Transcript Using Motivational Interviewing Techniques to Help

Using Motivational
Interviewing Techniques to
Help Patients to Change
Risky/Problem Behaviours
Linda Carter Sobell, Ph.D., ABPP
Nova Southeastern University
[email protected]
www.nova.edu/gsc
Objectives
Learn how to construct a
conversation with
patients to influence their
receptiveness to consider
changing problematicor
risky behaviours while
not evoking resistance
using Motivational
Interviewing techniques
Constructing a Conversation
with Patients
• WHY USE MI TECHNIQUES? So
patients feel comfortable discussing
their risky problematic behaviours
with you
• HOW DO YOU APPROACH THEM?
• Present information in non
judgmental, neutral context about
risks of continuing the behaviour vs.
benefits of changing
• INTENT: Increase a patient’s
commitment to consider changing
Motivational Interviewing
New Interviewing Style
FOR WHOM? Patients ambivalent
about changing
• WHY? To build rapport
• GOAL: Help patients explore and
resolve ambivalence about changing
• HOW: In a manner likely to increase a
patient’s motivation to change
• AIM: Elicit reasons for changing from
patients vs. confronting or telling
them to change
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Motivational Interviewing
Patient-centered, directive
method for eliciting intrinsic
motivation to change, by
exploring and resolving a
patient’s ambivalence to
change using reflective
listening
Focus of
Motivational Interviewing
• Patient’s concerns and beliefs
• Explore ambivalence about
changing in manner that
increases motivation to changing
without invoking resistance
• MI gives patients sense of
empowerment
Motivational Interviewing
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Developed early 1980s
Bill Miller (US) and Steve
Rollnick (UK)
Initially for substance
abusers
Why did it develop?
High dropout, high relapse
rates, and poor outcomes
Motivational Interviewing:
Common Currency
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Over past 20 years, MI has had wide
application to variety behavioural
domains and patient populations
Today practitioners use MI with all types
of patients and problems (e.g., dietary
and medication compliance problems-hypertension, asthma, insulin dependent
diabetes to eating disorders to
schizophrenia to flossing)
> 150 clinical studies
Today MI “COMMON CURRENCY”
among Health Care Practitioners
New View of Motivation
Conceptualized As
• STATE of Readiness to Change
• Can vary from situation to
situation
• Dynamic, fluctuating and a
modifiable state
• Importantly, can be influenced
by Practitioner’s interaction
style
EMPATHY KEY MI FEATURE
WHY? High levels of empathy
associated with positive patient
outcomes
• Key to expressing empathy through
Reflective Listening
• Listening in a reflective manner
demonstrates an understanding of
patients and validates their concerns
“It sounds like you are ambivalent
about changing (insert behaviour)”
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Focus:
Eliciting Change Talk
• HOW: Arguments for changing elicited
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from patients
You are (insert problem or concern), what
will happen if you don’t change (insert
behaviour) in (use time frame if you want)
Example 1: “You’re 55 & seem to be having
difficulty breathing. What will happen in 5
years if you continue to smoke.
Example 2:“I sounds like you are not
happy with having to take you insulin.
What do you know about what might
happen if you don’t take it regularly?
Tone of
Motivational Interviewing
• Nonjudgmental, nonconfrontational,
empathic, supportive climate where patients
can discuss good and less good things
related to changing (insert behaviour).
• Inquisitive Tone allows you to address
discrepancies between what patients say
and do without engendering defensiveness
• “Help me to understand on the one hand
you’re coughing, having trouble breathing
and on the other hand you say cigarettes
are not causing you any problems.”
• RESPECTFUL APPROACH
Motivational Interviewing
Two Key Components
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STYLE: How you say it
CONTENT: What you say
Critical Components for
influencing receptiveness
to consider changing
STYLE:
How You Say It
Use an Empathic,
Nonjudgmental,
Nonconfrontational,
Supportive Manner
CONTENT:
What You Say
“Do you floss?” vs. “What are
the good and less good
things about flossing?”
“Why are you still smoking?”
vs. “It sounds like you are
ambivalent about quitting.”
MI and Non-MI
Comparison Exercise
Short Role Play Exercise:
Compare and contrast
effectiveness of talking with
a smoker about quitting
smoking using two
interviewing approaches:
Non MI and MI
1st Role Play
90 seconds
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Role Play #1: Divide into pairs; one
person is Health Care Provider
(HCP) and one is Patient (PT)
HCP: Read questions as they
appear
PT: Answer in any way
Then we will evaluate how it felt
DO NOT GO TO ROLE PLAY #2
Therapist/ Health Care
Practitioner
Patient seeing you for a
routine visit and you
noticed that on the medical
history form they indicated
they currently smoke
cigarettes
Patient
25 years old and married
• Smoked for 10 years
• Smokes about 1 pack a day
• Eventually plans to quit, but
currently not worried about
smoking and it is not causing
any problems
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How Did It Feel?
In One Word
Non-MI Scenario
Patient
HCP
2nd Role Play
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90 seconds
Role Play #2: Keep same PT
& HCP roles as 1st role play
HCP: Again read questions
as they appear
PT: Answer in any way
Then we will evaluate how it
felt
How Did It Feel?
In One Word
Patient
MI Scenario
TH/HCP
MI Views Health Care Practitioner and
Patient’s Relationship as Collaborative
Recognize patients’ ambivalence; Give
patients advice so they can make better
informed decisions; but ultimately the
patients are responsible for changing
Health Care Practitioner
Patient
Simulated Patient Scenarios
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First 2 scenarios with same
patient
• 1st demonstrates non-MI
interview
• 2nd demonstrates MI
interview
After viewing both compare
& contrast 2 interview styles
NON MI
SCENARIO
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are needed to see this picture.
MI
SCENARIO
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are needed to see this picture.
• Which skit is
more likely to
result in the
patient quitting
smoking?
• Why?
Workshop Focus
Key MI Techniques
ASKING PERMISSION to discuss
target change behaviour or for
providing information about it
• REFLECTING what patients say
• NORMALIZING
• Using DECISIONAL BALANCING
• Using READINESS RULERS to
assess readiness to change
• Patients GIVE VOICE to changing
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Asking Permission
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“Do you mind if we talk about your
(insert behaviour)”
Communicates respect for patients; more
likely to get them talking about quitting
“Tell me a bit about your alcohol use, any
quit attempts, how has it affected your
health?”
“Would you be interested in learning
more about how how alcohol can affect
your hypertension?”
VALUE OF ASKING
PERMISSION
Major MI technique with patients
• Provides opportunity to discuss patient’s
behaviour when not presenting problem
(e.g., coming for physical or blood
pressure check) and you want to talk
about how exercise, diet, smoking can
affect their overall health
• Allows conversation to continue even if
patient not thinking of changing
• Respectful
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Motivational
Interviewing
Creates an
Understanding
of Why People
Do What They
Do
Often Difficult to Understand Why
Patients Continue to Engage In
Problematic/Risky Behaviours
• Practitioners mostly see negatives
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— death, health problems,
divorces
Rarely, do we SEE or TALK about
good things about the behaviour
from patient’s perspective
MI recognizes that MOST
behaviour has GOOD and LESS
GOOD THINGS that maintain it
What Can be Done to Help
Patients Consider Changing?
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Get patients to explore their
emotional attachment to their
behaviour — to look at the
good things they get from it
and then the less good things
Remember they’re
ambivalent!
Most People, Not Just Patients,
Ambivalent About Changing
• AMBIVALENCE critical concept in MI
• Working with ambivalence is working
with HEART of the problem
• Ambivalence normal everyday
occurrence
• How many of you have ever
made
New Year’s Resolution?
AMBIVALENCE IS NOT
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Reluctance to do something
Heightened psychological
conflict about choosing
between two courses of action
Continue Behaviour vs.
Changing Behaviour
Ambivalence difficult to resolve
each side has costs & benefits
Ambivalence is a
Powerful Emotion!
From the movie “Girl Interrupted”
Vanessa Redgrave (Psychiatrist):
“How do you feel about your
behaviour….?”
Winona Ryder (Client): “Ambivalent”
Redgrave: “That’s a pretty powerful
emotion, let’s explore that together.”
Decisional Balancing
Helping Patients to
Consider Changing
Decisional
Balancing
• Can discuss problem risky
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behaviours without
suggesting its a problem
Asking about good things creates
SAFE context to then talk about
“less good things”
Allows Practitioners to sound
credible as they VALIDATE a
patient’s behaviour (good things)
Asking About Good and Less
Good Things About Smoking
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“Tell me some of the good things
about insert behaviour.”
“Tell me some of the less good or
not so good things about insert
behaviour.”
“What will your life be like if you
continue engaging in insert
behaviour for the next 5 years?”
“How would your life be different
if you did change?”
VALUE OF DECISIONAL
BALANCING
Explores good things and
less good things related to
the problematic/risky
behaviour
• Addresses patient’s
ambivalence about changing
• Goal: Tip scale in favor of
changing
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READINESS RULERS
Assessing Readiness to
CHANGE
Definitely NOT Ready
To Change
Definitely Ready
To Change
Using Readiness
Rulers
• On a scale from 1 to 10, where 1 is
Definitely Not Ready to Change & 10 is
Definitely Ready to Change, what # best
reflects how READY you area at the
PRESENT TIME to change? Patient says 5
• On this same scale, where were you 6
months ago? Patient says 2
• How did you go from 2 to 5 (# 6 mo-NOW)?
• What would it take for you to change?
• What would be best outcome if you
change?
VALUE OF USING
READINESS RULERS
Patients at different levels of
readiness to change
• Assess patient’s readiness to
change
• Helps Practitioners recognize and
deal with a patient’s ambivalence
• Allows patients to give voice to
changing: “Where are you now.
Where were you 6 months ago.”
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Motivational
Interviewing
Requires a Special
Type of Listening
of the Kind We
Don’t Normally Do
REFLECTIVE LISTENING
Primary way of responding to patients
• After patient speaks Practitioner
paraphrases the patient’s comments
• “I get the sense that you are wanting
to change, but are concerned about
gaining weight”
• “It seems there is a lot of pressure for
you to change, but you are not sure
you can do it because you have tried
before. What have you tried before?”
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REFLECTIVE LISTENING
More Examples
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“What I hear you saying is that insert
behaviour is not causing you any
problems now. What might it take for
you to change?”
“So what I hear you saying is that you
know that insert behaviour is not good
for you, but you are not experiencing
any serious consequences that you are
aware of. What do you know about the
long-term consequences of insert
behaviour over the next 5 years?”
Normalizing
• Communicates to patients that
difficulty in changing is not
uncommon — others have had
similar experiences
• “Many women report feeling like you,
they want to quit for the health of
their baby, but find it difficult.”
• “That is not unusual, many people
report making several attempts.”
• “A lot of people are concerned about
gaining weight when quitting.”
VALUE OF REFLECTIONS
AND NORMALIZING
• REFLECTIONS validate what
patients are feeling
• REFLECTING back what
patients say indicates you
understood what they said
• NORMALIZING communicates
that difficulty changing is not
uncommon
Key MI Strategy
Advice Giving
• Often patients have little or
misinformation about their
behaviours
• Advice or information presented in
neutral, nonjudgmental manner can
help patients make better more
informed decisions about changing
• Focus on positives if possible
Simple Advice “Being Told”
vs. MI Advice Strategies
• Traditionally, Practitioners encourage
changing using Simple Advice
• “If you don’t stop….. this will
happen……health consequences”
• Research shows effectiveness of
simple advice very limited — only 5%
to 10% people likely to change
• WHY? Most people don’t like being
“told what to do”
MI Alternatives to
Simple Advice
Offer relevant new information in
neutral, nonjudgmental, sensitive
manner
• Ask Permission: “Do you mind if we
spend a few minutes talking about your
insert behaviour?
• Ask: “What do you know about how
behaviour affects your health?”
……your unborn child?”
……your teeth and gums?”
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Focus on Benefits of Quitting
VALUE OF PROVIDING
INFORMATION TO PATIENTS
• Often patients have little or no
information about changing
• Can help patients make better
informed decisions about
changing
• How information is presented can
affect how it is received
• Examples: “What do you know
about….?” “Are you interested in
learning more about…..?”
Research Shows
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Effective and empathetic
communication between Practitioners
and patients leads to
Greater patient satisfaction
Greater compliance with medication
and treatment and attendance
Reduced health care costs, and
Significantly improved clinical
outcomes
Decreased malpractice litigation
MI Scenario
Skills To Be Demonstrated
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Asking permission to discuss risky or
problematic behaviour(s)
Reflecting what the patient said
Normalizing
Using Decisional Balancing
Using Readiness Ruler to assess
readiness to change
Asking patient to give voice to new
goals
Asking permission to provide
information
QuickTime™ and a
YUV420 codec decompressor
are needed to see this picture.
Your Turn
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You will now have the
opportunity to practice ALL the
MI techniques you have seen
today
Break into pairs
Each person will practice a brief
negotiated interview using the MI
Card and Readiness Ruler
What Stood
Out Today?