“un-helpful” responses introduction to motivational …faculty.washington.edu/pmatsuda/rehab 503...

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Introduction toMotivational Interviewing

Charles H. Bombardier, Ph.D.

Department of Rehabilitation Medicine

University of Washington School of Medicine

[email protected]

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

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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

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Give it to me straight doc.

How long do I have to ignore your advice?

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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?

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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

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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!

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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”?

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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

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MI Acronym-OARS

� Open-ended questions

� Affirmations

� Reflections

� Summaries

Communicating is to MI

asStepping is to Dancing

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WHY BOTHER LEARNING MOTIVATIONAL INTERVIEWING?

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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)

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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)

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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

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Determinants of Patient Adherence

Meichenbaum and Turk, 1987

Treatment

Symptoms

Organization

Patient

Relationship

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Resistance is Interpersonal

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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

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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.

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Facilitators of Change

� Rogers-Accurate empathy promotes change.

� Therefore, we use reflective listening to demonstrate understanding and acceptance of

the client’s subjective situation

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� 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.

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“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)

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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

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� 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.

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� 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

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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

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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)


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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


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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

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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

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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…

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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

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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.”




6. I have already tried that kind of exercise and it

did not work.

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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.

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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”

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Practice Open Ended Questions







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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

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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

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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.

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Practice Reflections







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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.”

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Practice Reflections II







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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

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Find Something to Affirm







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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?

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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 ______________

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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…”

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Predictors of Behavior Change

Desire Ability Reasons Need

Commitment Language

Behavior Change

Amrhein, Miller, Yahane JCCP, 2003

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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?

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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!

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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?

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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

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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

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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.”

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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.”

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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.”




6. “I have already tried that kind of exercise and

it did not work.”

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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

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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?”

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Importance and Confidence

Confidence

Imp

ort

ance

Readiness

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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

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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

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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

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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?”

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Good things, less good things

� Ask about the good things about the “bad”

behavior first

� Why?


� Ask about the not so good things about the “bad” behavior


� Summarize both sides

� Ask key question: Where does this leave you?

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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

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Predictors of Behavior Change

Desire Ability Reasons Need

Commitment Language

Behavior Change

Amrhein, Miller, Yahane JCCP, 2003

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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

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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

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Educational Resources

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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? [email protected]

“un-helpful” responses introduction to motivational …faculty.washington.edu/pmatsuda/rehab 503...

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