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Motivational Interviewing Deborah L. Drew, Ed. D., LCPC and Evan Williams, PharmD Husson University HICHEP Presentation August 24, 2013

Motivational Interviewing

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Motivational Interviewing. Deborah L. Drew, Ed. D., LCPC and Evan Williams, PharmD Husson University HICHEP Presentation August 24, 2013. Agenda. Welcome and Introductions Hour 1: What is Motivational Interviewing? Hour 2: Components of Motivational Interviewing - PowerPoint PPT Presentation

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Motivational Interviewing

Motivational Interviewing

Deborah L. Drew, Ed. D., LCPC and Evan Williams, PharmDHusson UniversityHICHEP PresentationAugust 24, 2013Welcome and IntroductionsHour 1: What is Motivational Interviewing?Hour 2: Components of Motivational InterviewingHour 3: Tools and PracticeHour 4: Action Plan: Implementing Change inYour PracticeSummary and Evaluations

2Agenda3Welcome and IntroductionsDeb3Hour 1:

What is Motivational Interviewing?Clinicians can only provide patients with clinical knowledge and education

Patients make the ultimate decision to change

What can clinicians do to influence patient change?Scare tacticsLecture and educateMotivate the patient to changeOverview5Evan5Describe the development and evidence for the use of motivational interviewing

Implement components of the model for motivational interviewing

Develop an action plan to implement the elements and principles of motivational interviewing in practiceObjectives6Evan6Think of a bad habit you have tried to changeDietary habitsExercise habitsWorkplace habitsRelationship habitsHow long did it take to realize that this habit had a negative impact on you or others?Months? Years?Were you successful? Did you relapse? 7Self ReflectionDeb7Think about patients who have difficulty making change8Reflection on Your PracticeDeb8

Maslows Hierarchy of NeedsDeb910Stages of ChangePrecontemplation No intention of changing their behavior for the foreseeable futureNot thinking about changing their behaviorMay not see the behavior as a problemContemplation Aware a problem exists Seriously considers actionNot yet made a commitment to an actionPreparation Intent upon taking action soon Often report some steps in that directionAction Aware a problem exists Actively modifies their behavior, experiences and environment in order to overcome the problem Commitment is clear Great deal of effort to changeMaintenance Sustained change New pattern of behavior has replaced the oldBehavior is firmly established Threat of relapse becomes less intenseProchaska, J. O., & DiClemente, C. C.

Deb10Stages of Change

Deb11Motivational Interviewing (MI) is a collaborative, personcentered form of guiding to elicit and strengthen motivation for change.

Defined by the identification, examination, and resolution of ambivalence about changing behaviorAmbivalence: Feeling two ways about behavior changeDefining Motivational Interviewing12http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfhttp://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

12Method of communicationNot a techniqueIncreases mutual understanding

CollaborativeHonors patient autonomy

Strengthens a persons own motivation for and commitment to change Patient-centeredPrinciples of MI13http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfEvan

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

13William R. MillerMotivational Interviewing with Problem DrinkersBehavioral Psychotherapy - 1983 Stephen Rollnick and William R. Miller1991 articleOutlines clinical proceduresHas been revised and applied to many settingsDevelopment Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy. 1983, 11 (2); pp 147-17214Deb14Growing body of evidence6 references 1980-198978 references 1990-1999707 references 2000-2009Most studies show MI to be beneficialPublication bias?Most studies have limitationsSmall sample sizeWeak comparator groupsVarious providers offering MIProviders have differing levels of training in MIDifficult to assess the manner in which MI is usedEffectiveness of MI15Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan15Pattern of results show MI is likely To confer at least a 10% advantage in success rates versus weak comparatorsTo be as good or better than established treatments To take less time and resources

Best outcomes may be using MI pre-treatmentMI Meta Analyses16Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan

Integrate with other treatment strategies

Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312

16Effective regardless of gender or age

Training level does not significantly impact effectivenessVersatile

In what areas is MI most effective?17MI Meta AnalysesLundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan1718MI Meta Analyses

Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan1819MI Meta Analyses Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

Evan19

MI Meta Analyses 20Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312Evan20Limitations Interventions ranged from 10-120 min (60 min most common)Variable follow up periods

UsefulnessProvides evidence that MI can elicit significant change Overall about 75% of studies show there was an effectMI Meta Analyses 21Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312Evan

Such heterogeneity can introduce skewedness where the longer intervention studies significantly more effective and changing overall results?2122Hour 2:

Components of MIKey Elements of MICollaborationEvocationAutonomy

Principles of MIExpress EmpathySupport Self EfficacyDevelop DiscrepancyRoll with Resistance

Components of MI23http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

Key Elements realized through principles of MI23CollaborationDismisses hierarchy

Builds rapport

Non-confrontational

Focus is mutual understandingKey Elements of MI24http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

This does not mean that the therapist automatically agrees with the client about the nature of the problem or the changes that may be most appropriate. Although they may see things differently, the therapeutic process is focused on mutual understanding, not the therapist being right.

24RG is a 57 year old male with hypertension and hyperlipidemia. On questioning it is revealed that he smokes about 1 pack of cigarettes daily. You would like him to quit smoking.

Example of Collaboration25Together

Which of the following shows the spirit of collaboration consistent with MI?A. You need to stop smoking now.B. What reasons do you have to stop smoking?C. If you continue to smoke, you are increasing your risk for having a heart attack or stroke.D. Let me help you to stop smoking.

Answer: B allows pt to reflect on his own reasons to quit. The other answers attempt to pressure the pt or in the case of D, violate his autonomy.

25EvocationPatients discover their own motivation and skills for change

Draw out the patients own thoughts and ideas

..lasting change is more likely to occur when the client discovers their own reasons and determination to changeKey Elements of MI26http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfEvan

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf26Pharmacist: Ive noticed you have been late filling these medications the last 2 months.

Patient: Yeah, Ive been having a hard time keeping up with things as I am moving to a new home across town in a few weeks. I know taking my medications is important but Ive been so busy lately that I forget sometimes.

Pharmacist: It sounds like you would like to take your medications but it has been a tough time dealing with the move.Example of Evocation27Evan Pharmacist; Deb - Patient

The final response allows the patient to elaborate on how he feels and possibly consider some of the reasons and motivation he has to change. 27AutonomyUltimately it is the patients decision to change

Empowers the patient and gives them responsibility

As clinicians, we can encourage patients to develop their own SMART goalsSpecific, Measurable, Achievable, Relevant, TimelyKey Elements of MI28http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

SpecificMeasurableAttainable/AchievableRelevant Timeframe

28DK is a 44 year old patient newly diagnosed with diabetes. After discussion, it is revealed that he eats desserts for relaxation. When asked how he thinks this impacts his diabetes, he states he does not know.

Example of Autonomy 29Together

The response that best exemplifies autonomy consistent with MI is:A. May I tell you some information about how sweet foods impact your blood sugars?B. Sugary dessert foods increase your blood sugar and negatively impact your diabetes.C. Here is a pamphlet about how foods impact blood sugar.

Answer: A- asking permission preserves pt autonomy compared to being lectured (B) or using a non-conversational technique ( C )29Express EmpathySee the situation from the patients perspectiveGain perspective on what the patients motivation may beIt sounds like this has been tough for youIt seems like this situation has been difficult for you to acceptPrinciples of MI30http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfEvan

Reflective responses allow for the patient to elaborate while allowing the clinician to express concern and empathy to the patient. 30Support Self Efficacy

Focus on strengths and skills patient already has

Highlight previous successes

Patient needs to believe that change is possible Principles of MI http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf31Evan31Develop DiscrepancyPatients identify their values and goalsPatients evaluate their current behaviorsAmbivalence is discovered when conflict between values/goals and behaviors is identifiedChange is more likely when patients realize their behaviors are in conflict with their selfidentified values or accomplishment of goals

On the one side, you feel unhappy that you cannot keep up with your grandkids because of your COPD, but on the other hand, you feel that smoking is one of the only ways you can relax.Principles of MI32http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfEvan32Roll with ResistanceDo not challenge resistant statementsConfronting resistance promotes defensiveness and diminishes the likelihood of a patient finding their own reasons to changeUse the resistance as an opportunity to further explore the patients viewsBe aware of when a patient is becoming frustratedClosed body languageNegative verbal responsesShortened verbal responsesPrinciples of MI 33http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb33BG is an overweight veteran recently discharged from the Air Force. He has gained much of this weight since his discharge 14 months ago. The clinician suggested that BG enroll in clinic sponsored program for weight loss. BG declines enrollment. BG states that he is just not willing to exercise for 30 minutes 5 days a week because he is just too exhausted after work.

Example of Rolling with Resistance34Which response best exemplifies the spirit of MI? A. If you dont lose weight, you are putting yourself at risk for other serious problems.B. Could you try to exercise just a few days a week?C. How much are you willing to exercise?D. Why dont you want to be healthy?

Answer: C- this allows patient to reconsider his own goals and motivation, as how much he exercises is his decision. Bargaining (B), trying to scare the patient (A), or directly arguing with the patient is not constructive and does not exemplify rolling with resistance. 3435Hour 3:

Tools and PracticeOARSOpen-Ended QuestionsAffirmationsReflective ResponsesSummaries

RULES of Motivational InterviewingResist the righting reflexUnderstand the patients motivationListen with empathyEmpower the patientTools to Help Implement MIBrief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov 36Evan

Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

36Elicit better responses from patientsMake a conversation less one-sidedAre not answerable with a simple yes or noOpen-Ended QuestionsOpen-Ended Question WordsClosed-Ended Question WordsHow?Why?Tell me more about...When?What kinds ofDo you?Have you?Can you?Will you?Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov 37Evan37

Try it Out Open Ended Questions

Deb

In pairs, talk about the change you wished to make. Practice using open ended questions to explore thoughts about the change.38Statements that recognize a patients strengths

Help support self efficacyTries to help patient believe change is possible despite past failures

Affirmations39http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb39Reflective ResponsesRestate how the provider perceives the patientAllows for increased clarityAllows the listener to affirm the patients feelingsPatient feels understoodBrief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov 40Evan

Reference: TMS bit

Builds rapport

Helps prevent my doctor wont listen to me!40

Try it Out Affirmations and Reflections

In pairs talk about the change. Practice affirming and reflecting.41Reflection that recaps visit and highlights important areas

Can clarify ambivalence and discrepancies Summaries42http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb42

Try it Out Summaries

In pairs, practice summarizing what you have heard.4344Communication:The art of really listening Its Not About the Nail - Dhttp://counselingvideos.blogspot.com/2013/06/its-not-about-nail.html

I know what is bestRemoves autonomy from the patient by insinuating the patient does not know what is best for themselvesRe-establishes hierarchyCan undermine the patients motivation for changeCan create conflictResist the righting reflexBrief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov 46Evan

Of course useful in emergencies.Patient needs to rely on self, not clinician46Patients reason for change is more important than the clinicians

Explore importance of changingAsk for a scaled answerWhy is it that number and not another? Understand patients motivationBrief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

47Deb

Reference TMS Often the clinicians and patients reasons will be different.

47Scaling Questions On a scale from zero to ten how important is it for you to?Tell me why you chose that number?What could happen that would move you to higher number?On a scale from zero to 10, how confident are you that you can make this change?Tell me more why you chose that number for your confidence level?What do you think might help become more confident in making a change?

Deb48Use reflective responses Allows patient to tell you moreClarifies patients concernsConfirms mutual understanding

Be aware of body languageEye ContactNoddingPosture

Do not understandListening with empathyBrief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov 49Evan

Reference: TMS, PSAP

Staring at computer screen chartingFolded armsStaring at clock

Clinicians will not understand dont patronize patient with this phrase49S-sit squarelyO-open postureL-lean forwardE-eye contactR-relax50SOLER(Egan, 2010) D&EDeb and Evan Demonstrate50Patients must believe change is possible

Failures can be demoralizing

Focus on previous successesEven small victories can be uplifting

Encourage the patient

Let the patient know that they are in control of the changeEmpower the patientBrief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov 51Deb

Reference TMS

Thank the patient for talking to you about thisHow confident of change are you? Why that number?Ask permission to share information

51Think again about those patients you identified earlier who are resisting change52Your Practice Revisited Deb52Example #1

53

Roll with ResistanceAffirmationOpen Ended QuestionCollaborationRespected patients autonomyReflective ResponseListening with EmpathyCollaborationOpen Ended QuestionElaborationListening with Empathy

Autonomy respected by asking permission.

Discrepancy developed between family and smoking and risk of heart attack through use of open ended questioning and reflective responses need and reason for change elicited

Ability clarified with prior use of patches, committed to change for values that are from within the patient (family), pt actively taking steps to begin treatment to make change

53What went right?

How well did the pharmacist do using reflective responses?

What could the pharmacist have done to improve?

Discussion of Example #154Autonomy respected by asking permission.

Pt confrontational provider rolled with resistance, allowed pt to state their piece, resisted righting reflex

Respected pts autonomy. Asked for permission.

54

Try it Out

In pairs, practice motivational interviewing with all the steps including scaling. Use SOLER.5556Hour 4 Implementing Change in Your PracticeDARN-CATDesire (I want to change)Ability (I can change)Reason (It is important to change)Need (I need to change)Commitment (I will make changes)Activation (Im ready and prepared to change)Taking steps (I am doing specific things to change)Eliciting Change Talk57http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfEvan57Ask questions that will elicit answers that are consistent with DARN-CATDeveloping discrepancyDesireReasonNeedChange rulerAbilityActivationSMART Goal SettingAbilityActivationTaking stepsChange Talk58Evan58

Change Talk Disadvantages of Status Quo

What concerns you about your current situation?What makes you think you need to do something about your weight?What concerns you about not checking your blood glucose on a regular basis?What do you think might happen if you dont change your diet?

Deb59Change Talk Advantages of Change

How would life be different for you if?If you could wake up tomorrow and things changed by magic, how would things be better for you?What are the main reasons you see for ..?What would be the benefits of for you?

Deb60Explore Goals and ValuesYou mentioned how important it is for you to be able to play with your grandchildren and how your current weight interferes with that

You said you would really like to be able to hike with your friends on vacation and how your current energy level keeps you from doing that

Deb61Change Talk Expressing OptimismWhat do you think would work if you decided to change?How confident are you that you can make this change?What kind of support would be helpful in making this change?What encourages you to change if you want to do it?

Deb62Change Talk Intention to Change D I can see you are feeling stuck right now. What is going to have to change?How important is it for you to .?What do you intend to do?What do you think you might be able to do?

http://www.youtube.com/watch?v=sWc0g2K9LAI

64A Taste of MIDeb64

Try it Out

Apply the model in Pairs eliciting change talk.65Online resources or live classes

Begin smallTry only adding one component at a timeReflective responses are a great starting point

Keep working at itIt may feel uncomfortable the first few times

Add components as you become more adeptApplication Strategies66Evan

What techniques do you think you could start with?How do you anticipate applying this to your setting?What successes have you had in the past?What barriers do you anticipate?Can I share some strategies I think may be helpful?

Reflective responses builds rapport, lets the pt know you are listening

Driving is uncomfortable the first time, giving presentations you begin to get a comfort with what you know66MI is a useful technique to help people change

It is useful in combination with other techniques for eliciting change

MI should not replace your method of patient interaction, but enhance itConclusions67Evan67Motivational interviewing is a collaborative, personcentered form of guiding to elicit and strengthen motivation for change.

Key ElementsCollaborationEvocationAutonomySummary68Evan68Principles Express EmpathySupport Self EfficacyDevelop DiscrepancyRoll with ResistanceSummary69Strategies for implementation OARSOpen-Ended QuestionsAffirmationsReflective ResponsesSummaries RULEResist the righting reflexUnderstand the patients motivationListen with empathyEmpower the patientSummary70Group by profession.Discuss how you would implement MI in your work setting.71Group Summary and ApplicationQuestions?

7272Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare. 2008 14:48Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov Burke B, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology 2003; 71, 843-861(Egan, 2010) D&EHettema J, Steele J, Miller W. Motivational Interviewing. Annual Review of Clinical Psychology 2005; 91-111http://counselingvideos.blogspot.com/2013/06/its-not-about-nail.htmlhttp://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfhttp://www.youtube.com/watch?v=sWc0g2K9LAI Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Lundahl B, Tollefson D, Kunz C et al. Meta analysis of motivational interviewing: twenty five years of research. Research on Social Work Practice 2009Maslows Hierarchy en.wikipedia.org Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983; 11(2),147-172Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, 2nd Ed. New York: Guilford Press. Prochaska, J. O., & DiClemente, C. C.Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice 2005; April, 305-312Vasilaki E, Hosier S, Cox W. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta analytic review. Alcohol and Alcoholism 2006; 41, 328-35

73References