Jonathan P. Stoehr, MD PhD Ananth Shenoy, MD …...hear you saying you are worried about keeping the...

Jonathan P. Stoehr, MD PhD Ananth Shenoy, MDEndocrinology Chief Medical Resident

Virginia Mason Medical CenterSeattle, WA

Review the Stages of Change Understand how to assess readiness. Discuss relapse as a stage of change.

Review the principles of motivational interviewing and discuss their application to patients. Basic Skills Principles of Communication

Patient relapsed into weight gain following a period of successful lifestyle change.

Patient’s behavior does not match their expressed willingness to change.

Patient seems to resist every proposed treatment.

Patient does not value diabetes treatment as highly as pain management.

Anti-vaccinator parents.

Stages of Change

Relapse is not regarded as a failure or evidence of patient defect.

Patients may relapse from any stage, to any other stage of change, at any time.

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The patient is not even considering changing. They may be “in denial” about a health problem, or not consider it serious. They may have tried unsuccessfully to change so may times that they have given up.

Strategy: Educate on risks vs. benefits and positive outcomes related to change.

Source: Zimmerman et al, 2000; Tabor and Lopez, 2004

The patient is ambivalent about changing. During this stage, the patient weighs benefits vs. costs / barriers (i.e. time, expense, bother, fear).

Strategy: Identify barriers to change, or misconceptions. Address concerns. Identify support systems.

Source: Zimmerman et al, 2000; Tabor and Lopez, 2004

The patient is prepared to experiment with small changes.

Strategy: Develop realistic goals and timeline for change (specific details).Provide positive reinforcement.

Source: Zimmerman et al, 2000; Tabor and Lopez, 2004

The patient takes definitive action to change his / her behavior.

Strategy: Provide positive reinforcement.

Source: Zimmerman et al, 2000; Tabor and Lopez, 2004

The patient strives to maintain the new behavior over the long term.

Strategy: Provide encouragement and support. Anticipate triggers for relapse, and discuss strategies to avoid these.

Source: Zimmerman et al, 2000; Tabor and Lopez, 2004

Original theory: return of the original behavior. Patient returns to the precontemplative stage.

General Theory: patient may relapse from any stage, to any other stage, at any time.

Relapse is accepted as a normal part of the process of change, and is not necessarily evidence of failure or inability to change in the future.

Source: Zimmerman et al, 2000; Tabor and Lopez, 2004 Back

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Overall strategy: create a favorable climate for change. Patient will encounter and confront ambivalence about change. This ambivalence is likely to raise some conflict within the patient.

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“Do you mind if we talk about [behavior]?”

“Can we talk a bit about your [behavior]?”

“I noticed on your medical history that you have hypertension, do mind if we talk about how different lifestyles affect hypertension?”

“What would you like to see different about your current situation?”

“What makes you think you need to change?”

“What will happen if you don’t change?”

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Develop Discrepancy Avoid Argumentation Roll with Resistance Express Empathy Support Self-efficacy

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Arguing Negating Blaming Excusing Ignoring Minimizing Challenging the provider’s knowledge,

competence, etc. Non-adherence with treatment

TRY NOT TO THINK…

Patient is incapable of change.

Patient is crazy.

We can overcome the resistance through coercion or logical arguments.

TRY TO REMEMBER….

Resistance constitutes information to the provider.

Patient may not view the problem in the same way.

Patient is expressing ambivalence.

Resistance is frequently a reaction to a perceived loss of freedom or choice.

Simple Reflection Amplified Reflection Double-sided Reflection with “AND” Changing the Perspective Reframing Siding with the Negative Judo “Going to Ground”

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Repeating a statement back to the patient.

Allows physician to verify that he/she has the correct information.

Reinforces to the patient that he/she is being listened to.

Allows the patient to hear and reconsider their own statement more critically.

ResistanceBasic Skills

“It sounds like….” “What I hear you saying…” “It seems as if….” “I get the sense that….” “It feels as though….”

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Not a direct repeat of patient’s last statement, but with careful adjustment of the emotional content.

Reflect back to the patient from the point of view of someone slightly lower on the readiness to change scale.

Theory: an ambivalent patient will argue against the position of someone lower on the motivational scale.

Reflection

Patient: I’m not sure I can quit smoking. Provider: You’re not sure it can be done.

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Reflect back a negative AND a positive aspect of change in a single statement.

Consider using “AND” instead of “BUT”…

Theory: the patient will begin to weigh both pros and cons, and may gravitate to the “center” of those two statements.

Negative Positive

“You’d like to reduce your weight and you’re finding it difficult to find time for exercise.”

Patient: I can't believe I've been ordered to treatment for a single DWI. This is a long way to go to keep from having my license suspended. You'd think the legal system had bigger fish to fry.

Provider (double-sided reflection): On the one hand, you're not too happy to be here, and on the other, there might be a substantial benefit to keeping your license from being suspended.

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Patient: I can't believe I've been ordered to treatment for a single DWI. This is a long way to go to keep from having my license suspended. You'd think the legal system had bigger fish to fry.

Provider (simple reflection): You're having a hard time making sense of why you're here.

Provider (amplified reflection): You don't think the legal system has any business dealing with these issues.

Provider (double-sided reflection): On the one hand, you're not too happy to be here, and on the other, there might be a substantial benefit to keeping your license from being suspended.

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Redirecting the conversation away from significant obstacles or barriers.

Patient: But I can't quit drinking. I mean, all of my friends drink!

Provider: You're getting way ahead of things here. I'm not talking about your quitting drinking here, and I don't think you should get stuck on that concern right now. Let's just stay with what we're doing here - talking through the issues - and later on we can worry about what, if anything, you want to do about it.

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Acknowledging the facts provided by the patient, but proposing a different interpretation.

Patient: “My husband is always nagging me about my drinking--always calling me an alcoholic. It really bugs me.”

Provider: ”It sounds like he really cares about you and is concerned, although he expresses it in a way that makes you angry. Maybe we can help him learn how to tell you he loves you and is worried about you in a more positive and acceptable way.”

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Introducing an idea with the intent of getting a patient to argue in favor of change.

Goal: Induce the patient to say “Yeah, but…”

Theory: an ambivalent patient who resists the therapist will resist the status quo.

Idea

Physician: “Bill, I know you have been coming to treatment for two months, but you are still drinking heavily, maybe now is not the right time to change?”

Patient: “No, I know I need to change, it’s just tough putting it into practice.”

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Instead of pushing back against resistance…PULL!

Acknowledge that patient may decide not to change… the choice is theirs.

Patient: But I can't quit using. I mean, all of my friends use!

Provider: And it may very well be that when we're through, you'll decide that it's worth it to keep on drinking as you have been. It may be too difficult to make a change. That will be up to you.

Patient: Okay.

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Motivating patients to change requires maintaining trust and rapport.

Requires us to understand and acknowledge the patient’s point of view.

Judging Labeling Criticizing Blaming

Imposing an external point-of-view.

Skillful, reflective listening.

Acceptance, respect.

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Our response to our patients’ concerns has direct effect on their resistance to change.

Direct confrontations usually cause defensive reactions and increased resistance to change.

Pay attention to yourself. Check your emotions. Ask “am I ok?”

Remember, most patients are ambivalentabout change. Acknowledge and summarize that ambivalence.

Change the perspective. Acknowledge the patient’s point of view.

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Motivation for change is created when a person feels a discrepancy between present behavior and an important personal goal.

Not the goals of the healthcare provider.

Techniques to summarize existing discrepancy: Reflective listening Summarizing statements Decisional Balancing

Techniques to directly introduce discrepancy: The “Colombo” Technique

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Provider prompts the patient to state the “good”, and “less good” aspects of their current behavior.

When followed by a brief summary statement or reflective listening, this allows the patient to begin to deal with their ambivalence.

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Modeled after 1970s Peter Falk character. Directly introduces discrepancy without confrontation.

Example: “On the one hand you’re coughing and are out of breath, and on the other hand you’re saying cigarettes are not causing you any problems. What do you think is causing your breathing difficulties?”

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“Help me understand, on the one hand I hear you saying you are worried about keeping the custody of your children. Yet, on the other hand you are telling me that you are using crack occasionally with your boyfriend. Since you also told me you are being drug screened on a random basis, I am wondering how using cocaine might affect your keeping custody of your children.”

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A person’s belief / confidence in their own ability to carry out a target behavior successfully.

Increasing the confidence helps improve motivation to change.

Supportive statements.

Setting reasonable, achievable goals.

Provider should express that he/she believes that the patient can achieve the goal.

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Open-ended Questions Affirmations Reflective Listening Summary Statements

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“How would you like things to be different?” “What do you know about the risks of ___?” “How have you tried to ___ in the past?”

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Positive statement of support for change, and belief that the patient can change.

NOT cajoling, persuading Must be genuine

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“You’ve tried very hard to quit…” “That’s a good suggestion…” “I appreciate that you were willing to share

that with me…”

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Let me see if I understand this so far...

Here is what I’ve heard. Tell me if I’ve missed anything.

What you’ve said is important.

We covered that well. Now let’s move on to…

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Pt wants provider to continue obviously risky treatment prescribed by outside provider.

Patient minimizes importance / “plays dumb” regarding risky behavior.

Patient highly resistant to treatment based on pre-conceived / outside facts.

Patient resists allopathic medical advice, preferring Naturopath.