Motivational Interviewing: Helping People Change Problem Behaviors Using Smoking Cessation as the Model

Andrée Aubrey, MSW, LCSW, CTTS Director, Area Health Education Center FSU College of Medicine Department of Family Medicine and Health Affairs Andree.aubrey@med.fsu.edu 850-645-6439

At the end of this training, learners will be able to: Articulate the key components of MI interventions; Demonstrate competence in an evidence based and practical approach to behavior change counseling; Focus the assessment interview on identifying and/or enhancing the client’s own reasons for wanting to quit tobacco or make other health related changes; Use reflective listening skills to more fully understand clients’ perspectives about “the problem” and potential strategies to address those problems; Enhance client self-efficacy for making a change.

What would you say to this patient? Video slide here Too much stress to quit

Typical Tobacco Cessation Counseling Video slide here The way in which we communicate with people SIGNIFICANTLY influences their motivation about change.

Problems with Traditional Approach Focuses on “fixing” the problem Assumes knowledge and information are keys to motivating behavior change “Teaches” patients how to make the desired change Often leads to a “Yes, but…” tug of war Knowledge weakly correlated with behavior change The traditional approach is: ID problem; evaluate risk of behavior; advise pt. to change “I am going to teach you.”/ provider is expert and pt. should follow his advice. If pt. does not change, the counseling/ interaction has been a failure. The way in which you talk w/ pts. about their health can substantially influence their personal motivation for behavior change.

You can lead a horse to water but you cannot make him drink…. Motivational Interviewing is NOT a treatment for tobacco dependency. It is an evidence-based intervention for tobacco users WHO ARE NOT YET READY TO QUIT. You can lead a horse to water but you cannot make him drink….

Practical Counseling Pharmacotherapy Systems level interventions The most effective treatment for tobacco dependency is a combination of …. Practical Counseling Pharmacotherapy Systems level interventions MI “salts the oats”

TX for Tobacco Dependency Practical Counseling Problem Solving: compulsions to use, triggers to smoke, changes in lifestyle Coping Skills: developing or enhancing other coping mechanisms Pharmaco-therapy Nicotine Replacement Therapy: Patch, gum, lozenge, nasal spray, inhaler Bupropion: Wellbutrin SR Verenicline: Chantix Systems Interventions ASKING every client at every visit about tobacco use – paper screening like a vital sign OR electronic health record (EHR) prompt ADVISING about the benefits of quitting REFERRING for treatment if not able to provide on-site Reminder systems which prompt clinicians to do the 2A/R intervention

What is Motivational Interviewing? A collaborative, person-centered form of guiding to elicit and strengthen motivation for change Empirically validated approach for helping people change addictive or other problematic behaviors www.motivationalinterviewing.org Spirit and style more than specific techniques – shaped by a guiding philosophy and understanding of what triggers change. It involves the conscious and disciplined use of specific communication principles and strategies to evoke the person’s own motivations for change

MI A consumer-centered, yet guiding style of counseling that is shaped by a guiding philosophy and understanding of what triggers change. Involves the conscious and disciplined use of specific communication strategies to evoke the person’s own motivations for change.

Three Essential Elements of MI MI is a particular conversation about change MI is collaborative (person-centered, not expert-recipient; partnership; honors autonomy and self-determination) MI is evocative – seeks to call forth the person’s own motivation and commitment Takes place in context of interpersonal relationsip.

Persuasion Exercise: Part 1 SPEAKER: Talk about something you’d like to change. May be a behavior, attitude, or habit but something it would be good to change. COUNSELOR #1: Explain why he/she should make this change Give at least 3 benefits of making the change Tell him/her how to do it Emphasize how important it is to make the change

Persuasion Exercise: Part 2 COUNSELOR #1 Why would you want to make this change? If you do decide to make this change, how might you go about it in order to succeed? What are your three best reasons to do it? On a scale of 0 to 10, how important is it for you to make the change? *Why are you at___ and not 0?

Persuasion Exercise: Part 3 COUNSELOR #2 Give a short summary of the speaker’s motivation for change: Summarize desire, ability, reasons, need for change Then, ask “So what do you think you will do?” Affirm strengths of the speaker

TO BE DOING MI THERE MUST BE… a Target such as a health related behavioral change; attitude; decision (forgiveness); habit Change Talk Without these, there may be great rapport building and patient-centered listening, but not MI

Underlying Theory of MI People are ambivalent about making changes When the clinician advocates for change, it will evoke resistance from the person Resistance predicts lack of change Getting the person to talk about making the change makes it more likely that he/she will do it

Change Talk An argument FOR change -There is good evidence to suggest that people can literally “talk themselves in and out of change” (Walters, et al., 2003). For instance, there are linguistic studies that suggest that the speech of the provider sets the tone for the speech of the client, which in turn, influences the ultimate outcome (Amrhein, et. al., 2003). -In short, certain statements and questions—and especially a certain provider style—seem to predict whether people decide to change during brief conversations. -Community members may come in with a certain range of readiness, but what the organizer said from that point on makes a difference in how the community member speaks and thinks, and ultimately in how they choose to behave when deciding if they wanted to register to vote.

Refuses to take care of herself Lost Cause! Resistant Non-compliant Unwilling to change Refuses to take care of herself Non-adherent Difficult person Doesn’t understand Waste of my time

Sustain Talk Argues for the status quo Argues against change Change Talk and Sustain Talk are opposite sides of the same coin both sides of ambivalence

Resistance Now framed as “SUSTAIN TALK + DISCORD” Only “resistance” when the person has something to push against The individual’s sustain talk is causing discord in the relationship (that’s our reaction!)

Recognizing “Change Talk” Categories of Change Talk: Desire to change “I would really like to quit smoking.” Ability to change “I think I could start cutting back.” Reasons for change “My relationship w/ my wife would be better if I quit drinking.”

Recognizing “Change Talk” Categories of Change Talk: Need to change “I have to lose weight or my breathing is just going to get worse.” Commitment to change “I’ve decided I’m going to start an exercise program this week.” Taking steps “I’ve stopped smoking in my car and cleaned out all the cigarette packs in the glove compartment.” Notes on 6: usually when see pts over time Pt taken some steps, baby steps I tried a couple of days w/o drinking this week I got some condoms from the CHD DO NOT OFFER SKEPTICISM – “condoms only work when you use them” AAFIRMATIONS/ encouragement

DARN- CT How change talk fits together

Where do we start? Understanding basic principles of MI MI skills: Open ended questions Affirmations Reflective listening Summaries and Informing/ Advising Emphasize SPIRIT AND STYLE OF COUNSELING. EARLY METHODS: we don’t call them early methods because we use at the beginning and then abandon; it is important to use them right from the start Informing/ Advising: Just don’t give the info. Ask how the person wants to obtain info.

Open Ended Questions Open questions Closed questions Encourages patient speech More efficient for gathering information Builds relationship – patients perceive clinician as caring and showing personal interest Closed questions Effective for gathering information, if you ask the right questions! Question-answer trap A series of questions (lends itself to quantification focus) Questions that do not invite brief answers. Establishes an atmosphere of acceptance and trust so clients will be able to explore their concerns. Client should do most of the talking w/ counselor listening carefully and encouraging expression. Important for client to do more than 50% of talking- process of MI involves eliciting and shaping certain kinds of client speech.

Video Example of MI in action! Open-ended Questions Video Example of MI in action!

Video slide here Help them talk more about the problem area. Don’t just note the info.

Open ended questions to evoke change talk Disadvantages of the status quo What worries you about your current situation? What do you think will happen if you do not change anything? How has this stopped you from doing what you want in life? What hassles or difficulties have you had in relation to your __________? What makes you think you need to do something about_________?

Open ended questions to evoke change talk Advantages of change How would you like for things to be different? If you could make this change immediately, by magic, how might things be better for you? What would be the good things about ________? What would you like your life to be like in five years? The fact that you are here indicates at least part of you thinks it’s time to do something. What are the main reasons you see for making a change?

Open ended questions to evoke change talk Optimism about change What makes you think that if you did decide to change, you could do it? What encourages you to think that you can change if you want to? When else in your life have you made a significant change like this? How did you do it? What personal strengths do you have that will help you succeed? What do you think would work for you, if you decided to change?

Open ended questions to evoke change talk Intention to change What do you think you might do? I can see that you’re feeling stuck at the moment. What’s going to have to change? How important is this to you? How much do you want to do this? What would you be willing to try? Of all the options we’ve talked about, which one sounds like it fits you best?

Affirmations Statement of appreciation and understanding Builds rapport and conveys respect for their struggles, feelings, achievements, humanity Reinforces open exploration Promotes self-efficacy for change The point is to notice and appropriately affirm the person’s strengths and efforts Appropriate level and frequency of affirmations will vary across social contexts

Affirmations “I am sure that when you do decide to quit, you will figure out a way that works for you.” “You are clearly a resourceful person, to cope with so many difficulties for so long.” “If I were in your position, I would have a hard time dealing with so much stress.” “I know this is not easy to hear.” Appropriate level and frequency of affirmations will vary across social contexts. The point is to notice and affirm

Reflective Statements Person Clinician Listen to one’s own reasons Hear how the behavior fits into one’s life Freedom to explore the desire or reasons for change in a safe environment Keep the person talking and thinking Avoid a premature focus on solutions Improve “adherence” Enjoy your interactions more A foundational skill! Reflective Statements

Reflective Listening Use a down-turn in inflection Make statements, rather than asking questions Focus on change talk ROLL with RESISTANCE Listening is a complex clinical skill: What is said and not said, cultural filters, etc. Offer more reflections than questions because questions can slow momentum that is building toward change.

Practice Simple Reflections Tobacco user: “All my friends smoke, and I feel like I wouldn’t belong anymore if I quit.” Instead of: “Would you rather die from lung cancer?” Try: “Smoking helps you fit in.” Tobacco user: “I know I need to quit, but I don’t know how I would deal w/ my depression without smoking.” Instead of: “We’ve got a great medication that will help you quit and help w/ your depression at the same time. Let’s get you a prescription and I’ll sign you up for one of our Quit Smoking now classes.” Try: “You have had some thoughts about quitting.” Try: “You’ve been using smoking as a coping mechanism for a long time.” Try: “It’s kind of scary to think about quitting.” Your reflective statements need to be nonjudgmental, even if you do not agree with what the patient says. To help you do this sincerely and honestly, add phrases such as, "It sounds like you feel..." or "So, the way you see it is..."

Janine has been at the detox program for three days and has an appointment with you this morning, before being discharged. “Well, I’ve ben wearing the patch since I got admitted and haven’t really been craving cigarettes. But I am just not sure what is going to happen once I get home. “ Alternatives: You are exploring options for quitting. You are thinking about quitting.

It’s surprising to you that the cravings have been pretty manageable. You were not expecting to give up smoking when you got admitted for alcohol detox. It’s surprising to you that the cravings have been pretty manageable. Your experience with the NRT patch has been positive. Alternatives: You are exploring options for quitting. You are thinking about quitting. Not smoking or drinking while at detox has been a positive experience and you are wondering how your home environment is going to influence your sobriety.

Levels of Reflective Listening Small jump Big jump Repeating– simply repeating an element of what the client has said Rephrasing– substitutes synonyms or slight re-phrases, while keeping the same message Paraphrasing– clinician infers meaning and adds to/extends what has already been said Reflection of feeling– emphasizes the emotional dimension through feeling statements, metaphor, etc.

Complex Reflections You’re tired of people telling you what to do. [patient’s true meaning] On the one hand, you really want to quit smoking, and on the other hand, you like the social aspect of it. [double-sided] You’re disappointed when you miss out on fun activities because you can’t keep up. [patient feeling] You really want to make this change so that you will be healthy. [importance] Quitting smoking would be like giving up sex [metaphor/simile] You can’t imagine how you would ever be able to actually quit. [amplified] You’ve only had a few, really minor difficulties as a result of your smoking. [minimizing]

Double-sided Reflections May be used to highlight ambivalence “On one hand, there are some things about smoking that you really enjoy like socializing with your friends, and yet you are worried about the health effects of continuing to smoke and the impact it has on your children.”

Yes….but People usually are ambivalent about change Comfortable w/ status quo and disadvantages to change Arguments on either side of the ….but… cancel each other out. “You would like to cut down on your drinking and you are concerned about fitting in with your friends.” AA Some important health behaviors are unpleasant (pricking your finger for glucose monitoring; exercising after surgery, side effects of meds, etc.) People get stuck in ambivalence I should exercise more BUT it is too hot I should lose some weight BUT I hate exercising I really should stop smoking BUT I am under so much stress right now.

Reflective Listening Skills TALKER: Discuss something you’ve been thinking about changing LISTENER: Respond with reflective listening STATEMENTS Something you have been thinking about changing in your own life. A habit, attitude, or behavior. Something you have not changed yet. Something that would be GOOD for you to change or something you SHOULD change. Remember, you don’t have to hit a home run, just put a little wood on it!

Summaries: Putting it all together Effective transitions when moving from the “building motivation” phase to the “goal-setting” stage Useful if the person starts to get off track Focus on the person’s own motivations for change

Help Get Person Back On-track "So far you've listed three reasons to keep smoking; and three reasons to quit. And you found that quitting for your daughter's sake was the most important of all these reasons."

Possible Responses? Video slide here $100 for Zyban

Possible Responses? Video slide here Video slide here NO drugs in my body

Is it change talk? I want to quit smoking so I’ll be here for my grandchildren. My boss told me I had to join this QSN class or my insurance costs will double. No one can tell me what to do! I wish my life was different. It took me 12 years to get off cocaine. I am not using any drug, not even NRT!

Questions?

Video Example of MI in action! Responding to Sustain Talk The “master” at work Video Example of MI in action! Disc 2 Title 3: Chapter 10 33:20 to 37:47 Spontaneous reason for change – save $, that’s a good thing. Notice use of the amplified reflection – Smoking is something you’ll probably do for the rest of your days. No, I’d like to quit in the future, it is just so hard.

video

Responding to Change Talk Use your EARS!!! Explore/Elaborate: ask for elaboration, more detail, In what ways? Could you give me an example? Affirm: comment positively, express agreement, appreciation, encouragement Reflect: continue the paragraph Summarize: present the person with a change talk “bouquet”

Offering Information or Advice Ask Permission “If you’re interested, I have some ideas for you to consider. Would you like to hear them?” “If you’d like, I can tell you about some things that other people have tried successfully. Would that be okay?” Offer Advice “Based on my experience, I would encourage you to consider ________________ .” “Given what you’ve told me so far, I think you might have some success if you tried __________________ .”

Offering Information or Advice (cont.) Emphasize Choice “And I recognize that it’s your choice to do so.” “Of course you know best what will work for you.” Voice Confidence “I’m very confident that if there comes a time when you make a firm decision and commitment to ___________, that you’ll find a way to do it.” “I strongly believe that you will accomplish __________ when you decide this if what you want to do.” Elicit Response “What do you think about those ideas?” “I’m interested in hearing your thoughts about these ideas.” Add affirmations slide Conveys respect for their values, feelings, struggles, accomplishments