1. Helping patients reduce sexual health risk using a Motivational Interviewing approach STIF workshop 15.9.08

2. Objectives Summarise the NICE recommendations for reducing STI/HIV Consider the primary HCW role in helping people reduce sexual health risk Introduce Motivational Interviewing (MI) (Miller 1983) Introduce the Stages of Change model (Prochaska & DiClemente 1986) Consider feasibility of integrating into practice Review local service provision

3. Prevention of STI and under 18 conceptions (NICE 2007) Recommendations 1 & 2 One to one structured discussions with individuals at high risk of STIs… structured on the basis of behaviour change theories. … address factors that can help reduce risk-taking and improve self-efficacy and motivation. each session …15–20 minutes. The number of sessions will depend on individual need.

4. Challenges with risk reduction What difficulties have you encountered? What has worked well? Have you avoided such discussions – if so, why?

5. Process of Change Model Adapted from Prochaska & DiClemente (1986) Stable, ‘safer’ lifestyle Pre-contemplative Preparation Action Maintenance Relapse Contemplation

6. What is MI? “ A person-centred, goal-orientated approach for facilitating change by exploring & resolving ambivalence” Miller (2006) “ a skilful clinical style for eliciting the patient’s own good motivations for.change” (Rollnick, Miller & Butler 2008)

7. The spirit of MI “Dancing rather than wrestling” Collaborative –conversation between equals; working together; joint decision making Evocative –Elicits patients own motives and resources for change Honouring patient autonomy –Emphasise patient choice and control –Avoid creating resistance through coercion

8. RULE Guiding Principles Resist the righting reflex Understand your patient’s motivations Listen with empathy Empower your patient

9. Opening strategies - OARS O pen questions A ffirmations R eflective listening S ummarise

10. Exploring ambivalence Good things / not so good things ‘Decisional Balance’ demonstration – Good things about unprotected sex – Not so good things about unprotected sex – Good things about condom use – Not so good things about condom use

11. Decisional balance demonstration Patient 18 year old female Presents with PID symptoms 2 previous episodes of chlamydia 3 casual partners in past 6 months All unprotected vaginal sex

12. Assessing readiness to change  Importance  Confidence (self-efficacy) IMPORTANCE CONFIDENCE 10 1 1

13. Giving information Wait for client to ask or / seek permission Offer choices / what other do Elicit- provide- elicit

14. Roll with resistance Avoid arguing - may increase resistance to change Resistance cue to change strategies It is for the client to make decisions about change The client is the primary resource in finding answers and solutions

15. Group practice exercise Patient 18 year old female Presents with PID symptoms 2 previous episodes of chlamydia 3 casual partners in past 6 months All unprotected vaginal sex What would you not say? What might you say, in the spirit of MI?

16. MI in practice Let me explain just how serious chlamydia /PID is, and why you need to avoid it in future! You need to start using condoms! I know you are in a hurry but this won’t take long! What do you know about chlamydia / PID? Would it be helpful if I gave you a bit more information? How do you feel about using condoms? You seem in a hurry...is there anything you need to talk about before you go ?

17. What next? Goal setting: “What could you do to reduce your risk for STDs/HIV/pregnancy?” (Examples of goals: condom use, reducing number of sexual partners, safer sex, contraception, partner testing.) Action Plan: “How would you go about that?” “What would be the difficult thing about that?” “How would you overcome it?”

18. Summary Spirit of MI - collaborative, evocative, respect for autonomy RULE- Resist the righting reflex, understand, listen with empathy, empower Information giving - elicit – provide – elicit Exploring ambivalence – decisional balance (pros and cons) Importance and confidence Roll with resistance

19. Further reading Rollnick, Mason and Butler (1999) Health Behaviour Change: A Guide for Practitioners. Rollnick, Miller and Butler (2008) Motivational Interviewing in Health Care Miller & Rollnick (1991) Motivational Interviewing