Transcript 5 Motivational Interviewing 2 - CAMH

Tobacco Cessation
Interventions
Lunch and Learn Seminar
Series for Physicians,
Family Health Teams, and
other Health/Allied Health
Practitioners
Session 5:
Motivational
Interviewing Part 2
Faculty: Dr. Marilyn Herie, PhD, RSW
Housekeeping
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Please sign-in
Please ensure you have completed Learning Assessment 1
http://www.surveymonkey.com/s/fhtaugust2011la1
A link to Learning Assessment 2 will be sent by e-mail
Both Learning Assessments are required for the Letter of
Completion
If you haven’t already, please dial-in via audioconference
Conference #: 1-800-669-6180
Participant Code: 925619
The Adobe Connect webinar will remain ON until 1:00 pm
Dr. Marilyn Herie, PhD, RSW
[email protected]
(416) 535-8501 ext. 7434
Dr. Marilyn Herie has worked in a variety of clinical and leadership roles at
Ontario’s Centre for Addiction and Mental Health (CAMH) since 1992, and in 2007
became Director of the TEACH Project, a University of Toronto, Faculty of
Medicine Certificate Program in Cessation Counselling. She is also an Advanced
Practice Clinician at CAMH, Adjunct Professor at the Faculty of Social Work, U of
T, and Director-elect of the U of T School of Graduate Studies Collaborative
Program in Addiction Studies. Marilyn has taught graduate and undergraduate
university courses for the past eight years, and has facilitated professional training
workshops throughout Canada and internationally. She has co-authored books,
book chapters and articles in scholarly journals on brief treatment, motivational
interviewing, alcohol dependence, relapse prevention, dissemination research and
online learning, and is first author of the 2010 Oxford University Press book:
Substance Abuse in Canada. Her areas of interest include motivation and
behaviour change, group facilitation and presentation skills, and knowledge
transfer.
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Disclosures
Dr. Marilyn Herie
Honorarium from Pfizer, 2007
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The recipient of the funding is in
compliance with the CMA and the
CPA guidelines / recommendations
for interaction with the
pharmaceutical industry.
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Disclaimer
These materials (and any other materials provided in
connection with this presentation) as well as the
verbal presentation and any discussions, set
out only general principles and approaches to
assessment and treatment pertaining to tobacco
cessation interventions, but do not constitute
clinical or other advice as to any particular
situations and do not replace the need for
individualized clinical assessment and treatment
plans by health care professionals with knowledge
of the specific circumstances.
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Disclaimer: TEACH Curriculum Development
The TEACH Curriculum and slides were developed and compiled with funding
from the Government of Ontario, Ministry of Health Promotion. Content of
slides are primarily based on evidence based guidelines including:
US Guidelines Treating Tobacco Use and Dependence: clinical Practice
Guideline 2008 Update. US Department of Health and Human Services,
Public Health Service
Rethinking Stop-Smoking Medications: Treatment Myths and Medical
Realities OMA Position Paper, January 2008.
The development or delivery of the TEACH curriculum was not influenced or
funded in any part by tobacco industry. TEACH has not received funding
from the tobacco industry. The development of the TEACH curriculum has
not been influenced by pharmaceutical industry. TEACH project did receive a
$10 000 unrestricted grant from Pfizer, to develop video vignettes that are
used in our training. Information presented on pharmacotherapy refers to
generic products only, and recommendations are based on existing
research, including the US guidelines. An algorithm is provided to help
practitioners determine if and which pharmacotherapy is appropriate for a
smoker.
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Session 5: Learning Objectives
1.
2.
Integrate brief tobacco interventions into your clinical
practice
Apply the 5 Rs (components of brief, motivational
interventions in Primary Care) with patients
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2)
3)
4)
5)
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Rapport
Relevance
Rewards
Risks
Roadblocks
Review:
Spirit of Motivational Interviewing
A-C-E
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Autonomy
V
Collaboration
R
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Authority
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Coercion
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Education
E
S
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Evocation
U
S
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Review:
Three Communication Styles
Direct
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Follow
Guide
Review: Guiding
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Providing information, acts as a resource, tutor
Helps someone find their own way
Patient becomes his or her own “change
management” expert
Review: FRAMES
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Feedback: provide clients with personal and relevant
feedback regarding their individual status
Responsibility: emphasize personal responsibility for
change and the individual’s freedom of choice
Advice: include a clear recommendation on the need
for change, in a supportive rather than an authoritarian
manner
Menu: offer a menu of strategies for change, providing
options from which the client may choose
Empathy: be empathetic, reflective, warm and
supportive
Self-efficacy: reinforce clients expectation that she can
change
The 5 Rs
1.
2.
3.
4.
5.
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Relevance
Rewards
Risks
Roadblocks
Repetition
Selby’s modification of the 5 R’s
R= Rapport
(Doctor- Patient
Relationship)
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“relation marked by harmony, conformity,
accord, or affinity “
The 5 R’s
Roadblocks
Risk
Patient
Relevance
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Rewards
Rapport
These skills can be applied in any order, provided that
rapport is established
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At the “heart “ of MI is listening…
(cue laughter)
FOUR KEY STRATEGIES – OARS
OPEN questions (to elicit client change talk)
AFFIRM the client appropriately (support,
emphasize personal control)
REFLECT (try for complex reflections)
SUMMARIZE ambivalence, offer double-sided
reflection
Simple
Reflection
Complex
(Enhanced)
Reflection
Words
(content)
Feelings,
meaning,
relationship
(process)
“I am tired of people going on about my
smoking. I know it’s bad for me, but so are a
lot of things.”
“I am tired of people going on about my
smoking. I know it’s bad for me, but so are a
lot of things.”
People are really on
your case about this,
even though
smoking is not the
only harmful thing
out there.
It is frustrating
because it feels like
“why pick on
smoking”?
“I am tired of people going on about my
smoking. I know it’s bad for me, but so are a
lot of things.”
Smoking has some
negative
consequences, and
so do other things.
From your
perspective, smoking
is not the most
harmful thing to be
concerned about.
“I am tired of people going on about my
smoking. I know it’s bad for me, but so are a
lot of things.”
A lot of people are
pressuring you
about something you
already know is
unhealthy.
It is like nagging, and
that doesn’t feel very
supportive or helpful.
Practicing Reflective Listening (1)
“How I live my life is my
own business.”
“How I live my life is my own business.”
Simple Reflection:
___________________________________
___________________________________
Complex (Enhanced) Reflection:
___________________________________
___________________________________
“How I live my life is my own business.”
Simple Reflection:
You are the only one to decide how to
live your life.
Complex (Enhanced) Reflection:
Quitting smoking is not a concern for
you, and it feels intrusive for me to bring
it up.
Practicing Reflective Listening (2)
“I know you mean well, but
I don’t need this
medication any more.”
“I know you mean well, but I don’t need this
medication any more.”
Simple Reflection:
___________________________________
___________________________________
Complex (Enhanced) Reflection:
___________________________________
___________________________________
“I know you mean well, but I don’t need this
medication any more.”
Simple Reflection:
You see that I am concerned, but you are
ready to stop taking the medication.
Complex (Enhanced) Reflection:
I can share my concerns, but in the end
you are the expert in what will work and
what will not work.
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 Establish rapport
 Set agenda
 Assess importance and
confidence
– (readiness)
 Explore importance
 Build confidence
Reduce Resistance
Exchanging Information
Key Tasks in Consultations About Behaviour
Change
ASSESSING READINESS
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IMPORTANCE
– Given everything going on in your life right now,
on a scale of 0 to 10, how important would you
say it is for you to <stop smoking>?
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CONFIDENCE
– On a similar scale of 0 to 10, how confident do
you feel about being able to <stop smoking>?
Readiness to change
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“Readiness Ruler”
People usually have several things they would like to change in their lives – this may be only one of those
things. Answer the following three questions with respect to your goal for this week.
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How important is it to change this behaviour?
0
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2
3
4
5
6
7
8
9
10
How confident are you that you could make this
change?
0
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1
1
2
3
4
5
6
7
8
9
10
How ready are you to make this change?
0
1
2
3
4
5
6
7
8
9
10
Follow up with…
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Why are you at <number> and not zero?
How could you move from <original number>
to <higher number>?
What do you think that you will do?
Most confident
Not important
Most important
Not confident
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Most confident
Not important
Most important
Importance and
confidence are
high: Work with
patient to develop
a change plan
Not confident
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High Importance + High Confidence =
Readiness to Change
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Move to a change plan (E-B-M):
–
–
–
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Environment
Behaviour
Medication
Behavior Change Roadmap:
The 4-Point Plan
If you would like a copy of
the Behavior Change
Roadmap for Clients please
contact the TEACH Team
[email protected]
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Most confident
Not important
Importance
and/or confidence
are low: Develop
Most important
discrepancy by
seeking to
understand
Not confident
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Importance is low – seeking
understanding (1)
Help me
understand what
is good about
smoking for you
(Rewards)
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Importance is low – seeking
understanding (2)
What about the
other side –
what is not so
good about it?
(Risks)
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Importance is low – seeking
understanding (3)
What do you
think you will
do?
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Confidence is low – seeking
understanding (1)
Why did you
rate your
confidence as 3
out of 10, and
not zero?
(Relevance)
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Confidence is low – seeking
understanding (2)
What would
need to happen
in order for you
to rate you
confidence as 4
out of 10?
(Relevance)
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Confidence is low – seeking
understanding (3)
What is standing
in the way of
that happening?
(Roadblocks)
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Confidence is low – seeking
understanding (4)
What do you
think you will
do?
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Roadblocks: Brainstorm Solutions
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If you were to quit smoking how do you think
you might go about it?
What challenges will you face when quitting
smoking?
What has worked for you in the past?
What might you do this time?
Applying the Skills:
Jeanne Video: Session 1
http://www.youtube.com/user/teachproject#p/u
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As you watch the video after today’s
session, notice how Dr. Selby integrates
the 5 Rs:
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Relevance
Rewards
Risks
Roadblocks
•Rapport
Discussion and Debrief - Questions to
think about while watching the video
1.
2.
3.
4.
5.
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What did Jeanne identify as the rewards of
smoking?
What did she identify as the risks?
What were her roadblocks for change?
How did Dr. Selby build rapport with this
patient?
Overall, how would you rate Jeanne’s
confidence and importance for change?
Resources
TEACH YouTube Channel:
http://www.youtube.com/user/teachproject#p/u
British Medical Journal (2010)
British Journal of General Practice (2005)
http://www.motivationalinterview.org/library/RubakMIreview.pdf
Available from the TEACH Project
Email: [email protected]
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Remember …
A link to the Online Course Evaluation will be sent by
e-mail.
 A link to Learning Assessment 2 will also be sent by email. This must be completed by August 24th in order to
receive your Letter of Completion
 Next session: September 21, 2011:
Pharmacotherapies: Part 2 – The art and science
of pharmacotherapy with complex patients
**Application period will open tomorrow - August 18th**
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Thank
you!
Copyright
Copying or distribution of these materials is
permitted providing the following is noted on
all electronic or print versions:
© CAMH/TEACH
No modification of these materials can be
made without prior written permission of
CAMH/TEACH.
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