Motivational Interviewing to Improve IPV Screening, Brief Intervention, and Referral for Treatment (SBIRT)

Shahrzad Bazargan-Hejazi, PhD UCLA/CDU Medical Education Program November 6, 2012

IPV Training Objectives

1.

2.

3.

4.

Define signs, symptoms, consequences, and CA reporting policies of Interpersonal Violence (IPV).

Describe the essentials of the Motivational Interviewing (MI) approach.

Identify and describe steps in IPV-SBIRT Rehearse IPV-SBIRT via role-playing.

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Definition & Prevalence of IPV

IPV refers to behavior within an intimate relationship that causes physical, sexual or psychological harm.

IPV includes acts of: • • • • Physical aggression Sexual coercion Psychological abuse Controlling behaviors

Prevalence in the U.S.

• Women – 35.6% lifetime – 6.0% any year – 17.0 % sexual – 24.3% hit, kicked… – 28.8% fearful Men 28.5% 5.0% 8.0% 13.8% 5.2% • A high % of IPV is not reported to police (~50%)

Liebschutz JM, NEJM2013

Consequences of IPV

The harm that IPV causes can last a lifetime and span generations, with serious adverse effects on: •

Health, including:

– Physical injury – Unwanted pregnancy – Abortion – Gynecological complications – Sexually transmitted infections (including HIV/AIDS) – Post-traumatic stress disorder – Depression •

Parenting Skills

•

Child behavior

•

Education

•

Employment

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Cost of IPV for the U.S

$10.4 billion in 2012 42% higher cost of health care for IPV-experienced women

Risk Factors for Both IPV & Sexual Violence

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The Ecological Model

Source:

World report on violence and health

edited by Krug, E. et al. Geneva, World Health Organization, 2002.

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Typical Non-inju ry Signs of IPV

• Neurological (headaches & neck pain, tingling & numbness) • Cardiopulmonary (chest pain, tachycardia, feeling of choking) • Pelvic symptoms (pelvic pain & UTI, vaginal pain & painful intercourse) 9

Physical Signs of IPV

• Head, neck & facial scrapes, cuts & bruises, FRX and rope burns ,T.M. membrane rupture, loose and broken teeth • Abd & ext cuts, bruises & bite marks, and cigarette burns • Signs of old and new fractures and burns 10

Typical Behavior of the Abuser

• Refuses to leave the patient • Abuser overly controlling, and may insist on answering questions for the patient • Its very important to take the history in private 11

IPV Reporting Procedures

1. Inform the patient of the health care provider’s duty to report.

2. Inform the patient of the likely responses by law enforcement, and what will happen to the report.

3. Make a telephone report to the local law enforcement agency

where the incident occurred

, immediately.

4. Complete a Suspected Intentional Injury Reporting Form a) Send within 48 hours of receiving information about the person to the law enforcement agency

where the incident occurred

.

5. When two or more HHSA employees suspect a domestic violence incident that requires a report, only one person needs to submit the report. 12

IPV Reporting Procedures (cont.)

6.

All

health care providers involved are equally responsible to see that the report is made and completed, according to State requirements.

7. The report must be kept confidential 8. A report must still be made even if the person has died, 9. Enter the following into the patient’s chart: a) Any comments by the patient regarding past domestic violence b) “Body Diagram Map” c) A copy of the Suspected Intentional Injury Reporting form.

There will be a liability for failure to report.

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What

Do We Know about Management of IPV by Providers?

• Health care providers commonly have an optimistic bias toward the vulnerability of their patients in regards to IPV. 14

IPV Training & Provider Practice

• Empirical evidence shows that practitioners who receive IPV-related training are significantly more likely to screen for it.

• Conversely, health practitioners who do not receive adequate training on how to recognize, treat, and refer IPV victims and perpetrators are less willing to conduct routine screening.

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Existing Gap in IPV Training

• Despite a national interest in IPV issues, many U.S. medical schools still do not provide adequate training for IPV screening and prevention.

• Medical education and residency programs continuously look for mechanisms to teach IPV screening and identification, and measure their competencies for IPV screening and prevention. 16

Current Guideline Under Affordable Care Act (ACA)

New guideline under the ACA requires insurance coverage to include IPV screening and counseling as part of eight essential health services for women at no additional cost to the patient.

James L., Shaeffer S. : 2012: www.futureswithoutviolence.org

IPV-SBIRT in the Context of Motivational Interviewing (MI)

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What is MI

Definition:

change: MI is an effective way of talking with people about 19

The Spirit of MI

MI is a style of interviewing that is:  Patient-centered and collaborative approach       An invitation for partnership Direct persuasion is not effective We meet people where they are with change We negotiate change with the patient Supports/tolerates patient ambivalence Readiness to change is not a trait  Evocative   It elicits behavior change from the patient Non-judgmental listening rather than instilling  Responsibility of change is with the patient  Not coercive, but directive  Respectful of patient autonomy 20

Core Skills for MI: OARS

• Open-Ended Questions • Affirmation • Reflective Listening • Summery

O

pen- Question

1. R U in pain? Vs. How do U feel? 2. Don’t you want to move to a safer place? Vs. What are the advantages of moving to a safer place?

3. How much alcohol do you drink a day Vs. What is the role of alcohol in your life?

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A

ffirmations

• Statements about anything positive that you notices about the patient: – Awards, Attempts, Achievements, Accomplishments • • •

You really care about your family/child/work You do feel responsible to take of yourself It takes a lot of courage to do what you do

• Build self confidence, self-efficacy

R

eflective Listening

– Understanding what the patient is thinking and feeling, then saying it back to the patient in a statement form and not question –

I have been like this for as long as I know myself

Reflection: So all of this seems normal to you –

I don’t like my husband getting mad at me all the time

Reflection: You want your husband to manage his anger –

I don’t think that I have depression

Reflection: You are not sure about the diagnosis of depression

I cannot live with fear of him getting mad at me all time!!

I am worried about my childern

S ummaries

I love him but he is moody, sometimes I might be safer if I move closer to my family Let see if I understand you right, you are worried about your husband rage, and you have been thinking that if you live closer to your parents you be safer. But there is a downside to it, you family might find out about this. But you are also worried about you children. I worried about my family finding about this

The Four Processes of MI

1. Engaging 2. Focusing 3. Evoking 4. Planning

1. Engaging

“The process of establishing a trusting and mutually respectful relationship” – Establishing rapport; Attuning; Aligning  Question-Answer Trap/assessing      Confrontation-Denial Trap Expert Trap/telling how to fix a problem Labeling Trap/ Premature Focus Trap Blaming Trap

2. Focusing

“An ongoing process of seeking and maintaining direction” – Setting an agenda • Patient’s goals and priorities • Your goals and priorities • Clear direction for ultimate change plan

3. Evoking

“ Eliciting a patient’s own motivation for change” – Eliciting change talk • Patient’s statements that favor movement in the direction of change – I want – I wish – The reasons are – I can – I will

How to Generating Change Talk

D : Why do you want to make this change?

A : How might you be able to do it?

R : What is one good reason for making the change?

N : How important is it, and why? (0-10) C : What do you intend to do?

A : What are you ready or willing to do?

T : What have you already done?

D esire, A bility, R easons, N eeds, C ommitment, A ctivation, T aking action

4. Planning

“Developing a specific change plan that your patient agrees with and is willing to implement” SMART • Specific • Measurable • Achievable • Relevant • Timed

Signs of Resistance to Change

      Argument Interrupt Denial Pessimism Ignoring Non-answer 32

Signs of Readiness to Change

         Less resistance Feeling welcome Feeling comfortable Feeling understood Fewer questions about the problem Provides self-motivating statements More inquiry about change Optimism/envisioning Experimenting with change 33

The Main Goal of MI

Retention Motivation Goal of MI Resistance Outcome

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Steps in Conducting IPV-SBIRT

       Establish rapport Ask permission to discuss the subject Explore pros and cons Explore discrepancies between present condition and intended goal Assess readiness to change Negotiate a plan to change Plan follow-up 35

Readiness Ruler

• How ready are you to change this situation (abuse) for yourself?

Not Ready (1-3) Unsure (4-7) Ready (8-10)

1 2 3

EXPRESS CONCERN, OFFER INFO. FOLLOW-UP

4 5 6 7 8 9 10 EXPLORE

PROS

& CONS

HELP PLAN, IDENTIFY RESO, CONVEY HOPE

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Good News/Bad News

Good News

: • A substantial number of counselors in the U.S. are being training in MI and report that they are “doing MI” in their sessions

Bad News:

• A substantial number of physicians are not trained in MI • Research demonstrates that most of those who say they are doing MI really are

not

– Unless they record sessions that can later be rated, it is not possible to know if they are really doing MI or are adhering to MI rules

Take Home Message

• IPV is prevalent • IPV is preventable • Health Care Providers Should Take action • IPV-SBIRT 38