Motivational Interviewing

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

2. Agenda Welcome and Introductions Hour 1: What is Motivational Interviewing? Hour 2: Components of Motivational Interviewing Hour 3: Tools and Practice Hour 4: Action Plan: Implementing Change in Your Practice Summary and Evaluations

3. Welcome and Introductions

4. Hour 1: What is Motivational Interviewing?

5. Overview • 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 tactics • Lecture and educate • Motivate the patient to change

6. Objectives • Describe 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 practice

7. Self Reflection • Think of a “bad”habit you have tried to change • Dietary habits • Exercise habits • Workplace habits • Relationship habits • How 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?

8. Reflection on Your Practice • Think about patients who have difficulty making change

9. Maslow’s Hierarchy of Needs

10. Stages of Change Precontemplation No intention of changing their behavior for the foreseeable future Not thinking about changing their behavior May not see the behavior as a problem Contemplation Aware a problem exists Seriously considers action Not yet made a commitment to an action Preparation Intent upon taking action soon Often report some steps in that direction Action 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 change Maintenance Sustained change New pattern of behavior has replaced the old Behavior is firmly established Threat of relapse becomes less intense Prochaska, J. O., & DiClemente, C. C.

11. Stages of Change

12. Defining Motivational Interviewing • “Motivational Interviewing (MI) is acollaborative, person‐centered form of guiding to elicit and strengthen motivation for change.” • Defined by the identification, examination, and resolution of ambivalence about changing behavior • Ambivalence: Feeling two ways about behavior change http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

13. Principles of MI • Method of communication • Not a technique • Increases mutual understanding • Collaborative • Honors patient autonomy • Strengthens a person’s own motivation for and commitment to change • Patient-centered http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

14. Development • WilliamR. Miller • Motivational Interviewing with Problem Drinkers • Behavioral Psychotherapy - 1983 • Stephen Rollnick and William R. Miller • 1991 article • Outlines clinical procedures • Has been revised and applied to many settings 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 147-172

15. Effectiveness of MI • Growing body of evidence • 6 references 1980-1989 • 78 references 1990-1999 • 707 references 2000-2009 • Most studies show MI to be beneficial • Publication bias? • Most studies have limitations • Small sample size • Weak comparator groups • Various providers offering MI • Providers have differing levels of training in MI • Difficult to assess the manner in which MI is used Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

16. MI Meta Analyses • Pattern of results show MI is likely • To confer at least a 10% advantage in success rates versus weak comparators • To be as good or better than established treatments • To take less time and resources • Best outcomes may be using MI pre-treatment Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

17. MI Meta Analyses • Effective regardless of gender or age • Training level does not significantly impact effectiveness • Versatile • In what areas is MI most effective? Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

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

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

20. MI Meta Analyses 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

21. MI Meta Analyses • Limitations • Interventions ranged from 10-120 min (60 min most common) • Variable follow up periods • Usefulness • Provides evidence that MI can elicit significant change • Overall about 75% of studies show there was an effect Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45 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

22. Hour 2: Components of MI

23. Components of MI • Key Elements of MI • Collaboration • Evocation • Autonomy • Principles of MI • Express Empathy • Support Self Efficacy • Develop Discrepancy • Roll with Resistance • http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

24. Key Elements of MI • Collaboration • Dismisses hierarchy • Builds rapport • Non-confrontational • Focus is mutual understanding http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

25. Example of Collaboration • RG 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.

26. Key Elements of MI • Evocation • Patients 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 change” http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

27. Example of Evocation • Pharmacist: “I’ve noticed you have been late filling these medications the last 2 months.” • Patient: “Yeah, I’ve 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 I’ve 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.”

28. Key Elements of MI • Autonomy • Ultimately it is the patient’s decision to change • Empowers the patient and gives them responsibility • As clinicians, we can encourage patients to develop their own “SMART” goals • Specific, Measurable, Achievable, Relevant, Timely http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

29. Example of Autonomy • DK 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.

30. Principles of MI • Express Empathy • See the situation from the patient’s perspective • Gain perspective on what the patient’s motivation may be • “It sounds like this has been tough for you” • “It seems like this situation has been difficult for you to accept” http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

31. Principles of MI • Support Self Efficacy • Focus onstrengths and skills patient already has • Highlight previous successes • Patient needs to believe that change is possible http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

32. Principles of MI • Develop Discrepancy • Patients identify their values and goals • Patients evaluate their current behaviors • Ambivalence is discovered when conflict between values/goals and behaviors is identified • Change is more likely when patients realize their behaviors are in conflict with their self‐identified 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.” http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

33. Principles of MI • Roll with Resistance • Do not challenge resistant statements • Confronting resistance promotes defensiveness and diminishes the likelihood of a patient finding their own reasons to change • Use the resistance as an opportunity to further explore the patient’s views • Be aware of when a patient is becoming frustrated • Closed body language • Negative verbal responses • Shortened verbal responses http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

34. Example of Rolling with Resistance • BG 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.

35. Hour 3: Tools and Practice

36. Tools to Help Implement MI • OARS • Open-Ended Questions • Affirmations • Reflective Responses • Summaries • RULES of Motivational Interviewing • Resist the righting reflex • Understand the patient’s motivation • Listen with empathy • Empower the patient Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

37. Open-Ended Questions • Elicit better responses from patients • Make a conversation less one-sided • Are not answerable with a simple yes or no Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

38. Try it Out – Open Ended Questions

39. Affirmations • Statements that recognize a patient’s strengths • Help support self efficacy • Tries to help patient believe change is possible despite past failures http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

40. Restate how the provider perceives the patient Allows for increased clarity Allows the listener to affirm the patient’s feelings Patient feels understood Reflective Responses Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

41. Try it Out – Affirmationsand Reflections

42. Summaries • Reflection that recaps visit and highlights important areas • Can clarify ambivalence and discrepancies http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

43. Try it Out – Summaries

44. Communication:The art of really listening

45. It’s Not About the Nail - D http://counselingvideos.blogspot.com/2013/06/its-not-about-nail.html

46. Resist the righting reflex • “I know what is best” • Removes autonomy from the patient by insinuating the patient does not know what is best for themselves • Re-establishes hierarchy • Can undermine the patient’s motivation for change • Can create conflict Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

47. Understand patient’s motivation • Patient’s reason for change is more important than the clinician’s • Explore importance of changing • Ask for a scaled answer • Why is it that number and not another? Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

48. Scaling 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?

49. Listening with empathy • Use reflective responses • Allows patient to tell you more • Clarifies patient’s concerns • Confirms mutual understanding • Be aware of body language • Eye Contact • Nodding • Posture • Do not “understand” Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

50. SOLER • S-sit squarely • O-open posture • L-lean forward • E-eye contact • R-relax (Egan, 2010) – D&E