Transcript Training Pediatricians in Smoking Cessation Counseling

Motivational Interviewing 101: Tips
for Effective Tobacco Cessation
Counseling
Artwork by Liu W. © 2013 American Academy of Pediatrics (AAP) Children's
Art Contest. Support for the 2013 AAP Children's Art Contest was from the
Flight Attendant Medical Research Institute.
Objectives
• Describe the basic steps of motivational
interviewing
• Apply Motivational Interviewing techniques to
facilitate open conversations with parents or
family members that smoke
Principles of Tobacco Dependence
Treatment
• Nicotine is addictive
• Tobacco dependence is a chronic
condition
• Effective treatments exist
• Every person who uses tobacco
should be offered treatment
Smokers Want to Quit
• 70% of tobacco users report wanting to quit
• Most have made at least one quit attempt
• Tobacco users cite health expert advice as
important
• Regardless of type of provider! THIS MEANS YOU!
Artwork by Aishani S. © 2013 American Academy of
Pediatrics (AAP) Children's Art Contest. Support for the
2013 AAP Children's Art Contest was from the Flight
Attendant Medical Research Institute.
Counseling 101
• Patients and families expect you to discuss tobacco
use
• If counseling is delivered in a non-judgmental
manner, it is usually well-received
• Even small “doses” are effective - and cumulative!
• Strength of Evidence = A
Counseling IS Effective
• As little as 3 minutes of counseling doubles quit
attempts and successes
• Intensive counseling is more effective
– Dose-response relationship
• Most effective:
–
–
–
–
Problem-solving skills
Support from clinician
Active referral
Social support outside of treatment
Requirements for Change
X
Motivation
(Should I?)
=
Self-Confidence
(Can I?)
Commitment
(Will I?)
Your Goal: Help the Tobacco
User Take the Next Step
Help a precontemplator become a contemplator…
…a contemplator start to make plans…
…someone who relapsed become “ready for action”…
And so on….
The Challenge
• People don’t follow physicians’ advice and
recommendations
– 50% don’t follow long term medication regimens
– Many don’t follow advice to change health behavior
• Patients often do not recall anticipatory advice given
Research Has Shown:
• Clinician-patient interactions influence the behavior
change process.
• When given the tools to help motivate patients to
change health behaviors, good doctors become even
more effective.
• When patients arrive at action plans that fit within their
personal goals and values, change is more likely.
Motivational Interviewing (MI):
Key Elements
• Use key counseling skills (open ended questions,
reflective listening, empathy)
• “Roll with resistance”
– The MI encounter resembles a dance rather than a
wrestling match Assess importance and confidence
• Develop discrepancy between the patient’s goals and
current behaviors
• Support patient’s change efforts
Overview of the MI Encounter
• Set the agenda
– Collaborative process
• Use key counseling skills to understand the patient’s
experience
• Determine importance and confidence
• Enhance importance and confidence
• Elicit patient’s “change language”, reinforce it, and
build on it
• Help patient develop action steps
Agenda Setting
• Elicit items patient wishes to discuss
– “What were you hoping to talk about today?”
– Always ask permission before discussing a topic
• Raise items you wish to discuss and ask permission
– “I’m concerned about your child’s frequent asthma attacks.
Would it be okay if we talked about it today?”
• Prioritize multiple concerns
• Agree on what you’re going to talk about
Key Counseling Skills:
Open-Ended Questions
• Goal-understand meaning rather than collect facts
• Use “How” and “What” questions
– Caution: “Why” questions can sound judgmental
• Examples:
–
–
–
–
Tell me about…
Could you help me understand more about…
What have you tried before?
How was that for you?
Key Counseling Skills:
Reflective Listening
• Listening is often considered the passive part of
conversation
• Reflective listening is an active process
• Reflect the meaning of what your patient said
• Every reflection opens a possibility
– The patient may verify, correct, add to, or refine their
message
– The clinician can clarify, correct misinterpretations, and
learn about their own assumptions and distortions
Key Counseling Skills:
Reflective Listening (continued)
• Stems:
–
–
–
–
–
–
It sounds like you…
So what I hear you saying is…
You’re wondering if…
You feel…and that makes you want to…
It seems like…
You are…
Key Counseling Skills:
Expressing Empathy
• Empathy:
– Understand the experience of another at a deeper level
– Acknowledge and value the other person’s perspective
and feelings
– Empathy communicates to your patient that what they
say, think, and feel is important to you.
• Empathy is NOT:
– Sympathy - Shared suffering
– Pity - A condescending relationship which separates
physician and patient
– Reassurance
Key Counseling Skills:
Expressing Empathy
• “You seem pretty frustrated”
• “So you’re just not sure what to do next.”
• “So you really want to change your eating habits, but
its overwhelming because you’re not sure where to
start.”
• “Most people I know would feel anxious in that
situation.”
• “It sounds like deciding to take that first step is a
little scary for you.”
Exchanging Information vs.
Advice on Empty Ears
•
Exchanging information is different from advice, which
is a one-way process
•
Always ask permission before giving information
•
Elicit-Provide-Elicit Process
– ELICIT interest
•
“Would you like to know more about…?”
– PROVIDE feedback neutrally
•
“What happens to some people is…Other people find…”
– ELICIT the patient’s interpretation and follow it
•
•
“What do you make of this?”
“How do you see the connection between smoking and your health?”
Assessing Importance and Confidence
• Goal: Understand how the patient feels and
thinks about changing their current behavior
• Strategy: Scaling questions
• In order to move toward change, the patient may
need to:
– Further explore the importance of change
– Build the confidence to undertake change
– Enhance both importance and confidence
Assessing Importance
Not at all
important
0 1 2 3 4 5 6 7 8 9 10
Extremely
important
• “On a scale of 0 to 10, how is important is it to you to
_________ (make this change)?
• Follow-up Questions:
–
–
–
–
“What makes you say a 5?”
“What led you to say 5 and not zero?”
“What would it take to move it to a 6 or a 7?”
“What could I do to help you make it a 6 or 7?”
Strategies for Enhancing Importance:
Examining Pros and Cons
• Examining pros and cons gives a lot of information
about how the patient views the issue (Ex.: all cons
and no pros)
• Patients often experience ambivalence about the
value of change
– There are costs and benefits to changing as well as staying
the same
– New behaviors can be hard to do
• There are 2 ways of examining pros/cons:
– Look at the current behavior
– Look at change
Current Behavior
Change
Pros
Pros
“What are some of the good things about
eating so much junk food?”
“What are some of the good things about
changing the way you eat?”
I like how it tastes
If lose weight, will feel more attractive
Going out with my friends-we like to hang out It would be easier to fit into the kinds of clothes I
at McDonalds
want to wear
I’d feel good about accomplishing it
Cons
Cons
“What are the not so good things about
eating junk food?”
“What are some of the not so good things about
changing the way you eat?”
I don’t like how I look-I think its making me
heavy and it also make my skin greasy
I’d have to think about what I can and can’t eat
all of the time
I can’t run as well as I used to, so I’m doing
badly on my field hockey team
I’d have to give up my favorite junk food
It would be hard to go out with my friends
How would you summarize both sides of what you hear?
Responding to Ambivalence
• Return to a reflective statement
• Double-sided reflection
– “So, on the one hand…while on the other hand…”
• Roll with resistance
– Patient: “I know you expect me to quit eating all the things I
like. I want to lose weight, but I don’t plan on sticking to
some strict diet where you can only eat salad!”
– Clinician: “A lot of people feel the same way you do when
they start thinking about changing the way they eat. Tell me
more about your concerns.”
Assessing Confidence
Not at all
confident
0 1 2 3 4 5 6 7 8 9 10
Totally
confident
• “On a scale of 0 to 10, how confident are you that
you can _______ (make this change)?
• Follow-up questions:
– “What makes you say a 6?”
– “What led you to rate your confidence 6 and not 2?”
– “What would help you move your confidence from a 6 to a
7 or 8?”
Strategies for Enhancing Confidence
• Recall times in the past when the patient has
been successful making changes
– Explore role of family and peers in supporting change
– Affirm persistence-often many attempts
• Break it down
– Define small, realistic, and achievable steps
• Identify specific barriers and problem-solve
– “What might get in the way?”
– “What might help you get past that?”
– “Here’s what others have done.”
The Ingredients of Readiness to Change
Importance
(Why should
I change?)
Readiness
Confidence
(Can I do it?)
Change Talk
• Change talk includes desire, ability, reasons, need
– “I really want to start eating healthier”
– “I’m sure that I can turn the TV off after school”
– “I need to cut back on junk food because I am starting to
gain weight”
– “It’s important for me to take my asthma medicine”
• Listen carefully for change talk throughout the
interview
• Acknowledge, appreciate, affirm, and express
support for change talk
How Do We Help the Patient Turn
Interest Into Action?
• Most people need help picking one do-able step
that’s not too big
• More likely to be successful if they come up with the
options rather than you
– You can prime the pump if they are stuck
– Limit the number of changes to be attempted
• Convey optimism and belief in their strengths
• Write it down for the patient
Assess Readiness for Change
• Ask permission:
– “Would it be okay if we spent a few minutes talking about
_____?”
• Understand their view of the problem. (“Tell me…”) :
• Ask about readiness:
– “On a scale of 0-10, how ready are you to consider ____?”
• Ask scaling questions:
– Backward: “What makes it a 5 and not a 2?”
– Forward: “What would help you move it from a 5 to a 7?”
Assess Readiness (con’t)
• Pay attention to change talk:
– Change talk includes desire, ability, reasons, need
– Change talk give clues about readiness to change
– People are more persuaded by what they hear themselves say than by
what someone tells them Summarize change talk
• Confirm:
– “Did I get it all?”
• Ask about the next steps:
– “Where does _______ fit into your future?”
• Show appreciation:
– “Thank you for your willingness to talk about ___ with me.”
• Voice confidence:
– “I’m confident that if and when you make a firm decision and
commitment to ___ you will find a way to do it.”
Ready for Action?
• Not ready to attempt change
– Goal: Raise awareness
– Tasks: Inform & encourage
• Unsure about change
– Goal: Build importance and/or confidence
– Tasks: Explore ambivalence
• Ready for Action
– Goal: Agree on action steps and strategies
Not Ready - Inform & Encourage
• Always ask permission before giving information
• Elicit-Provide-Elicit Process
– ELICIT interest
• “Would you like to know more about…?”
– PROVIDE feedback neutrally
• “What happens to some people is…Other people
find…”
– ELICIT the patient’s interpretation and follow it
• “What do you make of this?”
• “How do you see the connection between smoking
and your health?”
Unsure - Explore Ambivalence
• Ask permission:
– “It seems that you have a lot of thoughts about this, Can
we talk a little more about it?”
• Ask “disarming” open-ended question:
– “What are some of the advantages for keeping things just
the way they are?”
• Ask “reverse” open-ended question:
– “On the other hand, what are some of the reasons for
making a change?”
• Summarize both sides of ambivalence
– Start with the reasons for not changing, followed by
reasons for changing
Unsure - Explore Ambivalence (cont.)
• Ask about the next step:
– “What’s the next step, if any?”
• Show appreciation:
– “Thank you for your willingness to talk with me about _____.”
• Voice confidence:
– “I’m confident that if and when you make a firm decision and commit
to making a change, you’ll find a way to do it.”
Ready - Agree on Action Steps
• Many people need help picking one do-able step that’s not
too big
• People are more likely to be successful if they come up with
the options rather than you
– You can prime the pump if they are stuck
– Involve both mother and child
• Show appreciation
• Convey optimism and belief in their
strengths
• Write down one simple next step
What if the Patient Can’t Come up
With Any Ideas?
• Ask permission:
– “If you’re interested, I have an idea for you to consider.
Would you like to hear it?”
• Offer advice:
– “Based on my experience, I would encourage you to
consider _________.”
• Emphasize choice:
– “Of course, it is totally up to you.”
• Elicit response:
– “What do you think about this idea?”
Recap of the MI Encounter
• Set the agenda
– Collaborative process
• Use key counseling skills to understand the patient’s
experience
• Determine importance and confidence
• Enhance importance and confidence
• Elicit patient’s “change language”, reinforce it, and
build on it
• Help patient develop action steps
Back to Tobacco: YOUR Agenda
• Use clear, strong messages
• Anticipate challenges
– Ask about cues to use tobacco
– There are fewer cues in Smoke Free
homes and cars
• Practice problem-solving
• Prescribe or provide information about
pharmacotherapy
• Help the patient or family member set a quit date
• Document your advice
What Do You Say?
• Clear: “I strongly advise you to quit smoking.”
(ok, it’s a one-way statement…but important to say!)
• Strong: “Eliminating smoke exposure of your son is
one of the most important things you can do to
protect his health.”
• Personalized: Emphasize the impact on health,
finances, the child, family, or patient.
“Smoking is harmful for you (and your child/family). I
can help you quit.”
Be Specific…
• Remember MI: Ask Permission to give this advice, or it may
fall on deaf ears…
– “There are some things that may be helpful to know about what it
means to have a Smoke Free Home. Can I go through them with you?”
• Having a Smoke Free Home means no smoking ANYWHERE
inside the home or car!
• It DOES NOT mean smoking:
– Near a window or exhaust fan
– In the car with the windows open
– In the basement
– Inside only when the weather’s bad
– Cigars, pipes, or hookahs
– On the other side of the room
Help With Challenges
• Tobacco use can be a source of family discord
– Smoking by a household member can be a source of
tension
– Not always identified by the patient or family member as a
barrier
• Moms are more often the “gatekeepers” for
maintaining a smoke free home
– BUT, they may not be willing to risk a
relationship
– Want to maintain peace, may rationalize
the risk
Help With Challenges
• Strategize with the patient or family member about
ways to deliver the “you can quit” and “our home and
car should be tobacco free” messages
• Some patients and family members would like to have
a Smoke Free Home and car, but do not feel like they
have the POWER to set this rule.
– ASK if they can set a firm, 100% Smoke Free Rule
– If they don’t have the power, ASK if a note from you will
help!
Assist by Following Up
• Plan to follow up on any behavioral commitments
made – they are beginning a process of change!
– Just asking at the next visit makes a big impression
– Need to monitor and reinforce behavior change
• If they set a quit date
– Schedule follow-up in person or
by telephone soon after the
quit date
• Look for “teachable moments”
in the future
Refer: To State Quitline
• To find information about your state quitline visit:
http://map.naquitline.org/
• What do you say?
– “I recommend that you call this number. It’s a free service
– and the person on the other end of the telephone can
help you get ready to quit.”
– “One thing that helps a lot is to learn as much as you can
about quitting – the more you know, the more successful
you’ll be. The quit line staff can help.”
– “We’ve got a great state quit line. If you go on line and
click a button, they call YOU back right away!”
Close on Good Terms
• Offer praise and encouragement
– Earnestly praise for work done
• Summarize your patient’s view on importance and
confidence
• Emphasize any agreement that was reached
Motivational Interviewing
• http://www.motivatehealthyhabits.com/
– Rick Botelho is a family doc who does a fabulous job
• http://www.motivationalinterview.org/
– The website for motivational interviewing trainers; many
good resources from the psychology literature
Need more information?
American Academy of Pediatrics
Julius B. Richmond Center of Excellence
www.aap.org/richmondcenter
American Lung Association
www.lung.org/cessationta
Audience-Specific Resources
State-Specific Resources
Cessation Information
Coding & Payment Information
Tobacco Control E-mail Lists
Clinical Practice Change Resources