Transcript Therapeutic Implications of Patient Non

Motivational Interviewing (MI):
Righting Reflex, Resistant
Patients, Micro Skills
Jan Kavookjian, MBA, PhD
Associate Professor, Harrison School of Pharmacy
Auburn University
Overview
• Background
– Research
– Training
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MI Assumptions
Righting Reflex
MI Communication Principles
Micro Skills
Provider-Centered
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Information giving
“Save” the patient
Dictate behavior
Compliance
Authoritarian
Motivate the patient
Persuade, manipulate
Resistance is bad
Argue
Respect expected
Literacy level of
communication may be
high
Patient-Centered
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Information exchange
Patient “saves” self
Negotiate behavior
Adherence
Servant
Assess motivation
Understand, accept
Resistance is information
Confront
Respect earned
Literacy level of
communication at patient
level
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Motivational Interviewing (MI)
 Major Assumption: Patient-centered “SPIRIT of MI”
 Major Assumption: Building ongoing relationship/ trust
 Major Assumption: Not motivating the patient; helping
patient get to his/her existing internal motivation
 Major Assumption: Patient should doing most of talking
 Major Assumption: Tool box with communication strategy
choices
 Major Assumption: Addresses ambivalence and resistance
•Rollnick, Miller & Butler (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior, New York, NY: The
Guilford Press.
•Rollnick S, Mason P, Butler C. (2000). Health Behavior Change: A Guide for Practitioners, London: Churchill Livingstone.
•Miller WR, Rollnick S. (2002). Motivational Interviewing, 2nd Edition: Preparing People for Change, New York, NY: The Guilford
Press.
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Ambivalent: Jane Smith,
34 yo, T2D, Obese
“Yeah, I know I need to lose weight and I know it will help my
numbers. I don’t feel like I can do it. I AM worried that my
A1C is 10%; I should start an exercise routine because I
feel better when I do, and my doctor will quit bugging me
about it if I lose some weight, and I like my smaller size
clothes, but it’s hard to fit exercise into my day and it
hurts… and I don’t like people to see me exercising – it’s
embarrassing. And, I just really feel comfort in the foods I
eat- they’re what I have always eaten. Besides, it seems
like every time I try to do anything, it’s not enough to make
a real difference; I don’t know what I could do that would
change things.”
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Resistant: John Jones
58 yo,T2D, HTN
“I know you’re going to try to make me feel bad about myself
like everyone else did, so you may as well quit now. I just
don’t see why it’s a big deal – my numbers aren’t that far
out of range and I feel fine. I work hard and I am not giving
up my after-work drinks and cigarettes, nor am I giving up
my all-you-can eat buffet lunches with my buddies at work.
And, I take my medicine most of the time anyway so I
should be able to eat what I want – okay, so I miss it a few
days a week, but don’t make a big deal out of it – I feel
fine.”
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“Yes, but……”
• A very common reactive response
• Assumes ‘I know better than you’ (violates
face)
• Forces patient defensiveness
• When patient defends, it reinforces why not
to change
• Resistance is now justified in mind of patient
Bottom Line:
Patients must have their own
internal motivation
for change.
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Most interventions try to push
or pull patients to temporary
change when they are not
ready (external motivation).
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The ‘Righting Reflex’
People in the Helping Professions
have a Natural Tendency to want to
FIX what’s ‘wrong’ with patients.
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MI Communication Principles
• Expressing empathy (early and often)
• Supporting self-efficacy
• Rolling with resistance/Avoiding arguments
• Developing discrepancy
Expressing Empathy
• Feeling or identifying affectively with another
1. Careful listening
2. Reflecting understanding
3. Patient feels understood
4. Reduces anxiety
5. Improves adherence & patient outcomes
Expressing Empathy Example
• Patient: “I just cannot endure this diabetes
diet! I’ve had to give up too many of the
things I like and the small portion sizes
leave me hungry!”
• Provider: “Mr. Johnson, you sound angry.
The idea of having to limit yourself with a
diet you didn’t get to choose is frustrating.”
Empathic Responses
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“You seem_____”
“In other words…”
“You feel ___ because ___”
“It seems to you…”
“As I understand it, you seem to be saying…”
“I sense that…”
“You sound…..”
• AVOID: “I understand how you feel.”
Support Self-Efficacy
• Notice, support, encourage patient attempts or
even thoughts about change.
• Praise the behavior, not the person.
• Look for opportunities to support the change
efforts of your patients.
Caution: over-praising sounds insincere.
Support Self-Efficacy Examples
“Mr. Richards, it’s great that you take your diabetes
medicine every day the way you planned. Keep it up!”
“You were able to lose weight before, I am confident that
you can do it again. What worked for you last time?”
“That’s great that your A1C has come down since last time!
Tell me about the things you’re doing that are helping you
succeed!”
Roll with Resistance/Avoid Arguments
• Ignore antagonistic statements.
• Don’t add to patient’s resistance by forcing
mutual defensiveness.
• Shift focus away from resistance; stay focused
on the purpose of the encounter and important
issues.
• Emphasize personal choice.
Rolling with Resistance Example
Patient: “I don’t like the idea of blood pressure
medicine. I hear it can have bad side effects.”
Provider: “And it really is your decision. All I can do
is tell you the advantages and disadvantages and
give you my opinion. It really is up to you.”
Rolling with Resistance Example
Patient: “I just don’t think I can quit eating my
nightly bowl of ice cream- that’s how I relax
before I go to bed.”
Provider: “May I tell you what concerns me?”
 Insurance Card strategy
Develop Discrepancy
• Strategy 1. Repeat back Pros (benefits)
and Cons (barriers) stated by the
patient.
Strategy 1 Example
“So, on the one hand, you want to reduce your
risk of ending up on dialysis by lowering your
blood sugar, but on the other hand you don’t
like to take medication and you feel fine.”
“I am concerned that if …. This worries me….
What are your thoughts?”
Develop Discrepancy
• Strategy 2. Ask questions about
behaviors that don’t support
goals set by the patient.
Strategy 2 Example
“Mr. Jones, I am concerned that your diabetes
medicine refill has been ready for about two
weeks. What are your thoughts about how this
might affect the goal you told me last time
about reducing your risk of the diabetes
complications your mother had?”
Develop Discrepancy
Strategy 3. Thought-Provoking Questions
“If I were to give you an envelope, what would the
message inside have to say for you to think about
quitting smoking?”
OR
“What would have to happen for you to think
about getting more activity into your daily
routine?”
OR
“What will life be like for you when you lose the 30
pounds [you have set as your goal this year]?”
MI Micro Skills
 FIRST establish patient understanding about diagnosis &
risks/susceptibility
 Maintain patient autonomy by using open-ended questions,
agenda setting, and asking permission to give
information/advice
 Engage the patient in ‘change talk’: the patient talking about
the change, benefits/pros, prior successes
 Self-efficacy building & incremental goals
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Establishing Risk/ Susceptibility
• Patient has to make the link to WHY
change is needed
• Patient may have forgotten
• Patient may be avoiding
• Health beliefs
• Early in the conversation, useful later
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Establishing Risk/ Susceptibility
Dialog
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Mrs. Smith, tell me what you know about what this blood sugar
number (A1C) puts you at risk for?
[I don’t know, or knows minimal or incorrect information]
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May I share with you some [additional] information about that? [yes]
[provider gives information, citing evidence/CPGs]
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What do you think about that?
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I don’t want those things to happen to me.
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I don’t want those to happen to you either.
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If it’s okay with you, I’d like to talk with you about some things you
can do to help prevent those from happening to you.
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Patient Autonomy: Agenda-Setting
• Maintains autonomy/choice
• Organizes the conversation structure
-‘We can talk about taking medication, small changes you can
make in the foods you eat, and getting more activity into your
daily routine. Which of these would you like to talk about first?’
[medication taking]
‘ Now that we’ve talked about the medicine, which of the other two
topics would you like to talk about next?’
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Patient-Autonomy: Open-ended
vs. Yes/No Questions
• To explore (‘Tell me what you know…’ vs ‘Do
you know?’) (What are your thoughts about
walking to get activity in your routine?)
• To get patient input (‘What are some things you
can do to remind yourself to take this
medication?’)
• Prevents patient feeling judged or interrogated
(vs. ‘Did you try this?’ ‘Have you thought about trying walking?’)
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Patient Autonomy: Asking Permission to
Give Information*
• To avoid a sense of advising and ‘fixing’
– Ask permission if you need to give information (“May I
share with you some things you can do to help prevent
being readmitted to the hospital?”)
– *Treatment for the Righting Reflex
• Avoid arguing the patient’s point of view (when they
argue their barriers, they are reinforcing why not to change)
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Process for Asking Permission to Give
Information
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1. Ask what they know
2. Affirm what they do know (if they do)
3. Ask permission to fill in the blanks
4. Give the information/advice about disease and/or
treatment and/or changes needed
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‘Mrs. Smith, what are some things you can think of to do to remember to
take your medicine?’ [don’t know or knows minimal]
‘May I share with you some things other patients have said help them to
remember?’ [yes]
[customizing a plan that fits patient’s routine]
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Change Talk
 What do you see as the benefits of changing?
 What would your life be like if you changed?
 What would you like about your life if you changed?
 When you were successful at this target behavior before,
what were the things you were doing that got you there?
 How ready are you to change?
 How important is the change to you?
 How confident are you that you can change?
Change Talk: Readiness Ruler
(OR, Importance, Confidence)
• “On a scale of 1 to 10, with 1 being not at all and 10
being completely, how ready are you to cut down
on salt to reduce your blood pressure?” [ 7 ]
• 1. “Okay, a 7, that’s great! Why a 7 and not a 1?” (Identify
motivators and support SE that it’s a 7 and not a 1)
• 2. “What would have to happen for it to be a 8 or 9?”
– Change Talk, motivators, incremental expectations
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Incremental Goals
• Self-efficacy building via small successes
– Success in small things can progressively build confidence
towards bigger change
• Avoiding use of BIG words like ‘diet’ and ‘exercise’
and ‘quitting’ (smoking)
• Instead: ‘small changes in some of the foods you eat,’ ‘getting
more activity into your routine,’’ cutting back on the number of
cigarettes per day’, ‘cutting one soda out of your daily routine for
the next week and see how that goes’
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Strategies for Those Most Resistant
Patients
• Maintain ‘Spirit of MI’ & relationship
• Early and frequent Empathy
– ‘It sounds like you’re not ready to quit smoking.’
• Roll with it – stick to topic at hand
• EXPLORE the resistance (e.g., using the rulers)
• Develop discrepancy
• Emphasize personal choice-unexpected
• Use the ‘insurance card’ (“May I tell you what concerns me?”)
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Contact Information
Jan Kavookjian, MBA, PhD
Associate Professor of Pharmacy Care Systems
Harrison School of Pharmacy
212 Dunstan Hall
Auburn University, AL 36849-5506
Phone: 334-844-8301
E-mail: [email protected]