Motivational Interviewing 101: Tips for Effective Tobacco Cessation

Counseling

Artwork by Liu W. © 2013 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2013 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

Objectives• Describe the basic steps of motivational

interviewing• Apply Motivational Interviewing techniques to

facilitate open conversations with parents or family members that smoke

Principles of Tobacco Dependence Treatment

• Nicotine is addictive• Tobacco dependence is a chronic

condition• Effective treatments exist• Every person who uses tobacco

should be offered treatment

Smokers Want to Quit• 70% of tobacco users report wanting to quit• Most have made at least one quit attempt• Tobacco users cite health expert advice as

important• Regardless of type of provider! THIS MEANS YOU!

Artwork by Aishani S. © 2013 American Academy of Pediatrics (AAP) Children's Art Contest. Support for the 2013 AAP Children's Art Contest was from the Flight Attendant Medical Research Institute.

Counseling 101• Patients and families expect you to discuss tobacco

use

• If counseling is delivered in a non-judgmental manner, it is usually well-received

• Even small “doses” are effective - and cumulative!• Strength of Evidence = A

Counseling IS Effective

• As little as 3 minutes of counseling doubles quit attempts and successes

• Intensive counseling is more effective– Dose-response relationship

• Most effective: – Problem-solving skills– Support from clinician– Active referral– Social support outside of treatment

Requirements for Change

XX ==

MotivationMotivation(Should I?)(Should I?)

Self-ConfidenceSelf-Confidence(Can I?)(Can I?)

CommitmentCommitment(Will I?)(Will I?)

Your Goal: Help the TobaccoUser Take the Next Step

Help a precontemplator become a contemplator……a contemplator start to make plans……someone who relapsed become “ready for action”…

And so on….

The Challenge

• People don’t follow physicians’ advice and recommendations– 50% don’t follow long term medication regimens– Many don’t follow advice to change health behavior

• Patients often do not recall anticipatory advice given

Research Has Shown:• Clinician-patient interactions influence the behavior

change process.

• When given the tools to help motivate patients to change health behaviors, good doctors become even more effective.

• When patients arrive at action plans that fit within their personal goals and values, change is more likely.

Motivational Interviewing (MI): Key Elements

• Use key counseling skills (open ended questions, reflective listening, empathy)

• “Roll with resistance”– The MI encounter resembles a dance rather than a

wrestling match Assess importance and confidence

• Develop discrepancy between the patient’s goals and current behaviors

• Support patient’s change efforts

Overview of the MI Encounter

• Set the agenda– Collaborative process

• Use key counseling skills to understand the patient’s experience

• Determine importance and confidence

• Enhance importance and confidence

• Elicit patient’s “change language”, reinforce it, and build on it

• Help patient develop action steps

Agenda Setting

• Elicit items patient wishes to discuss– “What were you hoping to talk about today?”– Always ask permission before discussing a topic

• Raise items you wish to discuss and ask permission– “I’m concerned about your child’s frequent asthma attacks.

Would it be okay if we talked about it today?”

• Prioritize multiple concerns

• Agree on what you’re going to talk about

Key Counseling Skills: Open-Ended Questions

• Goal-understand meaning rather than collect facts

• Use “How” and “What” questions – Caution: “Why” questions can sound judgmental

• Examples:– Tell me about…– Could you help me understand more about…– What have you tried before?– How was that for you?

Key Counseling Skills: Reflective Listening

• Listening is often considered the passive part of conversation

• Reflective listening is an active process

• Reflect the meaning of what your patient said

• Every reflection opens a possibility– The patient may verify, correct, add to, or refine their

message– The clinician can clarify, correct misinterpretations, and

learn about their own assumptions and distortions

Key Counseling Skills: Reflective Listening (continued)

• Stems:– It sounds like you…– So what I hear you saying is…– You’re wondering if…– You feel…and that makes you want to…– It seems like…– You are…

Key Counseling Skills: Expressing Empathy

• Empathy:– Understand the experience of another at a deeper level– Acknowledge and value the other person’s perspective

and feelings– Empathy communicates to your patient that what they

say, think, and feel is important to you.

• Empathy is NOT:– Sympathy - Shared suffering– Pity - A condescending relationship which separates

physician and patient– Reassurance

Key Counseling Skills: Expressing Empathy

• “You seem pretty frustrated”

• “So you’re just not sure what to do next.”

• “So you really want to change your eating habits, but its overwhelming because you’re not sure where to start.”

• “Most people I know would feel anxious in that situation.”

• “It sounds like deciding to take that first step is a little scary for you.”

Exchanging Information vs. Advice on Empty Ears

• Exchanging information is different from advice, which is a one-way process

• Always ask permission before giving information

• Elicit-Provide-Elicit Process– ELICIT interest

• “Would you like to know more about…?”– PROVIDE feedback neutrally

• “What happens to some people is…Other people find…”– ELICIT the patient’s interpretation and follow it

• “What do you make of this?”• “How do you see the connection between smoking and your health?”

Assessing Importance and Confidence

• Goal: Understand how the patient feels and thinks about changing their current behavior

• Strategy: Scaling questions

• In order to move toward change, the patient may need to:– Further explore the importance of change– Build the confidence to undertake change– Enhance both importance and confidence

Assessing Importance

• “On a scale of 0 to 10, how is important is it to you to _________ (make this change)?

• Follow-up Questions:– “What makes you say a 5?”– “What led you to say 5 and not zero?”– “What would it take to move it to a 6 or a 7?”– “What could I do to help you make it a 6 or 7?”

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10Not at all important

Extremely important

Strategies for Enhancing Importance:Examining Pros and Cons

• Examining pros and cons gives a lot of information about how the patient views the issue (Ex.: all cons and no pros)

• Patients often experience ambivalence about the value of change– There are costs and benefits to changing as well as staying the

same– New behaviors can be hard to do

• There are 2 ways of examining pros/cons:– Look at the current behavior– Look at change

Current Behavior Change

Pros Pros

“What are some of the good things about eating so much junk food?”

I like how it tastes

Going out with my friends-we like to hang out at McDonalds

“What are some of the good things about changing the way you eat?”

If lose weight, will feel more attractive

It would be easier to fit into the kinds of clothes I want to wear

I’d feel good about accomplishing it

Cons Cons“What are the not so good things about eating junk food?”

I don’t like how I look-I think its making me heavy and it also make my skin greasy

I can’t run as well as I used to, so I’m doing badly on my field hockey team

“What are some of the not so good things about changing the way you eat?”

I’d have to think about what I can and can’t eat all of the time

I’d have to give up my favorite junk food

It would be hard to go out with my friends

How would you summarize both sides of what you hear?

Responding to Ambivalence

• Return to a reflective statement

• Double-sided reflection– “So, on the one hand…while on the other hand…”

• Roll with resistance– Patient: “I know you expect me to quit eating all the things I

like. I want to lose weight, but I don’t plan on sticking to some strict diet where you can only eat salad!”

– Clinician: “A lot of people feel the same way you do when they start thinking about changing the way they eat. Tell me more about your concerns.”

Assessing Confidence

• “On a scale of 0 to 10, how confident are you that you can _______ (make this change)?

• Follow-up questions:– “What makes you say a 6?”– “What led you to rate your confidence 6 and not 2?”– “What would help you move your confidence from a 6 to a

7 or 8?”

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10Not at all confident

Totallyconfident

Strategies for Enhancing Confidence• Recall times in the past when the patient has been

successful making changes– Explore role of family and peers in supporting change– Affirm persistence-often many attempts

• Break it down– Define small, realistic, and achievable steps

• Identify specific barriers and problem-solve– “What might get in the way?”– “What might help you get past that?”– “Here’s what others have done.”

The Ingredients of Readiness to Change

Importance (Why should I change?)

Confidence

Readiness

(Can I do it?)

Change Talk• Change talk includes desire, ability, reasons, need

– “I really want to start eating healthier”– “I’m sure that I can turn the TV off after school”– “I need to cut back on junk food because I am starting to

gain weight”– “It’s important for me to take my asthma medicine”

• Listen carefully for change talk throughout the interview

• Acknowledge, appreciate, affirm, and express support for change talk

How Do We Help the Patient Turn Interest Into Action?

• Most people need help picking one do-able step that’s not too big

• More likely to be successful if they come up with the options rather than you– You can prime the pump if they are stuck– Limit the number of changes to be attempted

• Convey optimism and belief in their strengths

• Write it down for the patient

Assess Readiness for Change

• Ask permission:– “Would it be okay if we spent a few minutes talking about

_____?”

• Understand their view of the problem. (“Tell me…”) :

• Ask about readiness:– “On a scale of 0-10, how ready are you to consider ____?”

• Ask scaling questions:– Backward: “What makes it a 5 and not a 2?”– Forward: “What would help you move it from a 5 to a 7?”

Assess Readiness (con’t)• Pay attention to change talk:

– Change talk includes desire, ability, reasons, need– Change talk give clues about readiness to change– People are more persuaded by what they hear themselves say than by

what someone tells them Summarize change talk

• Confirm: – “Did I get it all?”

• Ask about the next steps:– “Where does _______ fit into your future?”

• Show appreciation:– “Thank you for your willingness to talk about ___ with me.”

• Voice confidence:– “I’m confident that if and when you make a firm decision and commitment

to ___ you will find a way to do it.”

Ready for Action?

• Not ready to attempt change– Goal: Raise awareness– Tasks: Inform & encourage

• Unsure about change– Goal: Build importance and/or confidence– Tasks: Explore ambivalence

• Ready for Action– Goal: Agree on action steps and strategies

Not Ready - Inform & Encourage• Always ask permission before giving information

• Elicit-Provide-Elicit Process– ELICIT interest

• “Would you like to know more about…?”– PROVIDE feedback neutrally

• “What happens to some people is…Other people find…”

– ELICIT the patient’s interpretation and follow it• “What do you make of this?”• “How do you see the connection between smoking

and your health?”

Unsure - Explore Ambivalence• Ask permission:

– “It seems that you have a lot of thoughts about this, Can we talk a little more about it?”

• Ask “disarming” open-ended question:– “What are some of the advantages for keeping things just the way

they are?”

• Ask “reverse” open-ended question:– “On the other hand, what are some of the reasons for making a

change?”

• Summarize both sides of ambivalence– Start with the reasons for not changing, followed by reasons for

changing

Unsure - Explore Ambivalence (cont.)

• Ask about the next step:– “What’s the next step, if any?”

• Show appreciation:– “Thank you for your willingness to talk with me about _____.”

• Voice confidence:– “I’m confident that if and when you make a firm decision and commit

to making a change, you’ll find a way to do it.”

Ready - Agree on Action Steps

• Many people need help picking one do-able step that’s not too big

• People are more likely to be successful if they come up with the options rather than you– You can prime the pump if they are stuck– Involve both mother and child

• Show appreciation

• Convey optimism and belief in their strengths

• Write down one simple next step

What if the Patient Can’t Come up With Any Ideas?

• Ask permission:– “If you’re interested, I have an idea for you to consider.

Would you like to hear it?”

• Offer advice:– “Based on my experience, I would encourage you to

consider _________.”

• Emphasize choice:– “Of course, it is totally up to you.”

• Elicit response:– “What do you think about this idea?”

Recap of the MI Encounter

• Set the agenda– Collaborative process

• Use key counseling skills to understand the patient’s experience

• Determine importance and confidence

• Enhance importance and confidence

• Elicit patient’s “change language”, reinforce it, and build on it

• Help patient develop action steps

Back to Tobacco: YOUR Agenda

• Use clear, strong messages• Anticipate challenges

– Ask about cues to use tobacco– There are fewer cues in Smoke Free

homes and cars• Practice problem-solving• Prescribe or provide information about

pharmacotherapy• Help the patient or family member set a quit date• Document your advice

What Do You Say?

• Clear: “I strongly advise you to quit smoking.”(ok, it’s a one-way statement…but important to say!)

• Strong: “Eliminating smoke exposure of your son is one of the most important things you can do to protect his health.”

• Personalized: Emphasize the impact on health, finances, the child, family, or patient.“Smoking is harmful for you (and your child/family). I can help you quit.”

Be Specific…• Remember MI: Ask Permission to give this advice, or it may fall on deaf ears…

– “There are some things that may be helpful to know about what it means to have a Smoke Free Home. Can I go through them with you?”

• Having a Smoke Free Home means no smoking ANYWHERE inside the home or car!

• It DOES NOT mean smoking:– Near a window or exhaust fan– In the car with the windows open– In the basement– Inside only when the weather’s bad– Cigars, pipes, or hookahs– On the other side of the room

• Tobacco use can be a source of family discord – Smoking by a household member can be a source of tension– Not always identified by the patient or family member as a barrier

• Moms are more often the “gatekeepers” for maintaining a smoke free home– BUT, they may not be willing to risk a

relationship– Want to maintain peace, may rationalize

the risk

Help With Challenges

Help With Challenges• Strategize with the patient or family member about

ways to deliver the “you can quit” and “our home and car should be tobacco free” messages

• Some patients and family members would like to have a Smoke Free Home and car, but do not feel like they have the POWER to set this rule.– ASK if they can set a firm, 100% Smoke Free Rule– If they don’t have the power, ASK if a note from you will

help!

Assist by Following Up• Plan to follow up on any behavioral commitments

made – they are beginning a process of change!– Just asking at the next visit makes a big impression– Need to monitor and reinforce behavior change

• If they set a quit date– Schedule follow-up in person or

by telephone soon after the quit date

• Look for “teachable moments” in the future

• To find information about your state quitline visit: http://map.naquitline.org/

• What do you say?– “I recommend that you call this number. It’s a free service

– and the person on the other end of the telephone can help you get ready to quit.”

– “One thing that helps a lot is to learn as much as you can about quitting – the more you know, the more successful you’ll be. The quit line staff can help.”

– “We’ve got a great state quit line. If you go on line and click a button, they call YOU back right away!”

Refer: To State Quitline

Close on Good Terms

• Offer praise and encouragement– Earnestly praise for work done

• Summarize your patient’s view on importance and confidence

• Emphasize any agreement that was reached

Motivational Interviewing

• http://www.motivatehealthyhabits.com/– Rick Botelho is a family doc who does a fabulous job

• http://www.motivationalinterview.org/– The website for motivational interviewing trainers; many

good resources from the psychology literature

www.aap.org/richmondcenter

Need more information?

American Academy of PediatricsJulius B. Richmond Center of Excellence

Audience-Specific Resources State-Specific Resources

Cessation InformationCoding & Payment InformationTobacco Control E-mail Lists

Clinical Practice Change Resources

American Lung Associationwww.lung.org/cessationta