Motivational interviewing: Collaborating with patients about - - PDF document
Motivational interviewing: Collaborating with patients about behaviour change Anthony Talbot Clinical Psychologist Alfred Cystic Fibrosis Service With thanks to Dr. Michelle Earle Principal Clinical Psychologist Victorian HIV Service, The
1
Anthony Talbot
Clinical Psychologist Alfred Cystic Fibrosis Service With thanks to Dr. Michelle Earle Principal Clinical Psychologist Victorian HIV Service, The Alfred
2
3
Treatments
Poorer adherence when treatments are: Difficult or complicated Time consuming Offer no immediate feedback Offer no immediate benefit and (instead) negative consequences
Behavioural
Deferral for “later” Denial Avoidance Disorganisation Lack of time Forgetting Skill acquisition Habit/ momentum Improved adherence with adults when treatments are: There is a degree of choice Treatments yield immediate benefits
Family and social environment
Climate of home life, family disagreements, over- involvement and poor communication Illness can cause a centripetal effect: reliance on parents, parental anxiety and reluctance to hand-
Knowledge and understanding
Gaps in specific knowledge Suppressing information (avoidant coping)
Latchford, G.J., and Duff, A.J.A. (2011). A guide to adherence in CF. Jones, S., et al., (2015). Cochrane review on CF adherence.
4
Health beliefs Psychological barriers
Beliefs Fear Motivation Confidence Schemas (core memories
beliefs) that filter interpretations and drive behaviour
Mental ill health Trauma/sensitisation
Beliefs about illness What do I expect to happen? Perceived susceptibility
(e.g., “it will be bad if I don’t change”)
Perceived severity
(e.g., “this is only mild”)
Costs/benefits Beliefs about what to do How important is to me? What sort of person am I? What are my values? Subjective norms/influences
(e.g., “Mum and the doctor think I should do this”)
Self-efficacy (e.g., “I can handle this”) Beliefs about medicine Balancing necessity and concerns Do I need it? Will it work? What are the side effects?
Latchford, G.J., and Duff, A.J.A. (2011). A guide to adherence in CF.
5
Health professionals Patient
❋Giving advice tends to not work unless someone is ready to hear it. ❋A conversation is still the best tool we have for helping patients ❋Clinicians have a responsibility to update their communication skills. ❋Effective conversations can elicit better information on which to base
decisions and prescribing.
Atul Gawande, surgeon, on incremental care: “We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases… New vaccines routed polio, diphtheria, rubella, and
…heart attacks could be stopped; cancers could be cured….
Chronic illness …requires a more patient kind of skill ... steady intimate care”. Incrementalism: “It’s no one thing we do. It’s all of it”
Atul Gawande, The Heroism of Incremental Care, The New Yorker Jan 23, 2017 Latchford, G.J., and Duff, A.J.A. (2011). A guide to adherence in CF.
6
Gawande, Atul. (2004). The bell curve. The New Yorker, December 6, 2004. Latchford, G.J., and Duff, A.J.A. (2011). A guide to adherence in CF. Health professionals Patient
“Warren Warwick Principles” (Minneapolis CF Center)
❋Collaboration: share the dilemma of managing treatment
regimens, listen to patients and families, building patient’s confidence, informed decisions.
❋Consistently convey high expectations. ❋Careful listening and communication: patients and health
professionals use words differently; avoid assumptions.
❋Validating non-adherence: clinicians are honest about their
❋Reframing non-adherence as “experimenting” ❋Expectation of a reciprocal relationship and collaboration
“You will need to work very hard to make this collaboration successful.”
The combination of an actively-listening clinician and actively-engaged patient leads to truly collaborative relationships (Latchford and Duff, 2011).
Motivational interviewing, n. collaborative, person-centred form of guiding to elicit and strengthen motivation for change
Miller & Rollnick (2012)
7
Bill Miller, psychologist and Stephen Rollnick, physician (Miller & Rollnick, Motivational interviewing: Helping people change. 3rd ed., 2012) Began in field of addictions (Britt et al., 2003) Natural extension of Rogerian client-centred counselling e.g., warmth, genuineness, accurate empathy, unconditional positive regard (Rogers, 1951) Empirical backing with psycholinguistic analysis of transcripts (Moyers, Miller and Hendrickson, 2005). Research and publications http://www.motivationalinterviewing.org
Efficacy among primary care, acute medical and chronic illness populations. Schaefer and Kavookjian, 2017; Salimi, et al.,
2016; VanBuskirk, et al., 2014.
Positive impacts on a range of outcomes: e.g., improved
adherence, quality of life and symptom reduction for asthma, HIV, diabetes, dental cavities, cholesterol level, blood pressure, HIV viral load, alcohol and other substance misuse, body weight. Lundahl, et al., 2013
(review 48 RCT studies)
Small-modest-moderate effect sizes. Fidelity to MI? Barriers to using MI: minimum 2-day practice workshop and ongoing coaching.
8
“I hope so” “I wish I could” “I do” “I do”
9
“Yes, but…”
Change talk can predict commitment and actual change Examples
“I need to …” “I will”
(Prochaska & DiClemente, 1983; 1994)
10
Change talk Commitment talk
Change talk Commitment talk
change and commitment talk
11
…a method of communication rather than a set of therapeutic techniques… It selectively focuses on asking about the not-so- good side of a problem behaviour… …time-limited (i.e. one off intervention)…
(Miller & Rollnick, 2002)
MI can be used in a range of ways: A stand alone, change-oriented intervention Combined with another intervention (e.g., medical consult, cognitive-behavioural therapy, risk assessment, discharge process). A way to engage the client to prepare for a different intervention A way to handle loss of motivation or discord arising during the course of another intervention
12
tiredness, values, illness)
information, personal advantage)
(relationships).
Motivation
“yes, but…”
Three ingredients of motivation:
when change has a deeper meaning “I want to change”
“I want to change now”
change “I can change”
13
Spirit Principles Micro-Skills
OARS
T arget Behaviour
Who was your favourite teacher? What qualities come to mind?
14
Partnership Acceptance Evocation Compassion
MI Spirit
Partnership
answers or solutions.
Acceptance
personal meanings.
efforts
Evocation
persuade or advise.
Compassion
15
“I learn what I believe as I hear myself talk”
(Miller, 1995)
“We speak not only to tell
but to tell ourselves what we
thought”
Seeing Voices
neurologist (1933-2015)
“There is only one cardinal rule: One must always listen to the patient”
16
Express Empathy
Skilful reflective listening is fundamental Empathy is not a feeling, it is a behaviour that must be visible to a client.
17
Develop Discrepancy
Amplify any discrepancy between present behaviour and important personal goals or values. The client – not the health professional - presents the arguments for change
Roll with Sustain Talk and Discord
is normal
Discord
relationship (e.g., hostility, talking over, blaming, ignoring).
alliance.
18
Support Self-efficacy
The client’s belief in the possibility of change is motivating The client is responsible for choosing and carrying out change.
Every time we do work for the client we waste an opportunity for the client to learn that they can do it themselves.
19
questions
(strengths)
Why are open questions useful?
answers: more efficient
Examples “What to do you want to do?” “What are you most worried about?”
20
“You say you need to reduce your alcohol
“If you did decide to do it, how would you do it?” “What are the three best reasons for you to make this change?” “On a scale of zero to ten, how important is it for you to test your blood sugars?”
Open questions to elicit change talk
“How might you go about making this change?” “What gives you confidence you can do this?” “What would be a good first step?” “On a scale of zero to ten, how confident are you that you can practice protected sex?”
Open questions to elicit commitment talk
21
Reflect & reinforce strengths you hear from the client
Clients often discount valuable traits
Use downward inflections in your voice to promote a flowing conversation.
22
Types of Reflections
Repeating or slightly rephrasing (e.g., “you are feeling frustrated about your doctor’s approach”)
Going beyond what the person said to reflect content
(e.g., “your amphetamine use is harming your relationships”)
Reflects both sides of ambivalence, connected by “and” (not “but”) – both things are true. (e.g., “you are fearful about telling work about your health conditions and you can see that disclosing could be a big relief”).
Speaker
What the speaker means Words the speaker says Words the listener hears What the listener thinks the words mean
Reflection
Listener
The Proven Program for Raising Responsible Children.
23
Is a selective summary (bouquet) of all the change talk
(“I am listening”)
(“Have I heard you?”)
(“This is where we have got to”)
Example: “You have concerns about how your running away from
your health needs and over-working, you want to pace yourself and accept your limits. You are ready to reduce your work hours and make more time for exercise and your mental health”.
Turn to a neighbour. Choose a speaker and a listener. Speaker - “Something you should understand about me is that I am…. ” (use 1 or 2 words only) Listener - Make a reflective statement to clarify the meaning, inflecting your tone downwards: “You’re saying that you are….” (use 1 or 2 words only)…..” Speaker - answer “yes” or “no” only Offer 5 reflections. Take turns at being the listener.
24 On a scale from 0 to 10 where 0 is ‘not at all important’ and 10 is ‘extremely important,’ how important is it to you to [change this behavior]?
0-------1--------2--------3--------4---------5---------6---------7--------8---------9------10
Not at all Somewhat Extremely Important Important Important Why a 4 and not a 2……..? What would it take for you to get to a 6……..?
Elicit-provide-elicit strategy
A relationship lies at the heart of informing. Be attentive to the preferences and needs of the patient.
(Rollnick, Miller & Butler, 2008).
Elicit Provide Elicit
“Can you tell me what you understand about …?” “What you would you most like to know about …?” “What do you already know about ...?” “I have some other information that may be
if I shared that with you?” “Would you be interested in hearing about things that have worked for
“What do you make
“What are your thoughts about that?” “Do any of those ideas sound of interest to you?”
25
more likely to undertake change when they: see the change as important; are ready; and are confident about enacting change.
safety net to have conversations that don’t provoke discordance, and emphasises a person’s intrinsic worth and autonomy.
change, confidence and commitment.
Demonstrating empathy with reflective listening is an important skill. Less is more.
actively-engaged patient leads to truly collaborative relationships (Latchford and Duff, 2011).