Utilizing Motivational Interviewing Techniques to Address Sexual Risk Behavior

1. Utilizing Motivational Interviewing Techniques to Address Sexual Risk Behavior Terry Lee, MS, RN, BC Nurse Educator Denver STD/HIV Prevention Training Center

2. Disclosures • I have NO actual or potential conflict of interest in relation to this educational activity or presentation. • Terry Lee, MS, RN, BC

3. Denver PTC: www.denverptc.org

4. Goals and Purpose The primary goal of this presentation is to introduce participants to motivational interviewing techniques that can be utilized in a STI clinic setting to assist patients in developing risk reductions plans related to sexual behaviors.

5. Objectives Review current STI trends Identify the basic tenets of MI Discuss 5 steps of the Behavior Change Theory Describe Self Perception Theory Review the concept of personalizing risk Discuss key components to conducting a comprehensive sexual history

6. Why Diagnose and Treat STDs? • > 19 million STDs in US annually • Health consequences of untreated STDs • Women’s reproductive health • Untreated Chlamydia (CT) or gonorrhea (GC) may lead to pelvic inflammatory disease (PID) • Leading infectious cause of infertility in the U.S. • Infant mortality/morbidity • Neonatal HIV, herpes simplex virus (HSV) and congenital syphilis • HIV transmission • Health care cost • $16.4 billion (2009)† †Estimates incorporate minor corrections noted in Persp Sex Rep Hlth, Dec 2009.

7. Populations at Greatest Risk for STDs • Youth • Nearly 50% of STDs estimated to occur in 15-24 year olds • Racial/ethnic minorities • STDs among highest of all racial/ethnic health disparities • African-Americans: 71% of GC, 48% CT, 52% syphilis • Over last 5 years syphilis cases increased more than 150% among young African American men • MSM • Account for 62% of syphilis cases in 2009 • High rates of HIV co-infection

8. Gonorrhea—Rates by Age and Sex, United States, 2009 Men Rate (per 100,000 population) Women 750 600 450 300 150 0 0 150 300 450 600 750 Age 10–14 5.0 25.3 15–19 250.0 568.8 20–24 407.5 555.3 25–29 238.9 229.4 30–34 145.0 106.2 35–39 85.6 47.6 60.8 22.9 40–44 45–54 33.6 8.7 2.1 11.4 55–64 65+ 2.7 0.5 Total 92.2 105.7

9. Chlamydia—Rates by Age and Sex, United States, 2009 Men Rate (per 100,000 population) Women 3,800 3,040 2,280 1,520 760 0 0 760 1,520 2,280 3,040 3,800 Age 10–14 13.8 127.9 15–19 735.5 3,329.3 20–24 1,120.6 3,273.9 25–29 573.3 1,234.0 30–34 286.0 511.7 35–39 141.3 205.8 81.9 88.4 40–44 45–54 36.0 32.0 11.0 9.1 55–64 65+ 2.9 2.1 Total 219.8 593.4

10. Primary and Secondary Syphilis—Rates by Age and Sex, United States, 2009 Men Rate (per 100,000 population) Women 25 20 15 10 5 0 0 5 10 15 20 25 Age 10–14 0.0 0.2 15–19 6.0 3.3 20–24 20.7 5.6 25–29 18.5 3.6 30–34 15.8 3.0 35–39 13.3 1.9 13.7 1.6 40–44 45–54 8.3 1.0 0.2 2.9 55–64 65+ 0.5 0.0 Total 7.8 1.4

13. STD Prevention: Clinicians’ Role • Talk to patients about pre-exposure vaccination • Provide or refer for prevention/risk-reduction counseling • Talk to patients about testing • Assess patients’ risk and test accordingly • Diagnose and treat infected patients • Provide or refer for partner services • Report STD/HIV and AIDS cases in accordance with state and local statutory requirements • Keep STD/HIV reports confidential

14. How do we know if our patients are at risk for STDs/HIV? • Infections are commonly asymptomatic, so relying on report of symptoms is not adequate • Discussions about risk behaviors are necessary.

15. Do Providers Ask About Risk? N=208 providers % of Providers Who Assessed STD Risk N= 12.7 million visits N= 317 physicians N= 317 physicians N= 417 providers HIV Care Providers Metsch 2004 Ongoing care Private Physicians Tao 2003 Non-ID trained Physicians Duffus 2003 Primary Care Providers Bull 1999 ID trained Physicians Duffus 2003

16. Barriers to taking a sexual history • Structural barriers (time/reimbursement concerns) • Patient barriers (privacy/confidentiality concerns) • Provider barriers • Low priority given to STD prevention • Acute versus preventive role perception • Low priority given to sexual health issues • Provider discomfort discussing sexual issues • Unfamiliarity with content or language • Perceived complexity of the sexual history • Inadequate training

17. Client Centered Approach • Client is in charge/control • Clients are responsible for their own decisions and behavior changes • Options, rather than directives, are offered • Counseling is not interviewing or educating • Focus on feelings as much as information • Behavior change is a process

18. Motivational Interviewing Definition • A directive, client-centered counseling style for helping clients explore and resolve ambivalence about behavior change (Rollnick, 1991).

19. Motivational Interviewing Advantages Disadvantages • Builds rapport • Reduces client resistance • Increases motivation • Recognizes that change is a process not an event • Recognizes expertise of both pt and clinician More challenging May be more time consuming.

20. Basic Tenets of Motivational Interviewing OARS technique Building confidence Ambivalence Change Talk

21. OARS Technique Open Ended Questions Affirmations Reflections Summary

22. Open Ended Questions Allows patient to discuss concerns Solicits more information from patient Reinforces that patient has existing skills, knowledge Elicits more information quickly

23. Affirmations • Directly affirming and supporting the patient • Compliments • Statements of appreciation and or understanding

24. Reflections • Assures the patient that you have heard and understood what he/she is saying • To summarize in your own words what the patient tells you • Links material learned over the course of the interaction • Reinforces what has been discussed

25. Reflection • Reflecting Emotion • Client: (describing relationship with husband) I try and try but hardly get anywhere. Every time I try to do what he wants, it doesn’t work out. When I try to do things the way I think they should be done he doesn’t like that either. I just don’t know what to do. • Clinician: You’re feeling really frustrated right now.

26. Reflection Quiz • Client: yes, but my major concern is with my girlfriend. I think she’s been sleeping around, and I’m losing my mind trying to figure out what to do about it. • A. Sounds as though you feel desperate about the situation. • B. That must be awful. • C. You main concern, then is what to do about the situation with your girlfriend.

27. Summaries Collect the main themes of the conversation that the patient has offered and pull them together in a summary.

28. The Good, The Bad, The Ugly…

29. Building Confidence • Increase a patient’s belief or faith in his/her ability. • Techniques: • Hypotheticals • Confidence Ruler • Brainstorming • Providing information, advice, or suggestions • Evocative questions • Discussion of past successes

30. Ambivalence • simultaneous and contradictory attitudes or feelings (as attraction and repulsion) toward an action. • Patients usually experience ambivalence towards behavior change (while they understand the benefits of changing, they also enjoy some aspect of the current behavior.

31. Ambivalence Remember a common response to pro-change arguments made by clinicians will usually cause patients to defend the current behavior, which makes them talk themselves out of changing.

32. Change Talk • Helps patients make the argument for change. • Five Kinds of Change Talk (DARN) • Desire: what a patient wants (like, wish, want) • Ability: what a patient perceives within ability (can, could) • Reasons: specific reasons for change • Need: speak to necessity or need (need, have to, got to, should, ought, must) • Commitment: agreement or pledge (will, intend, plan, hope, try)

33. Change Talk These five steps make up DARN By exploring DARN, clinicians touch on the patient’s values and aspirations. It is important to explore these values as they can be a powerful motive to change.

34. Methods for Eliciting Change Talk • Evocative Questions • Advantages of Change • Importance Rulers • Exploring Decisional Balance • Elaboration • Querying Extremes • Looking Forward or Backward

35. Change Talk • Client: This is a new thing for me, I never used to have sex with so many guys, I guess I got wild after my divorce. I’m not even sure I like some of the men I sleep with, but I don’t like feeling alone.

36. Change Talk • Clinician responses: • Having partners helps you not feel lonely. What are some pros and cons to continuing this behavior? (Exploring Decisional Balance). • What is the worst thing that could happen to you if you keep having sex with multiple partners? (Querying Extremes) • On a scale of 1-10 how important is it for you to change your sexual activity? (Importance Ruler)

37. Stages of Change Theory Five stages represent ordered categories along a continuum of motivational readiness to change a problem behavior.  • Precontemplation • Contemplation • Preparation • Action • Maintenance

40. Self Perception Theory • To some extent, what we believe is a by product of what we say, especially in situations of ambiguity. • Remember patients recognize the behavior has drawbacks, but also values the behavior in some way, BOTH sides are important. • Therefore its important to engage patient in self talk related to change.

41. Exercise Four a 17 year old female is complaining of weight gain, breast tenderness and is concerned that she hasn’t had her menses. She has no other symptoms. She does not remember when her last menses was, but doesn’t think she can get pregnant. She has had 2 partners in the past 3 months, does not use condoms, and doesn’t believe in contraception. Her last intercourse took place 3 days ago.

42. Exercise Four cont… List 3 open ended questions to ask this patient Identify where you think this patient is related to stages of change? What are you led to believe based on the self perception theory?

43. Judgment vs. Non Judgment Judgment  the process of forming an opinion or evaluation by discerning and comparing. A discriminating or authoritative appraisal or opinion Non Judgment • Being aware of one’s own values and prejudices in order to avoid imposing them on patients. • being open-minded enough to understand that other people have different points of view, and that in their worldview, they may be correct.

44. Personalizing Risk Understanding how patients feel about discussing risk, can help us to be more empathetic. The next exercise will allow us to put ourselves in the role of our patients.

45. Personalizing Risk 1_______________________________4 Low High Risks/costs of behavior change

46. Case Study • Tom is a 33 yr old MSM (man who has sex with men) who visits the bathhouse regularly. He has had 6 new partners in the past month, and engages in both receptive and insertive anal sex. He does not use condoms, and rarely discusses HIV status with new/potential partners. Tom state he is at very low to no risk for contracting HIV/STIs. • Using the information in the previous slides determine Tom’s perception of risk and stage of change. Identify how that coincides or conflicts with your risk assessment.

47. Case Study Personalizing Risk 1______________________________4 Low High Risks/costs of behavior change

48. Case Study • Based on the information provided by Tom which stage of the transtheoretical model of behavior change is he displaying? • Precontemplation • Contemplation • Preparation • Action • Maintenance

49. Set the Stage: • Introductions • Private space or setting • Build rapport • Acknowledge clients feelings and the difficulty in disclosing • Be aware of facial expressions, body language, and other non-verbal ques.

50. Prepare the Client • Assure confidentiality • Assure the questions are asked of all patients • Use lead in questions for difficult or sensitive information • Be sensitive • Stress health issues related to sexual behaviors • Explain how the information will help you care for the patient