Behavioral Health and Diabetes Care

Motivational Interviewing for the Health Care Professionals How to engage your patients, overcome resistance and promote behavior changeAmy Walters, PhDLicensed Clinical PsychologistDirector of Behavioral Health ServicesSt. Lukes Humphreys Diabetes Center

ObjectivesAttendees will be able to do the following:

Define Motivational InterviewingIdentify at least 3 core elements to MI styleList the 3 guiding principles of MIIdentify ways to address patient resistancePractice the basic elements of an MI intervention

Definition (Miller & Rollnick)Motivational Interviewing is..

A client-centered, directive method for enhancing intrinsic motivation for change by exploring and resolving ambivalenceMI is . . . A collaborative, evocative, conversation about changeAcceptingCompassionateDirectionalA Partnership . . . promotes the interest of other person

Motivational InterviewingRoots are in substance abuse interventionFirst published in early 90s by Miller & RollnickExpanded to other health conditionsHundreds of randomized clinical trials and publicationsActivate patients motivation for change

Developments in MI: 2003 - 2011 Over 200 randomized trials Total publications tripled to >1200 > 40 books 2011 over 30,000 Google Scholar articlesMeta-analyses of MI research New research on MI processes theory Rapid diffusion into health care, corrections Newer diffusion into mental health, education, dentistry, social work Areas of study : alcohol, drugs, dual dx, gambling, offenders, eating, smoking, HIV, cardiac, diabetes, psychiatric, health promotion, family violence, asthma, dental, cancer (listed by freq) (Miller, 2013)Motivational Interviewing Basic premise: How we speak with people about behavior change matters

Shift from expert role: I know what is best to guide role :You tell me what is best and let me guide youTour guide in the land of health behavior change

MI is not a method, it is a style

Key Elements of MICollaboration

Person Centered

Guidance encourages self-based problem solving

Empathy relationship is the foundation

Elicit and strengthen motivation for change

MI Spirit Developing proficiency in MI is like learning to play a musical instrument. Some initial instruction is helpful, but real skill develops over time with practice, ideally with feedback and consultation from knowledgeable others. As with other complex skills, gaining proficiency in MI is a lifelong process.-William Miller, 2008

Adapted from Steve Berg-Smith 2011Interpersonal StyleEmpathicWarm & friendlyCollaborativeAcceptingRespectfulOptimisticEliciting & ListeningHonoring of autonomy & choice* Adapted from Steve Berg-Smith 2011Common Communication Styles3 common styles of communication for practitionersDirecting advice givingGuiding empathetic listening and encouraging ideasFollowing listening only

Guiding style provides the best outcome and most likely to lead to behavior change Dancing not Wrestling

3 Guiding Principles of MICollaboration/partnershipGuiding rather than directing and dancing rather than wrestlingCollaborative conversations and joint decisionsEvocation: elicit hows and whys from the patientRather than giving advice, we evoke motivation and resources for changeAutonomy Respect and support patient autonomy for decisions directing and coercing leads to resistance

Paradox of change when people feel accepted for who they are and what they do (regardless of how unhealthy) it allows them the freedom to consider change, rather than needing to defend against it (Miller and Rollinick, 2010)

Studies suggest empathy is the best predictor of patient behavior change4 fundamental processesEngaging - form the relationship

Focusing what is our goal, where are we going

Evoking calling forth desires

Planning how will we get there

Not a checklist; rather a process you revisit over and over; dancing around the floor

Interaction StyleREAL PrincipleRespect

Empathy

Active collaboration

Listen

Importance of EmpathyEmpathy is a key ingredientEvidence based element of treatmentPredicts outcomes (e.g. drinking change)Empathy alone is a significant intervention low level empathy associated with poor outcomesRelationship is the vehicle for change . . . building it for brief encounters is even more important

Reflective ListeningA core skill

Eye contactEngagementPaceWord choiceInquisitive ContentFeelingMessage

Reflect general content and emotion the core message, not a mirrorBasic FlowListen and identify the issueAsk/Evoke: Why make the change?How could go about it to succeed?What are 3 best reasons to do it?How important is to make change 1-10 (why )Summarize Confirm: What do you think you will do?

Taste of MI

Best way to learn MI is to experience MI

Choose a partner - not with your boss or supervisor One will be the speaker and the other will be the listener

2 part exercise ExerciseReflection/Persuasion ExerciseSpeaker: Choose a topic - something thinking about changingListener 1) Choose a side and try to persuade accordingly2) Practice reflective listening & evokingEx Qs: Why make change? 3 best reasons?How important is the change?Summary?What do you think you will do?

You Tube VideoEffective Physicianhttp://www.youtube.com/watch?v=URiKA7CKtfc

Diabetes Educatorhttp://www.youtube.com/watch?v=5h0i-b0xrnI

Adapted from Steve Berg-Smith 2011Core Skills - OARSOARS Open questions Affirm Reflective listeningSummarize

Gather the pearls of the conversation and present them with a string that summarizes it and highlights change talk

Core Skill Change TalkChange talk Any statements that favor changing the target behaviorGoal: clarify ambivalence & elicit change talkEncourage change talk identify, reinforce, respond The goal is for the patient to talk him/herself into changingReflect: desire, ability, reasons, need, commitment, steps to actionEx: I want to, I could, I need to, I will

Importance of IntentionMultiple studies highlight the importance of intensionIntension is greatest predictor of future behavior (25-30% of variance)StableBased on personal factors (vs social norms)Specific and detailed (Bruin et al, 2012)Types of Change TalkDARNSDesire Ability Reasons Need Steps

Questions to Promote Change TalkDesire

Ability

Reason

Need

StepsWhat do you want, wish, hope?

What? How?

Why ? Benefits?

How important is it?

What might be a next step?Strategies to Encourage Change TalkAll EARS: E: evoke & ask for elaboration (be curious)A: affirmR: reflect S: collect bouquet of change talk flowers and offer in summaryCore Skill - EvokingEvoking: recognize, elicit & respond to change talkReasons we miss change talk - dont listen, other agenda, expert roleSet the stage so patient is one that brings it upDifferential response: Reinforce change talk Ignore sustain talkEvoking QuestionsAsk evocative, open ended QsUse importance ruler & confidence rulerQuery extremes best thing, worst thingLook back and forwardExplore goals and values- what matters to you, care about most, guides decisionsQs: How will that happen for you; what would help you be successful

Core Skills EOE RhythmEOE Rhythm ExploreOffer Explore

Painter analogy good outcomes are all about the prep work

Sharing InformationAsk permissionSlow downBe clear and concise: Small nuggets!Avoid information overload: Less is more!Use visual supportAvoid technical terms and jargonOffer choicesExplore Offer ExploreEducation, feedback, skills, referrals*Adapted from Steve Berg 2011Clinician:"Jackie, tell me a little about what you know about anti- depressants.[Explore]

Patient:"Well, I know that lots of women are told they have depression and then take these pills that lowers their sex drive and makes them fatter. How can that be helpful?

Clinician:"You're absolutely right! These side effects can and do happen for many women. Could I tell you some other things about anti-depressants that we know as well?[Ask permission to Offer]

Patient:"Well, I suppose."

Clinician:"Great; thanks! There are many newer anti-depressants that don't seem to have the same side effects for most women; they seem to lessen the depression only and not the sex drive. And your sex life sounds important to you.[Offer] What do you think about that?[Explore]

Patient:"Well, I guess I could try one of those other ones if you really think it might help -and that I won't gain more weight!"ResistanceResistance is a by-product of communicative style and approach Its a sign we are dancing to a different song STOP listen to the beat try to join the patients rhythmBeing heard can be the most healing response

Resistance signals ambivalence and a need to step back, listen and help the patient explore the optionsResistance TrapsThe question-answer trapThe taking sides trapThe expert trapThe scare tactics trapThe cheerleading trapThe pouncing trapThe information over-load trapThe premature action planning trap

Dealing with Resistance/DiscordSigns: interrupting, arguing, challenging, discounting, hostility, withdrawal, ignoring, changing the topic

Responsive to style Not dancing together wellStep back, listen and evoke concerns

Addressing Ambivalence and ResistanceBack away from the problemMove to exploration and guidanceExplore why and how change might occur

Ambivalence is a normal phenomenon when considering change resist the righting response (advice)

The RULE PrincipleResist the righting responseRoll with resistance, invite perceptions, listen and reflectUnderstand motivationExplore values for change, listen for core values & motivationListen with empathyWarmth & acceptance, reflection, safe connection Empower ability to changeAffirmation, evidence of ability to solve problems

Open the ConversationNegotiate the AgendaBuild Motivation*Ask Open Ended QuestionsAssess Readiness avoid premature planExplore AmbivalenceClose the ConversationThe Next StepAdapted from Steve Berg Smith 2011Readiness for ChangeHow important is health behavior change to you?How confident are you in your ability to change your behavior?How committed are you to changing your behavior?

0 1 2 3 4 5 6 7 8 9 10Specific Techniques and StrategiesRuler ratingsGather pearls (selectively reinforce change talk)Choices for directionCircle chartDecision Square

44Final PointsBehavior change is a key element of healthy living and wellnessMany patients struggle to achieve behavior change, despite good intentionsTraditional methods of advice giving may increase resistance to changeMI is a research-based technique that may assist health care professionals to support patients in their behavior change efforts

Final Points Health behavior change is not a by-product of education, medication or provider instruction- behavior change is always the result of patient motivation

Release the responsibility to fix - Patients hold responsibility for their own health choices and behaviors

Research indicates the most effective providers:

Focus on patient goals and priorities Follow the patients pace Communicate high levels of empathy Provide guidance to reach health goals

ReferencesMiller, W & Rollnick (2013) Motivational Interviewing: Helping People Change (3rd Edition). Guilford Press, New York Miller, W & Moyers, T (2013) Advanced Workshop in Motivational Interviewing, Albuquerque, NM September 2013 Rollnick, S. , Miller, W., & Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press, London.

Arkowitz et al. (2008). Motivational Interviewing in the Treatment of Psychological Problems. Guildford Press, London. Berg Smith, S. (2011). Intensive Introduction to Motivational Interviewing : 3 day training, San Fransisco, CA, December 2011.Bruin et al. (2012) Self regulatory processes mediate the intention behavior relation of adherence and exercise behavior; Health Psychology,31 (6), 695-703.Groot et al. Depression Among Adults with Diabetes: Prevalence, Impact and Treatment.(2010) Diabetes Spectrum 23: 15-18.Welch, G., et. al. (2006). Motivational Interviewing and Diabetes: What is it? How is it used? Does it work? Diabetes Spectrum 19: 5-11.www.motivationalinterview.org