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Funded by: www.sbirtonline.org
Alan Lyme, LCSW
Sylvia Shellenberger, PhD
Southeastern Consortium for Substance Abuse Training – Advanced Practice Registered Nurses
Funded by Grant 1U79T1025372-01
Substance Abuse and Mental Health Services Administration (SAMHSA)
Last revised: April 5, 2014
Motivational InterviewingSteps and Core Skills
Funded
by:
SECSAT-APRNSoutheastern Consortium for Substance Abuse Training -
Advanced Practice Registered Nurses
Key Contributors &SECSAT – APRN Site Coordinators
Mercer University, School of MedicineJ. Paul Seale, MD
Principal Investigator
Annie Biers, LPC, Project Coordinator
Sylvia Shellenberger, PhD
Mercer University, Georgia Baptist College of NursingDr. Frieda Fuller Dr. Laura K. Baraona
Armstrong Atlantic University
Dr. Anita NivensDr. Linda Tuck
Emory University, Nell Hodgson Woodson
School of Nursing Dr. Carolyn Clevenger
Dr. Ursula KellyDr. Phyllis Wright
University of North Georgia Dr. Sharon Chalmers
South UniversityDr. Doris Parrish
Johns Hopkins University
Dr. Christine SavageDr. Deborah Finnell
Georgia College & State University
Dr. Deborah MacMillanDr. Sallie Coke
University of Alabama, Birmingham
Dr. Susanne Fogger
At the end of the session, you will be able to—
1. Identify MI basic steps.
2. Identify MI core skills.
3. Demonstrate and practice MI using core skills.
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Learning Objectives
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Motivational Interviewing Steps
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1. ENGAGE
Express empathy
Ask questions
Use affirmations
Support autonomy
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2. FOCUS
Reflect
Summarize
Develop discrepancies
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3. EVOKE
Motivation
Concerns
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4. PLAN
Raise the subject
Support self-efficacy
Address elements of change
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Video Demonstration
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Play video: The Effective Physician
Motivational Interviewing: Core skills for
understanding values
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Core MI skills for exploring values
Open-ended questions
Affirmations
Reflections
Summaries
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Open-Ended Questions
Using open-ended questions—
Enables the patient to convey more information
Encourages engagement
Opens the door for exploration
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Open-Ended Questions
What are open-ended questions?
Gather broad descriptive information
Require more of a response than a simple yes/no or fill in the blank
Often start with words such as— “How…”
“What…” “Tell me about…”
Usually go from general to specific
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Open-Ended Questions
Why open-ended questions?
Avoid the question-answer trap which:
• Puts patient in a passive role
• Allows no opportunity for patient to explore ambivalence
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Open-Ended Questions
Why open-ended questions?
Opportunity to explore and make transparent the patient’s own ambivalence
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Closed-Ended QuestionsCreate Conversational Dead Ends
Closed-ended questions typically—
Are for gathering very specific information
Tend to solicit yes-or-no answers
Convey impression that the agenda is not focused on the patient
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Exercise
Turning closed-ended questions into open-ended questions
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Closed QuestionsSo, you are here because you are concerned about alcohol, correct?
Do you feel depressed or anxious?
How many children do you have?
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Open Questions• What is it that brings
you here today?
• How have you been feeling?
• Tell me about your family.
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Closed• Can you tell me about
your marijuana use? Do you like to smoke?
• When do you plan to quit drinking?
• Do you agree it would be a good idea for you to go for treatment?
Open-Ended• Tell me about your
marijuana use. What are some of the things you like about smoking?
• So, what, if anything, do you think you want to do about your drinking?
• What do you think about the possibility of going for treatment?
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Affirmations
What is an affirmation?
Statement of appreciation, recognition, or understanding
How do they help?
Recognize positive behaviors
Support the person as they describe difficult situations
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Affirmations May Include: Commenting positively on an attribute
─ “You are determined to get your health back.”
A statement of appreciation─ “I appreciate your efforts despite the discomfort
you’re in.”
A supportive statement
─ “You worked hard today.”
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Affirmation example
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Patient: I’ve tried to quit drinking and get my job back. I really liked the work I was doing, and I want to earn my own living.
Clinician: You are a person with a strong sense of ethics that includes working and earning your own living.
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Affirmation Example
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Patient: No one ever cared whether I went to school or not. Everyone at home was drinking or using drugs. I had to get there myself.
Clinician: You’ve come a long way thanks to your determination and persistence.
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Reflective Listening
“Good reflective listening tends to keep the person talking, exploring, and considering.”
(Miller and Rollnick, 2013)
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Reflective Listening
Involves listening and understanding the meaning of what the patient says
Has the effect of encouraging the patient to elaborate, amplify, confirm or correct.
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Reflective Listening
Why listen reflectively?
─ Demonstrates that you have accurately heard & understood the patient
─ Strengthens the empathic relationship
─ Encourages further exploration of problems & feelings
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Levels of reflection
REPEAT
REPHRASE
INFER or ADD NEW MEANING
SUMMARIZE
De
pth
of
em
pa
thy
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Levels of reflection
REPEAT - restate what client has said
REPHRASE – offer a synonym
INFER or ADD NEW MEANING –empathic, double-sided, reflections of feelings
SUMMARIZE – gather client utterances
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Simple Reflections
Stay close to the content spoken by patient by
Repeating
Rephrasing (substitutes synonyms)
Example
Patient: I hear what you are saying about my drinking, but I don’t think it’s such a big deal.
Clinician: So, at this moment you are not too concerned about your drinking.
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Exercise: Reflect by repeating, or substituting a synonym
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Patient: You just don’t know how hard this is.
Clinician: ?
Patient: My boss complains about my being
late.
Clinician: ?
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Complex ReflectionsMake a guess or paraphrase becoming a major restatement, infer meaning
Patient: Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint!Clinician: It’s hard to imagine how I could possibly understand.
Patient: I just don’t want to take pills. I ought to be able to handle this on my own.Clinician: You don’t want to rely on a drug. It seems to you like a crutch.
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Complex – Reflection of feeling
Reflection of feeling is the deepest form of empathic
reflection
Patient: My wife decided not to come today. She says this is my problem, and I need to solve it or find a new wife. After all these years of my using around her, now she wants immediate change and doesn’t want to help me!
Clinician: Her choosing not to attend today’s meeting
was a big disappointment for you.
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Exercise: Reflection of feeling
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Patient: They said this wouldn’t take long, but here it is an hour later. How much longer will I be?
Clinician: ?
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Complex – Reflection that is Double-Sided
Attempts to reflect back both sides of the ambivalence the patient experiences.
Patient: But I can't quit smoking. I mean, maybe I should, but all my friends smoke!
Clinician: You can't imagine how you could not smoke with your friends, and at the same time you're worried about how it's affecting you.
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The summary is like a bouquet of flowers (change talk) that we collect
and give to the patient
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Effective summaries
• Facilitate and guide
• Are selective and concise
• Reflect ambivalence
• Accentuate “change talk”
• Affirm and reinforce motivation to change
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Summaries
Periodically summarize the discussion.
Summary usages
─ Begin an appointment
─ End an appointment
─ Transitions
Advantages
─ Enhances collaboration
─ Assures patient and clinician are in sync
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Summaries
Strategic summary—select what information should be included and what can be minimized or left out.
Additional information can also be incorporated into summaries—for example, past conversations, assessment results, collateral reports, etc.
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Summaries
Examples
─ “So, let me see if I’ve got this right…”
─ “So, you’re saying… is that correct”
─ “I’d like to make sure I’m understanding exactly what you’ve been trying to tell me…”
Double sided reflections are often highly effective as summaries to illustrate ambivalence.
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Learning Exercise
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Exercise
OARS in
practice
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A taste of MIDivide into pairs. Speaker:
In a minute you will have the opportunity to talk aboutsomething that you have been thinking of changing; something you either want to change, need to change, or should change, but haven't changed yet (i.e., something you're ambivalent about.)
**For group consideration: How advantageous/fun might it be to use the goal of implementing SBIRT into your practice for this role play?
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APRN:Listen carefully with a goal of understanding the dilemma. Give no advice. Ask these three questions and reflect the answers: 1. Why would you want to make this change? 2. How might you go about it, in order to succeed? 3. What are the three best reasons to do it?
Give a short summary/reflection of the speaker's motivations for change.
Then ask, "So what do you think you'll do?" and just listen with interest.
A taste of MI - cont’d
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DEBRIEF:
Speaker: What was your experience of talking about your potential change goal?
APRN: What was your experience? How was this difficult? Easy? What might you try again?
Conclusion
In this session, you have learned the steps and core motivational interviewing skills.
In the next session, you will use these core skills plus selected tools that help patients better understand their competing priorities and ambivalence to change—to resolve their ambivalence and increase motivation for behavior change.
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QUESTIONS?