Motivating Patients to Make Change

1. Motivating Patients to Make Change Ann Landes, Ph.D. alandes@zoho.com

2. Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there areno conflicts of interest represented in the presentation.

3. Objectives • Introduce the model of Motivational Interviewing (MI) • Provide an overview of the concept of "Stages of Change" and its application to patient self-management • Explain how MI can be employed by medical providers to encourage collaboration between the patient and the medical provider, as they work toward positive behavior change and improved quality-of-life

4. Support for Motivational Interviewing

5. Hettema, Steele, and Miller (2005) • Found significant support for the efficacy of MI across 75 randomized controlled trials (RCTs). • Adding MI to the beginning of treatment led to sustained outcome improvements. • Outcomes were better when no manual was used. *(e.g., focus more on the alliance/relationship between provider and patient)

6. Applications • Alcohol abuse • HIV risk reduction • Illicit drug use • Smoking • Treatment adherence • Diet/exercise • Gambling • Intimate relationships • Eating disorders • Water purification to promote health

7. Beach, Keruly, & Moore, 2005; Schneider, et al., 2004 Patient-Centered Communication from Provider Effective Patient-Physician Relationship & Communications= Greater patient satisfaction in medical care Greater improvements in general medical conditionIncreased adherence to medical treatments

8. What is mi?

9. Motivational Interviewing is a… • method that has been found to be successful in increasing intrinsic motivation to change by exploring and resolving ambivalence • collaborative effort between the provider and patient (Miller & Rollnick, 2002)

10. Motivational Interviewing … • helps patients identify and address roadblocks to change (i.e., fears, lack of skills/information, needed supports, etc.) • focuses on the way we as providers can inspire positive change in the lives of patients (Miller & Rollnick, 2002)

11. The Spirit of MI

12. Notes about Ambivalence • When an individual feels two ways about something • Normal to the process of change Trap If we argue for change, the patient may argue for the status quo, leading to decreased likelihood for change.

13. Motivational Interviewing is a method that … • works to create collaboration between the provider and the patient • focuses on patient choice/autonomy • sees ambivalence as pathological • Answers “1” and “2” • None of the above

14. The Individual and Change

15. Patients with HIV/AIDs and Change • Adherence to current medication schedule • Maintaining regular medical appointments • Making healthy choices about use of alcohol, tobacco, illicit drugs • Attending to self-care needs, such as diet and exercise • Practice consistent precautionary behaviors to reduce transmission (prevention) • Enlisting social support(s)

16. Prochaska and DiClemente’sStages of Change Model

17. Pre-contemplation • “I see no problem(s) to address at this time.” • “I know there’s a need for change, but I don’t want to right now.” (… has not given much thought to change) Provider Role Bring awareness to the issue Encourage engagement of the patient

18. Tell-Tale Signs – “I’m not ready” • Argues/disagrees with the provider’s diagnosis or suggestions • Resists offers of assistance • Expresses denial of problems/concerns • Communicates a sense of hopelessness about the situation

19. Contemplation • “Yeah, I’ve thought about my health needs, but I’m just not ready yet to change.” (ambivalence) Provider Role Increase awareness about the options for and benefits of change * Keep the patient thinking about positive change.

20. Preparation/Determination • “OK, I’m prepared to make some changes, but, I’m not really sure I can or know how to do it.” Provider Role Decrease barriers to change by providing resources, information & offering assistance Address issues of self-efficacy

21. Action/Will Power • “I know I need to make some changes; I have had to make changes before and did it.” Provider Role Encourage movement by helping to develop realistic goals and a plan-of-action Offer resources and support

22. Maintenance • “Wow! I have made some impressive changes! How can I continue on this path?” Provider Role Help maintain positive focus and reduce opportunities for relapse

23. Relapse • “I was doing really well, I thought, but then I got tired of having to focus so much energy on caring for my health. So, I just quit.” Provider Role Normalize that relapse is “OK” (reduce shame) Encourage honest discussion about what led to relapse Assist in re-exploration of personal goals Help develop strategies for re-engagement

24. Tips To Remember • It is not about us. • Responsibility lies with the individual patient and what they feel they need in their life. • Our role is to be active, caring observers who are present to help the patient. • Because individual behaviors can change over time, we need to remain vigilant about checking-in at each encounter(Metsch, et al., 2004).

25. The Health Care Provider & Motivational Interviewing Instruments of change

26. Provider Stance • Guiding or coaching (versus directing) and supporting • Respecting individual autonomy & empowerment • Expressing belief in the patient’s ability to make decisions • Resisting the reflex to make it “right” or to label actions as “good versus bad”

28. Four Processes of MI • Engaging: listening to understand – “OARS” • Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, offering information and advice • Evoking: selective eliciting, responding, summaries toward change talk • Planning: moving toward commitment and change

29. Change Speak – DARN-C Desire: I want to get healthier. Ability: I can do this if I set my mind to it. Reasons: My heavy drinking is causing me many health problems. Need: My family worries about me too much; it is not fair to them. Commitment: I will start getting more regular health check-ups.

30. Engaging: Building a therapeutic allianceStep 1 OARS Open ended questions Affirmations Reflective Listening Summaries http://motivationalinterview.org/clinical/interaction.html www.mpaetc.org/downloads/motiv_interv_09.pdf

31. O-A-R-S Open ended questions to elicit change talk: • “What are some of your reasons for decreasing your alcohol intake?” (desire) • “How might you go about decreasing your drug usage?” (ability) • “What do you see as some benefits to lowering your alcohol usage?” (reasons)

32. O-A-R-S Open ended questions to elicit change talk: • “How important is it for you to decrease your usage?” (need) • “What might you do to start reducing your alcohol consumption?” (commitment)

33. O-A-R-S Affirmations: • Use to encourage people to see their “resources” • Make them personal and genuine • Explore partial successes and attempts and intentions • Highlight patient attributes, effort “I’m really glad you decided to come in to see me today.”

34. O-A-R-S Reflective Listening (paraphrasing pt comments): “It sounds as if you are a bit concerned about how to make healthier choices in your life.” Summaries (restating patient’s main points): “Let me make sure I heard you correctly. You do want to address your drug usage and you want information about how to take more precautions in your sex life.”

35. O.A.R.S. is an acronym for the skills that can be used to engage patients in treatment; it stands for • O-offer assistance; A-ask questions; R-refer out; S-summarize • O-operationalize; A-attend; R-request tests; S-start goals • O-open ended questions; A-affirmations; R-reflective listening; S-summaries • O-open up discussion; A-attend to; R-reflect; S-shorten session

36. Focusing: Target one areastep 2 • Identify a strategic focus (agenda setting) • Explore patient’s motivation, while listening for change talk • Offer and share information - ask permission, Elicit-Provide-Elicit

37. Example • Target behavior:use of condoms • Agenda setting: “Hello, Sandy, it’s nice to see you. The last time we met, we spoke about your goal to begin using condoms more regularly. I’d like to start with that topic, unless you have something more pressing to discuss.” • Sandy: “I didn’t do too well - I do want to do better.” • Possible Reflections: • “You found it more difficult than you thought.” • “You’re still committed to change and you found it challenging.”

38. Example (cont.) • Sandy: “My partner doesn’t like using condoms. He won’t even talk to me about it.” • Reflections: • “It’s been difficult to make the change, especially since your partner doesn’t agree with the change.” • Sandy:“Yeah, I guess; I don’t really see the need either, since I am monogamous.” • Reflections: • “You have questions about the importance of using condoms, since you are having sex with just your partner.

39. (cont.) • Sandy: “Yeah, it’s such a big change; I’m not sure it’s worth it.” • Reflection: • “You feel a bit unprepared for making this change and uncertain about whether using condoms is what you want to do.” • Sandy: “Yeah. I do and I don’t’ want to make the change.” • Reflection: • “You have some motivation to change. We can work on this together. I have some ideas and information. Can I share them with you?” • Sandy:“Okay.”

40. Conversation continues • Transitional Summary: “Alright, if I can summarize what we have spoken about: You are confused about the reasons for using a condom, it’s been difficult to make the change since your partner does not agree with it, and you feel unprepared. So, you would like more information and some ideas that may work for you.” • Key Question: “Where do you want to begin – with information about condom use, ways to make the change, or how to approach your partner?” (autonomy)

41. “Elicit, Provide, Elicit” (information sharing process) • ELICIT readiness and interest • “What do you know about the effects of …” • “What concerns do you have about…?” • PROVIDE clear information or feedback • “What happens to some people is that…” • “The results of your tests suggest that…” • “As your doctor/counselor/nurse, I strongly urge you to…” • ELICIT the interpretation or reaction • “What do you think?” • “How do you think you might…?”

42. Evoking – pulling for change talkstep 3 • Encouraging, nurturing, reinforcing change talk • Guiding towards change –finding alignment (and discrepancy) between current behavior and goals and values • Rolling with resistance • Summarizingwhere you are

43. Approaches for Evoking Change Talk Ruler for importance Querying extremes Goals and Values Typical day Looking forward Coming alongside

44. Importance Ruler “On a scale of 0 to 10, how important is it to you to _________?” “What is the reason it’s (x) and not (a lower number)?” (If number is less than 8), “What would it take to move it up in importance just one number?” {Listen, reflect} …“What do you think you might do next?”

45. Querying Extremes “What are the worst things that could happen if you don’t make this change?” “What’s the best thing that could happen if you make this change?”

46. Goals and Values “Let’s, for a moment, move away from this ____ issue and focus on the things that are most important to you, your life dreams, goals, and values. Tell me the most important areas for you.” Listen, then say: “So being here, healthy, is important. How does your (behavior) fit in with that?” • Relate to values, bigger issues. May be useful to prompt or have visual aides that reflect common values and goals (family, work, country, spirituality, community) (Miller and C’deBaca, 2001)

47. Rolling with Resistance • Affirm and accept patient’s fears, concerns: “I can understand your worries about the side effects of all you medications. Let’s spend some time discussing this.” • Reflect other’s concerns:“I hear you saying that you don’t care about maintaining a healthy diet; but, how does this impact your partner?” • Reframing patient concerns to positive movement “So what you’re saying is that you desire to quit smoking and (instead of BUT) you realize this may be hard to do.” • Offer assistance “How can I help you move towards making positive change? What is needed?”

48. Assessment and Planningstep 4 • Summarizing where the patient is with regard to making change • Developing a goal and action plan • Exploring, building patient’s confidence/self-efficacy (affirmations) • Addressing real and perceived barriers, challenges • Scheduling follow-up

49. Assess Stage of Change “How confident/ready are you in making changes to your lifestyle?” “How do you feel about the requirements of maintaining your health?” “ What do you hope with regard to your health diagnosis for the future?” “What concerns do you have about your risk-reduction practices?”

50. Pre-contemplation Listen and help address any patient concerns “It sounds as if you want to reduce your alcohol intake, but your partner does not want to change his/her lifestyle. Maybe we can brainstorm ways that you can address this with your partner.” Encourage information sharing from patient “What is your opinion or belief about using condoms?” “Tell me how you have been able to manage your medication requirements.” Express interest and empathy “The decisions you have to make are very difficult. I know you can make the decision on your own, but I would like to assist you in learning more about your options.”