Transcript Conversations as Medicine*The Spirit of Motivational Interviewing

CONVERSATIONS AS
MEDICINE…AN
INTRODUCTION TO
MOTIVATIONAL
INTERVIEWING
Laura Heesacker, MSW, LCSW
Behavioral Health Consultant
5/2015
MOTIVATIONAL
INTERVIEWING AT ITS
BEST!
http://youtu.be/Ow0lr63y4Mw?t=1
m53s
Participant Poll
• “Given the way you are currently caring for your patients with complex
chronic pain (the challenging ones!) , do you see any room where you
could improve or are you basically satisfied with the way things are
going?”
• “What are the good things about how you are currently practicing?”
(Time? It is familiar? Etc.)
• “What are the “not so good” things about how you are currently
practicing?
• So on the one hand….and on the other hand…(discrepancy)
• Is this resistance or is it ambivalence? Which feels better inside?
What is Motivational Interviewing?
“… a collaborative, person-centered
form of guiding to elicit and
strengthen motivation for change.”
Developed by William Miller 1983
Motivationalinterviewing.org
Simple Definition of MI
An effective way of
talking with people about
change
Behavior Change Counseling
• Evidence-based method to prepare for change
(Rollnick & Miller).
• Both patient-centered & strategic (“directive”)
• Focuses on “why” change before the “how”
• Effective with “less ready” patients
• More than just brief advice...it’s a “spirit” or
way of approaching the visit/conversation.
Miller & Rollnick, 2002. Motivational Interviewing.
IT’S NOT ABOUT THE NAIL
HTTPS://YOUTU.BE/-4EDHDAHROG
The Operating
System that
runs in the
back ground…
The Spirit of MI
•Partnership-Work Collaboratively and
avoid the “expert” role
•Acceptance-Respecting the client’s
autonomy, potential, strengths, and
perspective (Let pt be in charge)
•Compassion-Keep the clients best
interests in mind
•Evocation-The best ideas come from the
client (get curious)
Don’t Try This at Home
Response “able” vs. Responsible
•“Oh I am not “Responsible” for my
patients to make the right choices” (D.
Terrazas, FNP)
•Be curious about client’s ideas and
soliciting them
•“quit your job”-be on the bus with the pt
•“What if we could think of our patients as
sunsets vs. math problems? (K. Wilson)
Deceptively Directive
Diplomacy-The act of getting others
to have your way
“Motivation is the art of getting people
to do what you want them to do
because they want to do it”
-Dwight Eisenhower
In Motivational Interviewing...
•The practitioner identifies where the
client is in regard to his/her readiness to
change (What stage of change is the
person in?) and then attempts to move
the client forward.
•If the patient is low on readiness to
change…Plant some seeds then take
your energy and time to the next room!
Miller & Rollnick, 2002. Motivational Interviewing.
Stages of Behavior Change
http://well-fitbodies.com/yahoo_site_admin/assets/images/Stages_of_Change.23130956_std.JPG
Stages of Change Simplified:
Not Ready
(Raise Doubt)
Unsure
Ready
(Explore idea of change)
Slide courtesy of C.Dunn, PhD. Harborview Medical Center, 2006
(Plan)
Questions to Elicit/Evoke Change Talk
A successful visit or interaction doesn‘t have to end with the client taking
immediate action-we plant seeds for change
Ask patients questions, maybe ask them not to answer until next appt…
• ”What would it look like if you were living your life in complete alignment with that
which is important and meaningful to you?”
• “What would you like to see different about your current situation?”
• “What makes you think you need to change?”
• “What will happen if you don’t change?”
• “What will be different if you loose weight?”
• “What would be the good things about changing your [insert risky/problem
behavior]?”
• “What would your life be like 3 years from now if you changed your [insert
risky/problem
• behavior]?”
• “Why do you think others are concerned about your [insert risky/problem
behavior]?”
MI Techniques
• Ask permission to discuss issue “You’ve been
having these worrisome lab results, can we discuss
this ?”
• Reflective listening Say back what you hear them
saying; focus on ambivalence
• Ask open-ended questions “What might your life
look like without this change?”
• Elicit a response “What do you know about..”
• Give affirmation “This is really hard” (use scale)
• Summary of conversation and interventions
Ideas for Getting Started
•“Given the way you are living your life now, do
you see any room where you could improve or
are you basically satisfied with the way things
are going?”
•Can you tell me what brings you here today?
•Do you mind if we talk about (insert behavior)?
•Can we talk a bit about (insert behavior)?
•I notice you have (hypertension, etc.), do you
mind if we talk about how different lifestyles
affect (hypertension, etc.).
When it comes to Complex Chronic Pain
•Make the switch in your mind first!
•Understand how the research backs it up
•Present your case with certainty and
compassion (over and over and over…..)
•Expect the patient to be ambivalent
about change (looks like resistance)
•Go slow, plant seeds, have confidence in
your patients, be a champion!
My Tool Box
•“It turns out the way we were told to
treat chronic pain is neither as safe or
effective as we were once lead to
believe.”
•“We know better so we do better” Kelle
Evans, RN
•Don’t get defensive (Sit in the resistance
chair)
•Get our patients working with us not
against us
Palimed.org
10
9
8
7
6
5
4
3
2
1
0
Opioid Overdose Risk (fatal & non-f:atal) by
Average
Daily Dose of Medically Prescribed Opioids
**
1.79 %
9-fold
increase
in risk
relative
to low-dose
patients
**
** Significant
0.68 %
0.04 %
Non-user
0.16 %
1-19 mg.
increment in
risk p<0.05
0.26 %
20-49 mg. 50-99 mg. 100+ mg.
Dunn et al., Annals Int Med, 2010
UW Medicine “Menu”
Reduction in Pain Intensity w/COT
• Physical Fitness:
• CBT/Mindfulness:
• Sleep Restoration:
• Tricyclic:
• Antiepileptic:
• Acupuncture:
• OPIOIDS
30-60%
30-50%
30-40%
less than 30%
less than 30%
greater than 10+%
less than 30%
Introducing Non-Opioid Tx
•Get your patients to tell
you….
•Talk to Learn, Listen to
Teach…
• The place where you hurt is the
place where you care.
• Chronic Pain is about loss of
contact with what you really
want your life to be about.
• Our Values are our largest
“reinforcers” of behavior
Values Clarification
“What is important and
meaningful in your life?”
Follow up questions
•What have you lost because of
your pain?
•How has your pain been pushing
you around?
•What do you want your life to
stand for?
•If you didn’t have this pain, how
would your life be different?
Committed Action
“What small step will you
commit to today to bring you
closer to what is important and
meaningful in your life.”
Let your patients tell you..
•“What % of pain relief are you currently
experiencing from your pain
medication?”
•“What are you expecting?”
Use the discrepancy as a way to start the conversation about
other modalities for the Tx of CCNP…
Managing Chronic Pain
• These things are
very important
health.
• No one does it
perfectly.
• It’s best to work
on one at a time.
• You won’t be
pushed into changing.
• Which one (if any)
would you like to
discuss?
Social Support
Movement
Nutrition
Sleep Hygiene
Education
Medical/pharmacy
Counseling
Validate and move forward …
“I hear that you are willing to take the
risks and that none of the non-opioid
treatments have worked for you in
the past AND we still need to make
some changes in your medications.
‘This is a safety issue’
How Do You Know When You’ve
Got It Right?
You are speaking slowly
The patient is doing much more of the talking
The patient is actively talking about behavior
change
You are listening very carefully, and gently
directing the interview at appropriate moments
The patient appears to be ‘working hard’, often
realizing things for the first time
The patient is actively asking for information and
advice
Rollnick, S., Mason, P., Butler, C. “Health Behavior Change A Guide for Practitioners”. 2000
Harcourt Publishers Limited
PAUSE……
2 Prerequisites for Behavior Change:
1. A sense of the importance of change.
2. A sense of confidence in one’s ability to change.
Use Scaling Questions
•Raise Importance and Build
Confidence
•Assess “Readiness” by evaluating
“Importance” and, “Confidence”
Exploring Importance
• On a scale of 0-10, how important is it to you to
(change)?
• Why did you give it ( # ) and not (lower number)?
• What would it take to give it a (higher number)?
I
m
0
1
p
2
o
3
r
4
t
5
Rollnick, 1999 Health Behavior Change
a
6
n
7
c
8
e
9
10
Exploring Confidence
0

On a scale of 0-10, how confident are you that
you can change successfully?

Why did you give it (patient’s number) and not
(lower number)?

What would it take to give it a (higher number)?
C
o
n
f
1
2
3
4
Rollnick, 1999 Health Behavior Change
i
d
5
e
6
n
7
c
8
e
9
10
Key Activities in a MI Discussion:
• Showing empathy through reflective listening
• Developing a discrepancy between the
patient’s real and ideal behavior
• Avoiding argument
• Rolling with Resistance (“dancing vs...
wrestling”)
• Enhancing self-efficacy-the idea that change
is possible
Getting out of “Potholes”
Helplessness:
acknowledge that “change is
hard”. Help patients reflect on what has led
to successful change in the past.
Resistance: when wrestling (arguing or
feeling tension), stop and briefly summarize
the discussion, getting back to dancing.
Lecturing: Stop, ask a question such as:
“What do you think of this?”
Cheerleading: Stop and return responsibility
for change back to the patient.
DARES Principles
• Develop Discrepancy-patient should present
arguments for change
• Avoid Argumentation-back off if too much resistance
• Roll with resistance- try to understand where they are
coming from (“I hate these meds”; “It hurts giving
myself shots”)
• Express empathy- reflective listening
• Support self-efficacy- support ability to change and
build confidence
Miller WR, Rollnick S. Motivational Interviewing, Second Edition: Preparing People for Change. New York: Guilford Press; 2002.
Develop Discrepancy
patient should present arguments for change
•When change is hard is is often because we are
Ambivalent
•Ambivalence=wanting and not wanting change
or wanting incompatible things at the same time
(“I want to feel better and I want to eat out
with my friends”)
•The problem with Ambivalence is that is is
uncomfortable, which leads to procrastination,
which leads to being “stuck”
•Being Stuck looks like “Resistance” (AKA
Ambivalence)
Develop Discrepancy
By Creating an Environment of Ambivalence
Goal is to create ambivalence as it is uncomfortable
and good because it can motivate change:
• “What are the good things about X (risky health
behavior)?
• “What are the less good things about X (the risky
health behavior)?
Avoid Argumentation
Roll with resistance
•The patient is choosing to do the very
thing they are told not to do
•As soon as our degrees of freedom
are jeopardized we automatically
push back (it is the human condition)
•Double-sided reflection-“on the one
hand…and on the other hand…”
Avoid Argumentation
Roll with resistance
•You say the “resistance talk” so the client
doesn’t have to say it, it takes resistance off
the table
•Health Care Professional sits in the
“Resistance Chair”
•E.g. Smoking with partner is the only quality
time they have, eating to soothe (trauma,
sadness, dispointment,etc.)?
Express empathy
•Reflective listening
•Be genuine
•Be curious (reframe what looks like
resistance is ambivalence) Quit your job,
sit on the bus or park bench with this
person
•Be “Response-Able” v.s feeling
responsible for behavior change.
Support self-efficacy
•Support ability to change and build
confidence
•Believe in your patients capacity to
change their behavior –STATE IT!
•Example: Michelle states the single most
important thing that helped her get off
opioids and benzos was her doctors
belief that she could!
Bibliography
Von Korff, M., Gruman, J., Schaefer, J.K., Curry, S.J. and Wagner, E.H., "Collaborative Management of Chronic
Illness," Annals of Internal Medicine. 1997, 127: 1097-1102
Huntington, J., Ward, D., Lessler, D, Dunn, C. & Rhoads, C., “Motivation: Behavior Change Counseling in
Chronic Care Teaching Guide”, (2003). Adapted from work done by Miller and Rollnick.
Miller, W. & Rollnick, S., “Motivational Interviewing: Preparing People to Change Addictive Behavior ”, Guilford
Press, NY, 1991.
Rollnick, S., Mason, P., & Butler, C., “Health Behavior Change: A Guide for Practitioners”, Churchill Livingston,
1999.
Rollnick, S., Heather, N., Bell, A., “Negociating Behavior Change in Medical Settings: The Development of Brief
Motivational Interviewing”, J. Ment. Health. 1992, 1: 25-37.
Rollnick, S., & Miller, W., “What is Motivational Interviewing?”, Behav. & Cog. Psychotherapty. 1995, 23: 32534.
Noonan, W.C., & Moyers, T.B., “Motivational Interviewing”, J. of Substance Misuse. 1997, 2: 8-16.
Scott, NCH, Rollnick, S, Rees MR, & Pill, RM, “Innovation in Clinical Method: Diabetes Care and Negociating
Skills”, Family Practice. 1995, 12: 413-18.
Bibliography
Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., & Minor, M. “Living a Healthy
Life with Chronic Conditions”, Bull Publishing, Palo Alto, CA, 2000.
Dickey, LL, Gemson, DH, Carney, P., “Office System Interventions Supporting CareBased Health Behavior Change Counseling”, Am. J. Prev. Med. 1999, 17: 299-308.
Witlock, Ep, Orleans, CT, Pender, N, Allan, J, “Evaluating Primary Care Behavioral
Counseling Interventions. An Evidence-Based Approach”, Am. J. Prev. Med. 2002, 22:
267-284.
Rollnick, S., Mason, P., Butler, C. “Health Behavior Change A Guide for Practitioners”.
2000 Harcourt Publishers Limited