Transcript Motivational Interviewing

Motivational Interviewing –
Approaching Behavior
Change
Prantik Saha, MD, MPH
Columbia University / Children’s
Hospital of New York
Health Status and Behavior
Change
 The United States ranks as one of the lowest in
terms of health status among economically
developed countries
 While many factors contribute to this low
ranking, health behaviors are considered to be
one of the most significant; behavior patterns
account for almost 40% of all deaths in the US.
 Schroeder SA. We Can Do Better – Improving
the Health of the American People. N Engl J
Med 2007; 357: 1221-8.
How do we establish a habit?
 There are pros and cons to every behavior
 We engage in a particular behavior based
on an assessment of these pros and cons
 Ambivalence is the unresolved conflict
between the pros and cons, and leads to
continues engagement of the behavior
 Persistent ambivalence is the principal
impediment to change
Prochaska & Di Clemente: Transtheoretical Model
of Behavior Change
Stages Involved In Behavior
Change
1. Identifying the
2.
3.
4.
5.
behavior
Identifying a problem
Desiring a Change
Feeling confident
about a change
Doing it!
Motivational Interviewing –
Background
 First described in the 1980’s by William
Miller and Stephen Rollnick, two
psychologists who had experience in
treating alcoholism
 Spirit or philosophy of MI and behavior
change considered most important;
techniques follow accordingly.
Goal of Motivational
Interviewing
 Finding out which stage the client is at, and
addressing the concerns specific to their stage
 Have the client articulate their “pros” and “cons”
so they can better process and ultimately
resolve the conflict between them.
 Empathizing and empowering the client to take
steps towards change by affirming their
strengths as well as the centrality of their
initiative in lasting change
MI and evidence
 Systematic reviews and meta-analyses have
shown some beneficial effect of MI interviewing
techniques compared to traditional advice giving
in various contexts outside of the addictions,
such as with diet, exercise and adherence to
medications.
 Some reviews have even shown statistically
significant change in direct measures such as
blood pressure, cholesterol, and body mass
index (Rubal, Sandbaek, et al. Motivational
Interviewing: A Systematic Review and MetaAnalysis. British Journal of General Practice
2005; 55: 305-312).
Effect measure
n
Estimate of
effect
Body mass index
1140
0.72
0.0001 (0.33 to 1.11)
HbA1c (%GHb)
243
0.43
0.155 (-0.16 to 1.01)
1358
0.27
0.0001 (0.20 to 0.34)
Systolic blood
pressure (mmHg)
316
4.22
0.038 (0.23 to 8.99)
Number of
cigarettes/day
190
1.32
0.099 (-0.25 to 2.88)
Blood alcohol
content (mg%)
278
72.92
0.0001 (46.80 to 99.04)
Standard ethanol
content (units)
648
14.64
0.0001 (13.73 to 15.55)
Total blood
cholesterol (mmol/l)
P-value (95% CI)
Case presentation
You are seeing a 4 year old boy with poorly
controlled asthma in clinic. He has been
admitted three times in the past 6 months
for acute exacerbations. During your
interview with the mother, a pack of
cigarettes falls from her coat. She quickly
states that she does not smoke “around
her son.”
SO…What stage is our client
at?
(hint: do we really know at this point?)
You get more history…
The mother says she has
been feeling very
stressed recently,
especially with her child’s
recent hospitalizations.
She has been smoking
since she was a teenager
(she is in her mid-20’s)
and she says that
smoking relaxes her.
She does think that quitting
would help her child’s
asthma, and several
people have told her that
she should stop smoking
in the interest of her
child’s health.
When asked about quitting,
she frowns and says she
has tried to quit smoking
several times in the past
without success.
Use of Scales
 A common way of assessing as well as
cultivating confidence or importance is the use
of scales. Scales can help clients/patients to
verbalize and process their ambivalence further.
In this case,
 “On a scale of 1 to 10, how important do you
think it is for you to quit smoking?” (Patient says
9 out of 10)
 “On a scale of 1 to 10, how confident are you
that you can quit smoking?” (Patient says 4 out
of 10)
So, now what do we do?
• Affirmations: recognizing client strengths and countering
a defeatist attitude
“Why did you give yourself a 4 instead of a 2?”
“I am impressed that you have been trying to quit
despite all the stress you are going through”
• Reflecting the pros and cons
“So, it is important for you to smoke in order to deal with
the stress in your life, but you also wish you could quit
in the interest of your child’s health”
• Look for client driven strengths
“What would make you go up to a 6 or 7?”
Well, what if we got this history?
The mother, who is 35
years old, smokes
with her girlfriends
who come and visit
her in her apartment.
She feels a sense of
community with them,
and smoking is a
shared pastime they
enjoy.
The mother does not think
her child’s asthma has
worsened because of her
smoking – “I’ve been
smoking since he was
born and his asthma
wasn’t this bad before”
When asked about quitting,
she says – “Yes, I’m sure
it would be better for my
health, but so would
moving out of New York
City!”
On a scale of 1 to 10…
 “How important do you think quitting
smoking is for your child?” (Patient says 3
out of 10)
 “How important is it for your own health?”
(Patient says 4 out of 10)
 What about confidence?
So, what do we do now?
 Reflecting and empathizing with the “pros” and
“cons”
“It seems that smoking is an important social
activity for you, but you also would like to quit
because it would be better for your health.”
“Yes, New York City can certainly be hazardous
to your health!”
 “Roll” with resistance
“Yes, it does seem that you’ve been smoking
for quite some time and your child’s asthma
has only recently been flaring up.”
 Emphasize the significance of this patient’s level
“Why did you give it a 3 and not a 1?”
Case Presentation #2
You are seeing a 7 year old girl with poorly
controlled asthma in your clinic. She has
been coughing 1 to 2 times a week at
nighttime, interfering with her sleep. The
mother is rightly concerned and would like
some treatment. You prescribe an inhaled
corticosteroid for twice daily use to be
continued even when her symptoms
resolve.
Case Presentation #2 (con’t)
Four weeks later, during a follow-up visit, the
mother tells you that she stopped the
inhaled steroid medication because her
child’s symptoms resolved. How would
you proceed at this point?
Find out where the client is at!
“What do you remember about the instructions for
the medication prescribed for your daughter’s
cough?”
“Do you have any concerns about the
medication?”
“Are there people you know who have taken
steroids for asthma?”
“Tell me what you feel [or know] about steroids”
You get more history…
The mother does remember that she was
instructed to continue the medication even
after her child’s cough resolved, but she
stopped giving the medication because
she “doesn’t like giving medications” to her
daughter. When asked why, she simply
repeats herself – “I just don’t like it!”
All right…what’s going on here?
Resistance!
 In motivational interviewing philosophy,
resistance is elicited when we try to push
clients farther than they are ready to go.
 Resistance also occurs when clients have
not been given sufficient opportunity to
direct their actions and have simply been
given instructions from their providers.
How do we deal with
resistance?
 Empathizing with the client
“It sounds like many of us have been telling you
what you should do and we’re not listening to
what you would like to do for your child”
 EMPOWER the client
“You know, it’s up to you what you would like to
do with your daughter’s medication – after all,
you are her mother.”
Case Presentation #3
 You are seeing a 13
 You have a
year old girl in clinic
because she is here
for the 2nd dose of
HPV vaccine
 She is sexually active
with one male
partner, but he does
not use condoms.
discussion with her
about the importance
of using latex barriers
to prevent sexually
transmitted infections.
 She seems to
understand, but is
hesitant about using
condoms.
So, how would you approach
this case?
 Find out the stage the client is at
 “Do you feel using condoms are important?”
 “Are you afraid of bringing up condom use
with your partner?” or “Have you talked with
your partner about using condoms?”
 “Do you or your partner not like using
condoms?”
 “Do you feel safe/happy in this relationship?”
 One manifestation of confidence here is
asserting oneself in a partnership
So, you get this history…
 She hasn’t spoken with her partner about
using condoms, but he often talks about
how great the sex is.
 She says that he does not have sex with
other people, but she is not sure.
 What other questions would you ask?
Try using a Decisional Matrix
Status Quo or Staying in
the Habit
(i.e., staying in this
relationship with current
sexual habits)
PROS
CONS
Change or Breaking
from the habit
(i.e., breaking from this
relationship or beginning to
use protection)
Try using a Decisional Matrix
Status Quo or Staying in
the Habit
(i.e., staying in this
relationship with current
sexual habits)
Change or Breaking
from the habit
(i.e., breaking from this
relationship or beginning to
use protection)
PROS
“Having unprotected sex with
him makes him happy, and I
like it when he’s happy”
“I don’t know. I guess I won’t
feel like a fool calling him all the
time”
CONS
“I don’t get any pleasure out
of sex”
“I’m the one who calls him all
the time just to hang out – he
never calls me”
“I might be lonely”
“All of my friends have
boyfriends, so I worry if I’ll be
left out”
WHAT ABOUT YOUR
EXPERIENCE SO FAR?
Are there any cases in which behavior
change was a prominent issue that you
would like to discuss?
So what about our habits?
 Break out into pairs
 One person will describe a habit or
behavior that they, a family member, or
friend have struggled with
 The other person will assess what stage
his/her partner is at as well as their “pros”
and “cons”
 Use the Scales and the Decisional Matrix
 Reverse roles!
Some final thoughts on MI
 It is a client-centered philosophy
 A non-judgmental tone and attitude helps clients
be more open about their “pros” and “cons”
 Focus on the stage the client is at – e.g., don’t
address confidence issues if the client is not yet
interested in changing their behavior
 We should dismantle the assumption that we
have failed if clients don’t make decisions
toward change at each visit