Motivation and Rehabilitation
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Transcript of Motivation and Rehabilitation
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Motivation and RehabilitationMotivation and Rehabilitation
Martin D van den BroekMartin D van den Broek
Friday 8Friday 8thth March 2013 March 2013
The Wolfson Neurorehabilitation Centre & Atkinson Morley’s The Wolfson Neurorehabilitation Centre & Atkinson Morley’s
Regional Neurosciences Centre, Regional Neurosciences Centre,
St.George’s Hospital, LondonSt.George’s Hospital, London
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• Gains may be limited
• Gains may fail to generalise
• Gains may not be maintained
Cicerone et al, 2000
Neurorehabilitation
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In-/Day-patient Admission
Discharge
Goal Planning Meeting 1
Goal Planning Meeting 2
Goal Planning Meeting 6
Goal Planning Meeting 3
2 weeks
10 weeksGoal Planning Meeting 4
Goal Planning Meeting 5
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Understanding Poor Motivation• Decide immediately what you are going to do
• Your decision must be definite and permanent
• You must stick to it
• You must actively work to realise it
• You must have no second thoughts
• Uncertainty will be judged as evidence that you are not serious, lacking insight, backsliding, violation of an agreement
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In-/Day-patient Admission
Discharge
Goal Planning Meeting 1
Goal Planning Meeting 2
Goal Planning Meeting 6
Goal Planning Meeting 3
2 weeks
10 weeksGoal Planning Meeting 4
Goal Planning Meeting 5
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• If patient’s wants do not match their
needs, then progress is unlikely
(Needs-Wants mismatch)
• What patients need is what they want
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• Would you like help to become more independent (with shopping, cooking, etc)…?
• Would you like to join the memory group to help you remember things better?
• How would you feel about learning to feel less angry/irritable/depressed…?
Offers of Rehabilitation
• I could ask the physiotherapist to see you for help with your walking
• Would you like some tablets to help you with your mood?
•The speech therapist may be able to help with your speech, would you
like to see him/her?
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• Staff unable to manage patient in acute setting
• Multidisciplinary team believe they can help
• Unit has services appropriate to patients’ problems
• Rehabilitation team have places on their programme
• Family or carers experiencing a burden of care
• MP or local politicians support family
• Lack of appropriate Nursing/Residential facilities
• Health Authority has policy of avoiding ‘blocked’
acute beds
Why Rehabilitation?
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• Progressive GP wants best for patient
• Progressive Solicitors want best for their client
• Solicitors need to demonstrate their client is minimising
his/her loss
• Insurers want to minimise final settlement
• Rehabilitation service must fulfil contract with purchasers
• Health authority does not want to fund private referral
• Patient has problems that he/she wants to overcome
Why Rehabilitation?
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• If the prime beneficiary of treatment is
not the patient, then progress is unlikely
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Contemplation
Det
erm
inat
ion
Action
Maintenance
Transtheoretical Model of Change
Prochaska, DiClemente & Norcross, 1992
PrecontemplationRel
apse
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1. Motivation to change is elicited from the client, and not imposed from without
2. It is the client's task, not the counsellor's, to articulate and resolve his or her ambivalence
3. Direct persuasion is not an effective method for resolving ambivalence
4. The counselling style is generally a quiet and eliciting one
5. The counsellor is directive in helping the client to examine and resolve ambivalence
6. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction
7. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles
Principles of Motivational Interviewing
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Stages of Change & Therapist Tasks (Miller & Rollnick, 1991)
Precontemplation: Raise doubt - increase client’s
perception of problems
Stage Therapist’s motivational tasks
Contemplation: Tip the balance - evoke reasonsfor change, risks of not changing;
strengthen self-efficacy for change in behaviour
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Determination: Help client to determine best
course of action
• Stage Therapist’s motivational tasks
Action: Help client to take steps towards
change; commence rehabilitation
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Maintenance: Help client identify & use strategies to prevent relapse
• Stage Therapist’s motivational tasks
Relapse: Help client to renew the
processes of contemplation,
determination and action, without
becoming stuck or demoralised
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Motivational Approach to Goal SettingMotivational Approach to Goal SettingExample: Diary Training
Goal Definition“I need to use a memory aid”
Option Appraisal“I could use a diary, notebook, organiser,
go to a self-help group”
Solution Selection“I’ll use a diary”
Precontemplation
Contemplation
Determination
Action
Problem Identification“I’ve got a problem with my memory”
Educational MethodsQuestion & Answer Method
Structured Information GatheringTest Results Feedback
Video FeedbackRole Reversal Exercises
Evoke reasons for RehabilitationDiscuss pros & cons of change
Discuss Importance & Confidence in achieving goal
Offer adviceProvide Affirmation
Clarify NeedsRemove Barriers
EnvisioningEmphasize Personal choiceClarify details (of aid use)
Strengthen Confidence
Start Diary Training
Motivational Readiness
Goal Setting Stage Intervention
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Does MI work in neurorehabilitation?
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Evaluation of MI after acute Stroke: Evaluation of MI after acute Stroke:
A Randomised Controlled TrialA Randomised Controlled Trial Caroline L. Watkins, Lancaster
Martin D.van den Broek, London
Cathy Jack, Belfast
Hazel Dickinson, Liverpool
C. F. Deans, M. F. Auton, D. Forshaw, H. Gardner, M. J. Leathley, C. F. Deans, M. F. Auton, D. Forshaw, H. Gardner, M. J. Leathley, C. E. Lightbody, J. Marsden, J. McAdam, I. McClelland, C. J. SuttonC. E. Lightbody, J. Marsden, J. McAdam, I. McClelland, C. J. Sutton
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Aim To determine whether Motivational Interviewing early after
stroke can alter:
Mood Function Expectations about recovery
At 3 months post-stroke and then at 12 months
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Results
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Recruitment1388
Assessed
696 Eligible
411 Consented & randomised
204 Intervention Group
Usual Care + MI
207 Control Group
Usual Care
285Refused
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Can MI alter mood?
VariableVariable
MI MI
(n = 204)(n = 204)
Usual careUsual care
(n = 207) (n = 207) Freq.Freq. %% Freq.Freq. %%
Baseline mood: Baseline mood: NormalNormal
LowLow
7777
127127
37.737.7
62.362.3
8080
127127
38.638.6
61.361.3
3m mood: 3m mood: NormalNormal
LowLow
100100
104104
49.049.0
51.051.0
8181
126126
39.139.1
60.960.9Significant benefit of MI over usual care (p=0.033)
OR (normal mood at 3m)=1.60, 95% CI = 1.04-2.46
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0%
20%
40%
60%
80%
100%
Baseline 3M
Time-point
Per
cent
age
of p
atie
nts
Normal mood Low mood Dead
Usual Care
80
Change in MoodChange in Mood
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0%
20%
40%
60%
80%
100%
Baseline 3M Baseline 3M
Time-point
Per
cent
age
of p
atie
nts
Normal mood Low mood Dead
Usual Care MI
80 77
Change in MoodChange in Mood
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0%
20%
40%
60%
80%
100%
Baseline 3M Baseline 3M Baseline 3M Baseline 3M
Time-point
Per
cent
age
of p
atie
nts
Normal mood Low mood Dead
Usual Care MI Usual Care MI
80 77 127 127
Change in MoodChange in Mood
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Conclusions
Results at 3 months post-stroke indicate that Motivational Interviewing
• Can benefit patients’ mood after stroke
• No effect on expectations or function
Results at 12 months similar.