Motivating your Patients for Behavior Change

1. Motivating your Patients for Behavior Change Steven D. LaRowe, Ph.D. Assistant Professor Department of Psychiatry and Behavioral Sciences Medical University of South Carolina Health Behavior Coordinator Ralph H. Johnson VAMC

2. Conflicts • No conflicts to report • Views expressed here are those of Dr. LaRowe and do not necessarily reflect those of MUSC or the VA

3. The nature of the problem… Your patient arrives for his (or her) appointment During the last visit, the patient was advised to follow a treatment plan Upon his return, you find that that patient has not implemented the plan What do you do?

4. The nature of the problem (continued)… Of course, you again recommend the patient follow the plan You provide logical reasons why the patient should do so Perhaps you remind the patient of the health consequences if the plan is not followed Does the patient argue or does he agree? The patient leaves… …and still no changes are made

5. What’s going on? Why do patients keep coming to appointments but make no change? Because the patients wants good health, but also wants to continue to do the things they are doing that cause bad health “Ambivalence is a state of having simultaneous, conflicting feelings toward a person or thing” – Thanks Wikipedia! Or, feeling the same way about two different conflicting things

6. Ambivalence: If I don’t quit I’ll have breathing problems! I love my cigarettes! Smoking helps me relax! Smoking leads to disease or death! Patient wants to avoid this… …but also wants to continue this.

7. How NOT address ambivalence • Our first instinct is often to provide information to “make it right,” to persuade or convince the patient to change their habits using logic • We should strive to avoid this because it is often ineffective…(but why?) • Hypothesis: If someone is AMBIVALENT and we argue for one side of an issue, their reflex will be to argue the OPPOSITE side of that issue. • In other words, when people feel criticized they tend to defend their behavior.

8. Arguing with the ambivalence… The ambivalent patient will argue for the side of ambivalence that is being attacked! Provider (logically) argues for change If you don’t quit smoking you can’t get surgery! If I don’t quit smoking, I can’t get surgery! I love my ciagrettes! Smokingcanlead to disease or death! Smoking helps me relax! Smokingcanlead to disease or death! (Provider) Patient argues more, and is now less ambivalent towards change than before Provider argues more

9. What can we do? Motivational Interviewing! Motivational Interviewing (MI) is …a conversation, not an argument, about behavior change …explores ambivalence …through use of reflective (person centered) communication skills …to emphasize the person’s own reasons for change. It is a strategic conversation method to help a person move toward a particular change goal …that uses specific communication techniques to elicit, strengthen and reinforce change talk …and provides a way to responds to resistance (non-change talk) in a non confrontational way

10. Motivational Interviewing • Is an Evidence-Based Practice associated with better health outcomes: • Led to reduced saturated fats (Brug et al. 2007) • Reduced weight, BP, cholesterol (Hardcastle et al. 2008, Armstrong et al. 2011,) • More fruit intake in African Americans (Resincow et al. 2001) • Can be used in brief encounters • NOTE: Not a panacea…appropriate for patients who are ambivalent, but may not be effective for people completely ready to change or people determined to make no changes

11. Review of MI: Spirit and Basic Skills • While we talk to patients, we want to emphasize their AUTONOMY, talk in a COLLOBORATIVE manner and EVOKE their values and abilities • In this context we use these basic skills… • Open-ended questions • Affirmations (reflecting a patient’s sense of his/her own accomplishment) • Reflections (MOST IMPORTANT SKILL!) • Summaries

12. OARS: Basic MI Skills… • Open-ended question: Can’t be answered with a simple YES or NO. Examples: “What brings you here today? Tell about…Tell me more about that…” • Affirmation: NOT praise, but a reflection of the patient’s sense of accomplishment. Ex.: “You’re really glad you’ve been able to cut down on sweets.” • Reflection: Paraphrasing, mirroring what patient says, labeling emotions. Ex.: “You have been cutting down on sweets…You seem worried about your diabetes…” • Summarizing: Bring all the above together in a summarizing statement

13. Goal of MI in Session • Providers often hope that Motivational Interviewing will motivate patients to immediately engage in desired behaviors • But MI Involves engaging in a conversation in the spirit of Autonomy, Collaboration, and Evocati0n, using OARS… • …To elicit and strengthen Change Talk… • The theory of MI: Increased Change Talk -> eventual change

14. What is Change Talk? • Patient language that moves toward change • Opposite from “Sustain Talk” – these are the reasons that patients give to defend their behavior • Specific to a particular target behavior or set of target behaviors. • Usually initiated by the patient, but also elicited by the clinician. • Expresses patient’s desires, ability, reasons, & need to change • States willingness & intention to change.

15. Change Talk (DARN C) • Desire for Change: “I think I should probably change my diet; I want, I wish, I would like…” • Ability to Change: “I’ve changed my eating habits before; I can, I could, I am able to…” • Reasons for Change: “Improving my diet will probably help me lose weight.” • Need for Change: “I need to eat less sugar to control my diabetes; I need to, I have to, I must, It’s important that I…” • Commitment to Change: “I will stop eating sugary snacks between meals this week. I will, I intend to, I am going to…” • *** If you are hearing COMMITMENT, I would argue this is the time to starting setting specific goals.***

16. Gauging expectation for MI Goals Providers sometimes expect that MI directly leads to changes and are highly invested in seeing those changes come to light… Use of MI to promote smoking cessation Change Talk Patient should makes changes (and soon)!! …but the CHANGE TALK is the goal in session. …and we might judge the intervention to be unsuccessful if patient does not engage in expected changes right away.

17. Evoke Change Talk to Gradually Guide Change Using MI skills facilitates change talk within session… Use of MI (OARS) to promote change (e.g. smoking changes) Patient expresses desire, ability, reasons, need, commitment to change. Change Made? Patient who has expressed change talks starts incremental movement towards change (e.g. cutting down, planning) NO YES …patient sometimes makes incremental changes on the way to the final change. Maintenance

18. Using MI skills to talk about stopping an unhealthy dietary habit… Open-Ended Question Summary Tell me what you like about smoking… Let me see if I understand, you don’t want to keep smoking, you’ve quit before, you want to be here for your children and improve your breathing I love my food! Reflection Open-Ended Question You really like to be able to smoke! Affirmation What are some of your concerns about your smoking? Sounds like this is something you feel confident you can do! Yes! (Finally a provider gets me!) Where do we go from here? Need I need to improve my breathing! I don’t want smoke because I could die! (Provider) I think I’ll cut down on my cigarettes, make an appointment, and start exercising again next week. I want to be here for my children! Desire I know I can quit, I’ve done it before! Commitment Ability Reason

19. Motivational Rulers Can Evoke Change Talk • Motivational Ruler: Ask patient to rate importance, readiness, or confidence for change on a scale of 0 (zero) to 10. • Example: “How ready are you to reduce your smoking on a scale of 0 to 10 where 0 is none at all and 10 is extremely important?” • Assuming there is a value other than 0 (zero), ask “Why (their value) and not (a lower value)?” – example, “Why a 5 and not a 2?” • The response to this will usually result in the patient giving you CHANGE TALK… • And this rating reveals much more than a simple yes/no answer

20. Using Motivational Rulers to evoke change talk… How important is it to you to reduce your smoking? I would say a 6. I think I will cut down cigarettes, make an appointment, and start exercising again next week. Why a 6 and not a 4? I need to improve my breathing! How confident are you that you can make this change on a scale of 0 to 10? Change talk, time to set goals Why an 8 and not a 4? I’d give it an 8. (Provider) You want to reduce your smoking and you’ve been able to do it before. Where do we go fro m here? I’ve done it before!

21. Barriers to Using MI • Doesn’t it take too much time? • It certainly takes time to learn, but can be done in brief fashion when mastered • Sometime reflective listening can diffuse tension and make patients more receptive • I have to ensure that patients understand a long list of educational information (e.g. in preparation for bariatric surgery, inpatient consults) • The use EVOCATIVE spirit of MI to find out what patients already know, supplement their knowledge • Open-ended questions and reflections help us gauge how well they are learning it

22. Final Thoughts • MI can be used to help elicit patients’ internal motivation to engage in behaviors necessary to improve dietary practices • MI takes time to learn, but can be used seamlessly within one’s practice once mastered • The motivational ruler is one technique that provides structure to practice these skills in a focused manner

23. Resources • For training and resources, visit www.motivationalinterviewing.org • Several consultants available via internet search • Steven D. LaRowe, Ph.D. Email: larowe@musc.edu