using motivational interviewing techniques to help patients to change risky/problem behaviours linda...

Using Motivational Interviewing Techniques to

Help Patients to Change Risky/Problem Behaviours

Linda Carter Sobell, Ph.D., ABPPNova Southeastern University

sobelll@nova.eduwww.nova.edu/gsc

ObjectivesLearn how to construct a

conversation with patients to influence their receptiveness to consider changing problematicor risky behaviours while not evoking resistance using Motivational Interviewing techniques

Constructing a Conversation with Patients

• WHY USE MI TECHNIQUES? So patients feel comfortable discussing their risky problematic behaviours with you

• HOW DO YOU APPROACH THEM? • Present information in non

judgmental, neutral context about risks of continuing the behaviour vs. benefits of changing

• INTENT: Increase a patient’s commitment to consider changing

Motivational Interviewing New Interviewing Style

• FOR WHOM? Patients ambivalent about changing

• WHY? To build rapport • GOAL: Help patients explore and

resolve ambivalence about changing• HOW: In a manner likely to increase a

patient’s motivation to change• AIM: Elicit reasons for changing from

patients vs. confronting or telling them to change

Motivational Interviewing

Patient-centered, directive method for eliciting intrinsic motivation to change, by exploring and resolving a patient’s ambivalence to change using reflective listening

Focus ofMotivational Interviewing

• Patient’s concerns and beliefs• Explore ambivalence about

changing in manner that increases motivation to changing without invoking resistance

• MI gives patients sense of empowerment

Motivational Interviewing• Developed early 1980s• Bill Miller (US) and Steve

Rollnick (UK)• Initially for substance

abusers• Why did it develop?• High dropout, high relapse

rates, and poor outcomes

Motivational Interviewing: Common Currency

• Over past 20 years, MI has had wide application to variety behavioural domains and patient populations

• Today practitioners use MI with all types of patients and problems (e.g., dietary and medication compliance problems-- hypertension, asthma, insulin dependent diabetes to eating disorders to schizophrenia to flossing)

• > 150 clinical studies• Today MI “COMMON CURRENCY”

among Health Care Practitioners

New View of MotivationConceptualized As

• STATE of Readiness to Change• Can vary from situation to situation

• Dynamic, fluctuating and a modifiable state

• Importantly, can be influenced by Practitioner’s interaction style

EMPATHY KEY MI FEATURE

• WHY? High levels of empathy associated with positive patient outcomes

• Key to expressing empathy through Reflective Listening

• Listening in a reflective manner demonstrates an understanding of patients and validates their concerns “It sounds like you are ambivalent

about changing (insert behaviour)”

Focus: Eliciting Change Talk

• HOW: Arguments for changing elicited from patients

• You are (insert problem or concern), what will happen if you don’t change (insert behaviour) in (use time frame if you want)

• Example 1: “You’re 55 & seem to be having difficulty breathing. What will happen in 5 years if you continue to smoke.

• Example 2:“I sounds like you are not happy with having to take you insulin. What do you know about what might happen if you don’t take it regularly?

Tone of Motivational Interviewing

• Nonjudgmental, nonconfrontational, empathic, supportive climate where patients can discuss good and less good things related to changing (insert behaviour).

• Inquisitive Tone allows you to address discrepancies between what patients say and do without engendering defensiveness

• “Help me to understand on the one hand you’re coughing, having trouble breathing and on the other hand you say cigarettes are not causing you any problems.”

• RESPECTFUL APPROACH

Motivational InterviewingTwo Key Components

• STYLE: How you say it• CONTENT: What you say • Critical Components for

influencing receptiveness to consider changing

STYLE: How You Say It

Use an Empathic, Nonjudgmental, Nonconfrontational, Supportive Manner

CONTENT: What You Say

“Do you floss?” vs. “What are the good and less good things about flossing?”

“Why are you still smoking?” vs. “It sounds like you are ambivalent about quitting.”

MI and Non-MI Comparison Exercise

Short Role Play Exercise: Compare and contrast effectiveness of talking with a smoker about quitting smoking using two interviewing approaches: Non MI and MI

1st Role Play

90 seconds• Role Play #1: Divide into pairs; one

person is Health Care Provider (HCP) and one is Patient (PT)

• HCP: Read questions as they appear

• PT: Answer in any way• Then we will evaluate how it felt• DO NOT GO TO ROLE PLAY #2

Therapist/ Health Care Practitioner

Patient seeing you for a routine visit and you noticed that on the medical history form they indicated they currently smoke cigarettes

Patient• 25 years old and married• Smoked for 10 years • Smokes about 1 pack a day• Eventually plans to quit, but

currently not worried about smoking and it is not causing any problems

How Did It Feel?In One Word

Non-MI Scenario Patient HCP

2nd Role Play

90 seconds• Role Play #2: Keep same PT

& HCP roles as 1st role play• HCP: Again read questions

as they appear• PT: Answer in any way• Then we will evaluate how it

felt

How Did It Feel?In One Word

MI Scenario Patient TH/HCP

MI Views Health Care Practitioner and Patient’s Relationship as Collaborative

Recognize patients’ ambivalence; Give patients advice so they can make better informed decisions; but ultimately the patients are responsible for changing

Health Care Practitioner Patient

Simulated Patient Scenarios

• First 2 scenarios with same patient• 1st demonstrates non-MI interview

• 2nd demonstrates MI interview

• After viewing both compare & contrast 2 interview styles

NON MI SCENARIO

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MI SCENARIO

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•Which skit is more likely to result in the patient quitting smoking?•Why?

Workshop FocusKey MI Techniques

• ASKING PERMISSION to discuss target change behaviour or for providing information about it

• REFLECTING what patients say• NORMALIZING• Using DECISIONAL BALANCING• Using READINESS RULERS to

assess readiness to change• Patients GIVE VOICE to changing

Asking Permission• “Do you mind if we talk about your

(insert behaviour)” • Communicates respect for patients; more

likely to get them talking about quitting• “Tell me a bit about your alcohol use, any

quit attempts, how has it affected your health?”

• “Would you be interested in learning more about how how alcohol can affect your hypertension?”

VALUE OF ASKING PERMISSION

• Major MI technique with patients• Provides opportunity to discuss patient’s

behaviour when not presenting problem (e.g., coming for physical or blood pressure check) and you want to talk about how exercise, diet, smoking can affect their overall health

• Allows conversation to continue even if patient not thinking of changing

• Respectful

Motivational Interviewing Creates an Understanding of Why People Do What They Do

Often Difficult to Understand Why Patients Continue to Engage In Problematic/Risky Behaviours

• Practitioners mostly see negatives — death, health problems, divorces

• Rarely, do we SEE or TALK about good things about the behaviour from patient’s perspective

• MI recognizes that MOST behaviour has GOOD and LESS GOOD THINGS that maintain it

What Can be Done to Help Patients Consider Changing?

• Get patients to explore their emotional attachment to their behaviour — to look at the good things they get from it and then the less good things

• Remember they’re ambivalent!

Most People, Not Just Patients, Ambivalent About Changing

• AMBIVALENCE critical concept in MI• Working with ambivalence is working

with HEART of the problem• Ambivalence normal everyday

occurrence• How many of you have ever made

New Year’s Resolution?

AMBIVALENCE IS NOT

• Reluctance to do something• Heightened psychological

conflict about choosing between two courses of action

• Continue Behaviour vs. Changing Behaviour

• Ambivalence difficult to resolve each side has costs & benefits

Ambivalence is a Powerful Emotion!

From the movie “Girl Interrupted” Vanessa Redgrave (Psychiatrist):

“How do you feel about your behaviour….?”

Winona Ryder (Client): “Ambivalent”

Redgrave: “That’s a pretty powerful emotion, let’s explore that together.”

Decisional BalancingHelping Patients to Consider Changing

Decisional Balancing• Can discuss problem risky

behaviours without suggesting its a problem

• Asking about good things creates SAFE context to then talk about “less good things”

• Allows Practitioners to sound credible as they VALIDATE a patient’s behaviour (good things)

Asking About Good and Less Good Things About Smoking

• “Tell me some of the good things about insert behaviour.”

• “Tell me some of the less good or not so good things about insert behaviour.”

• “What will your life be like if you continue engaging in insert behaviour for the next 5 years?”

• “How would your life be different if you did change?”

VALUE OF DECISIONAL BALANCING

• Explores good things and less good things related to the problematic/risky behaviour

• Addresses patient’s ambivalence about changing

• Goal: Tip scale in favor of changing

READINESS RULERSAssessing Readiness to

CHANGE

Definitely NOT Ready Definitely Ready To Change To Change

Using Readiness Rulers

• On a scale from 1 to 10, where 1 is Definitely Not Ready to Change & 10 is Definitely Ready to Change, what # best reflects how READY you area at the PRESENT TIME to change? Patient says 5

•On this same scale, where were you 6 months ago? Patient says 2

•How did you go from 2 to 5 (# 6 mo-NOW)?•What would it take for you to change?•What would be best outcome if you

change?

VALUE OF USING READINESS RULERS

• Patients at different levels of readiness to change

• Assess patient’s readiness to change

• Helps Practitioners recognize and deal with a patient’s ambivalence

• Allows patients to give voice to changing: “Where are you now. Where were you 6 months ago.”

Motivational Interviewing Requires a Special Type of Listening of the Kind We Don’t Normally Do

REFLECTIVE LISTENING• Primary way of responding to patients• After patient speaks Practitioner

paraphrases the patient’s comments• “I get the sense that you are wanting

to change, but are concerned about gaining weight”

• “It seems there is a lot of pressure for you to change, but you are not sure you can do it because you have tried before. What have you tried before?”

REFLECTIVE LISTENINGMore Examples

• “What I hear you saying is that insert behaviour is not causing you any problems now. What might it take for you to change?”

• “So what I hear you saying is that you know that insert behaviour is not good for you, but you are not experiencing any serious consequences that you are aware of. What do you know about the long-term consequences of insert behaviour over the next 5 years?”

Normalizing• Communicates to patients that

difficulty in changing is not uncommon — others have had similar experiences

• “Many women report feeling like you, they want to quit for the health of their baby, but find it difficult.”

• “That is not unusual, many people report making several attempts.”

• “A lot of people are concerned about gaining weight when quitting.”

VALUE OF REFLECTIONS AND NORMALIZING

• REFLECTIONS validate what patients are feeling

• REFLECTING back what patients say indicates you understood what they said

• NORMALIZING communicates that difficulty changing is not uncommon

Key MI Strategy Advice Giving

• Often patients have little or misinformation about their behaviours

• Advice or information presented in neutral, nonjudgmental manner can help patients make better more informed decisions about changing

• Focus on positives if possible

Simple Advice “Being Told” vs. MI Advice Strategies

• Traditionally, Practitioners encourage changing using Simple Advice

• “If you don’t stop….. this will happen……health consequences”

• Research shows effectiveness of simple advice very limited — only 5% to 10% people likely to change

• WHY? Most people don’t like being “told what to do”

MI Alternatives to Simple Advice

• Offer relevant new information in neutral, nonjudgmental, sensitive manner

• Ask Permission: “Do you mind if we spend a few minutes talking about your insert behaviour?

• Ask: “What do you know about how behaviour affects your health?”……your unborn child?” ……your teeth and gums?”

Focus on Benefits of Quitting

VALUE OF PROVIDING INFORMATION TO PATIENTS

• Often patients have little or no information about changing

• Can help patients make better informed decisions about changing

• How information is presented can affect how it is received

• Examples: “What do you know about….?” “Are you interested in learning more about…..?”

Research Shows• Effective and empathetic

communication between Practitioners and patients leads to

• Greater patient satisfaction • Greater compliance with medication

and treatment and attendance• Reduced health care costs, and• Significantly improved clinical

outcomes• Decreased malpractice litigation

MI Scenario Skills To Be Demonstrated

• Asking permission to discuss risky or problematic behaviour(s)

• Reflecting what the patient said• Normalizing • Using Decisional Balancing• Using Readiness Ruler to assess

readiness to change• Asking patient to give voice to new

goals• Asking permission to provide

information

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Your Turn• You will now have the

opportunity to practice ALL the MI techniques you have seen today

• Break into pairs• Each person will practice a brief

negotiated interview using the MI Card and Readiness Ruler

What Stood Out Today?