Motivational Interviewing in Health Care: Application to a Geriatric Patient Presented by

Brett Engle, PhD, LCSW Sponsored by

Miami Area Geriatric Education Center www.motivationalinterviewing.org

• Rationale and evidence-base • Target behaviors/change goals • Spirit of MI • Collaboration, acceptance, evocation

• Processes of MI and application • Engaging, focusing, evoking, and planning

• Techniques of MI • OARS • Exchanging information using elicit-provide-elicit

• DARN-CAT change and sustain talk

Rationale for MI • Brief and cost effective (Dennis et al., 2004) • Versatile-intensity/duration, professions, combined treatments, settings (Lundahl et al., in press; Miller & Rose, 2009)

• Humanistic-facilitates relationships, rapport and disclosure (Miller & Rose, 2009) • Consistent with SW ethics and values (Hohman, 2012)

• May be more effective with minorities (Hettema, Steele, & Miller, 2005)

• Established training tools and practices (Moyers et al., 2005; Madson & Lane, 2008)

Evidence-Base for MI • About 200 clinical trials and 1000 peer reviewed articles involving MI (Miller & Rose, 2009)

• Average dose: 2 sessions/2 hours • Effect size is often maintained or even increases through 1 year follow up when MI is added to beginning of treatment (Miller, 2005)

Evidence-Base for MI: Target Behaviors/Outcomes • • • • • • •

More likely to enter, stay in and complete treatment Participate in follow-up visits Adhere to glucose monitoring and improve glycemic control Increase exercise and fruit and vegetable intake Reduce stress and sodium intake Keep food diaries Weight loss http://www.nytimes.com/2010/10/26/health/26weight.html?_r=1&src=dayp

• • • • •

Reduce unprotected sex and needle sharing Improve medication adherence Decrease alcohol and illicit drug use Quit smoking Fewer subsequent injuries and hospitalizations Rollnick, Miller, & Butler (2008)

• • • •

Collaboration/Partnership Acceptance Compassion Evocation

• Interviewer functions as a partner or companion, collaborating with the client’s own expertise • Dancing versus wrestling • Avoiding the “expert trap” • Non-judgmental • Active collaborative conversation • Joint decision-making process

• • • •

Absolute worth Affirmation Accurate empathy Autonomy support

• Unconditional positive regard (Rogers) • Dignity and worth of the person (NASW Code of Ethics)

• Seek and acknowledge strengths, including change talk, resources, and values • Building blocks

• “to sense the person’s inner world of private personal meanings…” (Rogers, 1989, pp. 92-93) • Anticipating • Experiencing • Communicating

• • • •

Responsibility : Resistance trade off People can and will make own decision Paradoxical nature of behavior change Support both self-determination and selfefficacy • Detachment from outcomes

• To benevolently seek and value the wellbeing of others • To give priority to the person’s needs • Never exploit • Not necessarily to “suffer with.”

• Elicit and activate person’s own resources, rationale and motivation for behavior change • The person’s side of ambivalence that favors change • Includes their goals, values, and aspirations that relate to target behavior

• • • •

Engaging Focusing Evoking Planning

• • • • •

Meet where patient is Discord and sustain talk be prevalent Empathize Establish trust and rapport Verbally and non-verbally

• Lives with wife of 46 years and daughter • Quit smoking in 1994 • History of low fat diet and credits it for no chest pain • Regular exercise • History of checking blood sugar regularly (but not currently) • Checks blood pressure daily (but does not record) • Apparently take medications regularly

• Focus and structure conversation on an identified target behavior • Redirect discourse toward target behavior when necessary • Discuss possible change rather than history

• Checking blood sugar 2/daily like before and recording • Record blood pressure (in addition to checking, which he currently does) • Give self injections • Return to more consistent low fat diet (although apparently no chest pains still) • Return to regular exercise (osteoarthritis and gout may be barriers) • Driving • Referral to cardiologist • Two drinks daily (contraindications?) • Advanced directive

• Patient’s own ideas about change • Change talk side of ambivalence

• • • • • • •

Difficulty sleeping and frequent urination Possible depression (denies) Anxiety (not self report) Grief (loss of adult child 2 years ago) Low energy Low sex drive Forgetfulness (according to wife but he denies)

• Decision making • Action steps and target behaviors prioritized • Implementation intentions (Gollwitzer)

• • • •

Open questions Affirmations Reflections: Simple and complex Summaries

• Elicit – Ask permission – Clarify information needs and gaps – “May I ask what you already know about…”

• Provide – Prioritize – Support autonomy – Don’t prescribe the person’s response

• Elicit – Ask for person’s interpretation, understanding, or response

Preparatory Change (and Sustain) Talk Four Kinds DARN

• • • •

DESIRE to change (want, like, wish . . ) ABILITY to change (can, could . . ) REASONS to change (if . . then) NEED to change (need, have to, got to . .)

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Mobilizing Change (and Sustain) Talk reflects resolution of ambivalence

• COMMITMENT (intention, decision) • ACTIVATION (ready, prepared, willing) • TAKING STEPS

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Commitment-Behavior Change Model in Groups: Participant Desire, Ability, Reasons, and Need (DARN) change talk mediate Commitment Language, which in turn mediates their impact on health behavior.

Desire

Ability

(Self-efficacy)

Commitment Activation Taking Steps

Health behavior

Reasons

Need

From “How Does Motivational Interviewing Work? What Client Talk Reveals,” by P. C. Amrhein, 2004, Journal of Cognitive Psychotherapy: An International Quarterly, 18, 4, p. 331. Copyright 2004 by the Springer Publishing Company. Adapted with permission.

Supplemental Slides

12 Tasks in Learning MI 1. Understanding the spirit of MI 2. Developing skill and comfort with reflective listening and the client-centered OARS skills 3. Identifying change goals/target behaviors 4. Giving information in an MI adherent manner 5. Recognizing change and sustain talk 6. Evoking and reinforcing change talk 7. Responding to, reinforcing, and strengthening change talk 8. Responding to sustain talk and discord so as to not amplify it 9. Developing hope and confidence 10. Timing and negotiating a change plan 11. Strengthening commitment 12. Flexibly integrating MI with other skills and practices (Miller & Moyers, 2006; Miller & Rollnick, 2013)

Discord • Interpersonal behavior that reflects dissonance in the working relationship: Arguing, interrupting, discounting, or ignoring

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• Lay Definition: A collaborative conversation style for strengthening a person’s own motivation and commitment to change – Used in many contexts by many different professional or paraprofessional people

• Clinical Definition: A person-centered counseling style for addressing the common problem of ambivalence about change – Why should I as a clinician learn MI? – How would I use it?

• Technical Definition: A collaborative, goal-oriented style of communication with particular attention to the language of change, designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion – How does it work?

Directing

Guiding

Following

• • • •

Parameters of the working relationship Exceptions to confidentiality The nonnegotiables Providing information

• Understanding and taking an interest in the other person • Being curious and showing respect • Super listening

• Focus and structure conversation on an identified target behavior • Redirect discourse toward target behavior when necessary • Discuss possible change rather than history • Elicit/emphasize/reinforce change talk

What Good Listening Is Not

*

(Roadblocks: Thomas Gordon)

• • • • • •

Asking questions Agreeing, approving, or praising Advising, suggesting, providing solutions Arguing, persuading with logic, lecturing Analyzing or interpreting Assuring, sympathizing, or consoling 39

What Good Listening is Not (Roadblocks, from Thomas Gordon)

• • • •

Ordering, directing, or commanding Warning, cautioning, or threatening Moralizing, telling what they “should” do Disagreeing, judging, criticizing, or blaming • Shaming, ridiculing, or labeling • Withdrawing, distracting, humoring, or changing the subject 40

Hypothesized Relationship Among Process and Outcome Variables in MI Therapist Empathy & MI Spirit Client Preparatory Change Talk & Diminished Resistance

Training in MI

Therapist Use of MIConsistent Methods

Behavior Change

Commitment to Behavior Change

From Miller and Rose (2009) Toward a Theory of Motivational Interviewing., 64, p. 527-537. American Psychologist

Ten Things that MI is Not (Miller & Rollnick, 2008) 1. Based on the transtheoretical model of change 2. A way of tricking people into doing what you want them to do 3. A specific technique (MI is a counseling method; no specific technique is essential) 4. Decisional balance, equally exploring pros and cons of change 5. Assessment feedback 6. A form of cognitive-behavior therapy 7. Just client-centered therapy 8. Easy to learn 9. What you were already doing 10. A panacea for every clinical challenge

Evidence-Base for MI: Effects across Samples • • • •

25% no effect 50% small but meaningful effect 25% moderate to strong effect Average MI intervention: 99 minutes (Lundahl et al., in press)

• Brief MI in health care: 5-15 minutes (Martino et al., 2007)

Forming Reflections

Reflections

*

• Are statements rather than questions • Make a guess about the client’s meaning (rather than asking) • Yield more information and better understanding • Often a question can be turned into a reflection 44

Forming Reflections • A reflection states an hypothesis, makes a guess about what the person means • Form a statement, not a question – Think of your question: Do you mean that you . X X X X ..? – Cut the question words Do you mean that You . . – Inflect your voice down at the end

• There’s no penalty for missing • In general, a reflection should not be longer 45

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Collaboration: Giving Information/Educating Neutral language “Folks have found…” “Others have benefited from…” “Doctors recommend…” Conditional words “Might consider” vs. “ought to,” “should” Avoid the “I” and “Y” words “I think…” “You should…” Gary S. Rose, Ph.D. [email protected]