Transcript Behavioral Health and Diabetes Care

Amy Walters, PhD
Licensed Clinical Psychologist
Director of Behavioral Health Services
St. Luke’s Humphreys Diabetes Center
Objectives
Attendees will be able to do the following:
 Define Motivational Interviewing
 Identify at least 3 core elements to MI style
 List the 3 guiding principles of MI
 Identify ways to address patient resistance
 Practice the basic elements of an MI intervention
Definition (Miller & Rollnick)
 Motivational Interviewing is..
“ A client-centered, directive method for
enhancing intrinsic motivation for change by
exploring and resolving ambivalence”
MI is . . .
• A collaborative, evocative, conversation about
change
 Accepting
 Compassionate
 Directional
 A Partnership
. . . promotes the interest of other person
Motivational Interviewing
 Roots are in substance abuse intervention
 First published in early 90s by Miller & Rollnick
 Expanded to other health conditions
 Hundreds of randomized clinical trials and
publications
 Activate patient’s motivation for change
Developments in MI: 2003 - 2011







Over 200 randomized trials
Total publications tripled to >1200 > 40 books
2011 over 30,000 Google Scholar articles
Meta-analyses of MI research
New research on MI processes theory
Rapid diffusion into health care, corrections
Newer diffusion into mental health, education, dentistry,
social work
 Areas of study : alcohol, drugs, dual dx, gambling,
offenders, eating, smoking, HIV, cardiac, diabetes,
psychiatric, health promotion, family violence, asthma,
dental, cancer – (listed by freq)
(Miller, 2013)
Motivational Interviewing
 Basic premise: How we speak with people about
behavior change matters
 Shift from expert role: “I know what is best” to
guide role :
 “You tell me what is best and let me guide you”
 “Tour guide in the land of health behavior change”
 MI is not a method, it is a style
Key Elements of MI
 Collaboration
 Person Centered
 Guidance – encourages self-based problem solving
 Empathy – relationship is the foundation
 Elicit and strengthen motivation for change
MI Spirit
Partnership
Compassion
Evocation
Acceptance
“Developing proficiency in MI is like learning to play a
musical instrument. Some initial instruction is helpful,
but real skill develops over time with practice, ideally
with feedback and consultation from knowledgeable
others. As with other complex skills, gaining
proficiency in MI is a lifelong process.”William Miller, 2008
Strategy
Skills
Style
Adapted from Steve Berg-Smith 2011
Interpersonal Style
 Empathic
 Warm & friendly
 Collaborative
 Accepting
 Respectful
 Optimistic
 Eliciting & Listening
 Honoring of autonomy & choice
* Adapted from Steve Berg-Smith 2011
Common Communication Styles
 3 common styles of communication for practitioners
 Directing – advice giving
 Guiding – empathetic listening and encouraging ideas
 Following – listening only
 Guiding style provides the best outcome and most
likely to lead to behavior change
Dancing not Wrestling
3 Guiding Principles of MI
 Collaboration/partnership
 “Guiding rather than directing and dancing rather than
wrestling”
 Collaborative conversations and joint decisions
 Evocation: elicit hows and whys from the patient
 Rather than giving advice, we evoke motivation and
resources for change
 Autonomy
 Respect and support patient autonomy for decisions –
directing and coercing leads to resistance
Paradox of change
“ when people feel accepted for who they are and
what they do (regardless of how unhealthy) it
allows them the freedom to consider change,
rather than needing to defend against it” (Miller and
Rollinick, 2010)
Studies suggest empathy is the best predictor of patient
behavior change
4 fundamental processes
• Engaging - form the relationship
• Focusing – what is our goal, where are we going
• Evoking – calling forth desires
• Planning – how will we get there
• Not a checklist; rather a process you revisit over and over; dancing
around the floor
Interaction Style
 REAL Principle
 Respect
 Empathy
 Active collaboration
 Listen
Importance of Empathy
 Empathy is a key ingredient
 Evidence based element of treatment


Predicts outcomes (e.g. drinking change)
Empathy alone is a significant intervention
 low level empathy associated with poor
outcomes
 Relationship is the vehicle for change
. . . building it for brief encounters is even
more important
Reflective Listening
A core skill
Eye contact
Pace
Inquisitive
Feeling
Engagement
Word choice
Content
Message
 Reflect general content and emotion – the
core message, not a mirror
Basic Flow
 Listen and identify the issue
 Ask/Evoke:
Why make the change?
 How could go about it to succeed?
 What are 3 best reasons to do it?
 How important is to make change 1-10 (why )

 Summarize
 Confirm: What do you think you will do?
Taste of MI
Best way to learn MI is to experience MI
 Choose a partner - not with your boss or supervisor
 One will be the speaker and the other will be the
listener
 2 part exercise
Exercise
Reflection/Persuasion Exercise
 Speaker: Choose a topic - something thinking
about changing
 Listener
1) Choose a side and try to persuade accordingly
2) Practice reflective listening & evoking




Ex Qs: Why make change? 3 best reasons?
How important is the change?
Summary?
What do you think you will do?
You Tube Video
Effective Physician
 http://www.youtube.com/watch?v=URiKA7CKtfc
Diabetes Educator
 http://www.youtube.com/watch?v=5h0i-b0xrnI
Strategy
Skills
Style
Adapted from Steve Berg-Smith 2011
Core Skills - OARS
 OARS
 Open questions
 Affirm
 Reflective listening
 Summarize
 Gather the pearls of the conversation and present them
with a string that summarizes it and highlights change
talk
Core Skill – Change Talk
Change talk – Any statements that favor changing the
target behavior
 Goal: clarify ambivalence & elicit change talk
• Encourage change talk – identify, reinforce, respond
• The goal is for the patient to talk him/herself into
changing
• Reflect: desire, ability, reasons, need, commitment,
steps to action
• Ex: “I want to…, I could…, I need to…, I will…”
Importance of Intention
 Multiple studies highlight the importance of intension
 Intension is greatest predictor of future behavior
(25-30% of variance)
 Stable
 Based on personal factors (vs social norms)
 Specific and detailed
(Bruin et al, 2012)
Types of Change Talk
 DARNS
 Desire
 Ability
 Reasons
 Need
 Steps
Questions to Promote Change Talk
 Desire
 What do you want, wish, hope?
 Ability
 What? How?
 Reason
 Why ? Benefits?
 Need
 How important is it?
 Steps
 What might be a next step?
Strategies to Encourage
Change Talk
 All EARS:
 E: evoke & ask for elaboration (be curious)
 A: affirm
 R: reflect
 S: collect bouquet of change talk flowers
and offer in summary
Core Skill - Evoking
Evoking: recognize, elicit & respond to
change talk



Reasons we miss change talk
- don’t listen, other agenda, expert role
Set the stage so patient is one that brings it up
Differential response:
 Reinforce change talk
 Ignore sustain talk
Evoking Questions
Ask evocative, open ended Qs
 Use importance ruler & confidence ruler
 Query extremes – best thing, worst thing
 Look back and forward
 Explore goals and values- what matters
to you, care about most, guides decisions
 Qs: How will that happen for you; what
would help you be successful

Core Skills – EOE Rhythm
 EOE Rhythm
 Explore
 Offer
 Explore
 Painter analogy – good outcomes are all
about the prep work
Sharing Information








Ask permission
Slow down
Be clear and concise: Small nuggets!
Avoid information overload: Less is more!
Use visual support
Avoid technical terms and jargon
Offer choices
Explore –Offer –Explore
 Education, feedback, skills, referrals
*Adapted from Steve Berg
2011
Clinician:"Jackie, tell me a little about what you know about antidepressants.“[Explore]
Patient:"Well, I know that lots of women are told they have depression and then
take these pills that lowers their sex drive and makes them fatter. How can that be
helpful?“
Clinician:"You're absolutely right! These side effects can and do happen for many
women. Could I tell you some other things about anti-depressants that we know as
well?“[Ask permission to Offer]
Patient:"Well, I suppose."
Clinician:"Great; thanks! There are many newer anti-depressants that don't seem to
have the same side effects for most women; they seem to lessen the depression only
and not the sex drive. And your sex life sounds important to you.[Offer] What do
you think about that?“[Explore]
Patient:"Well, I guess I could try one of those other ones if you really think it might
help -and that I won't gain more weight!"
Resistance
“Resistance is a by-product of communicative style and
approach “
It’s a sign we are dancing to a different song
 STOP
 listen to the beat
 try to join the patient’s rhythm
 Being heard can be the most healing response
Resistance signals ambivalence and a need to step back,
listen and help the patient explore the options
Resistance Traps
 The question-answer trap
 The taking sides trap
 The expert trap
 The scare tactics trap
 The cheerleading trap
 The pouncing trap
 The information over-load trap
 The premature action planning trap
Dealing with Resistance/Discord
 Signs: interrupting, arguing, challenging, discounting,
hostility, withdrawal, ignoring, changing the topic
 Responsive to style
 Not dancing together well
 Step back, listen and evoke concerns
Addressing Ambivalence and
Resistance
 Back away from the problem
 Move to exploration and guidance
 Explore why and how change might occur
 Ambivalence is a normal phenomenon when
considering change – resist the righting response
(advice)
The RULE Principle
 Resist the righting response

Roll with resistance, invite perceptions, listen and reflect
 Understand motivation

Explore values for change, listen for core values & motivation
 Listen with empathy

Warmth & acceptance, reflection, safe connection
 Empower ability to change

Affirmation, evidence of ability to solve problems
Open the
Conversation
Negotiate the Agenda
Build Motivation
*Ask Open Ended Questions
Explore Ambivalence
Assess Readiness –
avoid premature plan
The Next Step
Close the Conversation
Adapted from Steve Berg –Smith 2011
Readiness for Change
 How important is health behavior change to you?
 How confident are you in your ability to change your
behavior?
 How committed are you to changing your behavior?
0
1
2
3
4
5
6
7
8
9
10
Specific Techniques and Strategies
 Ruler ratings
 Gather pearls (selectively reinforce change talk)
 Choices for direction
 Circle chart
 Decision Square
Final Points
 Behavior change is a key element of healthy living and
wellness
 Many patients struggle to achieve behavior change,
despite good intentions
 Traditional methods of “advice giving” may increase
resistance to change
 MI is a research-based technique that may assist
health care professionals to support patients in their
behavior change efforts
Final Points

Health behavior change is not a by-product
of education, medication or provider
instruction
- behavior change is always the result of patient
motivation
 Release the responsibility to fix
- Patients hold responsibility for their own health choices and
behaviors
Research indicates the most effective providers:
•
•
•
•
Focus on patient goals and priorities
Follow the patient’s pace
Communicate high levels of empathy
Provide guidance to reach health goals
References
 Miller, W & Rollnick (2013) Motivational Interviewing: Helping People Change
(3rd Edition). Guilford Press, New York
 Miller, W & Moyers, T (2013) Advanced Workshop in Motivational
Interviewing, Albuquerque, NM September 2013
 Rollnick, S. , Miller, W., & Butler, C. (2008). Motivational Interviewing in Health
Care: Helping Patients Change Behavior. Guilford Press, London.
 Arkowitz et al. (2008). Motivational Interviewing in the Treatment of





Psychological Problems. Guildford Press, London.
Berg – Smith, S. (2011). Intensive Introduction to Motivational Interviewing : 3
day training, San Fransisco, CA, December 2011.
Bruin et al. (2012) Self regulatory processes mediate the intention behavior
relation of adherence and exercise behavior; Health Psychology,31 (6), 695-703.
Groot et al. Depression Among Adults with Diabetes: Prevalence, Impact and
Treatment.(2010) Diabetes Spectrum 23: 15-18.
Welch, G., et. al. (2006). Motivational Interviewing and Diabetes: What is it?
How is it used? Does it work? Diabetes Spectrum 19: 5-11.
www.motivationalinterview.org