Motivational Interviewing: A Patient Centered Strategy that Builds Provider Awareness and Patient Reflection

Motivational Interviewing: A Patient Centered
Strategy that Builds Provider Awareness and
              Patient Reflection

                Gwen Alexander, PhD
             Henry Ford Health System
         Department of Public Health Sciences
             1R24HS022417–01 (JOHNSON-CENTER DIRECTOR)
 PERSONALIZING CARE FOR OBESE PATIENTS IN AN URBAN HEALTH SYSTEM

          Patient Centered Outcomes Research Group
                         R24 Webinar
                       August 22, 2014

Helping People Change
 Most interactions in health care are Provider to Patient
 In many cases, a behavior change is needed by the Patient
 Teaching or informing is involved, although most patients know
  what they need to do, or how to do it

 Some providers are more effective than others
 Some patients are not ready to or convinced that or capable of
  change that is requested

 This can lead to ineffective communication, resentment, lost
  opportunity to start reversing a health problem.
 Question: What is missing? Do we keep saying the same
  things – or make a change?

Outline
 Introduction to practical applications of Motivational Interviewing
 Being “stuck” and uncovering ambivalence
 Examples of coaching components
   – Motivations, confidence
   – Change talk
   – Affirm
   – Reflections
   – Goal setting
 Role of the coach

Motivational Interviewing
           – Preparing People for Change
----Title and subtitle for the 2nd edition book by William Miller   and
Stephen Rollnick

 MI is a person-centered, collaborative process that elicits and
  strengthens motivation for change
 Ambivalence is usually behind slow or no change (do/don’t)
 Uncover ambivalence -> awareness of what blocks desired
  change
 “Interview” - questions to identify and build motivation, and build
  commitment to reach desired change

 MI discussions about change require a lot of active listening
  and squashing the reflex to “fix it”.

Motivational Interviewing
 MI is consistent with the Self-determination Theory (Deci and
  Ryan, 1985*) that explores the range of motivation from internal
  (intrinsic – based on deeply held values) to external (extrinsic –
  based on opinion/threat from others)
 MI has its roots in addiction counseling in face to face interactions.

 MI makes use of client-centered counseling skills and includes
  goal-oriented components, guided by the coach/provider.
 MI aims to elicit internal motivations and strengths when
  ambivalence is impeding behavior change.

 MI takes a while to learn. Similarities to an athletic person learning
  a new sport. Proficiency requires learning, practicing and receiving
  feedback. **

   *(Deci and Ryan 1985)   **Naar-King S, Suarez M. pg 6.

Motivational Interviewing,               con’t

 Most MI coaching used “in the moment” as face to face or
  conversations by phone, recently I helped create an email
  format
 “Full blown” motivational interviewing for complicated
  behaviors (i.e., addiction) may take a number of sessions
 Brief adaptations are designed and used.
 Use in many health-related domains
   – Smoking            sexual risk        chronic illness management
     adherence          eating disorders obesity
   – health promotion
   – used with individuals, couples, adolescents, adults

 Not Used: if the person is fully motivated and ready to
  start making a change.

Discovering Ambivalence                                   competing motivations

               I want to…..                             And I don’t want to…

                                                       Cost of change
                                                     (benefits of status quo)
        Cost of status quo
        (benefits of change)

                      Decisional balance – weighing costs and benefits *

           “Discovering and understanding an individual’s motivations is an
                   important first step toward change.” **

 Miller and Rollnick 2nd Edit. 2002 *p 15, ** p 18

Provider Advice               vs.         Eliciting

 Health professionals (physicians, nurses, dietitians), who
  may have been trained traditionally, may go beyond
  giving expert advice to present instructions in a
  prescriptive way - steps people should take to change a
  health behavior.
 Challenge is to move to a collaborative, facilitator
  approach – which can be a big challenge for providers...
          Traditional                     MI eliciting
 “It is very important to your       “How, if at all, can you see
 health to stop smoking because…”      that smoking might affect your
                                      ability to spend time with your
                                       grandkids [personal value]?”

Best Practices: Listening and Reflection

 Provider needs to learn (interview) what is going on
   – Reflection to show he/she is listening
       “You wish the teasing would stop.”
   – Reflection to display the emotions/conflict: patient’s dilemma
       “You are furious that your boss recommended therapy to you.”
 Patient can untangle the complex motivations that
  creates feeling “stuck”
 Hearing a complex reflection helps untangle issues
   – Example: “On one hand, you always feel winded and worry that
     smoking is making your throat always feel irritated. On the other hand,
     your best way to relax is to smoke.”

MI Themes
 Autonomy - identify person’s decision to change, not provider’s
  direction
 Collaboration – partnership and guiding, rather than prescriptive
 Evoke and elicit - allow person to discover his ambivalence,
  and present his own reasons for change, rather than provider “fixing
  it”
 Express empathy – in reflection, let person know provider
  accepts his position, hears concerns
 Roll with resistance – provider expresses understanding of
  person’s point of view, avoids arguing for change:
       “Sounds like this diet journal is not going to work for you.”
 Support Self-Efficacy – (confidence that “I can do it”) the
  key element and good predictor of the outcome

     If you think you can do a thing, or if you think you can’t…,
     you are always right. (Henry Ford)

Phase 1 – Building Motivation for Change
 Key to understanding ambivalence is to know person’s perception
  of importance and confidence - Open Ended Questions
  “How important would you say it is for you to eat the recommended
servings of fruit and vegetables? (motivations to change)
              1=not at all …… 10 = extremely important

Response:
If 8- 9:   That is a high number. What makes it such a high number for
            you?” (identify motivations/values)
Reflecting:   Sounds like your nutrition course put you on a good track, and
                    you especially love fruit.
                Do I have that right? (check impression for accuracy)

Guiding:    What would it take to move your importance rating to a 10?
                  (by saying what they need to do – solve some issues)

Phase 1 – Building Motivation for Change, con’t

Next, assess confidence (self-efficacy):
  How confident are you that you could eat the recommended
servings of fruit and vegetables?
             1=not at all …… 10 = extremely confident

If lower, 5 or 6:
 Why that number rather than something lower, like a 3 or 4?
    This reveals the ability they believe they have.
  What would it take to move your confidence to a 7 or 8?

       This gives ways to solve some barriers.

Values – key to linking intrinsic motivations to
actions

 Exploring values and incongruities between actions
  and values can elicit change talk
 Coach: I am going to switch gears for a minute and
  ask you this question. What are some things that are
  very important to you in your life right now.*
      You already mentioned you want to be a good
      example for your children. What else?

*Can show a list or bring up something previously mentioned.

Phase II: Keys to Guiding Change
 Goal - move the person to identify and/or take the first steps of
  change.
 Change talk reveals the crack in the resistance - may include
  statements that include:
    – Disadvantages of status quo - “If I don’t change, I’ll probably get
      worse…”
         Coach: So you have some ideas about cutting down on salt so you won’t have to
          worry so much about… Tell me more about that.
    – Advantage for change – “I was hoping to fit into my bride’s maid dress
      for the wedding.”
         Coach: Tell me more about the wedding. You’ve picked out the dresses
          already? How much time would you have to work on fitting into that dress?
    – Intention to change/opportunity to change – “I wish I could start walking
      with my neighbors. They have asked me…”
    – Optimism about change – “I need to try something, I suppose I could cut
      back on my soda pop habit. It would be good for my kids to see me
      drink less pop, and get my wife off my back about it.”
         Coach: You think starting with soda might work for you. What ideas do you
          have?... …. (Affirm) That sounds like a good idea.

Affirm “You made this happen”
 Include personal strengths/empower in reflections:
   – You are dedicated to your health to make these changes,
     and have overcome the challenges of your very busy
     schedule to include more fruit in your lunches at work.

   – Kudos on your ability to make this happen. (Rather than
     “kudos” alone.)   … “good job” rather than “great”
   – You care enough about keeping on an even keel, and you
     feel confident/happy about how it is going with keeping to the
     plan you worked out for your insulin schedule.

More on Change Talk - coach initiates questions
 Coach: I wonder if you would be willing to tell me what you see
  for yourself, say in the next year or so? How do you imagine life
  to be? … How would you like for things to be different? … If you
  could [make this change] immediately, what advantages would
  you see?
 Patient: I want to apply for nursing school and get some
  clinical experience, but this diabetes... I would really need
  to have my insulin levels in good control for that.
 Coach: What would concern you most about managing your
  diabetes and getting your insulin levels evened out, if you were
  in this demanding training program? (Ask about extremes)

Reflection – stretch to find emotion, expect corrections
  Coach: Sounds like you are really upset about the way
   people tease you when you try to eat the right way.
  Patient: I’m not upset, I just worry that I will buckle under and
   not keep my promise to myself. My friends can be so
   annoying sometimes.
  Coach: Oh, you worry about keeping to your goals when you
   are having fun around some of your friends – it can really be a
   work out for you to follow your own choices [empower]… What
   ideas do you have to give you strength in these situations?
  Patient: I don’t know, can you help me?
  Coach: Let’s take a minute to come up with ideas you might have,
   and then, if it is OK with you, I can add some ideas that have worked
   for others. (Ask permission before offering)

Setting Goals with Patient’s Choice

 Once agreement that change is possible, ask:
  There are many possibilities that people have used. What
  do you prefer?
  – What do you think will work for you?
  – What specifically do you plan to do?

     We can…
      Write it out on this form
      Talk more about details
      Talk more about what support you have at home to help you, if
       you need it.
      Talk more about challenges once you get started.

Summarizing and Eliciting Commitment
 Coach: Let me see if I can summarize where you are.
  You have a couple of ideas on how to add more fruit and
  vegetables- take a small bag of fruit to work on Mondays,
  shop on Thursdays to be ready for the weekend, and set
  up a schedule on the calendar each week to help bring in
  variety. Do I have that right? Have I forgotten anything?

 Elicit Commitment …. And let me check with you – is
  this what you want to do? …. If you are not quite sure or if
  you want to try it out first, take a day or two and think about
  it. We can talk about it more next time.

MI Tools for Teacher/Coach/Provider to
               guide CHANGE
 Identify challenge/conflict/ambivalence
 Facilitate patient’s self-understanding
 Offer the chance for decisional balance sheet (+
  column, - column)
 Encourage and model reflection – say out loud
  what you might be thinking, check accuracy
 Identify values that can be linked with behavior
  change

     ….. This all requires a lot of listening.

Strength of this Approach

For providers – building awareness:
   – You now know what is delaying change, motivating change

 For patients – reflect on ambivalence and personal
  strengths, choices:
   – They know more about their own motivations, what might
     work for them, what will strengthen commitment.

MI Research Examples

 Diabetes Medication Adherence – workshop for pharmacists
  and diabetes nurse educators, monitoring and assessing coaching
  sessions over two 6-month follow up visits.

 Email coaching for Dietary Improvement – MENU GenY
  (21-30 yr olds) for 4 month online intervention with 12 month follow-up.
  Coaches are women with no experience in nutrition/heath education.

 New project – Coaching providers to talk to teens about the
  complications on a chronic health condition due to weight

Thank you

References:
Motivational Interviewing: Preparing People for Change. 2nd Edit. Miller
WR, Rollnick S. (Eds). Guilford Press:New York. 2002.

Motivational Interviewing with Adolescents and Young Adults. Naar-King
S, Suarez M. 2011.

galexan2@hfhs.org