Transcript Motivational Interviewing PowerPoint

Motivational Interviewing:
A Practical Approach
SARAH BLUST, LMSW, MPH
PROJECT MANAGER
PRIMARY CARE DEVELOPMENT CORPORATION (PCDC)
Learning Objectives
 To become familiar with the theory and essence of
Motivational Interviewing (MI)
 To gain a general understanding of the techniques of
MI
 To understand how MI techniques can be applied to
management of chronic conditions such as diabetes
and hypertension
But first…
Who’s in the room today?
Take off your mute button.
Say “here” when I call out
a role that applies to you!
 Any health educators in the room?
 Any providers?
MDs,
CNMs, NPs, PAs?
 How about nurses?
RNs
or LPNs?
 Social workers?
LMSWs,
LCSWs, MSWs
 How about Patient Navigators?
 Front desk staff?
 Medical assistants?
 Administrators?
Directors,
Managers
Program Managers, Office
 Did I miss anyone?
Thank you!
 Mute button back on please
Motivational Interviewing is an approach all
of you can use…
Story of MI
MI
Spirit
MI
Techniques
Apply to
Practice
• Substance Treatment:
Then & Now
• 200 Clinical Trials Later
• PCMH
• The spirit of MI
• Guiding Principles:
RULE
• OARS
• Recognizing change
talk
•Diabetes
• Cancer Screening
Story of MI
The Story of
Motivational Interviewing
 Originally came about as a different approach to
substance/alcohol treatment
 1970’s - treatment approach was to use counselors
who were also in recovery to “confront” clients about
their addiction and “make them” change
 However, when clients were confronted, their
natural instinct was to defend themselves - thereby
removing any desire to behave any differently
Enter William Miller, PhD
 William Miller, PhD
Center for Alcoholism, Substance Abuse and Addictions
Distinguished Professor of Psychology and Psychiatry
Departments of Psychology & Psychiatry at The University of New Mexico

As a student in training, Dr. Miller “accidentally” discovered
that other approaches could positively affect the behavior of
addicted patients
Listening
 Empathy


Over time, these experiences were studied, replicated,
modified and enhanced to become the field of Motivational
Interviewing
Subsequently, a more common treatment philosophy
for addiction is now:
Rather then the job of the client/patient to be
motivated for change….
 It’s our job as health professionals to help
people find the motivation for change that’s
already there within themselves
Where is the MI field now?
 MI has now been in the field for 30 years
 More than 200 clinical trials of MI have
been published
Positive results for
an array of target problems
•
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•
•
•
•
•
•
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Cardiovascular rehabilitation
Diabetes management
Dietary change
Hypertension
Illicit drug use
Infection risk reduction
Management of chronic mental disorders
Problem drinking
Smoking
Concomitant mental health & substance abuse
disorders
Other advantages
1) Relatively brief
2) Specifiable (but be careful with manuals)
3) Verifiable – is it being delivered properly
4) Generalizable across problem areas
5) Complementary to other treatment methods
6) Learnable by a broad range of providers
Leading to an
explosion of MI information
 Besides the >200 randomized clinical trials…
 >1000 publications
 Dozens of books and videotapes
 10 Multisite clinical trials
 Several coding systems for QA
 MIA-STEP to support MI supervisors
 Research on MI training
Training for MI
 Currently, there is no official certification for MI
 The Motivational Interviewing Network of Trainers (MINT)
can be used to train staff
 Many online resources and trainings exist (see end of
presentation)
 However, in-person supervision or peer support groups is
highly recommended as the way to achieve solid MI skills
Direction of healthcare - PCMH
 In the world of Patient Centered Medical Homes
(PCMH) a patient centered counseling approach is
also needed
 MI is not only the right thing to do, it’s become the
thing you should do and the thing you will get paid to
do
Reimbursement
 CPT Evaluation and Management codes allow
reimbursement for time spent counseling patients.
 Practices can also be reimbursed by having nurse
practitioners or physician assistants provide patientcentered counseling.
NCQA’s PCMH 2011 Standards
PCMH 3: Plan and Manage Care (17 points)
The practice systematically identifies individual patients and plans, manages and
coordinates their care, based on their condition and needs and on evidence-based
guidelines
(4 points)
Element C: Care Management
1. Conducts pre-visit preparations
2. Collaborates with the patient/family to develop an individual care
plan, including treatment goals that are reviewed and updated at
each relevant visit
3. Gives the patient/family a written plan of care
4. Assesses and addresses barriers when the patient has not met
treatment goals
5. Gives the patient/family a clinical summary at each relevant visit
6. Identifies patients/families who might benefit from additional care
management support
7. Follows up with patients/families who have not kept important
appointments
NCQA’s PCMH 2011 Standards
PCMH 4: Provide Self-Care Support and Community Resources
(9 points)
The practice acts to improve patients' ability to manage their health by
providing a self care plan, tools, educational resources and on-going support.
(6 points)
1. Provides educational resources or refers at least 50 percent of
patients/families to educational resources to assist in self management
2. Uses an EHR to identify patient-specific education resources and provide them
to more than 10 percent of patients, if appropriate
3. Develops and documents self-management plans and goals in collaboration
with at least 50 percent of patients/families
4. Documents self-management abilities for at least 50 percent of
patients/families
5. Provides self-management tools to record self-care results for at least 50
percent of patients/families
6. Counsels at least 50 percent of patients/families to adopt healthy behaviors
PCMH 4: Factor 4
Patients and families who feel they can manage their
condition, learn needed self-care skills or adhere to
treatment goals will have greater success.
Practices may use motivational interviewing to assess
patient readiness to change and self-management abilities,
including questionnaires and self-assessment forms.
The purpose of assessing self-management abilities is that
the practice can adjust self-management plans to fit
patient/family capabilities and resources.
 QUESTIONS?
 Spirit of MI
Eight Stages in Learning MI
1) The Spirit of MI
2) OARS
3) Recognizing change talk
4) Eliciting and strengthening change talk
5) Rolling with resistance
6) Developing a change plan
7) Consolidating client commitment
8) Engaging MI with other methods
Some Definitions
 Motivational interviewing (MI) is a clinical method
for helping people to resolve ambivalence about
change by evoking intrinsic motivation and
commitment.
 A skillful, clinical style for eliciting from patients
their own motivations for making behavior change in
the interest of their own health
The Spirit of MI - Collaborative
Collaborative Approach
 Clinician is not “above” the patient, telling them
what to do
 Conversation is more equal, in which joint
decision-making occurs
The Spirit of MI - Evocative
“Often healthcare involves giving patients what they lack…MI
instead seeks to evoke from patients that which they
already have”. (Rollnick, Miller & Butler, 2008)

MI seeks to understand the patient’s perspective by evoking
their own good reasons and arguments for change
The Spirit of MI –
Honoring Patient Autonomy
“There is something in human nature that resists being
coerced and told what to do. Ironically, it is acknowledging
the other’s right and freedom not to change that sometimes
makes change possible.” (Rollnick, Miller & Butler, 2008)
o Clinicians may inform, advise, even warn but ultimately it is the
patient who decides what to do.
o Honoring this can help facilitate change.
Four Guiding Principles
 RULE
Resist – the righting reflex
 Understand – the patient’s own motivations
 Listen – with empathy
 Empower – the patient

Motivational Interviewing in Practice
 How NOT to Do Motivational Interviewing
http://www.youtube.com/watch?v=kN7T-cmb_l0
R: Resist the Righting Reflex
 People who enter the helping professions often want
to set things right and prevent harm
 Can lead to a “correcting” of a person who is off
course
 Natural human tendency to resist persuasion
R: Resist the Righting Reflex
 “We tend to believe what we hear ourselves say. The
more patients verbalize the disadvantages of change,
the more committed they are to sustaining the status
quo” (Rollnick, Miller & Butler, 2008)
U: Understand Your
Patient’s Motivations
 It is your patient’s own reasons for change, not
yours, that are the most likely to trigger behavior
change
 Best use of your consultation time - ask patients why
they would want to make a change and how they
might do it – rather than telling them that they
should
L: Listen to your Patient
“A practitioner who is listening, even if it is just for a
minute, has no other agenda than to understand the
other person’s perspective and experience” (Rollnick,
Miller & Butler, 2008)
 Good listening is actually a complex clinical skill
 When done right, it can make the patient
feel they have had more time with you
then they actually have AND save time
E: Empower Your Patient
“A patient who is active in the consultation, thinking
aloud about the why and how of change, is more
likely to do something about this afterward.”
(Rollnick, Miller & Butler, 2008)
 QUESTIONS?
 Techniques
OARS
 Four communication techniques engender MI spirit:
 Open-ended
questions
 Affirmations
 Reflective
listening
 Summary statements (OARS).
 OARS has been shown to increase patient
collaboration and satisfaction, treatment adherence,
and patient-physician working alliance
 Underlying OARS is empathy – the ability to
understand the patient's thoughts, feelings, and
struggles from their point of view.
 Empathy is a strong predictor of treatment outcome
OARS: Open-ended questions
 Open-ended questions cannot be answered with a
yes or no.
 They produce less biased data because they allow
patients to “tell their story.”
 Open-ended questions elicit important information
that otherwise might not be asked.
 Closed-ended questions often damage rapport,
decrease empathic connections, and paradoxically
end up taking more time.
Example
Closed
 “Did you take your medicine last night?”
Open
 “Tell me what it’s like for you fitting medicine into
your day.”
OARS: Affirmations
 Affirmations are statements of appreciation, which
are important for building and maintaining rapport.
Efforts to make changes are acknowledged, no
matter how large or small
“I am impressed by your maintaining a weekly
schedule during the allergy injection build-up phase”
OARS: Reflective Listening
 Involves taking a guess at what the patient means
and reflecting it back, restating their thoughts or
feelings in a slightly different way
 Helps to ensure understanding of the patient's
perspective, emphasizes his or her positive
statements about change, and diffuses resistance.

Resistance occurs most often when patients experience a
perceived loss of freedom or choice.
 Reflective responses move the interaction away from
a power struggle and toward change.
Example
 “How was your day?”
 “So what I hear you saying is…”
 “Did I get that right?”
Reflective Listening –
Breast cancer screening
Table I. Types of reflections
1. Repeating
Patient
Patient Navigator
Use to diffuse resistance.
“I don't want to have a mammogram.”
“You don’t want to have a mammogram.”
2. Rephrasing
Patient
HCP
Slightly alter what the patient says to provide the
patient with a different point of view.
“I want to have a mammogram but last time I did it, it hurt
too much.”
“Having a mammogram is important to you.”
3. Empathic reflection
Patient
HCP
Provide understanding for the patient's situation.
“You've probably never had to deal with anything like this.”
“It's hard to imagine how I could possibly understand.”
4. Reframing
Patient
HCP
Help the patient think about his or her situation
differently.
“I keep trying to schedule a mammogram, but I don’t have
the time because of the kids and my job.”
“You are persistent, even when things are really difficult.
Getting a mammogram is important to you.”
Reflective Listening –
Colon Cancer Screening
Table I. Types of reflections
5. Feeling reflection
Patient
HCP
5. Feeling reflection
Patient
HCP
Reflect the emotional undertones of the
Reflect
the emotional undertones of the
conversation.
“I know that not getting a colon screen is a bad idea.
“You're worried that you might be at risk for colon
“I know that not taking medication is bad for my asthma.”
“You're
cancer.”worried about your asthma getting worse.”
6. Amplified
Amplifiedreflection
reflection
Patient
Patient
HCP
HCP
Reflect what the client has said in an exaggerated
Reflect what the client has said in an
way. This encourages the client to argue less and
exaggerated way. This encourages the client to
can elicit the other side of the client's ambivalence.
“My mom is totally exaggerating my symptoms. My asthma
“I think the statistics on colon cancer are totally
isn't that bad.”
“There's no reason to be concerned about your asthma.”
“There's no reason to be worried about colon cancer.”
(said without sarcasm)
argue less and can elicit the other side of the
client's
ambivalence.
7.
Double-sided
reflection
Patient
HCP
Acknowledge both sides of the patient's
ambivalence.
7. Double-sided reflection
“Taking medications just takes away my freedom. It's such a
hassle.”
Patient
“On the one hand, you find that medication takes away your
freedom.
On the other hand, you said that your asthma
HCP
symptoms limit your freedom by preventing you from doing
things you enjoy. What do you make of this?”
Acknowledge both sides of the patient's
ambivalence.
“My dad had colon cancer. But it’s such a hassle to go
through the screening.”
“On the one hand, you sound like you are worried about
colon cancer because your father had it. On the other
hand, you think it’s too much trouble to get a colon
screen. What do you make of this?”
conversation.
overrated. I don’t think I need to do this.”
(said without sarcasm)
OARS: Summary Statements
 Longer than reflections
 Used to transition to another topic
 Highlights both sides of a patient's ambivalence, or provide
recap at strategic points to ensure continued
understanding.
“You have several reasons for wanting to take your
asthma medication consistently; you say that your mom
will stop nagging you about it and you will be able to play
basketball more consistently. On the other hand, you say
they are a hassle to take, and that they taste bad. Is that
about right?”
CHANGE TALK
Recognizing Change Talk
 Change talk is any client speech that favors
movement in the direction of change
 Previously called “self-motivational statements”
(Miller and Rollnick, 1991)
 Change talk is by definition linked to a particular
behavior change target
DARN –
4 examples of Change Talk
 Desire to change
I wish, I want, I would like
 Ability to change
I can, I could
 Reasons to change
If…..then
 Need to change
Need to, have to, got to
Motivational Interviewing in Practice
 The Effective Physician
http://www.youtube.com/watch?v=URiKA7CKtfc
 QUESTIONS?
 Apply to Practice
 Staff need not apply the entire arsenal of MI
techniques during a single visit but rather chose the
strategies that fit best with their own style and with
patient readiness to change.
Focus: Asthma/COPD
 Successful asthma management requires an array of
patient behaviors.
 National asthma guidelines (National Asthma
Education and Prevention Program)1 suggest that
individuals with persistent asthma:




take 1 or more daily controller medications
use rescue medication as needed for symptoms
monitor lung function with peak flow monitors
need to avoid asthma triggers.
 Adherence rates for inhaled corticosteroids (ICSs)
range from 44% to 72%.
 Only 8% to 13% of patients taking ICSs continue to
fill their prescriptions 1 year after the initial
prescription.
 Non-adherence is associated with increased asthma
symptoms, frequent emergency department visits,
hospitalizations, and need for oral steroids.
However…
 Increasing asthma knowledge through education
yields little improvement in patient adherence or
asthma outcomes.
 Self-management approaches (i.e. identifying
barriers to adherence, self-monitoring medication
use, goal setting, and problem solving) have done
better:





fewer urgent care visits,
short-term improvements in adherence
higher asthma management self-efficacy
improved quality of life
reduced asthma symptoms
However…
 Limitation of both educational and self-management
approaches – assumes that patients are already
motivated to accept treatment recommendations.
 Making this assumption prematurely can actually
create resistance in patient
 Need for a medication adherence approach that:
 Targets
both those who are ready and
those who are not ready to change.
 Particularly relevant for asthma medication, about
which patients might falsely self-report adherence.3
 Creating a nonjudgmental atmosphere enhances the
likelihood of accurate self-report.30
 Studies have found that patients with asthma or
COPD desire greater participation in decision
making about their treatment.
 However, patients might be hesitant to voice their
agendas without being prompted.49
Where to Begin
 Set the agenda - collaboratively
 Begin by providing a “menu” of options for
discussion and let the patient decide where to start
the conversation.
“Would
you like to talk about taking your
medication, monitoring asthma symptoms, or
avoiding asthma triggers? What are you most
concerned about?”.50
Next - Discuss a typical day
 Ask a single open-ended question inquiring about
the patient's typical day

This allows you to assess the patient's social context and
adherence in a nonjudgmental framework
 Instead of asking, “How many times did you take
your medication this week?,” which can lead to facesaving answers, you can ask,
“What is a typical day like for you, from start to
finish, and, if you like, tell me about where taking
your medication fits into your day.”
Next, assess motivation
and confidence for change
 For example, you can ask, “How motivated are you
to take your medication? Rate your motivation on a
scale of 1-10, where ‘1’ is not at all motivated and
‘10’ is very motivated.”
 Confidence in the patient's ability to adhere can also
be rated.
Option - Use the
lower-higher exercise
 After motivation is assessed as outlined above, you
can ask: “Why not a lower number?”

This nonjudgmental approach helps to elicit positive
statements about change, which have been shown to be
associated with better treatment outcomes.37, 57
 After the patient provides several reasons, you can
ask, “What would it take for you to get to a 9 or a
10?”
This approach helps to identify
barriers and facilitators of adherence.
The same exercise can also be done
with confidence levels.

Then, explore the
pros and cons of change
This helps patients to:
(1) see both sides of their ambivalence simultaneously
(2) realize that you are interested in both sides of their
ambivalence and not only the “pro-change” side
(3) articulate and think more deeply about their reasons for
adherence and non-adherence.
 For example, you might start with the “not so good
things” about taking medication to convey a
nonjudgmental posture.
 You can then ask, "what about the other side; what
are some ‘good’ things about taking your
medication?”
Next, provide medical advice
and feedback
 In MI health information is shared in a manner that
increases the likelihood that the patient hears,
understands, and accepts the information.
Clear and understandable language
 Reflections that convey empathy and the patient's
concerns.

 MI uses the elicit-provide-elicit process to give
patients feedback about their health.24
 This approach, also called shared decision making,
has received empiric support across a variety of
studies,58, 60, 61 including studies in asthma.62
Even deeper, advise the patient
to change
 In MI, advice is given after a relationship has been
established and the patient's perspective on the
situation has been sufficiently explored.
 For example, you can say,
“As your doctor, I think the best thing you can do for your
asthma right now is to take your medication every day
(‘advice’).
I am not going to pressure you to do that; the decision to
take your medication is completely up to you (‘support
autonomy’).
I know that these decisions can sometimes be difficult
(‘empathy’).”
Ask those evocative questions
 There are several key questions you can ask to evoke
optimistic statements about adherence from
patients:



“If you were to take your medication consistently, what might
be the best results you can imagine?”
“What worries you most about your asthma?”
“How does asthma stop you from doing the things you want
to do?”
 Ending the consultation…
 The MI consultation ends with a summary and a
query about what the patient would like to do next, if
anything, about managing his or her asthma.
 Attainable goals are negotiated if the patient is
sufficiently motivated.
Motivational Interviewing in Practice
 Applying MI to Primary Care
http://www.youtube.com/watch?v=nwctPFfyG8M&f
eature=related
 Thank you!
 Questions?
Sarah Blust, LMSW, MPH
Project Manager, PCDC
[email protected]
212-437-3955
Last, but not least, a survey
 http://www.surveymonkey.com/s/5Z73FZY
Please complete as soon as possible!
Resources - Web
 http://www.motivationalinterview.org/
 http://motivationalinterviewing.org/about_mint
Resources - Books
Books:

Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (2006)
Developed as part of the NIDA Clinical Trials Network, this document provides a complete model
for developing staff competency in Motivational Interviewing.

Motivational Interviewing in Health Care; Helping Patients Change Behavior. Stephen Rollnick, William R.
Miller, and Christopher C. Butler

Building Motivational Interviewing Skills; A Practitioner Workbook. David B. Rosengren
Resources - Videos
Motivational Interviewing Training Video: A Tool for Learners (Hettema, 2009)

The 3 DVD set contains over 4 hours of educational material, including:

Interactive lessons on the background, principles, and core skills of motivational interviewing.

12 clinical vignettes demonstrating motivational interviewing.

Clinical analyses of each vignette.

Vignette and interview with Dr. William Miller.
Appropriate for a variety of audiences, including:

Physicians and other medical professionals.

Mental health workers.

Probation officers or criminal justice employees

Students or trainees.
Covers a range of problem areas, including:

Alcohol and drug use

Smoking

Anxiety disorders

Treatment engagement

Medication compliance

Diabetes

Cholesterol

Diet and exercise

Prenatal behavior

Infectious disease
Resources - Videos
Motivational Interviewing: Professional Training Series, (Miller and Rollnick, 1998)
This series of two DVDs, produced at the University of New Mexico, is intended to be used as a resource in professional
training, offering six hours of clear explanation and practical modeling of component skills. Because it is helpful to see how
a method is practiced in various contexts, the tapes include clinical demonstrations of the skills of motivational
interviewing, showing ten different therapists working with 12 clients who bring a variety of problems. Major sections
include:
A. Introduction to Motivational Interviewing
B. Opening Strategies
C. Handling Resistance
D. Feedback and Information Exchange
E. Motivational Interviewing in Medical Settings
F. Phase 2: Moving Toward Action
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