Motivational Interviewing in Healthcare Presented by: Christy Dauner, OTR
The Spirit of MI Create an atmosphere of acceptance, trust, compassion and respect Find something you like or respect about every patient Unconditional, positive regard for the patient (even when we disagree w/ their choices) Engage with the patient as our partner and see things from their perspective
The Spirit of MI Being present, kind and affirming An attitude of extreme respect for your patient Evoke their knowledge, skills and past successes (affirmations) Being non-judgmental, making the patient feel more comfortable
Why MI? The ambivalent patient: I know I should lose weight, but Once I get a job I ll be ready to I don t want to take pain meds, but I need to quit smoking, but
Why MI? Resolving ambivalence is the goal of MI How we approach patients can influence their motivation Show respect, acknowledge their reasons for NOT changing their behavior(s) Being non-judgmental
Change Talk Patient statements and/or behavior that reflects movement towards changing a target behavior Patients may express: Recognition of the problem Concern about the problem Awareness of the problem Potential benefits of changing their behavior Costs of not changing their behavior
Stages of Change & Patient Readiness Readiness is voiced through self-motivating statements or expressed reasons for change. These are forms of Change Talk and convey the strength of the readiness/commitment a client has to changing behaviors. Readiness is critical in the Stages of Change
Stages of Change Relapse Pre- Contemplation Phase I: Building motivation for change Maintenance Contemplation Phase II: Strengthening Commitment Action Preparation Prochaske and DiClemente: Transtheoretical Model of Change
How do we practice MI? Four Processes MI Spirit & Foundation Principles Engage 1 Agenda Setting with OARS Change Talk & Discord / Resistance Focus SMART Goals Evoke Plan 2 3 4
Four Processes of MI Engage * MI Spirit, empathy, welcoming * ACE (Autonomy, Collaboration, Evocation) * Stages of Change Theory Focus * OARS (Open-ended Q s, Affirmations, Reflections, Summaries)
Four Processes of MI Evoke OARS, listening for change talk Providing Info and Advice Plan SMART goals
ACE - Autonomy Respecting a patient s freedom to choose healthy or unhealthy behaviors By respecting their choices, we build trust and hold open the door to change Where would you like to make changes in your diet? You know I m here to help you when you re ready
ACE - Autonomy How will you know when you re ready to quit smoking? I m concerned about your cardiovascular fitness, and yet it s up to you to decide if this is something you want to work on.
ACE - Collaboration We are non-judgmental and collaborative with our patients, avoid directing them We collaborate we develop the treatment plan together Patients feel heard, respected, empowered and ultimately motivated to change
ACE - Collaboration I have ideas that may help, but first I d like to know what you ve already tried or considered. Some of my patients say helps them to start exercising. How do you think that would work for you?
ACE - Evocation Evoke the patient s own thoughts, feelings and reasons for wanting to change. Ask, without judgment, about the pros and cons of the change. Allow patients to articulate past successes and strengths, along with ideas about how to change. Motivation comes from within. It doesn t help to tell them why or how to change.
ACE - Evocation Use open-ended questions: What s the best case scenario? What s the worse case scenario? If you continue down this path and don t change your, how will you be doing in six months? What are some things that could help motivate you to start exercising more regularly?
Motivational Interviewing 90% of communication is non-verbal. As you practice nonjudgment, be mindful of: Tone of voice (calm, empathetic) Eye contact Facial expression Body language Don t cross arms Do lean in
The Change Ruler Example: On a scale of 1-10, how confident are you about starting a new exercise program? Patient: About a 7. Clinician: Why did you say 7 and not 5? (evokes patient s strengths), and/or What would it take to be an 8 or 9? (evokes their own ideas about how to change)
The Change Ruler Can also be used for readiness and importance Example: On a scale of 1-10, how important is it to you to start exercising? Patient: About an 8. Clinician: Why did you say 8 and not 5? (evokes patient s own ideas about change, patient self-identifies benefits of exercise)
The Change Ruler Example: On a scale of 1-10, how ready are you to start exercising? Patient: About a 4. Clinician: What would it take to be a 7 or 8? or What are the obstacles/barriers preventing you from being a 7 or 8? (evokes patient s own ideas about problem solving)
Lab: A Taste of MI Work in pairs, one speaker and one listener Patient: Identify a change you are considering (with some ambivalence), & share with your listener. Ex. Budgeting, water intake, hygiene habits, spending more time w/ friends/family, sleep more, diet, exercise Provider: Don t try to persuade or fix anything. Don t offer advice. Instead, ask the following four Q s one at a time, and listen carefully to what the person says.
Lab: A Taste of MI 1. How come you want to make this change? 2. What are the 3 best reasons for you to do it? 3. How important would you say it is for you to make this change, on a scale from 0-10, where 0 is not at all important, and 10 is extremely important? And why are you at # rather than (a lower number) #? 4. If you decide to make this change, how might you go about it in order to succeed?
Lab: A Taste of MI After you ve listened carefully to the answers to these Q s, give back a short summary of what you heard of their motivations to change Then, ask one more Q: So what do you think you ll do next?, and listen with interest to their answer
Four Processes of MI Engage MI Spirit, empathy, welcoming ACE (Autonomy, Collaboration, Evocation) Stages of Change Theory Focus/Evoke: OARS, listening for change talk Providing Info and Advice Plan
Focus/Evoke Use OARS Open-ended Q s Affirmations Reflective Listening Summaries
OARS: Closed Q s Closed Q s sound like: Do you Are you Did you Would you Have you? Are you doing your home exercises? Have you changed anything in your diet yet? Did you start cutting down on your smoking?
OARS: Open-ended Q s Start with who, what, when, where, how, tell me more about Open Q s can facilitate solutions rather than dictate solutions Example: Could you just go straight to your health club after work 3 days/wk to do your cardio exercises? vs. When would be the best times to fit cardio exercise into your week?
OARS: Open-ended Q s Open-ended Q s can emphasize forward vs. backward focus Example: Why didn t you stick to your diet last week? vs. What would help you get back on track with your diet?
DARN! These Q s are used to elicit change talk based on a person s own motivations, values and creative ideas. DESIRE What do you want, like, wish, hope, etc. ABILITY What is possible? What can or could you do? What are you able to do? REASONS Why would you make this change? What would be some specific benefits? What risks would you like to decrease? NEED How important is this change to you? How much do you need to do it?
OARS: Affirmations Statements that support, encourage, reinforce, and acknowledge appropriate attempts at behavior change 30% tone, 60% non-verbal, 10% content
OARS: Affirmations Level One Affirmation: Appreciations, Understanding, Compliments, Thank you for calling to say you d be late. Level two affirmation speaks to the person s character: That shows real integrity. You show real determination.
OARS: Reflections Reflections are one of the most important skills in MI You are Sounds like you It s been really And yet Typically add substantial meaning or emphasis to what the patient has said.
OARS: Reflections Reflections can be used to: Convey empathy and understanding of what has been said Focus the conversation Build self-efficacy Draw out more information/change talk There are several types of reflections
OARS: Reflections The provider adds meanings or feelings that the patient did not express: Patient: My LBP controls my life. Provider: You re overwhelmed and want to better manage your pain. (moves dialogue in direction of change)
OARS: Reflections The provider reflects two opposing sides of what the patient has been saying: Patient: I know I need to lose weight, but I hate exercise and don t have time for it. Provider: You re having a hard time finding time to exercise, and yet you know how important it is to lose weight.
OARS: Reflections The provider names the emotion that the patient has implied, but never actually stated: Patient is in apparent distress related to pain/tearful. Provider: The pain is overwhelming. It took a lot of strength/perseverance to get here today. (also an affirmation)
OARS: Reflections The provider chooses to emphasize one side for a particular effect: Patient: I don t mind coming here, but I hate all these appointments. Provider: You find your therapy/treatment helpful.
Lab: Sustained Reflections Divide into groups of three: Provider Patient - Observer/Coach Patient role: Think of some kind of behavior you want to change, but have been struggling to change (e.g. sleep, budget, exercise, diet). Talk about the behavior you want to change
Lab: Sustained Reflections Provider role: Give no advice! The goal of this exercise is to reflect as much as possible with a goal of using 2 reflections for every Q asked (more is better) Affirmations also count as reflections! Remember that Q s direct the flow of the conversation and should only be used when you re stuck
Lab: Sustained Reflections Your primary goal is to understand the patient s dilemma by allowing them to talk openly about it. Demonstrate MI Spirit and genuine intent to know their perspectives by reflecting as much as possible. Consult the Observer/Coach prn
Lab: Sustained Reflections Observer/Coach role: Track the provider s responses and MI skill use, including Open-ended Q s, Closed-ended Q s & Reflections/Affirmations Provide gentle coaching when the provider asks more than 2 Q s in a row or gives advice Affirm the provider s efforts and provide feedback at the conclusion of their role
Lab: Sustained Reflections Open-ended Q s, Closed-ended Q s Reflections/Affirmations Goal: 2 reflections for every open-ended Q!
OARS: Summaries A recap of key information: the patient s situation, their reasons for not changing unhealthy behaviors, change talk, past successes and strengths Followed by a key question about importance or commitment: What do you think you ll do? How will you know when you are ready to What do you think would be a good first step towards?
Providing Info & Advice Elicit Provide Elicit Elicit the patient s own ideas and knowledge on the subject before giving your expert advice: What have you heard about how people get support to stop smoking?
Providing Info & Advice Provide advice or info with permission: Can I make a suggestion? Would you be interested in some resources? Would you like to know what has worked for some of my other patients? Elicit their response to the suggestion or info: What do you think of that? How does that sound to you?
Four Processes of MI Engage Focus Evoke Plan Help patient to set SMART goals Specific, Measurable, Achievable, Realistic, Time-based
Quick Review ACE Respect patient s autonomy Collaborate and refrain from judgment Evoke patient s own reasons for wanting to change Use your OARS
Lab: OARS in Action! Arrange in groups of 5-6 in a circle Patient: State what you are considering changing, including any sustain talk (i.e. reasons why you haven t yet) Stay in your groups for the next lab!
Lab: OARS in Action! 1 st person will begin with an open-ended Q Patient will respond naturally 2 nd person: Give an affirmation Patient will respond naturally 3 rd person: Reflection Patient will respond naturally 4 th person: Any skill (OAR) for groups of 6 Patient will respond naturally 5 th person: Summarize
Documentation In Assessment section of SOAP note: Education & Skilled Counseling provided during interventions & outcome: e.g. Pt. has avoided CV exercise up to this time due to fear of getting worse. Coaching was provided to facilitate initiating a walking program to increase her overall health and decrease pain. In Ther Activity section: e.g. Series 2, Coaching provided to help pt create pacing plan to return to jogging. or Coaching provided to help pt to create a CV plan to walk 10 min on Mon, Wed & Fri this week, before work. Be sure to make notes in Plan section for next therapist to follow-up, e.g. Did pt go on any walks since last visit? (see CV plan above)
Motivational Interviewing in Health Care The process of evoking change talk need not require a long time. You may be able to elicit significant change talk within the space of a few minutes of conversation. Success in evoking behavior change has more to do with your skill in the guiding style than with the length of time that you have to do it. At the heart of your use of MI is a conviction that patients have most of the answers within them.
Motivational Interviewing in Health Care The power of listening: There is something about being heard and understood, about being the focus of full compassionate attention, that is in itself healing. Research shows that people are much more likely to carry through with behavior change when they express their intentions in more specific terms of what, when and how.
Lab: Sustain Talk This is an exercise to help you practice expressing empathy. Change is hard! Be sure to remain nonjudgmental. Remain in same groups of 5-6. How would you respond to the following? (each person chooses one statement) The remaining group members are then encouraged to give examples of other possible responses.
Lab: Sustain Talk My pain level is a 10-11 on the 0-10 scale. I don t think therapy is going to help, and I m just going to have to live with this. There s no way I m going to be able to get to the gym. You have no idea what I m dealing with! Worker s comp accuses me of exaggerating my pain. I can t do the things you are asking me to do at home because I don t have anyone to help me. I can t do these stretches because it will make the pain worse. I hurt all over and everything makes it worse. It never goes away.