Improving Treatment Adherence and Health Behaviours through Motivational Interventions Opportunistic...
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- Slide 1
- Improving Treatment Adherence and Health Behaviours through
Motivational Interventions Opportunistic Brief Interventions Jos
Silveira B.Sc., M.D., FRCPC, Dip. ABAM Assistant Professor, Dept.
of Psychiatry, UofT Medical Director, Mental Health and Addiction
Program St. Josephs Health Centre, Toronto
- Slide 2
- Faculty/Presenter Disclosure Faculty: Dr. Jose Silveira
Program: 51 st Annual Scientific Assembly Relationships with
commercial interests: None 29 November 2013 10:30 - 12:00
- Slide 3
- Disclosure of Commercial Support This program has received
financial support OCFP from in the form of Honoraria for
presentation. This program has received in-kind support from none
in the form of none. Potential for conflict(s) of interest: None 29
November 2013 10:30 - 12:00
- Slide 4
- Mitigating Potential Bias Not Applicable 29 November 2013 10:30
- 12:00
- Slide 5
- Content 1. Introduction 2. Critical Assumptions 3. What we
automatically/routinely do 4. Background 5. How to do it 1. Brief
Motivational Techniques 2. Listening for and Recognizing
opportunities 29 November 2013 10:30 - 12:00
- Slide 6
- Introduction 29 November 2013 10:30 - 12:00
- Slide 7
- Scope of Session 29 November 2013 10:30 - 12:00 Interventions
that foster the motivation to change Brief and Simple Build from
what we already know Informed Consent Not Motivational Interviewing
Requires formal course and coaching
- Slide 8
- Are You in the Correct Session 29 November 2013 10:30 - 12:00
By show of hands... In regards to improving treatment adherence and
health promoting behaviours You want to be more effective? You want
to feel more competent? You want to feel more confident? You want
to be able to do it easily? You want to feel less frustrated in
your efforts?
- Slide 9
- My Goal 29 November 2013 10:30 - 12:00 Make the task more
enjoyable and less frustrating so that we dont lose you!
- Slide 10
- Why Focus on You Patients spend minutes in treatment. Providers
spend years. Prochaska and DiClemente 1984 29 November 2013 10:30 -
12:00
- Slide 11
- Quotes from the field 29 November 2013 10:30 - 12:00 After 20
years of practice and trying to get patients to change behaviour, I
dont care anymore. Sometimes i think to myself while seeing a
patient, Why am I seeing you? this is a waste of my time. Patients
dont seem to want to do something until its too late. Why should I
bother with patients that just complain but dont want to do
anything.
- Slide 12
- Group Exercise 29 November 2013 10:30 - 12:00 In pairs Share
with one another Why you chose to attend this session? How your
professional life would be easier or more satisfying if you felt
more competent in helping patients improve treatment adherence or
change behaviour?
- Slide 13
- Motivational Interventions Motivational Interventions is what
we will be looking at This is not to be confused with motivational
interviewing which is a skill which involves extensive training,
practice and coaching. We will go through simple, easy to use
techniques that foster a patients motivation to change 29 November
2013 10:30 - 12:00
- Slide 14
- Critical Assumptions 29 November 2013 10:30 - 12:00 These
techniques are contingent upon several assumptions.
- Slide 15
- Critical Assumptions - Capable 29 November 2013 10:30 - 12:00
The patient is capable to consent to treatment Patient acknowledges
the target problem Able to describe to you the risks and benefits
in their own words The patient is able to make reasonable
decisions
- Slide 16
- Critical Assumptions Informed 29 November 2013 10:30 - 12:00
Risks and benefits have been explained Using language that is clear
and detailed Confirmed patient understands the risks and benefits
Patient has explained their understanding to you or a delegate
- Slide 17
- Authority without Data... 29 November 2013 10:30 - 12:00...is
Religion Stephen Hawking
- Slide 18
- Critical Assumptions - Voluntary 29 November 2013 10:30 - 12:00
The patient has voluntarily come to you requesting assistance or
expressing concern about their health The target behaviour is not
legally mandated (e.g., prohibition on alcohol use) The target
behaviour is not exclusively the concern of others
- Slide 19
- Critical Assumptions - Language 29 November 2013 10:30 - 12:00
The patient is language concordant
- Slide 20
- Critical Assumptions - Delegates 29 November 2013 10:30 - 12:00
When you work with a delegate every provider working on the target
behaviour is saying the same thing and using the same techniques
Explicit information is the same E.g., Risks and benefits are not
contradicted between providers No good cop, bad cop Using fear of
adverse outcomes is more effective in entrenching the status quo
behaviours than the fragile use of enabling interventions
- Slide 21
- Limitations 29 November 2013 10:30 - 12:00
- Slide 22
- Limits to MI in medical care Patients found incapable to
consent to treatment Emergency situations in which patient is
momentarily incapable The patient is a risk to themselves or others
in the context of a mental disorder 29 November 2013 10:30 -
12:00
- Slide 23
- What we tend to do 29 November 2013 10:30 - 12:00
- Slide 24
- 2 Magic Words
http://www.youtube.com/watch?v=Ow0lr63y4Mw&featur
e=player_detailpage#t=50
http://www.youtube.com/watch?v=Ow0lr63y4Mw&featur
e=player_detailpage#t=50 Boiled down the essence of our automatic
behaviour modification approach 29 November 2013 10:30 - 12:00
- Slide 25
- The Other Approach 29 November 2013 10:30 - 12:00
- Slide 26
- Motivational Interventions 29 November 2013 10:30 - 12:00
Status Quo Target Behaviour Patient
- Slide 27
- Motivational Interventions 29 November 2013 10:30 - 12:00
Status Quo Target Behaviour Physician
- Slide 28
- The Righting Reflex 29 November 2013 10:30 - 12:00 Providers
want to fix things and make things right Patients are ambivalent to
change When the righting reflex meets ambivalence the result is
confrontation Confrontation = Intensification of resistance to
change and more fervently defend the status quo
- Slide 29
- Background Key Knowledge, Principles and Contrasts 29 November
2013 10:30 - 12:00
- Slide 30
- What Are We Up Against? 29 November 2013 10:30 - 12:00 What are
some of the factors that make treatment adherence and changing
health behaviours extremely challenging?
https://www.youtube.com/watch?v=YOD2fflXIfM&featur
e=player_detailpage
https://www.youtube.com/watch?v=YOD2fflXIfM&featur
e=player_detailpage discounting our future selves
- Slide 31
- Advanced Consent and Capacity 29 November 2013 10:30 - 12:00
Motivational interventions are absolutely consistent with the
Consent and Capacity Legislation in the Health Care Consent Act and
the Expectation that health providers obtain informed consent
before delivering any intervention Think of these techniques as a
detailed articulation of informed consent
- Slide 32
- Motivational Interviewing Motivational interviewing is a
collaborative, person- centered form of guiding to elicit and
strengthen motivation for change. It is about Selectively eliciting
and reinforcing the clients own arguments and motivations for
change Explicitly honors autonomy, peoples right and irrevocable
ability to decide about their own behavior. Patients talk
themselves into change 29 November 2013 10:30 - 12:00
- Slide 33
- PRINCIPLES 29 November 2013 10:30 - 12:00 1. The best interests
of the patient are central to all physician-patient interactions.
2. Respect for the autonomy and personal dignity of the patient is
central to the provision of ethically sound patient care. Through
the translation of these ethical principles to law, the Supreme
Court of Canada has confirmed the fundamental right of the
individual to decide which medical interventions will be accepted
and which will not. 3. In order to exercise their autonomy,
patients must be capable of making informed decisions about their
health care. 4. The goals of the Health Care Consent Act (HCCA)
include promoting individual autonomy and decision-making capacity,
and facilitating communication between health care practitioners
and their patients. 5. Physicians have the obligation to secure
consent and patients have the legal right to either consent to or
refuse treatment. (Who recognizes these principles? Show of
hands.)
- Slide 34
- Recognition of Principles 29 November 2013 10:30 - 12:00
Consent to Medical Treatment. CPSO Policy Statement, Policy
#4-05
- Slide 35
- Techniques in this session... Are not a way of tricking people
into doing what they dont want to do To the contrary Assume
personal autonomy that people make their own behavioral choices,
and that such power of choice cannot be appropriated by another. It
is about eliciting the persons own inherent arguments for change,
not imposing someone elses. (This is why it is critical that the
patient is capable and you have ensured that they understand the
risks and benefits) 29 November 2013 10:30 - 12:00
- Slide 36
- Evidence 29 November 2013 10:30 - 12:00 Well studied Widely
applied in certain domains of health care
- Slide 37
- The Litmus Test Brief interventions for alcohol problems: a
meta- analytic review of controlled investigations in
treatment-seeking and non-treatment-seeking populations Anne Moyer
et al. Addiction, 2002, 97, 279292 This review summarizes
additional positive evidence for brief interventions compared to
control conditions typically delivered by health-care professionals
in non-treatment- seeking samples. 29 November 2013 10:30 -
12:00
- Slide 38
- Comprehensive Primary Care Training practitioners to deliver
opportunistic multiple behaviour change counselling in primary
care: a cluster randomised trial Christopher C Butler et al BMJ
2013;346:f1191 doi: 10.1136/bmj.f1191 (Published 19 March 2013)
...but it did increase patients recollection of discussing
behaviour change with their clinicians, intentions to change,
attempts to change, and perceptions of having made a lasting change
at three months 29 November 2013 10:30 - 12:00
- Slide 39
- Opportunistic Brief Interventions Prevention and Lifestyle
Behaviour Change: A Competence Framework NHS Yorkshire and the
Humber 2011 29 November 2013 10:30 - 12:00
- Slide 40
- Rationale In a comprehensive primary care setting: Brief
statements Easy statements to learn Applied to all patient
encounters May have greater impact than specifically targeted MI
techniques on a population basis 29 November 2013 10:30 -
12:00
- Slide 41
- Misinformation Is Important A factual knowledge of the kinds of
misinformation which people receive about health and wellbeing and
how these can be counteracted 29 November 2013 10:30 - 12:00
- Slide 42
- Example of Misinformation 29 November 2013 10:30 - 12:00
https://www.youtube.com/watch?feature=player_detailpag
e&v=_KNIPGV7Xyg#t=273
https://www.youtube.com/watch?feature=player_detailpag
e&v=_KNIPGV7Xyg#t=273 To 4:45
- Slide 43
- Performance Criteria 1. Be alert to opportunities for brief
advice 2. Identify cues from individuals expressed needs or
concerns 3. Observe individual for any signs of lifestyle health
related issues 4. Explore, in a non-threatening manner, the
individuals views and feelings about their lifestyle and health
behaviours 5. Assess whether the individual is willing to engage in
further discussion about the issue 29 November 2013 10:30 -
12:00
- Slide 44
- Performance Criteria 6. When an individual is not willing to
engage at that moment, invite them to return and ask questions at
any time in the future 7. When an individual is willing to engage,
provide general health information in an empathetic,
non-confrontational manner 8. Maintain up-to-date and accurate
information about additional sources of support 9. Signpost the
individual to appropriate additional support according to the
individuals needs 29 November 2013 10:30 - 12:00
- Slide 45
- Communicate in a manner that: a. is appropriate to the
individuals b. encourages an open exchange of views and information
c. minimises any constraints to communication whilst maintaining
confidentiality d. respects people as individuals 29 November 2013
10:30 - 12:00
- Slide 46
- Encourage individuals to: a. assess how their behaviour is
affecting their health and wellbeing b. identify the changes that
might benefit their health and wellbeing c. identify their
motivation to change their behaviour d. identify the situations
that will help them change e. identify barriers to change and ways
of managing them 29 November 2013 10:30 - 12:00
- Slide 47
- Assist individuals to: a. identify specific, measurable,
achievable, realistic and timely goals for changing their behaviour
(SMART goals) b. identify one easily-achievable goal to start
working on c. identify any skills that need to be learnt to achieve
this goal d. develop a personal action plan that will help them
achieve their goals e. identify who and what will help them achieve
their plan f. make sure they get the support they need in achieving
their plan g. record their progress in achieving their plan h.
identify when and how their plan will be reviewed 29 November 2013
10:30 - 12:00
- Slide 48
- Support individuals to achieve their plan by: a. reviewing
their progress in achieving their goals b. providing feedback,
support and encouragement c. helping them recognise and value their
achievements d. developing their confidence in bringing about
change and maintaining change 29 November 2013 10:30 - 12:00
- Slide 49
- Help individuals to Maintain Changes a. evaluate the changes
they have made to their behaviour and their effects on their health
and wellbeing 29 November 2013 10:30 - 12:00
- Slide 50
- Opportunistic Brief Interventions (OBI) Providers tasks Listen
for statements from patient relating to either current discontent
or desired outcomes that provider can link to target intervention
Respond to patients comment with nonjudgmental reflection that
links altered status quo to the patients own statement 29 November
2013 10:30 - 12:00
- Slide 51
- Identifying Opportunities 29 November 2013 10:30 - 12:00
- Slide 52
- Identifying Patient Motivation 29 November 2013 10:30 - 12:00
The next few exercises are intended to assist you in identifying
patient statements and questions that may translate into
opportunities for fostering behaviour change
- Slide 53
- Identifying Opportunities
https://www.youtube.com/watch?feature=player_detailpag
e&v=_KNIPGV7Xyg#t=100
https://www.youtube.com/watch?feature=player_detailpag
e&v=_KNIPGV7Xyg#t=100 To 4 Minutes Listen for specific
statements by the patient that would be an opportunity for building
on to foster motivation to change. Identify what the NP actually
did and rewrite a potentially more motivating statement 29 November
2013 10:30 - 12:00
- Slide 54
- Identifying Opportunities 29 November 2013 10:30 - 12:00
https://www.youtube.com/watch?feature=player_detailpag
e&v=-aTe4LpGz_E#t=150
https://www.youtube.com/watch?feature=player_detailpag
e&v=-aTe4LpGz_E#t=150 To 3:34 Listen for specific statements by
the patient that would be an opportunity for building on to foster
motivation to change.
- Slide 55
- Recognizing Provider Techniques 29 November 2013 10:30 - 12:00
https://www.youtube.com/watch?v=-
zEpwxJlRQI&feature=player_detailpage#t=240
https://www.youtube.com/watch?v=-
zEpwxJlRQI&feature=player_detailpage#t=240 To 4:55 Identify
interviewer techniques
- Slide 56
- Brief Intervention Diabetes
https://www.youtube.com/watch?feature=player_detailpag
e&v=_KNIPGV7Xyg#t=405
https://www.youtube.com/watch?feature=player_detailpag
e&v=_KNIPGV7Xyg#t=405 To 9:33 Record patient statements that
are motivational opportunities to foster change Record provider
responses to the opportunities 29 November 2013 10:30 - 12:00
- Slide 57
- An Overview 29 November 2013 10:30 - 12:00
https://www.youtube.com/watch?v=dm-
rJJPCuTE&feature=player_detailpage#t=40
https://www.youtube.com/watch?v=dm-
rJJPCuTE&feature=player_detailpage#t=40 Record patient
statements that are motivational opportunities to foster change
Record provider responses to the opportunities
- Slide 58
- Critique the following 29 November 2013 10:30 - 12:00 Using
what you now know critique the following encounter Record provider
statements/responses that could be improved Write an improved
response We will ask volunteers to share their critiques
https://www.youtube.com/watch?v=mu0-
TnfRNHQ&feature=player_detailpage
https://www.youtube.com/watch?v=mu0-
TnfRNHQ&feature=player_detailpage
- Slide 59
- SMART Goals specific, measurable, achievable, realistic timely
29 November 2013 10:30 - 12:00
- Slide 60
- Orchestrated Success Initial tasks selected by patient should
be certain to be achieved Success promotes repetition and growth of
motivation Failure promotes cessation and shrinkage of motivation
Feelings of competence increase motivation slowly Feeling
incompetent decreases motivation quickly 29 November 2013 10:30 -
12:00
- Slide 61
- Foster Feelings of Competence Guide patients towards SMALL
objectives that are EASY to accomplish Orchestrated Success 29
November 2013 10:30 - 12:00
- Slide 62
- Scaling questions https://www.youtube.com/watch?v=dm-
rJJPCuTE&feature=player_detailpage#t=177
https://www.youtube.com/watch?v=dm-
rJJPCuTE&feature=player_detailpage#t=177 29 November 2013 10:30
- 12:00
- Slide 63
- Scaling questions 29 November 2013 10:30 - 12:00 On a scale of
0 -10: 1. How important is it to you to achieve X (e.g. Lose
weight, improve blood sugars, etc.,)? 2. How confident are you that
you can do X (e.g., take your metformin consistently)?
- Slide 64
- Scaling questions 29 November 2013 10:30 - 12:00 Working with
the numbers 1. Why are you not a 0? 2. What would make it possible
for you to increase from X to X+Y?
- Slide 65
- Signs My Technique Needs Help The discussion feels
confrontational I am feeling frustrated The client is not engaged I
am doing all of the talking I am not confident the client is being
honest in their communications I feel like I am doing all the work
29 November 2013 10:30 - 12:00
- Slide 66
- Techniques For the Silent Patient 29 November 2013 10:30 -
12:00 The next 2 techniques can be used to facilitate change
related discussions in patients that are Not spontaneous in
communicating Generally not articulate
- Slide 67
- Decisional Balance ProsCons Change Status Quo 29 November 2013
10:30 - 12:00
- Slide 68
- About Taking My Medication Things I likeThings I dont like
Assist patient in thinking Chart is updated over visits as the norm
is for the issues to emerge over time as the client becomes more
engaged in the process. 29 November 2013 10:30 - 12:00
- Slide 69
- Stepped Approach Application to Office Practice 29 November
2013 10:30 - 12:00
- Slide 70
- Step 1 Informed Consent 29 November 2013 10:30 - 12:00 Describe
Risks and Benefits of Proposed Intervention Describe Risks and
Benefits of Status Quo Elicit Misinformation patient has heard or
read or derived Provide above in written form for patient to take
home Standard patient information sheets or documents are
sufficient Tips: Monitor yourself to ensure use of non-judgemental
language Answer all questions If time is short do not rush instead
book another visit
- Slide 71
- Step 2 Ensure Informed Patient 29 November 2013 10:30 - 12:00
Guide the patient in demonstration of understanding Ask patient to
describe personal understanding of Risks and Benefits of Proposed
Intervention Ask patient to describe Risks and Benefits of Status
Quo While the patient is doing so make note of misunderstandings
that will require factual correction After the patient is finished
review misunderstandings with patient and correct factual errors
Ask patient about any related concerns
- Slide 72
- Step 3 Ensure Informed Patient 29 November 2013 10:30 - 12:00
Guide the patient in demonstration of understanding Ask patient to
describe personal understanding of Risks and Benefits of Proposed
Intervention Ask patient to describe Risks and Benefits of Status
Quo While the patient is doing so make note of misunderstandings
that will require factual correction After the patient is finished
review misunderstandings with patient and correct factual errors
Ask patient about any related concerns
- Slide 73
- Step 4 Elicit Ambivalence 29 November 2013 10:30 - 12:00 Elicit
Ambivalence to Change Identify during open ended questions
Decisional Matrix Likes vs. Dislikes table
- Slide 74
- Step 5 Foster Motivation 29 November 2013 10:30 - 12:00 Elicit
Ambivalence to Change Reinforce current behaviour that approached
target Scaling Questions Guide the patient to develop SMART
goals
- Slide 75
- Final Discussion 29 November 2013 10:30 - 12:00