motivational interviewing – how to enhance lifestyle changes in general practice professor eivind...

Motivational Interviewing – How to enhance lifestyle changes in

General Practice

Professor Eivind Meland and

Associate Professor Thomas Mildestvedt

Section for General Practice

Department of Public Health and

Primary Health Care

University of Bergen

The Krokeide Centre Heart Rehabilitation Study

Objectives of the study

1.Compare an individualised, autonomy supportive and cognitive behavioural intervention (elements from MI) with “business as usual” in a RCT

2.Identify predictors of lifestyle changes during two years follow up.

Main results from the study

• No significant between group differences neither in short nor longterm follow up

• Elements from MI (self-efficacy and autonomous motivation) seem important especially for longterm maintenance of health behaviour change

NEJM 2007 Schroeder

Listen to Julian Tudor Heart!• Julian T Heart: The social inequalities and the

undue social selectiveness of the fitness-movement are strong arguments to support proactive care in clinical practice (1990)

• Eivind Meland: The radical position from the seventies with solidarity with the oppressed and socially less well off groups has been replaced by liberal indifference. This indifference is camouflaged as autonomy support and anti-medicalisation efforts. Solidarity in our societies is under threat. We have to restore it! (2009)

Listen to …

• Roll up your sleeves! We have to–Increase preventive and health

promotive efforts in our practices

–Apply more effective counselling methods in clinical practice, such as motivational interviewing

Reactions from the audience

• We are not interested in the contra-arguments!

• How did you react?

• Why did you react?

• In what way could the experience promote changes in your preventive efforts?

• In what way did the experience prevent changes?

Motivational interviewing (MI)

• Origins in addictions field

• Importance of interaction between clinicians and patients– Confrontation can lead to resistance

• Inappropriate assumptions about change – Client must/wants change and change must

happen now

Motivational interviewing (2)

• Patient centred approach

• Motivation –readiness for change

• Directive - help patients explore and resolve their ambivalence

Stages of change

Motivational interviewing (3)• Five key principles

– Express empathy– Develop discrepancy– Avoid argumentation– Roll with resistance– Support self-efficacy

Miller & Rollnick, 1991

MI in healthcare settings

• MI applied to:– different lifestyle behaviours– different patient populations

Discussion in groups of 3

• How do you feel about increasing your efforts for preventive health promoting in your practice?

• Explore ambivalence

Promoting lifestyle changes

• Changing a lifestyle is often a long process

• The counsellor can facilitate steps towards maintained change

• Ambivalence is normal

Exercise in triads:

• Counsellor, ”client” and observer

• Decide who is who

Readiness exercise

• Think of an area of life not to personal that you would like to change but you have ambivalent feelings about

• Share this with your neighbour

• The listeners task is to understand the dilemma without giving any advice

The observers’ tasks

• Note how much the client is verbally active

• Note ”change talk” from the client– Statements about intentions for, preparation

for or accomplishment of changes

• Note the ”precursors” of change talk– Verbal or non-verbal behaviour from the

counsellor prior to change talk

Readiness exerciseOptional MI questions

• Why would you make this change? what are the best reasons to change?

• How could you succeed?

• What do you think you will do? (If appropriate)

Video demonstration of promoting readiness

• Cholesterol and hypertension in a clinical setting

Tensions and conflicts

• Is the era of patient centredness over?

• Patient centredness confused with servility under consumers in a health marked?

• Time for introducing doctoring as leadership and professional authority (not confuse it with paternalistic and authoritary medicine)?

The tension between advice and exploration of the pts’ agenda

Advice

Explore

Authoritary and paternalistic medicine

Indifference or ignorance Consumer servility or ”soft manipulation”

Professional authority and mutual respect in the consultation