Motivational Interviewing for Busy Residents PBL Session 3 Ken Saffier, MD July 18, 2014

Disclosures Still nothing to disclose Member, Motivational Interviewing Network of Trainers (M.I.N.T.) www.motivationalinterviewing.org

Learning Objectives By the of this session, you will be able to: 1. Recognize and use O.A.R.S. microskills in patient visits. 2. Use reflections to “roll with resistance” in challenging situations. 3. Apply MI tools to evoke change talk in patient interviews. 4. Develop an individual MI learning plan.

Spirit of MI Collaboration Acceptance Evocation Compassion

Eight Stages of Learning MI 10/8/2013 Eight Stages of Learning MI Spirit of MI – evocative, collaborative, respectful of client autonomy OARS – Client-centered counseling skills Recognizing and reinforcing Change Talk – DARN CAT Eliciting & strengthening Change Talk Miller, WR, Moyers, TB, 2006 K. Saffier, MD

Eight Stages of Learning MI 5. Rolling with Resistance – Reflections: simple, amplified, double- sided 6. Developing a Change Plan – moving from Change Talk to Commitment 7. Consolidating Client Commitment – moving from “I can”/”I’d like to” … to “I will” 8. Switching between MI and other Counseling Methods Miller, WR, Moyers, TB, 2006

Four Processes in MI Planning Evoking Focusing Engaging Miller and Rollnick, 2013 Planning Evoking Focusing Engaging

Open-ended Questioning Affirming Reflective Listening Summarizing Building Motivation: OARS (the microskills) 10/8/2013 O A R S Open-ended Questioning Affirming Reflective Listening Summarizing Tom Freese, PhD K. Saffier, MD

Reflective Statements Levels Repeating. The simplest reflection simply repeats an element of what the speaker has said. Rephrasing. Here the listener stays close to what the speaker said, but substitutes synonyms or slightly rephrases what was offered. Paraphrasing. This is a more major restatement, in which the listener infers the meaning. Continues the paragraph. Reflection of feeling. Deepest form of reflection, a paraphrase that emphasizes the emotional dimension through feeling statements

Recognizing Change Talk

and Elicit – ChangeTalk D A R N - CAT Desire to change:

D A R N – C A T Ability to change: “ I could …” 10/8/2013 K. Saffier, MD

D A R N – C A T Reasons to change:

D A R N – C A T Need to change:

D A R N – C A T Desire Ability Reasons Need C: commitment—Will, intend to, going to A: activation—Ready to, willing to (w/o specific commitment) T: taking steps—Report recent specific action toward change Amrhein et al., 2003

Which Style Do You Prefer? Dancing Wrestling

10/8/2013 Motivation is particularly sensitive to Interpersonal Communication Styles Counsel in a directive, confrontational manner— Resistance increases Change talk decreases Counsel in a reflective, empathic manner— Resistance decreases Change talk increases Mi Principle Express empathy. Miller & Rollnick, Motivational Interviewing, 2002 K. Saffier, MD 17

Rolling with Resistance Strategies: “Well, I over do it sometimes, but I don’t have a problem with meth.” Coming alongside: You feel mostly in control with your meth use and don’t see it as an issue. Amplified reflection: Your meth use has never really caused any problems or unpleasant effects in your life. Double-sided reflection: You think you use too much at times, but you also don’t think of yourself as a problem user. Ideal outcome: is the pt argues against this mirror you’ve just put up.

Roll With Resistance/Sustain Talk Avoid arguing for change. Resistance is not directly opposed. New perspectives invited, not imposed. A sign to respond differently. Miller and Rollnick, Motivational Interviewing, 2002

“Batting Practice” Write down one or two examples of resistance from your experience what your patients have said. We all get to take turns “batting” one or two examples to practice “rolling with resistance” (or sustain talk).

Expert Demonstration Listening for: O.A.R.S. and change talk: D.A.R.N. - C.A.T.

A Brief Review of MI Tools Pros and cons Pros and cons squared Explore – Offer – Explore (Elicit – Provide – Elicit aka Ask – Tell – Ask) Decisional (importance and confidence) rulers Strategic summary statements followed by an evocative question.

Pros and Cons What’s good about _______________? What’s not so good about __________? For contemplative and pre-contemplative stages of change.

Tools for Contemplation Pros & Cons squared “good” and “not so good” DON’T CHANGE CHANGE PROS CONS

Valuable MI Tools Elicit – provide – elicit (Ask – Tell – Ask) E What is your understanding about _______? (May I share some information about this?) P Information shared… E What do you think about this? Importance and confidence rulers to elicit change talk.

Assess Readiness to Change Once you identify a problem….where do you go? “On a scale of 1 to 10, how important is it for you to make a change, to ___? “Why did you pick ___, and not 1 or 2 (a lower number)?” “On a scale of 1 to 10, how confident are you that you can ________ “What would it take to go from ___ (lower #) to ___ (higher)? (Jennifer Hettema, PhD)

Summarizing Statement Special form of reflection Pick a bouquet of flowers Focus on change talk or underlying dilemmas Reassures that you heard the person Moves the conversation along MJ relaxes you & it’s a way to socialize with your friends. But you want to limit your MJ use, because its interfering with school and it takes a big bite out of your budget. Summarization after reviewing pros & cons. Note: ended with cons or change talk.

Evocative Questions Why would you want to make this change? If you did decide to make this change, how would you go about it in order to succeed? What are the 3 best reasons to do it? So what do you think you’ll do? How important would you say it is for you to make this change, on a scale of 0 to 10, and 10 is extremely important? And why are you at __ and not a lower number or 0?

Demonstrations http://www.youtube.com/watch?v=80XyNE89eCs “Not so good” http://www.youtube.com/watch?v=URiKA7CKtfc “Good”

Time to Practice

Exercise – Pass the Stethoscope Your patient has ___________________. One provider opens the visit, learns what is important to the patient, and after 2 interactions, passes the stethoscope to another, who continues the interview, using OARS, and MI tools. Pick a card from the table and practice with that tool. Then pass the stethoscope.

MI is Effective Across Cultures MI in Everyday Practice 9/7/2010 MI is Effective Across Cultures Based on broad generalizable principles of human behavior. Cultural competence = cultural humility, respectful listening, learning, appreciating and understanding differences = “Spirit” of MI. Evidence: increased effect sizes in studies with predominantly minority populations. (Hettema, Steele and Miller, 2005) E. Bierer, MD, K. Saffier, MD

Eight Stages of Learning MI 10/8/2013 Eight Stages of Learning MI Spirit of MI – evocative, collaborative, respectful of client autonomy OARS – Client-centered counseling skills Recognizing and reinforcing Change Talk – DARN CAT Eliciting & strengthening Change Talk Miller, WR, Moyers, TB, 2006 K. Saffier, MD

Eight Stages of Learning MI 5. Rolling with Resistance – Reflections: simple, amplified, double-sided 6. Developing a Change Plan – moving from Change Talk to Commitment 7. Consolidating Client Commitment – moving from “I can”/”I’d like to” … to “I will” 8. Switching between MI and other Counseling Methods Miller, WR, Moyers, TB, 2006

Learning MI – consider: Attend a training workshop (CME) Read: Miller, Rollnick, others. Tape record your real plays or a clinic visit (after consent obtained) and then: Rate yourself. Have a colleague or mentor provide feedback, return the favor. Develop a learning plan and a timetable www.motivationalinterviewing.org

Your Individualized Learning Plan 1. What you will practice in the coming week? 2. Where will you try out these tools? 3. With whom will you practice? 4. When will you do this? 5. How will you do this?

Recommended Reading

Many Thanks to: Sharone Abramowitz, MD Karena Franses, LCSW Tom Freese, PhD Jennifer Hettema, PhD Steve Berg-Smith, MS, CWP