Motivating Patients to Make Change

Ann Landes, Ph.D.alandes@zoho.com

Disclosure of Financial Relationships

This speaker has no significant financial relationships with commercial entities to disclose.

This slide set has been peer-reviewed to ensure that there areno conflicts of interest represented in the presentation.

Objectives

1. Introduce the model of Motivational Interviewing (MI)

2. Provide an overview of the concept of "Stages of

Change" and its application to patient self-management

3. Explain how MI can be employed by medical providers to

encourage collaboration between the patient and the

medical provider, as they work toward positive behavior

change and improved quality-of-life

SUPPORT FOR

MOTIVATIONAL INTERVIEWING

Hettema, Steele, and Miller (2005)

• Found significant support for the efficacy of MI across 75 randomized controlled trials (RCTs).

• Adding MI to the beginning of treatment led to sustained outcome improvements.

• Outcomes were better when no manual was used.

*(e.g., focus more on the alliance/relationship between provider and patient)

Applications• Alcohol abuse • HIV risk reduction • Illicit drug use• Smoking • Treatment adherence• Diet/exercise• Gambling• Intimate relationships• Eating disorders• Water purification to promote health

Beach, Keruly, & Moore, 2005; Schneider, et al., 2004

Patient-Centered Communication from Provider

Effective Patient-Physician Relationship & Communications

=

Greater patient satisfaction in medical care

Greater improvements in general medical condition

Increased adherence to medical treatments

WHAT IS MI?

Motivational Interviewing is a…

• method that has been found to be successful in increasing intrinsic motivation to change by exploring and resolving ambivalence

• collaborative effort between the provider and patient

(Miller & Rollnick, 2002)

Motivational Interviewing …

• helps patients identify and address roadblocks to change (i.e., fears, lack of skills/information, needed supports, etc.)

• focuses on the way we as providers can inspire positive change in the lives of patients

(Miller & Rollnick, 2002)

The Spirit of MI Autonomy

Focusing on patient choice

Asking “permission” to provide assistance , info.

CollaborationComing along side;

nonjudgmental

Viewing the patient as the “expert”

EvocationExploring what motivates the

patient

Making no assumptions

Appreciation of

Ambivalence

Notes about Ambivalence• When an individual feels two ways about

something

• Normal to the process of change

Trap

If we argue for change, the patient may argue for the status quo, leading to decreased

likelihood for change.

Motivational Interviewing is a method that …

1. works to create collaboration between the provider and the patient

2. focuses on patient choice/autonomy

3. sees ambivalence as pathological

4. Answers “1” and “2”

5. None of the above

The Individual and Change

Patients with HIV/AIDs and Change

• Adherence to current medication schedule

• Maintaining regular medical appointments

• Making healthy choices about use of alcohol, tobacco, illicit drugs

• Attending to self-care needs, such as diet and exercise

• Practice consistent precautionary behaviors to reduce

transmission (prevention)

• Enlisting social support(s)

Prochaska and DiClemente’s Stages of Change Model

Pre-contemplatio

nContemplatio

n Preparation Action Maintenance Relapse

Pre-contemplation• “I see no problem(s) to address at this time.”

• “I know there’s a need for change, but I don’t want to right now.”

(… has not given much thought to change)

Provider Role

Bring awareness to the issue Encourage engagement of the patient

Tell-Tale Signs – “I’m not ready” Argues/disagrees with the provider’s

diagnosis or suggestions

Resists offers of assistance

Expresses denial of problems/concerns

Communicates a sense of hopelessness about the situation

Contemplation• “Yeah, I’ve thought about my health needs, but I’m

just not ready yet to change.” (ambivalence)

Provider Role

Increase awareness about the options for and benefits of change

* Keep the patient thinking about positive change.

Preparation/Determination• “OK, I’m prepared to make some changes, but, I’m

not really sure I can or know how to do it.”

Provider Role

Decrease barriers to change by providing resources, information & offering assistance

Address issues of self-efficacy

Action/Will Power• “I know I need to make some changes; I have had to

make changes before and did it.”

Provider Role

Encourage movement byhelping to develop realistic goals and a plan-of-action

Offer resources and support

Maintenance• “Wow! I have made some impressive changes! How

can I continue on this path?”

Provider Role

Help maintain positive focus and

reduce opportunities for relapse

Relapse• “I was doing really well, I thought, but then I got tired of

having to focus so much energy on caring for my health. So, I just quit.”

Provider Role

Normalize that relapse is “OK” (reduce shame)Encourage honest discussion about what led to relapse

Assist in re-exploration of personal goalsHelp develop strategies for re-engagement

Tips To Remember

It is not about us.

Responsibility lies with the individual patient and what they feel they need in their life.

Our role is to be active, caring observers who are present to help the patient.

Because individual behaviors can change over time, we need to remain vigilant about checking-in at

each encounter (Metsch, et al., 2004).

INSTRUMENTS OF CHANGE

The Health Care Provider&

Motivational Interviewing

Provider Stance

Guiding or coaching (versus directing) and supporting

Respecting individual autonomy & empowerment

Expressing belief in the patient’s ability to make decisions

Resisting the reflex to make it “right” or to label actions as “good versus bad”

Four Processes of MI 1. Engaging: listening to understand – “OARS”

2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, offering information and advice

3. Evoking: selective eliciting, responding, summaries toward change talk

4. Planning: moving toward commitment and change

Change Speak – DARN-C

Desire: I want to get healthier.

Ability: I can do this if I set my mind to it.

Reasons: My heavy drinking is causing me many health problems.

Need: My family worries about me too much; it is not fair to them.

Commitment: I will start getting more regular health check-ups.

Engaging: Building a therapeutic allianceStep 1

OARSOpen ended questions

AffirmationsReflective Listening

Summaries

http://motivationalinterview.org/clinical/interaction.htmlwww.mpaetc.org/downloads/motiv_interv_09.pdf

O-A-R-SOpen ended questions to elicit change talk:

• “What are some of your reasons for decreasing your

alcohol intake?” (desire)

• “How might you go about decreasing your drug usage?”

(ability)

• “What do you see as some benefits to lowering your

alcohol usage?” (reasons)

O-A-R-SOpen ended questions to elicit change talk:

• “How important is it for you to decrease your usage?” (need)

• “What might you do to start reducing your alcohol consumption?” (commitment)

O-A-R-SAffirmations:

• Use to encourage people to see their “resources”

• Make them personal and genuine

• Explore partial successes and attempts and intentions

• Highlight patient attributes, effort

“I’m really glad you decided to come in to see me today.”

O-A-R-SReflective Listening (paraphrasing pt comments):

“It sounds as if you are a bit concerned about how to make healthier choices in your life.”

Summaries (restating patient’s main points):

“Let me make sure I heard you correctly. You do want to address your drug usage and you want information about how to take more precautions in your sex life.”

O.A.R.S. is an acronym for the skills that can be used to engage patients in treatment; it stands for

1. O-offer assistance; A-ask questions; R-refer out; S-summarize

2. O-operationalize; A-attend; R-request tests; S-start goals

3. O-open ended questions; A-affirmations; R-reflective listening; S-summaries

4. O-open up discussion; A-attend to; R-reflect; S-shorten session

Focusing: Target one areastep 2

• Identify a strategic focus (agenda setting)

• Explore patient’s motivation, while listening for change talk

• Offer and share information - ask permission, Elicit-Provide-Elicit

Example• Target behavior: use of condoms• Agenda setting: “Hello, Sandy, it’s nice to see you. The

last time we met, we spoke about your goal to begin using condoms more regularly. I’d like to start with that topic, unless you have something more pressing to discuss.”

• Sandy: “I didn’t do too well - I do want to do better.”• Possible Reflections:

• “You found it more difficult than you thought.”• “You’re still committed to change and you found it

challenging.”

Example (cont.)• Sandy: “My partner doesn’t like using condoms. He won’t

even talk to me about it.”• Reflections:

• “It’s been difficult to make the change, especially since your partner doesn’t agree with the change.”

• Sandy: “Yeah, I guess; I don’t really see the need either, since I am monogamous.”

• Reflections: • “You have questions about the importance of using

condoms, since you are having sex with just your partner.

(cont.)• Sandy: “Yeah, it’s such a big change; I’m not sure it’s worth it.”• Reflection:

• “You feel a bit unprepared for making this change and uncertain about whether using condoms is what you want to do.”

• Sandy: “Yeah. I do and I don’t’ want to make the change.”• Reflection:

• “You have some motivation to change. We can work on this together. I have some ideas and information. Can I share them with you?”

• Sandy: “Okay.”

Conversation continues• Transitional Summary: “Alright, if I can summarize

what we have spoken about: You are confused about the reasons for using a condom, it’s been difficult to make the change since your partner does not agree with it, and you feel unprepared. So, you would like more information and some ideas that may work for you.”

• Key Question: “Where do you want to begin – with information about condom use, ways to make the change, or how to approach your partner?” (autonomy)

“Elicit, Provide, Elicit” (information sharing process)

• ELICIT readiness and interest• “What do you know about the effects of …”• “What concerns do you have about…?”

• PROVIDE clear information or feedback• “What happens to some people is that…”• “The results of your tests suggest that…”• “As your doctor/counselor/nurse, I strongly urge you to…”

• ELICIT the interpretation or reaction• “What do you think?”• “How do you think you might…?”

Evoking – pulling for change talkstep 3

• Encouraging, nurturing, reinforcing change talk

• Guiding towards change – finding alignment (and discrepancy) between current behavior and goals and values

• Rolling with resistance• Summarizing where you are

Approaches for Evoking Change Talk

Ruler for importanceQuerying extremesGoals and Values

Typical day Looking forward

Coming alongside

Importance Ruler “On a scale of 0 to 10, how important is it to you to

_________?”

“What is the reason it’s (x) and not (a lower number)?”

(If number is less than 8), “What would it take to move it up in importance just one number?”

{Listen, reflect}

…“What do you think you might do next?”

Querying Extremes

“What are the worst things that could happen if you don’t make this change?”

“What’s the best thing that could happen if you make this change?”

Goals and Values“Let’s, for a moment, move away from this ____ issue

and focus on the things that are most important to you, your life dreams, goals, and values. Tell me the most important areas for you.”

Listen, then say: “So being here, healthy, is important. How does your (behavior) fit in with that?”

• Relate to values, bigger issues. May be useful to prompt or have visual aides that reflect common values and goals (family, work, country, spirituality, community)

(Miller and C’deBaca, 2001)

Rolling with Resistanceo Affirm and accept patient’s fears, concerns:

“I can understand your worries about the side effects of all you medications. Let’s spend some time discussing this.”

o Reflect other’s concerns:“I hear you saying that you don’t care about maintaining a healthy diet; but, how does this impact your partner?”

o Reframing patient concerns to positive movement “So what you’re saying is that you desire to quit smoking and

(instead of BUT) you realize this may be hard to do.”

o Offer assistance “How can I help you move towards making positive change? What

is needed?”

Assessment and Planningstep 4

• Summarizing where the patient is with regard to making change

• Developing a goal and action plan

• Exploring, building patient’s confidence/self-efficacy (affirmations)

• Addressing real and perceived barriers, challenges

• Scheduling follow-up

Assess Stage of Change

“How confident/ready are you in making changes to your lifestyle?”

“How do you feel about the requirements of maintaining your health?”

“ What do you hope with regard to your health diagnosis for the future?”

“What concerns do you have about your risk-reduction practices?”

Pre-contemplationListen and help address any patient concerns“It sounds as if you want to reduce your alcohol intake, but your partner

does not want to change his/her lifestyle. Maybe we can brainstorm ways that you can address this with your partner.”

Encourage information sharing from patient“What is your opinion or belief about using condoms?”

“Tell me how you have been able to manage your medication

requirements.”

Express interest and empathy “The decisions you have to make are very difficult. I know you can make

the decision on your own, but I would like to assist you in learning more about your options.”

Planning for Change (Contemplation Stage)

Attend to ambivalence“I hear that part of you wants to make some positive changes, but a

part of you is also hesitant.” – reflect intention

Foster Self-efficacy and Autonomy• Elicit current knowledge: “What do you know about __?”

• Provide information: “If I may, let me provide some information.”

• Elicit Pt reaction: “What are your reactions to this information?”

• “Ultimately, it is your decision to make about ___.”

Movement Towards Change (Preparation and Action)

“What do you think would be a ‘do-able’ first step towards your goal that you can do today?”

“What do you plan to do between now and next week?”

“ When do you think you will be able to start?”

“What strategies have you employed in the past to achieve goals?”

“What will we be looking for that indicates success?”

Addressing Barriers to Change & Enlisting Support

“What can I do to assist you?”

“Can I provide you some resources?”

“Who can you ask to be a support for you during this time?”

Maintaining Positive ChangeNormalize any possible set-backs (reduce shame)

“It’s OK if you don’t always meet your goals of ___”.

Help patient develop a plan to ensure success

“What other things can you do to encourage your progress

towards ____.”

“What might be some barriers or temptations that hinder you?”

Provide Continued Support

“I would you like to meet again to check-in and see how you are

doing. How does that sound?”

When Relapse Happens

Normalize relapse “Relapsing is a normal part of any change process.”

Assist patient in remaining engaged“I believe you are quite capable of continuing on toward your

goals – you did it before and you can do it again!”

“What lessons can be learned from this relapse to help you remain focused on ___. What might you do differently?”

“Where do you think we should go from here?”

Case Study H.A., a 42-year-old, Caucasian, divorced male is

referred to your care after he was found to be HIV-seropositive. H.A. is currently unemployed and homeless and though he has a long history of abusing drugs and alcohol he states that he is trying to “get clean”. H.A. states that he is really concerned about his deteriorating physical and mental health. When asked about social supports, HA replies that he has a brother and a sister who live close by. He adds that he also receives great support from his case manager, a social worker at the community-based recovery program for homeless persons with addictions.

What is the patient’s stage of change and how would you nurture his change talk?

1. Precontemplation Stage; provider would express empathy and encourage info. sharing

2. Contemplation Stage; provider would attend to patient’s ambivalence and foster his self-efficacy and autonomy

3. Preparation Stage; provider would help patient set goals and develop action plan

4. Maintenance Stage; provider would normalize relapse

Remind yourself that even if the patient does not choose to change, the intervention is not a failure.

Any discussion or talk about change is planting a seed.

ReferencesBeach, M., Keruly, J., & Moore, R. D. (2005). Is the quality of the

patient-provider relationship associated with better adherence and health outcomes for patients with HIV? Journal of General Internal Medicine, 21, 661.

Metsch, L. R, Pereyra, M., del Rio, C., Gardner, L., Duffus, W. A., Dickinson, G., et al. (2004). Delivery of HIV prevention counseling by physicians at HIV medical care settings in 4 US cities. American Journal of Public Health, 94(7), 1186.

Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York: Guilford.

References

Miller, W. R., & C’deBaca, J. (2001). Quantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives. New York: Guilford Press.

Schneider, J., Kaplan, S. H., Greenfield, S., Li, W., & Wilson, I. B. (2004). Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. Journal of General Internal Medicine, 19, 1096.

ReferencesCook, P. F., Bradley-Springer, L., & Corwin, M. A. (2009, August).

Motivational interviewing and HIV: Reducing risk, inspiring change. Retrieved July 2, 2010, from www.mpaetc.org/downloads/motiv_interv_09.pdf

Motivational interviewing [resources for clinicians, researchers, and trainers.](n.d.) Retrieved July 2, 2010, from http://motivationalinterview.org/clinical/interaction.html

Family Health International. (2007). Nursing care of patients with HIV/AIDS. Retrieved August 19, 2010, from http://www.fhi.org/NR/rdonlyres/erwyyfde6xm6oxea3vg46q5fpg7lottczgkru5ymvykflcipkasb3jkqkfomo3ybedwpeis5z6sxlp/NursesCarePatientsParticipantsGuideHV.pdf

Questions?• Contac• Office: 352-376-1611 (x-4745)

Disclosure of Financial Relationships

This speaker has no significant financial relationships with commercial entities to disclose.

This slide set has been peer-reviewed to ensure that there areno conflicts of interest represented in the presentation.