motivational interviewing in primary care

BR ADLEY SAM U EL , PHDDIR EC TO R O F BE HAVIO R A L HEALTH

EDU C ATIO NU N IVER SITY O F NE W MEX IC O SC HO O L O F

MEDIC I N EDEPA RTM EN T O F FAM ILY & C O MM U N ITY

MEDIC I N E

MOTIVATIONAL INTERVIEWING IN PRIMARY

CARE

ASSUMPTIONS ABOUT MOTIVATION

MOTIVATION IS MALLEABLESUBJECT TO CHANGE IN CONTEXT OF

PATIENT-PROVIDER RELATIONSHIPTHE WAYS IN WHICH ONE TALKS WITH

PATIENTS CAN INFLUENCE PERSONAL MOTIVATION FOR BEHAVIOR CHANGE

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

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

LISTENING CAREFULLY & EMPATHICALLYASKING ABOUT OPTIONS CONSIDEREDOFFERING WHAT YOU KNOW ABOUT

DECISION MAKING, RELATIONSHIPS, ETC.RECOGNIZING & HONORING THAT “IT IS

YOUR DECISION TO MAKE.”

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

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

ASKINGLISTENING 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

“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

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

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

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

DESIREABILITYREASONSNEED

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

TAKING STEPS

ZERO TO TEN ASSESSMENTS

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

0---------------------------------10 scaleFOCUS 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

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

EXPLORING AMBIVALENCEGATHERING CHANGE TALKMEASURING MOTIV., CONFIDENCE,

HOPEFULNESS, IMPORTANCELISTENING, GUIDING, INFORMINGSUMMARIZING MOTIVATION FOR CHANGETIMING MOSTLY OPEN ENDED

QUESTIONSASKING FOR WILLINGNESS TO CHANGEDEVELOPING PLAN

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

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

MOTIVATIONAL INTERVIEWING IN HEALTH CARE: HELPING PATIENTS CHANGE BEHAVIOR

STEPHEN ROLLNICKWILLIAM R. MILLERCHRISTOPHER BUTLER

GUILFORD PRESS