1. Motivational Interviewing: A Tool for Communicating With Patients to Facilitate Engagement and Change Denise Ernst, PHD

2. Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

3. Financial support provided by the American Academy of Family Physicians Foundation

4. MI has substantial evidence base supporting it’s effectiveness in facilitating change in behaviors that are hard to change MI is effective with both psychological (behavior change) and physical outcomes (BMI, BP, BAC) MI focuses the responsibility for change on the patient; encourages self-management and self- determination Why is Motivational Interviewing (MI) a method to consider?

5. MI out performs traditional advice giving in 80% of studies Effective in 10-20 minutes More encounters over longer time period increase likelihood of an effect Physicians and other health providers can be as effective as psychologists or counselors The efficacy of MI –meta analyses

6. Effect of MI is enhanced when combined with other treatments such as education, self-management support, or “treatment as usual” MI may be most effective when focused on treatment retention and/or adherence Average short-term between-group effect size of MI was 0.77, decreasing to 0.30 at follow-ups to one year. The efficacy of MI –meta analyses

7. Motivational Interviewing (MI) is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.

8. Directing Guiding Following MI is considered a refined form of guiding Three styles of communication used in health care

9. Evocation of patient’s motivation, hopes, dreams, desires, values, goals, and abilities. Partnership with the patient; MI is done “for” and “with” a person and not “to” a person. Acceptance including accurate empathy, affirmation, absolute worth of the person, and support of the person’s autonomy. Compassion; active promotion of the patient’s welfare and needs. The Spirit of MI

10. What else to watch for in conversations about change? Righting reflex; avoid convincing, arguing, trying to fix, prescribing, directing Ambivalence; normal part of the change process, not pathological or a sign of denial but a place where people get stuck

11. Compare and Contrast Clip # 1 Wrestling………………………………….Dancing 1 2 3 4 5

12. Compare and Contrast Clip # 2 Wrestling………………………………….Dancing 1 2 3 4 5

13. Engaging Focusing Evoking Planning Four Foundational Processes

14. Open-ended questions to keep the conversation moving forward and encourage self-exploration Affirming the client’s strengths, efforts, character and worth Reflective listening to stay focused on the client and convey understanding and empathy Summarizing to provide the big picture and to transition Engaging with OARS: The MI micro skills

15. Examples of OARS OQ- –What made you decide to quit smoking when you were pregnant? –Where do you think we should go from here? Reflection –The risks were so scary then that you were able to stop, but they don’t feel as scary to you now.

16. May be a clear focus with a single topic like attending cardiac rehab or stopping smoking May negotiate an agenda based on a menu of options –“These are things we typically discuss with people who want to reduce their risk of serious illness; healthy eating, physical activity, healthy drinking, and sleep health. I’m wondering if one of these is something you would be interested in exploring?” Clarifying the focus may be the first goal –“What I thought we’d do today is explore what, if any changes you’d like to make to improve your health. I’d like to hear what makes your health important to you and what your health goals are.” Focusing the conversation on change

17.  Treatment adherence, engagement, and retention  Lifestyle changes such as physical activity or dietary change  Behavioral components of complex treatment regimens such as behavioral activation or self-monitoring  Medication adherence  Changes in attitude such as acceptance of a diagnosis or self-management of a chronic condition  Substance use; alcohol, tobacco Common Change Targets: What are we guiding towards?

18. How does our conversation get focused? I did want to talk to you though- I’m a little bit concerned looking through his chart at how many ear infections he’s had recently and I noticed you had checked the box that someone’s smoking in the home so I was wondering if you could tell me a little more about that?

19. How the client talks about the change is important to the outcome The topic or focus of conversation or goal or desired outcome needs to be clear for the clinician to actively guide the conversation The clinician influences how the client talks by choosing: – what to reflect – what type of questions to ask – when to ask for elaboration – when to “ignore” or redirect focus Evoking through guiding….

20. Change talk; patient language that moves towards the desired change in behavior –I know it’s not good for him, I mean I’ve read those things about ear infections and asthma and stuff … Sustain talk; patient language that supports the status quo or moves away from change –…but other kids have ear infections and their parents don’t smoke. The Importance of Patient Language

21. Asking for and getting change talk Clinician: Well, what made you say 5, rather than 2 or 3? Patient: I know all the ways it’s bad for me and I don’t want him to grow up thinking that it’s okay to smoke. I don’t want him to use any kind of- I don’t want him to chew or anything like that. So I know I need to especially before he gets old enough to understand what mommy’s doing but I just don’t know if I can do it.

22. Responding to change talk with a mini- summary that captures the ambivalence Clinician: Okay so it sounds like you have a lot of reasons why you’d like to quit, you have been successful quitting in the past, and right now you’re just feeling a little bit hesitant about your ability to do it.

23. Asking permission Finding out what the patient already knows Tailoring your information to meet the needs of the patient Providing time and space for the patient to think about and respond to the information Acknowledging that the patient is the expert on his/her own life Encouraging the patient to use the information in the way that suits them best Informing in the MI way

24. Patient: I don’t know I’d like some help, I just don’t know what kind of help I need. Clinician: Sure well if you’d be interested that’s something I can definitely talk to you about. There are a lot of new options that can actually help people be way more successful in their attempt at quitting. There’s different medications you can try. Patient: I don’t like medicine. Clinician: Okay there’s also a lot of support groups and classes that you can take where you have other people to go through it with you and sometimes just having that support can be a big part of it especially for people like you, where smoking is such a stress reliever. Patient: That sounds nice, but I’m not sure if I have the time for all that. Clinician: Sure it feels like something that would take up a lot of time and maybe not fit in to your life. I wonder if we could talk about some options that might fit into your life.

25. Planning in the MI way Avoiding prescribing the treatment or providing “the plan” Patient-centered problem solving, solution generating, and plan evaluation Building patient commitment and confidence in the plan Treating the plan as an experiment

26. A Taste of MI

27. MI can be learned by anyone with the desire to learn it and the underlying belief that the client has the answers within and the capacity to act on their own behalf Skill acquisition is not related to years of experience, years of education or profession For many people, the unlearning of old habits is as important as the learning of new skills Learning MI; Who can do it?

28. Rollnick, Miller, & Butler, (2007). Motivational Interviewing in Health Care: Helping Patients Change Behavior. The Guilford Press, New York, NY. Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing; Helping People Change. The Guilford Press, New York, NY. Rubak, et. al. (2005) MI: A systematic review and meta analysis. British Journal of General Practice 2005; 55: 305–312. Hettema, et. al. (2005) Motivational Interviewing. Annual Review of Clinical Psychology, 1:91–111. References

29. Additional Resources Motivational Interviewing Network of Trainers (MINT) website has a list of trainings coming up, trainers around the world, and an extensive bibliography of MI research and publications. motivationalinterviewing.org Denise’s email (feel free to contact me) d.b.ernst@att.net

30. Additional Resources The video of the more effective physician can be found at: http://www.youtube.com/watch?v=URiKA7 CKtfchttp://www.youtube.com/watch?v=URiKA7 CKtfc This is thanks to Lisa Merlo PhD, University of Florida Psychiatry Department