1 Changing Landscape in Maternal and Child Health Growing body of - - PDF document

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The Well Woman Visit Pre/Interconceptional Care, One Year Later

Motivational Interviewing

Peg Dublin, RN, MPH Richard Rutschman, EdD. IDHS Bureau of Maternal & Infant Health Satellite Conference June 17, 2008

Objectives

• Identify key differences between traditional

provider/client interaction and Motivational Interviewing adherent interaction.

• Describe the key elements and characteristics of

the spirit and process of Motivational Interviewing.

• List 2-3 examples of research demonstrating

evidence of benefits of motivational interviewing in practice settings related to behavioral and lifestyle change.

Changing Landscape of Healthcare

Rise in chronic conditions Less emphasis on acute care Greater attention to lifestyle

modification and disease management

2 Changing Landscape in Maternal and Child Health

Growing body of evidence of

importance of preconception and interconceptional health Training of Public Health and Healthcare Professionals

Traditionally trained to respond to

acute, short-term illnesses

Hierarchical model of relationships Emphasis on patient instruction and

patient compliance

Different approaches are needed to help people manage and thrive in their

• wn cultural and

environmental context.

3 Self-Management

“The individual’s ability to manage the

symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”

• Barlow, 2002

Core Self-Management Skills

Problem-solving Decision making Resource utilization Forming of a patient/health care

provider partnership

Taking action

Lorig and Holman, 2003

Self-Management Support

Relies on a collaborative process

between clients and providers/staff

4 Self-Management Support

Empowers and prepares clients to

manage their health and health care

Emphasizes the client’s central role

in managing their health

Motivational Interviewing

A client-centered counseling style that helps people build motivation for change by allowing them to articulate reasons for and against change…

• William Miller & Stephen Rollnick, 2002, Motivational

Interviewing

Role Play Activity

5 Paired Activity: Two Trials

Decide who would like to discuss some

“possible change” being considered, such as “I ’d like to lose 5 lbs. or increase my activity level”; you will be the client.

The other person will be the counselor.

I nstructions for the counselor

As soon as the person tells you what they are

considering changing do some of the following:

Trial One Instructions for Counselor

• 1. Ordering, directing, or commanding
• 2. Warning or threatening
• 3. Giving advice, making suggestions, or providing solutions
• 4. Persuading with logic, arguing, or lecturing
• 5. Moralizing, preaching, or telling clients what they

"should" do

• 6. Disagreeing, judging, criticizing, or blaming
• 7. Shaming, ridiculing, or labeling
• 8. Questioning or probing

How did this interaction feel?

• As the client I felt:

1. 2. 3. 4.

• As the counselor I felt:

1. 2 3. 4. …

6 Trial Two Instructions

• 1. Why would you want to …?
• 2. If you did decide, how would you do it?
• 3. What reasons are there …?
• 4. On a scale of 1 to 10, with 10 being most

important, how important is this to you?

• 5. Give a summary of what you heard why she/he

is prepared to change .

• 6. Final question: What do you think you need to

accomplish this?

How did this interaction feel?

• As the client I felt:

1. 2. 3. 4.

• As the counselor I felt:

1. 2 3. 4. …

Comparison Activity

Discussion of two trials

7 Spirit of MI

Health Priority—belief that humans develop

in the direction of health and adaptive behavior if given support.

Empathic—able to put oneself in their

shoes, listening so well to be able to enter their world

Safe Environment—creates trust & rapport Collaborative/ Egalitarian—treats client as

an equal and as their ally.

Spirit . . .

Non-Judgmental—accept person as they

are, does not give opinion

Honors Autonomy—makes clear that

control and choice is clearly theirs regarding change

Builds on Theoretical Underpinnings—

self-perception, self-determination and self- efficacy

Theoretical Underpinnings

Bem’s Self-Perception Theory

(psychologist Daryl Bem)

Self-Determination Theory Bandura’s Self-Efficacy Theory

(Albert Bandura, 1986)

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Underlying Concepts of MI

Clients are ambivalent about change Practitioner’s pushing for change

evokes “resistance” from the client

Resistance predicts lack of change Evoking the client’s own change talk

will enhance behavior change

Is MI Evidence-based?

Literature search found 72 randomized

controlled trials

Studies addressed wide range of behavioral

problems and diseases, such as obesity, alcohol use, smoking, HIV risk behavior, pain management

Meta-analysis showed significant effect for MI Using MI in brief encounters of 15 min., 64%

• f studies showed effect
• Rubak, Sandboek et al., 2005

Motivational Interviewing: A Schematic

Ambivalence Resistance Change Talk Importance Confidence

9 How to Start?

Got the Spirit? Establish Rapport Set Agenda Behavioral Focus

Tasks in consultations about behavior change

Establish Rapport Set agenda

Assess importance and confidence Explore importance Build confidence Multiple behaviors Single behavior

From: Rollnick, Stephen, Mason, Pip, & Butler. Health Behavior Change, 1999.

Establishing Rapport

Body language Collaborative language Time Open-ended questions

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Diet Relationship Issues School/Work Stress Exercise Losing Weight

Agenda Setting Chart Practices of Motivational Interviewing

Express Empathy Develop discrepancy Roll with resistance Support self-efficacy

Client–Centered Counseling Skills

O= open-ended questions A= affirmations R= reflections S= summaries

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Open-Ended Questions

Example

“Tell me about how things have been

going with your pregnancy since I last saw you a month ago?”

“Tell me what your thoughts are

about breastfeeding.”

Affirmations

Examples

“You really care about your health.” “Look at how well you’ve cut back on

drinking pop.”

Reflections

Simple Reflection

Paraphrase, short Examples

“You’re frustrated.”

Complex Reflection

Picking out the change talk or unstated

emotion

Examples

“You really want to have a healthy pregnancy.”

12 Summaries

Metaphoric bouquet of flowers Review of what’s been said Targeting “change talk” Transition to next steps

Eliciting Change Talk

D – Desire

“In what ways would it be good for you to …”

A – Ability

“If you did decide to … how would you do it?”

R – Reasons

“What would be the good things about …?

N – Need

“Why would you want to . ..”

On a scale from 0 - 10... what number would you give yourself regarding … Desire?…Ability?…Reason? …Need? 10

DARN Scale (Ruler)

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Importance How important is it for you right now to...? On a scale from 0 - 10... what number would you give yourself? 10 Confidence If you did decide to change, how confident are you that you would succeed? On a scale from 0 -10... what number would you give yourself? 10

I mportance & Confidence Ruler

Responding to Change Talk

Reflect it – restate it back Ask for examples/elaboration Affirm Summarize Activity – Drum Roll

Rolling with Resistance

Reflection Amplified reflection Double-sided reflection Emphasize autonomy

14 EPE for Giving Information

Elicit-Provide-Elicit Ask what they know (Elicit) Ask or get permission to Provide

Information/Options (Provide)

If advice, offer several options rather

than one (for some people…)

Ask what they think now (Elicit) ACTI ON PLAN This is something you WANT to do! Describe your plan for the next week or weeks. What? Where? When? How Much? How Often? How confident are you that you can accomplish the entire plan? 1 2 3 4 5 6 7 8 9 10

Not at all confident Totally confident

Example of a positive change you’ve made in the past: Barriers you might face when working on this plan: Plans to overcome challenges: Date of Follow-Up:_________________

Demonstration of MI

Audience to observe and count OARS, using handout

15 Feedback from Panel Next Steps for Audience

Training Opportunities MI website

www.motivationalinterview.org

Contact Info:

Peg Dublin:

dubp@accesscommunityhealth.net or 773-257-5359

Richard Rutschman:

richrutsch@ameritech.net or 773-510-6515