MOTIVATIONAL INTERVIEWING

Assisting With Patient Directed Health Decisions

Lisa Becker, MAHS, DPh, NCPSClaremore Comprehensive Indian Health Facility

PATIENT ASSESSMENT TOOLS

To assist in behavior change, providers must first assess patients’:

Health care knowledgeConcernsBarriers

OBJECTIVESDefine motivational interviewing (MI)Discuss differences between provider and patient

centered communicationDefine role of health care provider in patient guided

disease managementVerbalize key concepts of patient centered

decision makingIdentify several MI processes to aid in assessing

and resolving patient resistance or ambivalenceIdentify several patient assessment tools useful

in practice and medical home models of care

The ProblemCurrent models of care are paternalistic

Communication is practitioner-centered, not patient-centered

Information giving vs. information exchange

Save the patients vs. patients save themselves

Labeling of patient: in denial, difficult, etc.

Compliance vs. adherence

Dictate rather than negotiate behavior change

MI DefinedThe most recent definition of motivational

interviewing (2009) is:

“A collaborative, person-centered form of guiding to elicit and strengthen motivation for change”

The Spirit of MI

The “spirit” of MI is based on three key elements:

Collaboration between the therapist and the client,

Evoking or drawing out the client’s ideas about change,

Emphasizing the autonomy of the client.

Motivational Interviewing (MI)Useful in Chronic Disease, Chronic

Care Models?Useful in Health Promotion/Disease

Prevention?

YES!Evidence based standards guide self

managed care with resulting improved outcomes.

The Tool Kit

READS

Motivational Interviewing Skills

READS principles Roll with resistance Express empathy Avoid argumentation Develop discrepancy Support self-efficacy

Importance, confidence rulers The envelope The insurance card A look over the fence

R: Roll with ResistanceExample:

“You are not ready to quit smoking at this time.”

When to use?

When patients are expressing issue resistance

E: Express Empathy

Example: “You are worried that you may not be able to

quit without your husband quitting.”

When to use ?

To demonstrate understanding and to address a patient’s core concern

(Active Listening, Safe environment, Support, Information, Rephrase with “feeling”)

Empathy Starters:“You seem_____”

“In other words…”

“You feel ___ because ___”

“It seems to you…”

“You seem to be saying…”

“I gather that…”

“You sound…”

NOT: I UNDERSTAND !

Express Empathy, example ?Patient: Everyone makes it sound so easy…

just take the medicine, quit smoking, change your diet, and exercise more!

HCP: Well, studies show that these things do improve quality of life. Just follow the plan I give you and start taking care of yourself.

NOT!

Express Empathy, example Patient: Everyone makes it sound so

easy…just take the medicine, quit smoking, change your diet, and exercise more!

HCP: You sound frustrated. You have been asked to make a lot of changes to control your diabetes and blood pressure and people don’t seem to appreciate how overwhelming and difficult all of it can be.

A: Avoid ArgumentationExample : “You do not see yourself quitting smoking

at this time. What types of things are you willing to do to get your cholesterol down?”

When to use?

To demonstrate understanding and to prevent creating relational

resistance

Avoid Argumentation, examplePatient: My doctor says I need to lose weight,

take the medicine, quit smoking, and reduce the salt in my diet. I don’t think I need to quit smoking, do you? How about cutting back?

HCP: It sounds like a lot to do. It’s great that you are willing to take your medicine and watch your salt intake. Cutting back on your smoking would be a great first step. Ultimately, quitting smoking would be the healthiest thing to do. What are your thoughts?

D: Develop DiscrepancyExample: “On the one hand, you have an important goal of

lowering your blood pressure to prevent stroke and heart attack. On the other hand, your smoking raises your blood pressure and your risks. What are your thoughts?”

When to use?

To create change talk and throw the patient’s system out of kilter without

creating more resistance (Identify core values of patient and if their behavior

is consistent with those values)

Develop Discrepancy, examplePatient: I want to lower my blood pressure and reduce my risk of stroke or heart attack.

HCP: On the one hand, taking your medicine as you do really supports your goal of lowering your blood pressure. On the other hand, smoking raises your blood pressure and interferes with your goal.

S: Support Self-efficacy Example: “I am really glad to hear that you are

thinking more about quitting. What has you thinking more about that?”

When to use?To reinforce both thoughts and

actions regarding behavior change

Supporting Self-efficacy, examplesPatient: I don’t think I am ready to walk 4 days a week, but I am willing to try twice a week.

HCP: That sounds like a great start and will really help with your osteoporosis.

Patient: I’ve thought a little more about what you said about quitting smoking.

HCP: Great. Tell me more about what you have been thinking. What’s got you thinking about it?

CONVERSATIONAL TOOLS

“FIRE”

F: Fence“A LOOK OVER THE FENCE”

“If you were to wake up tomorrow and you were no longer a smoker, what would you like about that?”

“If you could snap your fingers and be at the weight you wanted to be at, what would you like about that? What would you see as the benefits?”

“Encourage change talk, create dissonance”

I: The Insurance Card

“MAY I TELL YOU WHAT CONCERNS ME?”

Patient: We’ve all got to die some time. Might as well go out doing something I enjoy.

HCP: You really enjoy smoking and no one can live forever any way.

Patient: Right.HCP: May I tell you what concerns me?

Prevent “fixing” or “saving” the patient

R: The RulerScale TWO concepts: Importance and Confidence

Example: from a 1 to 7 or a 1 to 10 scale

How important is this change for you?How confident are you that you can make this change if you want to?

Why did you choose a ____, not a 1?

Elicits “Change Talk”

E: The Envelope Example:

“If I were to hand you an envelope, what would the message have to say inside for you to consider quitting?”

(or whatever change you are discussing)

Explore readiness for change

Primary Skills in MIASK, INFORM, LISTEN

“Change talk”: communication with the patient in a way that elicits their own reasons for change:A. Disadvantages of status quoB. Advantages of changeC. Optimism for changeD. Intention to change

Progression of MIEarly emphasis on developing a solid

relationship with the patientLess relational work required later

Later emphasis on engaging the patient’s reasoningAllows you to speed up because patient is

not defensive and argumentativeSaves time by precisely targeting the

patient’s thinking: rifle vs. shotgun

Patient MotivationReflecting and empathizing with the

patient’s core motivational issuesHelps to create early rapport with the patientHelps to initiate the process of engaging

the patient’s reasoning process

If the patient feels that you haven’t heard and haven’t respected their issues, the patient will become defensive and/or aggressiveThe patient is no longer listening to you

Example:Patient: I’ve tried to quit smoking for a while,

but I always come back to it again. So, I don’t see the point in trying any more.

HCP: It feels pointless to try to quit one more time if you are just going to smoke again anyway.

Patient: You got it!

HCP: Now, you said that you’ve been successful in quitting previously, but then you start back again. When you quit initially, what worked for you?

F-I-GFollow (reflect)

Reflect back your understanding of core concerns and line of reasoning

Inform (ask permission) and identify

Ask permission to give information, make suggestions, or clarify

Identify the core concerns

Guide:

Present a menu of options and determine what the patient wants to work on

O-A-R-S Often called micro-counseling skills, OARS is a

brief way to remember the basic approach used in MI.

These are core behaviors employed to move the process forward by establishing an alliance and eliciting discussion about change.

Open Ended QuestionsAffirmationsReflectionsSummaries

Quick QuizOn a scale from 1 to 7, where 1 is not at all

important and 7 is very important, how important is it for you to quit smoking?

May I tell you what concerns me about your continuing to smoke?

You are certainly right about smoking being bad for you. Tell me more about that.

Earlier, you told me that you have a goal of reducing your risk of stroke and heart attack. On the other hand, smoking increases those risks. What are your thoughts about that?

It has been hard to quit smoking even though you are concerned about its impact on your health.

Quiz, continuedIt sounds like you know smoking is bad for you,

yet it is difficult for you to quit. If you were to wake up tomorrow and were no longer a smoker, what would you see as the benefits? What would you like about that?

You see long-term negative effects to smoking. What concerns you the most?

What would have to change for you to consider quitting?

What makes it most difficult for you to quit?On the one hand, you see smoking as bad for your

health, but on the other hand, you are not ready to quit.

Key Concepts and Principles Always maintain the spirit of motivational

interviewing (AGAPE)—acceptance and compassion Be patient (client)-centered—what does the patient

want to work on? What are his/her goals? Address the patient’s core concern(s) and line of

reasoning Create a climate that is safe for the patient to learn The patient needs to make the argument for change—

ask the patient what are the benefits of the change?

Key Concepts and Principles (cont) Assess the patient’s understanding

of the risk/susceptibility involved in not treating the illness or changing a behavior (eg, quitting smoking)

What does the patient understand about the illness and its treatment?

Be honest and truthful with the patient—

don’t “soften” lab values (blood pressure is 155/110—“It’s a little high”) to “protect the patient”—it backfires

Be explicit in your empathy Explore the decisional balance When faced with ambivalence or resistance, EXPLORE,

don’t explain

Be aware of issue and relational resistance

SummaryWhat does the patient know and

understand about the illness and its treatment?

What is the patient’s understanding of what can happen if the illness (behavior) is not changed?

What are the patient’s goals?

What options are available to the patient?

What does he/she want to work on first?

MI: Inspiration“The mediocre teacher tells.The good teacher explains.The superior teacher demonstrates.

The great teacher inspires.

*William A. Ward

Suggested ReadingsBerger, BA, APhA. Communication Skills for

Pharmacists. Washington, DC, 3rd edition. Definition of Motivational Interviewing. www.motivationalinterview.org Rollnick, S, Miller, WR, Butler, CC.

Motivational Interviewing in Health Care.The Guilford Press, New York. 2008.

Rollnick, S, Mason, P, and Butler, C. Health Behavior Change. Churchill Livingstone, London. 2000.