“un-helpful” responses introduction to motivational …faculty.washington.edu/pmatsuda/rehab 503...
Post on 19-Jun-2020
0 Views
Preview:
TRANSCRIPT
1
Introduction toMotivational Interviewing
Charles H. Bombardier, Ph.D.
Department of Rehabilitation Medicine
University of Washington School of Medicine
chb@u.washington.edu
Bombardier 3-06
“Un-Helpful” Responses
What are some the things we automatically want to say to patients in response to statements like these?
1. “I don’t think these exercises are going to help me.”
2. “I’m only here because my daughter (or doctor) wants me to.”
3. “I don’t have time to exercise at home.”
4. “I’m too tired/sore to exercise today.”
5. “I’m afraid I’ll get hurt if I do those exercises.”
6. “I have already tried that kind of exercise and it did not work.”
Bombardier 3-06
“Taste” of Motivational Interviewing
� Taste not training
� Reasons to consider MI
� Stages of Change/Readiness to change
� Empirical and theoretical basis for MI
� Model motivational interviewing strategies
� Practice selected motivational interviewing strategies
Bombardier 3-06
Ground Rules and Expectations
� There’s no magic bullet
� I am not here to change your overall style or
approach to patient care
� Some strategies may fit
your style, others may not
� Take what you can use and leave the rest
Bombardier 3-06
Give it to me straight doc.
How long do I have to ignore your advice?
Bombardier 3-06
Pros and Cons of Using MI
� You already may be quite skilled at motivating
people to change. What are some strengths or skills you already have in this area?
� What concerns do you have about learning different skills?
� What do you think might be some of the potential benefits of trying other approaches to motivating patients?
2
Bombardier 3-06
Contrasting Therapeutic Styles
MI Style
� Patient-oriented
� Collaborative
� Focus on motivation
� Explore ambivalence
� Elicit reasons to change
� Elicit concerns
� Clinician listens more
Traditional Fixer Style
� Goal-oriented
� Expert role
� Focus on action
� Direct persuasion
� Give reasons to change
� Give warnings
� Clinician talks more
Bombardier 3-06
Persuasion Exercise
� Pair up with a person next to you� Think about a health behavior that you have thought
about changing that you feel comfortable talking about� One person is the HCP; one is the patient� The patient tells the HCP about the health behavior
they have thought about changing� The HCP adopts a traditional “fixer” role: give them
reasons to change, give advice about how to change, warn them about what will happen if they don’t change and generally try to persuade the person to make this change now.
� You have three minutes…Go!� Switch!
Bombardier 3-06
Persuasion Exercise: Debrief
� What was it like playing the HCP?
� What did you observe regarding willingness or
resistance to change?
� What was it like being the patient?
� At the beginning, how much, if at all did you want to change?
� What aspects of the interaction made you more or less motivated to change?
� Anyone experience the “righting reflex”?
Bombardier 3-06
What is Motivational Interviewing?
Motivational interviewing is a
client-centered, directive
method for enhancing intrinsic
motivation to change by
exploring and resolving
ambivalence
www.motivationalinterview.org
Bombardier 3-06
MI Acronym-OARS
� Open-ended questions
� Affirmations
� Reflections
� Summaries
Communicating is to MI
asStepping is to Dancing
3
WHY BOTHER LEARNING MOTIVATIONAL INTERVIEWING?
Bombardier 3-06
Bombardier 3-06
The Problem of Non-adherence
Simply giving patients advice to take medications or make lifestyle changes is often not effective.
Rates of Nonadherence
� Anti-hypertension drugs: 50%
� Physical therapy: 33%-66% Sluijs, 1993
� Home exercise program: 36% never do Forkan, 2006
� Antibiotics: 27% (qd), 48% (tid), 58% (qid)
� Rule of one-third(Meichenbaum & Turk, 1987)
Bombardier 3-06
Stages of Change Heuristic
� Precontemplation-not considering change; reluctant, resigned, resistant, unaware
� Contemplation-normal ambivalence about change, both pros and cons of change are present within the person
� Determination-getting ready to change
� Action-overt change begins
� Maintenance-sustaining change for >6 months
� Relapse-normal resumption of pre-change behavior (5-8 relapses are common)
Bombardier 3-06
Stages of Change for Selected Health Behaviors
19%14%34%7%Start Exercising*
35%4%8%52%Sunscreen Use
57%3%18%23%Low Fat Diet
15%18%53%14%Weight Control
37%20%27%15%Quit Smoking
MaintenActionContempPreConBehavior
*25% were in Determination
Bombardier 3-06
Determinants of Patient Adherence
Meichenbaum and Turk, 1987
Treatment
Symptoms
Organization
Patient
Relationship
4
Bombardier 3-06
Resistance is Interpersonal
Bombardier 3-06
Determinants of Resistance
� Personality differences play a minor
role in resistance/motivation
� Resistance/Motivation is interpersonal.
� Confrontation increases resistance and
predicts poor outcome one year later
� Empathic listening decreases resistance
� Reducing resistance is the health care professional’s responsibility
Motivational Interviewing is Theoretically Sound
Bombardier 3-06
Inhibitors of Change
� Patterson-therapist teaching and confronting
increase client resistant behaviors in therapy sessions.
� Therefore, we avoid confronting patients with information or giving unsolicited advice. We
ask for permission before giving advice. We reflect rather than confront resistive statements.
Bombardier 3-06
Facilitators of Change
� Rogers-Accurate empathy promotes change.
� Therefore, we use reflective listening to demonstrate understanding and acceptance of
the client’s subjective situation
Bombardier 3-06
Facilitators of Change
� Rokeach-Awareness of a discrepancy between
behavior and core values creates change
� Therefore, we elicit the person’s core values or
goals and then clarify how their behavior fits or does not fit with these important ideas.
5
Bombardier 3-06
Facilitators of Change
“People are generally better persuaded
by the reasons which they themselves
discovered, than by those which have come into the mind of others.”
Paschal’s Pensees (17th century)
Bombardier 3-06
Facilitators of Change� Bem/Self Perception Theory: As I hear myself talk, I
learn what I believe.
� Festinger/Cognitive Dissonance Theory: If I say it and no one has forced me to say, I must believe it.
� Therefore, we use reflections and open-ended questions to elicit from the person “change talk” i.e. reasons to change, intent to change, commitment to change……AND
� Avoid the reverse….eliciting resistive statements
Bombardier 3-06
Facilitators of Change
� Sanchez-Craig - Choice enhances adherence.
� Brehm/Theory of Reactance - Threats to freedom elicit resistance.
� Therefore, we try to give the client choices and
explicitly emphasize their autonomy and right to choose or even refuse.
Bombardier 3-06
Facilitators of Change
� Bandura/Self-efficacy Theory: Optimism and hope facilitate change.
� Therefore, we try to reinforce successive approximations to the goal. We affirm the
person, point out their successes, even small ones. We reframe “failures” as intermediate successes whenever possible.
Motivational Interviewing is Evidence-Based
Bombardier 3-06
Efficacy of MI: Randomized Controlled Trials
� Alcohol abuse� N=13; ES 0.26 (0.18-0.33)
� reduced drinking and re-injury (Gentilello et al., 1999)
� lower frequency and problems (Marlatt et al., 1998)
� fewer drinks and drinking days (Miller et al., 1993)
� less risky driving (Monti et al., 1999)
� Drug use� N=13; ES 0.29 (0.15, 0.43)
� Smoking cessation� N=14; ES 0.14 (0.09, 0.20)
Hettema, Steele, Miller Ann Rev Clin Psychol 2005
6
Bombardier 3-06
Efficacy of MI: Randomized Controlled Trials
� HIV risk reduction
� 5 studies ES 0.53 (0.24, 0.81)
� Diet and exercise
� N=4; ES 0.78 (0.41-1.16)
� increased physical activity (Harlan, 1999)
� better treatment adherence (Smith, 1997)
� Treatment compliance
� N=5; ES 0.72 (0.56, 0.89)
Hettema, Steele, Miller Ann Rev Clin Psychol 2005
Bombardier 3-06
Conclusions from Meta-analysis
� 72 clinical trials; average dose 2.24 hours
� Average short-term between group ES = 0.77; long term ES=0.30
� Effect sizes were larger with ethnic minorities and when treatment was not manual guided
� Trends toward larger more durable effects when MI was added at the outset of another
treatment program
Hettema, Steele, Miller Ann Rev Clin Psychol 2005
Bombardier 3-06
Interim Summary
� Nonadherence to medical advice is poor
� People are not always ready to change
� Resistance to change is the clinician’s responsibility
� Motivational interviewing has a strong theoretical and empirical basis
� A wide variety of clinicians can to learn MI to add to their communication skills
Bombardier 3-06
Listening for ReadinessCommitment = Green Light
� “Tell me what I need to do.”
� “I will do that.”
� “I am going to do that.”
� “I am committed to doing that.”
� On a scale of 0-10 readiness I am 8, 9 or 10
Bombardier 3-06
Listening for ReadinessAmbivalence = Yellow Light
� Ambivalence about changing
� Yes…..but,
� I’m not sure…
� Half-hearted commitment
� I’ll try to …
� I wish I could…
� Giving in
� If you say so…
Bombardier 3-06
Listening for ReadinessResistance = Red Light
Verbal
� Arguing
� Interrupting
� Denying
� Disagreeing
� Minimizing
� Pessimism
� Sidetracking(Miller & Rollnick, 1991)
Non-Verbal
� Poor eye contact
� Arms/legs crossed
� Turned away
� Volume
� Facial/body tension
� Clenched jaw/fists
� Slouched posture
7
Bombardier 3-06
Listening for Stage of Change
1. “I don’t think these exercises are going to help
me.”
2. “I’m only here because my daughter (or
doctor) wants me to.”
3. “I don’t have time to exercise at home.”
4. “I’m too tired/sore to exercise today.”
5. “I’m afraid I’ll get hurt if I do those exercises.”
6. I have already tried that kind of exercise and it
did not work.
Bombardier 3-06
Open Questions
� Open questions are ones that cannot be
answered with a “yes’ or “no”
� Open questions gets the client talking,
hopefully about change
� Using open questions you can demonstrate
empathy and acceptance, elicit “change talk”, develop discrepancy, etc.
Bombardier 3-06
Practice Open-ended Questions
� Look at practice sheet (next slide)
� Try to come up with more than one open ended question that would help get the conversation going in a positive direction.
� Initial goals might be to communicate:� Acceptance
� Non-judgmental attitude
� Not going to control them
� Elicit values
� Maybe “Good things, not so good things”
Bombardier 3-06
Practice Open Ended Questions
1. “I don’t think these exercises are going to help me.”
2. “I’m only here because my daughter (or doctor) wants me to.”
3. “I don’t have time to exercise at home.”
4. “I’m too tired/sore to exercise today.”
5. “I’m afraid I’ll get hurt if I do those exercises.”
6. “I have already tried that kind of exercise and it did not work.”
Bombardier 3-06
Tips on Reflective Listening
� Guess at what they mean.
� Make a statement not a question. With questions inflection goes up at the end. With statements, inflection stays down at the end.� “So, you think…”
� “Your are wondering if…”
� “It sounds like …”
� Repeat an element (short summary)
� Paraphrase with synonyms
� Reflect a feeling
Bombardier 3-06
Reflective Listening
� Demonstrates your understanding
� Demonstrates empathy, acceptance
� Mirrors back to the person elements of what they are saying that they may not be aware of
� Facilitates their self-understanding, insight
� Decreases resistance
8
Bombardier 3-06
Simple Reflections-Batting Practice
� I will throw out some statements
� Attempt to simply reflect the content of the statement
� Don’t worry about not being perfect, just try to get some “wood” on the ball.
� Next, let’s attempt to reflect the feeling behind the statement.
Bombardier 3-06
Practice Reflections
1. “I don’t think these exercises are going to help me.”
2. “I’m only here because my daughter (or doctor) wants me to.”
3. “I don’t have time to exercise at home.”
4. “I’m too tired/sore to exercise today.”
5. “I’m afraid I’ll get hurt if I do those exercises.”
6. “I have already tried that kind of exercise and it did not work.”
Bombardier 3-06
Types of Reflective Listening
� Simple reflection – demonstrate empathy, highlight change talk
� “Exercise does not seem that useful to you.”
� Double-sided reflections - used to reflect both
sides of ambivalence toward change
� “Your doctor wants you to exercise but you are not interested.”
� Amplified reflections - often used to reflect resistive statements
� “You think exercise would be a waste of your time.”
Bombardier 3-06
Practice Reflections II
1. “I don’t think these exercises are going to help me.”
2. “I’m only here because my daughter (or doctor) wants me to.”
3. “I don’t have time to exercise at home.”
4. “I’m too tired/sore to exercise today.”
5. “I’m afraid I’ll get hurt if I do those exercises.”
6. “I have already tried that kind of exercise and it did not work.”
Bombardier 3-06
Affirming
� Elicit their strengths and successes
� Reinforce some strength or small success
� If they attained part of a goal, focus on what part they accomplished not the part left undone
� Reframe failure as a partial success or something they can learn from
� Set goals that have a high likelihood of success
� Try affirming Helpful Responses statements
Bombardier 3-06
Find Something to Affirm
1. “I don’t think these exercises are going to help me.”
2. “I’m only here because my daughter (or doctor) wants me to.”
3. “I don’t have time to exercise at home.”
4. “I’m too tired/sore to exercise today.”
5. “I’m afraid I’ll get hurt if I do those exercises.”
6. “I have already tried that kind of exercise and it did not work.”
9
Bombardier 3-06
Values and Goals
� What keeps you going through all this?
� What keeps you motivated?
� When you think of your whole life, what matters most to you?
� Or use values checklist
� And…where do all these exercises fit in with
that?
Bombardier 3-06
Values Checklist
� Good parent
� Good spouse/partner
� Competent
� Healthy
� Attractive
� Energetic
� Responsible
� Youthful
� Athletic
� Spiritual
� Considerate
� Disciplined
� Respected at work
� Efficient
� Independent
� Good role model
� In control
� Strong
� Popular
� Faithful
� Other ______________
Bombardier 3-06
Eliciting Change Talk - Content
DARN
� Desire to change
� Ability to change
� Reasons to change
� Need to change
Commitment to Change
� “I will do that”
� “I intend to ..”
� “I am going to…”
Bombardier 3-06
Predictors of Behavior Change
Desire Ability Reasons Need
Commitment Language
Behavior Change
Amrhein, Miller, Yahane JCCP, 2003
Bombardier 3-06
Eliciting Change Talk
� Disadvantages of the status quo-What
concerns do you have about these exercises?
� Advantages of change-How do you think
exercising might help people?
� Optimism about change-What makes you think
you could exercise if you wanted to?
� Intention to change-What exercises would you
be willing to try?
Bombardier 3-06
Eliciting Change Talk
� Pair up with a person next to you
� One person is the HCP; one is the patient
� The patient tells the HCP about a health behavior they have thought about changing.
� The HCP asks the open-ended question: “What are some of the reasons you have been thinking about making this change?”
� The HCP only listens (wait, nod, “tell me more”). Your job is to let them identify as many reasons to change as they can.
� No advice giving or feedback or analysis is permitted
� You have three minutes…Go!
� Switch!
10
Bombardier 3-06
Debrief
� What did you notice in the HCP role?
� What did you notice in the patient role?
� Compare/contrast your experiences to the persuasion exercise we did before.
� What were some of the similarities and
differences between the two approaches to motivating the patient?
Bombardier 3-06
Summarize
� Collecting summary-reinforces (elements of) what has been said, lets them know you are following� Reflect, reflect, what else? Summarize
� Linking summary-ties together what the person has just said with earlier material, usually to help them reflect upon ambivalence� On one hand you feel x, y, z and on the other hand
you also feel a, b, c.
� Transitional summary-wrap up the end of a session or move on to another topic
Bombardier 3-06
Rolling with resistance
Six strategies:
1. Simple reflection
2. Amplified reflection
3. Double-sided reflection
4. Shifting focus
5. Emphasize personal control.
6. Reframing
7. Giving choices
Bombardier 3-06
Ways to Roll With Resistance
“I don’t think exercising is the answer to my weight problem.”
� Simple reflection: “You don’t think exercising is all that useful.”
� Amplified reflection: “You think exercising is a waste of time.”
� Double-sided reflection: “Your doctors are worried that your weakness and deconditioning contribute to your weight being up, yet you are convinced exercising really will not help.”
Bombardier 3-06
Ways to Roll With Resistance
“I don’t think exercising is the answer to my weight problem.”
Shifting focus:
“I’m not sure what is the most important thing you can do to reduce your weight. Exercising may not have the biggest payoff.”
Emphasize personal control:
“You may be right. You may decide it is more important to change something else. That decision is up to you.”
Reframing
“I can see how, after all the hassles you have had over trying to exercise, you may just want to ignore that part of your health.”
Bombardier 3-06
Practice Rolling With Resistance
1. “I don’t think these exercises are going to help
me.”
2. “I’m only here because my daughter (or
doctor) wants me to.”
3. “I don’t have time to exercise at home.”
4. “I’m too tired/sore to exercise today.”
5. “I’m afraid I’ll get hurt if I do those exercises.”
6. “I have already tried that kind of exercise and
it did not work.”
11
Bombardier 3-06
Good things, less good things
� Ask about the good things about the “bad” behavior first� Why?
� Reflect, reflect, summarize
� Ask about the not so good things about the “bad” behavior� Reflect, reflect, summarize
� Summarize both sides
� Ask key question: Where does this leave you now
Bombardier 3-06
Giving Advice: Elicit-Provide-Elicit
� Elicit what they already know and think
� Provide information
� Ask for permission to give information
� Use neutral, non-personal language
� “What other people in your situation have done …”
� Be a little reluctant “You’re the expert about your life, but if you want I’ll offer some ideas.”
� Offer at least two potential options
� Elicit their reaction “Now I wonder what you
make of all this?”
Bombardier 3-06
Importance and Confidence
Confidence
Imp
ort
ance
Readiness
Bombardier 3-06
Brief MI: Importance
� How important is it right now for you to …? On
a scale from 0 to 10 what number would you give yourself?
� Why are you at X and not at 1?
� What would need to happen for you to get from
X to (slightly higher number)?Rollnick, 1999
Bombardier 3-06
Brief MI: Confidence
� If you decided to change, how confident are
you that you would succeed? On a scale from 0 to 10 what number would you give yourself?
� Why are you at X and not at 1?
� What would need to happen for you to get from
X to (slightly higher number)?Rollnick, 1999
Bombardier 3-06
Five Phases in MI Consultation
1. Create psychological safety zone the client
needs to be honest and accept help
2. Neutral exploration to create common
understanding of the potential change, mostly from the patient’s perspective
3. Expanding understanding of potential change; planting seeds, exploring alternatives
4. Building motivation--envisioning change, eliciting change talk, narrowing the focus
5. Eliciting decisions and commitment; negotiating a realistic change plan
12
Bombardier 3-06
Giving Advice: Elicit-Provide-Elicit
� Elicit what they already know and think
� Provide information
� Ask for permission to give information
� Use neutral, non-personal language---“What other people in your situation have done …”
� Be a little reluctant “You’re the expert about your life, but if you want I’ll offer some ideas.”
� Offer at least two potential options
� Elicit their reaction “Now I wonder what you make of all this?”
Bombardier 3-06
Good things, less good things
� Ask about the good things about the “bad”
behavior first
� Why?
� Reflect, reflect, summarize
� Ask about the not so good things about the “bad” behavior
� Reflect, reflect, summarize
� Summarize both sides
� Ask key question: Where does this leave you?
Bombardier 3-06
Menu of Options Strategy-Choice
Improved
nutrition
Pressure reliefs Other?
Skin checks
In people with pressure ulcers we can work on different things to
promote healing or prevent recurrence. Which of these seems
most relevant to you?
Seating Surfaces
Transfer
training
Bombardier 3-06
Predictors of Behavior Change
Desire Ability Reasons Need
Commitment Language
Behavior Change
Amrhein, Miller, Yahane JCCP, 2003
Bombardier 3-06
Process of MI
Open-ended questions-Elicit change talk:
• Desire, Ability, Reasons, Need
• Good things, not so good things…
• Decisional balance exercise
• Importance-Confidence exercise
• Values/Discrepancy
Reflections and
Affirmations
Summaries
Key Question
Negotiate
Change Plan
Empathy, Autonomy, Collaboration, Self-EfficacyBombardier 3-06
Ultra-Brief Personal Action Planning
� (Based on what we have talked about) Is there anything you would like to do for your [health] over the next few days (weeks) before I see you again?
� Elicit what, where, when, how often & commitment
� That sounds like a great plan. How confident are you that you will carry out the plan on 0-10 scale?
� If < 7/10 suggest they modify the plan to get to a higher confidence level
� Great, let’s make a date for our next appointment so we can check on how you are doing with the plan.
From Steve Cole, MD
13
Bombardier 3-06
Goal vs. Implementation Intentions
� Goal intention: I intend to do [behavior]
� Implementation intention: I intent do to [behavior when, where, how]
� Good: Get commitment to a goal e.g. exercise
� Better: Get commitment to an implementation plan e.g. On Mon, Wed, Fri will get up at 5:30AM, go to the gym where I am a member
and either run on the treadmill or do the elliptical trainer.
Gollwitzer & Sheeran, 2006Bombardier 3-06
Wrap-Up
� What, if anything, do you want to do to begin
integrating motivational interviewing tools into how you interact with patients?
� Listen for client readiness, resistance
� Notice what happens when I give unsolicited advice
� Try asking more open ended questions and notice what happens
� Try listening and reflecting more and see what happens
� Sign up for a two-day course on MI
Bombardier 3-06
Educational Resources
Bombardier 3-06
For more information...
� Miller W. & Rollnick, S. (1991, 2002)
Motivational Interviewing: Preparing People for Change. Guilford Press: New York.
� Rollnick, S., Miller, W. & Butler, C. (2008). Motivational Interviewing In Health Care. Guilford Press: New York.
� www.motivationalinterview.org
� Questions? chb@u.washington.edu
top related