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 1
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 own cultural and environmental context. 2
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 3
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 4
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. … 5
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 6
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) 7
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% of studies showed effect Rubak, Sandboek et al., 2005 � Motivational Interviewing: A Schematic Ambivalence Resistance Change Talk Importance Confidence 8
How to Start? � Got the Spirit? � Establish Rapport � Set Agenda � Behavioral Focus Tasks in consultations about behavior change Establish Rapport Set agenda Multiple behaviors Single behavior Assess importance and confidence Explore importance Build confidence From: Rollnick, Stephen, Mason, Pip, & Butler. Health Behavior Change, 1999. Establishing Rapport � Body language � Collaborative language � Time � Open-ended questions 9
Agenda Setting Chart Diet Exercise Losing Weight Relationship Stress Issues School/Work 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 10
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.” 11
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 . ..” DARN Scale (Ruler) On a scale from 0 - 10... what number would you give yourself regarding … Desire?…Ability?…Reason? …Need? 0 10 12
I mportance & Confidence Ruler Importance How important is it for you right now to...? On a scale from 0 - 10... what number would you give yourself? 0 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? 0 10 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 13
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 14
Feedback from Panel Next Steps for Audience � Training Opportunities � MI website � www. motivational interview.org Contact Info: � Peg Dublin: dubp@accesscommunityhealth.net or 773-257-5359 � Richard Rutschman: richrutsch@ameritech.net or 773-510-6515 15
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