Rolling with Resistance: Using the Motivational Interviewing Model to Manage Challenging Patient & Family Behaviors

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Imagine you go to your doctor and find out you are pre-diabetic. What would you be thinking? What might you be wondering about?

Dr: “You are pre-diabetic. You need to exercise more and pay more attention to your diet or you will face dire consequences. ”

Then your doctor leaves.

How would this be helpful? How could this be harmful?

Traditional heath care professional communication focuses on telling patients what to do, imposing an agenda, and then scolding or blaming patients when they don’t do what they are told.

Can you think of situations or typical patients who are labeled as “resistant” or “non-compliant?”

The level of resistance to making a “good” change usually increases when

others try to push for the change.

2 FORMS OF RESISTANCE1. RELATIONAL RESISTANCE: Occurs when a practitioner prescribes behavior

change & create a situation where the patient will likely fail & lose face. 2. ISSUE RESISTANCE: Related to specific issues like medication compliance,

smoking, & caregiving issues.

Ambivalence—to simultaneously want & not want—is a natural part of the human condition. Patients usually feel ambivalent about change, especially if it’s a change that is

“good” for them. Most people are comfortable in their ambivalence. A move in any direction requires effort.

REALITY CHECK ABOUT THE PROCESS OF CHANGEIf information was all that we needed to make “good” changes, we would all be making great lifestyle decisions, & none of use would

be struggling with diet, exercise, or unhealthy behaviors.

Motivational Interviewing honors patient wisdom.

The power of alliance, of curiosity, of open-ended questions.

Free yourself from the mentality of needing to “fix” the patient, & the assumption that we know how to “fix” problems.

Motivational Interviewing! MI is a collaborative conversational

style for strengthening a patient’s own motivation for & commitment to change.

For personal change, nearly everything a person needs is already within themselves.

The Spirit of MI: CAPE

Compassion: Actively promote the patient’s welfare & give priority to their identified needs.Acceptance: The patient is valued as a competent (the expert of their life), with the ability to make their own choices.Partnership: The practitioner avoids an authoritarian or expert stance, promoting a collaborative atmosphere. Evocation: Draw out the patient, elicit their wisdom, reality, & hope, rather than imparting information.

DANCE VERSUS WRESTLE

Case StudyConfrontingPatient: I don’t want to talk about it (a POLST or DNR).Clinician (confronting): If you don’t have a POLST, then EMTs are legally required to take you to the hospital and perform all available interventions to keep you alive.Patient: I don’t feel like talking anymore.

Querying ExtremesPatient: I don’t want to talk about it (a POLST or DNR).Clinician (exploring): I can understand why it might be difficult to discuss. What is the best thing that could happen if we talked about it? And what is the worst thing?Patient: It is hard. The best thing could be making a decision that makes sure that my wishes are followed. The worst is feeling upset because I am thinking about death.

MI Core Skills: OARSOpen-Ended Questions: Ask questions that encourage elaboration. Affirmations: Promote optimism & acknowledge the patient’s expertise & efforts. Reflections: Paraphrase & repeat the content that was expressed explicitly or implicitly. Summaries: Summarize the patients change talk points. The goal is to help the patient organize their experience.

CASE STUDYConfrontingClinician: What have you heard about hospice?Patient: My Aunt was in hospice. It was terrible! All they wanted to do was to give her that morphine. She died two days after she got into hospice, just because they were pushing that morphine on her.Clinician (confronting): Actually, that’s not what hospices are about. They only want to give you medications just to help your pain, not to hasten death.Patient: (angrily): I just know what I saw is all. I’m not going to give up and just go into some hospice.

Rolling with ResistanceClinician: What have you heard about hospice?Patient: My Aunt was in hospice. It was terrible! All they wanted to do was to give her that morphine. She died two days after she got into hospice, just because they were pushing that morphine on her.Clinician (reflection): Your aunt’s experience was not good. You would not want that to happen to you.Patient: Yeah. I want to my pain controlled but I sure don’t want to be drugged up.Clinician (reflection): It’s important to you that you have control & can decide if & how you get medication. I want you to have good pain control too & to help you be awake & enjoying life as long as possible. In my experience, the hospice I work with is pretty good at both those things so it might be different than the one your aunt had experience with. Would it be okay if I tell you a little bit more about it?Patient: Ok.

What Guiding looks like:1. Elicit: Ask permission. Clarify information needs & gaps.2. Provide: Prioritize. Be clear. Support Autonomy. Don’t prescribe the

patient’s response.3. Elicit: Ask for the patient’s interpretation, understanding, or response.

All 3 styles have a place, but guiding is the primary style in MI.

3 Communication Styles• Following: Listening & following the patient’s lead. Helpful at

the beginning for rapport building.• Directing: Take charge & tell the patient what to do from the

role of expert (some cultures expect this from health care).• Guiding: Helps the patient accomplish their own goals.

CHANGE TALK“I know I need help…

SUSTAIN TALK…I want to be independent.”…but…

TYPES OF CHANGE TALK: DARN CATPreparatory Change Talk (DARN)1. Desire: Statements about preference for change. “I want to… I wish…”2. Ability: Statements about capability. “I could… I might be able to…”3. Reasons: Specific arguments for change. “I would probably feel better if

I…This pain keeps me from…”4. Need: Statements about feeling obliged to change. “I ought to… I have

to… I really should…”

Mobilizing Change Talk (CAT)5. Commitment: Statements about likelihood of change. “I will… I plan to…”6. Activation: Statements about specific actions patient will take. “I’m going

to ___ today.”7. Taking Steps: Statements about an action taken. “This week I started…”

Now imagine you go to your doctor’s office and he asks you open-ended questions.

Dr.: “How can I be helpful today?” “How do you feel about your health?” “What tools can I provide you?” “Is it okay if I offer you some information?”

What is helpful about this? What is harmful?

As the patient, how would this conversation feel to you, as opposed to the conversation the doctor had with you earlier?

Research shows that while MI may take a more time at first, it saves time in the long run & improves patient outcomes.

1. MI outperforms traditional advice giving in 75% of studies.

2. Effectiveness was shown in even brief encounters of only 15 minutes.

3. Effect was not related to a practitioner’s educational background.

Source: S. Rubak, A. Sandboek, T. Lauritzen, & B. Christensen. “Motivational Interviewing: A Systematic Review & Meta Analysis” British Journal of General Practice, April 2005.

Motivational Interviewing Works!

HOW TO IMPLEMENT

• Slow down, don’t jump to fix a problem, create the space for the patient to share their experience & then take the situation back to the team.

• Focus on the spirit of MI.

• Build awareness of if you are directing, following, or guiding; strive to guide more.

• Use reflective listening.

• Practice with coworkers.

TROUBLESHOOTING

Monitoring how strongly you feel about patient behavior change is the first step in avoiding difficulties.

•Descending into directing•Persuading too hard•Rescuing the Patient•Just following the pt and getting lost•Overloading patients with information•Pursuing problems and weaknesses aka “policing”

Resist the “Righting Reflex”: The urge to “fix” the patient. Arguing for change can have a paradoxical effect.

“But I can’t let go of responsibility.”

Before we jump to problem solving, we want to elicit where the patient or family is coming from to further build rapport, instead of jeopardizing our relationship with them.

“I don’t have the time!”

Studies show that this technique is actually a time saving and more successful strategy.

“I don’t have counseling training.”

Studies show that MI is just as effective when a social worker, nurse, doctor, physical therapist, or other disciplines utilize the MI tools.

• Berger, B. Motivational Interviewing for Health Care Professionals; American Pharmacists Association, 2013.• Pollak, K, Childers, J, Arnold, R. Applying Motivational Interviewing Techniques to Palliative Care Communication ; Journal of

Palliative Medicine, Vol 14, Number 5, 2011.• Rollnick, S, Miller, W, & Butler, C. Motivational Interviewing in Health Care: Helping Patients Change Behavior ; Guilford Press, 2008.• Rubak, S, Sandboek, A, Lauritzen, T, & Christensen, B. Motivational Interviewing: A Systematic Review & Meta Analysis; British

Journal of General Practice, April 2005.

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