Motivational interviewing in primary care
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MOTIVATIONAL INTERVIEWING IN PRIMARY CARE. BRADLEY SAMUEL, PHD DIRECTOR OF BEHAVIORAL HEALTH EDUCATION UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE DEPARTMENT OF FAMILY & COMMUNITY MEDICINE. ASSUMPTIONS ABOUT MOTIVATION. MOTIVATION IS MALLEABLE

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MOTIVATIONAL INTERVIEWING IN PRIMARY CARE

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Motivational interviewing in primary care

MOTIVATIONAL INTERVIEWING IN PRIMARY CARE

BRADLEY SAMUEL, PHD

DIRECTOR OF BEHAVIORAL HEALTH EDUCATION

UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE

DEPARTMENT OF FAMILY & COMMUNITY MEDICINE


Assumptions about motivation

ASSUMPTIONS ABOUT MOTIVATION

MOTIVATION IS MALLEABLE

SUBJECT TO CHANGE IN CONTEXT OF PATIENT-PROVIDER RELATIONSHIP

THE WAYS IN WHICH ONE TALKS WITH PATIENTS CAN INFLUENCE PERSONAL MOTIVATION FOR BEHAVIOR CHANGE


Spirit of motivational interviewing

SPIRIT OF MOTIVATIONAL INTERVIEWING

COLLABORATIVE – Active collaborative conversation and joint decision making process.

EVOCATIVE – Access & activate motivation and resources for change.

HONORS PATIENT AUTONOMY – Requires some detachment from outcomes. Recognition that ultimately it is patients who decide what to do.


Styles of communication

STYLES OF COMMUNICATION

  • DIRECTING

  • FOLLOWING

  • GUIDING

  • (All three are valid…Guiding is best tool for behavior change and motivation)

  • (Helping professionals typically rely on Directing)

  • (Following is best after giving information)


Guiding

GUIDING

LISTENING CAREFULLY & EMPATHICALLY

ASKING ABOUT OPTIONS CONSIDERED

OFFERING WHAT YOU KNOW ABOUT DECISION MAKING, RELATIONSHIPS, ETC.

RECOGNIZING & HONORING THAT “IT IS YOUR DECISION TO MAKE.”


Guiding in mi

GUIDING IN MI

MOTIVATIONAL INTERVIEWING:

1) Is specifically goal directed wherein practitioner has a behavior change goal in mind and gently guides patient in ways that he/she may pursue that goal.

2) Pays particular attention to specific aspects of patient language and actively seeks to evoke patients own arguments for change.

3) Involves competent use of well defined set of clinical skills to evoke patient behavior change…


Agenda setting

AGENDA SETTING

GUIDING MEANS FINDING OUT WHERE PERSON WANTS TO GO…

BRIEF DISCUSSION IN WHICH PATIENT IS GIVEN AS MUCH DECISION MAKING FREEDOM AS POSSIBLE.

QUESTIONS LIKE “WHAT CONCERNS YOU MOST?” OR “WHAT WOULD YOU LIKE TO FOCUS ON FIRST?”

PROGRESS OR BEHAVIOR CHANGE IN ONE AREA OFTEN GENERALIZES…DO IT IS OK FOR PATIENT TO CHOOSE EASIEST OPTION FIRST.


Three core communication skills

THREE CORE COMMUNICATION SKILLS

  • ASKING

  • LISTENING

  • INFORMING

    • MOST PRACTIONERS REPORT UTILIZING ASKING & INFORMING IN THE SERVICE OF A DIRECTING STYLE.

    • MI PROPOSES THAT PRACTIONERS CONSIDER AN ASKING, LISTENING, INFORMING APPROACH THAT IS IN THE SERVICE OF GUIDING.


Ambivalence

AMBIVALENCE

  • “I need to lose weight, but I hate exercise…”

  • “I should quit smoking, but I can’t seem to do it.”

  • “I mean to take my medicine, but I keep forgetting.”

    • HALLMARK OF AMBIVALENCE IS USE OF THE TERM BUT


Resolving ambivalence

RESOLVINGAMBIVALENCE

ACKNOWLEDGE AND REFLECT BOTH SIDES OF AMBIVALENCE i.e. “You want to lose weight and hate exercising…”

COLLABORATIVE EXPLORATION

*NOTE THAT REFLECTION SHIFTS FROM “BUT” TO “AND.”

HOLD OFF ON TRYING TO FIX THIS NOW.

LISTEN FOR, AND ELICIT, CHANGE TALK.

WE WANT THE PATIENT TO VOICE REASONS FOR CHANGE.


Listening for change talk

LISTENING FOR CHANGE TALK

  • RECOGNITION OF, AND ATTUNEMENT TO, CHANGE TALK.

  • LEARNING TO ELICIT CHANGE TALK…

  • EXAMPLES OF CHANGE TALK…

    • “YES I WILL…”

    • “I MIGHT BE ABLE TO…”

    • “I WISH I COULD…”

    • “I’LL TRY…”


Levels of change talk

LEVELS OF CHANGE TALK

DESIRE – “I want to…”

ABILITY – “I can…”

REASONS – “I would probably feel better if…”

NEED – “I should…”

COMMITMENT – “I will…”

TAKING STEPS – “I started…”


Pre commitment levels of change

PRE-COMMITMENT LEVELS OF CHANGE

  • DESIRE

  • ABILITY

  • REASONS

  • NEED

    • KEY IS TO LISTEN, REFLECT, AND AFFIRM AT THESE LEVELS.

    • SKILLED USE OF LISTENING AND COMMUNICATION AT THESE LEVELS INCREASE LIKLIHOOD OF COMMITED CHANGE.


Commitment levels of change talk

COMMITMENT LEVELS OF CHANGE TALK

COMMITMENT

TAKING STEPS


Zero to ten assessments

ZERO TO TEN ASSESSMENTS

“HOW IMPORTANT IS IT FOR YOU TO QUIT SMOKING (MAKE THIS CHANGE)?

0---------------------------------10 scale

FOCUS DISCUSSION ON “WHY NOT LOWER” RATHER THAN “WHY NOT HIGHER.” e.g. “WHY DID YOU CHOOSE FIVE INSTEAD OF THREE?”

THIS FACILITATES CHANGE TALK INSTEAD OF AMBIVALENCE OR RESISTANCE.


Guiding through change talk

GUIDING THROUGH CHANGE TALK

  • TASK IS TO ELICIT CHANGE TALK RATHER THAN RESISTANCE FROM PATIENTS.

  • THE ‘HOW OF IT’ IS TO ASK OPEN ENDED QUESTIONS THAT REFLECT CURRENT LEVEL OF CHANGE TALK & THEN LISTEN.

  • EXAMPLES:

    • “WHY WOULD YOU WANT TO QUIT SMOKING?”

    • “HOW WOULD YOU DO IT, IF YOU DECIDED TO?”

    • “WHAT AR E THE REASONS YOU WOULD QUIT IF YOU DECIDED TO?”


Moving from talk to behavior change

MOVING FROM TALK TO BEHAVIOR CHANGE

EXPLORING AMBIVALENCE

GATHERING CHANGE TALK

MEASURING MOTIV., CONFIDENCE, HOPEFULNESS, IMPORTANCE

LISTENING, GUIDING, INFORMING

SUMMARIZING MOTIVATION FOR CHANGE

TIMING MOSTLY OPEN ENDED QUESTIONS

ASKING FOR WILLINGNESS TO CHANGE

DEVELOPING PLAN


Three practical recommendations about asking listening

THREE PRACTICAL RECOMMENDATIONS ABOUT ASKING & LISTENING

1) USE OPEN RATHER THAN CLOSED ENDED QUESTIONS.

2) TRY NOT TO ASK TWO QUESTIONS IN A ROW.

3) TRY TO OFFER AT LEAT TWO REFLECTIIONS FOR EVERY QUESTION.


Summarizing in mi

SUMMARIZING IN MI

MOSTLY SUMMARIZING WHAT PATIENT, NOT PROVIDER, HAS SAID.

REFLECTIONS ARE MINI-SUMMARIES AS YOU GO.

SUMMARIZING CAN BE USED AS A SEGWAY FOR CHANGING DIRECTION.

SUMMARIZING HELPS BUILD AND MAINTAIN RAPPORT & CONVEYS UNDERSTANDING.

A GOOD SUMMATION DEMONSTRATES THAT YOU HAVE BEEN LISTENING & REMEMBERING WHAT PATIENTS HAVE SAID.


Bibliography and resources

BIBLIOGRAPHY AND RESOURCES

MOTIVATIONAL INTERVIEWING IN HEALTH CARE:

HELPING PATIENTS CHANGE BEHAVIOR

STEPHEN ROLLNICK

WILLIAM R. MILLER

CHRISTOPHER BUTLER

GUILFORD PRESS


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