Motivational Interviewing with Adolescents in Primary Care: The Basics

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1 Motivational Interviewing with Adolescents in Primary Care: The Basics Nick Weiss, MD Vancouver, WA January 26, 2019 Objectives Describe the rationale for MI Relate MI to the Stages of Change Model Describe the spirit and principles of MI Illustrate key techniques in MI 1

2 What is MI? Motivational Interviewing is a collaborative conversation style for strengthening a person s own motivation and commitment to change. Miller and Rollnick, 2013 The Spirit of Motivational Interviewing Partnership Collaborative, rather than directive Autonomy Informs and encourages choices without judgment Compassion Seeks to understand the internal struggle involved in behavioral change Evocation Seeks to find and strengthen the patient s own motivation for change, IN THEIR OWN WORDS 2

Why Use Motivational Interviewing: the Rationale Change is really hard Adolescents cherish autonomy Adolescents are skeptical of experts Information usually isn t enough to activate change People

3 Why Use Motivational Interviewing: the Rationale Change is really hard Adolescents cherish autonomy Adolescents are skeptical of experts Information usually isn t enough to activate change People have to persuade THEMSELVES to change Why Use Motivational Interviewing: the Evidence Base There is extensive evidence supporting motivational interviewing in adults across many health related behaviors. There is preliminary evidence supporting motivational interviewing in adolescents in the following areas: Substance abuse Childhood and adolescent obesity and diabetes Asthma Dental health Accident prevention 3

4 Other Potential Areas of Use in Teens Going to counseling Using coping skills Medication adherence Risky sex Sleep hygiene The Stages of Change Change is a process, not an event Best to match intervention to stage Unmatched intervention RESISTANCE 4

5 What to Do at Each Stage of Change Pre-contemplation: express empathy and curiosity Contemplation: build motivation, build confidence Preparation: clarify goals and plan a course of action Action: provide advice on follow-through, set SMART goals Maintenance: reinforce the benefits of change, provide advice on relapse prevention Which of the following is most appropriate to say to a pre-contemplative patient? 1. Actually, marijuana isn t harmless. That s a myth. It can lower IQ. 2. Will you commit to going to counseling at least once? 3. Tell me more about how you and your friends drink. 4. You ended up in the ER. You almost died. What would get you to stop drinking? 5

6 MI Principles (Approaches) Express empathy Normalize ambivalence Roll with resistance Assess readiness Evoke readiness Set SMART goals Expressing Empathy Listening in a supportive, reflective manner. Demonstrating you understand their concerns and feelings. Encouraging a nonjudgmental, collaborative relationship. Complimenting, rather than criticizing or warning. Understanding the teen s values. 6

7 JR6 The Righting Reflex Patient: Well, I overdo it sometimes, but I don t have a problem with drinking. Doctor: Wait a sec! You got a DUI on prom night! JR7 How to avoid the Righting Reflex Patient: Well, I overdo it sometimes, but I don t have a problem with drinking. Coming Alongside You feel mostly in control of your drinking and don t see it as an issue. Amplified Reflection Drinking has never really caused any problems at all for you. Double-sided Reflection You think you ve gone too far sometimes, but you don t think you have an alcohol problem. 7

8 Slide 13 JR6 (Brett could record these as well) Johanna Rosenthal, 9/17/2018 Slide 14 JR7 (Brett could record these as well) Johanna Rosenthal, 9/17/2018

to hang out with your friends and have fun.

9 Normalize Ambivalence Seems like you feel torn about this. On the one hand you want to drink less, but on the other hand you want to hang out with your friends and have fun. A lot of kids don t feel like going to therapy, even if they think it might help. Rolling with Resistance 8

JR5 Rolling with Resistance: Example Patient: I don t smoke that much. It totally helps with my anxiety. And helps me sleep. It works a lot better than those pills Dr. Nick gave me.

10 JR5 Rolling with Resistance: Example Patient: I don t smoke that much. It totally helps with my anxiety. And helps me sleep. It works a lot better than those pills Dr. Nick gave me. They didn t do $#@! Clinician: Are there any downsides to smoking? Patient: Not for me. Clinician: Ok. Maybe your parents think it s a problem? Patient: Yeah. They think it s affecting my grades. Clinician: What do you think? Assessing Readiness: The Readiness Ruler 9

11 Slide 17 JR5 (May need to change end of patients first line to be They didn t do anything. ) Nick, if you re going to make some comments about the roll play afterwards, we could have Brett and Michelle do the roll play and you just introduce it and comment. Johanna Rosenthal, 9/17/2018

12 Questions to Use with Readiness Rulers On a scale of 1-10, how ready are you to smoke less? Why are you a 7 and not an 8? Why are you a 7 and not a 6? What might move you from a 7 to an 8? Would anything move you in the other direction, down to a 6? How could I help you get from a 7 to an 8? Why Use Readiness Rulers? Helps you to establish the stage of change Helps to prevent black and white thinking Facilitates a nonjudgmental atmosphere Supports visual learners 10

13 What is Readiness? IMPORTANCE + CONFIDENCE Importance Rulers 11

14 Strategies When Importance is Low Education Open-ended questions Developing discrepancy Decisional balance Open-Ended Questions Tell me about your smoking? What are some of the things you like about it? What are some of the things you don t like about it? What have you heard about the risks? What would change in your life if you cut back? 12

15 Develop Discrepancy Help clients consider the gap between their current behavior and their values or hopes. Example: African-American youths are much more likely than other youths to view cigarette smoking as conflicting with their ethnic pride. Explore whether true for your patient Decisional Balance No Change: Keep drinking the same amount Change: Drink less 13

Motivation Confidence Ways to Build Confidence Review past successes & affirm strengths Break things down into small steps Brainstorm solutions Address barriers I remember when you pulled your grades

16 Motivation Confidence Ways to Build Confidence Review past successes & affirm strengths Break things down into small steps Brainstorm solutions Address barriers I remember when you pulled your grades up last year. That was really impressive. What about trying just one day without smoking? Maybe you could use an app to help you stop smoking. If your friends are pushing you to smoke, maybe you could just say that you ve got a cold. 14

17 SMART Goals Specific Measurable Attainable Reasonable Timely A simple, specific plan for starting to change Best used for youth in the Preparation or Action stages If it turns out that they re not ready to make a plan, ask can we leave the door open on this? SMART Goals: Examples Starting on Tuesday I ll practice square breathing at least once a day for at least a week. Beginning this Friday I ll limit myself to just one drink (one cup of alcohol) in a night until our next meeting. Starting tomorrow I ll take my fluoxetine every morning with breakfast for at least the next 2 weeks. Starting this week I won t buy any weed for at least 2 weeks, though I might use some if my friends offer it. I ll go to counseling next week and the week after even if I really don t feel like going. 15

18 Conclusions Motivational interviewing is a collaborative, nonconfrontational approach to supporting behavior change with preliminary research support among teens. The spirit of MI: Partnership, Autonomy, Compassion, Evocation. Key techniques: rolling with resistance, readiness rulers, open-ended questions, and decisional balance. SMART goals increase the likelihood of follow-through. Don t try SMART goals until the youth is ready. JR1 Resources Short Online Guide to MI: ational_interviewing_definition_principles_approach.pdf Decisional Balance Sheet Handout: %20CBT/pages/2%20Engagement/Decisional%20Balance%20Scale.pdf Live Training Opportunities: Web-Based Training for Primary Care: 16

19 Slide 32 JR1 Lori, please hyperlink these resources for a cleaner look and get rid of the urls, IF the learner WILL be able to click on the slide to access. These resources should also go in the Resources tab. Johanna Rosenthal, 9/17/2018

Evidence-Base for MI Borrelli et al. Motivational Interviewing for Parent-child Health Interventions: A Systematic Review and Meta-Analysis. Pediatric Dentistry, 37, 254-65.

20 Evidence-Base for MI Borrelli et al. Motivational Interviewing for Parent-child Health Interventions: A Systematic Review and Meta-Analysis. Pediatric Dentistry, 37, Brown, R, Abrantes, A, Minami, H, et al. Motivational Interviewing to Reduce Substance Use in Adolescents with Psychiatric Comorbidity. J Subst Abuse Treat 2015 Dec; 59:20. Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); (Treatment Improvement Protocol (TIP) Series, No. 35.)Center for Substance Abuse Treatment. Gayes L and Steele R. A meta-analysis of motivational interviewing interventions for pediatric health behavior change. Journal of Consult and Clinical Psychology, Jensen, et al. Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review. Journal of Consulting and Clinical Psychology, 79, Miller, M and Leffingwell T. Meta-Analysis of Motivational Interviewing for Adolescent Health Behavior: Efficacy Beyond Substance Use. Journal of Consulting and Clinical Psychology, 82, Mutschler C, Naccarato E, Rouse J, Davey C, McShane K. Realist-informed review of motivational interviewing for adolescent health behaviors. Syst Rev Jul 27;7(1):

Motivational Interviewing in Primary Care: The Basics

Motivational Interviewing in Primary Care: The Basics Nick Weiss, MD Assistant Professor of Psychiatry, U of Washington Consultant, Partnership Access Line and 2nd Opinion Consults Seattle Children s Hospital