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An Introduction to Motivational Interviewing

An Introduction to Motivational Interviewing. Evan Williams, PharmD Assistant Professor of Pharmacy Practice Husson University School of Pharmacy. Disclosures. I have no financial disclosures. Overview. Clinicians can only provide patients with clinical knowledge and education

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An Introduction to Motivational Interviewing

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  1. An Introduction to Motivational Interviewing Evan Williams, PharmD Assistant Professor of Pharmacy Practice Husson University School of Pharmacy

  2. Disclosures • I have no financial disclosures

  3. Overview • Clinicians can only provide patients with clinical knowledge and education • Patients make the ultimate decision to change • What can clinicians do to influence patient change? • Scare tactics • Lecture and educate • Motivate the patient to change

  4. Objectives • Describe Motivational Interviewing (MI) and its components • Identify tools pharmacists and pharmacy technicians can use to help implement Motivational Interviewing in their practice setting • Review literature that supports the effectiveness of Motivational Interviewing

  5. Pre-Test Questions • MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change. MI is a style of communication, not a technique. True or False?

  6. Pre-Test Questions • OARS in MI stands for A. Open Communication, Active listening, Reasoning with the patient, and Seeking change B. Oral arguments, Active listening, Rolling with Resistance, and Summaries C. Open-Ended Questions, Affirmations, Reflective Responses, and Summaries D. Ongoing dialogue, Affirmations, Resisting the Righting Reflex, and Seeking change

  7. Pre-Test Questions • Developing discrepancy involves: A. The patient discovering how current behaviors conflict with personal values or goals B. Telling the patient the negative results of current behaviors C. Allowing the patient to choose between two treatment options D. None of the above

  8. Self Reflection • Think of a “bad”habit you have tried to change • Dietary habits • Exercise habits • Workplace habits • Relationship habits • How long did it take to realize that this habit had a negative impact on you or others? • Months? Years? • Were you successful? Did you relapse?

  9. Defining Motivational Interviewing • “Motivational Interviewing (MI) is acollaborative, person‐centered form of guiding to elicit and strengthen motivation for change.” • Defined by the identification, examination, and resolution of ambivalence about changing behavior • Ambivalence: Feeling two ways about behavior change http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  10. Principles of MI • Method of communication • Not a technique • Increases mutual understanding • Collaborative • Honors patient autonomy • Strengthens a person’s own motivation for and commitment to change • Patient-centered http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  11. Development • WilliamR. Miller • Motivational Interviewing with Problem Drinkers • Behavioral Psychotherapy - 1983 • Stephen Rollnick and William R. Miller • 1991 article • Outlines clinical procedures • Has been revised and applied to many settings Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press. Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy. 1983, 11 (2); pp 147-172

  12. Components of MI • Key Elements of MI • Collaboration • Evocation • Autonomy • Principles of MI • Express Empathy • Support Self Efficacy • Develop Discrepancy • Roll with Resistance http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  13. Key Elements of MI • Collaboration • Dismisses hierarchy • Builds rapport • Non-confrontational • Focus is mutual understanding http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  14. Example of Collaboration • RG is a 57 year old male with hypertension and hyperlipidemia. On questioning it is revealed that he smokes about 1 pack of cigarettes daily. You would like him to quit smoking. • Which of the following shows the spirit of collaboration consistent with MI? • A. You need to stop smoking now. • B. What reasons do you have to stop smoking? • C. If you continue to smoke, you are increasing your risk for having a heart attack or stroke. • D. Let me help you to stop smoking.

  15. Key Elements of MI • Evocation • Patients discover their own motivation and skills for change • Draw out the patients own thoughts and ideas • “..lasting change is more likely to occur when the client discovers their own reasons and determination to change” http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  16. Example of Evocation • Pharmacist: “I’ve noticed you have been late filling these medications the last 2 months.” • Patient: “Yeah, I’ve been having a hard time keeping up with things as I am moving to a new home across town in a few weeks. I know taking my medications is important but I’ve been so busy lately that I forget sometimes.” • Pharmacist: “It sounds like you would like to take your medications but it has been a tough time dealing with the move.”

  17. Key Elements of MI • Autonomy • Ultimately it is the patient’s decision to change • Empowers the patient and gives them responsibility • As clinicians, we can encourage patients to develop their own “SMART” goals • Specific, Measurable, Achievable, Relevant, Timely http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  18. Example of Autonomy • DK is a 44 year old patient newly diagnosed with diabetes. After discussion, it is revealed that he eats desserts for relaxation. When asked how he thinks this impacts his diabetes, he states he does not know. • The response that best exemplifies autonomy consistent with MI is: • A. “May I tell you some information about how sweet foods impact your blood sugars?” • B. “Sugary dessert foods increase your blood sugar and negatively impact your diabetes.” • C. “Here is a pamphlet about how foods impact blood sugar.”

  19. Principles of MI • Express Empathy • See the situation from the patient’s perspective • Gain perspective on what the patient’s motivation may be • “It sounds like this has been tough for you” • “It seems like this situation has been difficult for you to accept” http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  20. Principles of MI • Support Self Efficacy • Focus onstrengths and skills patient already has • Highlight previous successes • Patient needs to believe that change is possible http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  21. Principles of MI • Develop Discrepancy • Patients identify their values and goals • Patients evaluate their current behaviors • Ambivalence is discovered when conflict between values/goals and behaviors is identified • Change is more likely when patients realize their behaviors are in conflict with their self‐identified values or accomplishment of goals • “On the one side, you feel unhappy that you cannot keep up with your grandkids because of your COPD, but on the other hand, you feel that smoking is one of the only ways you can relax.” http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  22. Principles of MI • Roll with Resistance • Do not challenge resistant statements • Confronting resistance promotes defensiveness and diminishes the likelihood of a patient finding their own reasons to change • Use the resistance as an opportunity to further explore the patient’s views • Be aware of when a patient is becoming frustrated • Closed body language • Negative verbal responses • Shortened verbal responses http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  23. Example of Rolling with Resistance • BG is an overweight veteran recently discharged from the Air Force. He has gained much of this weight since his discharge 14 months ago. The pharmacist suggested that BG enroll in clinic sponsored program for weight loss. BG declines enrollment. BG states that he is just not willing to exercise for 30 minutes 5 days a week because he is just too exhausted after work. • Which response best exemplifies the spirit of MI? • A. If you don’t lose weight, you are putting yourself at risk for other serious problems. • B. Could you try to exercise just a few days a week? • C. How much are you willing to exercise? • D. Why don’t you want to be healthy?

  24. Tools to Help Implement MI • OARS • Open-Ended Questions • Affirmations • Reflective Responses • Summaries • RULES of Motivational Interviewing • Resist the righting reflex • Understand the patient’s motivation • Listen with empathy • Empower the patient Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

  25. Open-Ended Questions • Elicit better responses from patients • Make a conversation less one-sided • Are not answerable with a simple yes or no Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

  26. Affirmations • Statements that recognize a patient’s strengths • Help support self efficacy • Tries to help patient believe change is possible despite past failures http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  27. Restate how the provider perceives the patient Allows for increased clarity Allows the listener to affirm the patient’s feelings Patient feels understood Reflective Responses Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

  28. Summaries • Reflection that recaps visit and highlights important areas • Can clarify ambivalence and discrepancies http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  29. Resist the righting reflex • “I know what is best” • Removes autonomy from the patient by insinuating the patient does not know what is best for themselves • Re-establishes hierarchy • Can undermine the patient’s motivation for change • Can create conflict Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

  30. Understand patient’s motivation • Patient’s reason for change is more important than the clinician’s • Explore importance of changing • Ask for a scaled answer • Why is it that number and not another? Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

  31. Listening with empathy • Use reflective responses • Allows patient to tell you more • Clarifies patient’s concerns • Confirms mutual understanding • Be aware of body language • Eye Contact • Nodding • Posture • Do not “understand” Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

  32. Empower the patient • Patients must believe change is possible • Failures can be demoralizing • Focus on previous successes • Even small victories can be uplifting • Encourage the patient • Let the patient know that they are in control of the change Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

  33. Eliciting Change Talk • DARN-CAT • Desire (I want to change) • Ability (I can change) • Reason (It is important to change) • Need (I need to change) • Commitment (I will make changes) • Activation (I’m ready and prepared to change) • Taking steps (I am doing specific things to change) http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

  34. Change Talk • Ask questions that will elicit answers that are consistent with DARN-CAT • Developing discrepancy • Desire • Reason • Need • Change ruler • Ability • Activation • SMART Goal Setting • Ability • Activation • Taking steps

  35. Examples of MI in Action

  36. Example #1

  37. Discussion of Example #1 • What went wrong? • What could the pharmacist have done instead?

  38. Example #1- Revisited

  39. Example #2

  40. Discussion of Example #2 • What principles of MI were used by this pharmacist? • How well did the change ruler work? • What else could the pharmacist have done?

  41. Example #3

  42. Discussion of Example #3 • What went right? • What examples of change talk did the patient give? • What could the pharmacist have done to improve?

  43. Evidence for Use of MI

  44. Effectiveness of MI • Growing body of evidence • 6 references 1980-1989 • 78 references 1990-1999 • 707 references 2000-2009 • Most studies show MI to be beneficial • Publication bias? • Most studies have limitations • Small sample size • Weak comparator groups • Various providers offering MI • Providers have differing levels of training in MI • Difficult to assess the manner in which MI is used Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

  45. Example: Police Officer Fitness • Effectiveness of MI on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study • N=109 officers • 67 officers completed the program (13 women, 54 men) • Previously completed a “high performance training seminar” • 10-week program • Goal to improve fitness, nutrition, and lipids • Weekly meetings with health coach • MI included to help the officers identify and achieve goals • 10-week endpoints were compared to baseline Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare. 2008 14:48

  46. Example: Police Officer Fitness

  47. Example: Police Officer Fitness • Significant improvements in physical fitness, blood pressure, and lipids for those who completed the 10-week course • Baseline values already at BP/Lipid goals • Unknown cardiovascular/diabetes risks • Changes in lipids comparable to low dose statin • Changes in BP comparable to addition low dose ACEi • Average Adherence to fitness regimen: • 80% for cardiovascular activity • 75% for strength training http://summaries.cochrane.org/CD003823/ace-inhibitors-for-the-treatment-of-high-blood-pressure

  48. Example: Police Officer Fitness • Limitations • large drop out rate (42%) • Selection Bias • Those who completed study were likely more motivated and active prior to study • Results likely only reflective of increased exercise • Short follow-up • Were benefits maintained • Is MI beneficial for long term lifestyle changes?

  49. MI Meta Analyses • Pattern of results show MI is likely • To confer at least a 10% advantage in success rates versus weak comparators • To be as good or better than established treatments • To take less time and resources • Best outcomes may be using MI pre-treatment Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

  50. MI Meta Analyses • Effective regardless of gender or age • Training level does not significantly impact effectiveness • Versatile • In what areas is MI most effective? Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

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