healthy as can be. 6
Why Should We Be Interested In Patients Motivation For Behavior Change? 7
Center for Disease Control and Prevention Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the U.S. Chronic diseases account for 70% of deaths each year. Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of these diseases. Source: http://www.cdc.gov/nccdphp/ 8
Why Are Health Care Professionals (Outside Behavioral Health) interested In MI? Behavioral/lifestyle factors in health issues Exercise Smoking Weight control Treatment adherence Diet/nutrition Conceptual consistency with patient-centered approaches Positive and promising results from research on outcomes 9
Definition of Motivational Interviewing A patient-centered, yet directive method for enhancing intrinsic motivation for positive behavior change by exploring and resolving ambivalence. Miller, W.R. & Rollnick, S.(2002) 10
Motivation is viewed as multidimensional a state, which is dynamic and fluctuating modifiable influenced by communication style Our job is to elicit and reinforce patient motivation for change. 11
Rapid Diffusion Into Health Care Settings 12
Motivational Interviewing Practice Basics: Spirit, Principles, Micro-skills 13
MI Spirit A way of being with patients which is Collaborative Evocative Respectful of autonomy 14
Collaboration (not confrontation) Developing a partnership in which the patient s expertise, perspectives, and input is central to the consultation Fostering and encouraging power sharing in the interaction 15
Evocation (not education) The resources and motivation for change reside within the patient Motivation is enhanced by eliciting and drawing on the patient s own perceptions, experiences, and goals Ask key open ended questions 16
Autonomy (not authority) Respecting the patient s right to make informed choices facilitates change The patient is charge of his/her choices, and, thus, is responsible for the outcomes Emphasize patient control and choice 17
What MI is Not A way of tricking people into doing what you want them to do A specific technique Problem solving or skill building Just client-centered therapy Easy to learn A panacea for every clinical challenge Source: Miller & Rollnick (2009) 18
Four Guiding MI Principles: 1. Resist the righting reflex If a patient is ambivalent about change and the clinician champions the side of change 19
Four Guiding MI Principles: 2. Understand your patient s motivations With limited consultation time, it is more productive asking patients what or how they would make a change rather than telling them that they should. 20
Four Guiding MI Principles: 3. Listen to your patient When it comes to behavior change, the answers most likely lie within the patient, and finding them requires some listening 21
Four Guiding MI Principles: 4. Empower your patient A patient who is active in the consultation, thinking aloud about the what and how of change, is more likely to do something about it. 22
Core MI Skills Asking Listening Affirming 23
Asking Use of open ended questions allows the patient to convey more information Encourages engagement Opens the door for exploration 24
Closed Ended Question Open Ended Question 1. Are you having any pain today? 2. Is there anything that is worrying you right now? 3. Are you short of breath? 4. Are you doing okay? 5. Why haven t you tried this exercise? 6. Are you refusing treatment? 7. Do you have a follow up appointment scheduled? 25
Listening Clinician accurate empathy is a robust predictor of behavior change Involves careful listening with the goal of understanding the meaning of what the patient says Skillful reflective listening looks easy, but it s a complex skill 26
Listen For Change Talk D A R N C Change Desire: I want/wish/prefer to Ability: I can, could, able, possible Reason: why do it? what would be good? Need: important, have to, matter, got to Commitment: I will/am going to signals behavior change 27
Affirming Supports patient self-efficacy Emphasize patient strengths Notice and appreciate positive action Genuineness is critical 28
Affirmations May Include: Commenting positively on an attribute (You are determined to get your health back.) A statement of appreciation (I appreciate your efforts despite the discomfort you re in.) A compliment (Thank you for all your hard work today.) 29
Theoretical Framework of Motivational Interviewing Readiness to Change 1. Precontemplation not yet considering change 2. Contemplation evaluating reasons for and against change 3. Preparation planning for change 4. Action making the identified change 5. Maintenance working to sustain changes 30
Stages of Change Maintenance Precontemplation Relapse Contemplation Action Preparation - Determination 31
Stages of Change Model CONCEPT DEFINITION APPLICATION PRE-CONTEMPLATION Not considering possibility of change. Does not feel there is a Problem. Goal: Raise awareness. Task: Inform and encourage. Validate lack of readiness. CONTEMPLATION PREPARATION Thinking about change, in the near future. Making a plan to change, setting gradual goals. Goal: Build motivation and Confidence. Task: Explore ambivalence. Evaluate pros and cons. Goal: Negotiate a plan. Task: Facilitate decision making. ACTION MAINTENANCE Implementation of specific action steps, behavioral changes. Continuation of desirable actions, or repeating periodic recommended step(s). Goal: Implement the plan. Task: Support self-efficacy. Goal: Maintain change or new status quo. Task: Identify strategies to prevent relapse. 32
REMEMBER: READINESS TO CHANGE IS A STATE, NOT A TRAIT. 33
Readiness Rulers A Precontemplation Stage Tool 34
Readiness Rulers: I-C-R Importance: The willingness to change Confidence: In one s ability to change Confidence Readiness: A matter of priorities 35
Importance Ruler On a scale of 1 to 10, how important is it for you to make a change? 1 2 3 4 5 6 7 8 9 10 Not at all important Somewhat important Extremely Important 36
Importance to Change Readiness Ruler We show the patient the Importance Readiness Ruler & ask: On a scale of 1 to 10, how important is it to you to make a change in...? Example, If you are a 5, why are you a 5 and not a 3? Or if you are a 5, what needs to happen for you to go to a 7? How could I assist you in getting to a 7? 37
Confidence Ruler On a scale of 1 to 10, how confident are you that you could make a change if you wanted to? 1 2 3 4 5 6 7 8 9 10 Not at all confident Somewh at confident Extremely confident 38
Confidence to Change Readiness Ruler We show the patient the Confidence Readiness Ruler & ask: On a scale of 1 to 10, how confident are you to make a change in...? Example, If you are a 5, why are you a 5 and not a 3? Or if you are a 5, what need to happen for you to go to a 7? How could I assist you in getting to a 7? 39
Strategies to Enhance Confidence Review past successes Define small steps that can lead to success Problem solve to address barriers Hypothetical change ( If you were able to quit smoking tomorrow, how do you think things would be different? ) Attend to the progress and use slips as occasions to further problem-solve rather than failure 40
Simplified Motivational Categories Confidence in Ability Importance of Change Low High Low High Group 1 Little interest in change; don t think they could even if they wanted to. Group 3 Believe they could change, but not interested right now. Group 2 Want to change, but don t think they are able. Group 4 Want to change and believe they have the ability. 41
Readiness Ruler On a scale of 1 to 10, how ready are you to make a change? Not at all ready 1 2 3 4 5 6 7 8 9 10 Somewhat ready Extremely Ready 42
Readiness to Change Readiness Ruler We show the patient the Readiness Ruler & ask: On a scale of 1 to 10, how ready are you to make a change in...? Example, If you are a 5, why are you a 5 and not a 3? Or if you are a 5, what need to happen for you to go to a 7? How could I assist you in getting to a 7? 43
Decisional Balance A Contemplation Stage Tool 44
Decisional Balance: An Explanatory Model of Behavior Change Highlights the individual s ambivalence regarding maintaining vs. changing a behavior It is a balancing of the costs of status quo with the costs of change And the benefits of change with the benefits of the status quo. 45
Decisional Balance Decisional Balance Worksheet (Fill in what you are considering changing) Good things about behavior: Not so good things about behavior: Not so good things about changing behavior: Good things about changing behavior 46
Decisional Balance Sheet Reasons for staying the same Good things about: 1. 2. 3. Reasons for making a change Not so good things about: 1. 2. 3. Not so good things about changing: 1. 2. 3. Good things about changing: 1. 2. 3. 47
Conducting a Decisional Balance Discussion Accept all answers. (Don t argue with answers given by patient.) Explore answers. Be sure to note both the benefits and costs of current behavior and change. Explore costs/benefits with respect to client s goals and values. Review the costs and benefits. 48
Imagine Extremes What is the worst that can happen if you continued? What do you think would have to happen to make you decide to tell yourself, ok that s enough? 49
Looking Back When was the last time things were going well for you and what was it like for you? What do you think could have prevented this setback? What was your life like before this happened? As you step back and look at all this, what do you make of it? 50
Looking Forward What would you like your life to be like in 2 years? How does what you are doing now make that difficult? What would it be like if you continue with the way things are now? Suppose things don t change, how do think your life will look? 51
Motivation for Change Motivation is an intrinsic process Ambivalence Alternative behaviors have pluses and minuses Motivation arises out of discrepancy Values/goals conflict with current behavior Ambivalence discrepancy change Change Talk facilitates change 52
Strengthening Commitment Summarize patient s own perception of problem, ambivalence, desire/intention to change, and can include your own assessment. Ask a key question, i.e.: What is the next step? 53
Negotiating a Change Plan Setting goals Have patient develop a menu of strategies brainstorm. Have patient decide on a specific plan & summarize it. 54
Elicit commitment Negotiating a Change Plan (cont.) Have patient restate what they intend to do. Involve others: the more the patient verbalizes the plan to others, the more commitment is strengthened ( no going back now concept) 55
MI Traps to Avoid Expert trap: problem-solving, prescribing the solution makes patient the passive recipient and undermines building intrinsic motivation Labeling: evokes dissonance & focuses energy unnecessarily on the label (esp. with addiction problems). 56
Other MI Traps to Avoid Premature focus: patient needs to be ready (determine stage of change) Blaming: Provider must attempt to render blame irrelevant (including self-blame): Shame & blame usually squash selfefficacy & intrinsic motivation to change. 57
Summary: Benefits of Using MI Evidence-based Provides some structure to the consultation Readily adaptable to health care settings 58
What Do You Think? 1. On a scale of 1 to 10, how important is it for you to start using motivational interviewing in your practice? 2. On a scale of 1 to 10, how confident are you to start using motivational interviewing in your practice? 3. On a scale of 1 to 10, how ready are you to start using motivational interviewing in your practice? 59
More Information on Motivational Interviewing Literature on MI: www.motivationalinterview.org Miller and Rollnick. Motivational Interviewing: Preparing People for Change. Guilford Press. New York and London. 2002 Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press. New York and London. 2008 60
For Additional Information Thomas E. Broffman, PhD, LICSW, LCDP, LCDS, CEAP Broffman Training & Consultation Services (401) 338-5605 tbroffman@cox.net 61