Motivational Interviewing Techniques for Physical

TherapistsAn introduction to a tool for building patient confidence to change

Presented by James Cumming PT, MPT

Board Certified Orthopedic Clinical Specialist

Agenda

● Introduction to MI ○ Spirit and Guiding Principles of MI

● Setting the stage for MI○ Ambivalence○ Change talk○ Stages of Change○ Process of MI

● Core techniques with lots of practice○ Asking ○ Listening ○ Informing

● Evidence (in slides only, will not be discussed)● Practice of MI as a whole

Motivational Interviewing is:

a collaborative conversation style for strengthening a person’s own motivation and commitment to change.

To do this we use specific conversational techniques to increase the amount of change talk from our patients: ask questions listen accurately inform patients in non-authoritarian way

was born out of substance abuse counseling

Another way to define MI

● “MI is designed to find a constructive way through the challenges that often rise when a helper ventures into some else’s motivation for change. In particular, MI is about arranging conversations so that people talk themselves into change, based on their own values and interests. Attitudes are not only reflected in but are actively shaped by speech.”

Miller and Rollnick, 2013, pg 4

Spirit of MI

- without the following accepted “rules” or “assumptions”, motivational interviewing is only a set of skills, and can quickly become more of a “trick” than true help

- “Taking on this spirit is not a prerequisite for doing MI, rather doing MI teaches you this spirit” (adapted per Miller and Rollnick, 2015)

Spirit of MI● Partnership - an active collaboration between experts

● Acceptance● Absolute Worth - unconditional positive regard● Accurate Empathy - active interest and effort to

understand a person’s internal perspective (but not sympathy)

● Autonomy Support - honor and respect a person’s freedom to choose their own path

● Affirmation - seek and acknowledge the person’s strengths and efforts

Spirit of MI (cont.)

● Compassion - actively promote another’s welfare

● Evocation- people already have within them what is needed to change

Other Guiding Principles

● Resist the righting reflex○ Do not argue for change, approach decisions with

curiosity

● Empower your patient with hope and optimism○ Positive spin as much as possible ○ Outcomes are better when patients take an active

interest in their care

Sympathy vs. Empathy

Motivational Interviewing Is Not...

● manipulation● trickery● convincing a patient they need to change● an argument style

---> you do not “MI” them

NOT

A Dance

Wresting

Example

Setting the Stage for MI

● Ambivalence

● Change talk

Setting the Stage:Ambivalence

Patients are often aware of the changes to make, but are often more content with the status quo

"But"

- a telltale sign of ambivalence!!

Ambivalence is fertile ground for use of motivational interviewing

Setting the Stage:Change Talk

● Change talk is language that hints at or indicates a change in target behavior

○ “I wish I could lose weight”○ “I need to get off by butt”○ “I know what I need to do, I just need to do it”○ “I would love to know what it is like to not have pain”

● Conversations are full of change talk, it is your job to recognize it and reflect it back, “keeping it on the surface of the conversation”

Setting the stage:Change Talk

● Different words indicate different levels of intention for change, for example

○ "I wish"○ "...if I can"○ "I would like to"○ "I am sure I will"

● Kinds of change talk - "DARN CAT" words○ Desire - "want","wish", "like"○ Ability - "can", "could", "able", "capable"○ Reasons ○ Need - "must", "got", "need", "should"○ Commitment - “I will”, “I promise”○ Activation - “I plan to..” ○ Taking steps - “I started to…”

Setting the stage:Sustain Talk

● Language which indicates a continuation of the target behavior

○ “there is no way I can lose weight..it is hopeless”○ “this will never work”○ “I have done this all my life, why stop now”○ “This isn’t going to hurt me, I see no reason to stop”

Activity - change or sustain talk

- Clap for change talk

- Snap for sustain talk

- ooo for discordinance, something in between

Stages of Change:Transtheoretical Model

● precontemplation● contemplation● preparation● action● maintenance● relapse

Different techniques and strategies may be used depending on which stage a client is in

Application of MI in Stages of Change

● precontemplation - explore motivations/desire, come alongside and empathize, hints at change and test reaction, most useful stage for MI

● contemplation - develop and build reasons / need for change

● preparation - develop commitment, some activation● action - education, plan for relapse/failure, reflect

consequences of change● maintenance - continue to reflect how change has

made impact, plan for relapse/failure, least useful stage for MI

● relapse - emphasize past success, how it felt to change, similar to contemplation

The Processes of MI

Planning

Engaging

Evoking

Focusing

The Processes of MI: Engaging

Engaging

● establish rapport ● in gold standard MI, 20% of your time● in PT setting with average patient, maybe 30-50%● common skills

● reflection (simple, coming alongside)● stage of change - precontemplation, contemplation

The Processes of MI: Focusing

Focusing

● establishing targeted behavior, deciding on what to talk about/work on

● common skills● agenda setting● asking permission to talk about a topic and how it

relates to their chief PT complaint● stage of change: pre-contemplation, contemplation,

replapse

Evoking

● recognizing and cultivating change talk● the true HEART of MI● the hardest process● the process you will come out of today least

experienced with● common skills: ALL of them● stage of change: contemplation, preparation, action

The Processes of MI: Evoking

The Processes of MI

Planning

● develop goals● develop support plan● build confidence● the heart of PT, the easy part!● don’t jump too soon!● common skills: E-P-E● stage of change: preparation, action, maintenance

Core Techniques:“How” of MI

- O - open ended questioning- A - affirmations- R - reflections- S - summary

Our focus today:

- asking- listening- informing

Example video: engaging and focusing

Asking

Open Ended questions

● encourage patient dialogue● one technique which allows the patient to dictate the

session

● shows your curiosity and engagement, feels less rote, cold and informal

● Stems: What , How, Tell me, Describe● Don't stop the process by throwing a closed follow-up!

Asking

Write a question intending to assess the role of stress in your patient’s condition

Examples: stress and pain

Open

● Tell me about the stress in your life?

● Tell me about a time when your stress affected your body and not just your mind.

● Describe your day-to-day stress and how it interacts with your condition

Closed

● Do you think there is a connection between stress and your pain?

● Tell me about the stress in your life, is it connected to your pain?

● Is your pain worse when you are having a bad day at work?

Examples: stress and pain

Cautions with Open-Ended Questioning

● don’t “close off” open ended questions● Not every question that starts with the stems

recommended is a good question: “How is your home exercise program going?”

● → “tell me about your home exercise program”● quite often a closed ended question is appropriate,

especially when looking for accurate information to clarify

Key questions - Evoking Questions

● “What do you hope our work together will accomplish” (desire)

● “What ideas do you have for how you could____?” (ability)● "What would be the first step for you?" (ability)● “What is the downside of how things are now” (reason)”● “What are the best 2 or 3 reasons for making this change”● “How serious or urgent does this feel to you?” ● "What do you think you will do?" (commitment)

THESE TYPES OF QUESTIONS HELP BRING OUT THE CHANGE TALK!

Activity

- handouts- converting closed questions- questions after statements

Techniques in Asking

● Using a "ruler" or “scaling” related to importance, readiness, etc..

● Agenda setting

Techniques in Asking Building Confidence (cont’d)

● Scaling rulers (often rate readiness, ability/ confidence)0-5 How ready are you to make the change? Tell me what helped you choose a 4 and not a 1?

6-9 How confident are you that you can do this?You chose a 5, what would help make it a 7?

● Evoking readiness● What’s different for you this time?

Techniques in Asking (cont)

● Pros and cons for both changing AND not changing behavior → pros pros list

● Using hypotheticals - for those with less readiness to change

● In this case, use/feed them "DARN" wordsDesire - "want","wish", "like"

Ability - "can", "could", "able", "capable"

Reasons

Need - "must", "got", "need", "should"

Example - If you could find a way to stop smoking, what would your life look like?

Another example video

Listening

Reflective listening

Summarizing

Reflective Listening - What Is It?

Accurately understanding your patient

1)Hear what they are saying

2)Make a guess about the underlying meaning/emotion (its okay if you are wrong...they will clarify for you!)

3)Choose your direction (what is worth probing?)

4)Make your reflection as a statement

Example video - reflective listening

ReflectionsListen more than you talk

Inflect down for a statement NOT up talk-question

Reflect as much as you ask questions

Simple vs ComplexBut wait...I sound like an annoying parrot,how is this going to work?

Simple reflections = empathy (perspective) and rapport building

Complex reflections = support patient change/movement towards goal

Skillful Reflective Listening Looks Like:

● More listening than talking● Reflections are concise● Just as many (or more) reflections as questions ● Simple reflections - reinforce “being heard”● Complex reflections (advanced fidelity >50%)

● move the conversation forward● introduce, suggest, or reinforce change talk● infer deeper meaning● often followed by a pause

How do you choose what to reflect?

You hear:

Resistance - reflect resistance directly "I don't think these exercises are going to help"

Change talk - reflect with change talk "I feel so winded, this smoking is holding me back"

Ambivalence - reflect with reasons for change"I want to feel better, but I just can’t seem to get out of bed in the morning to exercise."

Let’s Try: How would you reflect? ● “I just don’t have time to exercise”

→ “Exercise takes too much time.”

● “I know I am overweight, I hear it all the time”→ “Hearing you are overweight isn’t news to you”

● “I'm just not getting around the way I used to”→ “Your health is holding you back.“

● “I have to do something about my smoking”→ “You are ready to make a change.”

More practice

- complex reflections practice (in handout)

- Virginia reel - on note card, write a statement you heard often or that sticks out from your memory in the context of a conversation about behavior change

- 2nd round - with clinical examples

Other listening techniques

● Silence ● gives words more meaning● offers time for reflection (both you and the patient)● allows space for more conversation● try 10 seconds of silence!

● Summarizing● synopsis of what you heard the patient say● allows another opportunity for correction of meaning

-->listening● allows for more natural transition to the next step in the

session

Example video: building reasons to change (2:16 - 4:38, 6:30- 7:45)

InformingTypes of information

● Assessment or screening results

● Recommendations or referral

● Evidence about the targeted behavior

● Observation or concern for the patient

Types of Informing

● "Chunk" "Check" "Chunk" - more typical in health care setting

● Elicit-Provide-Elicit (EPE) - motivational interviewing technique

Elicit-Provide-Elicit

Elicit-permission to share "Would it be okay if I shared with you...?" “Would it help to know more about…?”

Provide-objective information

Elicit-patient's thoughts

"What are your thoughts on this?"

Tips for Informing

● ask and listen more than inform

● slow down, don't rush

● positive messages matter

● offer choices

● talk about what others do

Informing Activity #1

Your patient is a 75 year old male with a complex history including diabetes. He has knee pain that through your exam seems consistent with DJD with some possibility of a meniscal tear. The patient has a younger friend that has had knee pain, and got great relief from a meniscal repair. He is quite reluctant to do PT as he feels he needs surgery (a meniscal repair) ASAP.

- summarize then inform your patient about some possible misconceptions

Informing Activity #2

Your patient presents with low back pain. Your examination reveals a very complex condition, with multiple contributing factors, including his smoking habit, as well as his poor body mechanics while performing their job.

- summarize then inform your patient on how you will both approach therapy and healing

Case example

● 60 year old female● presents for bilateral knee pain, back pain● BMI 50● inactive - sits in a chair most of the day● hints at change talk during initial evaluation● 3-4 reflections led to talk about diet change and

walking daily to help lose weight

Bringing it homeIn pairs role play as a therapist talking with a patient about a health behavior that plays a role in why you are seeing them in PT…..

Ideas : smoking, lack of exercise, seeking care for mental illness, non-compliance with home exercises, or use patient scenario (handout)

You are required to:

- reflect- summarize

but feel free to practice other elements such as open-ended questioning, affirmations, informing, etc….

Jim’s Perspective Using MI in PT Practice

● be curious about your patients about why they make the choices they make

● avoid the pitfall of assuming your patient is malingering, seeking secondary gain, or “mentally ill”

● listen actively, check in on your understanding often ● -->reflective listening● this CAN be used on all patients

● reserve your vast knowledge for the right time, the right place, suppress the verbal vomit

Jim’s Perspective Using MI in PT Practice (cont..)

● I don’t often use it in its “full form”, but….

● I treat with the spirit of MI at all times

● I believe my sessions are rich in empathy and partnership

● Deliberate MI is used in <5-10% of cases (this is an approximation) as the vast majority of patients have motivation to change, as that is what brought them to PT in the first place

When do I use MI?

When you find yourself arguing for/forcing change

When you feel frustrated by lack of results

When you feel like YOU are putting all the effort in

STOPAsk yourself, can I try MI here?

Evidence for MI

● increasing change talk, decreasing resistance

● predicting lack of change with resistance

● MI in health care, including physical therapy

MI INCREASES CHANGE TALK

● Problem drinkers randomly assigned to MI (vs. confront/direct) showed 111% more change talk (Miller, Benefield & Tonigan, 1993)

● Psycholinguistic analysis of MI showed robust, atypical increases in change talk (Amrhein et al., 2003)

● Increased use of MI predicts change talk (Moyers and Martin)

MI DECREASES RESISTANCE

● Problem drinkers randomly assigned to confront/direct showed 78% more resistance than those in MI. (Miller, Benefield & Tonigan, 1993)

● Psycholinguistic analysis of MI showed robust decreases in commitment to drug use during MI (Amrhein et al., 2003)

● Decreased use of MI predicts resistance to change (Moyers and Martin)

CLIENT RESISTANCE PREDICTS LACK OF CHANGE

● Level of client resistance during counseling predicted absence of change in drinking (Miller, Benefield & Tonigan, 1993)

● Verbal commitment to drug use during MI predicted continued drug use (Amrhein et al., 2003)

● Resistance-poor outcome relationship replicated in several other studies

MI in Health Care

● Monthly nurse led MI sessions compared to usual care improved smoking cessation, BMI, blood pressure than compared with patients who received usual care in patients awaiting CABG (McHugh et al, 2001)

MI in Health Care (cont.)

● Motivational enhancement (version of MI) along with PT intervention improved exercise compliance, pain (not sig.), and lifting capacity (Vong et al, 2011)

MI in Health Care (cont)

● 12 weeks of traditional cardiac rehab along with 1 hour of motivational interviewing session per week with clinical psychologist significantly improved perceived stress, physical activity, and dietary fat intake as compared to cardiac rehabilitation with lectures and group discussion on heart disease (Scales, 1998)

MI in Health Care (cont.)

● systematic review of RCTs using MI showed combined effect estimates for body mass index, total blood cholesterol, systolic blood pressure, blood alcohol concentration and standard ethanol content (Rubak et al, 2005)

MI in RA

● compared to a group who received an educational session only, a group of patients with rheumatoid arthritis who did not meet minimal physical activity requirements who received the educational session as well as a session with a PT who used motivational interviewing techniques, and 2 f/u sessions with a nurse on self-regulation improved significantly at 6 mo f/u in terms of time in physical activity (Knittle et al, 2015)

MI in diabetes

● systematic review of MI to improve diet behavior in diabetics showed at least short term improvements (Ekong, et al 2016)

Flaws of MI studies

● fidelity to MI● few studies measure fidelity● few studies match true MI process, often done in very

short sessions/ few contacts● few studies have adequate control group with equal

“face to face time”

Converting Closed Questions Create open ended questions for commonly asked closed questions from a PT setting:

How is your home exercise program going?

1.

How is your day going?

1. 2.

How does that feel?

1. Do you have any questions?

1. Are you married?

1. 2.

Do you perform regular physical activity?

1. 2.

Please write 2-3 other open ended “starter” questions that would be useful for first encounters:

1. 2.

Questions after statements Formulate an open ended question in response to the following statements. Try your best to make the questions relevant to the content of the statement as a whole instead of specific components of the statement. I have had 4 treatments so far, and it is really hard for me to get here. I don’t understand how this is going to help me. I have tried PT before, and it didn’t work for me.

1. 2.

I am sick and tired of this. I am tired of being in pain, I would love to have a day without pain. The doctors don’t know what is wrong with me. I think I need a whole body MRI.

1. 2.

I had a hard time getting my exercises in. I just can’t seem to fit them into my busy day. I come home and have to make dinner and take care of the kids, put them to bed then I just want to lie down in bed and crash.

1. 2.

I did my exercises seven times a day, and my back pain was much worse. I figured more was better, I really want to get better by next weekend before my trip to Florida.

1. 2.

I don’t need to exercise. I work on my feet all day at the factory, that is exercise enough for anyone. If people were to do my job, they would be exhausted.

1. 2.

The MRI shows I have disc degeneration in my low back. If it is there, I am sure it has set into my shoulders as well, not to mention my neck and elbow. I am just like my Mom.

1. 2.

Agenda

Complex Reflections: Types Type

Strategy Statement Reflection Example

Reframe Suggest a new way of looking at something that is more consistent with behavior change

“I’ve done my exercises every night this week and I don’t notice any differences.”

“You are determined to heal yourself.”

Amplification Offer an exaggerated form of what the person said to allow them to look at the other side of ambivalence. Note: Empathy, not sarcasm ☺

“I am really busy and just don’t have time to exercise.”

“Exercise isn’t important in your life”

Double-sided Capture both sides of ambivalence. Note: connect with “and” not “but” & finish with change talk

“I want my knee to get better, so I’m in PT but I think sometimes it’s not worth the trouble….I am just getting old.”

“You are frustrated AND you want to feel better.”

Affective Reflect feeling – either stated or implied.

“The pain is too much to bear sometimes.”

“You feel weighed down.”

Metaphor Use descriptive language that paints a picture for the other person.

“I’ve tried contacting my doctor and my insurance company, but I can’t get anyone to call me back.”

“You feel like you are spinning your wheels, but you aren’t getting anywhere.”

Emphasizing Choice

Point out individual choice and control.

“I don’t think this is going to help. I think there may be better options”

“You want to choose a different path in your healing.”

Coming Alongside

Take up the argument for no change to allow the other person to take up the argument for change

“I have the patch on, but every morning I wake up and light a cigarette. It’s just no use.”

“Quitting smoking isn’t working for you right now”

Continuing the Paragraph

Venture the next sentence in the person’s paragraph, instead of merely echoing the last one.

“I’m at a crossroads and I need to make a decision about my health.”

“And you need more information to figure out your next step.”

MI guides and tools: Croyle & Saunders (Adapted by A. Shannon 2014)

Complex Reflections Practice

Work as a group to develop a complex reflection based the following statements for each category listed. I am convinced I have chronic traumatic encephalopathy, just like those NFL players, but there is nothing I can do about it now. The past is the past. Continuing the paragraph: Reframe: Affective: Metaphor: I think I am going to have to just live with this. It has been two months, and not much has changed. Paraphrase: Amplified: Double-sided: Affective: I am not sure I have control over my diabetes. My father and mother had it, and my brother does to. When it is genetic, there really is no use in working to control your sugars. Emphasizing choice: Amplified: Coming alongside: Double-sided:

My doctors think this is all in my head. There is no way I can go back to work. I can’t do that job, but my doctors don’t seem to care. Affective: Amplified: Double-sided: Coming alongside: I am beginning to wonder about the fall I took. I am a strong person, but that fall really shook me up mentally. Paraphrase: Reframe: Continuing the paragraph: Affective: I don’t need to use my walker. I only fell twice, and it just holds me back. It makes me look old. Emphasizing choice: Amplified: Metaphor: Coming alongside:

 

 

 

 

 

Complex vs. Simple Reflections Your patient presents to you with both chronic knee and hip pain, presumably related to 

osteoarthritis. Her other current medical problems include diabetes, hypertension, as well as 

anxiety and depression. She is a generally sedentary individual, and admits to poor dietary 

habits, including having a lot of candy in her household which, according to her husband, she 

eats quite a bit of. She also admits not liking exercise in any way. She states that it makes her 

pain worse, and doesn’t understand why you would do anything that makes your pain worse. 

She is also not monitoring her blood sugar. Her husband is also in clinic with her today, and is 

especially worried about his wife’s health. In fact, he comes across as hostile, and quite 

demeaning of his wife and her habits. You sense conflict between them, and perhaps conflict 

directed from the patient and her husband directed at you. He says to you during the session 

“don’t you think losing 40 lbs would help?”  

 

How would you reflect the following statements from the patient? 

1. “I don’t think there is anything you can do for me.” 

 

● Simple reflection:  

 

● Complex reflection: 

 

2. “Every time I exercise, my knee pain gets worse. How does that help?” 

 

● Simple reflection:  

 

● Complex reflection: 

 

3. “How does my diabetes have anything to do with this?” 

 

● Simple reflection:  

 

● Complex reflection: 

 

4. “I used to monitor my blood sugar, but the numbers didn’t mean anything” 

 

● Simple reflection:  

 

● Complex reflection: 

 

5. “I don’t eat that much candy. Besides, I don’t eat a lot of other foods that are 

bad for me, like fried foods” 

 

● Simple reflection:  

 

● Complex reflection:

 

Affirmations practice  Scenario: You have been working for a couple months with Debra, a 57 year-old woman, who struggles with knee-pain from osteoarthritis aggravated by being overweight (60 lb.) and her diabetes. Before starting PT she had not been monitoring her diabetes well. Since you mentioned that all three conditions are linked she has been monitoring her blood sugar daily and has made an appointment with her primary care physician. She has only lost 5 lbs. and is really disappointed at her lack of progress. Strengths: Affirmation: Scenario: Juan is a 38-year-old cheese factory worker seeing you for a work-related torn rotator cuff. His healing has been limited. He has mentioned difficulty adhering to his HEP. He has a busy life with lots of family responsibilities. He has two young kids, a wife and lives with his parents. His employer has not been supportive of the time off he needed to heal or to attend his PT appointments. He has made all of his appointments. He tells you he has been doing 2 of the 4 exercises you gave him since your last appointment. Strengths: Affirmation: Scenario: Helen is a 45-year-old coming to PT for low back pain. She has suffered with back pain for 20 years. She has low affect, low self-esteem, and many other symptoms of depression. In one treatment you mentioned that many things can affect healing and pain regulation including depression and anxiety. She didn’t respond. This week she came in and said she thinks maybe she is depressed, but she isn’t sure what to do about it. She asks if you know of someone she can talk to about it. Strengths: Affirmation:

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Rollnick, S., Miller, W.R., Butler, C.C. (2008). Motivational interviewing in health care: helping patients change behavior. Guilford Press.

Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. Guilford Press.