Disclosure Information Western Occupational Health Conference 2011 Robert Scales, Ph.D. I have no financial relationships to disclose I will not discuss off label use and/or investigational use in my presentation Western Occupational Health Conference 2011 Why Wrestle When You Can Dance? Improving the Odds of Success through Motivational Interviewing Robert Scales, Ph.D. Mayo Clinic in Arizona September, 2011 Taste of Motivational Interviewing
Lifestyle Regression Trials Lifestyle Heart Trial (1990) Heidelberg Trial (1992) SCRIP Trial (1994) Ornish, D. et al. The Lancet, 336: 129-133 (1990). Schuler, G. et al. Circulation, 86: 1-11 (1992). Haskell, W. L. et al. Circulation, 89: 975-990 (1994). Problem How do we motivate patients to adopt and maintain a lifestyle that may stabilize the atherosclerosis? Stages of Change (1) Precontemplation (5) Maintenance (4) Action (2) Contemplation (3) Preparation Prochaska, J.O., DiClemente, C.C. Psychotherapy, 20: 161-173. (1992).
Cardiovascular Health Initiative & Lifestyle Education (CHILE) Study Motivational Interviewing and Skills-Based Counseling in Cardiac Rehabilitation CHILE Study: 61 CAD Patients 12-Week Early Outpatient Cardiac Rehab Control (32 patients) Baseline Assessment Random Assignment Experimental (29 patients) Traditional Program (Exercise & Education) Traditional Program plus Motivational Interviewing 1-hour (wks 1 & 13) & Skills-Based Counseling 3 x 30 minute (wks 2, 3 & 7) 12 & 24 Wk Assessment Global Approach to Lifestyle Change Manage Stress Eat a Low Fat Diet Avoid Smoking Take Medications as Prescribed Exercise and Become Physical Active
Scales, R. et al. Annals of Behavioral Medicine, 20: 68 (1999). Heidelberg-II Trial The Impact of Leisure Time Physical Activity on Disease Progression 3-4 hours/week slowed the progression 4-5 hours/week halted the progression 5-7 hours/week showed signs of disease reversal Hambrecht, R. et al. J.Am.Coll.Cardiol., 22: 468-477. (1993).
Motivational Interviewing Research Well-defined teachable method Evidence-based: Over 200 RCTs since 1983 Good evidence that it works Relatively brief Cross-cultural approach Applicable to numerous health behaviors Complements other treatment methods www.motivationalinterview.org What is Motivational Interviewing? Miller, W. R., Rollnick, S. Motivational Interviewing: Preparing People for Change, 1 st Ed., Guilford Press (1991). Miller, W. R., Rollnick, S. Motivational Interviewing: Preparing People for Change, 2 nd Ed., Guilford Press (2002).
The Righting Reflex Natural tendency to advocate for change & offer solutions Often seen as confrontational by patients Miller, W. R., Rollnick, S. Motivational Interviewing: Preparing People for Change, 2nd Ed., Guilford Press (2002). Predicted Causal Chain Confrontation Resistance Status Quo Miller, W. R. et al. Journal of Consulting and Clinical Psychology, 61: 455-461 (1993).
Predicted Causal Chain Motivational Interviewing Change Talk Behavior Change Amrhein, P. et al. Journal of Consulting & Clinical Psychology, 71: 862-878 (2003). Encouraging Talk About Change Arranging conversation so that patients make the argument for change AVOID ARGUMENTS Arguments are hard work A signal to change strategies Miller, W. R., Rollnick, S. Motivational Interviewing: Preparing People for Change, 2nd Ed., Guilford Press (2002).
REPLACE WRESTLING WITH DANCING Motivational Interviewing: A Person-Centered Approach COLLABORATION Vs CONFRONTATION DRAWING OUT Vs EDUCATING PERSONAL CHOICE Vs PROVIDER AUTHORITY COMPASSION DANCING Vs WRESTLING Rollnick, S., Miller, W. R., Butler, C. Motivational Interviewing in Health Care, Guilford Press (2008). Key Components of MI Scales, R., Miller, J. H. Motivational techniques for improving compliance wıth an exercise program: Skılls for primary care clinicians. Current Sports Medicine Reports, 2: 166-172 (2003).
EXPRESS APPRECIATION AND OFFER APPROPRIATE PRAISE (AFFIRMING) Finding something positive about the patient s behavior & expressing it Being genuine SET A COLLABORATIVE TONE Show respect for the individual s freedom of choice State an intention to work as a collaborator rather than taking the expert role USE OPEN-ENDED QUESTIONS Open vs. Closed?
Asking Good Questions Good question: A question for which the answer is change talk. (It draws out the reasons and intentions for change) Not-so-good question: A question for which the answer is resistance (commitment to the way things are) Good Question or Not? In what way has your weight been a concern for you? What do you think keeps you from being successful in controlling your blood sugar? What can you tell me about the benefits of this medication for the heart?
LISTEN WITH EMPATHY Listening with focused attention and striving to not only understand what has been said but also what the person is feeling Holding up a mirror to enable the person to hear what they have said and discover how they feel (Reflective Listening) Listen more than tell Empathy in Addiction Counseling Empathy is the single best predictor of higher success rate in addiction counseling Less resistant More likely to stay in treatment More likely to recover Less likely to relapse Miller, W. R. et al. Journal of Consulting and Clinical Psychology, 48: 590-601 (1980). Responding with Reflections (28 year-old female) I ve tried every diet there is and I still can t lose the weight. Possible Response You are frustrated that you haven t been rewarded for your efforts.
Tips for Forming Reflections Make a guess about meaning and feelings Brief summary statements Inflection turns down at the end Responding with Reflections (66 year-old male) I had a doctor who told me if I didn t quit smoking immediately, I d be dead in six months. That was ten years ago and I m still smoking like a chimney. Possible Response Scare tactics just don t work with you. MATCH STRATEGIES TO READINESS FOR CHANGE Assess readiness Meet people where they are in their readiness to change Use appropriate strategies
BE OPTIMISTIC ABOUT CHANGE There are things to do that work & You can do them! Providing Information & Advice An Empathy-Based Approach to Providing Information and Advice ASK/ASK/PROVIDE/ASK PROVIDE A MENU OF OPTIONS FOR CHANGE A way to emphasize personal choice Some people in a similar situation do this, others do this What do you think might work for you?
USE SUMMARIES Let me make sure I m getting this, you are saying Did I get everything? ASK FOR A DECISION TO CHANGE Where does this leave you now? What would you like to do about your (weight gain, smoking, diabetes, etc.)? But, be careful, don t ask too soon! Help People Talk Themselves into Behavior Change The way in which we communicate can make a difference Suppress the Righting Reflex Empathic listening works It doesn t have to take a long time
Conclusion Perhaps our patients need a good listening to! For more information on motivational interviewing http://www.motivationalinterview.org/ scales.robert@mayo.edu
Training in Motivational Interviewing A two-day training workshop improves competency in MI Feedback and ongoing supervision helps to enhance proficiency Miller et al. Journal of Consulting and Clinical Psychology, 72, 6: 1050-1062 (2004). How do we know if our consultations are empathy-based? Ask for client feedback (CARE Measure) Mercer et al. Family Practice, 21 (6), 699-705 (2004).