Erica R. Thomas MS DDA Health Initiative

Erica R. Thomas MS DDA Health Initiative

Learning Objectives Nurses will be able to identify, practice and apply the basic strategies of motivational interviewing Nurses will be able to define the importance of incorporating motivational interviewing strategies Nurses will be able to define ambivalence and how it relates to behavior change Nurses will utilize the Stages of Change model to determine if a person is ready for a behavioral change

Understanding what MI is Getting the person on board with MI Starting the conversation about change

Motivational Interviewing (MI) Collaborative conversation style for strengthening a person s own motivation and commitment to change Person-centered Addresses the common problem of ambivalence about change Partnership

MI Recipe Understanding what MI is: Partnership, acceptance, compassion & evocation Getting the person on board with MI: Engaging, focusing, evoking & planning Starting the conversation about change: Open-ended questions, affirming, reflecting & summarizing

Understanding What MI Is PACE Partnership Acceptance Compassion Evocation

Partnership For and with the person Active collaboration between experts Exploration Curiosity Support Simply leading a person on the path to change

Acceptance Acceptance Recognizing the person s absolute worth Expressing empathy (Important key to MI) Effort to understand the person, his/her feelings and perspectives Putting yourself in that person s shoes Empathy is NOT sympathy Autonomy Right and capacity to make their own decisions

Expressing Empathy - NURSE Name the emotion: You seem scared. Understand the emotion: I can see why this would be scary to you. Respect: Thank you for sharing that with me. Support: I am glad you came to talk to me about this. Explore: Tell me more about why this is so scary for you.

Sympathy vs. Empathy

Compassion What benefits the person? What is in service to the person and his/her needs? Promote the person s abilities Give priority to the person s needs Keep the person s interests in mind Have your heart in the right place

Evocation What motivates the person to change? Kids Significant other Health scare Job-related Time for a change The person knows himself/herself Find the answers together The person has what it takes to get to where s/he wants to go, s/he just needs a push

Traditional Approaches Usually when we try to get someone to change a behavior we try one (or more) of the following: Confrontation Coercion Persuasion Focus on the urgency Focus on the benefits of change Do you think any of the approaches above will increase the likelihood of change?

Getting On Board with MI Engaging Establish a connection with the person Focusing Develop and maintain the direction of the change conversation Evoking Figuring out what motivates the person to change Planning Getting the person to commit to the change and developing a plan of action

Examples of Engaging Establish a connection with the person How comfortable is this person in talking to me? Am I being supportive or judgmental? Do I understand the person s perspectives and concerns? How comfortable do I feel in this conversation? Does this feel like a partnership?

Examples of Focusing Develop and maintain the direction of the change conversation What goals for change does this person have? Are we working together with a common purpose? Does it feel like we are moving together and not in different directions? Do I have a clear sense of where we are going? Does this feel like dancing or wrestling?

Examples of Evoking Figuring out what motivates the person to change What is this person s own reasons for change? Is there reluctance about change? What change talk am I hearing? Am I steering too far or too fast in a particular direction? Is the righting reflex pulling me to be the one arguing for change?

Examples of Planning Getting the person to commit to the change and developing a plan of action What would be a reasonable next step toward change? What would help this person to move forward? Am I remembering to evoke rather than prescribe a plan? Am I offering needed information or advice with permission? Am I retaining a sense of quiet curiosity about what will work best for this person?

Starting the Conversation About Change OARS Open-Ended Questions Affirmations Reflective Listening Summarize

Open-Ended Questions (OEQ) Invites the person to talk more about the topic Use OEQ to get more information Use OEQ to understand the person s perspective OEQ do not prompt a yes or no answer What do you want to do today? Are you going to exercise today?

Examples of OEQs What lifestyle changes do you need to make? Tell me about your drinking. What makes you think you should stop smoking? If you decide to not take your BP medication today, what do you think will happen? How do you see yourself one year from now? How can I help you?

OEQ Practice Person You Support: I don t want to take my medication because I want to drink alcohol. Write down three OEQ to get this person to open up more

Affirming Comment on the person s strengths, abilities, intentions and efforts Strengthens the relationship because you are focusing on the person s strengths and not his/her weaknesses Accentuate the positives Must be genuine Affirmation is not praise (Try not to use I statements)

Examples of Affirming Remember - no I statements You are awesome! I think you did a great job! Even though you had a tough week, you are back for another challenge. That s great! You have come a long way! I believe you have reached and exceeded your goal. You are so ready!

Affirming Practice Follow up with words of affirmation for each person below: 1. I stopped smoking for three days, but I had one cigarette today. 2. I lost twenty pounds. 3. I did not go to my dental appointment because it was scheduled during my work hours, but I went to my psychology appointment after work. 4. I am going out to drink with my friends tonight. I am not taking my medication.

Reflective Listening Making a guess about what the client said (the person will correct you if you are not right, thus giving you more clarity) People often do not say exactly what they mean Listen carefully to decode the meaning Reflective listening will keep the person talking (as opposed to questioning a choice) Shines light on the issue Reflections should be short

What is a Reflection? Person you support: I am feeling hopeless. I don t know if I can lose all of this weight. Nurse: (Simple reflection) You re feeling discouraged. (Complex reflection) You have been working really hard at losing the weight, but you still have more pounds to lose.

Reflective Listening Examples It seems like you are missing medical appointments because they are during your work hours It sounds like you are having a tough time losing weight I feel like you are really concerned about smoking around your baby and you want to quit I am hearing you want to stop drinking, but all of your friends are doing it

Reflective Listening Practice Give one simple reflection and one complex reflection for the scenario below: I hate taking my blood pressure medicine. It makes me have to use the bathroom all the time. Plus I am tired and I don t feel like doing anything. I am better off not taking it. It is my right to not take it. You can t make me take it.

Summarizing Put it all together A good way to end the session Makes sure you understand what is being said Ensures that you heard the person and value what he/she told you Provides an opportunity for anything additional What else? moment

Summarizing Examples You said you were going to go to the gym 3 times a week because you want to try to lose weight. You wanted to go early in the evening because you will be done with work and home in time for dinner and your favorite television show. It seems like you have come a long way. You stopped smoking, which is great, and you said you feel much better. You are no longer out of breath, your clothes don t stink and you have more energy.

MI Incorrect

MI Correct

MI Review Ask Permission Hello, today let s talk about your weight loss goals. Hello, when we last met, we talked about your weight loss goals. Is that something you want to explore today? Elicit or Evoke Change Talk What makes you think you need to change? Why do you want to change? Explore Confidence How confident are you that you will quit drinking? You tried quitting drinking before and you didn t do too well. How confident are you now?

Motivational Interviewing Practice Pick a partner One person is the interviewer One person is the interviewee Think of a behavior you want to change (something you are comfortable with changing) Practice the parts of MI 5 minutes

Relationship to Motivational Interviewing Tools to assist with ambivalence (DARN, Stages of Change and importance rulers)

What is Ambivalence? When a person has mixed or contradictory feelings/emotions/ideas about something or someone When dealing with health and wellness, people often know there is a problem, but go back and forth about making the necessary lifestyle changes The see-saw effect Ambivalence is normal and people may stay in this stage for a while

Examples of Ambivalence I really want to lose weight, but I don t like going to the gym I should quit smoking, but it makes me feel so good I really should take my medicine regularly, but it gives me a stomach ache I want to invite her to the party, but she doesn t get along with everyone I need to get more sleep at night, but my favorite show comes on at midnight I should save more money, but I like going out to eat

What Does Ambivalence Have to Do with MI? The person doing the interviewing will: Evoke change talk The person s own statements that favor change Try to get the person to resist sustain talk The person s own arguments for not changing I need to do something about my weight (change talk), but I ve tried dieting and it doesn t work (sustain talk). If you are arguing for change and the person you support is against it, you ve got it exactly backwards

Ambivalence and Behavior Change How you get an ambivalent person to change? DARN Desire: I want to lose weight. Ability: I can do it; I have to set my mind to it. Reasons: I want to be more fit. Need: I have to make some changes.

Desire OEQs How do you want things to change? What do you hope to accomplish? Tell me what you don t like. Tell me how you want life to be one year from now.

Ability OEQs If you really want to lose the weight, how could you do it? What do you think you can change? What ideas do you have to lose weight? What strategy seems more possible to accomplish?

Reasons OEQs Why do you want to get more exercise? What s bad about how things are going now? What are the benefits of losing weight?

Need OEQs What needs to happen? How serious are you? How important is exercising everyday? What has to change?

Stages of Change

Precontemplation Not ready to change No intention of taking action May be due to multiple unsuccessful attempts at change Tendency to avoid reading, talking, or thinking about their high-risk behaviors Often characterized as resistant, unmotivated, or unready for help

Precontemplation Example

Contemplation Getting ready The stage in which people intend to change in the next six months They are more aware of the pros of changing, but are also aware of the cons Can produce profound ambivalence that can cause people to remain in this stage for long periods of time

Contemplation Example

Preparation Ready Stage in which a person intends to take action in the immediate future, usually measured as the next month Typically, they have already taken some significant action in the past year These people have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book or relying on a self-change approach

Preparation Example

Action Stage in which a person has made specific modifications in their lifestyles within the past six months Because action is observable, the overall process of behavior change often has been equated with action

Action Example

Maintenance Stage in which people have made specific modifications in their lifestyles and are working to prevent relapse While in the Maintenance stage, people are less tempted to relapse and grow increasingly more confident that they can continue their changes Based on self-efficacy data, researchers have estimated that Maintenance lasts from six months to about five years

Maintenance Example

Relapse During the change process, most people will experience relapse Relapses can be important for learning and helping the person to become stronger Alternatively, relapses can be a trigger for giving up To recover from a relapse, review the quit attempt up to that point, identify personal strengths and weaknesses, and develop a plan to resolve those weaknesses to solve similar problems the next time they occur

Relapse Example

Still Ambivalent? Importance Ruler How important is it to make this change? Not Ready to Change Thinking of Changing Undecided/ Uncertain Somewhat Ready Very Ready to Change 1 2 3 4 5

Scenario #1 The Situation: You are a busy nurse working with people with IDD. You have been tasked with conducting health screenings for at-risk people within your agency. You will have 10 minutes with each person. The Person: The first person you meet with is clearly overweight, a smoker, and eats fast food almost daily. Her blood pressure and cholesterol are elevated. She wants to change her diet, but still wants to smoke and eat out. Your Task: How do you start the conversation with this person about doing something about her diet and smoking?

Scenario #2 The Situation: Someone you support drinks too much and his drinking has become a concern to his staff, roommate and boyfriend. The Person: The person drinks a six pack and a pint of vodka every night. Sometimes he will miss his evening medications so he can drink. He wants to quit drinking, but likes drinking with his boyfriend. Your Task: Is this person ambivalent? How do you know? Pick out the change talk and the sustain talk.

Scenario #3 The Situation: Someone you support is a smoker. He has a bad cough and he always smells like cigarette smoke. The Person: The person smokes at least a pack a day. He said he hates coughing all the time and he gets upset when people tell him he smells like cigarettes. He says it is something he does when he gets bored. Your Task: How do you find out what can motivate this person to quit?

Scenario #4 The Situation: Someone you support refuses to use condoms when having sex. The Person: I refuse to use condoms. The sex doesn t feel good with a condom on. I like finding random people in the community to have sex with. I like the companionship and the way the sex feels. If I am not with a man or having sex with a man I feel depressed and sad. I crave the attention and I will continue to engage in the risky behaviors. Your Task: Give a simple reflection and a complex reflection.

Scenario #5 The Situation: Someone you support is missing her medical appointments. The Person: The person is missing medical appointments because they are set during her work schedule. When she can make an appointment, she goes. If the appointment is during work hours, she refuses to go. She has missed quite a few dental appointments and risks a no-show fine. Your Task: Is this a situation where you can provide words of affirmation for this person? If so, give an example.

Look Back If the person is still unsure about change, challenge them to look back to a time when things were better Was there ever a time when things were going well for you? What has changed? What were things like before you started gaining weight? What differs from who you are today and who you were in the past?

Look Forward Help the person to think of a changed, better, future If you decide to stop drinking, what do you think will be different? What does 5 years from now look like? Let s say you don t stop smoking what will life be like a year from now?

Resources Miller, William R., and Stephen Rollnick. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford, 2013. Moore, Margaret, and Bob Tschannen- Moran. Coaching Psychology Manual. Philadelphia: Wolters Kluwer Health/Lippincott, Williams & Wilkins, 2010. Arloski, Michael. Wellness Coaching for Lasting Lifestyle Change. 2nd ed. Duluth, MN: Whole Person Associates, 2007.

Any Questions? Erica R. Thomas ert24@georgetown.edu 202.687.8814