Motivation and Rehabilitation

1. Motivation and Rehabilitation Martin D van den Broek Friday 8th March 2013 The Wolfson Neurorehabilitation Centre & Atkinson Morley’s Regional Neurosciences Centre, St.George’s Hospital, London

2. Neurorehabilitation • Gains may be limited • Gains may fail to generalise • Gains may not be maintained • Cicerone et al, 2000

3. In-/Day-patient Admission 2 weeks Goal Planning Meeting 1 Goal Planning Meeting 2 Goal Planning Meeting 3 10 weeks Goal Planning Meeting 4 Goal Planning Meeting 5 Goal Planning Meeting 6 Discharge

4. Understanding Poor Motivation • Decide immediately what you are going to do • Your decision must be definite and permanent • You must stick to it • You must actively work to realise it • You must have no second thoughts • Uncertainty will be judged as evidence that you are not serious, • lacking insight, backsliding, violation of an agreement

5. In-/Day-patient Admission 2 weeks Goal Planning Meeting 1 Goal Planning Meeting 2 Goal Planning Meeting 3 10 weeks Goal Planning Meeting 4 Goal Planning Meeting 5 Goal Planning Meeting 6 Discharge

6. If patient’s wants do not match their • needs, then progress is unlikely • (Needs-Wants mismatch) • What patients need is what they want

7. Offers of Rehabilitation • Would you like help to become more independent (with shopping, cooking, etc)…? • Would you like to join the memory group to help you remember things better? • How would you feel about learning to feel less angry/irritable/depressed…? • I could ask the physiotherapist to see you for help with your walking • Would you like some tablets to help you with your mood? • The speech therapist may be able to help with your speech, would you • like to see him/her?

8. Why Rehabilitation? • Staff unable to manage patient in acute setting • Multidisciplinary team believe they can help • Unit has services appropriate to patients’ problems • Rehabilitation team have places on their programme • Family or carers experiencing a burden of care • MP or local politicians support family • Lack of appropriate Nursing/Residential facilities • Health Authority has policy of avoiding ‘blocked’ • acute beds

9. Why Rehabilitation? • Progressive GP wants best for patient • Progressive Solicitors want best for their client • Solicitors need to demonstrate their client is minimising • his/her loss • Insurers want to minimise final settlement • Rehabilitation service must fulfil contract with purchasers • Health authority does not want to fund private referral • Patient has problems that he/she wants to overcome

10. If the prime beneficiary of treatment is • not the patient, then progress is unlikely

11. Transtheoretical Model of Change Relapse Maintenance Precontemplation Action Contemplation Determination Prochaska, DiClemente & Norcross, 1992

12. Principles of Motivational Interviewing • Motivation to change is elicited from the client, and not imposed from without • It is the client's task, not the counsellor's, to articulate and resolve his or her ambivalence • Direct persuasion is not an effective method for resolving ambivalence • The counselling style is generally a quiet and eliciting one • The counsellor is directive in helping the client to examine and resolve ambivalence • Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction • The therapeutic relationship is more like a partnership or companionship than expert/recipient roles

13. Stages of Change & Therapist Tasks (Miller & Rollnick, 1991) Stage Therapist’s motivational tasks Precontemplation:Raise doubt - increase client’s perception of problems Contemplation: Tip the balance - evoke reasons for change, risks of not changing; strengthen self-efficacy for change in behaviour

14. Stage Therapist’s motivational tasks Determination:Help client to determine best course of action Action: Help client to take steps towards change; commence rehabilitation

15. Stage Therapist’s motivational tasks Maintenance:Help client identify & use strategies to prevent relapse Relapse: Help client to renew the processes of contemplation, determination and action, without becoming stuck or demoralised

16. Motivational Approach to Goal Setting Example: Diary Training Motivational Readiness Goal Setting Stage Intervention Educational Methods Question & Answer Method Structured Information Gathering Test Results Feedback Video Feedback Role Reversal Exercises Precontemplation Problem Identification “I’ve got a problem with my memory” Goal Definition “I need to use a memory aid” Evoke reasons for Rehabilitation Discuss pros & cons of change Discuss Importance & Confidence in achieving goal Contemplation Option Appraisal “I could use a diary, notebook, organiser, go to a self-help group” Offer advice Provide Affirmation Clarify Needs Remove Barriers Determination Solution Selection “I’ll use a diary” Envisioning Emphasize Personal choice Clarify details (of aid use) Strengthen Confidence Action Start Diary Training

17. Does MI work in neurorehabilitation?

18. Evaluation of MI after acute Stroke: A Randomised Controlled Trial Caroline L. Watkins, Lancaster Martin D.van den Broek, London Cathy Jack, Belfast Hazel Dickinson, Liverpool C. F. Deans, M. F. Auton, D. Forshaw, H. Gardner, M. J. Leathley, C. E. Lightbody, J. Marsden, J. McAdam, I. McClelland, C. J. Sutton

19. Aim To determine whether Motivational Interviewing early after stroke can alter: • Mood • Function • Expectations about recovery At 3 months post-stroke and then at 12 months

20. Results

21. 1388 Assessed 696 Eligible 411 Consented & randomised 285 Refused 204 Intervention Group Usual Care + MI 207 Control Group Usual Care Recruitment

22. Can MI alter mood? • Significant benefit of MI over usual care (p=0.033) • OR (normal mood at 3m)=1.60, 95% CI = 1.04-2.46

23. Change in Mood 80 Usual Care

24. Change in Mood 80 77 Usual Care MI

25. Change in Mood 80 77 127 127 Usual Care MI Usual Care MI

26. Conclusions Results at 3 months post-stroke indicate that Motivational Interviewing • Can benefit patients’ mood after stroke • No effect on expectations or function Results at 12 months similar.