let's talk research 2015 - emma joy holland -the feasibility of delivering motivational...

INNOVATIVE THINKINGFOR THE REAL WORLD

The feasibility of delivering motivational interviewing to those with communication

difficulties following a strokeDr Emma-Joy Holland

INNOVATIVE THINKINGFOR THE REAL WORLDINNOVATIVE THINKINGFOR THE REAL WORLD

BackgroundAfter stroke:

• Depression common: 33% (Hackett et al., 2005)

• Communication difficulties: +30% (Tsouli et al., 2009)

• Post-stroke communication difficulties associated with poorer outcomes:– Increased depression (Kauhanen et al., 2000)

– Reduced social participation (Mayo et al., 2002)

– Increased mortality (House et al., 2001)

• In 71% studies of depression, patients with communication difficulties were excluded (Townend et al., 2007)


Motivational Interviewing

• Person-centred, directive, talk-based therapy

• Elicit patient’s thoughts on coping strategies

• Previously used in field of addictions

• Adjustment to life after stroke

• No specific area of focus - lack of targeted ‘problem’ behaviour


Evidence for Motivational Interviewing in Stroke (Watkins et al., 2007)

• Can intervention early post-stroke alter mood?

• Usual Care (UC) vs MI and UC

• Included some patients with mild communication difficulties

• Benefit of MI over UC on mood at 3m

• Possible benefit to those with communication difficulties

• But, unclear if MI could be delivered the same in those with moderate to severe communication difficulties


Feasibility Study: Communication Difficulties after Stroke

AimTo explore the feasibility of widening access to a psychological

therapy, Motivational Interviewing (MI), for patients with

moderate to severe communication difficulties


Methods • Series of single patient case studies (n=6-12)

• Early after stroke

• Moderate to severe communication difficulties

• Baseline SLT communication assessment guided aids and

adaptations

• Eight 30-minute sessions over four weeks

• Video recorded


Methods: Aids

Takingmats.com

Talking Mats


Visual Rating Scale (VRS)

Pen and paper

Photo book


MI Video AnalysisCoded using Nvivo:

MI Fidelity Motivational Interviewing Skills Code (MISC): MI consistency

“not a set of specific techniques”

Global MISC ratings

MISC Codes


MI Video Analysis

Motivational Interviewing Skills Code (MISC) MI consistency (e.g. affirm, reflect) – Expert (>90%) threshold (>80%)

Global MISC ratings (Therapist/Patient/Interaction)– Expert (6) threshold (5)


Results

Patient Age Sex Communication No of sessions

John 44 M Severe 5

Joyce 65 F Moderately severe

8

Mary 87 F Moderate 7


Results: Mary (Moderate)Sess. Global MISC ratings (max. 7) MI consistency (%)

Therapist Patient Collaboration

1 6 6 6 902 5 7 5 1003 6 7 6 1004 5 7 6 935 6 6 5 886 6 6 6 977 5 6 5 100


Results: Joyce (Moderately severe)

Sess. Global MISC ratings (max. 7) MI consistency (%)


1 6 6 5 93

2 6 6 5 95

3 6 6 5 964 6 6 5 1005 5 5 5 966 5 6 5 947 5 6 5 958 6 6 6 96


Results: John (Severe) Sess. Global MISC ratings (max. 7) MI consistency (%)


1 4 5 4 88

2 4 6 5 90

3 6 6 5 95

4 4 6 5 71

5 4 4 3 72


Results: John (Severe) Sess. Global MISC ratings (max. 7) MI

consistency (%)

Use of VRS

Open questions

Closed questions


1 4 5 4 88 3 8 72

2 4 6 5 90 7 13 59

3 6 6 5 95 14 17 49

4 4 6 5 71 2 5 99

5 4 4 3 72 5 2 131


ResultsAdaptations• Slow pace of conversation

• Allowing additional time for

patient response

• Increased use of gesture

• Increased summaries

• Increased reflections

• Reflections of NVB


Discussion

• Aids and adaptations facilitate MI sessions

• These may be more important for those with more

severe communication difficulties

• Therapist role is crucial – MI ability/confidence

• Communication is not static – aids and adaptations must

adapt to suit the patient


Conclusion• With aids and adaptations to sessions, patients with post-

stroke communication difficulties can participate in

Motivational Interviewing

INNOVATIVE THINKINGFOR THE REAL WORLD

ANY QUESTIONS?

[email protected]


ReferencesHackett, M.L., Yapa, C., Parag, V. and Anderson, C.S., 2005. Frequency of Depression After Stroke: A Systematic Review of Observational Studies. Stroke, 36(6), pp. 1330-1340. House, A., Knapp, P., Bamford, J. and Vail, A., 2001. Mortality at 12 and 24 months after stroke may be associated with depressive symptoms at 1 month. Stroke, 32(3), pp. 696. Kauhanen, M.L., Korpelainen, J.T., Hiltunen, P., Määttä, R., Mononen, H., Brusin, E., Sotaniemi, K.A. and Myllylä, ,V.V., 2000. Aphasia, depression, and non-verbal cognitive impairment in ischaemic stroke. Cerebrovascular diseases (Basel, Switzerland), 10(6), pp. 455-461. Mayo, N.E., Wood-Dauphinee, S., Cote, R., Durcan, l. and Carlton, J., 2002. Activity, participation, and quality of life 6 months poststroke. Archives of physical medicine & rehabilitation, 83(8), pp. 1035-1042. Townend, E., Brady, M., and McLaughlan, K., 2007. Exclusion and Inclusion Criteria for People with Aphasia in Studies of Depression after Stroke: A Systematic Review and Future Recommendations. Neuroepidemiology, 29, pp. 1-17. Tsouli, S., Kyritsis, A.P., Tsagalis, G., Virvidaki, E. and Vemmos, K.N., 2009. Significance of aphasia after first-ever acute stroke: impact on early and late outcomes. Neuroepidemiology, 33(2), pp. 96-102. Watkins, C.L., Auton, M.F., Deans, C.F., Dickinson, H.A., Jack, C.I., Lightbody, C.E., Sutton, C.J., vand en Broek, M.D and Leathley, M.J., 2007. Motivational interviewing early after acute stroke: a randomized, controlled trial. Stroke (00392499), 38(3), pp. 1004-1009.

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