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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BRADLEY SAMUEL, PHD
DIRECTOR OF BEHAVIORAL HEALTH EDUCATION
UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE
DEPARTMENT OF FAMILY & COMMUNITY MEDICINE
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
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.
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.”
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…
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.
ACKNOWLEDGE AND REFLECT BOTH SIDES OF AMBIVALENCE i.e. “You want to lose weight and hate exercising…”
*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.
DESIRE – “I want to…”
ABILITY – “I can…”
REASONS – “I would probably feel better if…”
NEED – “I should…”
COMMITMENT – “I will…”
TAKING STEPS – “I started…”
“HOW IMPORTANT IS IT FOR YOU TO QUIT SMOKING (MAKE THIS CHANGE)?
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.
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
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.
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.
MOTIVATIONAL INTERVIEWING IN HEALTH CARE:
HELPING PATIENTS CHANGE BEHAVIOR
WILLIAM R. MILLER