FOLLOW GUIDE DIRECT MOVING FROM WHY TO HOW Barcelona, 2009 Ken Resnicow, PhD

1. FOLLOW GUIDE DIRECT MOVING FROM WHY TO HOW Barcelona, 2009 Ken Resnicow, PhD University of Michigan School of Public Health Ann Arbor, MI Kresnic@umich.edu

2. What they tell us…. “Ok, I got the reflection thing. I got the change talk thing. But where do I go from there. How do I bring this all together. ”

3. Perceived Barriers in the Treatment of Overweight Children and Adolescents Percentage Responding “Most of the Time” and “Often” RDs PNPsPediatricians Barrier (n= 441) (n = 293) (n = 201) Lack of patient motivation 61.9 78.2 85.7 Lack of parent involvement 71.8 82.5 81.2 Lack of clinician time 31.2 45.9 58.0 Lack of reimbursement 68.1 46.8 45.8 Lack of clinician knowledge 23.8 32.2 44.0 Lack of treatment skills 27.3 32.2 45.0 Lack of support services 55.5 57.0 60.0 Treatment futility 37.4 52.6 53.0 Eating disorder concerns 17.2 12.9 10.0 Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.

4. Barriers to Treatment of Pediatric Obesity % Report Encountering FPs PDs (n=74) (n=213) Lack of patient motivation 99% 97% Poor patient compliance 96% 95% Lack of effective therapy 83% 78% No insurance for referrals 74% 67% Lack of availability of referral services 65% 64% No insurance for in-office counseling 60% 51% No time for frequent follow-up 56% 49% Kolagotla L, Adams W. Ambulatory management of childhood obesity. Obesity Research 2004;12(2):275-83.

5. Attitudes toward pediatric obesity counseling Family PracticePeds (n=74) (n=213) Personal ability to counsel Poor 11% 6% Fair 30% 17% Average 44% 47% Good 15% 27% Excellent 0% 3% Efficacy of obesity counseling Poor 11% 23% Fair 48% 33% Average 36% 35% Good 5% 9% Excellent 0% 0.5% Kolagotla L, Adams W. Ambulatory management of childhood obesity. Obesity Research 2004;12(2):275-83.

6. Perceived Skill Level in Pediatric Obesity Management Among Practitioners % Low Proficiency Level RDs PNPsPediatricians Use of behavioral management 15.8 32.5 38.9 strategies Modification of eating practices 2.4 8.2 15.1 Modification of physical activity 10.6 7.2 13.6 Modification of sedentary behavior 12.9 11.0 18.4 Guidance in parenting techniques 31.0 20.7 25.0 Addressing family conflicts 45.9 30.2 30.0 Assessment of the degree of 4.3 22.3 16.8 overweight Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.

11. Study Design: Ahluwalia, J. S., Okuyemi, K., Nollen, N., Choi, W. S., Kaur, H., Pulvers, K., et al. (2006). The effects of nicotine gum and counseling among African American light smokers: a 2 x 2 factorial design. Addiction, 101(6), 883-891. • Six counseling sessions • three in-person (at randomization, week 1, week 8) • three by telephone (week 3, week 6 and week 16). • Health education (HE) focused on providing information and advice. Review the addictive nature of nicotine, health consequences of smoking and benefits of quitting, and concrete strategies for a quit plan. • MI explored the pros and cons of smoking/quitting;motivation and confidence to quit and values clarification. • Both HE and MI counselors participated in weekly supervision

14. MI not indicated in highly motivated? Baseline motivation to quit on a 1-10 scale was 9.1 AND Must be willing to set a quit date in the next 14 days and use nicotine gum for 8 weeks

15. Health care professionals want closing skills. They want to integrate MI with other Behavior Change skills For highly motivated clients, MI might be contraindicated.

16. 6. MI is not a form of cognitive-behavior therapy Cognitive-behavior therapies generally involve providing clients with something that they are presumed to lack. The missing piece might be new coping skills, conceptual education about how behavior is learned, counterconditioning, environmental contingencies, or the restructuring of faulty cognitions toward more adaptive ones. The expertise of CBT providers rests on their knowledge of and technical skill in applying principles of learning. The typically brief course of MI in one or two sessions does not involve teaching new skills, re-educating, counterconditioning, changing the environment, or installing more rational and adaptive beliefs. It is…. about eliciting from people that which is already there. It is not the communication of an expert who assumes that “I have what you need”, but rather the facilitative style of a companion whose manner says, “You have what you need, and together we’ll find it.”

18. The Contradiction “ In cognitive and behavioral therapies …. the therapist is there to teach the client strategies for change such as exposure, social skills, contingency management, and cognitive strategies for changing distorted thoughts or beliefs. ….Either implicitly or explicitly, when we do CBT we often take the role of teacher and advocate for change. In doing MI the decisions about whether to change and how to change are left primarily to the client.”

19. Reconciliation “MI can be viewed as a creative synthesis between Client-Centered Therapy and the action orientation of CBT. In CBT we do not formally address ambivalence about change, but in MI there are specific strategies for understanding and addressing this ambivalence to help the client become more ready for change. Since …MI does not assume readiness to change, but works to increase and maintain motivation for change, it may be a useful complement for CBT. ”

20. Integrative Approach “The therapist moves naturally and smoothly to examining and working with ambivalence in an MI style as it arises in the course of therapy. ” Arkowitz & Westra, 2004

21. Autonomy Supportive Closing(MI-Consistent Directing) • Action Reflections • Provide Menu of Options for Change • Usually client helps populate the list • Counselor Undersells Options • Provide Choice • What to change • How much change • When • How Monitored • Contingencies

22. Two Phase Model MI Behavior Therapy Why to Change How to Change Low Readiness High Readiness (Resistant/Angry/Ambivalent) (Convinced)

23. MOVING FROM WHY TO HOW MI Primary Modality MI CONSISTENT DIRECTING AUTONOMY SUPPORTIVE CLOSING WHY ChangeHOW to Change MI Background Platform Building MotivationBuilding an Action Plan Handling Resistance Self-Monitoring Resolving Ambivalence Shaping Contract Contingency Management Cognitive Restructuring

24. DIRECTING • Manage Prescribe • Lead Govern • Take Charge Authorize • Rule Reign • Steer Take Command

25. Listening Advising Informing Asking Following Understanding Guiding Deciding Directing Acting Closing Acting Structure

26. Three Phases of Consultation • Following (WHAT/WHY/WHY NOT) • COMFORT THE AFFLICTED • Build Initial rapport & Express Empathy • Obtain a history • Collaborative agenda setting • Explore pros, cons, hopes and fears (Reasons) • Guiding(IF) • AFFLICT THE COMFORTBLE • Build Motivation & Discrepancy • Elicit change talk • 0-10 Readiness Rulers • Importance (Reasons/Desire/Need) • Confidence (Ability) • Values Clarification (Desire & Need) • SPIN THE BALLS • Where does that leave you? • Obtain COMMITMENT • Move toward a behavior decision • Directing (if a decision/commitment has been made) (WHEN/HOW) • Taking STEPS • Establish a Goal • Provide Menu of Options • Set an Action Plan • Overcome/anticipate barriers • Make a contract & Discuss follow up

27. Phase I: Following • COMFORT THE AFFLICTED • Build Initial rapport & Express Empathy • Obtain a history • How long, how often, how much • Collaborative agenda setting • Explore pros, cons, hopes and fears (Reasons) • Guiding(IF)

28. Phase II: Guiding • AFFLICT THE COMFORTBLE • Build Motivation & Discrepancy • Elicit change talk • 0-10 Readiness Rulers • Importance (Reasons/Desire/Need) • Confidence (Ability) • Energy (Effort) • Values Clarification (Desire & Need) • SPIN THE BALLS • Where does that leave you? • Obtain COMMITMENT • Move toward a behavior decision • Directing (if a decision/commitment has been made)

29. Phase III: What should we call it? MI-CONSISTENT DIRECTING AUTONOMY SUPPORTIVE CLOSING • ACTION REFLECTIONS • Provide Menu of Options • Establish a Goal • Set an Action Plan • Overcome/anticipate barriers • Make contract • Monitoring Plan • Discuss follow up

30. Types of Reflections Content Feeling/Meaning Double-Sided Rolling with Resistance Amplified Negative Reflection on Omission Action

31. Moving things forward:Using reflections that embed potential solutions

32. Advanced Reflections • Imbed Solutions to Barriers • Imbed Action Plans • Undersell • You might want to… • You might want to consider… • Sounds like…..might be an option… • If we are to move forward you might need to address….

33. Bringing the Water…. X has not worked for you You are looking for something other than X Any thoughts about Y Y might be an option

34. Action Reflections • 1) Invert Barrier • Sounds like we will need to address barrier a,b,c • 2) General Behavior Fix • Sounds like doing something like x,y,z • 3) Specific Behavior Fix • Sounds like doing x may be a possibility • 4) Cognitive Fix • Sounds like you may have to think about x differently (make peace, no all or nothing thinking)

35. Maybe it’s time to quit. I am 55, my dad died of heart disease…and I am coughing up all this junk every morning. But I am dreading it. I cannot deal with the withdrawal…the cravings, the edginess, and the hunger..plus it is annoying having everyone commenting to me about how proud they are of me………

36. So if you could find a way to reduce the withdrawal symptoms, you might be more willing to quit Something to reduce cravings, edginess, and hunger might be of interest to you

37. Action Reflections So if you could find a way to reduce the withdrawal symptoms, you might be more willing to quit (invert barrier) Something to reduce cravings, edginess, and hunger might be of interest to you (general fix) A medicine to reduce craving might be something for us to talk about (general fix) Your might be interested in learning about a new drug called Chantix that helps with craving (specific fix) You might want to quit without telling others, to avoid being under the microscope (specific fix) If you could make peace with your fears, or realize you in fact CAN handle, that might make quitting easier (cognitive fix)

38. We tried to reduce the amount of TV she watches but it didn’t go so well. In the morning I need to get dressed, take a shower, make some breakfast and I usually end up letting her watch the Wiggles or Dexter’s Laboratory just to give me some free time. In the afternoon I feel it might be easier…since maybe I could get her involved in an art project or playing outside.

39. So it might be more realistic to work on the afternoon TV first. Getting her involved in something more creative might help her fulfill her potential. Art is the way to go

40. I tried giving my kids fruit for snack, if they don’t have their cookies they make a huge fuss… they expect sweets after school and I can’t stand the sound of their whining when they don’t get what they want. Plus, I kind of like baking homemade treats….

41. So baking something that has some fruit in it, or is a little more healthy might satisfy both you and your kids

42. I've tried everything to help my child lose weight. I always have carrot sticks available and don’t let him eat any fried food. I tell him exactly what he can have, and watch what he eats very closely. I also make him exercise every day. I’m constantly on him, and yet he hasn’t lost a pound!

43. So trying to control what your child does hasn’t worked very well. Telling your child what to eat isn’t helping him lose weight.

44. So far you have not involved your son in the decisions Involving your son might help him buy into the changes better than setting new rules for him

45. I really want to lose weight..so this week I decided to be really good and tried to cut out all sweets from my diet. However, I felt miserable by the end of the day and finally broke down and ate a whole box of chocolates..

46. So cutting out all sweets entirely doesn’t work for you. Finding a way to lose weight might need to include having a few sweets.

47. Bringing it all together F O L L O W G U I D E D I R E C T Get permission Set agenda Assess current level Discuss History Assess 0-10 importance/confidence  Probe lower/higher/what would it take Assess core values  Link behavior to values Summarize & Spin: Where does that leave you? Build Menu of Choices Ask Client to Pick Option What can you do to make it happen?  This week  Today

48. Throughout the session, listen for action talk Often, clients will already have an idea for what they MIGHT try Make a mental note and mention that you may go back to that idea later Action Item Parking LOT Idea 1 Idea 2 Idea 3

49. Three Steps Toward Change…MI DIRECTING 101 • Build a Menu of Options • List possible ideas mentioned by client during session • Ask patient for other solutions • Offer “other ideas that have worked with people with similar concerns” • Ask “which if any of these” might work best for you”. If they choose one… • Ask “what might you be able to do to increase your chances of success in the next day or week”

50. Cognitive Options for Change Abstinence violation syndrome/Not All or Nothing Craving/discomfort will pass You can in fact deal with it The withdrawal/side effect is normal Focusing on the benefits Making peace with the fact that the benefit is difficult to observe Taking actions gives you a sense of control