An Introduction to Motivational Interviewing
-
Upload
catherine-mccall -
Category
Documents
-
view
30 -
download
2
description
Transcript of An Introduction to Motivational Interviewing
An Introduction to Motivational Interviewing
Evan Williams, PharmDAssistant Professor of Pharmacy Practice
Husson University School of Pharmacy
2
I have no financial disclosures
Disclosures
3
Clinicians can only provide patients with clinical knowledge and education
Patients make the ultimate decision to change
What can clinicians do to influence patient change?◦ Scare tactics◦ Lecture and educate◦ Motivate the patient to change
Overview
4
Describe Motivational Interviewing (MI) and its components
Identify tools pharmacists and pharmacy technicians can use to help implement Motivational Interviewing in their practice setting
Review literature that supports the effectiveness of Motivational Interviewing
Objectives
5
MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change. MI is a style of communication, not a technique.
True or False?
Pre-Test Questions
6
OARS in MI stands forA. Open Communication, Active
listening, Reasoning with the patient, and Seeking change
B. Oral arguments, Active listening, Rolling with Resistance, and Summaries
C. Open-Ended Questions, Affirmations, Reflective Responses, and Summaries
D. Ongoing dialogue, Affirmations, Resisting the Righting Reflex, and Seeking change
Pre-Test Questions
7
Developing discrepancy involves:A. The patient discovering how current
behaviors conflict with personal values or goals
B. Telling the patient the negative results of current behaviors
C. Allowing the patient to choose between two treatment options
D. None of the above
Pre-Test Questions
8
Think of a “bad” habit you have tried to change◦ Dietary habits◦ Exercise habits◦ Workplace habits◦ Relationship habits
How long did it take to realize that this habit had a negative impact on you or others?◦ Months? Years?
Were you successful? Did you relapse?
Self Reflection
9
“Motivational Interviewing (MI) is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change.”
Defined by the identification, examination, and resolution of ambivalence about changing behavior– Ambivalence: Feeling two ways about behavior
change
Defining Motivational Interviewing
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
10
Method of communication◦ Not a technique◦ Increases mutual understanding
Collaborative◦ Honors patient autonomy
Strengthens a person’s own motivation for and commitment to change ◦ Patient-centered
Principles of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
11
William R. Miller◦ Motivational Interviewing with Problem Drinkers
Behavioral Psychotherapy - 1983 Stephen Rollnick and William R. Miller
◦ 1991 article◦ Outlines clinical procedures
Has been revised and applied to many settings
Development
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy. 1983, 11 (2); pp 147-172
12
Key Elements of MI◦ Collaboration◦ Evocation◦ Autonomy
Principles of MI◦ Express Empathy◦ Support Self Efficacy◦ Develop Discrepancy◦ Roll with Resistance
Components of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
13
Collaboration◦ Dismisses hierarchy
◦ Builds rapport
◦ Non-confrontational
◦ Focus is mutual understanding
Key Elements of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
14
RG is a 57 year old male with hypertension and hyperlipidemia. On questioning it is revealed that he smokes about 1 pack of cigarettes daily. You would like him to quit smoking.
Which of the following shows the spirit of collaboration consistent with MI?◦ A. You need to stop smoking now.◦ B. What reasons do you have to stop smoking?◦ C. If you continue to smoke, you are increasing your risk for having a heart attack or stroke.◦ D. Let me help you to stop smoking.
Example of Collaboration
15
Evocation◦ Patients discover their own motivation and skills
for change
◦ Draw out the patients own thoughts and ideas
◦ “..lasting change is more likely to occur when the client discovers their own reasons and determination to change”
Key Elements of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
16
Pharmacist: “I’ve noticed you have been late filling these medications the last 2 months.”
Patient: “Yeah, I’ve been having a hard time keeping up with things as I am moving to a new home across town in a few weeks. I know taking my medications is important but I’ve been so busy lately that I forget sometimes.”
Pharmacist: “It sounds like you would like to take your medications but it has been a tough time dealing with the move.”
Example of Evocation
17
Autonomy◦ Ultimately it is the patient’s decision to change
◦ Empowers the patient and gives them responsibility
◦ As clinicians, we can encourage patients to develop their own “SMART” goals Specific, Measurable, Achievable, Relevant, Timely
Key Elements of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
18
DK is a 44 year old patient newly diagnosed with diabetes. After discussion, it is revealed that he eats desserts for relaxation. When asked how he thinks this impacts his diabetes, he states he does not know.
The response that best exemplifies autonomy consistent with MI is:◦ A. “May I tell you some information about how sweet foods impact your blood sugars?”◦ B. “Sugary dessert foods increase your blood sugar and negatively impact your diabetes.”◦ C. “Here is a pamphlet about how foods impact blood sugar.”
Example of Autonomy
19
Express Empathy◦ See the situation from the patient’s perspective◦ Gain perspective on what the patient’s motivation
may be “It sounds like this has been tough for you” “It seems like this situation has been
difficult for you to accept”
Principles of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
20
Support Self Efficacy
◦ Focus on strengths and skills patient already has
◦ Highlight previous successes
◦ Patient needs to believe that change is possible
Principles of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
21
Develop Discrepancy◦ Patients identify their values and goals◦ Patients evaluate their current behaviors◦ Ambivalence is discovered when conflict between
values/goals and behaviors is identified◦ Change is more likely when patients realize their
behaviors are in conflict with their self‐identified values or accomplishment of goals
◦ “On the one side, you feel unhappy that you cannot keep up with your grandkids because of your COPD, but on the other hand, you feel that smoking is one of the only ways you can relax.”
Principles of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
22
Roll with Resistance◦ Do not challenge resistant statements
Confronting resistance promotes defensiveness and diminishes the likelihood of a patient finding their own reasons to change
◦ Use the resistance as an opportunity to further explore the patient’s views
◦ Be aware of when a patient is becoming frustrated Closed body language Negative verbal responses Shortened verbal responses
Principles of MI
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
23
BG is an overweight veteran recently discharged from the Air Force. He has gained much of this weight since his discharge 14 months ago. The pharmacist suggested that BG enroll in clinic sponsored program for weight loss. BG declines enrollment. BG states that he is just not willing to exercise for 30 minutes 5 days a week because he is just too exhausted after work.
Which response best exemplifies the spirit of MI? ◦ A. If you don’t lose weight, you are putting yourself at risk for other serious problems.◦ B. Could you try to exercise just a few days a week?◦ C. How much are you willing to exercise?◦ D. Why don’t you want to be healthy?
Example of Rolling with Resistance
24
OARS◦ Open-Ended Questions◦ Affirmations◦ Reflective Responses◦ Summaries
RULES of Motivational Interviewing◦ Resist the righting reflex◦ Understand the patient’s motivation◦ Listen with empathy◦ Empower the patient
Tools to Help Implement MI
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
25
Elicit better responses from patients Make a conversation less one-sided Are not answerable with a simple yes or no
Open-Ended Questions
Open-Ended Question Words
Closed-Ended Question Words
How?Why?Tell me more about...When?What kinds of…
Do you?Have you?Can you?Will you?
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
26
Statements that recognize a patient’s strengths
Help support self efficacy◦ Tries to help patient believe change is possible
despite past failures
Affirmations
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
27
Words the patient uses
Words clinician hears
What the clinician
thinks the patient meant
What the patient meant
Reflective Responses
Restate how the provider perceives the patient
Allows for increased clarity
Allows the listener to affirm the patient’s feelings
Patient feels understood
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
28
Reflection that recaps visit and highlights important areas
Can clarify ambivalence and discrepancies
Summaries
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
29
“I know what is best”◦ Removes autonomy from the patient by
insinuating the patient does not know what is best for themselves
◦ Re-establishes hierarchy◦ Can undermine the patient’s motivation for
change◦ Can create conflict
Resist the righting reflex
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
30
Patient’s reason for change is more important than the clinician’s
Explore importance of changing◦ Ask for a scaled answer◦ Why is it that number and not another?
Understand patient’s motivation
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
31
Use reflective responses ◦ Allows patient to tell you more◦ Clarifies patient’s concerns◦ Confirms mutual understanding
Be aware of body language◦ Eye Contact◦ Nodding◦ Posture
Do not “understand”
Listening with empathy
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
32
Patients must believe change is possible
Failures can be demoralizing
Focus on previous successes◦ Even small victories can be uplifting
Encourage the patient
Let the patient know that they are in control of the change
Empower the patient
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
33
DARN-CAT◦ Desire (I want to change)◦ Ability (I can change)◦ Reason (It is important to change)◦ Need (I need to change)◦ Commitment (I will make changes)◦ Activation (I’m ready and prepared to change)◦ Taking steps (I am doing specific things to
change)
Eliciting Change Talk
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf
34
Ask questions that will elicit answers that are consistent with DARN-CAT◦ Developing discrepancy
Desire Reason Need
◦ Change ruler Ability Activation
◦ SMART Goal Setting Ability Activation Taking steps
Change Talk
35
Examples of MI in Action
36
Example #1
37
What went wrong?
What could the pharmacist have done instead?
Discussion of Example #1
38
Example #1- Revisited
39
Example #2
40
What principles of MI were used by this pharmacist?
How well did the change ruler work?
What else could the pharmacist have done?
Discussion of Example #2
41
Example #3
42
What went right?
What examples of change talk did the patient give?
What could the pharmacist have done to improve?
Discussion of Example #3
43
Evidence for Use of MI
44
Growing body of evidence◦ 6 references 1980-1989◦ 78 references 1990-1999◦ 707 references 2000-2009
Most studies show MI to be beneficial◦ Publication bias?
Most studies have limitations◦ Small sample size◦ Weak comparator groups◦ Various providers offering MI◦ Providers have differing levels of training in MI◦ Difficult to assess the manner in which MI is used
Effectiveness of MI
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
45
Effectiveness of MI on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study
N=109 officers ◦ 67 officers completed the program (13 women, 54 men)
◦ Previously completed a “high performance training seminar” 10-week program
◦ Goal to improve fitness, nutrition, and lipids◦ Weekly meetings with health coach
MI included to help the officers identify and achieve goals 10-week endpoints were compared to baseline
Example: Police Officer Fitness
Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare. 2008 14:48
46
Pre and Post intervention Measurements
Variable Pre Test Post Test Difference p-value
SBP 127 119 8 (6%) <0.001
DBP 82 75 7 (9%) <0.001
% Body Fat 24.8 21.5 3.3 (13%) <0.001
Total Cholesterol 188 175 13 (7%) <0.001
HDL 49.5 56.8 7.3 (15%) <0.001
LDL 113 96 17 (15%) <0.001
Triglycerides 138 123 15 (11%) <0.001
Example: Police Officer Fitness
47
Significant improvements in physical fitness, blood pressure, and lipids for those who completed the 10-week course◦ Baseline values already at BP/Lipid goals
Unknown cardiovascular/diabetes risks◦ Changes in lipids comparable to low dose statin◦ Changes in BP comparable to addition low dose ACEi
• Average Adherence to fitness regimen:• 80% for cardiovascular activity• 75% for strength training
Example: Police Officer Fitness
http://summaries.cochrane.org/CD003823/ace-inhibitors-for-the-treatment-of-high-blood-pressure
48
Limitations ◦ large drop out rate (42%)◦ Selection Bias
Those who completed study were likely more motivated and active prior to study
◦ Results likely only reflective of increased exercise◦ Short follow-up
Were benefits maintained Is MI beneficial for long term lifestyle changes?
Example: Police Officer Fitness
49
Pattern of results show MI is likely ◦ To confer at least a 10% advantage in success
rates versus weak comparators◦ To be as good or better than established
treatments ◦ To take less time and resources
Best outcomes may be using MI pre-treatment
MI Meta Analyses
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
50
Effective regardless of gender or age
Training level does not significantly impact effectiveness◦ Versatile
In what areas is MI most effective?
MI Meta Analyses
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
51
MI Meta Analyses
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
52
MI Meta Analyses
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
53
MI Meta Analyses
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312
54
Limitations • Interventions ranged from 10-120 min (60 min most
common)• Variable follow up periods
Usefulness• Provides evidence that MI can elicit significant
change • Overall about 75% of studies show there was an
effect
MI Meta Analyses
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312
55
Online resources or live classes
Begin small◦ Try only adding one component at a time◦ Reflective responses are a great starting point
Keep working at it◦ It may feel uncomfortable the first few times
Add components as you become more adept
Application Strategies
56
MI is a useful technique to help people change
It is useful in combination with other techniques for eliciting change
MI should not replace your method of patient interaction, but enhance it
Conclusions
57
Motivational interviewing is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change.
Key Elements◦ Collaboration◦ Evocation◦ Autonomy
Summary
58
Principles ◦Express Empathy◦Support Self Efficacy◦Develop Discrepancy◦Roll with Resistance
Summary
59
Strategies for implementation ◦ OARS
Open-Ended Questions Affirmations Reflective Responses Summaries
◦ RULE Resist the righting reflex Understand the patient’s motivation Listen with empathy Empower the patient
Summary
60
MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change. MI is a style of communication, not a technique.
True or False?
Post-Test Questions
61
OARS in MI stands forA. Open Communication, Active
listening, Reasoning with the patient, and Seeking change
B. Oral arguments, Active listening, Rolling with Resistance, and Summaries
C. Open-Ended Questions, Affirmations, Reflective Responses, and Summaries
D. Ongoing dialogue, Affirmations, Resisting the Righting Reflex, and Seeking change
Post-Test Questions
62
Developing discrepancy involves:A. The patient discovering how current
behaviors conflict with personal values or goals
B. Telling the patient the negative results of current behaviors
C. Allowing the patient to choose between two treatment options
D. None of the above
Post-Test Questions
63
Questions?
64
Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare. 2008 14:48
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov Burke B, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta analysis of
controlled clinical trials. Journal of Consulting and Clinical Psychology 2003; 71, 843-861 Hettema J, Steele J, Miller W. Motivational Interviewing. Annual Review of Clinical Psychology 2005;
91-111 http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&
%20Approach%20V4%20012911.pdf Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych
2009;65(11) 1232-45 Lundahl B, Tollefson D, Kunz C et al. Meta analysis of motivational interviewing: twenty five years of
research. Research on Social Work Practice 2009 Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983;
11(2),147-172 Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York:
Guilford Press. Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of
controlled clinical trials. Brit J General Practice 2005; April, 305-312 Vasilaki E, Hosier S, Cox W. The efficacy of motivational interviewing as a brief intervention for
excessive drinking: a meta analytic review. Alcohol and Alcoholism 2006; 41, 328-35
References