amy e. sass, md, mph jennifer l. woods, md, ms...3/28/2016 1 using motivational interviewing to...
TRANSCRIPT
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Using Motivational Interviewing to Elicit Healthy Behavior Changes in your PAG Patients:
Partner, Don’t Preach!
AMY E. SASS, MD, MPHJENNIFER L. WOODS, MD, MS
A D O L E S C E N T M E D I C I N E U N I V E R S I T Y O F C O L O R A D O
C H I L D R E N ’ S H O S P I T A L C O L O R A D O
Financial Disclosures
Dr. Sass and Dr. Woods do not have any relevant financial relationships with any commercial interests to disclose.
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Learning Objectives
Explore the main principles of motivational interviewing and utility in the PAG clinical settinginterviewing and utility in the PAG clinical setting
Practice applying MI strategies in a variety of real-life PAG clinical scenarios: contraceptive options counseling and choosing LARC
disclosing STI diagnoses and need for treatment to partners
discussions with teens about sexual health and personal responsibility
What is Motivational Interviewing?
Developed in 1983 by a clinical psychologist, William Miller, PhDMiller, PhD
Later refined by Miller and Stephen Rollick, PhD for work with alcoholism
“Motivational interviewing is a directive client Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence."
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Ready, Willing and Able
MI seeks to increase the perceived importance of making a change and to increase the patient’s belief making a change and to increase the patient s belief that change is possible
Willing, Unable Willing, Able
Unwilling, Unable Unwilling, Able
OR
TA
NC
E
g, g,
CONFIDENCE
IMP
O
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Ambivalence and Motivation
Ambivalence A normal part of the
h
Motivation A state of readiness to
h change process
Wanting something and not wanting it at the same time
change
The probability that a patient will enter into, continue, and adhere to a specific change strategy
Often there are both reasons to change and reasons not to change
MI seeks to help patients move beyond ambivalence
MI: Stages of Change
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Factors Associated with Adolescent Mental and Physical Health
Internal Factors External Factors
Acute/ChronicIllness
Physical GrowthDevelopment
Cognitive and EmotionalPeer and Social
Social/Economic
Family
temponormality
structurestabilityharmonysupport
incomeS.E. classracesex
AdolescentMentalandPhysical
Development
Personality
Heredity
Environmental
Peer and SocialPressuretempo
judgmentintelligencemood fluctuation
self-esteemself-imagetraits
peer groupfriends
stabilityschoolwork
Health
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Psychological Development and Reproductive Health
• Early Adolescence (9-13 years)• Begin pubertal developmentg p p
• Increased importance on same-sex peer relationships
• Concrete thinkers
• Sexuality Preoccupied with their own bodies Uncertain about their appearance Think about the opposite sex a lot May develop “crushes” on idealized adults Typically not engaged in true romantic relationships
Psychological Development and Reproductive Health
• Middle Adolescence (14-17 years)• Increased independence and conflict with their parents• Increased independence and conflict with their parents
• Peek level of peer conformity
• Begin to make choices based on abstract values Imagine the consequences of their actions, but still do not fully
understand them
Experiment with risk behaviors
• Concerned about peer norms regarding sexuality
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Psychological Development and Reproductive Health
• Late Adolescence (17 years and older)• Sense of responsibility for their health with a more • Sense of responsibility for their health with a more
clearly defined body image and gender role
• Have often reaccepted some of their parents’ values and place less emphasis on peer conformity
• Increased capacity for abstract thought and begin to • Increased capacity for abstract thought and begin to better understand the thoughts and feelings of others
• More mature approach to sexuality More emphasis on supportive, intimate relationships.
The Spirit of MI
CollaborationCollaboration
AcceptanceCompassion
Evocation
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Four MI Processes
Engagingg g g
“Shall we travel together?”
Focusing
“Where to?”Evoking
“Whether”
“Why”
Planning
“How”
“When”When
Miller & Rollnick 2013Aaron Armelie PhD, Tulane
Case-Abigail
16 yo – in clinic for birth control follow-up visit
PMH of unintended pregnancy and spontaneous first trimester miscarriage 8 mos ago
She has struggled with depression and somatic complaints since her loss.
States today that she has “learned from my past” and has decided to stop Depot medroxyprogesterone because she is now focused on school and doesn’t plan on having sex anytime soon.
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Video #1: Abigail
Observations?
How did the provider do in regard to the 4 processes of MI?
MI Principles- “DARES”
Develop Discrepancy
Avoid Argumentation
Roll with Resistance
Roll with Resistance
Support Self-efficacy
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Expressing Empathy
Skillful reflective listening is fundamental
Acceptance facilitates change
Ambivalence is normal
Roll with Resistance
The patient is the primary resource in finding solutions to problemssolutions to problems
Avoid arguing for change
Perceptions can be shifted Statements from the patient can be re orded or reframed to Statements from the patient can be reworded or reframed to
create a new ‘momentum’ toward change
Resistance is a signal for provider to change strategy
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Develop Discrepancy
Create and amplify the discrepancy between the patient’s present behavior (status quo) and personal patient s present behavior (status quo) and personal goals (change)
Being aware of consequences is important
The patient should present the arguments for their The patient should present the arguments for their own change
Support Self-Efficacy
A patient’s belief in the possibility of change and success is an important motivatorsuccess is an important motivator
The patient is responsible for choosing and carrying out change
MI seeks to increase patient awareness about their MI seeks to increase patient awareness about their own skills, resources, and abilities in order to achieve their goals
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Avoid Argumentation
Arguing is not listening
Arguing is counterproductive
Defending breeds defensivenessDefending breeds defensiveness
Arguing may cause resistance
Case-Destiny
19yo young woman with a new diagnosis of chlamydiay
Has current female partner for past 1 month
Previously, male partners
No barrier methods in current or past relationships
Uncertain if she can inform partner of dx
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Video #2: Destiny
Observations?
How did the provider do?
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MI Technique- “OARS”
Open-ended questions
Affirming
Reflective listening
Summarizing
Open-ended questions
Avoid questions with ‘yes’, ‘no’ or ‘maybe’ answers
Broad questions allow patients maximum freedom to respond without fear of a right or wrong answer
“If you had one habit that you wanted to change in order to improve your health, what would that be?”p y ,
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Affirming
Affirmations identify something positive about the patient and give credit, acknowledgementpatient and give credit, acknowledgement
Communicate that change is possible and that they are capable of implementing that change
Can be rare and valuable for patients focused on failure Can be rare and valuable for patients focused on failure
Should always be genuine and never condescending
Reflective Listening
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Reflective Listening
Key to MI
Reflections mirror back content, process or emotion to the patient Giving words to something that the patient may not have been able
to express Listen to what has worked and what hasn’t Focus in on change-talk
Reflections are always statements, not questions
Keeps momentum moving forward
Summarizing
Specialized form of reflective listening
Calling attention to the salient elements of the discussion, allowing the patient to correct any misunderstandings and add anything that was missed
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Video #3: Destiny
Observations?
How did the provider do?
Case-Erica
• 14yo female presents to clinic with close friend and her mother “for Plan B”
• Story that Mom knows: was at a party last weekend and had unprotected sex
• Confidential story: attended the party with plan to run away from home. “Crashed with friends,” had at least 12 y ,alcoholic drinks and multiple marijuana joints
• Describes being careful to “serve myself so that someone couldn’t slip me the date rape drug”
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Summary
This workshop is a good start…but it is just the beginning for implementing MI.beginning for implementing MI.
Feedback and coaching are important in real-time.
Keep practicing!
What take away points did you learn today to implement in your practice?
References
Armelie, Aaron (2013). Using Motivational Interviewing to Build Collaborative Healping Relatinshipswith People Living with and Affected by HIV/AIDS. Retrieved from https://www.apa.org/pi/aids/programs/bssv/motivational-interviewing-techniques.pdf.
Barnes AJ Gold MA (2012) Promoting healthy behaviors in pediatrics: motivational interviewing Barnes AJ, Gold MA (2012). Promoting healthy behaviors in pediatrics: motivational interviewing. Pediatr Rev. 2012;33:e57-68.
Barnet B, et al. Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial. Ann Fam Med. 2009;(5):436-45.
Center for Health Training. (2010) The OARS model essential communication skills. Retrieved from https://public.health.oregon.gov/HealthyPeopleFamilies/ReproductiveSexualHealth/Documents/edmat/OARSEssentialCommunicationTechniques.pdf.
Committee on Health Care for Underserved Women, ACOG. Motivational Interviewing: a tool for behavioral change, committee opinion 423. (2009). Retrieved from https://public health oregon gov/HealthyPeopleFamilies/ReproductiveSexualHealth/Documents/edhttps://public.health.oregon.gov/HealthyPeopleFamilies/ReproductiveSexualHealth/Documents/edmat/OARSEssentialCommunicationTechniques.pdf.
Elicit Provide Elicit Handout. Retrieved from http://www.fdihb.org/files/downloads/nutrition/motivational-interviewing-resources/EPE-handout.pdf.
Gold MA, et al. A randomized controlled trial to compare computer-assisted motivational intervention with didactic educational counseling to reduce unprotected sex in female adolescents. J PediatrAdolesc Gynecol. 2016;(29):26-32.
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References
Gold, MA, Kokotailo, PK (2007). Motivational interviewing strategies to facilitate adolescent behavior change. Adolesc Health Update, 20(1), 1-10.
Malas N, et al. Motivational interviewing in paediatric residency. Clin Teach. 2016;(13):1-7.
Miller M, et al. Brief behavioral intervention to improve adolescent sexual health. A Feasibility study in the emergency department. Pediatr Emerg Care. 2016;(32):117-19.
Kolli, Ravi. (2010, April 20). Motivational Interviewing. Retrieved from http://www.slideshare.net/ravikolli/motivational-interviewing-by-ravi-kollimd?related=1.
Loewen, Mark. (2014, July 25). Basic Tenets of Motivational Interviewing. Retrieved from http://www.slideshare.net/LaunchPadCounseling/basic-tenets-of-motivational-interviewing?qid=494a8b7c-84d0-4ffe-9b70-c6f63ee28489&v=qf1&b=&from_search=11.
Rae, Cosette et al. (2009, February 20). Motivational Interviewing for Addictive Behaviors. Retrieved from http://www.slideshare.net/heavensfield/MotivationalInterviewing?qid=245ba79b-51d4-4f04-b2ed-http://www.slideshare.net/heavensfield/MotivationalInterviewing?qid 245ba79b 51d4 4f04 b2ed8c8c3fd5fcad&v=default&b=&from_search=12.
Sciacca, Kathleen. (2009). Motivational Interviewing-MI, Glossary & Fact Sheet. Retrieved from http://www.motivationalinterview.net/miglossary.pdf.
Whitaker AK, et al. Motivational interviewing to improve postabortion contraceptive uptake by young women: development and feasibility of a counseling intervention. Contraception. 2015;(92):323-9.