Motivational Interviewing in Tobacco Cessation and Chronic Diseases Physicians’ Institute info@physiciansinstitute.org Copyright Berger Consulting, LLC bbergerconsulting@gmail.com A Program of the Cease Smoking Today Partnership www.ceasesmoking2day.com . 1

The Problem Current models of care are paternalistic Communication is practitioner-centered, not patient-centered Information giving vs information exchange Save the patient vs patients save themselves Labeling of patient: in denial, difficult, etc Compliance vs adherence Dictate rather than negotiate behavior change

The Problem (cont.) Resistance is dealt with as a flaw rather than useful information that needs to be explored We don’t spend time identifying how patients make sense of illness and treatment and how we can helpwhat benefits do they derive from tobacco? What do they know and understand about the risk of not treating the illness? Schools teach HCPs that they are the expert New models of communicating with patients are needed

Motivational Interviewing Defined: Miller and Rollnick (1) Motivational interviewing is a person-centered (Rogers) directive (guided) method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence and resistance. Note: focus on ambivalence and resistance this is the key.

Key Points Motivational interviewing is concerned with assessing a patient’s motivation for change, not motivating the patient The skills used in motivational interviewing are matched to the patient’s motivation (or readiness) for change Create a climate that is safe to change and safe to learn Assist the patient in making the argument for change A look over the fence: smoker, weight loss What would have to change?

Key Points (cont.) Be honest and truthful with patients so they can make informed choices BP of 160/110 Be patient-centered Identify and respond to patient’s core concerns and line of reasoning “Disease management” High cholesterol patient

The Spirit of Motivational Interviewing Agape Caring Collaboration Patient is the focus, not me Asthma patient, 27-year-old male smoker “You people” “I only signed up for the decrease in premiums and no, I don’t want to quit smoking”

Key Concepts: Decisional Balance Health behaviors involve voluntary behavior change Patients develop an internal decisional balance about the change (pros and cons, benefits and risks, etc) This balance may be subjective, but it must be explored and “tilted” in favor of the benefits if change is to take place The balance is quantitative and qualitative Exploring the decisional balance Benefits or pros Downside or risks or cons Data on barriers to adherence are conflicting.

Key Concepts: Resistance and Ambivalence When people resist change, the worst strategy is persuasionit forces them to defend the very behavior you are trying to change When people are ambivalent, the pros=cons When they are resistant, the cons >pros When faced with ambivalence or resistance, exploredon’t explain 2 types of resistance Issue Relational Data on barriers to adherence are conflicting.

Issue Resistance “I am not ready to quit smoking. It relaxes me.” Strategy Empathize with the core concern (issue) and explore the line of reasoning

Relational Resistance “I am so tired of you people hounding me about my smoking. Everyone acts like it’s so easy.” Strategy Respect the resistance, roll with it, apologize, and, when appropriate, shift

Relational Resistance Issue-Based Resistance 2 Forms of Resistance Relational Resistance Issue-Based Resistance

Relational Resistance Issue-Based Resistance What MI Does Relational Resistance Issue-Based Resistance Info #1 Info #2 Info #3 Info #4

Relational Resistance Issue-Based Resistance What MI Does: 2 Steps Relational Resistance Issue-Based Resistance Commitment Info #1 Info #2 Change Talk Info #3 Info #4

Inappropriate Responses to Resistance Persuasion The Righting Reflex Produces paradoxical responses More information

Key Concepts: Dissonance Anxiety or discomfort when goals, thoughts, and behaviors don’t match up We want to create dissonance in our patients between where they are now in their health behaviors and where they need to be regarding health Creating dissonance A look over the fence Realistic goals and then behaviors that don’t match Discrepancies in what patients say vs what they do Data on barriers to adherence are conflicting.

Key Concepts: Face and Face Loss What do people do when they fear they are losing face? 2 types of face loss Autonomy face loss: Patient’s blood pressure is still up. “You need to quit smoking (take your medicine)…we have been over this before.” Competency, approval face loss: Patient doesn’t think chew is as bad as smoking. “Do you think I would tell you it was bad for you if it wasn’t?” Motivational interviewing does not cause face loss Data on barriers to adherence are conflicting.

Other Key Concepts Importance, confidence, and readiness Autonomy Respect Susceptibility or risk Understanding of the illness and treatment Treatment options: the menu Core concern: what is the primary concern of the patient? Line of reasoning: how does the patient make sense of things? Core concern and line of reasoning must be addressed or you will not move forward Data on barriers to adherence are conflicting.

F-I-G Follow (reflect) Inform (ask permission) and identify Reflect back your understanding of core concerns and line of reasoning Inform (ask permission) and identify Ask permission to give information, make suggestions, or clarify Identify the core concerns Guide: present a menu of options and determine what the patient wants to work on Data on barriers to adherence are conflicting.

Case Study: Asthma Julie Stockton is a 37-year-old Caucasian female Her daughter, Sara, is 10 years old and has been in the emergency room 4 times in the past year She has not been using her chronic inhaler for her asthma When asked about this, Julie says defensively, “I don’t want Sara using a steroid and don’t bother to talk to me about my smoking. I smoke outside so it doesn’t affect Sara.”

Motivational Interviewing Skills READS principles Roll with resistance Express empathy Avoid argumentation Develop discrepancy Support self-efficacy Importance, confidence rulers The envelope The insurance card A look over the fence 19

Roll With Resistance

Roll With Resistance Patient: I just don’t see how I can quit smoking when my wife smokes too and she won’t quit. HCP: You suspect that it will be much more difficult for you to quit smoking if your wife continues to smoke. Patient: Right…I just don’t see that working. HCP: How important is it for you to quit right now? 23

Express Empathy

Empathy Starters “You seem_____” “In other words…” “You feel ___ because ___” “It seems to you…” “You seem to be saying…” “I gather that…” “You sound…”

Express Empathy Patient: Everyone makes it sound so easy…just take the medicine, quit smoking, change your diet, and exercise more! HCP: You sound frustrated. You have been asked to make a lot of changes to control your diabetes and blood pressure and people don’t seem to appreciate how overwhelming and difficult all of it can be. 23

Express Empathy (cont.) Patient: I know smoking is bad for me, it’s just that all of my friends smoke and we hang out together. HCP: You realize that smoking can have harmful effects on your health, yet it has been difficult for you to quit because your friends smoke and they are important to you. 23

Express Empathy (cont.) Expressing empathy to prevent face loss Patient: Other people have blood pressure that is much higher than mine. Mine is not so bad. HCP: You are right…there are many people whose blood pressure is quite a bit higher. May I tell you what concerns me? 21

Ways to Express Empathy Repeating back the words with the feeling Slight paraphrasing Major paraphrasing Framing To clarify the motivational issue 21

Avoid Argumentation

Avoid Argumentation Patient: My doctor says I need to lose weight, take the medicine, quit smoking, and reduce the salt in my diet. I don’t think I need to quit smoking, do you? How about cutting back? HCP: It sounds like a lot to do. It’s great that you are willing to take your medicine and watch your salt intake. Cutting back on your smoking would be a great first step. Ultimately, quitting smoking would be the healthiest thing to do. What are your thoughts? 23

Develop Discrepancy

Develop Discrepancy Patient: I want to lower my blood pressure and reduce my risk of stroke or heart attack. HCP: On the one hand, taking your medicine as you do really supports your goal of lowering your blood pressure. On the other hand, smoking raises your blood pressure and interferes with your goal. 23

Develop Discrepancy (cont.) HCP: On the one hand, you hate feeling ashamed because you keep going back to smoking. On the other hand, you actually started to feel better when you quit, but stress in your life triggers your smoking. 23

Develop Discrepancy (A Look Over the Fence) “If you were to wake up tomorrow and you were no longer a smoker, what would you like about that? What would be the benefits to you?” “If you could snap your fingers and be at the weight you wanted to be at, what would you like about that? What would you see as the benefits?” 23

Supporting Self-Efficacy

Supporting Self-Efficacy Patient: I don’t think I am ready to walk 4 days a week, but I am willing to try twice a week. HCP: That sounds like a great start and will really help with your osteoporosis. 23

Supporting Self-Efficacy (cont.) Patient: I’ve thought a little more about what you said about quitting smoking. HCP: Great. Tell me more about what you have been thinking. What’s got you thinking about it? 23

2 Forms of Resistance Relational Resistance Issue-Based Resistance Roll with resistance Express empathy Avoid argumentation Issue-Based Resistance Express empathy Develop discrepancy Support self-efficacy

Rulers 2 concepts Scale from 1 to 7 or 1 to 10 Importance Confidence Scale from 1 to 7 or 1 to 10 How important is this change for you? How confident are you that you can make this change if you want to? Why did you choose a ____, not a 1? Elicits change talk

The Envelope “If I were to hand you an envelope, what would the message inside have to say for you to Consider quitting smoking.” Take your medicine as prescribed.” Monitor your blood sugar twice a day?”

The Insurance Card Patient: We’ve all got to die some time. Might as well go out doing something I enjoy. HCP: You really enjoy smoking and no one can live forever any way. Patient: Right. HCP: May I tell you what concerns me?

MI Summary Example Patient: I know smoking is bad for me. I know I should quit. HCP: Then why don’t you? (biomedical)

Possible MI Responses It sounds like you know smoking is bad for you, yet it is difficult for you to quit. If you were to wake up tomorrow and were no longer a smoker, what would you see as the benefits? What would you like about that? You see long-term negative effects to smoking. What concerns you the most? What would have to change for you to consider quitting? What makes it most difficult for you to quit? On the one hand, you see smoking as bad for your health, but on the other hand, you are not ready to quit.

Possible MI Responses (cont.) On a scale from 1 to 7, where 1 is not at all important and 7 is very important, how important is it for you to quit smoking? May I tell you what concerns me about your continuing to smoke? You are certainly right about smoking being bad for you. Tell me more about that. Earlier, you told me that you have a goal of reducing your risk of stroke and heart attack. On the other hand, smoking increases those risks. What are your thoughts about that? It has been hard to quit smoking even though you are concerned about its impact on your health.

Summary What does the patient know and understand about the illness and its treatment? What is the patient’s understanding of what can happen if the illness (behavior) is not changed? What are the patient’s goals? What options are available to the patient? What does he/she want to work on first?

Summary (cont.) Explore the decisional balance Respond to the patient’s core concern(s) Focus on one issue at a time, based upon what is of paramount importance to the patient Respond with empathy throughout (be explicit) Stay in the spirit

Suggested Readings Miller, WR, and Rollnick, S. Motivational Interviewing. The Guilford Press, New York, 2002. 2nd edition. Rollnick, S, Miller, WR, Butler, CC. Motivational Interviewing in Health Care. The Guilford Press, New York. 2008. Berger, BA, APhA. Communication Skills for Pharmacists. Washington, DC, 3rd edition. Rollnick, S, Mason, P, and Butler, C. Health Behavior Change. Churchill Livingstone, London. 2000.