Motivational Interviewing. Having Good Conversation about Behavior Change 10/19/2017. Objectives. Basic Assumption

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1 Motivational Interviewing: Having Good Conversation about Behavior Change KU Medical Center Area Health Education Center Mary Koehn, PHD, APRN, CHSE Education Associate Professor, KU School of Medicine-Wichita October 24, 2017 Objectives Discuss theory and evidence associated with Motivational Interviewing Discuss Motivational Interviewing as a communication strategy to promote behavioral change Describe Motivational Interviewing techniques Demonstrate Motivational Interviewing techniques Basic Assumption Healthcare Providers are committed to excellent patient and family care Respect for patients and families True desire to care for and collaborate with patients Healthcare Providers want to do even better 1

2 Theoretical Basis No specific theory Social psychology Cognitive dissonance Self-efficacy Methods of Carl Rogers (Britt, Hudson, & Blampied, 2004) Link with Transtheoretical Model of Change (Prochaska, O., & DiClemente, C., C. (1984) Berger & William s (2013) theoretical approach The Transtheoretical Model of Change Integrative, biopsychosocial model to conceptualize the process of intentional behavior change Pro-change Behavior Systems, Inc. (2017). The Transtheoretical Model Contemplation Intends to take action in the near future, although may be ambivalent. Pre-contemplation Is not considering changing or intending to take action. Relapse - or recycling Reworking preparation and action after setbacks. STAGES of CHANGE Preparation Intends to take action very soon and has taken some steps in this direction. Action Changes behavior. Maintenance Maintaining a new behavior over time. Prochaska & DiClemente. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. 2

3 Stage 1 Precontemplation (Not Ready) Is not considering changing or intending to take action in the foreseeable future, i.e., the next six months The person may be uninformed or under-informed about the consequences regarding their behavior Both uninformed and the under-informed tend to avoid reading, listening, talking about the risks of the behavior Often characterized as resistant, non-compliant, unmotivated, etc. Possible Strategies: Inform about the benefits of change of behavior Explore the barriers and support for change Explore and clarify myths and misconceptions about changing Use language of I am concerned Pro-change Behavior Systems, Inc. (2017). The Transtheoretical Model Stage 2 Contemplation (Getting Ready) Intend to take action in the next six months The person is aware of the pros of changing but acutely aware of the cons Can create ambivalence so may remain in this stage for a long time May be characterized as behavioral procrastination Possible Strategies: Help strengthen commitment for change by creating a plan Explore ways to prepare for changing behavior, but probably not ready for immediate action Pro-change Behavior Systems, Inc. (2017). The Transtheoretical Model Stage 3: Preparation (Ready) Intend to take action in the immediate future Usually measured in the next month Typically have taken some significant action in the past year May have a plan of action Consider for recruiting for action-oriented programs Possible Strategies: Help strengthen commitment for change by creating a plan for change action oriented Pro-change Behavior Systems, Inc. (2017). The Transtheoretical Model 3

4 Stage 4: Action Action is observable: have made specific overt modifications in their behaviors The action is observable But not all modifications count as action Persons must meet a criterion that professionals agree will help reduce disease risk Consensus: For example, only total abstinence counts with smoking, not just cut back Possible Strategies: Explore ways to avoid or counter triggers Develop short-term rewards that can help sustain motivation Enlist support to help maintain the behavior change Pro-change Behavior Systems, Inc. (2017). The Transtheoretical Model Stage 5: Maintenance Have made specific overt modifications in their lifestyles and are working to prevent relapse Person do not have to apply change processes as frequently as in Action stage Less tempted to relapse More confident Possible Strategies: Review the progress of the client Review the benefits of behavior change Explore potential situations that may lead to relapse and develop a coping strategy in advance Pro-change Behavior Systems, Inc. (2017). The Transtheoretical Model Stage 6: Termination 100% Self-Efficacy Less than 20% have reached zero temptation and total self-efficacy May be a lifetime goal of maintenance Pro-Change Behavior Systems, I. (2017). The Transtheoretical Model. 4

5 Theory of Planned Behavior Fishbein, M., & Ajzen, I. (1975) Behavioral Beliefs Links the behavior to expected outcomes Assumes that the belief about the behavior and the value of the expected outcome determine the attitude toward the behavior Behavioral Beliefs Attitude Towards the Behavior Intention Behavior Normative Beliefs Perceived behavioral expectations of important referent individuals spouse, family, friends Assumes normative beliefs + motivation determines the subjective norm Normative Beliefs Suggestive Norm Intention Behavior 5

6 Control Beliefs Perceived presence of factors that may facilitate or impeded performance Assumes control beliefs + perceived power of each control factor determines the perceived behavior control Control Beliefs Perceived Behavioral Control Intention Behavior Intention Behavior Motivational Interviewing? A collaborative, person-centered form of guiding to elicit and strengthen motivation for change. No person is completely unmotivated Miller & Rollnick, (2009) 6

7 Motivational Interviewing Motivational interviewing is the process of activating patients own motivation for change and followthrough with treatment The spirit of motivational interviewing Collaborative Evocative Honoring patient autonomy Center for Excellence in Women s Health. (2013). Part Setting the stage - Framework for practice - Motivational interviewing Motivational Interviewing: Guiding Principles (RULE)) R: Resist the righting reflex U: Understand your patient s motivations L: Listen to your patient E: Empower your patient Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Ambivalence Lack of motivation is often ambivalence Example: If you argue for one side, an ambivalent person will defend the other As a person defends the status quo, likelihood of change decreases Resist the urge to take-up the good side of ambivalence Don t say, you absolutely must change initial response will be to defend their behavior Verbalizing the status change predicts their behavior; don t tell people what to do; ask Rollnick, S., Miller, W.R., & Butler, C.C. (2008). 7

8 Best Evidence Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013) Systematic review and meta-analysis 48 studies with 51 comparisons (some studies had more than one comparison group) Overall, beneficial effects 63% of the main comparison showed statistically significant advantages favoring MI Range of outcome measures Blood pressure, HIV viral load, body weight, smoking abstinence, intention to change, and more Not statistically significant for Blood glucose, healthy eating, medication adherence, breastfeeding, and more Clinical significance: Patients receiving 1.55 times more likely to improve than the control groups Best Evidence VanBuskirk, K. A., & Wetherell, J. L. (2014) Purpose: Is motivational interviewing effective in improving behavior modification in patients seeking treatment for health conditions in primary care settings, as compared to treatment-asusual or other interventions, in randomized controlled trials (RCTs)? Sample: 12/272 studies identified. Results: 9 positive results MI more effective than control conditions (usual care, didactic pamphlets) 2 mixed results 1 no significant effect of MI 7/12 targeted substance abuse-related outcomes 5 addressed dietary and exercise-related goals, medication adherence, colorectal screening Conclusion: MI has been found to be effective in as little as one minute session with an individual with minimal training in MI techniques (p. 110) Best Evidence Teeter, B. S., & Kavookjian, J. (2014). Telephone-based motivational interviewing for medication adherence: A systematic review. Purpose: To examine/describe evidence and gaps for telephone delivered MI interventions for medication adherence Sample: 9 studies In person and telephone delivered MI Telephone delivered MI with educational materials Results: 6/9 studies reported significant differences between intervention and control groups for change in adherence Suggest that telephone-based MI may help improve medication adherence 8

9 Best Evidence Copeland, L., McNamara, R., Kelson, M., & Simpson, S. (2015). Systematic Review: 37 studies Possible mechanisms underlying effectiveness of MI to health behaviors Varying and limited evidence for the different links in the causal chain (inconsistent, poor quality, lack of studies investigating mechanisms) Limited evidence to support client change talk behavior as a mechanism Much of the research has focused on self-efficacy, with the majority of studies finding statistically non-significant results. Motivation and MI spirit appear to be the most promising mechanisms of MI. The way you are with patients is more important than what you say to patients How does our conversation sound? Merlo Lab. (2009). The ineffective physician: Non-motivational approach. How motivational interviewing sounds Tell me about It sounds like Why did you make that decision? ( what made you make that decision would be better) What made you decide to quit when you were pregnant? The effective physician: Motivational Interviewing Demonstration : 9

10 More words Right now it seems too difficult How were you successful when you quit before? You are doing the best you can do On a scale of 1-10 What made you say 5 rather than 2 or 3? Where should we go from here? What are the barriers or what keeps you from. Strategies for Evoking Change Use open-ended questions Explore possible decisions: pros and cons of changing or staying the same Explore the positives and negatives of the change in behavior (the good things/the not so good things) Look back: What worked before? Look forward: What happens if you continue as is? Use Change Rulers: on a scale of how important is losing weight to you? Come Alongside: Perhaps smoking is so important to you that you won t give it up Barriers to MI Talking on auto-pilot using our trained everyday professional talk Not listening for and addressing how patients make sense of their situation Berger & Williams,

11 Common Problems I just need to tell my patients what to do Patients will do what makes sense to them; People make their own choices I just need to educate my patients Knowing is NOT enough I need to empower my patients Means giving authority ; patients already have power and authority It is my job to motivate my patients MI is not about taking charge and motivating; it is about caring for and being a resource Berger & William, 2013 Common Problems I need to fix or save my patients Results in paternalistic and condescending language I do disease management Patients do disease management My patients lie to me Probably if feeling judged or treated as if they are stupid I feel like I am wrestling with my patients Pushing too hard rather than exploring I am the expert here i.e., we do not have to listen; patients are not experts Berger & William, 2013 MI is The implementation of patient-centered healthcare We cannot provide patient-centered care with provider-centered communication habits Berger & William, 2013, p. 26 MI achieves optimal power through a synergy that occurs when rapport with the patient is used to lovingly address the doubts, worries, concerns, and issues arising within the patient Berger & William, 2013, p

12 Expert Expert = Team The way you are with patients is more important than what you say to patients Developing rapport Steps Reflecting your understanding of the patient s understanding (their sense-making) Don t presume understanding ( I understand how you feel ); and don t say I hear you saying ; rather, it s hard to lose weight. Reframing (HCPs often get stuck with what to say or do next) I know being overweight is bad for me. I know I need to lose weight. ~ So, you know that being overweight can cause serious health problems, while on the other hand, it is hard to change eating habits I don t smoke that much ~ Since you don t smoke that much, it doesn t seem like a problem I ve tried that before ~ It s discouraging when you work so hard and then Steps Ask permission to provide additional information offers a transition to altering their sense making Respects autonomy Treats the patient as a partner I don t smoke that much it s not an issue ~ May I tell you my concerns? Provide new information Must address the patient s sense making - it must make sense to the patient Must be expressed in a neutral form Any loss of weight will help your blood pressure Ask what the patient thinks of the new information? What are your thoughts? Summarize and discuss next steps Berger & William,

13 Bill Bill is 56 year old; has worked in the aircraft industry for 30 years; he is married Jenny and they have two grown children, two grandchildren, John and Kate. He was a 1 pack/day smoker until 10 years ago. He is overweight (about 50 lbs) and has lately been experiencing some episodes of shortness of breath with exertion. He says he gets considerable walking with his job but doesn t otherwise regularly exercise. Medical History: Overweight Diabetic for past 5 years High blood pressure Today, his HgbA1c is 9.8. You want to discuss weight loss and exercise to help with his multiple health issues. What might you say? 1. Bill, you need to lose weight. 2. Do you exercise? 3. Do you eat out? 4. Do you take your blood pressure medicine? Or 1. I am concerned about your A1C. 2. What do you think is going on with your A1c? 3. Tell me about your shortness of breath. Other words I am concerned about your weight, your blood pressure and your diabetes your A1c is running too high. You said you have had some shortness of breath lately, tell me more about your breathing. Would it be alright if we talk about your weight? What types of exercise appeal to you? What have you tried in the past to lose weight? 13

14 MI: In summary Collaborative - allows you to provide healthcare with the patient Evocative activates the patient s motivations Honors patient autonomy gives the work back to the patient MI takes practice Practice using the words (remember I am concerned, tell me about, what, what keeps you from etc.) Allow time for patient to respond (a little silence is good) Think team (expert to expert) The way you are with patients is more important than what you say to patients References Berger, B. A., & William, A. V. (2013). Motivational interviewing for health professionals. Washington, DC: American Pharmacist s Association. Britt, E., Hudson, S. M., & Blampied, N. M. (2004). Motivational interviewing in health settings: a review. Patient Education and Counseling, 53(2), doi: Copeland, L., McNamara, R., Kelson, M., & Simpson, S. (2015). Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: a systematic review. Patient Education & Counseling, 98(4), doi: /j.pec Fischbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: A systematic review and metaanalysis of randomized controlled trials. Patient Education and Counseling, 93(2), doi: References Merlo Lab. (2009). The effective physician: Motivational interviewing demonstration. Accessed on October 12, Merlo Lab. (2009). The ineffective physician: Non-motivational approach. Accessed on March 2, 2015 from Miller, W. R. & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37, Prochaska, O., & DiClemente, C., C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, Ill.: Dow Jones-Irwin. Pro-Change Behavior Systems, I. (2017). The Transtheoretical Model. Retrieved October 17, 2017, from Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational interviewing in healthcare. New York: The Guildford Press VanBuskirk, K. A., & Wetherell, J. L. (2014). Motivational interviewing used in primary care: A systematic review and meta-analysis. Journal of Behavioral medicine, 37(4), doi: /s

15 Mary Koehn, PhD, APRN-CNS, CHSE 15