MOTIVATIONAL INTERVIEWING Assisting With Patient Directed Health Decisions Lisa Becker, MAHS, DPh, NCPS Claremore Comprehensive Indian Health Facility

PATIENT ASSESSMENT TOOLS To assist in behavior change, providers must first assess patients’: Health care knowledge Concerns Barriers We know this already! Do you plan a trip to somewhere you have never been without a map- are you going to drive or swim to hawaii?? Not usually! This is the same sort of thing: can you help plan changes in health behaviors without a map- or some idea of the factors involved.?The question is HOW to we assess these things and help patient decide on healthy steps to take in our restrained time limits with the patient? Its easy to look at a lab and see high cholesterol, or ask if patient smokes, but then what? MI doesn’t take much more time than “telling” patients what to do over and over, but is more effective because it helps patient take responsibility for their own health decisions. What is the definition of stupid? “doing the same thing over and over and expecting different results”… An example: the Old way of counseling: TELLING instead of guiding…

OBJECTIVES Define motivational interviewing (MI) Discuss differences between provider and patient centered communication Define role of health care provider in patient guided disease management Verbalize key concepts of patient centered decision making Identify several MI processes to aid in assessing and resolving patient resistance or ambivalence Identify several patient assessment tools useful in practice and medical home models of care

The Problem Current models of care are paternalistic Communication is practitioner-centered, not patient-centered Information giving vs. information exchange Save the patients vs. patients save themselves Labeling of patient: in denial, difficult, etc. Compliance vs. adherence Dictate rather than negotiate behavior change Nuff said: Provider: “This patient has been coming here for years and still has a1c over 9 and never follows my plan for food choices . Some people just don’t want to try and I finally told him that if he doesn’t do what I say he is going to die.(paternalistic, practitioner centered, “telling” patient what to do, can’t “save” the patient, labeling patient (difficult and non compliant), dictate behavior change “or else”.

MI Defined The most recent definition of motivational interviewing (2009) is: “A collaborative, person-centered form of guiding to elicit and strengthen motivation for change” Not just a cheerleader type of “Lets go..rah rah..”Now, since this is only a 30 minute presentation, we will get into the NEW acronym that may help you quickly assess patients’ readiness to change … remember this is only touching on the basics…this stuff really requires more training and practice…

The Spirit of MI The “spirit” of MI is based on three key elements: Collaboration between the therapist and the client, Evoking or drawing out the client’s ideas about change, Emphasizing the autonomy of the client. The Spirit of Motivational Interviewing is more than a technique. It is characterized by a particular “spirit” or clinical “way of being” which is the interpersonal relationship within which the techniques are employed.

Motivational Interviewing (MI) Useful in Chronic Disease, Chronic Care Models? Useful in Health Promotion/Disease Prevention? YES! Evidence based standards guide self managed care with resulting improved outcomes. In short presentation, don’t have time for too many details, since this MI technique over a two day workshop wasn’t even enough time, so we will get right into the use of the MI tools, followed by examples that may be useful in practice. Remembering these acronyms may help: READS, FIRE,

The Tool Kit READS

Acronym READS. we could use acronym “fire” for the tips at bottom: fence, insurance, ruler, envelope… This slide, and information in this session, came from a training at AZ on MI in tobacco cessation, and presented by >>>> Berger Consulting?? And some info. In this presentation partly from a core concepts in DM care at an AADE seminar. So, can be useful in chronic care and health promo both!

R: Roll with Resistance Example: “You are not ready to quit smoking at this time.” When to use? When patients are expressing issue resistance

To demonstrate understanding and to address a patient’s core concern E: Express Empathy Example: “You are worried that you may not be able to quit without your husband quitting.” When to use ? To demonstrate understanding and to address a patient’s core concern (Active Listening, Safe environment, Support, Information, Rephrase with “feeling”)

Empathy Starters: “You seem_____” “In other words…” “You feel ___ because ___” “It seems to you…” “You seem to be saying…” “I gather that…” “You sound…” NOT: I UNDERSTAND !

Express Empathy, example ? Patient: Everyone makes it sound so easy…just take the medicine, quit smoking, change your diet, and exercise more! HCP: Well, studies show that these things do improve quality of life. Just follow the plan I give you and start taking care of yourself. NOT! Provider “telling”, not empathetic,…

Express Empathy, example 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. Rephrase, “feeling”….

A: Avoid Argumentation Example : “You do not see yourself quitting smoking at this time. What types of things are you willing to do to get your cholesterol down?” When to use? To demonstrate understanding and to prevent creating relational resistance If time, we could give lots of funny or disturbing “real life” examples of situations where hcp did NOT avoid argumentation… 

Avoid Argumentation, example 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? “Old” answer: heck yes you need to quit!

D: Develop Discrepancy Example: “On the one hand, you have an important goal of lowering your blood pressure to prevent stroke and heart attack. On the other hand, your smoking raises your blood pressure and your risks. What are your thoughts?” When to use? To create change talk and throw the patient’s system out of kilter without creating more resistance (Identify core values of patient and if their behavior is consistent with those values) Picture “double Ds” – “on the one hand, on the other hand”……

Develop Discrepancy, example 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. Feelings..neg and pos…facts…

S: Support Self-efficacy Example: “I am really glad to hear that you are thinking more about quitting. What has you thinking more about that?” When to use? To reinforce both thoughts and actions regarding behavior change

Supporting Self-efficacy, examples 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. 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? Bolded words: What are YOUR thoughts? Lots of letting patient guide the plan… opening up, developing relationship…

CONVERSATIONAL TOOLS “FIRE”

“Encourage change talk, create dissonance” F: Fence “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?” “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?” “Encourage change talk, create dissonance” When to use – to encourage change talk and assisting the patient in making the argument for the change— creates dissonance (develop discrepancy)

I: The Insurance Card Prevent “fixing” or “saving” the patient “MAY I TELL YOU WHAT CONCERNS ME?” 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? Prevent “fixing” or “saving” the patient

R: The Ruler Elicits “Change Talk” Scale TWO concepts: Importance and Confidence Example: from a 1 to 7 or a 1 to 10 scale 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”

Explore readiness for change E: The Envelope Example: “If I were to hand you an envelope, what would the message have to say inside for you to consider quitting?” (or whatever change you are discussing) Explore readiness for change I don’t know about this one. Maybe you do. I think if I was in a mode of resistance to change, I would answer like “well I would need a GUARANTEE “. . ???

Primary Skills in MI ASK, INFORM, LISTEN “Change talk”: communication with the patient in a way that elicits their own reasons for change: A. Disadvantages of status quo B. Advantages of change C. Optimism for change D. Intention to change

Progression of MI Early emphasis on developing a solid relationship with the patient Less relational work required later Later emphasis on engaging the patient’s reasoning Allows you to speed up because patient is not defensive and argumentative Saves time by precisely targeting the patient’s thinking: rifle vs. shotgun

Patient Motivation Reflecting and empathizing with the patient’s core motivational issues Helps to create early rapport with the patient Helps to initiate the process of engaging the patient’s reasoning process If the patient feels that you haven’t heard and haven’t respected their issues, the patient will become defensive and/or aggressive The patient is no longer listening to you

Example: Patient: I’ve tried to quit smoking for a while, but I always come back to it again. So, I don’t see the point in trying any more. HCP: It feels pointless to try to quit one more time if you are just going to smoke again anyway. Patient: You got it! HCP: Now, you said that you’ve been successful in quitting previously, but then you start back again. When you quit initially, what worked for you? Empathizing, self efficacy talk, ..

F-I-G Follow (reflect) Inform (ask permission) and identify Guide: 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. Another acronym: reads, fire, fig, now OARS

O-A-R-S Open Ended Questions Affirmations Reflections Summaries Often called micro-counseling skills, OARS is a brief way to remember the basic approach used in MI. These are core behaviors employed to move the process forward by establishing an alliance and eliciting discussion about change. Open Ended Questions Affirmations Reflections Summaries

Quick Quiz 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. wHICH tool is each of the following responses: “ruler”. “insurance card “ “.supporting self efficacy.” “dissonance” “empathy”

Quiz, continued 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. “look over the fence” avoid argumentation“” ?“roll with resistance?” “create dissonance?”

Key Concepts and Principles Always maintain the spirit of motivational interviewing (AGAPE)—acceptance and compassion Be patient (client)-centered—what does the patient want to work on? What are his/her goals? Address the patient’s core concern(s) and line of reasoning Create a climate that is safe for the patient to learn The patient needs to make the argument for change—ask the patient what are the benefits of the change?

Key Concepts and Principles (cont) Assess the patient’s understanding of the risk/susceptibility involved in not treating the illness or changing a behavior (eg, quitting smoking) What does the patient understand about the illness and its treatment? Be honest and truthful with the patient— don’t “soften” lab values (blood pressure is 155/110—“It’s a little high”) to “protect the patient”—it backfires Be explicit in your empathy Explore the decisional balance When faced with ambivalence or resistance, EXPLORE, don’t explain Be aware of issue and relational resistance

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?

MI: Inspiration “The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires. *William A. Ward

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