Transcript MOTIVATIONAL INTERVIEWING IN PRIMARY CARE

MOTIVATIONAL
INTERVIEWING IN PRIMARY
CARE
BRADLEY SAMUEL, PHD
DIRECTOR OF BEHAVIORAL HEALTH
EDUCATION
UNIVERSITY OF NEW MEXICO SCHOOL OF
MEDICINE
DEPARTMENT OF FAMILY & COMMUNITY
MEDICINE
ASSUMPTIONS ABOUT MOTIVATION
 MOTIVATION IS MALLEABLE
 SUBJECT TO CHANGE IN CONTEXT OF PATIENT-
PROVIDER RELATIONSHIP
 THE WAYS IN WHICH ONE TALKS WITH
PATIENTS CAN INFLUENCE PERSONAL
MOTIVATION FOR BEHAVIOR CHANGE
SPIRIT OF MOTIVATIONAL INTERVIEWING
 COLLABORATIVE – Active collaborative
conversation and joint decision making
process.
 EVOCATIVE – Access & activate motivation
and resources for change.
 HONORS PATIENT AUTONOMY –
Requires some detachment from outcomes.
Recognition that ultimately it is patients
who decide what to do.
STYLES OF COMMUNICATION
 DIRECTING
 FOLLOWING
 GUIDING
 (All three are valid…Guiding is best tool for behavior
change and motivation)
 (Helping professionals typically rely on Directing)
 (Following is best after giving information)
GUIDING
 LISTENING CAREFULLY & EMPATHICALLY
 ASKING ABOUT OPTIONS CONSIDERED
 OFFERING WHAT YOU KNOW ABOUT DECISION
MAKING, RELATIONSHIPS, ETC.
 RECOGNIZING & HONORING THAT “IT IS YOUR
DECISION TO MAKE.”
GUIDING IN MI
MOTIVATIONAL INTERVIEWING:
1) Is specifically goal directed wherein practitioner
has a behavior change goal in mind and gently
guides patient in ways that he/she may pursue that
goal.
2) Pays particular attention to specific aspects of
patient language and actively seeks to evoke patients
own arguments for change.
3) Involves competent use of well defined set of
clinical skills to evoke patient behavior change…
AGENDA SETTING
 GUIDING MEANS FINDING OUT WHERE
PERSON WANTS TO GO…
 BRIEF DISCUSSION IN WHICH PATIENT IS
GIVEN AS MUCH DECISION MAKING FREEDOM
AS POSSIBLE.
 QUESTIONS LIKE “WHAT CONCERNS YOU
MOST?” OR “WHAT WOULD YOU LIKE TO FOCUS
ON FIRST?”
 PROGRESS OR BEHAVIOR CHANGE IN ONE
AREA OFTEN GENERALIZES…DO IT IS OK FOR
PATIENT TO CHOOSE EASIEST OPTION FIRST.
THREE CORE COMMUNICATION SKILLS
 ASKING
 LISTENING
 INFORMING
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
MOST PRACTIONERS REPORT UTILIZING ASKING &
INFORMING IN THE SERVICE OF A DIRECTING STYLE.
MI PROPOSES THAT PRACTIONERS CONSIDER AN
ASKING, LISTENING, INFORMING APPROACH THAT IS IN
THE SERVICE OF GUIDING.
AMBIVALENCE
 “I need to lose weight, but I hate exercise…”
 “I should quit smoking, but I can’t seem to do it.”
 “I mean to take my medicine, but I keep forgetting.”
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HALLMARK OF AMBIVALENCE IS USE OF THE TERM
BUT
RESOLVING
AMBIVALENCE
 ACKNOWLEDGE AND REFLECT BOTH SIDES OF
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AMBIVALENCE i.e. “You want to lose weight and
hate exercising…”
COLLABORATIVE EXPLORATION
*NOTE THAT REFLECTION SHIFTS FROM “BUT”
TO “AND.”
HOLD OFF ON TRYING TO FIX THIS NOW.
LISTEN FOR, AND ELICIT, CHANGE TALK.
WE WANT THE PATIENT TO VOICE REASONS
FOR CHANGE.
LISTENING FOR CHANGE TALK
 RECOGNITION OF, AND ATTUNEMENT TO,
CHANGE TALK.
 LEARNING TO ELICIT CHANGE TALK…
 EXAMPLES OF CHANGE TALK…
 “YES I WILL…”
 “I MIGHT BE ABLE TO…”
 “I WISH I COULD…”
 “I’LL TRY…”
LEVELS OF CHANGE TALK
 DESIRE – “I want to…”
 ABILITY – “I can…”
 REASONS – “I would probably feel better if…”
 NEED – “I should…”
 COMMITMENT – “I will…”
 TAKING STEPS – “I started…”
PRE-COMMITMENT LEVELS OF CHANGE
 DESIRE
 ABILITY
 REASONS
 NEED
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KEY IS TO LISTEN, REFLECT, AND AFFIRM AT THESE
LEVELS.
SKILLED USE OF LISTENING AND COMMUNICATION AT
THESE LEVELS INCREASE LIKLIHOOD OF COMMITED
CHANGE.
COMMITMENT LEVELS OF CHANGE TALK
COMMITMENT
TAKING STEPS
ZERO TO TEN ASSESSMENTS
 “HOW IMPORTANT IS IT FOR YOU TO QUIT
SMOKING (MAKE THIS CHANGE)?
 0---------------------------------10 scale
 FOCUS DISCUSSION ON “WHY NOT LOWER”
RATHER THAN “WHY NOT HIGHER.” e.g. “WHY
DID YOU CHOOSE FIVE INSTEAD OF THREE?”
 THIS FACILITATES CHANGE TALK INSTEAD
OF AMBIVALENCE OR RESISTANCE.
GUIDING THROUGH CHANGE TALK
 TASK IS TO ELICIT CHANGE TALK RATHER
THAN RESISTANCE FROM PATIENTS.
 THE ‘HOW OF IT’ IS TO ASK OPEN ENDED
QUESTIONS THAT REFLECT CURRENT LEVEL
OF CHANGE TALK & THEN LISTEN.
 EXAMPLES:
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“WHY WOULD YOU WANT TO QUIT SMOKING?”
“HOW WOULD YOU DO IT, IF YOU DECIDED TO?”
“WHAT AR E THE REASONS YOU WOULD QUIT IF YOU
DECIDED TO?”
MOVING FROM TALK TO BEHAVIOR CHANGE
 EXPLORING AMBIVALENCE
 GATHERING CHANGE TALK
 MEASURING MOTIV., CONFIDENCE,
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HOPEFULNESS, IMPORTANCE
LISTENING, GUIDING, INFORMING
SUMMARIZING MOTIVATION FOR CHANGE
TIMING MOSTLY OPEN ENDED QUESTIONS
ASKING FOR WILLINGNESS TO CHANGE
DEVELOPING PLAN
THREE PRACTICAL RECOMMENDATIONS ABOUT
ASKING & LISTENING
 1) USE OPEN RATHER THAN CLOSED
ENDED QUESTIONS.
 2) TRY NOT TO ASK TWO QUESTIONS IN
A ROW.
 3) TRY TO OFFER AT LEAT TWO
REFLECTIIONS FOR EVERY QUESTION.
SUMMARIZING IN MI
 MOSTLY SUMMARIZING WHAT PATIENT, NOT
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PROVIDER, HAS SAID.
REFLECTIONS ARE MINI-SUMMARIES AS YOU
GO.
SUMMARIZING CAN BE USED AS A SEGWAY FOR
CHANGING DIRECTION.
SUMMARIZING HELPS BUILD AND MAINTAIN
RAPPORT & CONVEYS UNDERSTANDING.
A GOOD SUMMATION DEMONSTRATES THAT
YOU HAVE BEEN LISTENING & REMEMBERING
WHAT PATIENTS HAVE SAID.
BIBLIOGRAPHY AND RESOURCES
 MOTIVATIONAL INTERVIEWING IN
HEALTH CARE:
HELPING PATIENTS CHANGE BEHAVIOR
STEPHEN ROLLNICK
WILLIAM R. MILLER
CHRISTOPHER BUTLER
GUILFORD PRESS