Motivational Interviewing: Enhancing Healthy Changes and Chronic Disease Self-Management

1. Motivational Interviewing:Enhancing Healthy Changes and Chronic Disease Self-Management September 15, 2010 Division for Heart Disease & Stroke Prevention Annual Meeting Robin L. Roberts, MA Carol D. Hamilton, PA-C, Ed.D. 1

2. Learning Objectives Describe evidence regarding effectiveness of Motivational Interviewing Discuss basic constructs of Motivational Interviewing Demonstrate three skills of Motivational Interviewing Describe common challenges/barriers to implementing Motivational Interviewing 2

3. What Is Motivational Interviewing? A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence Motivational Interviewing Training for New Trainers (MINT) Updated: November 11, 2008 3

4. Does Research On Motivational Interviewing Show: MI increases �change talk?� MI decreases resistance? Client resistance predicts lack of change? Frequency of client change talk predicts behavior change? 4

5. Motivational Interviewing Increases �Change Talk� TRUE Problem drinkers randomly assigned to MI (vs. confront/direct) showed 111% more change talk (Miller, Benefield & Tonigan, 1993) Psycholinguistic analysis of MI showed robust, atypical increases in change talk (Amrhein et al., 2003) 5 How many people think this is true? How many people think this is true?

6. Motivational Interviewing Decreases Resistance TRUE Problem drinkers randomly assigned to confront/direct showed 78% more resistance than those in MI Counselor confront responses specifically predicted client level of resistance (Miller, Benefield & Tonigan, 1993) Psycholinguistic analysis of MI showed robust decreases in commitment to drug use during MI (Amrhein et al., 2003) Miller, W. (2004) Toward a Theory of Motivational Interviewing. MINT 6 How many people think this is true? (Of course, the caveat here, is that MI, done well or skillfully, decreases resistance.)How many people think this is true? (Of course, the caveat here, is that MI, done well or skillfully, decreases resistance.)

7. Client Resistance Predicts Lack of Change TRUE Level of client resistance during counseling predicted absence of change in drinking (Miller, Benefield & Tonigan, 1993) Verbal commitment to drug use during MI predicted continued drug use (Amrhein et al., 2003) Resistance-poor outcome relationship replicated in several other studies Miller, W. (2004) Toward a Theory of Motivational Interviewing. MINT 7 How many people think this is true?How many people think this is true?

8. Frequency of Client Change Talk Predicts Behavior Change FALSE Miller, Benefield & Tonigan, 1993 Peterson master�s thesis (unpublished) Miller, Yahne & Tonigan, 2003 Miller, W. (2004) Toward a Theory of Motivational Interviewing. MINT 8 How many people think this is true? Well� actually� it�s not-- as several studies have shown. It turns out that people, including us here in this room, are much better at talking about doing what we should do than actually doing it. We�ll talk more about this later. How many people think this is true? Well� actually� it�s not-- as several studies have shown. It turns out that people, including us here in this room, are much better at talking about doing what we should do than actually doing it. We�ll talk more about this later.

9. Is Motivational Interviewing Effective? What does the evidence say? 9

10. Meta-Analysis MI reliably produces or triggers change across a broad range of target problems, settings and practitioners Is variable depending on site, setting, and practitioner/provider Miller, W. (2004) Toward a Theory of Motivational Interviewing. MINT 10 Look at the second point carefully, because it is critical� highly skilled practitioners have a much higher success rate than those who are less skilled.Look at the second point carefully, because it is critical� highly skilled practitioners have a much higher success rate than those who are less skilled.

11. Definition of Self-Management The tasks that the individual must undertake to live well with one or more chronic conditions, (including have the skills and confidence): Medical Management Role Management Emotional Management of their Condition Adapted from the Institute of Medicine, 2004 �what people do on a day to day basis to feel better and pursue the life they desire Adams, Greiner, Corrigan (Eds) Report of a summit. The 1st annual crossing the quality chasm summit-a focus on communities. 2004, Washington, DC National Academies Press 11

12. International Conference on Supportfor Self Management of Health ScotlandMay 11-13, 2010 Asthma Diabetes Stroke/neurological Cancer survivors COPD MS Arthritis Heart disease/CHF Cystic Fibrosis Kidney disease Vision loss/Aphasia Learning disabilities Multiple morbidities Leg ulcers Weight management Mental health Obesity Dementia Sleep HIV/AIDS 12 Self-Management pertaining to all of the chronic conditions shown here was discussed at this conference. Self-Management pertaining to all of the chronic conditions shown here was discussed at this conference.

13. Listening Exercise 13

14. Basic Constructs 14

15. Motivational Interviewing 15

16. Principles of Motivational Interviewing READS Roll With Resistance Express Empathy Avoid Argumentation Develop Discrepancy Support Self-Efficacy 16

17. Skills in Motivational Interviewing OARS Open-Ended Questions Affirmations Reflective Listening Summarize 17

18. Spirit of Motivational Interviewing Is collaborative rather than authoritarian Evokes the client�s own motivation rather than trying to install it Honors the client�s autonomy Rollnick & Miller (1995) 18

19. From a Program Viewpoint Person-Centered Collaborative Partnership Positive Interpersonal Atmosphere Avoids Telling a Person What to Do Recognizes it is the Person Who Must Make the Change 19

20. Change Talk - Stages of Change 20 Of course, this comes from DiClemente�s & Prochaska�s transtheoretical model of changeOf course, this comes from DiClemente�s & Prochaska�s transtheoretical model of change

21. Change Talk Change Talk refers to the participant�s mention and discussion of change Six kinds of change talk Desire Ability Reasons Need Commitment Taking Steps Rollnick, Miller,& Butler (2008) 21

22. How Change Talk Fits Together 22

23. Readiness Ruler 23

24. Exercise 2 24

25. It�s Not the Frequency of Change Talk, But the Strength of It That Counts Strength scaling of natural language Strength of Desire Strength of Ability Strength of Reasons Strength of Need Strength of Commitment Amrhein et al (2003) 25

26. Basic Constructs of Motivational Interviewing Resolution of ambivalence to change is promoted by accurate empathy Resolution in a particular direction is influenced by differential reinforcement of the client's speech adapted from William Miller--MINT 2004 26

27. Motivational Interviewing Demonstration 27

28. Remember OARS Open-Ended Questions Affirmations Reflective Listening Summarize 28

29. Decisional Change Tool 29

30. Decisional Change Tool

31. Decisional Change Tool

32. Practice! 32

33. Challenges to Implementing Motivational Interviewing 33

34. Questions? 34

35. Wrap Up 35

36. Learning Objectives Describe evidence regarding effectiveness of Motivational Interviewing Discuss basic constructs of Motivational Interviewing Demonstrate three skills of Motivational Interviewing Describe common challenges/barriers to implementing Motivational Interviewing 36 Depending on time�can ask learners to tell you what the take home points re: Basic constructs Skills of Motivational Interviewing Common Challenges to implementationDepending on time�can ask learners to tell you what the take home points re: Basic constructs Skills of Motivational Interviewing Common Challenges to implementation

37. Resources Berg-Smith Training & Consulting http://www.berg-smithtraining.com/index.html Stephen Cole, M.D., Comprehensive Motivational Interventions http://stevencolemd.com/default.aspx Michigan WISEWOMAN Program http://www.michigancancer.org/bcccp/WiseWomanProgram Motivational Interviewing Network of Trainers (MINT), http://www.motivationalinterview.org/ Institute for Motivation &Change http://www.motivationalinterview.org/ Stephen Rollnick, http://stephenrollnick.com 37

38. Select Bibliography Amrhein, P., Miller, W.R., Moyers, T.B., & Rollnick, S. (2005) A Consensus Statement on Change Talk. MINT Bulletin 12 (2), 3-4. Dull, C., & Rollnick, S. (2003). Rapid Reference to Lifestyle & Behavior Change: Rapid Reference Series. London: Elsevier Health Services. Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing Preparing People for change (2nd edition). New York: Guilford Press. Rollnick, S., Miller, W.R., Butler, C. (2008) Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press. Rosengren, David B. (2009) Building Motivational Interviewing Skills. New York: Guilford Press. 38

39. References Adams, Greiner, & Corrigan (Eds) (2004). Report of a summit. The 1st annual crossing the quality chasm summit-a focus on communities. Washington, DC National Academies Press. Amrhein, P.C., Miller, W.R., Yahne, C.E., Palmer, M. & Fulcher, L. (2003). Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting & Clinical Psychology. 71 (5), 862-878. Butterworth, S. W. (2008). Influencing Patient Adherence to Treatment Guidelines. Journal of Managed Care Pharmacy, 14(6), S21-S25. Cummings, S. M., Cooper, R. L., & Cassie, K. M. (2008). Motivational Interviewing to Affect Behavioral Change in Older Adults. Research on Social Work Practice, 19(2), 195-204. Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles.� Journal of Consulting and Clinical Psychology, 61, 455-461. Miller, W.R., Yahne, C.E., & Tonigan, J.S. (2003). Motivational Interviewing in Drug Abuse Services: A Randomized Trial. Journal of Consulting and Clinical Psychology, 2003, Vol. 71, No. 4, 754�763, 39

40. References (continued) Motivational Interviewing Network of Trainers (2008). Training for New Trainers (TNT): Resources for Trainers. http://www.motivationalinterview.org/ Ogedegbe, G., Chaplin, W., Schoenthaler, A., Statman, D., Berger, D., Richardson, T., Phillips-Caesar, E., Spencer, J., & Allegrante, J. (2008). A Practice-Based Randomized Control Trial of Motivational Interviewing and Medication Adherence in Hypertensive African Americans. Journal of General Internal Medicine, 23, 238 Ogedegbe, G., Chaplin, W., Schoenthaler, A., Statman, D., Berger, D., Richardson, T., Phillips, E., Spencer, J., & Allegrante, J. P. (2008). A Practice-Based Trial of Motivational Interviewing and Adherence in Hypertensive African Americans. American Journal of Hypertension, 21(10), 1137-1143 Prochaska, J.O.& DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice. 19, 276-288. 40