Motivational Interviewing: The Challenging Patient & Interactive Case Studies

1. Motivational Interviewing: The Challenging Patient & Interactive Case Studies Michael Vallis, PhD R Psych Psychologist and Lead, CH Behaviour Change Institute Associate Professor, Dalhousie University 4th Annual Chronic Disease Self-Management Conference

2. Let’s Start With What We Know • The strongest predictor of future behaviour is .............? • PAST BEHAVIOUR! • What does this say about the likelihood of behaviour change? • NOT!

3. And, by the way, the strongest predictor of changed behaviour is.........? SELF-EFFICACY A person’s confidence to perform a specific behaviour in a specific context for a specific time period and in the face of specific barriers

4. Self-Management Support Skills • Relationship skills - establishing a change based relationship using motivational interviewing • Motivational skills - getting to the behaviour • Behaviour change skills - making sustainable changes • Emotion management skills - helping to maintain the behaviour

5. What Does Self-ManagementSupport Really Mean? • Fundamental change in the relationship between the individual and the HCP • From • Expert clinician with uninformed helpseeker • “Let me tell you what you need to do” • “Let me tell you what you need to know” • To • We both have a role to play • “I understand that you will make your own decisions and I respect that. Can we have a conversation about your health”

6. Change-Based Relationships • A helping alliance involves 3 components: • Bond • Task • Goal

7. Motivational Interviewing • Ask questions, Minimize statements • Express Empathy • Take a curious, nonjudgmental stance • Learn to sit with ambivalence • Avoid argument • Roll with resistance • Support Self-Efficacy

8. Determine Readiness • Is the behaviour (or lack of it) a problem for you? • Does the behaviour (or lack of it) cause you any distress? • Are you interested in changing your behaviour? • Are you ready to do something to change your behaviour now?

9. Getting to the Behaviour Readiness Assessment Not Ready Ambivalent Ready • Understanding the behaviour • Personal meaning • Seriousness, personal responsibility, controllability, optimism • Expanding on readiness • Personal/meaningful reasons to change • Willingness to work hard - connect to principles • Delay of gratification Go Right to Behaviour Modification • Decisional Balance • Self-Efficacy • Barriers/Temptations • Especially social, cultural and environmental

10. Working With the Behaviour:Behaviour Modification • Goal Setting • SMART GOALS • Specific, measurable, achievable, relevant, timely • Shaping • Importance of NEXT STEP • Stimulus control • Respecting the environment • Reinforcement Management

11. Maintaining Change:Emotion Management • Your Task • Identify • Educate • Recommend • Support

12. Managing Emotions • Dealing with unhealthy coping strategies • Recognize the value of unhealthy behaviour and focus on replacing the function • Stress Management • Physical discharge • Physical calming • Express emotions • Seek social support • Referral for psychological intervention

13. “I want to eat what I want, when I want” • “I feel fine, I am sure if my diabetes was a problem I would feel sick?” • “Everytime you follow advice new research gets released that says the old way was better”

14. CASES • 50 yo single female living with elderly mom (depressed drinker), - diabetes COPD dysthymic - she is stuck - not moving • 17 adolescent male - grass - referred from school - cocaine and alcohol - struggle to avoid situations -he’s becoming concerned • 19 yo referred from probation (drinking/driving) - meets regularly - says wants to make changes (don’t believe him) - “are you here because of probation” - ambivalent but slippery • 70 yo female - smoker (1ppd) - relapse when stressed - motivated - COPD, ca, diabetic and bipolar