Using Motivational Interviewing to Help Your Patients Quit SmokingScott M. Strayer, MD, MPHAssociate Professor of Family MedicineUniversity of Virginia Health System
Disclosures Scott M. Strayer, MD, MPH disclosed that he has no financial relationships related to this presentation. CS2day is supported by an educational grant from Pfizer Inc.
Sound Familiar? “I tell them what to do, but they won’t do it.” “It’s my job just to give them the facts, and that’s all I can do.” “These people lead very difficult lives, and I understand why they smoke.” “Some of my patients are in complete denial.” Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.
Why Do Our Patients Struggle? (“strong” endorsements by physicians) poor self-discipline 53.2% poor will-power 50.0% not scared enough 36.9% not intelligent enough 16.3% Polonsky, Boswell and Edelman, 1996
Algorithm for Treating Tobacco Use Does patient nowuse tobacco? See Chapter 2 NO YES Is patient nowwilling to quit? Did patient onceuse tobacco? YES NO YES NO Provide appropriatetobacco dependencetreatments See Chapters3A and 4 Promote motivationto quit See Chapter 3B Prevent relapse* See Chapter 3C Encouragecontinuedabstinence a *Relapse prevention interventions are not necessary in the case of the adult who has not used tobacco for many years.
What Should we do? Explain what patients could do differently in the interest of their health? Advise and persuade them to change their behavior? Warn them what will happen if they don’t change their ways? Take time to counsel them about how to change their behavior? Refer them to a specialist? Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.
Treatment Recommendations: Counseling For Smokers Not Willing to Make a Quit Attempt at This Time • Recommendation: Motivational intervention techniques appear to be effective in increasing a patient’s likelihood of making a future quit attempt; therefore, clinicians should use motivational techniques to encourage smokers who are not currently willing to quit to consider making a quit attempt in the future (strength of evidence = B)
Definition of MI “…a client-centered, directive counseling method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” Miller, W.R. & Rollnick, S.(2002)
“People are generally better persuaded by the reasons they have themselves discovered, than by those which have come into the mind of others.” Pascal, 17th Century
Motivation for Change • Motivation is an intrinsic process • Ambivalence • Alternative behaviors have pluses and minuses • Motivation arises out of discrepancy • Values/goals conflict with current behavior • Ambivalence discrepancy change • “Change Talk” facilitates change
DecisionalBalanceAn explanatory model of behavior change • Highlights the individual’s ambivalence regarding maintaining vs changing a behavior • it is a balancing of the costs of status quo with the costs of change • and the benefits of change with the benefits of the status quo.
Decisional Balance Costs of Change Benefits of Status Quo Costs of Status Quo Benefits of Change Miller, W.R. & Rollnick, S.(2002)
The Righting ReflexThe Best Intentions Can Backfire • Most patients are ambivalent about unhealthy behaviors. • When we (physicians) see an unhealthy/risky behavior, our natural instinct is to point it out & advise change. • The patient’s natural response is to defend the opposite (no change) side of the ambivalence coin.
Collaboration Evocation Autonomy “Dance” Confrontation Education Authority “Wrestling” The Spirit of Motivational Interviewing vs. Miller, W.R. & Rollnick, S.(2002)
Motivational InterviewingFive Key Elements (DARES) 1. Develop discrepancy 2. Avoid argumentation/Roll with resistance 3. Express empathy 4. Support self-efficacy
Step 1: Express Empathy • Acceptance facilitates change. • Skillful reflective listening is fundamental. • Ambivalence is normal. Miller, W.R. & Rollnick, S.(2002)
Step 2: Develop Discrepancy • The patient should present the arguments for change. • Change is motivated by a perceived discrepancy between present behavior and important personal goals or values. Miller, W.R. & Rollnick, S.(2002)
Step 3: Avoid Argumentation/ Roll with Resistance • Avoid arguing for change • Resistance is not directly opposed. • New perspectives are offered if invited, but not imposed • The patient, not the doctor, is the primary resource in finding answers & solutions. • Resistance is a signal to respond differently • Reframing • Emphasizing personal choice & control
Step 4: Support Self-Efficacy • Belief in the possibility of change is an important motivator. • The patient, not the MD, is responsible for choosing and carrying out change. • The MD’s own belief in the person’s ability to change becomes a self-fulfilling prophecy. Miller, W.R. & Rollnick, S.(2002)
“Early” Methods to Enhance Motivation (OARS) • Open-ended questions- get the patients agenda • Affirm- reinforce statements or actions that promote change • Reflective listening—ie, listen & reflect back what you think they’re trying to say. • Summarize- distill the key elements of what the patient has told you in terms of decisional balance & any change talk.
More “Early” Methods to Enhance Motivation Elicit change talk- 4 types • Intention to change. • Disadvantages/advantages of the status quo • Advantages/disadvantages of change. • Optimism about capacity to change.
The “Readiness Ruler”- Importance/Confidence Scales • “On a scale from 0 to 10, how important would you say it is for you to ____, where 0 is not at all important, and 10 is extremely important.” • “Again, on the 10-point scale, how confident are you that if you decided to ____, you could do it?” • Responses to patient’s responses: Why are you a _ and not a zero?” What would it take to get you from a _ to a higher number?”
Trigger Questionsto Elicit Change Talk • Advantages of the status quo: “What do you like about ______? • Disadvantages of the status quo: “What problems have you experienced in relation to your ___?” • Advantages of change: “What would be the good things about ___?” • Disadvantages of change: “What would be the bad things about _______? • Optimism about change: “How confident are you that you can ___?” or “What do you think would work for you, if you decided to ___?”
More Trigger Questions • Intention to change: “What would you be willing to do?” or stronger language: “What do you intend to do?” • Explore extremes: “What’s the worst thing about your ___? What would be the best thing about changing?”
Strategies to Enhance Confidence • Review past successes • Elicit personal strengths and supports • Brainstorming • Hypothetical change (“If you were able to quit smoking tomorrow, how do you think things would be different?”)
Traps to Avoid • Expert trap: problem-solving, prescribing the solution makes patient the passive recipient and undermines building intrinsic motivation • Labeling: evokes dissonance & focuses energy unnecessarily on the label (esp. with addiction problems).
Other Traps to Avoid • Premature focus: patient needs to be ready (determine stage of change) • Blaming: • MD must attempt to render blame irrelevant (including self-blame): • shame & blame usually squash self-efficacy & intrinsic motivation to change.
Strengthening Commitment • Summarize patient’s own perception of problem, ambivalence, desire/intention to change, and can include your own assessment. • Ask a “key question”, ie: “What is the next step?”
Negotiating a Change Plan • Setting goals • Have patient develop a menu of strategies—brainstorm. • Have patient decide on a specific plan & summarize it. • Elicit commitment • Have patient restate what they intend to do. • Involve others: the more the patient verbalizes the plan to others, the more commitment is strengthened (“no going back now” concept)
Obtaining the 2008 Guideline The full text of the 2008 Guideline, www.ahrq.gov/path/tobacco.htm#clinic To order the 2008 Guideline and the various supplemental materials go to www.ahrq.gov/clinic/tobacco/order.htm UW-CTRI www.ctri.wisc.edu CS2day http://cs2day.org/
More Information on MI • Literature on MI and information on training (MINT) www.motivationalinterview.org • Miller and Rollnick. Motivational Interviewing: Preparing People for Change. Guilford Press. New York and London. 2002 • Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press. New York and London. 2008
Time to Practice Think of some healthy change you’d like to make …but you aren’t certain you really want to (or you would have already done it!)
Persuasion Techniques • Agree that speaker should make the change • Explain why the change is important • Warn of consequences of not changing • Advise speaker how to change • Reassure speaker that change is possible • Disagree if speaker argues against change • Tell the speaker what to do • Give examples of others (other patients, peers, celebrities) who have made similar healthy changes
Time to Practice Think of some healthy change you’d like to make, but you just haven’t done it yet. Now, let’s practice using the techniques to elicit change talk.
Time to Practice- The “Action Plan” Intervention 1. Identify area for behavior change -Importance and confidence should be elevated 2. Determine a specific action plan -Meaningful, action-oriented, measurable, behavioral 3. Make certain that goals are practical/achievable -Break down, specify, and limit steps as needed 4. Ask about obstacles, and problem solve 5. Feed back your understanding of the plan Offer support/sincere encouragement, BUT: OFFER AS LITTLE ADVICE AS POSSIBLE!