Prevention for Positives with Motivational Interviewing

Prevention for Positives with Motivational Interviewing S H A R L E N E J A R R E T T C L I N I C A L P S Y C H O L O G I S T ( M & E O F F I C E R N A T I O N A L H I V / S T I P R O G R A M M E, J A M A I C A )

Objectives Define Motivational Interviewing and its basic principles Discuss the pros and cons of motivational interviewing Identify how this approach may benefit patient adherence Sensitization not a Training

What is Positive Prevention? Positive prevention seeks to strengthen the overall well-being of HIV+ individuals by addressing individuals who are currently practicing risk behaviours that expose both themselves and their sex partners or their offspring to HIV infection, other STIs, and ARV resistance

Population estimates & epi update Est. 1.7% prevalence (2009 UNAIDS) Estimated 34,000 living with HIV; 50% unaware of status The number of HIV/AIDS cases reported per year increased by 80% between 1996 (971 cases) and 2009 (1738 cases).

JAMAICA Cumulative HIV Advance HIV AIDS Cases & AIDS Deaths 1982-2009

JAMAICA AIDS Cases & Deaths Reported Annually in Jamaica (1982 to 2009)

Positive Prevention cont d Address issues related to coping Disclosure, S&D, etc Asking to start a new behaviour Take many pills twice daily, for life Change a maladaptive behaviour Start 100% condom use

What do we need to understand before we can have patients adopt these new behaviors?

Factors that influence behaviour change The level of intrinsic motivation or intention to change The beliefs underlying the behaviour; The value of the behavior The perceived costs and benefits of changing; The barriers to changing; Beliefs about their ability to perform the behaviour change The support and reinforcement of others

So The diagnosis of a health problem is rarely sufficiently motivating Neither is information/education about the diagnosis sufficient And certainly not verbal licks

In fact Only 50% of people successfully quit smoking after a myocardial infarction About 40% of all patients needing to take antibiotics fail to do so appropriately 38% of people needing medication to treat tuberculosis do not take it appropriately

more than meets the eye Behaviour Values, beliefs, support, Skills, costs, benefits, Information, motivation, intentions, etc

Motivational interviewing Empathic, person-centered counseling approach that prepares people for change by helping them to resolve ambivalence, enhance intrinsic motivation, and build confidence to change. Kraybill and Morrison, 2007

Is it effective? A recent systematic review that included 72 studies found that motivational interviewing outperformed traditional advice giving in 80% of studies.

What s so different about MI? Motivational interviewing involves helping patients to say why and how they might change, and is based on the use of a guiding style vs. directive

The Spirit of MI It is not done "to" or "on" patients, but "with" them.

Ambivalence No change Change

Stages of change Relapse Precontemplation Maintenance Contemplation Action Preparation

Four Main Principles of MI Principle What it means How to do it Express Empathy Develop Discrepancy Increase Selfefficacy and Optimism The capacity to feel or perceive something as does another person Awareness of discrepancy between where he/she is now and where/he or she wants to be Clients belief in their own ability to carry out and succeed at a task Accept clients feelings without, judging criticizing or blaming. Communicate respect for the patient and listen more than you talk. Identify the difference between the current and ideal situation (patient generated goal). Encourage clients to set small, achievable goals. Change talk Roll with Resistance Resistance can manifest in arguing, ignoring, interrupting, or denying. Avoid confrontation with the client. Reflect; Shift focus; Emphasize client s choice and control; Reframe

Who can use MI? All members of the multidisciplinary treatment team Physician Nurse Contact investigator Social Worker Adherence Counsellor Nutritionist/Dietician

3 steps to implement MI 1. Practise a guiding rather than directing style; 2. Develop strategies to elicit the patient s own motivation to change; 3. And refine your listening skills and respond by encouraging change talk from the patient

Step 1 Practise a guiding rather than directing style

Case 28 year old HIV positive mother of a 5 year old child. Her child s father passed away two years ago. She was diagnosed after his death. Since then she has not been in a stable relationship but has many partners and does not feel she can inform them about her status as this will make her unattractive and undesirable. Other than HIV, she had no previous history of STIs. However in the past 12 months, she has presented with Gonorrhea and Chlamydia. And today, HPV. Plus, her CD4 fell from 340 to 220 since initiating ART

Directive approach may include Identifying how health is negatively affected by behaviour. Warning about risk Lecturing about need to change Providing resources to help them change Prescribing goals for patient to change All this, to provide the patient with motivation

Directing style "OK, so your refusal to use condoms is putting your health at serious risk. I m looking at your docket and this is your third STI this year. (Patient often resists at this point.). You do know they are really easy to prevent if you would use a condom every time and reduce the number of sex partners? (HCP hands the patient condoms).there s no way you can get around that simple fact. (Patient replies with a "yes, but... argument.). These infections are wrecking your immune system. And looking at your CD4 result, i m guessing that you re not taking your ARVs...

Four Main Principles of MI Principle What it means How to do it Express Empathy Develop Discrepancy The capacity to feel or perceive something as does another person Awareness of discrepancy between where he/she is now and where/he or she wants to be Accept clients feelings without, judging criticizing or blaming. Communicate respect for the patient and listen more than you talk. Encourage client to achieve a positive behaviour change Increase Selfefficacy and Optimism Roll with Resistance Clients belief in their own ability to carry out and succeed at a task Resistance can manifest in arguing, ignoring, interrupting, or denying. Avoid confrontation with the client. Encourage clients to set small, achievable goals.change talk Reflect; Shift focus; Emphasize client s choice and control; Reframe

Vs. a Guiding Style "OK Mrs. Johnson, we have another infection and your CD4 fell quite a bit (summary of situation). Let s have a look at this together and see what you think. (collaboration) My thought is, using condoms and reducing your risk for new STIs and reviewing how you re taking your ARVS will help your health, but tell me what feels right for you? (Patient often expresses ambivalence at this point.)...

So you can see the value of these things, but it s hard to imagine how you can succeed at this point in time. OK. It s up to you to decide when and how to make any changes. I wonder, what sort of changes might make sense to you? (Patient says how change might be possible.)

What s so different? "Ask" open ended questions invite the patient to consider how and why they might change;

"Listen" to understand your patient s experience "capture" their account with brief summaries or reflective listening statements such as taking medicines day in and day out is not easy. So I appreciate that sometimes it is possible to miss a dose. With that in mind, can you tell me how many doses you may have missed or taken late during the last week?

"Inform" by asking permission to provide information, and then asking what the implications might be for the patient.

Tools

Tools may include Set the agenda Examine the Pros and Cons Assess importance (why) and confidence (how) Exchange information Set goals make decisions about change

Agenda setting Agenda setting (what to change?) invite them to select an issue or behaviour that they are most ready and able to tackle

that s very helpful. Are you more ready to focus on condom use, partner reduction, or medication? Or is there some other topic that you would prefer to talk about? I d like to talk about how to reduce your risk for STI at some point and disclosure to sex partners, but what makes sense to you right now?"

Pros and cons (why change?) Ambivalence No change Change

"I want to try to understand your reasons for not using a condom(taking ARVs/smoking/disclosing) from your perspective. Tell me about the benefits for you and the drawbacks. Can I ask you firstly what you like about sex without a condom/not taking ARVs/smoking/not disclosing?" (Patient responds. Use your curiosity to elicit a good understanding.).

"Now can I ask you what you don t like about sex without a condom/ not taking ARVs/smoking/not disclosing?" (Patient responds. Remember it s their experience that counts, so avoid offering your perspective for the time being.)

(Then you summarise both sides, as briefly as possible, capturing the words and phrases that the patient came up with.) "OK, so let s see if I have this right? You like the fact that not using a condom helps you to feel closer to him, and risky or not, you feel normal and not like you re being scorned because of your HIV status. On the other hand, your main concern is about its effect on your health, especially reinfection, and you also worry about him getting sick. Is that about right? OK."

(Very important -Then you invite the patient to consider the next step.) "So where does that leave you now?" (Patient usually describes readiness or not- and any need for advice or information)

Assess importance (why) and confidence (how) Do you mind if we took some time to understand exactly how you feel about taking these ARVs? (An invitation promotes collaboration and patient autonomy.) "How important is taking this medication for you right now?" (Elicit a brief review of patient s feelings, fears, and aspirations, then ask:) "How confident do you feel about taking these medicine as prescribed?" (Elicit, and then summarise patient s view of importance and confidence.)

(Then tailor your next step accordingly for example, if importance is low, consider something like:) "Well, do you mind if I just give you some information about why it s important for you to use condoms all the time with all of your partners; but it will be up to you to decide in the end." (Emphasizing autonomy always helps.)

Exchange information "elicit-provide-elicit "OK so can I check your understanding of the situation? What do you know about the risks of poor adherence?" (Elicit understanding.)... "Well you are right about it putting you at risk for resistance. And because you are now on second line therapy, it will really limit our treatment options.. (Provide information.) OK, now can I ask, how do you think this information applies to you?" (Elicit patient s interpretation.)

Make decisions about change (setting goals) (Summarising the patient s situation.) "It will be up to you to decide when and how to do it (emphasising the patient s freedom of choice) but I am wondering how do you see yourself succeeding with this? (Inviting the patient to envision change. Patient responds, usually identifying main challenges.)

Types of Motivational Statements Cognitive recognition of the problem (e.g., I didn t think it was this bad. This is really serious.") Affective expression of concern about the perceived problem (e.g., "I'm really worried that this is happening to me.") A direct or implicit intention to change behavior (e.g., I really need to stop this") Optimism about one's ability to change (e.g., "I know if I just try, mi can do it.")

Summary Key Points Seek to understand the patient s point of view. Be positive, affirming, and hopeful. At all costs, avoid argumentation. Remember, the patient is the one responsible for making a choice. The arguments for change must come from the patient.

Top 10 useful questions What changes would you most like to talk about? What have you noticed about...? How important is it for you to change...? How confident do you feel about changing...? In what way...? How do you see the benefits of...? How do you see the drawback of...? What will make the most sense to you? How might things be different if you...? Where does this leave you now?

References Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a metaanalysis of controlled clinical trials. J Consult Clin Psychol 2003;71:843 61 Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioural domains: a systematic review. Addiction 2001;96:1725 42 http://www.bigshouldersdubs.com/clients/ama/22-ama-motivating.htm Lundahl D, Tollefson D, Gambles C, Brownell C. A meta-analysis of motivational interviewing: twenty five years of empirical studies. Res Soc Work Pract 2010; 20: 137-60 Rollnick, S., Butler C C, Kinnersley J G, Mash P. Motivational Interviewing. BMJ 2010; 340:c1900 Kraybill, K. and Morrison, S. (Forthcoming). Assessing Health, Promoting Wellness: A Guide for Non- Medical Providers of Care for People Experiencing Homelessness. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Manuscript submitted for publication. Bundy C. Changing behaviour: using motivational interviewing techniques. J R Soc Med 2004;97(Suppl. 44):43 47