Communication Skills to Better Pain Management: Motivational

Interviewing

Stephen R. Gillaspy, Ph.D.Stephen-Gillaspy@ouhsc.edu

Department of PediatricsUniversity of Oklahoma College of Medicine

Learning ObjectivesLearning Objectives

1. Discuss common barriers to pediatric pain management.

2. Describe and discuss fundamentals of Motivational Interviewing (MI).

3. Describe and discuss specific motivational interviewing techniques.

What are barriers?What are barriers?

1. Motivation– Patient– Parent / caregiver

2. Communication

3. Expectations

Why Motivational Interviewing?

• Evidence-base– Hundreds of randomized trials– Several meta-analyses– MI > TAU, direct advice alone, education

• Practice Guidelines– Tobacco:

• USPHS Guidelines (“5 A’s”), American Academy of Pediatrics (2009), AMA

– Alcohol• Screening, Brief Intervention, Referral to Treatment

(SBIRT), American Academy of Pediatrics (2010), AMA

Behavior change

Why don’t people change?

procrastination

behavioral economics

avoidance

self-affirmation biases

habit-driven

reactance

biases toward downward comparison

reject labels

negative affect

How do people change?

What is “Motivational Interviewing”

• “…a client-centered, directive method for

enhancing intrinsic motivation to change by

exploring and resolving ambivalence.” (Miller &

Rollnick, 2002, p. 25)

• In MI, we attempt to:1. observe, respect, and avoid opposing sustain talk and;

2. elicit, amplify, and affirm change talk

Style and Spirit of MI

• Relentlessly, radically patient-centered

• A way of being with people, characterized by:

Collaboration (vs. one-up, authoritarian relationship)

Evocation (vs. imparting or inserting knowledge)

Autonomy-supportive (vs. controlling)

Direction (vs. avoidant, distracted)

Empathy (vs. dismissive, disrespectful)

Evocation

• Good practice:– Clinician works to proactively evoke patient’s own

reasons for change and ideas about if and how changes should happen.

• Poor practice:– Clinician actively provides his or her reasons why

the patient should change, or education about change, in the absence of attention or regard for the patient’s knowledge, ideas, or motivations

Collaboration

• Good practice:– Clinician actively fosters and encourages power

sharing, shows respect for patient ideas, and allows client ideas to substantially influence conversation.

• Poor practice:– Clinician actively assumes expert role for majority

of interaction.

Autonomy Support

• Good practice:– Clinician is accepting and supporting of patient

choice and autonomy and works to expand patient’s experience of control and choice.

• Poor practice:– Clinician actively detracts from or denies patient’s

perception of choice or control, assumes that client cannot move in appropriate direction without input from clinician

Direction

• Good practice:– Clinician exerts influence on session and maintains

focus on topic of target behavior change.

• Poor practice:– Clinician does not influence topic of conversation,

and direction is entirely in hands of patient

Empathy

• Good practice:– Clinician shows evidence of deep and sincere

understanding of patient’s point of view; demonstrates curiosity about patient; accurate reflections

• Poor practice:– Clinician has no apparent interest or curiosity in

patient’s worldview; may demonstrate indifference or dismissal of patient’s experiences or ideas; reflections, when present, are inaccurate or shallow

Specific Behaviors

• Microskills – operationalize global ratings

• Prescribed Behaviors:– Seek permission to add target behavior to agenda

– Evocative questioning

– Empathic reflective listening

– Other MI-consistent behaviors

Seek permission

• Demonstrate respect for autonomy and desire for collaboration immediately

• Ask for permission before transitioning to discussion of target behavior– Do you mind if we spend a few minutes today

talking about your child’s ……?

– If you don’t mind, I would like to spend a little time today visiting about Johnny’s ……..

Evocative Questioning

• Use more open-ended questions than closed questions– Open-ended questions require elaboration, not quite

sure where answer might lead.• Can you tell me more about that?

• How did you make that decision in the past?

– Closed-ended questions require a simple answer and leave direction in the hands of the asker.

• How many times during the week do you ……….?

• Where does it hurt?

Evocative Questioning (cont.)

• Scaled questions are very useful and highly recommended

• Can ask about readiness, importance, or confidence– On a 1-10 scale, how ready would you say you are

today to make changes to your ………..?– On a 1-10 scale, how important is it to you today to

get Johnny’s ………. under control?• Most important questions are follow-up

questions– Why did you say “3” and not “1”?– What would it take to move from “5” to “9” or

“10”?

Role of Reflections

What the patient means

What and how the patient says

What the clinician hears and sees

What the clinician understands

Hypothesis Testing Model of Listening

Empathic, Reflective Listening

• Respond to patient statement and ideas with reflective statements– Can include restatement, rephrasing, metaphor,

summary, etc.

– Try to reflect true meaning of patient expression

• Important for building rapport and enacting spirit of collaboration, empathy, autonomy support, and evocation

Other MI-Consistent Behaviors

• Advise and educate, with permission– Ask for permission explicitly

• Do you mind if I share with you some information…

– Give permission to disregard• I’m not sure if this would work for you or not, but my advice

would be to…

• Collaborate on potential solutions or plans– Offer a menu of options for addressing the problem– Explore patient’s ideas for “goodness of fit” or “next

steps”

Other (cont.)

• Affirm and support the patient– Reinforce good choices, ideas with praise and

encouragement

– Offer statements of compassion or sympathy

• Emphasize choice, autonomy, or control– Be explicit about your respect for the patient’s

choice• It is up to you, nobody can make this decision for you.

• You know yourself better than anyone.

Proscribed Behaviors

• Confrontation– Avoid disagreeing, arguing, correcting, shaming,

blaming, criticizing, labeling, moralizing, ridiculing, etc.

– Often turn conversation into a wrestling match• Advising (without permission)

– Language usually includes words such as: should, why don’t you, consider, try, how about, etc.

• Over-directing– Commands, orders, imperatives– You should, you must, etc.

Comparison of usual practice vs. MIComparison of usual practice vs. MI

Usual Practice• Clinician sets agenda• Tell patient what’s important• Clinician decides when to move ahead w/goals• Clinician is responsible for patient making changes• Clinician is instructor• Success measured by

clinician definition

Motivational interviewing• Patient sets the agenda• Patient decides what is

important, in line w/corevalues, beliefs and needs

• Patient sets pace for work• Patient is responsible for if,

what & when behavior change occurs

• Clinician is a guide• Success is measured by

patient’s own values and goals