improving treatment adherence and health behaviours through motivational interventions opportunistic...

Improving Treatment Adherence and Health Behaviours through Motivational Interventions Opportunistic Brief Interventions Jos Silveira B.Sc., M.D., FRCPC, Dip. ABAM Assistant Professor, Dept. of Psychiatry, UofT Medical Director, Mental Health and Addiction Program St. Josephs Health Centre, Toronto

Faculty/Presenter Disclosure Faculty: Dr. Jose Silveira Program: 51 st Annual Scientific Assembly Relationships with commercial interests: None 29 November 2013 10:30 - 12:00

Disclosure of Commercial Support This program has received financial support OCFP from in the form of Honoraria for presentation. This program has received in-kind support from none in the form of none. Potential for conflict(s) of interest: None 29 November 2013 10:30 - 12:00

Mitigating Potential Bias Not Applicable 29 November 2013 10:30 - 12:00

Content 1. Introduction 2. Critical Assumptions 3. What we automatically/routinely do 4. Background 5. How to do it 1. Brief Motivational Techniques 2. Listening for and Recognizing opportunities 29 November 2013 10:30 - 12:00

Introduction 29 November 2013 10:30 - 12:00

Scope of Session 29 November 2013 10:30 - 12:00 Interventions that foster the motivation to change Brief and Simple Build from what we already know Informed Consent Not Motivational Interviewing Requires formal course and coaching

Are You in the Correct Session 29 November 2013 10:30 - 12:00 By show of hands... In regards to improving treatment adherence and health promoting behaviours You want to be more effective? You want to feel more competent? You want to feel more confident? You want to be able to do it easily? You want to feel less frustrated in your efforts?

My Goal 29 November 2013 10:30 - 12:00 Make the task more enjoyable and less frustrating so that we dont lose you!

Why Focus on You Patients spend minutes in treatment. Providers spend years. Prochaska and DiClemente 1984 29 November 2013 10:30 - 12:00

Quotes from the field 29 November 2013 10:30 - 12:00 After 20 years of practice and trying to get patients to change behaviour, I dont care anymore. Sometimes i think to myself while seeing a patient, Why am I seeing you? this is a waste of my time. Patients dont seem to want to do something until its too late. Why should I bother with patients that just complain but dont want to do anything.

Group Exercise 29 November 2013 10:30 - 12:00 In pairs Share with one another Why you chose to attend this session? How your professional life would be easier or more satisfying if you felt more competent in helping patients improve treatment adherence or change behaviour?

Motivational Interventions Motivational Interventions is what we will be looking at This is not to be confused with motivational interviewing which is a skill which involves extensive training, practice and coaching. We will go through simple, easy to use techniques that foster a patients motivation to change 29 November 2013 10:30 - 12:00

Critical Assumptions 29 November 2013 10:30 - 12:00 These techniques are contingent upon several assumptions.

Critical Assumptions - Capable 29 November 2013 10:30 - 12:00 The patient is capable to consent to treatment Patient acknowledges the target problem Able to describe to you the risks and benefits in their own words The patient is able to make reasonable decisions

Critical Assumptions Informed 29 November 2013 10:30 - 12:00 Risks and benefits have been explained Using language that is clear and detailed Confirmed patient understands the risks and benefits Patient has explained their understanding to you or a delegate

Authority without Data... 29 November 2013 10:30 - 12:00...is Religion Stephen Hawking

Critical Assumptions - Voluntary 29 November 2013 10:30 - 12:00 The patient has voluntarily come to you requesting assistance or expressing concern about their health The target behaviour is not legally mandated (e.g., prohibition on alcohol use) The target behaviour is not exclusively the concern of others

Critical Assumptions - Language 29 November 2013 10:30 - 12:00 The patient is language concordant

Critical Assumptions - Delegates 29 November 2013 10:30 - 12:00 When you work with a delegate every provider working on the target behaviour is saying the same thing and using the same techniques Explicit information is the same E.g., Risks and benefits are not contradicted between providers No good cop, bad cop Using fear of adverse outcomes is more effective in entrenching the status quo behaviours than the fragile use of enabling interventions

Limitations 29 November 2013 10:30 - 12:00

Limits to MI in medical care Patients found incapable to consent to treatment Emergency situations in which patient is momentarily incapable The patient is a risk to themselves or others in the context of a mental disorder 29 November 2013 10:30 - 12:00

What we tend to do 29 November 2013 10:30 - 12:00

2 Magic Words http://www.youtube.com/watch?v=Ow0lr63y4Mw&featur e=player_detailpage#t=50 http://www.youtube.com/watch?v=Ow0lr63y4Mw&featur e=player_detailpage#t=50 Boiled down the essence of our automatic behaviour modification approach 29 November 2013 10:30 - 12:00

The Other Approach 29 November 2013 10:30 - 12:00

Motivational Interventions 29 November 2013 10:30 - 12:00 Status Quo Target Behaviour Patient

Motivational Interventions 29 November 2013 10:30 - 12:00 Status Quo Target Behaviour Physician

The Righting Reflex 29 November 2013 10:30 - 12:00 Providers want to fix things and make things right Patients are ambivalent to change When the righting reflex meets ambivalence the result is confrontation Confrontation = Intensification of resistance to change and more fervently defend the status quo

Background Key Knowledge, Principles and Contrasts 29 November 2013 10:30 - 12:00

What Are We Up Against? 29 November 2013 10:30 - 12:00 What are some of the factors that make treatment adherence and changing health behaviours extremely challenging? https://www.youtube.com/watch?v=YOD2fflXIfM&featur e=player_detailpage https://www.youtube.com/watch?v=YOD2fflXIfM&featur e=player_detailpage discounting our future selves

Advanced Consent and Capacity 29 November 2013 10:30 - 12:00 Motivational interventions are absolutely consistent with the Consent and Capacity Legislation in the Health Care Consent Act and the Expectation that health providers obtain informed consent before delivering any intervention Think of these techniques as a detailed articulation of informed consent

Motivational Interviewing Motivational interviewing is a collaborative, person- centered form of guiding to elicit and strengthen motivation for change. It is about Selectively eliciting and reinforcing the clients own arguments and motivations for change Explicitly honors autonomy, peoples right and irrevocable ability to decide about their own behavior. Patients talk themselves into change 29 November 2013 10:30 - 12:00

PRINCIPLES 29 November 2013 10:30 - 12:00 1. The best interests of the patient are central to all physician-patient interactions. 2. Respect for the autonomy and personal dignity of the patient is central to the provision of ethically sound patient care. Through the translation of these ethical principles to law, the Supreme Court of Canada has confirmed the fundamental right of the individual to decide which medical interventions will be accepted and which will not. 3. In order to exercise their autonomy, patients must be capable of making informed decisions about their health care. 4. The goals of the Health Care Consent Act (HCCA) include promoting individual autonomy and decision-making capacity, and facilitating communication between health care practitioners and their patients. 5. Physicians have the obligation to secure consent and patients have the legal right to either consent to or refuse treatment. (Who recognizes these principles? Show of hands.)

Recognition of Principles 29 November 2013 10:30 - 12:00 Consent to Medical Treatment. CPSO Policy Statement, Policy #4-05

Techniques in this session... Are not a way of tricking people into doing what they dont want to do To the contrary Assume personal autonomy that people make their own behavioral choices, and that such power of choice cannot be appropriated by another. It is about eliciting the persons own inherent arguments for change, not imposing someone elses. (This is why it is critical that the patient is capable and you have ensured that they understand the risks and benefits) 29 November 2013 10:30 - 12:00

Evidence 29 November 2013 10:30 - 12:00 Well studied Widely applied in certain domains of health care

The Litmus Test Brief interventions for alcohol problems: a meta- analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations Anne Moyer et al. Addiction, 2002, 97, 279292 This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals in non-treatment- seeking samples. 29 November 2013 10:30 - 12:00

Comprehensive Primary Care Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial Christopher C Butler et al BMJ 2013;346:f1191 doi: 10.1136/bmj.f1191 (Published 19 March 2013) ...but it did increase patients recollection of discussing behaviour change with their clinicians, intentions to change, attempts to change, and perceptions of having made a lasting change at three months 29 November 2013 10:30 - 12:00

Opportunistic Brief Interventions Prevention and Lifestyle Behaviour Change: A Competence Framework NHS Yorkshire and the Humber 2011 29 November 2013 10:30 - 12:00

Rationale In a comprehensive primary care setting: Brief statements Easy statements to learn Applied to all patient encounters May have greater impact than specifically targeted MI techniques on a population basis 29 November 2013 10:30 - 12:00

Misinformation Is Important A factual knowledge of the kinds of misinformation which people receive about health and wellbeing and how these can be counteracted 29 November 2013 10:30 - 12:00

Example of Misinformation 29 November 2013 10:30 - 12:00 https://www.youtube.com/watch?feature=player_detailpag e&v=_KNIPGV7Xyg#t=273 https://www.youtube.com/watch?feature=player_detailpag e&v=_KNIPGV7Xyg#t=273 To 4:45

Performance Criteria 1. Be alert to opportunities for brief advice 2. Identify cues from individuals expressed needs or concerns 3. Observe individual for any signs of lifestyle health related issues 4. Explore, in a non-threatening manner, the individuals views and feelings about their lifestyle and health behaviours 5. Assess whether the individual is willing to engage in further discussion about the issue 29 November 2013 10:30 - 12:00

Performance Criteria 6. When an individual is not willing to engage at that moment, invite them to return and ask questions at any time in the future 7. When an individual is willing to engage, provide general health information in an empathetic, non-confrontational manner 8. Maintain up-to-date and accurate information about additional sources of support 9. Signpost the individual to appropriate additional support according to the individuals needs 29 November 2013 10:30 - 12:00

Communicate in a manner that: a. is appropriate to the individuals b. encourages an open exchange of views and information c. minimises any constraints to communication whilst maintaining confidentiality d. respects people as individuals 29 November 2013 10:30 - 12:00

Encourage individuals to: a. assess how their behaviour is affecting their health and wellbeing b. identify the changes that might benefit their health and wellbeing c. identify their motivation to change their behaviour d. identify the situations that will help them change e. identify barriers to change and ways of managing them 29 November 2013 10:30 - 12:00

Assist individuals to: a. identify specific, measurable, achievable, realistic and timely goals for changing their behaviour (SMART goals) b. identify one easily-achievable goal to start working on c. identify any skills that need to be learnt to achieve this goal d. develop a personal action plan that will help them achieve their goals e. identify who and what will help them achieve their plan f. make sure they get the support they need in achieving their plan g. record their progress in achieving their plan h. identify when and how their plan will be reviewed 29 November 2013 10:30 - 12:00

Support individuals to achieve their plan by: a. reviewing their progress in achieving their goals b. providing feedback, support and encouragement c. helping them recognise and value their achievements d. developing their confidence in bringing about change and maintaining change 29 November 2013 10:30 - 12:00

Help individuals to Maintain Changes a. evaluate the changes they have made to their behaviour and their effects on their health and wellbeing 29 November 2013 10:30 - 12:00

Opportunistic Brief Interventions (OBI) Providers tasks Listen for statements from patient relating to either current discontent or desired outcomes that provider can link to target intervention Respond to patients comment with nonjudgmental reflection that links altered status quo to the patients own statement 29 November 2013 10:30 - 12:00

Identifying Opportunities 29 November 2013 10:30 - 12:00

Identifying Patient Motivation 29 November 2013 10:30 - 12:00 The next few exercises are intended to assist you in identifying patient statements and questions that may translate into opportunities for fostering behaviour change

Identifying Opportunities https://www.youtube.com/watch?feature=player_detailpag e&v=_KNIPGV7Xyg#t=100 https://www.youtube.com/watch?feature=player_detailpag e&v=_KNIPGV7Xyg#t=100 To 4 Minutes Listen for specific statements by the patient that would be an opportunity for building on to foster motivation to change. Identify what the NP actually did and rewrite a potentially more motivating statement 29 November 2013 10:30 - 12:00

Identifying Opportunities 29 November 2013 10:30 - 12:00 https://www.youtube.com/watch?feature=player_detailpag e&v=-aTe4LpGz_E#t=150 https://www.youtube.com/watch?feature=player_detailpag e&v=-aTe4LpGz_E#t=150 To 3:34 Listen for specific statements by the patient that would be an opportunity for building on to foster motivation to change.

Recognizing Provider Techniques 29 November 2013 10:30 - 12:00 https://www.youtube.com/watch?v=- zEpwxJlRQI&feature=player_detailpage#t=240 https://www.youtube.com/watch?v=- zEpwxJlRQI&feature=player_detailpage#t=240 To 4:55 Identify interviewer techniques

Brief Intervention Diabetes https://www.youtube.com/watch?feature=player_detailpag e&v=_KNIPGV7Xyg#t=405 https://www.youtube.com/watch?feature=player_detailpag e&v=_KNIPGV7Xyg#t=405 To 9:33 Record patient statements that are motivational opportunities to foster change Record provider responses to the opportunities 29 November 2013 10:30 - 12:00

An Overview 29 November 2013 10:30 - 12:00 https://www.youtube.com/watch?v=dm- rJJPCuTE&feature=player_detailpage#t=40 https://www.youtube.com/watch?v=dm- rJJPCuTE&feature=player_detailpage#t=40 Record patient statements that are motivational opportunities to foster change Record provider responses to the opportunities

Critique the following 29 November 2013 10:30 - 12:00 Using what you now know critique the following encounter Record provider statements/responses that could be improved Write an improved response We will ask volunteers to share their critiques https://www.youtube.com/watch?v=mu0- TnfRNHQ&feature=player_detailpage https://www.youtube.com/watch?v=mu0- TnfRNHQ&feature=player_detailpage

SMART Goals specific, measurable, achievable, realistic timely 29 November 2013 10:30 - 12:00

Orchestrated Success Initial tasks selected by patient should be certain to be achieved Success promotes repetition and growth of motivation Failure promotes cessation and shrinkage of motivation Feelings of competence increase motivation slowly Feeling incompetent decreases motivation quickly 29 November 2013 10:30 - 12:00

Foster Feelings of Competence Guide patients towards SMALL objectives that are EASY to accomplish Orchestrated Success 29 November 2013 10:30 - 12:00

Scaling questions https://www.youtube.com/watch?v=dm- rJJPCuTE&feature=player_detailpage#t=177 https://www.youtube.com/watch?v=dm- rJJPCuTE&feature=player_detailpage#t=177 29 November 2013 10:30 - 12:00

Scaling questions 29 November 2013 10:30 - 12:00 On a scale of 0 -10: 1. How important is it to you to achieve X (e.g. Lose weight, improve blood sugars, etc.,)? 2. How confident are you that you can do X (e.g., take your metformin consistently)?

Scaling questions 29 November 2013 10:30 - 12:00 Working with the numbers 1. Why are you not a 0? 2. What would make it possible for you to increase from X to X+Y?

Signs My Technique Needs Help The discussion feels confrontational I am feeling frustrated The client is not engaged I am doing all of the talking I am not confident the client is being honest in their communications I feel like I am doing all the work 29 November 2013 10:30 - 12:00

Techniques For the Silent Patient 29 November 2013 10:30 - 12:00 The next 2 techniques can be used to facilitate change related discussions in patients that are Not spontaneous in communicating Generally not articulate

Decisional Balance ProsCons Change Status Quo 29 November 2013 10:30 - 12:00

About Taking My Medication Things I likeThings I dont like Assist patient in thinking Chart is updated over visits as the norm is for the issues to emerge over time as the client becomes more engaged in the process. 29 November 2013 10:30 - 12:00

Stepped Approach Application to Office Practice 29 November 2013 10:30 - 12:00

Step 1 Informed Consent 29 November 2013 10:30 - 12:00 Describe Risks and Benefits of Proposed Intervention Describe Risks and Benefits of Status Quo Elicit Misinformation patient has heard or read or derived Provide above in written form for patient to take home Standard patient information sheets or documents are sufficient Tips: Monitor yourself to ensure use of non-judgemental language Answer all questions If time is short do not rush instead book another visit

Step 2 Ensure Informed Patient 29 November 2013 10:30 - 12:00 Guide the patient in demonstration of understanding Ask patient to describe personal understanding of Risks and Benefits of Proposed Intervention Ask patient to describe Risks and Benefits of Status Quo While the patient is doing so make note of misunderstandings that will require factual correction After the patient is finished review misunderstandings with patient and correct factual errors Ask patient about any related concerns

Step 3 Ensure Informed Patient 29 November 2013 10:30 - 12:00 Guide the patient in demonstration of understanding Ask patient to describe personal understanding of Risks and Benefits of Proposed Intervention Ask patient to describe Risks and Benefits of Status Quo While the patient is doing so make note of misunderstandings that will require factual correction After the patient is finished review misunderstandings with patient and correct factual errors Ask patient about any related concerns

Step 4 Elicit Ambivalence 29 November 2013 10:30 - 12:00 Elicit Ambivalence to Change Identify during open ended questions Decisional Matrix Likes vs. Dislikes table

Step 5 Foster Motivation 29 November 2013 10:30 - 12:00 Elicit Ambivalence to Change Reinforce current behaviour that approached target Scaling Questions Guide the patient to develop SMART goals

Final Discussion 29 November 2013 10:30 - 12:00

improving treatment adherence and health behaviours through motivational interventions opportunistic...

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