Motivational Interviewing Nicotine Dependence Center Mayo Clinic

Transcription

1 Motivational Interviewing Nicotine Dependence Center Mayo Clinic Thomas Gauvin, MA, CTTS 2013 MFMER slide-1

2 Behavior Change Change is a process 2013 MFMER slide-2

3 Stages of Change Precontemplation (No intention) Contemplation (Change on horizon next 6 months) Preparation (Getting ready next 30 days) Action Consistently changed (within 6 months) Maintenance Staying there (More than 6 months) Relapse (Recycling) 2013 MFMER slide-3

4 Meet the patient at his/her place of readiness What are your thoughts about 2013 MFMER slide-4

5 Traditional Health Behavior Change Confrontational Expert driven What makes an expert? 2013 MFMER slide-5

6 People tend to resist that which is forced upon them People tend to support that which they helped to create Vince Pfaff 2013 MFMER slide-6

7 What should be in a definition of MI? It s a conversation about change It s collaborative and not expert driven The interviewer uses skills to evoke 2013 MFMER slide-7

8 Spirit A way of being with people Partnership Acceptance Compassion Evocation 2013 MFMER slide-8

9 The Spirit of Motivational Interviewing (MI) The Dance Partnership - Not Confrontation Acceptance Not Judgment Compassion Not Indifference Evocation Not Advice Careful eliciting of the values, assumptions, fears, expectations and hopes of the client 2013 MFMER slide-9

10 Spirit of Motivational Interviewing Partnership/Collaboration Acceptance Absolute Worth Autonomy Support Empathy Affirmation Compassion Evocation 2013 MFMER slide-10

11 Processes for MI (Overlapping, Guiding Principles) Engagement Focusing Evoking Planning 2013 MFMER slide-11

12 Engaging Establishing a connection Either party can become disengaged Exploring strengths, values & goals Key is listening To understand dilemma and values 2013 MFMER slide-12

13 2013 MFMER slide-13

14 Focusing Develop a direction The Client s direction The Setting (agency) Clinical Expertise Agenda Mapping look at options & move to agreed upon focus 2013 MFMER slide-14

15 Focusing Giving Information & Advice 1. The client asks for advice 2. You ask permission to give advice 3. You qualify your advice to emphasize autonomy 2013 MFMER slide-15

16 Evoking Eliciting client s own motivation Let client show the argument for change 2013 MFMER slide-16

17 Planning Developing commitment to change Formulating a specific plan of action 2013 MFMER slide-17

18 Planning The bridge to change Strengthening commitment Involves negotiating (goals & plans) Implementing & adjusting 2013 MFMER slide-18

19 Planning Utilizing MI, when do you negotiate a specific change plan? If and when the client is ready! 2013 MFMER slide-19

20 Signs of Readiness for Planning Increased change talk Taking steps Diminished sustain talk Resolve Envisioning Questioning - What happens here in this Tx program? 2013 MFMER slide-20

21 It s Motivational Interviewing when 1. The person-centered communication involves empathic listening (ENGAGE) 2. There is a specific target for change that is the topic of conversation (Focus) 3. The interviewer is evoking the client s own motivations for change (EVOKE) 2013 MFMER slide-21

22 What is Unique to MI? Attuned to and guided by certain types of language (change talk) Intentional, differential evoking and strengthening of change talk Strategic-directional use of client-centered methods (reflections, affirmations, summaries) 2013 MFMER slide-22

23 Motivation Can be internal or interpersonal 2013 MFMER slide-23

24 What gets people to change? Factors of Motivation: Importance Confidence 2013 MFMER slide-24

25 Sustain Talk vs. Change Talk Change Talk Sustain Talk 2013 MFMER slide-25

26 Change Talk Any speech that favors movement in direction of change Linked to a particular behavior change target DARN-CAT 2013 MFMER slide-26

27 Preparatory Change Talk What to look for: Desire - I really want to Ability - I ve done it before. Reason - I would have more energy if I lost weight. Need - I can t go through life like this. I have to 2013 MFMER slide-27

28 Mobilizing Change Talk What to look for: Commitment I will make changes Activation I m ready, prepared, or willing to make changes Taking Steps I am taking specific action to change DARN-CAT 2013 MFMER slide-28

29 Strength of Change Talk On a scale of 1 to 5 +5 Definite, strong, emphatic, absolute inclination +1 Highly diminished inclincation 2013 MFMER slide-29

30 Desire +5 I definitely want to +4 I really wish +3 I d like to +2 I mostly want to +1 I guess I d like to 2013 MFMER slide-30

31 Ability +5 I m sure that I could +4 I m pretty sure that I could +3 I think I can +2 Probably I can +1 I might be able to 2013 MFMER slide-31

32 Change Talk & Sustain Talk (Opposite Sides of the Coin) Sustain Talk: I really like eating desserts (Desire) I don t see how I could give up sugar (Ability) I eat because I m surrounded by a family who also eats hearty meals (Reason) I don t think I need to lose weight (Need) I m not willing to do this (Activation) I intend to stay the way I am (Commitment) 2013 MFMER slide-32

33 Find the Mobilizing Language 1. I want to quit smoking 2. I quit drinking, so I probably could do this too 3. I m going to quit 4. I d have more money if I quit 2013 MFMER slide-33

34 Which question would you ask to evoke mobilizing language? So what will be your first step? How confident are you that you can do it? What makes this important to you? Why do you want to make this change? 2013 MFMER slide-34

35 Discrepancy Change is motivated by a perceived discrepancy between present behaviors and personal goals or values Use strategies to assist client in identifying discrepancy and move toward change Patient: I want to be a good role model for my children MFMER slide-35

36 Developing Discrepancy Let s put aside the how to do it, for right now, and just talk about how you would like things to be different. Discrepancy leads to ambivalence 2013 MFMER slide-36

37 Values Activity 2013 MFMER slide-37

38 Ambivalence Smoking helps me relax I really enjoy it I m afraid I m going to die young I hate the way I smell 2013 MFMER slide-38

39 2013 MFMER slide-39

40 Communication Methods Open-ended questions Affirmations Reflections Summaries 2013 MFMER slide-40

41 Open-Ended Questions Patient Benefits Allows patient to express himself Patient verbalizes what is important to him at the moment How would you do that? What do you see as your biggest challenge? Tell me more about that. Counselor Benefits Learn more about the patient Sets a positive tone for the session 2013 MFMER slide-41

42 Open-Ended Questions Exercise 2013 MFMER slide-42

43 Affirmations Statements of appreciation to nurture strengths Strategically designed Anchor clients to their strengths, values and resources despite difficulties/challenges 2013 MFMER slide-43

44 Discouraged Patient I ve tried sixteen times to quit smoking. Support selfefficacy Counselor: Wow, you ve already showed your commitment to trying to stop smoking several times. That s great! More importantly you re willing to try again MFMER slide-44

45 Affirmations I ve completed all the goals we discussed last week. I ate fruits and vegetables every single day, and I worked out three times this week Strengths: Completion of goals, practiced healthy behaviors including diet and exercise Affirmation: You really follow through when you put your mind to something MFMER slide-45

46 Affirmations Jane Goal is to become more organized in many aspects of her life. She has missed many appointments and has been written-up at work because of tasks left uncompleted. She believes she is perceived as lazy when in fact she feels she is simply unorganized. I used post-it notes as reminders all last week and I also used my notes feature in my iphone to keep track of some things. I didn t do so good with calendar management though. I missed a doctor s appointment this week. STRENGTHS: AFFIRMATION: You 2013 MFMER slide-46

47 Reflections convey: I am interested It s important to me to understand you I want to hear more What you say is important to me 2013 MFMER slide-47

48 Reflections I am an organized person. You mean that You like to have things orderly You tend to rely on routines You don t like it when things change unexpectedly 2013 MFMER slide-48

49 Reflections I don t like conflict You mean that It makes you uncomfortable when people argue You work hard to resolve differences You avoid confrontation Anger scares you 2013 MFMER slide-49

50 Reflections Mary: I m afraid that my daughter is going to smoke because she sees me smoke. You mean that You re worried about how the things that you do like smoking, might impact your daughter MFMER slide-50

51 Summarize Can be used to gather more information ( what else? ) Can be used to move into a new direction ( now can we talk about? ) Can be used to link both sides of ambivalence ( On the one hand on the other hand ) (Linking Summary) 2013 MFMER slide-51

52 Summaries Reflecting elements that will aid the client in moving forward Selective judgment in what to include & what to exclude 2013 MFMER slide-52

53 Summarizing My parents were good role models, and they taught me that good habits are a priority. I work hard at living a good, balanced, healthy lifestyle by eating lots of fruits and vegetables. My neighbors eat really well. They have a garden. I don t like to exercise but know I need to try harder. I travel a lot for work which is really challenging because it s hard to eat right and really difficult to exercise, but overall I think I do pretty good MFMER slide-53

54 Is there such a thing as a resistive client? How we respond matters Sustain Talk & Discord 2013 MFMER slide-54

55 Deconstructing Resistance Sustain Talk About the target behavior Discord A breakdown in working alliance May be present when clients are defending to keep their integrity, autonomy or self-esteem May be a power struggle - Who are you to tell me? May be interrupting to say, You don t get it you don t understand 2013 MFMER slide-55

56 Sustain Talk or Discord? I m just not sure I d be able to manage the diet that the doctor recommends. You people get a thrill by telling others what to do. I m tired of people like you taking my rights away. I really don t have any problems from being overweight. My blood pressure is good and my cholesterol is good MFMER slide-56

57 Yeah, but syndrome I can t afford the medications. I m afraid I ll gain weight if I quit. I don t smoke nearly as much as some other people that I know MFMER slide-57

58 Types of Reflections Repeating: repeats an element of what the speaker said Rephrasing: stays close to what was said but, slightly rephrases what was offered Paraphrasing: restatement, infer meaning in what was said and reflect back in new wordsadds to or extends what was said Reflection of feeling: paraphrase emotional dimension 2013 MFMER slide-58

59 Reflective Listening to Decrease Resistance Simple reflection Acknowledges the patient, reflecting here is what I heard you say Amplified reflection Reflect back the resistant issue in an exaggerated way, usually the patient will back off Double-sided reflection Reflect back the patient s ambivalence, both sides of the coin 2013 MFMER slide-59

60 Reflective Listening Simple reflection: An acknowledgment of the person s disagreement, feelings or perception. Patient: I m trying the best I can to at least cut back on smoking. Geez, I ve already made a lot of other changes in my life too, like dieting and exercise. Practitioner: You re working hard on the changes you need to make MFMER slide-60

61 I just can t quit smoking right now. I m a single mother trying to deal with a very active four year-old. I have no money and can barely afford to live. On top of all that, I m taking care of my sick father MFMER slide-61

62 Reflective Listening Amplified reflection: Exaggerate to encourage the person to back off a bit and talk about the other side of the argument. Patient: My mother is a worrier. She drives me crazy, hounding me all the time about my smoking. Practitioner: Your current health is really none of your mother s business MFMER slide-62

63 Double-sided Reflection Mirrors Ambivalence On the one hand at the same time 2013 MFMER slide-63

64 Reflections Responding to Sustain Talk 2013 MFMER slide-64

65 Responding to Sustain Talk & Discord 2013 MFMER slide-65

66 Back to Jane: I used post-it notes as reminders all last week and I also used my notes feature in my iphone to keep track of some things. I didn t do so good with calendar management though. I missed a doctor s appointment this week. I admire your creativity. It s important to you to maintain your commitments, and you found ways last week to manage some of your tasks. You find creative ways to manage your tasks despite the difficulties for you in maintaining organization You find creative ways to manage your tasks because it s important to you to maintain your commitments and be seen as the reliable person that you are MFMER slide-66

67 Developing Discrepancy Using Reflective Listening Back to Mary I m afraid that my daughter is going to be obese because she sees my bad eating habits. You re worried about the impact your lifestyle behavior might have on your daughter. Being a good role model is important to you, and it worries you that your lifestyle choices could have an impact on your daughter MFMER slide-67

68 Discussion What happens when you begin your session? 2013 MFMER slide-68

69 Change Talk Methods Evocative Statements What worries you about your smoking? Ask for Elaboration Tell me more about that MFMER slide-69

70 Change Talk Methods Looking Forward Helping the patient envision a changed future How would you like things to be different? How would you like your life to be like in five years? 2013 MFMER slide-70

71 Change Talk Methods Highlights the discrepancy between how things are at present and the possibility of life being better How has your life changed since you started smoking? 2013 MFMER slide-71

72 Change Talk Methods Looking back Helpful when patient has a period of success in the past What was is like for you when you quit for six months? 2013 MFMER slide-72

73 Responding to Change Talk Open-ended questions to elaborate Why else In what ways Tell me more about that.. Affirm to reinforce it That sounds like a great idea. Reflective Listening to clarify & encourage more Summarize 2013 MFMER slide-73

74 Getting Started Exploring and enhancing motivation for a behavior change may be more important than giving a how to plan 2013 MFMER slide-74

75 Exploring and Enhancing Motivation 2013 MFMER slide-75

76 2013 MFMER slide-76

77 What to Address First Importance or Confidence? 2013 MFMER slide-77

78 Re-assess Readiness Where does this leave you now? Next steps 2013 MFMER slide-78

79 Reach Agreement Think about it Read brochures Bring it up at next visit Take one small step Follow-up 2013 MFMER slide-79

80 Closing the Session Summarize Praise Review the agreement 2013 MFMER slide-80

81 Brief Interventions 2013 MFMER slide-81

82 Brief Intervention Elicit-Provide-Elicit 2013 MFMER slide-82

83 Brief Intervention Elicit-Provide-Elicit Provide - Information in a neutral nonjudgmental fashion Research suggests that vs You re putting your fetus at risk every time you take a puff off that cigarette MFMER slide-83

84 Brief Intervention Elicit-Provide-Elicit Elicit - The patient s interpretation What does this mean to you? How can I help? vs It s obvious from this information that you have no choice and you must quit MFMER slide-84

85 Summary Importance, Confidence & Readiness = Motivation OARS Listen for Change Talk Scaling understand and encourage importance and confidence Decisional Balance examine pros & cons Spirit Collaboration, Evocation & Autonomy 2013 MFMER slide-85

86 Research on MI 2008 Clinical Practice Guideline Study of 137 smokers with cancer, found MI significantly increased quit attempts, compared to advice component. Study of a brief MI session with smokers with schizophrenia found: more likely to contact tobacco counselor and attend initial session then those who got brief psychoeducational or advice 2013 MFMER slide-86

87 Research on MI 2008 Clinical Practice Guideline evidence of the reviewed motivational interventions, such as MI, increase quit attempts with those less motivated to quit. However, not find higher long-term abstinence rates. Studies are difficult to compare, since the adherence to MI principles can vary widely in the studies MFMER slide-87

88 Research on Effectiveness of Motivational Interviewing Meta-analysis of controlled studies: Demonstrate 10-20% more effective then no treatment And at least as effective as other treatments up to one year post treatment 2013 MFMER slide-88

89 Meta-analysis (cont) Shows a dose effect (although MI is typically used as brief treatment) Effective regardless of problem severity, age, gender, or ethnic minority clients Equally learnable by practitioners of diverse professions, optimally in 2-day workshops with follow-up supervision 2013 MFMER slide-89

90 References/Resources Dunn, C. & Rollnick, S. (2003). Lifestyle change. London: Elsevier Limited. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. US Department of Health and Human Services, Public Health Service. (May 2008) Miller, W. R. & Rollnick, S. (2012). Motivational interviewing (3rd ed.). New York: The Guilford Press. Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change. New York: Churchill Livingstone. Lundahl, Brad., Burke, Brian L. The Effectiveness and Applicability of Motivational Interviewing: A Practice-Friendly Review of Four Meta-Analyses. Journal of Clinical Psychology: In Session, Vol. 65(11), (2009) MFMER slide-90