Motivational Interviewing

Transcription

1 Motivational Interviewing Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital s Department of Surgery to develop an e- module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT The traditional methods of evoking change in the healthcare environment involve educating patients and often dictating information to them that is crucial to their health. This mentality and direction of information may or may not be helpful to many people, who may end up feeling criticized or judged for their decisions and who may have little motivation to change at all. Motivational interviewing seeks to change the interaction between the provider and the patient by assessing the patient s desire and levels of motivation and then working together to bring about change. It is a collaborative process; and, successfully used with other forms of therapy to support engagement between the provider and patient. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1

2 Continuing Nursing Education Course Director & Planners William A. Cook, PhD, Director, Douglas Lawrence, MS, Webmaster, Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner Accreditation Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Credit Designation This educational activity is credited for 10 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Course Author & Planner Disclosure Policy Statements It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise. Statement of Need Motivational interviewing focuses on the patient and their desire to change behavior to improve the state of their health. Nurses are integral in supporting patients to recognize the need for change and to facilitate improvements in their health outcomes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2

3 Course Purpose To provide nurses and health team associates knowledge about the use of motivational interviewing to support health behavior change in patients. Learning Objectives 1. Define motivational interviewing and the basic structure of its use in treatment or therapy. 2. List the four main principles associated with motivational interviewing. 3. Describe techniques used as part of motivational interviewing to assess ambivalence and foster change in the client. 4. Describe how motivational interviewing may be used as part of care for a pregnant client. 5. Describe how motivational interviewing can be used to help clients quit smoking. 6. Explain how motivational interviewing can be used as part of treatment for substance abuse and addiction. 7. Define diabetes and explain the purpose of motivational interviewing in its treatment and prevention. 8. Define heart disease and explain the purpose of motivational interviewing in its treatment and prevention. 9. Describe how motivational interviewing is used among patients with mental illness. 10. Explain how motivational interviewing may be incorporated with other forms of therapy. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3

4 Target Audience Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates Course Author & Director Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MS Susan DePasquale, CGRN, MSN, FPMHNP-BC all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Activity Review Information Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC. Release Date: June 28, 2014 Termination Date: June 28, 2017 Please take time to complete the self-assessment Knowledge Questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4

5 1. Which best describes what occurs during the contemplation phase of the change process? a. Family members and friends may recognize that the client has a problem but the client is often unaware b. The client recognizes the need for change but he or she may be so ambivalent that no change occurs at all c. The client may still be ambivalent about what to do, but he is planning to try for a change d. The client does a lot of activity that demonstrates working toward the change 2. The R in the DARN CAT acronym stands for: a. realistic b. random c. reason d. recognize 3. A client is talking with a nurse and telling her about how difficult it was to accept the death of his father last year. While the client is talking, the nurse leans toward him, makes eye contact, and nods her head periodically. These activities are best described as: a. utilizing silence b. clarifying c. active listening d. mirroring 4. Which of the following is a consideration that must be recognized when working through motivational interviewing with an adolescent client? a. The provider must avoid taking on the role of a parent toward the client b. The client typically only responds in group situations c. The provider must alter most techniques used in motivational interviewing to fit the developmental needs of the client d. The client cannot be expected to make much progress until he or she has completed puberty nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5

6 5. According to Burke, et al., there are four states that contribute to self-efficacy in a person: mastery experience, vicarious experience, physical and emotional states, and: a. personal success. b. high self-esteem. c. generation of power. d. social persuasion. 6. A nurse has contacted a pregnant client to talk with her about the services available to her from the healthcare center. After the nurse asks the client if there are any services she would be interested in receiving, the client states she does not know. The most appropriate response of the nurse is: a. Can I give you some information about educational offerings available? b. Are you feeling ambivalent about making a decision? c. There is a lot of information to digest. We do not need to discuss this anymore. d. I think that you should consider one of our parenting courses. 7. Which best describes an example of the self-efficacy step of the FRAMES method when used with a pregnant client? a. The client receives a list of options to consider for changing her behavior b. The provider helps the client to become more confident in herself by taking charge of her health c. The client is made aware that she is responsible for herself and the health of her baby d. The provider advises the client about what she can do to make changes in her life 8. A nurse is using the techniques of motivational interviewing to work with a client who is trying to quit smoking. The nurse starts the conversation by introducing herself and explaining her job title and role at the clinic. Which best describes the purpose of this introduction? a. To provide an empathic approach to the client s care b. To give the client a menu of options for making decisions c. To establish rapport and begin to build trust with the client d. To promote confidence in the client for making decisions nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6

7 9. Which of the following describes a difference between substance abuse and addiction? a. Substance addiction is disruptive to daily living while abuse causes physical dependence on the substance b. Substance abuse causes symptoms of withdrawal when trying to quit while addiction does not c. Substance abuse is disruptive to daily living while addiction causes physical dependence on the substance d. Substance abuse and addiction are used interchangeably; they have the same definition 10. After going through an oral glucose tolerance test, a client has a blood glucose level of 160 mg/dl. This result would be defined as: a. impaired glucose tolerance b. type 2 diabetes c. impaired fasting glucose d. altered glycogen synthesis 11. A patient has developed cardiomegaly as a form of heart disease. This is best described as: a. decreased circulation in the coronary arteries due to plaque development b. areas of tissue ischemia that cause pain and decreased cardiac function c. pain in the legs with exercise and increased activity d. enlargement of the heart muscle that has developed because of tissue damage 12. While working with a client who has heart disease, the healthcare provider is reviewing some medical information from the client s chart. Which of the following BMI results indicates that the client is classified as overweight? a b c d nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7

8 13. A nurse is discussing the benefits of exercise with a client who has been diagnosed with coronary artery disease. The client states, I know I need to exercise more to improve my health, I just don t know how to get started. What is the most appropriate response of the nurse? a. For your condition, you should start with walking twice a week. b. What do you think you should do to exercise? c. It is important that you think about the types of food you eat as well. d. Can we talk about some of the different types of exercise that you might enjoy? 14. People who commit suicide do so for a variety of reasons, although as many as who do did not communicate their suicidal intent prior to death. a. 15 percent b. 33 percent c. 50 percent d. 90 percent 15. An important aspect of motivational interviewing that is essential to remember when working with clients who have comorbidities of mental health issues is: a. giving unsolicited advice is usually necessary b. self-efficacy is an ultimate goal but is rarely achieved c. empathy is offered on a case-by-case basis d. eliciting change in someone who is not ready will be counterproductive 16. The first P of the PAPA technique, as stated by the book, Intervention in Mental Health-Substance Abuse stands for: a. provider b. provoke c. permission d. prepare nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8

9 17. Which thoughts or feelings are most commonly associated with cluster B personality disorders? a. paranoia, feeling threatened b. anxious, fearful, helpless c. anger, hatred, feeling criticized d. dramatic, emotional, theatrical 18. Which of the following is a consideration when using motivational interviewing among patients with personality disorders? a. Motivational interviewing does not cure the underlying disorder but instead helps the client to make better behavioral choices b. Motivational interviewing is more effective when used with personality disorders and concurrent substance abuse issues c. Motivational interviewing resolves anger issues but cannot treat other clusters of personality disorders d. Motivational interviewing is usually ineffective in personality disorders and should not be attempted 19. Which of the following must be considered when using motivational interviewing to work with an angry and aggressive client? a. The provider should always have a form of protection available during each session. b. Client sessions must be broken down into intervals of 20 minutes or less in order to be effective. c. The probability for repeat offending in this population is high. d. Despite large numbers of patients undergoing MI for aggression, there are still many who continue to suffer. 20. Which of the following is a true statement about mindfulness? a. Mindfulness is a state of hypnosis in which the person is given suggestions for changing behavior. b. Mindfulness is more effective when used in group settings than when used alone. c. Mindfulness involves the belief in and connection with a higher power for facilitating change. d. Mindfulness involves a form of meditation in which the person focuses on what is happening within herself in the present moment. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9

10 INTRODUCTION Motivational interviewing (MI) is a method that promotes behavior change, and can be used in a multitude of environments and situations to foster growth and to help people to take on challenging situations. It uses the principles of therapeutic communication and instead of providing advice, or even just a listening ear, the interviewer acts as a coach for the client. Motivational interviewing is a collaborative process that edifies the client and makes him or her responsible for personal choices. It is not necessarily a stand-alone type of therapy, but instead can be incorporated into treatments and routine care for clients with various health issues, including those with physical health problems, mental health issues, or substance abuse and addiction. MI has also successfully been used along with other forms of therapy to improve connection between the client and the provider and to alter the process at which the client makes changes in his or her life. Healthcare providers can use motivational interviewing in a number of situations, yet it should always be recognized that no one could be forced to change. Many nurses, physicians, and allied health professionals witness the personal situations of clients and their families and grow frustrated by feeling powerless to help. Although MI does not allow the healthcare professional to change a person s behavior, it does guide the client toward making different choices that can foster change in his or her life. Figure 1 Motivational interviewing can be used in a number of different practice environments [1]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10

11 The concept of motivational interviewing began in the early 1980s with the publication of a book by William R. Miller, PhD, who focused his model of MI on working with people suffering from substance abuse and addiction. The book was titled Motivational Interviewing with Problem Drinkers and it was initially used among psychiatrists and other professionals who provided counseling services for people going through treatment for addiction [5]. Almost twenty years later, Miller and a colleague, Stephen Rollnick, published a second edition of the book. The second edition was geared, not only toward addiction professionals working in the field of psychotherapy, to any professional in the healthcare field who could utilize the principles and put the techniques of MI into practice with their clients [5]. Miller and Rollnick described motivational interviewing as a directive, clientcentered counseling style for eliciting behavior change by helping clients to restore and resolve ambivalence [5]. Ambivalence is a state in which a person is uncertain about which direction to take, if any. A person who feels ambivalent about his or her need for change or required treatments may approach the situation with a lack of motivation. The person may have such mixed feelings about the situation that making a decision can be paralyzing. When a therapeutic relationship starts, the client may be in various stages of ambivalence depending on the current situation. If he or she was recently diagnosed with an illness or disease, ambivalence may be paired with frustration or anger over the situation. Alternatively, the client may have known for quite some time that change is necessary but has been unwilling or unable to take steps to move forward. Motivational interviewing is more than just a set of techniques that can be implemented into conversations between healthcare providers and their clients. It recognizes several theories as a basis for its approach, including nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11

12 cognitive dissonance theory, which acknowledges that a person who acts against his or her beliefs will be motivated to either change behaviors or otherwise justify them; and self-perception theory, which is the idea that people conclude certain traits or ideas about themselves based on observing their own behaviors [33]. A basic premise exists in motivational interviewing that talk can be helpful for some situations, but without the motivation to change, talk, or simply telling a person to do something, will not get very far. The provider who is working with a client through motivational interviewing must recognize the level of motivation the client holds and must be willing to work through possible resistance to change in order to foster goal setting and to move forward [33]. Motivational interviewing can be used in many different types of specialties for helping clients to change. Although it may be considered a therapeutic approach that would traditionally be used in counseling or in sessions with a psychologist, motivational interviewing can actually be a part of some routine meetings or examinations for brief sessions. Motivational interviewing has been used successfully in implementing change in numerous situations, such as with drug or alcohol addiction, smoking cessation, vocational rehabilitation, criminal justice, pregnancy, and as part of treatment for many different medical conditions [29]. Similarly, motivational interviewing is not simply designated for counselors or psychologists. It can be successfully implemented into appointments or interactions with various healthcare providers, including nursing staff, primary care physicians, nurse practitioners, or allied health professionals. There is some formal training available in developing the techniques associated with motivational interviewing, although learning the techniques and the process of MI is typically either integrated into formal education nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12

13 programs, such as social work or psychiatry, or through stand-alone training opportunities, such as through workshops, conferences, or online educational programs. The Motivational Interviewing Network of Trainers (MINT) is a non-profit organization that was started by a group of MI practitioners who were originally trained by Miller and Rollnick in MI techniques. MINT promotes the use of motivational interviewing, as well as continuing research and appropriate training of practitioners. The organization is composed of independent trainers and practitioners and can give details about specific educational opportunities for those who want to learn more about motivational interviewing and to put its methods into practice [30]. STAGES OF READINESS FOR CHANGE The ultimate goal of working through motivational interviewing is to move the client through the various stages of change, from being ambivalent or unmotivated to dealing with unhealthy behavior and making more positive choices [21]. The stages of readiness for change is actually a cycle of steps identified by James Prochaska, and each step requires various interventions to move the client on to the next step. The stages of change include: precontemplation, contemplation, preparation, action, maintenance, and termination [21, 22]. The precontemplation stage occurs before the client is even aware that a change needs to happen. Family members, friends, and significant others may easily recognize that the client has a problem or that change needs to happen but the client is often unaware. During this phase, the client is resistant to change because he or she does not understand its necessity. The client may even be aware that life is difficult or there are several aspects of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13

14 life that demand attention that he or she cannot handle, but the concept of change is still foreign. The contemplation stage is when the client recognizes that a change needs to happen. It is often at this stage where motivational interviewing begins. Although the client may recognize the need for change, he or she may be so ambivalent about making the change or what steps to take that no change occurs at all. Many people remain in the contemplation stage for years, always feeling that something needs to be done, but never taking steps to do anything. The preparation stage involves planning to make a change soon. People in this stage may still be ambivalent about what to do, but they are planning to try for a change. They may be uncertain that their plans are the best for solving their situation and so may still be somewhat ambivalent about making choices toward change. They often need to convince themselves that change is necessary and that their plans are the best method of working through the problem. The action stage involves taking the steps to overcome the problem. It is during this stage that the client does a lot of activity that demonstrates working toward the change, such as quitting smoking or exercising more. Others can see the client s work toward the change as well, which can be encouraging. This stage also requires the most energy to continue with changes, even if they are uncomfortable. The maintenance stage is the ongoing phase that may be life long for some people. This stage occurs after a person has done the work of making changes but then needs to continue to make efforts to maintain the results. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14

15 For example, a person who has lost 50 pounds needs to maintain the weight loss by continuing with efforts that he or she implemented to lose the weight in the first place. If the person does not maintain the work, he/she may gain the weight back. The termination phase is one in which the initial issue is no longer a problem. Some people never reach this phase while working for change, as the principles they developed and the work they completed must continue to be maintained and reinforced for the rest of their lives. For others, the termination phase results when the initial change or struggle is no longer a problem and they can move forward into other activities without continuously maintaining their previous efforts [22]. Key principles Motivational interviewing can be broken down into key principles, followed by significant processes that are used. Each process or principle is then supported by various therapeutic techniques. Each technique may serve to uphold or meet the goals of one or more principle or process throughout the interview. To start, motivational interviewing consists of four key principles that guide practice, which are empathy, discrepancy, rolling with resistance, and supporting self-efficacy [5]. Empathy Motivational interviewing is characterized by empathy on the part of the provider. Without empathy, no amount of discussion, sympathy, or understanding will stir the client toward change. The client needs empathy from the provider in order to feel as if he or she is not alone in the process and to feel that someone truly understands. Knowing that someone else has empathy can reduce feelings of isolation and can spur change. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15

16 The goal of being empathic is to help the patient to feel that he or she can open up. The caregiver provides an open and non-judgmental attitude that conveys warmth. The provider s demeanor when engaging the client should express unconditional acceptance whereby the patient senses the provider s response to them to be: I know what you are going through; I care about what happens to you. Figure 2 Motivational interviewing is characterized by empathy on the part of the provider [2]. The provider during motivational interviewing does not try to change the client s ambivalence or condemn the situation. Rather, ambivalence should be accepted as part of the process and the provider should expect that the client would have those feelings. If not, then the motivational interview would not otherwise be necessary. The provider should instead look at ambivalence on the part of the client as the reason for their time together and go forward from there. Discrepancy Discrepancy describes the state the client is currently in compared to the point at which he or she wants to be. The clinician works through the motivational interview to help the client see not only where he or she is currently, but to remind the client of their goals. The client must understand that these are two different states. The state where he or she currently is - one of ambivalence about a situation requiring change - is not the same as the state where he or she wants to be. If it were, the client would not be working through the motivational interview [6]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16

17 To best help the client develop discrepancy the clinician assists the client to see how far he or she has come in other areas of success. The clinician may point out other areas of change such as by saying to the client: remember when you used to struggle so much with this? Look where you are now and how much you have achieved in that area. It can be helpful for the client to know that he or she has overcome ambivalence or past challenges to reach goals in other areas and can know that it can be done in this area as well. It is important for the clinician to remember that the practice of developing discrepancy requires a non-judgmental attitude. The clinician should also remember to ask before giving advice, and to speak clearly and in a supportive tone. Clarifying those items that do not make sense may also be necessary and is often an ongoing part of the process to avoid misunderstanding. By utilizing these techniques, the client will be better able to have a clear direction and understand where he or she is at in a process of changing behavior versus where the client wants to be at the conclusion of the motivational interviewing process [6]. The provider incorporates these key principles throughout the process of the motivational interview. Instead of being a straightforward path, MI is a somewhat fluid method that uses these principles as a general direction. The provider may also use other processes as part of motivational interviewing that support the initial principles discussed. These processes are: engaging the client, promoting change by supporting self-focus, determining the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17

18 client s motivation for change, and formulating a plan [6]. Roll with Resistance While working with clients through the process of change, there are bound to be times of resistance. When the provider discovers that the client is resistant to ideas, suggestions, or change overall, it is important to take it in stride and not create further tension; in other words, to roll with it. The provider should avoid responding in a manner that is harsh or critical, even if the client presents this type of demeanor. Often, the idea of change can be Figure 3 The provider may experience resistance on the part of the client [4]. threatening and some people may respond negatively out of fear. Even if this is the response of the client, the provider should work to remain calm and to continue with the relationship, providing the most support and direction possible through conversation. When the client starts to become upset or resistant to the MI process, it is a signal for the provider to slow down, avoid being forceful in any way, take a deep breath, and consider how their demeanor and delivery of information is presented to the client. The provider should consider his or her words, questions, and any types of non-verbal communication that could be threatening to the client and make adjustments as necessary. The provider should then determine how he or she can best present an empathic presence and show more understanding nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18

19 toward the client to prevent further resistance. It might be necessary for the provider to use some specific phrases during the interview that can clarify what the client is trying to say and to defuse the situation as necessary. For example, the provider could say: I hear what you are saying and I just want to make sure that I am understanding you correctly. That must be very difficult for you; I can t imagine how hard it is for you. It sounds as if you want to consider other options for dealing with what we are talking about. By responding differently, and not mirroring negative attitudes or behaviors, the provider prevents the conversation from unraveling and prevents the client from turning away from making changes because of feeling threatened or otherwise resisting the motivational interviewing process [6]. Support Self-Efficacy Self-efficacy defines how a person feels about his or her abilities. It differs from self-esteem, which describes how a person feels about themself and their value as part of society. Instead, self-efficacy is the personal selfconfidence to perform a task or to take on a situation. A person may have a strong sense of self-efficacy in one area of life but be weak in another. For example, a client may be strong and confident at his job and may be quite successful as a leader at work; however, the client may also lack selfefficacy when struggling with alcohol use and may be ambivalent about change if they feel unable to overcome the struggle [11]. Although high levels of self-efficacy feelings may help a person to feel more nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19

20 confident in his or her pursuit of a goal or involvement with a certain activity, having self-efficacy does not necessarily guarantee that the person will succeed [11]. A provider may work with a client to help them feel more positive about personal abilities, but unless realistic goals and techniques for achieving those goals are introduced into the equation, the client may still not succeed when trying to change. Self-efficacy requires motivation and effort to be successful. A person s belief that he or she can accomplish a goal works as a powerful motivation toward change. Ultimately, it is the work of the client that facilitates change, and not the provider. The client s ability to make the change, rather than requiring assistance or having a provider do the work for them, further supports self-efficacy in the client because they know that the accomplishment was achieved specifically by and for them. The provider s role is to be confident in the client s ability to change and to empower the client by asking questions and directing the discussion. Engaging the client The goal of expressing empathy is to build a relationship of trust between the provider and the client. Empathy involves accepting the client s state of ambivalence, even if the provider disagrees with the viewpoint. When the provider takes on a non-judgmental stance toward the client, he or she avoids being perceived as critical or otherwise condemning of the situation. This stance engages the client and supports the development of a trusting relationship. A client who is going through a crisis or other situation that requires motivational interviewing may already feel judged or criticized by others. Many people who are in need of change are also aware of that need, nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20

21 whether they can actually complete the change or not. For example, a client who needs to lose a significant amount of weight in order to establish a healthier lifestyle and to reduce the risk of developing certain health conditions is most likely aware of the need for weight loss. Often, when caregivers or the public judge or condemn others for their need for change, it only serves to further diminish the motivation for change while simultaneously causing negative feelings and disrupting self-esteem. Therefore, a non-judgmental, accepting attitude must be in place on the part of the caregiver before motivational interviewing even begins. Expressing empathy involves considering the thoughts and feelings of the other person by actually putting oneself into the place of the person. It differs from sympathy, in which subjective information may allow a provider to understand what a client is going through, but the provider can only acknowledge the other person s feelings as a method of providing comfort [7]. Sympathy is not wrong in itself, but empathy can actually break down potential barriers between the client and the provider by communicating comfort and building trust through understanding. A client who receives an empathic response from a provider during a motivational interview may be willing to open up more if he or she perceives that some of the struggles involved are shared. Determining self-focus The focusing component of motivational interviewing involves setting up the direction in which the conversations will go. It often starts with an initial meeting in which the client and the provider meet to discuss their purposes for talking and to discuss initial thoughts, concerns, or priorities of the client. Through focusing, the provider takes the information given during the initial conversation and helps the client to find a direction for where the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21

22 conversations will go [6]. It is important that the provider does not take complete direction with the interview by telling the client what he or she should do. Part of the goal of focusing is to allow the client to find his or her focus through the coaching involved with motivational interviewing, not to be told what to do. The provider should also avoid developing a premature focus in which he or she decides the direction of the interviews early on [6]. This can limit the potential for where the conversations could go and also impact how well the client is able to work toward change. If the provider decides on the focus for the client early on in the relationship, the client may be less likely to stay motivated or involved, particularly if he or she believes that the point of the relationship is only to work toward the clinician s goals, not the client s. To develop a focus for the interview process and the therapeutic relationship, the provider and the client should work together to decide what the goals of their time together should be. By collaborating on the focus, both the client and the provider have a vested interest in the relationship because they have worked together to set their goals. Figure 4 Focusing allows the client to find his own way, rather than being told what to do [34]. Evoking change nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22

23 The heart of motivational interviewing, according to Community Care of North Carolina, is evoking change through the relationship between the provider and the client. Evoking change involves helping the client to determine his or her own amount of ambivalence toward the subject at hand and the amount of motivation that he or she has to make a change [6]. Evoking change first requires understanding what the client wants to change. This comes about through initial interviews, but may change through the course of the relationship. If the provider and the client have determined a focus for the MI, this will guide the provider toward where to direct their discussions to evoke change. After the focus of the discussion has been identified, the provider then helps the client to explore more reasons for change, barriers to change, and what systems should be in place to evoke change [6]. Before change can begin, the provider must also bring up and discuss the client s level of ambivalence. If the client is uncertain about changing or which direction to take in order to make the change, the ultimate goals and focus of the relationship may not go far if ambivalence is not addressed. The provider should ascertain the amount of uncertainty the client is experiencing by guiding the discussion. For instance, the provider may ask the client some questions to explore any ambivalent feelings and determine what might be keeping the client from taking a step in one direction or another. Figure 5 Self-efficacy is empowering to the client [3]. Change may be more likely to occur if the discussion focuses on past nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23

24 successes for the client. This focus can help to improve confidence and feelings of self-esteem when a person knows that he or she has been successful when attempting a previous activity [6]. The provider might focus on the client s strengths at his or her job or in other relationships and use those strengths to apply to the current situation. For example, when considering a client who needs to lose a significant amount of weight, the provider might bring up that the client has been successful with committing to their duties at work and can stay focused on them. The client may bring up past success with completing projects or enduring through situations when circumstances were difficult. The provider can then use that information to empower the client toward his or her next goal of losing excess weight. By remembering personal successes, the client can bring that information to mind the next time he or she struggles with working toward a current goal. It should be noted that not all relationships developed through motivational interviewing evoke a complete change or result in change occurring at all. Some people, despite being willing to enter into the motivational interviewing situation and the therapeutic relationship, will be resistant to change. Making changes, regardless of the underlying need, can be scary and overwhelming and some people may ultimately decide that changing is not worth it. However, it is important for the provider that utilizes MI to understand that resistance to change does not have to be end of the relationship. Instead, it should be looked at as an opportunity for redirecting the focus of the relationship. The provider does not determine the path that the client takes. Rather, the provider helps the client along the path that he or she has chosen [5]. A final aspect of evoking change is preparing for the resources that will be nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24

25 needed to support that change. Typically, a client does not make changes all on his or her own, and even with the help of a provider, long-term and permanent change is not carried out without the help and support of others. The client must learn about what resources are available and where to turn for continued support. As these ideas are mapped out, the motivational interview moves into the planning stage for how tasks will be completed in order to achieve the desired goals. Planning The planning phase of the interview comes after much of the discussion surrounding change has occurred, including discussion of the client s motivation and levels of ambivalence, his or her desire for permanent change, and level of commitment to the change. Additionally, the provider and the client have set goals for where to direct the interview in order to best plan for the final outcomes. Planning involves structuring how the process of the interview will take place. The client and the provider work together throughout the process and continuously re-evaluate how well the client is working toward set goals and ideas for change. This may involve setting smaller benchmarks during the process and providing little rewards along the way as the client makes changes [6]. Figure 6 Planning final outcomes [82]. Planning also involves accountability between the client and the provider. The client remains accountable toward the interviewer to keep him or her nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25

26 updated about the work completed toward ultimate goals, the achievement of smaller goals set along the way, and what resources have been utilized in the process. This accountability allows for evaluation of what is working in the process and what is not, and allows the provider and the client to work together to make changes where necessary. Accountability is also required from the provider toward the client. The provider must follow through with his or her plans for coaching the client and commitment to the relationship. This involves keeping contact with the client, following up on unfinished business, and maintaining that side of the relationship to ensure that it will continue. MOTIVATIONAL INTERVIEWING TECHNIQUES Once the overall process of the motivational interview has been determined and the healthcare provider is aware of the need for empathy, finding a focus, evoking change in the client, and planning for resources, these processes are facilitated through the conversation. The provider can use a number of techniques to facilitate the interview, each with its own method of supporting the processes that make up the therapeutic relationship. Facilitating the process The motivational interview typically begins with a meeting between the client and the provider, who could be a nurse, physician, medical student, allied health professional, or Figure 7 Conversation. [83] someone in the field of counseling or psychotherapy. Often, the first meeting is the first actual encounter with the client, and the provider does nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26

27 not have much information into his or her background. The provider may be aware of the need for the client s change because of circumstances understood in broad terms, but in order to understand the client s feelings of ambivalence as well as the greater details of the need for change, the provider and client must have initial meetings to discuss the client s background and contributing factors for the relationship. The initial encounter involves a getting to know you process in which the client provides background information about him- or herself. Even at the beginning of the interviewing process, the provider must use techniques of therapeutic communication to gather information and to establish a basis for trust in the relationship. This involves active listening, avoidance of interruptions, and reflection on what the client has said [5]. Once the background discussion has taken place, the provider can move forward with the rest of the process of goal setting and evoking change by utilizing various therapeutic techniques that are inherent parts of the motivational interview. It is through these techniques that the client is able to open up and provide more information, learn to trust the provider, and work toward a mutual goal for the relationship. There are various techniques that make up the motivational interview and can be utilized effectively to support the different aspects of the relationship. OARS A technique that can be successfully used to engage the client, provide empathy, and promote communication is known as OARS, which stands for Open-Ended Questions Affirmations Reflection - Summaries. The process of using OARS in communication can be looked at in the same way as a reallife method of using oars in a rowboat. Wagner and Conners clarify the use nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27

28 of OARS this way: [OARS] give us power to move, yet it is not a powerboat. We don't zip from one place to another, yet with sustained effort OARS can take us a long way [8]. The provider uses open-ended questions to evoke more of a response than simply yes or no. Although closed questions are sometimes necessary or may be the only method of gaining some information, open-ended questions should be utilized to get the client to share more information [8]. Sometimes, by starting to talk with answering an open-ended question, the client will continue to share much more. Open-ended questions are probing but should not be too intrusive for the client, which can result in an opposite effect. They demonstrate that the caregiver is curious about the client s situation and wants to hear more [6]. Examples of opening lines of open-ended questions that may be used in the interview include: Tell me more about What did you do after Can you explain more about How did you feel when Affirmations are the second section of the OARS mnemonic. Affirmations look for successes from the client and point out those areas of accomplishment. The provider must be genuine when providing affirmations, as false praise is completely different than a genuine affirmation and a client can usually understand when someone is not being authentic [5, 8]. If the client does recognize that the provider is not genuine in his or her words, a roadblock will quickly go up that is destructive to building trust and will keep the client from sharing any more information. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28

29 Affirmations are words that are encouraging and optimistic; they are meant to help the client see progress being made. Examples of affirmations that could be included as parts of the interview are: I m glad that you want to talk about this. I think what you are doing would be very difficult, and you are putting a lot of work into it. You have made a lot of progress. You controlled yourself well in that situation. The third component of OARS is reflective listening. This considers what the patient has said and repeats it back to him or her in slightly different language. The provider is reflecting on what the patient has said, while the patient is listening to his or her own words said in a different way. This helps both the provider and the patient. The provider uses reflection to fully understand what the client is saying so that none of the information will be misinterpreted. Reflection also helps the client to think about what he or she is saying, consider its truth or inconsistencies, and clarify ideas that might have been misunderstood. Reflection should be a regular part of the motivational interview, as one missed idea from one side or the other in the conversation can lead to a set of false assumptions and misinformation that must be corrected before the conversation can move on. Instead, regular reflection continues to provide clarification for statements in a manner that is not threatening. Examples of the openings of reflections that could be used in the interview include: What I hear you saying is It sounds as if you want to nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29

30 So, your concern is that You believe it is important to From your point of view, you Summaries are the final component of the OARS mnemonic. Summarizing takes the information the client has said and what has been discussed during the interview and puts it into one or two concise statements. This process has several purposes. It reinforces the idea that the provider is listening to the client and has heard what he or she has been talking about; it serves as a type of reflection to help the client hear again what he or she has been saying and to think about it; it clarifies information from the part of the provider, and it provides a transition into the next segment, which could be closing the session or moving onto another topic [6]. A summary of the discussion can motivate the client because it supports the coaching provided by the provider. Summarizing also supports the focusing aspect of MI in that the client is able to see a few distinct areas in which to concentrate efforts, which can make the process seem less overwhelming and may give him or her a better idea of how to focus tasks later on. Examples of summarizing statements include: If we review what we have been discussing, I can see So, you believe that Am I correct? We have covered this information well by talking about Here are the points that I understand so far To summarize Informing or advice giving Providing information to the client and giving advice must be done very nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30

31 carefully to avoid taking over the direction of the conversation and telling the client what to do. There will be many times when clients are impressionable: if they are ambivalent about making a decision, they may want the provider to tell them what to do. This is an important scenario to avoid, as the client needs to process enough of the information in order to make his or her own decisions. Additionally, if the client makes a decision based on what he or she thinks the provider has said, there s a risk the client may later regret the choice or may not be willing to stay with the outcomes and then feel angry or blame the provider for suggesting the wrong thing to do. Figure 8 Informing avoids telling the client what to do [84]. By allowing the client to take their own direction and supporting them in decisions, the provider helps the client to feel empowered by their own choices and alleviates them of the role of being ambivalent to being more decisive and goal-oriented. Information and advice should be open and guiding, allowing the client to be the best expert for their own situation. The provider always asks permission before imparting advice or giving information about a situation, using statements or questions such as: Would it be all right if I shared with you I have seen this experience in the past. Can I tell you about it? nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31

32 Could I share with you what I have read about this? It may be helpful at the beginning of the relationship to determine what the client s best method of understanding information would be. Some people are visual learners and respond best to pictures or reading materials. Others are auditory learners, and can take in and better grasp the information that they hear. When the provider understands the various different types of learning methods, he/she can be better prepared to share information in a manner that has meaning for the client, such as by bringing reading materials that support the topic of the conversation [6]. Giving advice, even when it is permissible, is not simply telling the client what to do. Even if the client allows the advice, the provider should still never direct statements to the client to say such things as, if I were you, I would or you can fix this if you would Instead, the advice and the information must be connected to the client s concerns and address those thoughts and feelings. A menu of options offers choices to the client so that he or she does not feel as if the advice or information given by the provider is the only choice for the client s behavior. Instead, providing a menu of options as part of the information still allows the client to choose the best step for him- or herself [6]. DARN CAT A helpful mnemonic that can be used to elicit change is remembering DARN CAT, which stands for Desire Ability Reason Need Commitment Activation - Taking steps. When a provider considers approaching the client with talk about change, he or she can think of the DARN CAT acronym as a reminder of how best to build motivation in the client. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32

33 Desire means a statement or words that the client uses that indicates wanting to change. It is important to listen for desire statements, as the provider can remember these and use them to remind the client at a later time if he or she ever feels confused about their choices. Desire statements are the beginning of resolving ambivalence: if a patient has a desire for a change, he or she can at least understand the general direction in which to go. Desire statements include anything that signifies the client s wishes or needs: I need to get my life in order. I wish I could lose this weight to better care for my health. I want my blood pressure levels to be normal. The A of DARN signifies the client s ability to change, based on their beliefs that change can happen by working with the tools and guidance available from the provider. The provider can better direct the client toward thinking about items and successes that will support his or her abilities. The provider might say: You were able to accomplish this before, is there something stopping you now? Why do you want to do this? The client also may also make statements that will signify that they have a growing belief in themselves. These might be positive phrases or comments that indicate that the provider has noticed the client has been thinking about the change made and has grown in believing in themself: I ve done this before; there is no reason why I can t do it again. If I can just.i think I can do it. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33

34 I can make this change if I work at it. The R in DARN stands for reason and explores the reasons behind the change. The discussion may center on why it is important to change or the disadvantages of not making the change. Exploring the reasons behind the change also help to reduce ambivalence in the client because it provides a clearer direction of change for the client. The provider can ask questions to help the client better determine his or her need for change: Why do you think this change is important? What benefit do you see happening from this? The N in DARN CAT stands for need. This step is important for the client to better understand the true need for the change. Again, this step helps resolve some ambivalence when the client is able to see how the problem affects his life and how making the change can improve the situation. Some people become so involved with their situations that they fail to see how destructive their lifestyles are. They may not be aware of the detrimental effects of their choices or be able to see how change could make things better. For example, a provider might work with a client with a history of substance abuse and who is working toward making changes in their behavior and relationships with their family. The client may be so engrossed with accessing and using drugs and alcohol that they do not understand the impact that their behavior has had on their spouse and children. The client may come to the situation feeling ambivalent about change or even unsure whether the change is worth the time and effort. Over time, by discussing the situation with the provider through motivational interviewing, setting nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34

35 goals, and taking steps toward change, the client may be more likely to see how much better life could be if he or she follows through with the changes. The client better understands how truly important it is for them to change. The client who starts to understand the need for change may make statements that indicate his or her level of comprehension: I didn t realize before how hurtful this all was. I need to change so I can spend more time with my family. I want to do things differently and try to mend my relationship with my spouse. The first part of the acronym, DARN, is devoted to promoting change for the client. Each of the letters in the word are focused on what the provider can do to guide the client toward change, as well as how the client can recognize the importance of change and determine to make a difference. This is what is classified as change talk and is the focus of DARN. Alternatively, the CAT portion of the acronym consists of the second phase of mobilizing someone toward change. The C in CAT stands for commitment and signifies that the client is taking steps to commit to change. This step is important to acknowledge because verbalizing the commitment is the first step toward following through. If the client can speak his or her intent out loud, it may become clearer and may be easier to focus attention in the right direction. Examples of statements that indicate commitment on the part of the client include: I will quit, because... I plan to start nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35

36 I will finish The A of CAT stands for the activation of the stated commitment. Once a client commits to making a change, the provider and the client must work together to determine how to best go about making such a change. If the client is not equipped with the right tools for change, his or her words of commitment will be meaningless. Examples of phrases from the client that signify a readiness to activate the change include: I am ready for this. I am prepared to change by I will work at this through Finally, the T in CAT stands for taking steps, which are statements by the client that confirm the readiness to change. These statements demonstrate the client s commitment to change because they come from the client instead of being directed by the practitioner. Because they are in the client s own words, the client has formed the suggestions for change into a meaningful and realistic statement that he or she can now put into practice, such as: I called my doctor to ask for a prescription for medication that will help me quit smoking. I really had a craving for earlier today, but I took a walk instead. The implementation of the steps of DARN, followed by CAT, help the client to understand the need for change and then take the important steps toward completing interventions to reach his or her goal. Throughout the process of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36

37 working through the steps of the acronym, the provider should continually evaluate the progress being made and make changes when something doesn t work. If the client resists one of the steps, the provider should take a step back, clarify what is needed, and try to work through any gaps that have presented as part of the process. Elicit-provide-elicit Another method of helping the client to take charge of his or her decisions is the elicit-provide-elicit method. This idea serves to seek information from the client, provide advice that can be helpful and empowering, and then follow up with the success of the information. The elicit-provide-elicit method is directed by the provider but is actually a collaborative process between both the provider and the client. The first elicit establishes the client s expectations, beliefs, and goals of the interaction or the change that is required. The provider approaches the topic with sensitivity and asks permission before giving advice or otherwise directing the client. The provider may open with a question or a statement, such as: Do you mind if we talk about Can I clarify something that you said about Would you like to discuss the subject of Can I share some related information about Each opening phrase is designed to ask or clarify what the client knows about the situation; it also asks permission for the provider to provide more direction on the topic. The second step is to provide information about the topic or to clarify something the client has brought up that still might be unclear. The provider may say: nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37

38 This could be why What we know is Others have worked through this by During the provide step, it is important to avoid using statements that include I or you; and, to remain neutral. This avoids coming across as judgmental or condemning in any way. After providing advice or direction, the provider once again elicits information from the client to determine how well he or she understands the information presented and to get a better feel for how the information will be used. The second step of eliciting involves more about the patient s feelings for the situation and how the information is interpreted. The provider may say: What do you think of what we have talked about? Where can we go from here? How can I help you at this point? As with other interactions, it is important that the provider not tell the client what to do during the second elicit phase or give his or her opinion about the situation. Instead, it should be looked at as another opportunity to collaborate with the client by using known information to work toward results [5,10]. FRAMES Another guide used to solicit change is termed FRAMES, which stands for nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38

39 Feedback Responsibility Advice - Menu of options Empathy - Selfefficacy. Following the FRAMES model approach during the motivational interview can help the provider to remember the most important aspects of interaction to foster success for the client. Feedback involves the exchange of information between the provider and the client. The provider may ask for information from the client by asking open-ended questions and helping him or her to open up more with sharing. The provider may also give feedback as part of reflecting or summarizing the discussions and clarifying points. Alternatively, the provider may also offer feedback to the client in the form of thoughts or advice. An essential component of motivational interviewing is to always ask for permission before offering advice or feedback on the client s perspective. This practice respects the client s point of view and helps to address some of the client s ambivalence about the topic [9]. The R of FRAMES stands for responsibility, which outlines some of the expectations for the interviews as well as the responsibilities for change. Ultimately, it is the client s role to take responsibility for making changes within him- or herself, however, the provider serves as a coach or director for assisting with changes. The provider and client work together to collaborate on the change process but the provider should direct the client as to his or her expectations for change that they have decided on together. It is not appropriate, nor is it possible, for the provider to take responsibility for the client s change; that responsibility must belong to the client. Many providers who work with clients during the motivational interview process are skilled and have knowledge of various psychological concepts nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39

40 and therapeutic techniques that would be helpful to share with others who need guidance for making changes in their lives. Giving advice can be very helpful for some clients, particularly when they have enough ambivalence about a topic of change that they are unable to make a decision about where to begin. Just as with offering feedback, it is essential that the provider ask for permission from the client before giving advice. This is a crucial element of communication, as unsolicited advice is often not helpful and could be misconstrued as looking to provide an automatic response, rather than searching together to find the right answers for the client s situation [9]. The menu of options refers to a list or group of choices given to the client for making decisions. When a client is ambivalent about making a decision, it can be easier when presented with more than one option of steps that could be taken toward the goal. For example, if a client is trying to lower his or her high blood pressure and is having difficulty adjusting to lifestyle changes, the provider could offer a menu of options to choose from to change, any of which would contribute positively toward lowering the blood pressure. The client could choose to lower salt intake by 500 mg daily, choose to increase exercise activity to two 30-minute sessions each week, or could contact their physician about starting another form of blood pressure medication. The menu of options requires that a choice be made, but regardless of which choice the client decides, they would each help to take a step closer toward the client s goal of better health. Empathy refers to the method of engaging with the client to foster a trusting relationship and to impact the client s ambivalence toward making a change. By being empathic toward the client, the provider is better able to understand where he or she is coming from, but is also able to make a connection on a deeper level. When a person feels that a provider truly nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40

41 cares, a better sense of the degree of the client s ambivalence may be more evident and the client able to more likely to find direction toward the choice that should be made. The provider can express empathy through their statements and responses to the client by supporting what he or she has to say and expressing understanding of the situation. Self-efficacy is the final component of FRAMES; it refers to helping the client understand his or her own strengths in the situation of change. The provider can promote self-efficacy by talking with the client about his or her strengths and accomplishments. This may mean bringing up past successes to use as reminders and to promote confidence in the client. When a person believes in themselves, they are much more likely to continue moving in the direction of change, thereby reducing feelings of ambivalence. The client may be less likely to feel overwhelmed or incapable of change if they believe in their abilities and capacity for change. Pros and cons Exploring pros and cons of a situation can be helpful in assisting someone with making a decision. When a client experiences ambivalence about a situation, he or she may not have enough information to consider potential choices. Determining pros and cons of the situation can help to provide clear direction for deciding on the next step of change. Figure 9 Working together to make a decision [85]. Determining pros and cons is a relatively simple process. The provider can nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41

42 make a list or chart of the client s options, followed by an area to list the pros, or the good aspects of the choice, compared to the cons, which are the negative aspects of the choice. Listing the pros and cons helps both the provider and the client to explore and discuss each of the terms. Some people use the information from a list of pros and cons to go on to make their decisions. They may look at the number of pros versus the number of cons and decide based on sheer numbers alone. Alternatively, while one side may have more than the other, the client may make a decision of the pros and cons based on one or two aspects on the lists that really stand out as being more important. Non-verbal communication Non-verbal communication makes up the posture, attitude, gestures, and unspoken communication that both the client and the provider engage in. The provider who is conducting the interview must be very cautious of his or her non-verbal communication because it speaks volumes. Although the provider s words may be engaging and non-threatening, if the non-verbal communication says otherwise, the provider will create the same impact as if harsh or critical words had been spoken. Non-verbal communication supports the spoken word and helps a person to remember what has been said. Alternatively, non-verbal communication can convey certain messages all on its own. Facial expressions, eye contact, posture and gestures all make up types of non-verbal communication. A healthcare provider who is conducting a motivational interview should display active listening when the client is speaking. Active listening ties listening to the client with the appropriate non-verbal signals that show the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42

43 client that the provider is attuned to what he or she is saying. By actively listening to the client, the provider not only hears the words with their ears, but demonstrates other measures that shows the client that he or she is being listened to, such as by leaning forward, making eye contact, and nodding the head periodically [5]. Figure 10 Non-verbal communication is an essential component of working with clients [86]. Silence is another measure that may be implemented at the appropriate time if the right non-verbal cues are paired with it. Often, people do not necessarily like silence, believing that it makes conversations awkward. However, if a client is sharing information that is valuable and personal, or if he or she is experiencing emotions that can be overwhelming, the provider can silently listen and wait while giving appropriate non-verbal cues. For example, if a client begins to cry while talking about the death of their father, the provider can sit silently with the client while they cry, allowing them the opportunity to express grief. This silence can be much more effective than trying to fill the space with words, interrupting the client while they are emotional, or using automatic responses or clichés that are not helpful. Facial expressions involve non-verbal communication that could be overlooked during the conversation. At times, it may be difficult to maintain an appropriate or neutral facial expression when discussing distasteful or shocking information. It is important to maintain a positive or at least neutral facial expression when talking to a client, rather than a look that nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43

44 shows anger, disgust, contempt, or boredom, which will most likely be noticed by the client and could break down some of the lines of trust that have been developing. If the client is demonstrating strong feelings, it may be appropriate for the provider to mirror those feelings through facial expression. For example, if a client is angry about a situation involving a colleague at work, the provider may show anger as well to demonstrate that he or she understands the strong feelings. Eye contact is another area of non-verbal communication that sends a strong message. It may be difficult to determine whether eye contact is appropriate in some situations, as there are some cultures in which it is considered to be disrespectful or rude. Alternatively, for many people, eye contact shows interest in the conversation, it demonstrates a sense of openness from the provider, and encourages the client to continue talking [7]. The amount of eye contact used is also important, as staring or otherwise gaping at the client can put them off. Posture can convey several messages, depending on how it is used. The provider who wants to demonstrate openness and listening toward the client should sit in a way that is leaning slightly forward with their hands in the lap or at their sides. Alternatively, standing with the arms crossed in front of the body demonstrates a closed appearance that is not easily approachable or does not otherwise indicate a willingness to listen. Keeping the hands on the hips may convey irritation or superiority, while tapping the foot or the fingers demonstrates impatience or irritation [7]. Many people display themselves through their posture with little thought to how it appears to others. For example, a person who has self-confidence may naturally walk upright with a straight back and look others in the eye. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44

45 Alternatively, someone who has low self-esteem or who is very shy may have a slumped posture and may not make as much eye contact [7]. The healthcare provider who is conducting the motivational interview should be very aware of his or her own posture and how they carry themselves, and to think about how it may come across to others. It may help to study one s own posture in a mirror or to ask others to comment or give feedback about one s posture and gestures to see if changes should be made before interacting with a client. LIFESPAN AND CULTURAL PERSPECTIVES This section covers motivational interviewing in certain areas along the lifespan and in varying cultural settings. Special focus is given in this section to MI for children, adolescents and the older adult populations, and the unique aspects of MI during the times of life where increased family support is necessary and often crucial. A major development in the area of motivational interviewing is in the area of child and adolescent care, where youth require guidance in school and social settings. Its important for the provider to realize that youth at all ages may have difficulties with change because of the level of developmental changes they already undergo, and the level and impact of their family support. Interventions with children, in particular, during motivational interviewing have been successful to some extent and are sometimes implemented by teachers and counselors that work with them at school. Children are often more dependent on their parents and caregivers for support than adolescents and typically have little say in what goes on at home. Therefore, working with children through MI may need the added component of family therapy and discussion to ensure that the families involved are supporting nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45

46 the changes their children are experiencing [15]. Children and adolescents Motivational interviewing can be used with children and adolescents by helping them to explore their needs for change and address their feelings of ambivalence about change. A provider who works with a child can determine his or her readiness to change based on statements made about problems or the need for change. It can also help the provider to determine the level of motivation that the child has for making a change. The provider working with a child needs to recognize the importance to maintain and convey an attitude of respect for the child s situation and for his or her own decision about making a change. The provider must be careful not to take on a parental role by directing the child toward what he or she should decide, and, instead, continue with the appropriate coaching method that will help to guide the child toward the right decision. Because parents and families are typically responsible for managing the care of children and the fact that young children are often not developmentally capable to make certain decisions on their own, motivational interviewing techniques are best used for children and their families to facilitate change. The age at which to transition to working solely with the child to make his or her own decisions is based on several factors, including the developmental ability to rationalize cause and effect situations, such as: the understanding that certain behaviors can cause negative effects; the child s language skills, or ability to express feelings and address problematic behaviors; and, understanding of the self, in which the child recognizes discrepancies between their behavior and what they want to achieve. The age at which these developmental concepts are achieved varies between children, but often, working through MI exclusively with children without their parents nursece4less.com nursece4less.com nursece4less.com nursece4less.com 46

47 present does not occur until children have greater cognitive capacities for change, which is closer to the age of adolescence [16]. Adolescence can be particularly challenging for many families, as the time between childhood and adulthood is fraught with confusion, hormone changes, and outside pressures that can make many teens feel uncertain about themselves and may lead them to engage in potentially destructive or harmful behaviors. From the standpoint of MI, adolescence is an important time to discuss change and to recognize its power, as the time of adolescence often sets the stage for future habits and lifelong behaviors. Figure 11 Group motivational interviewing is helpful in some situations [81]. Those activities that an adolescent participates in during the teen years can impact health and behavior well into adulthood. Using motivational interviewing as a method to reach adolescents can then change some behaviors and help them to make better choices, not only for their current lifestyles but for their futures as well. Working with adolescents can be challenging, because the provider is faced with developmental factors as well as addressing ambivalence and the need for change. In addition to developmental changes, most adolescents live with others in families that have a strong influence because of their ages, and providers may need to simultaneously work with the teen through MI nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47

48 and handle the actions or viewpoints of the parents or caregivers. For example, a teen client who is going through motivational interviewing as a technique to lose weight may become motivated to change while working through the MI process; however, the client may also have little to no control over the types of food that is available at home because the client is not responsible for grocery shopping, and may or may not be able to make it to appointments consistently if dependent on others for a ride. If the parents or major caregiver of teen clients that are undergoing MI are not on board with the process, it can be much more challenging for the provider and the client to work together to make changes that are consistent and lasting [12]. Practitioners who work with teens may need to work around many changes that are occurring in these young peoples lives. These include biological changes, such as physical growth, hormone changes, and puberty; cognitive changes, including the development of more mature thoughts, ideas, and concepts; and, social changes, such as developing a personal identity, having friends and social relationships that may include pressure to change, to fit in, increasing levels of autonomy, and living with family members [12]. Although all of these developmental changes greatly contribute to the process and success of motivational interviewing, many practitioners also find that working with adolescents is quite rewarding, despite its challenges. Just as when using motivational interviewing while working with adults, the provider and the teen client can start out in an individual session by building rapport and investigating the levels of the client s ambivalence. While discussing the need for change and exploring ambivalence, the provider must also look at discrepancies in the client s behavior and desire for change. Because teens can be impressionable and there are often greater levels of confusion about the right way of behaving versus outside nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48

49 influences, there could be larger discrepancies seen. For instance, a teen who wants to have good grades at school and who states that this is important to him or her may also struggle with avoiding social groups that want to hang out all weekend, avoid studying, and otherwise engage in problem behaviors. This is a discrepancy for the client, who must choose between what he or she says is important and what is actually done [13]. As with any interview, it is important for the provider to convey an attitude of respect for the adolescent client. This may be difficult for some practitioners who view adolescents in general as too malleable to be able to make positive decisions for themselves. Before the interview even begins, the practitioner must commit to respecting the adolescent client s choices and plan for change. The provider acts as a coach or guide during the MI process and because many teens are impressionable, they may want someone to make decisions for them or to assist them with deciding what to do. There is a fine line to watch here to ensure that the provider does not overstep their role to act as a parent or caregiver to the adolescent client and make his or her decisions. Instead, the provider must always remember to act as a coach and assist the teen client in decision-making, ultimately allowing the decision to be the client s choice. The provider uses the principles of change talk with the teen client and promotes self-efficacy for change in the situation. The other techniques listed in this course can successfully be implemented with teen clients when working through motivational interviewing. One method that has been successful when working with teens in particular is the use of group motivational interviewing, in which teens meet together in a small group with a practitioner to go through the MI process together. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49

50 This may be challenging, as the provider must coordinate different opinions and ideas from those involved to continue to coach and guide the group. The various viewpoints and struggles that come from each of the teens involved may also be difficult to coordinate for the provider. The practitioner who is facilitating the group must be able to recognize the individual levels where each participant in the group is at and determine each member s willingness to change [14]. RAND has been working on an initiative to increase motivational interviewing in groups for teens and has shown that the program is beneficial. The approach uses small groups for interventions and employs the therapeutic principles of promoting self-efficacy and expressing empathy. The groupcentered approach has been a positive activity for those involved because it engages them with others who may be struggling with similar issues. It is also validating for those who participate when they see other adolescents with similar issues overcome and make changes in their own lives. [14] Older adults This section covers motivational interviewing in older adults and how it can successfully be used as a means of facilitating change. The older adult population should continue to be considered as a group worthy of continuing change in life that leads to greater well being, despite the opinions of some who deem older adulthood as a period of decline. Motivational interviewing works well in the older adult population but typically must be reserved for working with those who do not have cognitive disabilities [17]. The basic practices associated with motivational interviewing are the same for older adults and the geriatric population as they are for working with younger adults; evoking change through the principles of coaching and nursece4less.com nursece4less.com nursece4less.com nursece4less.com 50

51 guidance by the facilitator who uses empathy and who promotes selfefficacy. However, the provider must also recognize some challenges that can go with working among older adults. Life expectancy is shorter than when working among older adults and some may experience a sense of hopelessness for the future as they age. Older adults may also experience greater levels of grief from more frequent losses in relationships or changes in circumstances; they also have more health problems that develop because of the aging process and may be concurrently involved with physical treatments or taking larger amounts of medications [17]. Because of these changes that occur with aging, some modifications must be made through motivational interviewing when working with older adults. The provider may need a greater amount of flexibility with planning and goal setting with the ambivalent older adult. This can include reviewing goals frequently and re-evaluating the course of the interview on a regular basis. Many older adults are resistant to psychological treatment and therapy and attach a stigma to it; therefore, the provider may need to approach the process of MI from a slightly different standpoint, offering MI sessions in different settings, such as over the phone. Other strategies may include repetition of information on a regular basis to reinforce concepts and consulting with other providers who may be working with the older client to manage other physical conditions, such as another medical specialist who manages the clients health plan and prescriptions or a physical therapist who has been handling some of the client s physical limitations [17]. Despite some of the added challenges associated with pursuing motivational interviewing with older adults, working with this nursece4less.com nursece4less.com nursece4less.com nursece4less.com 51

52 population can be rewarding and satisfying for both the practitioner and the client. Cultural influences Just as it is necessary to consider the unique aspects of each person when conducting a motivational interview, whether it be due to age, developmental status, or change required in each situation, it is also essential that the interviewer recognize the impact of cultural influences on the interview process. A growing and increasingly diverse society requires that provider to recognize the varieties of people and cultural backgrounds that they may work with. Providers must initially place value on diversity in order to keep an open mind right from the beginning of the motivational interviewing process. Throughout the process of interviewing, the practitioner must maintain an awareness of the cultural preferences of the client and seek to not override those practices with their own. The provider must instead approach the process of change from the cultural perspective and preferences of the client. It may be difficult for the provider to have empathy for the client, particularly when such cultural differences exist between the client and the provider that it is hard to imagine a connection. The provider must symbolically put themselves into the shoes of the client in order to practice empathy; this requires a greater understanding of the client s cultural preferences before understanding how to do that. For instance, consider a situation in which a practitioner is working with a client who is religious and engages in regular prayer as part of making changes. Alternatively, the provider does not have the same beliefs as the client and does not consider nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52

53 the impact of prayer in their own life when making personal changes. How might the practitioner practice empathy in this situation if he or she does not share the same beliefs as the client? Although the provider cannot compare themselves in the exact same situation as the clients because the provider does not have the same beliefs, he or she should take a slightly broader perspective when trying to be empathic in this situation. The provider may not believe in the power of prayer in the same manner as the client, but may believe in something else that is powerful to them and that worked to help them to make changes in their own life. The provider can then consider the significance of these items in their own life when showing empathy to the client. It is not that the provider and client share the same exact beliefs, but they can both understand the significance of certain practices that influence change. That connection is where empathy is able to develop and where the provider can genuinely find the link between him- or herself and the client. In addition to being empathic toward the client, the provider must also express empathy in a genuine manner so the client understands the empathy and does not feel judged. A client who is seeking help through MI for making changes may already feel condemned in some ways because of the need for change. A client with a significantly different cultural background from the practitioner may feel even more threatened if he or she feels judged because of personal beliefs or cultural practices. It is imperative that the practitioner be empathic toward the client in a manner that is genuine and honest [18]. Because promoting self-efficacy is a key component of motivational interviewing, the process of reaching the point of confidence in making nursece4less.com nursece4less.com nursece4less.com nursece4less.com 53

54 changes for the client may differ between individuals with varying cultural practices. Some people do not value self-efficacy as much as others, which makes the concept a difficult one to teach. Additionally, factors such as poverty, immigration, or gender roles can impact a person s sense of selfvalue or feelings of self-efficacy. For example, a person who has lived in a refugee camp for years before eventually working through MI to make personal changes may have little value for feelings of self-efficacy when he has had to spend years simply trying to survive. There may be a range of feelings about self-efficacy and its value within different cultures. When a client places low value on self-efficacy because of cultural influences, the provider may need to work more with the client to explore the reasons behind this and to come up with solutions that will help the client to continue to work toward change. According to Burke, et al., there are four states that contribute to self-efficacy in a person: mastery experience, vicarious experience and modeling, social persuasion, and physical and emotional states. A person s background through experiences and social influences impacts their level of confidence and self-efficacy [19]. If the provider recognizes these influences, he or she can use some of their time with the client to support the value of self-efficacy as a positive step toward change. This may take longer and more in-depth study of the client s background and perceptions, but is worth the effort to connect with the client in a manner that will support his or her self-confidence and provide direction where ambivalence may exist. In order to successfully work with clients of differing cultural backgrounds, the provider must start by being aware of his or her own cultural beliefs and how they may differ from those of others. If the provider is secure in their own beliefs and preferences, they may be better able to work successfully with others who are different, as they will be less likely to feel threatened or nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54

55 challenged. Examining one s own beliefs first before starting to work with clients is foundational for the provider starting the motivational interviewing process. The provider can then function in their practice with recognition of the various differences in individuals and to value and respect the levels of diversity that are present in the population. PREGNANCY AND MI Motivational interviewing has been used successfully among pregnant clients who need to make lifestyle changes in order to improve their own health and that of their baby. MI may be an option for soliciting change among pregnant women in order to help them make healthy choices, such as following a healthy diet and engaging in regular exercise. It can also be used among some women who must make changes because Figure 12 Motivational interviewing can be a regular part of contact with a pregnant client [61]. they struggle with substance abuse or are smokers, both of which can cause health problems and increase the risk of complications during pregnancy. Pregnant clients may engage with members of the healthcare team who can provide motivational interviewing and who are often in the role of counseling or educating patients about pregnancy support. A client may have several visits with a healthcare provider during pregnancy as part of routine prenatal care. Regardless of whether a pregnant client needs assistance with changing negative or harmful habits, motivational interviewing can be part of regular contact with the client. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 55

56 When assessing a client who is seeking routine prenatal care, the provider may open the conversation by first seeking rapport with the patient, explaining their own role in the healthcare system, and identifying what type of services are provided that the provider can help with. This presents an open invitation without committing the client to any specific activity or change. If the client agrees to accept the services and participate in MI, the provider can then move to ask about the best ways to help the client. For example, the provider may say: How best can I help you at this time? What services are you looking for? These are open-ended questions that elicit longer explanations from the client, which can help the provider to better explore the direction of the services needed. As the client is answering, the provider listens intently, using body language that conveys an open and caring attitude. All of the provider s responses indicate empathy toward the client s situation. If there is a time when the client does not know what to do, the provider can help her to narrow down possibilities to better guide her toward making a decision. The provider should first ask permission, and then may say something such as: Can I explain to you some of the services we offer here? I can answer any questions you might have about your pregnancy. Are there any educational offerings you might be interested in learning more about, such as breastfeeding or the childbirth nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56

57 process? By offering a menu of options for the client, the provider gives suggestions for areas of focus without actually making the decision. These offerings help the client narrow down areas of content to focus on and ultimately, to make the decision herself. Once a client makes a decision about the focus of her care during pregnancy, the practitioner and client then work together to successfully incorporate the steps needed to accomplish the goals. Regular re-evaluation of the client s level of motivation, the need for services, and any issues or problems that have developed should be done throughout the process with the goal of getting the client through a healthy pregnancy by guiding her to take care of herself [20]. Figure 13 The pregnant client needs a menu of options [60]. Unfortunately, some women who are pregnant make unhealthy choices or engage in activities that can be detrimental to their health and can risk harming the baby. Substance use, such as alcohol, drugs, or smoking cigarettes can increase the risk of complications for the mother and fetus and may cause problems during labor and delivery. The American College of Obstetricians and Gynecologists (ACOG) supports the use of motivational interviewing to affect change among women who are pregnant to promote positive behavior choices [21]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 57

58 Motivational interviewing can be a part of regular routine prenatal visits for pregnant clients or, if a problem has developed during pregnancy, such as the identification of substance use, it can be a stand-alone objective in which the provider and client sit down together to discuss the client s choices and their effects. When MI is incorporated into routine prenatal visits, the provider could be someone such as the physician, the nurse, or the nurse practitioner that is managing the client s care. Adding MI to a regularly scheduled appointment adds little time to the overall encounter, but the results can be significant. According to ACOG, the process of active listening and motivational interviewing during a visit only adds approximately three minutes to the total time spent at the appointment [21]. Motivational interviewing can be incorporated into many discussions and topics that are covered through prenatal appointments for pregnant women. Most pregnant patients go through a course of appointments in which the mother s and the baby s health are evaluated during the time of pregnancy, with prenatal visits coming more often as the estimated date of delivery draws near. The physician or nurse practitioner caring for the patient typically orders routine lab work, such as a test for gestational diabetes, tests to check rubella status, or a complete blood count. Other tests can rule out the presence of certain diseases during pregnancy, such as tuberculosis, HIV, or other sexually transmitted diseases. Additionally, the mother s weight is monitored with each visit and other areas that could potentially cause complications are checked routinely as well, such as blood pressure readings. These aspects are monitored regularly to assess for changes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58

59 The results of many of these tests and procedures could point to an area in which a pregnant client needs to change. For example, consider a client who has just discovered that she is pregnant. She has her first prenatal visit, where her provider orders routine labs and checks her weight and blood pressure. Over the course of the next 3 to 4 months, the patient s weight increases at a rate that is much faster than what is normally expected during pregnancy. The provider tries to discuss the appropriate amount of weight gain during pregnancy and the patient starts to understand the necessity of keeping her weight under control. During many of the client s next visits to see her provider, her healthcare team, including the nurse or physician, can use motivational interviewing to guide the patient toward change by eating a healthy diet, increasing her activity levels, and monitoring her weight at home. Through this process of MI at regular visits, the client may move out of ambivalence and toward a better lifestyle that involves controlling her weight and taking care of herself. ACOG has reported that motivational interviewing has been effective in a number of areas among pregnant clients, including reducing fears related to childbirth, reducing the amount of alcohol consumption, smoking cessation, increasing education and promotion of breastfeeding after delivery, and limiting risky behaviors that can lead to sexually transmitted infections [21]. When clinicians specifically work with women who use alcohol during pregnancy, intervention through motivational interviewing is extremely important to prevent the development of fetal alcohol spectrum disorders (FASD). FASD is a range of conditions that can develop with alcohol use during pregnancy and can cause growth problems, central nervous system abnormalities, behavioral issues, and problems with everyday functioning. These problems are noted after birth and continue throughout the child s nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59

60 lifetime. FASD is preventable with eliminating exposure to alcohol, which is why proper identification and intervention among pregnant women who use alcohol is so important [23]. A provider who works with pregnant clients can assess for those who are high risk by using the FASD Clinician Toolkit developed by ACOG to identify those at risk and to intervene using motivational interviewing techniques to guide these clients toward change. According to ACOG, a multicenter study conducted on pregnant women who were engaged in risky drinking behaviors showed a 70 percent reduction of risk in having an alcoholaffected infant six months after engaging in motivational interviewing to educate them about the dangers of alcohol during pregnancy [23]. After determining who would benefit from motivational interviewing for highrisk behaviors during pregnancy, the provider can spend some time with the client to discuss unsafe behaviors and the effects on the fetus. The interview should not be long and could be incorporated into a routine prenatal visit. ACOG uses the FRAMES approach to demonstrate how to proceed in the discussion [23]: Figure 14 Features associated with FASD [59]. Feedback Provide information and data to the client about the effects of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60

61 alcohol use on the developing fetus. In some situations, the client may not be aware of the dangers of alcohol consumption during pregnancy. Responsibility The client needs to be made aware that she is responsible for herself and the health of her baby and it is up to her to make a choice about using alcohol while pregnant. Advice After asking permission, the provider advises the client about what she can do to avoid alcohol and the positive effects that can happen when she makes healthy choices. Menu of options The client receives a list of options to consider for changing her risky behavior or for how to find other alternatives to using alcohol when it is used as a coping strategy. Empathy Throughout the exchange, the provider conveys a sense of empathy and understanding for the client, recognizing the difficulties in making a change. Self-efficacy The provider helps the client to become more confident in herself by taking charge of her health and knowing she is taking better care of her unborn baby. By promoting self-efficacy, the client may be more likely to commit to the change and maintain healthy nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61

62 behaviors through the rest of her pregnancy. After the MI process in which the provider addresses the problem behavior, regular follow-up visits are necessary to ensure that the client maintains an understanding of the importance of change. If the patient is demonstrating changes at the next visit, the provider should be supportive of her progress and encourage her to continue, regularly checking up with her to see if she is following through. If the client is attempting to make changes but is unable to carry out the work, the provider and the client should explore these reasons together to determine if there are other methods of achieving the same goal that the client could implement more easily. If the client is unwilling to change, the provider should continue to work with her through motivational interviewing to come up with solutions for change, making referrals to other professionals as needed. SMOKING CESSATION AND MI Smoking tobacco is a leading cause of chronic disease and death throughout the world. People who start smoking cigarettes have a very difficult time quitting the habit because of the addictive properties of nicotine, which is found in tobacco. Nicotine has been shown to be as addictive as some illegal drugs, such as heroine, and people who smoke on a regular basis or who have smoked for many years become physically dependent on the nicotine, resulting in symptoms of withdrawal when trying to quit. Figure 15 Motivational interviewing can be used for smoking cessation [62]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62

63 Many people also become emotionally dependent on cigarettes, choosing to smoke in certain situations, such as during social interactions or as a source of comfort. They may have a difficult time quitting not just because of the physical withdrawal from the nicotine, but also because of the psychological impact that smoking has on their lives [25]. Smoking impacts almost every part of the body, causing damage to cells and resulting in acute or chronic diseases that can ultimately become life threatening. It worsens respiratory illnesses and causes a chronic cough, it can lead to other lung diseases, such as chronic obstructive pulmonary disease; and, it can also cause changes in the circulatory system that can increase the risk of heart disease, hypertension, and stroke. Additionally, smoking tobacco increases a person s risk of certain types of cancer and can cause complications with pregnancy among women who are pregnant and who smoke [25]. Figure 16 Smoking can damage every part of the body [63]. Many people are aware of at least some of the dangers associated with smoking, although not all people want to quit. Of the people who do want to quit, many try to stop again and again without making a lifelong commitment to stop. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63

64 There are many products and options on the market available to people who smoke and who would like to quit. Studies have shown that both pharmacological approaches and behavioral interventions have helped people to stop smoking. Pharmacological interventions include some types of medications that can reduce the craving for nicotine, while other interventions include nicotine replacement that slowly decreases the amount of nicotine taken in by the body over time until the dependence is minimal. Alternatively, behavior mechanisms for quitting smoking range from hypnosis to cognitive-behavioral therapy, to group therapy, to motivational interviewing. MI has been used successfully with many patients to take steps to change their lives and quit smoking permanently. A study by The Cochrane Collaboration looked at the positive impact of motivational interviewing to promote smoking cessation. The study considered whether MI was successful in promoting smoking cessation when compared to routine care or no advice. The study showed that the effects of MI are long lasting when compared with other forms of therapy; intensive sessions of MI that are longer in time or in number of sessions are more effective than single sessions; that people who quit smoking while using MI have similar long-term outcomes of relapse when compared with people who quit smoking while using other therapies, and that there are no adverse effects from using motivational interviewing [24]. The study was a meta-analysis of work done by using motivational interviewing for smoking cessation that examined randomized controlled trials for results. The studies used the principles of motivational interviewing as part of smoking cessation programs, including promoting change through self-efficacy, exploring ambivalence, and assessing the clients motivation to quit [24]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64

65 The study results showed the positive impact of motivational interviewing by using a non-judgmental and non-confrontational approach that improved self-efficacy among patients who were trying to quit smoking. The sessions that were at least 20 minutes long were more effective than short interventions, and most clients needed at least two, if not more sessions, in order to be successful in their attempts at quitting. The motivational interviews were successfully held in various settings, including general practice healthcare offices, outpatient settings of hospitals, through telephone conversations, or in clients homes [24]. A motivational interview session could develop in several different ways, depending on the client s initial desire to change and to quit smoking. The interview evolves as the provider engages the client and each learns more about the client s level of ambivalence toward quitting, as well as other factors that may be prominent, including resources available to help with the change, level of resistance on the part of the client, and even the connection and compatibility between the client and the provider. Because there are various factors that can affect the motivational interview, no two interviews will be alike. However, it is possible to anticipate varied directions that a motivational interview could take with the goal to support smoking cessation. The provider should begin with establishing rapport with the client, making introductions, and orienting the client to the purposes of the motivational interview [26]: Hello, my name is and I am a registered nurse here at the health clinic where we are meeting today. I thought we could talk nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65

66 about healthy lifestyle practices to better help you know how to stay healthy and feel good. Many people who smoke cigarettes eventually develop health problems associated with their heart or their circulatory systems. They can also become addicted to cigarette smoking because of nicotine, a substance found in cigarettes. You may or may not have these issues, and maybe you feel quite healthy. I would like to get your opinion about cigarette smoking and its effects on health. The opening is friendly and it establishes the provider s role and level of education, which may be something that establishes even a greater level of trust for the client. The provider also does not start out with telling the client about the hazards of smoking and then recommending that he or she quit to avoid having similar outcomes. Rather, the provider is non-judgmental and open to the possibility that the client does not have current health problems and instead would like to discuss his or her tobacco use. After an initial discussion that involves the client s opinions about cigarette smoking, the provider can then move on to determine the client s level of ambivalence about quitting. The client may give many clues during the initial sharing of opinions regarding smoking in the first place, but it is important to determine what level the client is currently at when considering the plausibility of quitting for good. The provider can give further feedback or make requests for more information, or she may clarify what the client has already said. To provide feedback or request more information from the client, the provider might start with: Tell me about your tobacco use. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66

67 What do you think of the effects of nicotine on a person s body? Do you think smoking could cause harmful effects to you? If the provider wants to clarify some information given by the client, she might use some of the examples or phrases that the client has said: What I hear you saying is that you believe smoking is harmful to your health. So, your family member died as a result of smoking and you don t want the same thing to happen to you. As the provider continues to assess the client s readiness for change and level of ambivalence about quitting smoking, he or she should continue to use words that reflect empathy, ask open-ended questions, and encourage the client to do a lot of the talking. Frequent reflection or re-evaluation of what the client has said is often necessary to continue to clarify important points and to ensure that the conversation stays on track to avoid misunderstandings [26]. Finally, at the end of the initial discussions, the provider should summarize what the client has said: To summarize, you have talked about how you know that smoking cigarettes is harmful to your health and you would like to quit, but you do not know how to get started. You are afraid that if you do no quit, you will develop a disease similar to your family member s condition and you could die from that. You feel that you have been smoking for so long that it would be impossible to quit now. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67

68 The next step of the process moves the client toward change. The provider has assessed the client s level of ambivalence and now should emphasize his or her talk on finding reasons for change, rather than maintaining the same behaviors. After the initial discussion, the provider may determine that the client is resistant to change, wants to change but doesn t know how, or wants to change and is ready to move forward. The following example might be one in which the client wants to change but doesn t know what to do next. To go forward from here, you have told me that you have been a smoker for fifteen years and you think it would be extremely difficult to quit at this point. However, you have also said that you would like to quit to benefit your health. What other reasons can you think of that might be a benefit of quitting smoking? This conversation supports the concept of discrepancy, in which the client sees the difference between where he or she is now and where she wants to be. By listing other reasons for quitting smoking in addition to improved health, the client verbalizes other measures that support his or her need for change. The next step might be to ask the client about his or her level of interest in quitting: Based on the reasons listed, do you think you should continue to smoke? You have discussed why you know smoking is harmful, what can you think of to do about your smoking habit? May I give you some more information? I think you know why it is important not to smoke and you want to quit, but nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68

69 This discussion places the responsibility for change in the client s hands. After starting with a foundational conversation about the importance of quitting smoking, the provider comes to the point where he or she must determine if the client will change or not. This determination then helps the client to know if they should move forward to setting goals and finding resources for quitting or if they need to revisit the discussion about the detrimental effects of smoking. If the client has agreed that he or she should play an active role and take responsibility for quitting smoking, the discussion with the provider can continue [26]. Once the client has committed to making a change, the next step is to identify those steps that the client should take to work toward that change. The provider and the client should work on identifying those steps together. In some cases, the client who is trying to quit smoking may not be aware of his or her options for taking steps to quit. Figure 17 A nicotine patch is one method that can help patients quit smoking [64]. Education is a component of this step, and the provider should give information that can be useful to the client, delivered in a sincere and empathic method. An example would be: I think you recognize that it is important to quit smoking and you are ready to take steps to quit. Let s talk about some options that you have for moving toward your goal of smoking cessation. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69

70 A menu of options provides the client with alternatives for how best to approach quitting smoking. For example, the provider might give the client a list of methods, such as using nicotine replacement patches or undergoing cognitive-behavioral therapy; contact numbers for support groups and organizations that may be of assistance or may provide support and help, or a referral to a healthcare provider to prescribe medication that can help with reducing nicotine cravings. The provider could introduce options to the client in the following way: I have a list of options that might be available for you to consider. Let s talk through each of these so you can better understand the pros and cons of each and then you can decide if there are one or more options that you could implement into your lifestyle to help you quit. Once you decide, we can then see how to get started with putting these into place. Once the provider has gone through the menu of options for the client, he or she should ask the client which option works best for their situation. If the provider encounters resistance, they should back up and talk through the client s decision to quit and then try to discuss the options again, acting as a guide for the client instead of simply telling him or her what to do. Other topics to explore might be obstacles or barriers that could develop that would prohibit the client from making a permanent change or the return of ambivalent feelings that would prompt the provider to revisit the client s level of motivation [26]. The level of motivation could be explored with such statements as: Are there any issues you see that would stop you from putting these interventions in place? nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70

71 Do you feel that you can take the next step and [place a phone call/contact a provider/ask for a prescription] to help you get started? Do you feel that if you implement these interventions, you will be better able to meet your goal? Finally, as the meetings draw to a close, the provider should continue to summarize and clarify in order to evaluate the effectiveness of the discussions that have taken place. Regardless of whether the client plans to change and quit smoking, the provider should thank the client for taking the time to talk about the issue involved and for at least considering a change in behavior. If the client decides to move forward with making a change toward quitting smoking, the provider must affirm this and help the client know what to do next [26]: We have talked about the importance of quitting smoking to you. You have said that you have smoked for a number of years and you know it will be difficult to quit. However, you also have had a family member pass away due to illness caused by smoking and you do not want the same thing to happen to you. Thank you for taking the time to discuss your concerns about smoking with me. We discussed a number of options that you can consider that can help you to quit and you have decided to try nicotine replacement therapy through the patch system. This sounds like an option that could work very well for you and you could incorporate it into your lifestyle. At the end of the discussions the provider should follow up with the client to determine how well the options are working and to see if the client needs assistance with any other issues. The client may have tried the options discussed but then found that they did not work out and may need further nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71

72 direction. Alternatively, the client may report that the situation has improved dramatically and he or she has been able to successfully quit smoking. Whenever a client agrees to make a change in his or her lifestyle as a result of motivational interviewing, someone should follow up to determine if other needs have occurred or whether the MI sessions were successful in helping to bring about and maintain change [26]. ADDICTIONS AND MI Motivational interviewing has been successfully used with patients suffering from substance abuse. The original work published by Miller in 1983 in the early stages of MI was targeted toward working with patients who had difficulties with alcohol addiction. Motivational interviewing continues to be a successful intervention when used among some patients who want to stop drinking alcohol. A study by Lundahl and Burke, which included a meta-analysis of 119 studies that examined the effects of motivational interviewing when working with patients with varying issues showed that motivational interviewing was at least as successful as other forms of therapy when compared with other types of interventions, and was significantly successful when compared to no treatment for alcoholism [33]. Figure 18 Motivational interviewing can be used with patients suffering from substance abuse [65]. Substance abuse differs from addiction, although the two scenarios can cause difficulties for the involved client and loss of relationships with others. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72

73 Substance abuse involves using a substance, often alcohol or some type of drug, in an inappropriate manner, such that it becomes disruptive to normal activities of daily living. Substance abuse interferes with responsibilities, such as those of going to school or work, maintaining a home, or providing childcare. Despite the problems that the use of substance causes, people who struggle with substance abuse continue to use, often with negative consequences. For example, a person who is struggling with substance abuse may use alcohol inappropriately to the point that it impacts his abilities to work or take care of family. The person s spouse and other family members are aware of the problems caused by the alcohol use, but the person continues to drink despite efforts to talk or convince him or her otherwise [56]. Alternatively, substance addiction causes problems for the person abusing the substances and also causes a dependence that typically requires using a larger amount in order to achieve the same effects. The person also experiences withdrawal when trying to stop using the substance, and may have made efforts to cut back or stop entirely without success [56]. Non-substance addictions, which may also be referred to as behavioral addictions or impulse control disorders, are those situations in which a person engages in an activity that produces some type of reward and continues to do the activity despite adverse consequences [57]. People who struggle with non-substance addictions may have great difficulties resisting the urge to perform an activity and may continue to do so on a repeated basis, which is often similar to substance addiction. Also similar to substance addictions, behavioral addictions cause a great amount of pleasure for the person performing the activity, which then may be followed by feelings of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73

74 remorse, anger, or helplessness. Unlike substance addictions, behavioral addictions do not cause symptoms of physical withdrawal when the addicted person stops performing the activity [57]. Examples of behavioral or non-substance addictions include pathological gambling, excessive shopping, Internet addiction, or compulsive sexual behavior. Patients who are addicted to these activities are at risk of potentially severe consequences that can occur in addition to the alienation and disruption to relationships that addiction causes. For instance, someone who struggles with pathological gambling may be at risk of financial difficulties through an inability to stop gambling, despite losing large amounts of money at times. Motivational interviewing has been used among professionals working with clients who suffer from substance abuse and addiction. The process can be implemented through counseling and alongside other treatments, such as pharmacologic therapy, to help individuals with substance abuse disorders make choices for their health and play an active role in managing their diseases. Because the provider in the interview collaborates with the client instead of taking on a paternalistic viewpoint, the partnership of working together through MI can help the client focus on his underlying need for substance use that resulted in addiction [58]. Motivational interviewing also works in use with clients with both substance addictions and behavioral addictions because the change is not forced and the client is guided to come to their own conclusions about what or how he or she wants to change, based on their level of motivation. This empowerment puts the responsibility for change on the client and the provider is not an authority figure, but, rather a coach or guide helping the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74

75 patient recognize this process. The main principles of MI support this process. For instance, when a provider is empathic toward the client who struggles with addiction, the client is less likely to feel judged or cornered. A person with a substance abuse problem who seeks treatment often already has a plethora of issues to face and overcome and putting him or her with a provider who is critical of personal choices will only derail the process of help and change. Instead, an attitude of empathy by the provider helps the client feel that someone cares about them despite their personal mistakes and background [58]. When the provider acts as a guide, he or she helps the client to better see the errors in some of their ways and the value of making changes. The client may seek care coming from a situation full of hurt and regret, with feelings of shame, hopelessness, or despair over an inability to stop whatever activity is causing the addiction. The client may be angry that life is not different or that the choices he or she has made have only led to confusion and trouble. Regardless of the client s feelings about their addiction, if they are willing to work with the provider to consider change through motivational therapy, then the client can see the discrepancy between where he or she is now (heartache, pain, confusion) and where he or she wants to be (a life of greater self-control, freedom from addiction). Figure 19 Addiction can take many forms [66]. 12-Steps programs nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75

76 Many people have found help from substance abuse and addiction by going through 12-step programs such as Alcoholics Anonymous (AA). The idea behind AA is to be a membership group where people who struggle with alcohol use and addiction can meet with others for support and help for their drinking. Alcoholics Anonymous meetings may have speakers or people may share their experiences and challenges with using alcohol in order to facilitate discussion. The AA program is based on 12 steps that each person works through in the process of handling alcohol addiction. Some of the 12 steps cover ideas that the person is powerless over alcohol, believes in a power greater than themself that he or she can turn their life over to for help with alcohol, has made a moral inventory of themself, has admitted to themself and to others the level of wrongs that they have committed, and has asked God or his higher power to remove those wrongs and shortcomings [88]. A benefit of going to AA and continuing involvement with it or any 12-step program that is used for help with substance abuse and addiction is that if the person is truly incorporating the 12 steps into his or her life, it is understood that he or she wants to change. In this respect, motivational interviewing can be incorporated into 12-step programs to facilitate change and better help people struggling with substance abuse or addiction to set goals for change and feel empowered to move forward. Figure step programs can be very helpful for people with addictions [76]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76

77 In some situations, change is mandated, and the client may or may not want to give up using drugs or alcohol. For instance, a situation in which a patient is required to attend counseling for drug abuse as part of a sentence for a criminal offense may only put the patient in a place where he grudgingly goes along with therapy. In these types of situations, motivation will be quite low and motivational interviewing may not be successful. Alternatively, in situations where the client is willing to take steps to change and has a sincere desire to give up the substance for the good of him- or herself and others, MI can be incorporated into treatment [87]. DIABETES AND MI Motivational interviewing has successfully been used in targeting patients who are at risk of developing diabetes as well as those who have already been diagnosed. There are modifiable risk factors for diabetes that, when implemented, can significantly reduce the risk of developing the disease. Motivational interviewing can help some patients to recognize their risks of developing diabetes and to take steps to change their lifestyle habits to minimize these risks. Alternatively, people who have been diagnosed with diabetes can still practice Figure 21 Main symptoms of diabetes [71]. many activities that contribute to health and wellbeing and that reduce the risk of complications associated with the disease. Motivational interviewing can challenge these patients as well, to help them understand the importance of healthy living through diet, exercise, and blood glucose nursece4less.com nursece4less.com nursece4less.com nursece4less.com 77

78 maintenance to control their disease [27]. Diabetes is a condition in which glucose levels in the bloodstream are too high. Normally, the blood glucose levels rise following a meal, as foods are broken down and digested. The body responds to this rise in blood glucose levels by secreting the hormone insulin from the pancreas, which acts to get the excess glucose out of the bloodstream and into the cells where it can be used for energy. This process provides energy to the cells and fuel for the body, and it also regulates blood glucose levels, which can be damaging when they remain consistently high over a period of time [28]. Diabetes is further broken down into two main types: type 1 diabetes, which used to be referred to as juvenile diabetes because it was consistently diagnosed in childhood for many patients; and type 2 diabetes, formerly known as adult onset diabetes, because it often developed during adulthood. Today, type 1 and type 2 diabetes can develop in people of any age, although type 2 is more common and has many more modifiable risk factors, including being overweight and obese. Type 1 diabetes often develops as a result of an autoimmune process in which the body attacks the cells in the pancreas, affecting its ability to produce insulin. The body then cannot keep up with insulin production needed to regulate blood glucose levels and glucose remains consistently high in the bloodstream. Type 2 diabetes develops when the cells become resistant to the effects of insulin. The body may still secrete insulin through the pancreas, but it is not as effective. The pancreas needs to secrete more and more insulin to control blood glucose levels and it ultimately cannot secrete enough to keep up with demands. This results in consistently elevated levels of glucose in the bloodstream as well [28]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 78

79 Both type 1 and type 2 diabetes can cause significant complications that impact a person s ability to heal from certain diseases and can lead to serious illness or even death. Diabetes is connected to heart disease, metabolic syndrome, kidney disease, blindness, diabetic neuropathy, eye disease, and problems with pregnancy [28]. Being diagnosed with diabetes requires lifelong maintenance of blood glucose levels, and often medications and other lifestyle changes in order to reduce the risk of developing complications. Clearly, it is important to manage diabetes as much as possible upon diagnosis or to recognize risk factors in the lives of some people to prevent its development in the first place to avoid considerable loss later. Motivational interviewing can work with many patients at different stages to recognize the various risk factors for diabetes or to better understand the importance of managing the disease to maintain a healthy lifestyle. Motivational interviewing can work well as a form of lifestyle factor intervention for clients who are at risk of diabetes. Pre-diabetes is defined as impaired glucose tolerance (IGT), which is demonstrated by a glucose level between 140 and 200 mg/dl upon undergoing an oral glucose tolerance test; or impaired fasting glucose (IFG), which is demonstrated as a fasting glucose between 100 and 125 mg/dl. People with IGT and IFG are at significantly higher risk of developing type 2 diabetes and its associated complications. However, studies have shown that instituting behavior interventions among people with pre-diabetes, such as by using the techniques applied through motivational interviewing, may reduce the risk of pre-diabetes developing into type 2 diabetes [27]. The Diabetes Prevention Program conducted a study that compared nursece4less.com nursece4less.com nursece4less.com nursece4less.com 79

80 therapeutic lifestyle changes with pharmacologic intervention in the prevention of type 2 diabetes among patients diagnosed with pre-diabetes. The study found that lifestyle interventions caused an overall reduction of diabetes risk in 58 percent of clients when compared with a 31 percent reduction in risk among clients who used metformin to control their risk of diabetes [27]. Motivational interviewing, when implemented into care visits or as a stand-alone effort for reaching people at risk of developing type 2 diabetes, can educate clients about the effects of implementing therapeutic lifestyle techniques and can promote change among clients who may know they need to reduce their risk of diabetes but who are uncertain about where to begin. For patients who have been diagnosed with type 2 diabetes, management of the disease can be difficult not only to understand the process, such as by checking blood sugar levels on a regular basis or calculating appropriate carbohydrate counts, but there may be other constraints that prevent some patients from implementing strategies to care for their health when they have type 2 diabetes. Some patients raise difficulties with paying for supplies or medications, and there may be time issues that prevent some people from being able to check their blood glucose levels or determine appropriate amounts of insulin to administer. As well, some people may not have access to regular appointments with healthcare providers to maintain contact and updates about their care [32]. Such factors can significantly affect motivation for change among clients, which can be addressed through MI. Figure 22 Insulin is necessary for many diabetics [72]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 80

81 One of the reasons why MI can be successful when working with patients who have type 2 diabetes is that it is an individualized approach that considers the specific needs of each client s situation. The method can address issues that impact motivation in each client, rather than providing a catch all method of giving generalized advice or using scare tactics [32]. An example of how each client is different in their needs and responses for MI can be understood in terms of the reasons why each client would seek help to control diabetes in the first place. Two clients with diabetes may be separately seeking help; and, while one client may not have been successful with managing their health because they cannot afford to pay for glucose monitor strips every day, the other client may not have made changes because they are simply afraid of checking glucose levels. During motivational interviewing, the provider can address each of these issues individually with the separate clients, helping each client to come up with solutions that are specific to their challenging situations. According to the Journal of Diabetes Nursing, motivational interviewing techniques were successfully implemented into educating and treating patients with type 2 diabetes. The study was known as the Diabetes Nurse Case Management and Motivational Interviewing for Change (DYNAMIC). The study was a randomized, controlled trial that separated participants into two different groups: a control group that received standard care for type 2 diabetes and a focus group that received care for their diabetes using the DYNAMIC intervention, which used motivational interviewing as a method of evoking change in health behaviors among participants. All of the participants involved in the study had type 2 diabetes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 81

82 The researchers conducting the DYNAMIC study found that nearly all of the participants involved had other psychological distress or issues connected to their type 2 diabetes diagnoses. The concurrent psychological findings ranged from depression related to a diabetes diagnosis and ongoing care to feeling judged and policed about performing activities within a certain timeframe, to lower levels of self-care behaviors related to anger or frustration. The participants were all, therefore, at greater risk of poor outcomes related to their diabetes control because of these additional distressing circumstances. The study showed that participants who went through MI as part of their treatment in the DYNAMIC group responded more and had more beneficial health outcomes when compared with participants who received standard diabetes care [32]. The participants who received the DYNAMIC intervention stated that they felt more positive about their role in taking charge of their health, they did not feel judged or policed for their behaviors but instead were met with empathic and consistently caring responses from their caregivers that made them want to cooperate more. Even in situations when lab results did not show changes or showed that participants had slipped in their accountability for change, the nurses performing the motivational interviewing remained non-judgmental and were accepting, which enhanced trust and a greater desire to cooperate from the participants [32]. Based on these outcomes, it can be said that motivational interviewing certainly provides a positive and healthy view of change that enhances in clients a motivation and desire to take charge of their health. Another study found in Diabetes Research and Clinical Practice also showed that patients who participated in motivational interviewing as part of their treatment for type 2 diabetes responded better to interventions when compared to patients who received standard treatment alone. The study nursece4less.com nursece4less.com nursece4less.com nursece4less.com 82

83 divided groups into two areas: one that received standard treatments and one that participated in motivational interviewing as part of treatment. All patients involved had type 2 diabetes. Some of the patients were more responsive to MI techniques as part of treatment and were more likely to respond to making healthy changes [31]. The patients who received standard care for their diabetes complained of feeling judged and facing paternalistic and critical responses from their providers. They often felt demeaned in their attempts to control their diabetes. Alternatively, the participants who were in the MI group stated that they had more positive feelings toward their treatment and received care in a non-threatening and helpful manner. According to the study, five themes emerged that participants commonly stated they felt was their experience: nonjudgmental accountability, encouragement and empowerment, being heard and responded to as a person, collaborative action and goal setting, and coaching rather than critiquing [31]. Effective communication is necessary when working with diabetic clients who often need to understand the seriousness of their disease. In many cases, healthcare providers are more aware of the complications and the Figure 23 Blood glucose testing [73]. complexity of diabetes than the clients and must communicate the information accordingly. Rather than directing clients about what they need to do and checking in to see if they have been successful in following directions, the provider through motivational interviewing can instead work alongside clients to provide information about the seriousness of diabetes, the need for self-care and management, and the importance of regular nursece4less.com nursece4less.com nursece4less.com nursece4less.com 83

84 healthcare follow-up [31]. Through motivational interviewing the provider is able to provide the needed follow-up to ensure that the client is making important changes and can address those issues that are prohibiting change. Rather than taking a paternalistic approach with diabetic clients, the provider through motivational interviewing demonstrates a more collaborative and successful approach to help prevent some very significant complications among this population. HEART DISEASE AND MI The American Heart Association (AHA) recognizes the importance of behavior changes in improving heart health and has stated that behavior changes are an important component of reaching the AHA s 2020 goals, which includes improving cardiovascular health of all Americans by 20 percent while reducing deaths from cardiovascular disease and stroke by 20 percent [40]. Cardiovascular disease, also Figure 24 Coronary artery disease [68]. referred to simply as heart disease, is actually a range of conditions that can affect and compromise the work of the heart. A number of conditions that affect the heart and blood vessels can be classified as heart disease, including coronary artery disease, heart attack, cardiomegaly, heart arrhythmias, and heart valve disease. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 84

85 Coronary artery disease is one of the most common forms of heart disease. It occurs as the result of plaque buildup in the coronary arteries, or the main arteries that provide blood to the heart. Plaque deposits build up inside the coronary arteries because of cholesterol and other substances, which eventually narrow the inside of the artery and decrease blood flow. When coronary artery disease develops, the patient is at higher risk of other complications, including stroke, heart attack, and peripheral vascular disease. A significant danger is the formation of blood clots. If a clot forms at the site of the atherosclerotic plaque or a piece of the plaque breaks off into circulation, it can become lodged in one of the vessels leading to the heart or the brain, causing a heart attack or stroke. Decreased circulation to the heart decreases its overall function and the function of major organs of the body. Blood may not reach the distal extremities as quickly as it once did and may result in pain in the legs when circulation cannot keep up with activity. If the atherosclerosis in the coronary arteries causes a complete blockage, a portion of the heart can become deprived of blood. Without adequate blood flow, the tissue in the area beyond the blockage becomes ischemic from lack of oxygen and tissue death begins to occur. This is what happens with a heart attack, which is a leading cause of death and disability among people with heart disease [41]. Other types of heart disease can also cause significant complications for patients and must be managed accordingly to avoid developing further problems or disabilities. Cardiomegaly occurs as enlargement of the heart muscle that often develops after the muscle tissue has been damaged. This nursece4less.com nursece4less.com nursece4less.com nursece4less.com 85

86 damage can be caused by impaired circulation due to coronary artery disease or hypertension. As the heart becomes larger in size, it is not able to pump blood as effectively, which further impacts overall circulation and decreases the amount of oxygen reaching the tissues and organs [41]. A heart arrhythmia is an irregularity in the rate in which the heart beats. Heart arrhythmia may occur as a result of coronary artery disease, electrolyte imbalances, cardiomegaly, or injury that occurred from a heart attack. When a heart arrhythmia develops, it can start in different areas of the heart and may be erratic, fast, or slow. The condition can increase a person s risk of developing blood clots if blood does not flow properly through the chambers of the heart and pools in certain areas within the heart. A heart arrhythmia may also significantly disrupt circulation, which affects other organs and can reduce how much oxygen and blood is reaching parts of the body. Finally, heart valve disease develops when the valves between the chambers in the heart do not function properly. They may have become stiff and stenotic, or they may not close completely when they are supposed to. As with some other forms of heart disease, blood flow can be impaired with valve disease as well. If blood backs up because it cannot flow through the heart chambers properly, it can cause heart failure (formerly called congestive heart failure), which leads to fluid accumulation in circulation, respiratory difficulties, and tissue edema [41]. Clearly, heart disease of any kind can be very significant, which is why so many efforts are aimed at preventing, managing, and treating these conditions. A number of lifestyle factors significantly contribute to the development of heart disease, including being overweight/obesity, inactivity, nursece4less.com nursece4less.com nursece4less.com nursece4less.com 86

87 and smoking. Patients who are at risk of developing heart disease because these lifestyle factors are a regular part of their lives or those who have already been diagnosed with heart disease can all benefit from making changes to incorporate healthier habits and either reduce the risk of developing the disease or reduce the risk of developing complications associated with heart disease. Patients are at risk of heart disease when they are overweight or obese. Overweight is classified as a body mass index (BMI) of , while obesity is classified as a BMI over 30. It can be extremely difficult for some people to lose weight and develop a healthy BMI, even with a diagnosis of heart disease. Many people have become so accustomed to unhealthy eating patterns, whether by choice of food because of taste, or due to other factors, such as financial concerns or the availability of cheap and unhealthy foods. Regardless of the reason behind unhealthy eating, it is important that the patient understands the need for changing food intake to employ choosing healthier foods in moderately sized portions in order to reduce the risk of heart disease. Motivational interviewing can help Figure 25 A nutritious diet is essential for weight loss [69]. the client to work with a provider to come up with solutions for problems with eating. For instance, if the client is having difficulties obtaining appropriate foods because junk food is cheaper than healthy food and he does not have a lot of money, the provider could work with the client to come up with options for obtaining and preparing healthier foods. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 87

88 Dietary intake impacts the work of the heart as well as circulation. Reducing levels of saturated fat and cholesterol, as well as controlling salt intake all impact the risk of coronary artery disease and hypertension. According to Franklin, et al. in an issue of Circulation, people who follow a healthy diet similar to those who live in Mediterranean areas and who consume greater amounts of unsaturated fats have up to a 31 percent reduced incidence of heart disease [40]. Further, changing dietary practices to include decreased saturated fat intake and decreased cholesterol intake may reduce plaque size in atherosclerosis, thereby potentially improving coronary artery disease [40]. Increasing physical activity has also been shown to improve heart health and reduce the risk of cardiovascular disease and complications associated with cardiovascular disease among those who have been diagnosed, with risk reductions in up to 50 percent of cases of cardiovascular mortality [40]. Increased physical activity regularly increases circulation and strengthens the heart muscle. The heart must pump faster in order to keep up with the demands of circulating blood to the tissues and the lungs when breathing is increased due to exercise. Patients who increase their physical activity levels may not only reduce the risk of heart disease and its complications, but may also lose weight, have improved stamina, and may have greater feelings of well being by participating in regular activities that are enjoyable. Increasing exercise levels is also a change that could be taken on through motivational interviewing. Patients who need to exercise more or who live sedentary lifestyles may or may not be aware of the benefits of exercise and the risks associated with a sedentary lifestyle. Motivational interviewing can give a provider an opportunity to work with a patient to assess how he or she feels about exercise and its benefits. After assessing the patient s levels nursece4less.com nursece4less.com nursece4less.com nursece4less.com 88

89 of ambivalence toward exercise, the provider and the patient can work together to set some goals for increasing exercise levels on a weekly basis, if the patient is willing to make a change. For example, a patient with hypertension is at risk of heart disease because of a high intake of saturated fats and because of a very sedentary lifestyle. The patient may know that exercise is important for some people but may not understand how it affects the heart or why there is a need to add it to his or her life. The provider can work with the patient to first help him or her better understand the importance of exercise on heart function and to teach or educate about how to incorporate more exercise into daily life. This information is given in a nonjudgmental and nonthreatening manner so that the patient may be more likely to respond positively. If the provider and the patient together determine that change is important and the client is willing to work toward change, the provider can then direct him Figure 26 The benefits of exercise [70]. or her toward programs or sources of support to help to increase the level of exercise. Together, the provider and the heart patient may discuss which types of exercise are most enjoyable or those that he or she could most easily begin. They could talk about the minimum amounts of exercise needed to derive benefits and then come up with ways to start slowly and increase to set goals of regular activity. Motivational interviewing holds many benefits for discussion and change talk to get a patient with a heart condition who needs to exercise more for the sake of their health make positive changes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 89

90 Smoking cigarettes greatly contributes to heart disease and its complications, and smoking kills 450,000 Americans every year. A study of British physicians found that people who smoke shorten their lifespans by approximately 10 years [40]. Although smoking causes harm to almost every organ in the body, it can significantly impact the work of the heart and the blood vessels, contributing the heart disease. The chemicals that are found in cigarette smoke cause damage to the blood vessels, which can impact how well they function. The decreased functional capacity of the blood vessels further contributes to atherosclerosis and coronary artery disease when the blood vessels are more rigid and blood flow is less efficient. Smoking, when combined with being overweight or obese and having a sedentary lifestyle, can significantly increase the risk of heart disease and its associated complications [42]. As discussed in the section of this course related to motivational interviewing and smoking cessation, motivational interviewing has helped some people to quit smoking permanently. When a patient seeks help with their health related to heart disease and the provider discovers that he or she is a smoker, the provider can use the techniques of MI to discuss the situation with the patient and address their level of motivation about quitting to support their health. If the patient is willing to take steps to quit smoking to reduce the risks of heart disease and improve their lifespan, the provider can then help the patient to find more resources to successfully quit smoking permanently. 5 A s of motivational interviewing Counseling professionals have recommended the use of the 5 A s when working with some clients to make lifestyle changes in general. Motivational nursece4less.com nursece4less.com nursece4less.com nursece4less.com 90

91 interviewing can be used alongside the 5 A s when its essential techniques of empathy, rolling with resistance, discrepancy, and supporting self-efficacy are followed. The 5 A s include [43]: Ask Advise Assess Assist Arrange Through motivational interviewing, the provider can first ask the client questions about him- or herself as a method of building rapport and trust between the client and the provider. When using MI to support smoking cessation, the provider also asks questions about the client s tobacco use, such as length of time spent smoking and the amount smoked. The advice and assessment methods could be paired together if they are presented in a non-judgmental manner and if the clinician asks for permission before giving advice. For instance, the provider might say, do you mind if I tell you and then share what he or she knows about the negative impact smoking has on heart disease. The assess step of the 5 A s then determines the client s level of motivation to quit smoking and make better choices for his health. During the assessment phase, the clinician asks the client outright if he or she wants to make a change and is willing to take steps toward a permanent change. If the client is willing to try to quit smoking, the provider then moves on to the assist portion of the 5 A s. It is at this point that the provider helps the client to come up with reasonable goals toward quitting smoking, such as using medication to reduce nicotine cravings or to attend support groups for nursece4less.com nursece4less.com nursece4less.com nursece4less.com 91

92 further encouragement. The provider can give the client resources to further support what has been discussed during the motivational interview. Finally, the arrange portion of the 5 A s involves arranging follow-up appointments to see if the client is continuing to take the steps that were discussed. This might mean following up with a phone call to check in with the client and determine how things are going, a follow-up appointment to meet together again to talk more, or an appointment with another professional who can continue to help the client in his or her work toward the goal, such as a meeting with a medical specialist. Whether or not patients with heart disease are willing to make these changes in their lifestyle is governed by a number of factors, including socioeconomic status, family or social support, and cultural factors. During the discussion of the need to make changes to manage heart disease, the provider must assess what factors are prohibiting the client from making changes and then work with the client to address those issues. For patients who have significant issues to overcome before starting to change or for those who state that they have too many obstacles standing in the way before they can get started might mean altering the goals somewhat to fit what these patients can do. In some cases, it is better to make some progress toward a lesser goal than to set a higher goal and then fail when it is too difficult for the patient. For example, a patient who never exercises and who leads a very sedentary life, including a desk job where he sits for most of the day, followed by spending his evenings on the couch at home watching television, is most likely not a candidate for setting a goal of becoming actively involved in a running program and striving to run a 10K by the end of the month. The patient may strive for this goal but might be more likely to fail or give up because it is too much of a change to start out. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 92

93 Although the patient may incorporate lifestyle changes and eventually reach the point where he or she is an active runner, it may be best to start out with smaller goals that can be achieved to improve self-efficacy. The patient could instead begin with a walking program where he or she walks twice around the block, two times a week. Although this goal would not meet the exercise recommendations given by the American Heart Association for moderate intensity exercise on five out of seven days a week, the patient is still doing more exercise than before. If the patient achieves this goal and is able to implement regular walking, then they may increase the time spent walking, as well as the number of days each week. The patient may walk further each time than previously done, and increase from two days a week to four. Some patients need to slowly work toward their goals to improve confidence and desire for change. The American Heart Association has recommended motivational interviewing as an effective method of promoting healthy outcomes by making lifestyle changes in patients with heart disease [44]. Use of MI can bring about changes in some patients that continue long term. A study by Hardcastle, et al., in the International Journal of Behavioral Nutrition and Physical Activity compared patients who received five sessions of motivational interviewing, combined with exercise and nutrition information with a group who only received the information but no MI. The patients were measured for their physical activity, dietary intake, BMI, blood pressure, and cholesterol immediately following the completion of the study and then again a year later. The goal of the study was to show that the use of MI not only produces changes in lifestyle factors for patients, but also to determine whether the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 93

94 changes can be maintained long term. The study showed significant changes in the patients who used motivational interviewing as part of their interventions in the areas of weight loss and cholesterol management. The MI intervention was particularly effective among those patients with the highest risk factors for heart disease. The study found significant increases in the amount of walking added among patients who used MI and as a lifestyle change, 12 months after the interventions ended. Alternatively, the group who did not use MI during the study had increased levels of cholesterol and BMI in the 12 months following the interventions [44]. Another study found in the Journal of Clinical Nursing performed a systematic review of literature to analyze current research findings that used motivational interviewing as part of practice in helping clients change to improve their cardiovascular health. The review included four metaanalyses, a systematic review, three literature reviews, and five primary studies related to motivational interviewing and its use in promoting cardiovascular health. The review found strong evidence that motivational interviewing is useful and effective when focusing on and implementing changes to promote cardiovascular health and, thereby, reducing the risk of disease [45]. Clearly, motivational interviewing has benefits in helping clients to make changes that will improve their lives and that will reduce the risk or impact of heart disease. Because so many patients with heart disease have multiple factors that must be addressed, including weight management issues, decreased activity levels; laboratory outcomes that can indicate severe risk of cardiac problems, including elevated total cholesterol levels, elevated levels of inflammation in the body that can lead to blood vessel changes, and increased levels of triglycerides; as well as other common contributing nursece4less.com nursece4less.com nursece4less.com nursece4less.com 94

95 factors, such as smoking or high blood pressure, motivational interviewing can work in each of these situations to come up with goals to make changes as needed in the lives of many people. Whether the change is radical and permanent, or whether the patient is able to achieve even smaller goals, MI can be used successfully to help people live longer by reducing their risks of heart disease. MENTAL HEALTH AND MI Severe and persistent mental illness, formerly referred to as chronic mental illness, consists of a group of conditions that cause complex symptoms and behaviors and that require ongoing treatment and management. People who have persistent mental illness often have symptoms that worsen and then abate over time, but do not necessarily go away permanently. Depending on the severity of the diagnosis, patients with severe and persistent mental illness may require assistance with activities of daily living, obtaining jobs, finding housing, going to school, or making social contacts [45]. Because severe and persistent mental illness is a long-term condition that often results in periods of relapse and recovery, healthcare providers must be aware of possible complications that can develop as part of maintaining appropriate behavior and for living as productive and healthy of life as possible. Ongoing case management and interventions may be necessary in some situations, while in other situations, daily thoughts and behaviors are under control but crisis situations may develop on an occasional basis. Some examples of common severe and persistent mental illnesses include severe depression, bipolar disorder, schizophrenia and delusional disorder [45]. Persistent mental illness can cause difficulties with thoughts and behaviors for those who have been diagnosed. The affected person may have difficulty nursece4less.com nursece4less.com nursece4less.com nursece4less.com 95

96 controlling his or her thoughts, which can lead to behavior that is sometimes considered erratic, bizarre, confusing, or concerning. For many people who struggle with mental illness, the disease takes over a considerable portion of their lives, impacting their abilities to function on a daily basis, and putting them at higher risk of complications that can develop as a coping mechanism for the ongoing illness, such as substance abuse, violence, or suicidal ideation. According to the American Foundation for Suicide Prevention, 90 percent of people who die by suicide had some form of mental disorder at the time of their deaths [47]. Suicide, which may also be classified as self-directed violence, is the willful taking of one s own life. People who commit suicide do so for a variety of reasons, although as many as one-third do Figure 27 Persistent mental illness [74]. did not communicate their suicidal intent prior to death [47]. Even more concerning are the results of one study that showed approximately 45 percent of people studied who had died by suicide had seen a primary care provider within the past month before their deaths and 77 percent had seen a primary care provider within the past year [47]. These statistics place the role of primary care providers and other healthcare providers in an important position to recognize situations that could contribute to suicidal ideation and intervene as necessary. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 96

97 The interventions provided through motivational interviewing can be helpful for patients who are considering suicide. If a provider has recognized the possibility of suicidal ideation in a patient, whether due to the presence of mental illness or through exhibiting other concerning symptoms, the nonjudgmental and non-threatening approach used with motivational interviewing could be a helpful intervention for the patient. Figure 28 Motivational interviewing can be utilized in suicide prevention [75]. A 2012 preliminary trial published in The Journal of Clinical Psychology worked with veterans who were hospitalized for psychiatric suicidal ideation to determine if motivational interviewing was effective as part of treatment. The participants completed two sessions of motivational interviewing after a preliminary assessment, another session following treatment and hospitalization and a final session 60 days after the intervention. The study showed that the participants were open to motivational interviewing as part of therapy and responded well to it as an intervention. The participants showed significant reductions in suicidal ideation, both after treatment had ended and at the 60-day follow-up appraisal. This study, because it is preliminary, opens the doors for further research into use of motivational interviewing as part of treatment and change for people who are experiencing thoughts of suicide and who need intervention [46]. Depression is another type of mental illness that can be classified according to different terms, depending on the types of symptoms experienced, the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 97

98 extent of the symptoms, and the length of time they have occurred. Depression is one of the most common mental health disorders in the United States. It is characterized by persistent feelings of sadness, emptiness, hopelessness, or pessimism; a loss of interest in normal activities that used to be pleasurable, suicidal ideation, fatigue, sleep problems, changes in appetite, difficulties with memory and concentration; and some physical discomfort, such as joint pain, or chronic back pain [48]. Depending on patient circumstances and symptoms, the main categories of depression are major depression and persistent depressive disorder. Major depression occurs when symptoms considerably disrupt a person s life and ability to function on a daily basis, while persistent depressive disorder may occur as underlying feelings of depression and its symptoms occur continuously over the course of at least two years. A person with persistent depressive disorder may have occasional exacerbation of depression symptoms, causing a disruption of daily activities, as well as the ongoing symptoms [48]. Other types of depression can also cause significant problems for some people but are classified slightly differently than major depression or persistent depressive disorder. Postpartum depression is diagnosed when depressive symptoms occur after delivering a baby; seasonal affective disorder results in depressive symptoms that more commonly develop during certain times of the year, such as during the winter when there is less environmental light; and psychotic depression, which occurs when a person has symptoms of depression as well as another type of mental illness, such as delusional disorder. Bipolar disorder is also classified as a form of depression, as the person nursece4less.com nursece4less.com nursece4less.com nursece4less.com 98

99 suffering from this condition has periods of depression followed by periods of mania. When depression is apparent, the patient with bipolar disorder experiences the symptoms associated with depression, including sadness, fatigue, and hopelessness. The person may later shift to a time of mania in which he or she experiences a very high mood and has increased energy and tolerance for activities. The cycles back and forth between depression and mania characterize bipolar disorder. The illness used to be called manicdepression [48]. People who suffer from depression are at higher risk of complications because the symptoms are often overwhelming. They may be more likely to consider suicide or other types of self-harm. People with depression may also suffer from other health conditions that either contributes to the depression or that have developed as a result of the depressive symptoms [48]. For example, a person who suffers from chronic pain from arthritis may develop symptoms of depression when he is unable to function in the same way that they once did. Treatment of depression through motivational interviewing can be challenging because it can be difficult to actively engage patients who are suffering from depressive symptoms to engage in a manner that leads to change. Treatment of depression through pharmacologic intervention may occur concurrently with motivational interviewing. In some situations, motivational interviewing may play a role in getting a client to take his or her medications to treat the depression. In other cases, MI can be adjunctive to medication use. Motivational interviewing can also be used in conjunction with other traditional forms of treatment for depression that are related to counseling nursece4less.com nursece4less.com nursece4less.com nursece4less.com 99

100 or psychotherapy. One form of psychotherapy that is commonly used as part of treatment for depression is cognitive-behavioral therapy (CBT). CBT focuses on negative thoughts, views, and opinions that the client holds and examines how those ideas affect his or her behavior. It may be used as a type of therapy for a number of mental disorders and has been effectively used as treatment for depression [49]. Burke, in Cognitive and Behavioral Practice, looked at how well motivational interviewing could be blended throughout the use of CBT to assess motivation, encourage self-efficacy, and resolve ambivalence among patients suffering from depression. Because motivational interviewing is not necessarily a distinct therapy itself, it can be blended with other therapeutic treatment approaches as a means of connecting with patients on a deeper level. Figure 29 Motivational interviewing can be blended with CBT [76]. Cognitive behavioral therapy and motivational interviewing have a number of elements in common. Both types of interventions work collaboratively with clients to set goals and both involve checking in or following up with clients to evaluate how they are progressing toward their goals [49]. Although cognitive behavioral therapy has been beneficial in treating many patients with depression, studies have shown that many patients who have undergone CBT for depression have successful remission rates of depressive symptoms at approximately 50 percent of those who undergo pharmacologic treatment for depression. Despite large numbers of patients undergoing CBT nursece4less.com nursece4less.com nursece4less.com nursece4less.com 100

101 for depression, there are still many of these patients who continue to suffer from depressive symptoms, even after this therapy [49]. Alternatively, there have been studies that have shown that patients with depression who went through therapy, focused on motivation and behavior activation, responded better to the treatment than those who went through therapy that was focused on cognitive interventions and used pharmacologic treatment. Because motivational interviewing focuses on behavior activation and motivation as studied, it is a viable intervention to add as part of traditional therapy and may show more promising results with depressed patients than when it is not used [49]. Patients with mental illness are at higher risk of developing concurrent disorders, most commonly substance abuse. This is often referred to as dual diagnosis or co-morbidity and occurs when one or more illnesses occur in a person, whether at the same time or one after the other. For instance, people who struggle with drug addiction are almost twice as likely to suffer from anxiety or mood disorders when compared to the general population [50]. Rates of mental illness are surging among adolescent clients, which are also often concurrent with substance abuse issues. A study by The Center for Substance Abuse Treatment found that 62 percent of male clients and 83 percent of female clients entering treatment facilities for substance abuse also had concurrent mental health diagnoses [13]. The co-morbidity of mental illness combined with substance abuse puts MI practitioners in the position of addressing more than one problem behavior. When discussing options with the client and assessing levels of motivation, providers and clients may need to determine the highest area of priority for change or whether to tackle both issues at the same time. The change talk that occurs as part of motivational therapy encourages individuals to share nursece4less.com nursece4less.com nursece4less.com nursece4less.com 101

102 more of their thoughts and feelings about their behavior in a method that is open-ended, non-judgmental, and promotes self-efficacy. When the client opens up and expands on certain subjects because of the change talk that happens during MI, he or she may be more likely to see the discrepancies between their current behavior and the lifestyle or behavior that they would like to have, which also may promote change. Another important aspect of motivational interviewing that is essential to remember when working with clients who have co-morbidities of mental health issues is that eliciting change in the client who is not ready for change is counterproductive, a waste of time, and can even be damaging to the therapeutic relationship. Thus, the provider needs to approach each individual with his or her diagnoses as individuals and at the levels of motivation in which they present. [51] Additionally, clients who are cognitively impaired at times because of their mental illnesses may also benefit from the elicit-provide-elicit technique of motivational therapy. This technique asks the client permission before offering or generating information or advice. When the client approves, the provider then gives the information and asks the client to respond. Using this process in a client who may be cognitively impaired because of mental illness can help to better keep the client on track with the conversation and what decisions are being made. The client often must repeat back the important information to the provider as part of this method, which further conveys his or her understanding of the topic and keeps the client on track [51]. According to the book, Intervention in Mental Health-Substance Abuse, this method is similar to the PAPA technique. The PAPA method starts with: Permission: the client seeking permission to give advice or information and when allowed; nursece4less.com nursece4less.com nursece4less.com nursece4less.com 102

103 Asks: the provider then asks the client what he or she knows about the topic they are discussing; Provided: further information is provided to the client to clarify about the topic or to summarize his or her understanding of the topic; Asked: finally, the client is asked about what he or she thinks of the topic and the idea of change. The PAPA method may elicit more information from the client and help him or her to stay on track with the conversation [51]. Personality disorders are a prevalent form of persistent mental illness and are classified into three groups, according to the American Academy of Family Physicians [52]: Cluster A: schizoid and paranoid personality disorders Cluster B: borderline, histrionic, narcissistic, and antisocial personality disorders Cluster C: avoidant, dependent, and obsessive-compulsive personality disorders Cluster A personality disorders are classified according to bizarre or odd characteristics among patients, and may involve an inability to maintain close relationships as well as misguided thoughts and feelings related to others. For example, some people who suffer from cluster A personality disorder may have a lot of paranoid feelings from others and feel judged or threatened. Cluster B personality disorders are more related to dramatic, self-involved behavior. They may include feelings of grandiosity, attention seeking, or lack of impulse control. People with cluster B types of illnesses can also cause difficulties with relationships when excessively emotional behavior or the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 103

104 near-constant need for validation gets in the way of the normal give and take of relationships. Cluster C illness is marked by anxious or fearful behaviors, which often impact relationships with others. Cluster C disorders may cause social phobia, overdependence on others, perfectionism and control, or clingy behaviors, which are often challenging to healthcare providers as well as the families and friends of these patients [52]. An important aspect of working with patients who have personality disorders is to avoid succumbing to or otherwise being drawn into their situations. A provider who is working with a patient who has a personality disorder must maintain a line of professionalism and a working relationship to avoid becoming too involved in the situation. For example, a provider working with a patient who has histrionic personality disorder may need to have a number of discussions that involve the patient s emotions and feelings. The patient may consistently talk about a number of situations that have caused her pain or that have been difficult for her, in an effort to get the provider to feel sorry for her and comfort her. In order to provide effective care for the patient, the provider must be aware of the challenges presented with this situation before even starting the therapeutic relationship, or she could easily get too involved. It can be difficult to know how to provide comfort and help to a patient without being drawn too far into the personal lives of some patients with personality disorders [52]. Personality disorders are treated in psychiatric practice through counseling and intervention but many patients with these types of mental illness are also seen for primary care in a number of other community settings, including by general health practitioners. As noted by their title, personality nursece4less.com nursece4less.com nursece4less.com nursece4less.com 104

105 disorders cause changes in personality, which may be characterized in a number of methods, from bizarre or confusing words and attitudes to outright anger, aggression, and violence. Often, providers who work with people with personality disorders are challenged with providing quality care while simultaneously managing feelings of frustration, helplessness, or even anger when trying to help these patients because of their personalities and attitudes [52]. Personality disorders may be prevalent in almost 15 percent of the population in the United States. It is not uncommon for some people to have more than one type of personality disorder or concurrent mental illness, including substance abuse that is connected with the condition [52]. Motivational interviewing has been shown to be helpful when working with some patients who have personality disorders. While the MI techniques will not change the disorder, it can help patients suffering from these illnesses to make positive choices that impact themselves and their behavior as well as their relationships with others. Motivational interviewing can be used as part of other therapeutic interventions or even during primary care evaluations to help clients with personality disorders with decision-making and through setting goals that will create positive outcomes. In the example of the patient with histrionic personality disorder, the provider may use motivational interviewing techniques during an appointment to discuss the clients need for taking care of their children. The client may recognize that he or she has trouble taking care of their children and getting home in time to help their spouse by being involved in the family. Through MI techniques, the provider could work with the client to come up with goals that will support this desire for change in one area of their life. The client might set a goal to start picking their children up from nursece4less.com nursece4less.com nursece4less.com nursece4less.com 105

106 daycare at the same time each day, or spending 30 minutes every evening playing games with them in a focused manner. The focus of motivational interviewing in this situation does not cure the personality disorder or even reduce demonstration of symptoms to a large degree, but rather helps the client with the disorder to better manage his or her life around the condition. One condition that providers may need to manage and that may coincide with personality disorders is crisis intervention. A crisis occurs when a person is overwhelmed by events and is unable to cope with the situation. If the person cannot handle what is happening, he or she may develop maladaptive behaviors in a further attempt to cope, such as through substance use or violence, or the person may succumb to the situation and exhibit behaviors that demonstrate an unwillingness or inability to function, such as having panic attacks or psychotic events [54]. Crisis intervention aims to work with clients in acute distress to help them manage the current situation. It may then go on to help affected clients with problem solving or assist them with changing their situations so that they are less likely to have another crisis. Therapy for crises involves counseling and working with family members and friends of the affected person to provide support and to educate those involved about appropriate coping mechanisms that are available [54]. It is important, however, that some techniques be used for a short time instead of a long therapeutic relationship. In many situations of working with people who are in crisis or who have personality disorders, motivational interviewing may need to be delivered in short but intense sessions in order to prevent the client from becoming dependent on the therapist [54]. Studies have shown that motivational interviewing can be helpful when nursece4less.com nursece4less.com nursece4less.com nursece4less.com 106

107 working with clients as part of crisis intervention. Motivational interviewing may be used concurrently with other forms of behavioral therapy and crisis intervention methods. It shows the client that the provider is a trusted partner in therapy and intervention and is someone who is willing to help bring about change. It also helps the client to better visualize the discrepancies in his or her behavior and the ultimate goals or outcomes [53]. For example, if a client is seeking help for excessive drinking and has concurrent narcissistic personality disorder, he may meet with a therapist for crisis intervention for help with stopping the harmful behaviors. During the course of the intervention, the practitioner may utilize motivational interviewing to discuss the client s current situation and assess his or her goals and objectives. During the interview, the client may become more aware that their current situation: drinking to excess and taking advantage of their personal relationships, is far from where they want to be. The provider can then use techniques of MI to promote self-efficacy in the client. The techniques leave the decision ultimately up to the client, although the provider will act as a guide along the way. Some personality disorders also leave patients more prone to violence and aggressive behavior, which could lead to a need for crisis intervention. Motivational interviewing is also beneficial in these situations because the core of the MI sessions is to have the client take responsibility for his or her own behavior. If the client is willing to change or sees the need for it, the provider works with the client to help him or her make the changes but ultimately it is the client s responsibility to take charge of angry or aggressive behavior. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 107

108 Anger is a normal feeling that may occur in response to feeling judged, slighted, insulted, or ignored. It can develop based on real or perceived situations. It is important that clients understand that anger is a normal emotion that almost everyone feels at one time or another, however, aggression and violence as a result of anger are not normal. Peter Prisgrove of the Western Australian Department of Corrective Services states that providers can work with clients on anger control issues through such interventions as cognitive-behavioral skills training, in which the focus is on recognizing the impact of thoughts related to behavior and working through negative or angry thoughts to recognize them and deal with them before they lead to problem behaviors. Behavioral skills training also consider those situations that might lead to aggressive or negative reactions and teaches the client how to behave and handle him- or herself when the urge to lose control happens [55]. When using motivational interviewing as part of cognitive or behavioral skills training, the client may have mixed responses for being motivated to change, depending on his or her background and the situation at hand. Some clients feel true remorse and are motivated to change because they have hurt someone they care for or they are facing legal consequences of their actions. Alternatively, other clients may have little motivation to change and may feel justified in their actions or continue to feel angry about the situation. Just as with any other situation that requires motivational interviewing, the provider must first assess the level of motivation from the client and his or her amount of ambivalence toward change before progressing into change talk. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 108

109 Prisgrove also states that there are two main types of aggression often seen among individuals who are in treatment for this kind of behavior: instrumental aggression and reactive aggression. Instrumental aggression often occurs because of a cause that the offender deemed necessary or justified at the time, or to achieve some sort of objective. An example might be when a client Figure 30 Anger management [80]. attacks their employer because they have been angry about unfair treatment at work and believes that through force the employer can be made to change. Alternatively, reactive aggression is the result of loss of control over a situation in which the client acts out. An example might be when a client comes home and becomes angry and violent toward their spouse because he or she forgot to run an errand for them [55]. In the treatment sense, different clients obviously will arrive for help and treatment of different needs. The provider using motivational interviewing will need to understand the background of the aggression, or whether it was instrumental or reactive aggression, in order to better understand the client s level of motivation for change. Finally, when working with aggressive clients, whether or not due to underlying personality disorders, the probability for repeat offenses is high [55]. A client may be seen for therapy or treatment of an aggressive outburst, go through the steps of change, and then return for treatment again at a later date. The change invoked through motivational interviewing may or may not nursece4less.com nursece4less.com nursece4less.com nursece4less.com 109

110 be permanent because the anger and aggression takes on an almost addictive framework in which the client is drawn to repeating the same offenses over and over. A client in this situation may need repeated sessions or ongoing, long-term treatment and therapy in order to handle aggressive feelings and avoid acting out. Studies have shown that the most difficult area of treating clients with anger-control issues is the long-term maintenance of behavior change [55]. The goal, therefore, of treatment along with motivational therapy is not to cure the client of their anger, but rather to help them change behavior so that he or she makes better choices when frustrating situations arise. This involves learning new skills, and the motivational interviewing process is there to help the client acquire these skills to implement them into daily life. If a lapse in behavior occurs, the client may have learned the skills needed to cope with the situation before he or she completely loses control. The provider, however, can use this lapse in behavior in a positive way to reinforce the need for change and to elicit further growth in the client [55]. DISEASE MANAGEMENT AND MI Motivational interviewing may often be implemented into specialty settings, particularly when working with clients with specific needs, such as drug or alcohol abuse, pregnancy, or certain medical conditions that require specialty training for treatment. However, motivational interviewing can also be included as part of primary practice and the interventions need not take much more time that a routine meeting with a specialist. There are both advantages and disadvantages to using MI in the primary care setting. Despite motivational interviewing being used primarily in specialty situations, it can be implemented into community and primary health care settings with some modifications. In order to facilitate the process of MI into nursece4less.com nursece4less.com nursece4less.com nursece4less.com 110

111 these settings, changes may be necessary in terms of time available to participate. Most encounters in the primary care or public health setting are very brief and may only allow a few minutes for discussion of issues. Depending on the situation, some primary care providers may have very limited time to see their patients, discuss the plan of care, and then document interactions before moving on to the next client because of time issues or the larger numbers of clients waiting to be seen. Taking the time to work with the client, as a guide toward change and implementing healthcare goals, may be a low priority for these providers. It may seem impossible to integrate MI into the primary care setting in these situations, however, with some adaptations, it can be done [39]. When first incorporating motivational interviewing into the primary care setting, the provider must begin by changing some assumptions or thoughts that he or she already has about delivery of ideas [39]. For example, a physician in a primary care office may have many clients to see in one day and most of them may need advice or instructions about how to better manage their health. The provider may have a prepared speech about the importance of weight loss, quitting smoking, or increasing exercise and may be prepared to give it as part of the routine appointment. However, the provider must first consider that instead of delivering the information in a paternalistic method and then moving on to the next client, he or she may need to change this idea and focus on first assessing the client s level of ambivalence or motivation toward change. As with other situations that incorporate motivational interviewing, the provider should ask open-ended questions and show empathy toward the client in order to draw him or her out more to talk about the situation. If the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 111

112 client s issue is clear, the provider may be able to quickly assess for a level of how much the problem is impacting the client s life by using a brief assessment scale or interview that have been specifically developed for this purpose. For example, Rollnick et. al have develop a questionnaire about smoking cessation that addresses the importance of quitting for health benefits and assesses the client s level of motivation and willingness to change. The assessment takes only about 5 to 10 minutes and gives the provider quick answers about where the client is coming from at the start of the interview [39]. The provider may take available information that he or she has about the client, such as data from the medical record, to use as points of discussion with the client to collaborate toward change. Using this information also supports the need for the appointment and increases the client s awareness of the need for intervention. If the client is not willing to change or is unsure, the provider may ask the client for permission to give more information about the topic and then follow up at a later time to see if he or she has considered the change further. Alternatively, if the client has decided that he or she is ready to change, the provider then gives the client a menu of options to consider that could successfully help to implement the change. The provider may also provide contact information for referrals if necessary [39]. Motivational interviewing has also been used successfully as an adjunct to other methods of working with clients to promote change. There are a number of different resources in the community that are available to help people see the need for change and to Figure 31 Meditation [77]. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 112

113 implement certain interventions into their way of life, whether through therapy, hypnosis, meditation, or other methods. In some practices, motivational interviewing is incorporated into techniques to improve outcomes for patients already seeking care through other alternative measures. Mindfulness is a concept that involves choosing to live in the present moment and accepting it, whatever is happening. Mindfulness originally started as a Buddhist practice but it is being incorporated into many different medical and psychological therapies today after researchers have discovered some of its many health Figure 32 Mindfulness [78]. benefits. Mindfulness has been shown to have a positive impact on mental health, including depression, substance abuse, anxiety, and obsessivecompulsive disorder. It can also benefit physical health and has been shown to lower blood pressure, relieve stress, and reduce chronic pain [35]. Mindfulness involves a form of meditation in which the person practicing it uses techniques to focus on what is happening within him- or herself in the present moment. It may involve focusing on body sensations, emotions, or sensory input that is happening, recognizing them for what they are, and accepting them without judgment [35]. People who use mindfulness regularly can learn the techniques and use them on their own or they may continuously practice them within groups or with others. Mindfulness may also be incorporated into motivational interviewing and nursece4less.com nursece4less.com nursece4less.com nursece4less.com 113