motivational interviewing: enhancing communications to improve health outcomes

1Celeste A. Hunter; MS, CRC 9/15/11

Motivational Interviewing:Enhancing communications to improve health outcomes

Celeste Hunter, MS, CRCDoctoral Candidate

Department of Rehabilitation PsychologyUniversity of Wisconsin-Madison

2011 Wisconsin Health Improvement and Research Partnership Forum

Celeste A. Hunter; MS, CRC 9/15/11

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Overview• Introduction to Motivational Interviewing

• Basic Tenants of MI

• Motivational Interviewing (MI) is designed specifically to alter patient motivation

• Use of MI in primary care settings can increase successful patient care

• Applications of MI across: o Patient populationso primary care clinic implementation (time permitting).

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Just wondering….

• What do we know about MI so far?

• What are our assumptions about how people change?

• To whom does this apply?

Celeste A. Hunter; MS, CRC 9/15/11

Celeste A. Hunter; MS, CRC 9/15/11

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Rehabilitation is hard work!

oAdhere to self-care, medication, & therapy• i.e. OT,PT, Speech

oExercise & eat rightoShow up to all appointments on timeoStop or curb substance useoUse “appropriate” behavior

In PC or other rehabilitation, we often ask patients to make significant changes in their behavior:

“Challenges” to pursuing “well” behaviorsPeople without acute/chronic health issues: No immediacy & importance to putting forth effort of:

Exercising Eating right Stop drinking, etc…

People with acute/chronic health issues:-May wonder… “why bother”-Already struggling w/ challenges of illness

(Lynch, in press)

Celeste A. Hunter; MS, CRC 9/15/11 5

Motivation & Health Care Outcomes“

• How successful people are towards rehab goals = what they do

• Clients are often > ready, willing, and able to make change

• Most clients seeking treatment or change are ambivalent about it:.

• They want it…and they don’t

Client motivational problems are a primary barrier to successful rehabilitation outcomes” Thoreson, et., al 1968.

Celeste A. Hunter; MS, CRC 9/15/11

Easy to say… But hard to do…

Arising from people's: internal cognitions significant others environment

Convenience or lack of: Facilities transportation

lack of information (Stuifbergen et al., 1990)

Celeste A. Hunter; MS, CRC 9/15/11 7

Barriers to Health Promo: Patient perceptions of the: unavailability,

inconvenience or difficulty of a particular health-promoting option

Motivation:Traditional Clinicians Perspective

• Motivation is the patients problem

• The patient “just isn’t ready to change

• The patient is getting “something”out of status quo: i.e.; social security, attention, relaxed lifestyle, etc.

orCeleste A. Hunter; MS, CRC 9/15/11

Introspective Exercise #1

• Think of a behavior you have tried to change and write it down.

• Think about how long it took you to make an earnest attempt at change after noticing the behavior.

• Who was helpful in that process and why?

Celeste A. Hunter; MS, CRC 9/15/11 9

Motivational Interviewing: A Definition

Motivational Interviewing is a collaborative, person

centered form of guiding to elicit and strengthen

motivation for change.

Motivation: MI’s Perspective• Motivation is the

probability that a person will change*

• Motivation is influenced by clinician responses

• Low patient motivation can be thought of as a clinician deficit

*Miller & Rollnick, Motivational Interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.

Celeste A. Hunter; MS, CRC 9/15/11

Assumptions About Behavior Change

• Attitude is everything: Impart belief in the possibility of change

• Empathy: Create an atmosphere in which the client safely explores

Celeste A. Hunter; MS, CRC 9/15/11

MI is Theoretically Sound

MI strategies are theoretically & empirically basedo Substance abuse (Miller & Rollnick, 2002)o Chronic pain treatment (Jensen, 2002)o Exercise and MS (Bombardier et al, in

progress)

Focus on Ambivalence: Feeling 2 ways about something: o Wanting to change, but not wanting to

Theoretical Basis of MICognitive Dissonance Theory (Festinger):

-‘If I say it and no one has forced me to say, I must believe it.’

Client-Centered Therapy (Rogers): • Accurate empathy, warmth, and

genuineness promote change.Belief System Theory (Rokeach): • Awareness of a discrepancy between

behavior and core values creates change.

Theoretical Basis of MI (continued)

Learned Optimism (Seligman): • Optimism and hope facilitate change.

Importance of Choice (Sanchez-Craig): • Choice enhances adherence.

Reactance Theory (Brehm): • Threats to freedom elicit resistance.

Stages of Change:Transtheoretical Model of Change Prochaska & Velicer, 1997

Transtheoretical model of change:• Explains or predicts a person's success or failure in

achieving a proposed behavior change, such as developing different habits.

• It attempts to answer why the change "stuck" or alternatively why the change was not made.Celeste A. Hunter; MS, CRC 9/15/11

Motivational Interviewing: 2 Phases

Phase #1

Increase Motivation to Change

Counselor evokes client’s:

• Desire• Ability• Reasons• Need for change

By responding with reflective listening

Phase #2

Consolidating Commitment

• Strength of language (not frequency) = change

• Low level = “I’ll try" or “I’ll think about it”

• High Level = “I promise” or “I will!”

• Final min of session = strongest predictor of behavior change (Amrhein et al. 2003)“I will do it!”

SKILLS

SPIRIT

STRATEGIES

Celeste A. Hunter; MS, CRC 9/15/11 18

“Spirit” is the foundation of MI practice

Research Shows…

General practitioners trained in MI can positively affect patients’ attitude to change behavior: Tend to open up and talk more in telling

their stories Tend to view professionals more positively

and express greater satisfaction with care received

Tend to follow treatment recommendations

Celeste A. Hunter; MS, CRC 9/15/11 19Rubak at el, 2009

The Spirit of Motivational Interviewing

3 main concepts:oCollaborationoEvocationoAutonomy

Spirit: Underlying Assumption:

oClients can and will develop direction of health and adaptive behavior

Essential for the full and effective use of MI

MI: Four General Principals

#1: Express empathy: (using short reflections)

• Acceptance facilitates change• Judgment change• Ambivalence is normal

#2 Develop discrepancy: (good things/not so good things)

o Client (rather than counselor) argues for changeo Change when perceived discrepancies in present behavior

important personal goals & values

MI: Four General Principals#3: Roll with Resistance:• giving advice change and resistance• New perspective are invited-- with permission• Resistance = Signal

- DO SOMETHING DIFFERENT!

#4: Support Self-Efficacy:• Person’s belief in possibility of increases

initiation & persistence of adaptive behavior

CollaborativeDancing Wrestlingvs.

We’ve all done it…, but…Lecturing provides little in the way of motivationUsual response = Annoyance or guilt Jensen, 2005

Information is to behavior change

as wet noodles are to bricks -Wilbert Fordyce

Celeste A. Hunter; MS, CRC 9/15/11 25

Accepting & Non-judgmental

The paradox of change:when people feel accepted for who they are and what they do - no matter what…

- it allows them the freedom to consider change rather than needing to defend against it.

Celeste A. Hunter; MS, CRC 9/15/11 26

Spirit… Facilitative CommunicationNothing ‘magical’ about the MI SPIRIT… …it’s just good communication skills that:

Honors Autonomy: Respects the other person’s freedom of

choice, personal control, perspective, and ability to make decisions

Elicits:Encourages the other person to do most of the talking

Celeste A. Hunter; MS, CRC 9/15/11 27

Please remember......• Just because MI seems SIMPLE,

that doesn’t mean it is EASY• Just because it seems like

COMMON SENSE, that doesn’t mean it is COMMON PRACTICE!

Spirit Summary

Underlying assumption that clients can develop in the direction of health and adaptive behaviorEssential for the full and effective use of MICan learn if curious and willing to entertain possibility of…

• Evocation• Autonomy• Collaboration

Celeste A. Hunter; MS, CRC 9/15/11 29

Applications to Rehabilitation Settings

There are many things you can do to increase motivation…

#1= LISTEN!

Celeste A. Hunter; MS, CRC 9/15/11 30

What to listen for…

Is this person ready to change? Identifying stage of change

What does this person value? Link rehabilitation outcomes to the person’s own goals

Why would this person want to participate?

Use the person’s own arguments for change

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Change-talk is client speech that favors movement in the direction of change

What do we know about change talk?

Change talk...Predicts behavior changeIs suppressed by confrontationIs enhanced by listeningIs under the control of the counselor

Change Talk DefinedChange talk is client speech that favors movement in the direction of change towards a specific target behavior.

Before we can EVOKE change talk… We need to learn to RECOGNIZE it.Celeste A. Hunter; MS, CRC

9/15/11 34

Preparatory Change Talk:DARN!

DESIRE to change (want, like, wish . . )ABILITY to change (can, could . . )REASONS to change (if . . Then)NEED to change (need, have to, got to .

.)

Ask for DARN to get DARN!• Why would you want to make this change?

(Desire)• How might you go about making this

change? (Ability)• What are the three best reasons to do it?

(Reasons)• On a scale of 0-10, how important would

you say it is for your to make this change? And why aren‘t you at a _____ (2 points lower)? (Need)

Two Kinds of DARN

It may reveal itself as:

-Attraction to change

“I want to change because I want to look great in a swimsuit.”

oras avoidance of the status quo

“I want to change because I don’t want to have low energy.”

Celeste A. Hunter; MS, CRC 9/15/11 37

Desire

They want or wish to change: “ I wish I could remember to test my blood sugars everyday.”

“I want to get off of disability.”

“I like the idea of eating better.”

Celeste A. Hunter; MS, CRC 9/15/11 38

Ability

They can or have change in the past…

“ I think I can lower my pain meds.”

“I used to exercise at least 3 times per week…”

“I might be able to fit in more fruits and vegetables …”

“I can imagine quitting smoking…”Celeste A. Hunter; MS, CRC 9/15/11 39

ReasonsThey have good reasons to change:

“I’m sure I would feel better about myself if exercised more.”“I want to healthy so I can have enough energy to keep my job.”“Eating more fruits and veggies would help me help me feel healthier…. And I’d set a good role model for my kids.”

Celeste A. Hunter; MS, CRC 9/15/11 40

NeedThey need to (have to, got to, should, ought to, must) change…

“ I must stop smoking...”“I’ve really got to loose weight… I don’t want a knee replacement.”“Cutting down on my drinking will help me keep my kids …”

Celeste A. Hunter; MS, CRC 9/15/11 41

C A T

• Commitment: What do you intend to do? • Activating: What are you ready or willing

to do? • Taking steps: What have you already

done?

Recognizing & Attending to Commitment

STRONG Commitment Talk Medium Commitment Talk

I willI definitely will

I promiseI swear

I guaranteeI know I will

I intend toI am ready toI am going to

I plan toI think I willI expect to

*Given more time, we would excavate this further… Celeste A. Hunter; MS, CRC 9/15/11 43

When in doubt, just remember…

Celeste A. Hunter; MS, CRC 9/15/11 44

Listening Practice to get DARN!

OARS

Key MI Skills: OARS

• Open-ended questions

• Affirmations

• Reflective listening

• Summarize

OARSWe use OARS to give our interactions..

Movement&

DirectionCeleste A. Hunter; MS, CRC 9/15/11 47

Open-Ended Questions

Questions can’t be answered yes or no

Questions that can’t be answered with

one or two words

Questions that are not rhetorical

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Open-Ended Questions

Probe widely for information

Help uncover patients’ priorities and values

Avoid socially desirable responses

Draw people out

Celeste A. Hunter; MS, CRC 9/15/11 49

Open or closed? What do you like about drinking?

Where did you grow up?

Isn’t it important for you to take your insulin regularly?

What brings you here today?

Do you want to continue receiving services?

Have you ever thought about how alcohol might effect

your memory?

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Example 1:

“Would you like to come back for your follow-up appointment?

A more open-ended question?

Open-ended questions (continued)

Celeste A. Hunter; MS, CRC 9/15/11 51

Example 2:

“How much pot do you smoke?”

A more open-ended question?

Open-ended questions (continued)

Celeste A. Hunter; MS, CRC 9/15/11 52

Open ended questions

Using only open ended questions, find out what

your partner will be doing this weekend

Celeste A. Hunter; MS, CRC 9/15/11 53

Reflective listening says:

“I hear you.”

“I’m accepting, not judging you.”

“This is important.”

“Please tell me more.”

“ I want to be sure I have this right.”

Reflective Listening

Celeste A. Hunter; MS, CRC 9/15/11 54

ReflectionsRemembering to reflect is easier said than done…

After a long client narrative, the most important things to reflect are:

Client experience

Client’s reaction to the experienceCeleste A. Hunter; MS, CRC

9/15/11 55

Types of Reflections - SimpleRepeating (repeats an element of the what the speaker said) Rephrasing (uses new words)

Note: Inflection turns D O W N ……at the end

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Types of Reflections: Complex

Paraphrase: (makes an educated stab at

unspoken meaning)

Accurate reflections of deeper meaning: (deeper, succinct reflections are ventured

as understanding increases)

Celeste A. Hunter; MS, CRC 9/15/11 57

Example 1:

“I really want to stop eating junk food, but no one in my family will stop bringing it into the house. I’m tired of trying.”

Reflective response?

Reflective Listening (continued)

Celeste A. Hunter; MS, CRC 9/15/11 58

Exercise #2• Choose a behavior you are

interested in changing and willing to share with a partner in this room

• Review the “DARN” principles as they relate to this change

• Role play with a partner as “counselor” and “client”

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Persuasion Exercise: Debrief

- Did the clinician observe movement in the direction of positive change?

- Did the speaker feel like making positive change?

- What are the underlying messages conveyed by advice giving and lecturing?

SummaryConveys to the patient/client:

“What you’ve said is important.”

“I value what you say.”

“Here are the salient points.”

“Did I hear you correctly?”

“We covered that well. Now let's talk about ...”

Celeste A. Hunter; MS, CRC 9/15/11 61

When do you know it is working?- You are speaking slowly

- The patient keeps talking

- The patient is talking more than you

- You are following and understanding

- The patient is working hard and seeming to come to new realizations

- The patient is asking for information or advice

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Benefits of Motivational Strategies

• Makes our job easier

• More rewarding

• More effective

Celeste A. Hunter; MS, CRC 9/15/11 63

In Conclusion…• Motivational issues are central to

effective Rehabilitation• We cannot make patients change

behavior• We can help to motivate patients in the

direction of positive changes by: Listening rather than lecturing Identifying the stage of change Matching our response to stages to encourage

movement to the next stageCeleste A. Hunter; MS, CRC 9/15/11 64

For more information...

Contact info: cahunter@wisc.edu