““Practical Strategies in Medication Adherence Practical Strategies in Medication Adherence in Patients with Cardiovascular Disease”in Patients with Cardiovascular Disease”

MOTIVATIONAL INTERVIEWING:MOTIVATIONAL INTERVIEWING:What is it? Does it work?What is it? Does it work?

Julie Culligan, PhDJulie Culligan, PhD

Health Behavior Coordinator, PsychologistHealth Behavior Coordinator, Psychologist

Mountain Home VAMCMountain Home VAMC

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MI PhilosophyMI Philosophy

"People are generally better persuaded "People are generally better persuaded by the reasons which by the reasons which theythey have have themselves discovered than by those themselves discovered than by those which have come in to the mind of which have come in to the mind of others.”others.”   

~ ~ Blaise PascalBlaise Pascal, , French mathematician, physicist and religious French mathematician, physicist and religious philosopherphilosopher

Learning ObjectivesLearning Objectives

Specify and discuss 3 elements of the Specify and discuss 3 elements of the “spirit” of Motivational Interviewing “spirit” of Motivational Interviewing

Identify the 4 principles of Identify the 4 principles of Motivational InterviewingMotivational Interviewing

Identify basic use of the following core Identify basic use of the following core MI skills: open-ended inquiry, MI skills: open-ended inquiry, affirmation, reflective listening and affirmation, reflective listening and summariessummaries

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Facilitating Behavior Facilitating Behavior ChangeChange

What makes behavior change so hard?What makes behavior change so hard? It works for usIt works for us ““Habit”Habit” It often involves multiple behaviorsIt often involves multiple behaviors Knowledge about how to change isn’t Knowledge about how to change isn’t

always enoughalways enough People are creatures of habitPeople are creatures of habit Health consequences are often delayedHealth consequences are often delayed Busy lifestyles require us to make time for Busy lifestyles require us to make time for

self careself care

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Motivational InterviewingMotivational Interviewing

““A person-centered, goal-oriented A person-centered, goal-oriented approach for facilitating change approach for facilitating change through exploring and resolving through exploring and resolving ambivalence.“ (Miller & Rollnick, 2006)ambivalence.“ (Miller & Rollnick, 2006)

A clinical “style;” a “way of being with A clinical “style;” a “way of being with people” (Miller & Rollnick, 2002; people” (Miller & Rollnick, 2002; Rollnick & Miller, 1995)Rollnick & Miller, 1995)

Motivational Interviewing: Motivational Interviewing: Based on TheoryBased on Theory

Conceptualized according to stage model of change (Prochaska & DiClemente, 1982)

Not everyone engages in treatment at the same stage of readiness

Different type of approach may be utilized for individuals at different stages

Transtheoretical Model: Transtheoretical Model: Stages of ChangeStages of Change

A STAGE MODEL OF THE PROCESS OF CHANGE

MaintenanceRelapse

Contemplation Determination

Action

Pre-Contemplation

Permanent Exit

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The Goal of MIThe Goal of MIThe goal of MI is to facilitate:The goal of MI is to facilitate: Fully informed,Fully informed, Deeply thought out,Deeply thought out, Internally motivated choices,Internally motivated choices,

Not to change Not to change behavior…..behavior…..

Resnicow, Resnicow, et al., 2002et al., 2002

Traditional vs. MotivationalTraditional vs. Motivational

The “Doctor”:The “Doctor”: Places the importance Places the importance

on the behavior on the behavior changechange

Controls the Controls the interactioninteraction

May direct/select the May direct/select the goals the patient goals the patient should achieveshould achieve

The “patient”:The “patient”: Determines the Determines the

importance of the importance of the behavior changebehavior change

Is listened to, shares Is listened to, shares concerns and needsconcerns and needs

Is supported in Is supported in decisions about decisions about change and goalschange and goals

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Empathic Style of MI and Empathic Style of MI and Brief InterventionsBrief Interventions

The key element in brief interventions is The key element in brief interventions is empathyempathy

Research on empathy and clinical outcomes:Research on empathy and clinical outcomes: Strongest predictor of outcomesStrongest predictor of outcomes Not accounted for by demographicsNot accounted for by demographics Not accounted for by treatment typeNot accounted for by treatment type

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Patient FocusPatient Focus

MI supports the patient in articulating MI supports the patient in articulating How personally important this change How personally important this change

(e.g., dietary) is, as opposed to how (e.g., dietary) is, as opposed to how important we think it isimportant we think it is

What stands in the way of making this What stands in the way of making this change (time, money, cultural factors, change (time, money, cultural factors, emotions, etc.)emotions, etc.)

Changes that might work in their lifeChanges that might work in their life How to increase the chances of successHow to increase the chances of success

Learning MILearning MI

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Spirit of Motivational Spirit of Motivational InterviewingInterviewing

EvocativeEvocative ((vsvs. Educational). Educational) – – patient is patient is responsible for change. responsible for change. (“What would you gain if you (“What would you gain if you changed your drinking?”) vs. implanting the changed your drinking?”) vs. implanting the right idea right idea (“You (“You really need to stop drinking.”)really need to stop drinking.”)

Honoring Autonomy Honoring Autonomy (vs. Authority) – (vs. Authority) – Allow the freedom not to change. Allow the freedom not to change. (“How ready are you (“How ready are you to change?) vs. push for commitment (“If you delay getting to change?) vs. push for commitment (“If you delay getting sober, you could die.”)sober, you could die.”)

CollaborativeCollaborative ((vs.vs. Confrontational)Confrontational) – – Work in Work in PartnershipPartnership. . (“How about we discuss some options together” (“How about we discuss some options together” vs. “I would urge you to quit drinking.”)vs. “I would urge you to quit drinking.”)

The The SpiritSpirit of MI of MI Motivation for change is elicited Motivation for change is elicited from from

within the patient,within the patient, not imposed from not imposed from outsideoutside

The The patientpatient must must articulate reasons articulate reasons for changefor change

The The patientpatient is the one responsible to is the one responsible to decidedecide

Direct persuasionDirect persuasion is ineffective is ineffective The clinician should The clinician should steersteer the the

conversation to focus on changeconversation to focus on change

AmbivalenceAmbivalence

Interesting, natural, human, Interesting, natural, human, understandableunderstandable

Not unique to characterological Not unique to characterological problems problems

Not indicative of defense (denial)Not indicative of defense (denial) ““I want to but I don’t want to”I want to but I don’t want to” Unhelpful to think of people as Unhelpful to think of people as

“unmotivated”“unmotivated”

SPIRIT OF MISPIRIT OF MIAmbivalenceAmbivalence

APPRECIATE AMBIVALENCEAPPRECIATE AMBIVALENCE HONOR, EMBRACE, EXPLORE HONOR, EMBRACE, EXPLORE

AMBIVALENCE. It’s the core.AMBIVALENCE. It’s the core. Many brief (and single session) Many brief (and single session)

therapies work by focusing on this therapies work by focusing on this ambivalence, not on skills (people ambivalence, not on skills (people frequently have the skills)frequently have the skills)

The The RIGHTINGRIGHTING Reflex Reflex

““This person SHOULD want to change.”This person SHOULD want to change.” NOW is the right time to change.NOW is the right time to change. A TOUGH/clear/honest approach is best.A TOUGH/clear/honest approach is best. Patient should follow my EXPERT ADVICE.Patient should follow my EXPERT ADVICE. If patient doesn’t change, the session If patient doesn’t change, the session

FAILED.FAILED. There’s There’s nothingnothing we can do for the we can do for the

“unmotivated.”“unmotivated.”

Rather than the Righting Reflex, Understand

Ambivalence Reflective listening

Helps patients to feel understood Provides comfort to patient (makes change

easier) Acceptance; non-judgmental; no blaming

Acceptance ≠ Agreement Ambivalence = normal (not pathological)

Communication is a Dance

Not a Tug of War

Evaluate the Pros and ConsEvaluate the Pros and Cons

Reducing/Giving up Tobacco

Pros (Good Things)

Cons(Downsides)

Smoking the Same

I can still smoke with I friends

It helps me deal with my stress

It’s hard to breatheIt’s a fire hazardIt’s bad for my healthIt’s expensive

Making Changes in Smoking

Feel better

Have more energy

Have more money

I wouldn’t be able to hang out with my friends who smoke

I wouldn’t have a way to deal with my problems

Evaluate the Pros and ConsEvaluate the Pros and ConsIncreasing Medication Adherence

Pros (Good Things)

Cons(Downsides)

Stay the Same, i.e., Non-Adherent

I can still smoke with I friends

It helps me deal with my stress

It’s hard to breatheIt’s a fire hazardIt’s bad for my healthIt’s expensive

Making Changes, i.e., Adherent

Feel better

Have more energy

Have more money

I wouldn’t be able to hang out with my friends who smoke

I wouldn’t have a way to deal with my problems

Four Key Principles of MIFour Key Principles of MI

Express empathy Develop discrepancy Roll with resistance Support self-efficacy

(1) Express Empathy(1) Express Empathy

Reflective listening Helps patients to feel understood Provides comfort to patient (makes change

easier) Acceptance; non-judgmental; no blaming

Acceptance ≠ Agreement Ambivalence = normal (not pathological)

(2) Develop Discrepancy(2) Develop Discrepancy

Change is motivated by perceived discrepancy between present behavior and personal goals/values

Discrepancy = importance of change for patient

Amplify the discrepancy to move patient from the status quo

Elicit discrepancy from the patient – they should make the argument for change

(3) Roll with Resistance(3) Roll with Resistance

Argument often pushes person in the opposite direction

Resistance is a call for the clinician to change, not the patient

Questions and problems should be reflected back to the patient, not “solved” by the clinician

(4) Support Self-Efficacy(4) Support Self-Efficacy Be aware of your own beliefs about a

patient’s ability to change (self-fulfilling prophecy)

Enhance patient’s self-belief about his or her capability to make a change

Be genuine

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What People What People saysay about about Change Change predictspredicts Behavior Behavior

ChangeChange

Self-perception theorySelf-perception theory

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Core MI Strategies Core MI Strategies

Four Early Strategies; Four Early Strategies; OARSOARS

OOpenpen QuestionsQuestionsAAffirmingffirmingRReflectiveeflective ListeningListening

SSummarizingummarizing

Elicit Positive “Change Talk”

Open-Ended QuestionsOpen-Ended Questions

Disarms resistanceDisarms resistance Creates momentumCreates momentum Avoids argumentsAvoids arguments You want them engaged and You want them engaged and

exploring – with you gently steeringexploring – with you gently steering

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Open Questions to Promote Open Questions to Promote ChangeChange

Disadvantages of the Status QuoDisadvantages of the Status Quo How do you feel about your weight?How do you feel about your weight?

Advantages of ChangeAdvantages of Change What would the benefits be for you, if you were to quit What would the benefits be for you, if you were to quit

smoking ?smoking ?

Optimism for ChangeOptimism for Change What makes you feel that What makes you feel that nownow is a good time to try is a good time to try

something different?something different?

Intention to ChangeIntention to Change What would What would youyou like to see happen? like to see happen? How might things be different for you, if you did make a How might things be different for you, if you did make a

change?change?

AffirmationAffirmation

Genuinely highlight patients’ strengths

Antidotes to demoralization Appreciative of partial success (ex.

Focus on success with quitting smoking for 2 years in past)

Appreciates their honesty regarding ambivalence

Reflective Listening – Reflective Listening – The Foundation of MIThe Foundation of MI

““MINI-SUMMARIES” used strategically to MINI-SUMMARIES” used strategically to lower resistancelower resistance

Used to highlight patient statements Used to highlight patient statements favoring change (“Change Talk”)favoring change (“Change Talk”)

A way of thinking, Difficult to learnA way of thinking, Difficult to learn Powerful for increasing readinessPowerful for increasing readiness Expert ratio 2 reflections for every Expert ratio 2 reflections for every

question vs. Novice ratio .5 reflections for question vs. Novice ratio .5 reflections for every questionevery question

Handy ReflectionsHandy Reflections Double-Sided (reflects both sides of Double-Sided (reflects both sides of

ambivalence) ambivalence) – takes the clinician out of the equation – puts the ambivalence in their own – takes the clinician out of the equation – puts the ambivalence in their own

laplap

So on the one hand, you like how alcohol So on the one hand, you like how alcohol makes you feel and at the same time, you makes you feel and at the same time, you worry about your Hepatitis.worry about your Hepatitis.

Amplified – can go in either directionAmplified – can go in either direction Undershoots so patient might elaborate, Undershoots so patient might elaborate,

“You’re a LITTLE confused…”“You’re a LITTLE confused…” Overshoots so patient can back down, “So Overshoots so patient can back down, “So

you don’t EVER intend to cut down…”you don’t EVER intend to cut down…”

Handy ReflectionsHandy Reflections

Shifting Focus – shift patient’s concern Shifting Focus – shift patient’s concern away from a potential stumbling block – away from a potential stumbling block – around barriers rather than over themaround barriers rather than over them c: “Okay, maybe I’ve got some problems c: “Okay, maybe I’ve got some problems

with drinking, but I’m not alcoholic.”with drinking, but I’m not alcoholic.” Argument with a Twist – offer initial Argument with a Twist – offer initial

agreement, but with a slight twist or agreement, but with a slight twist or change of directionchange of direction

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SummarizingSummarizing

Helps the other person:Helps the other person: Recall and reflect upon the conversationRecall and reflect upon the conversation Think of new ideasThink of new ideas Understand the importance of these Understand the importance of these

issuesissues Plan next stepsPlan next steps Feel more confident, instill hopeFeel more confident, instill hope

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Importance and ConfidenceImportance and Confidence

Importance:Importance: lets you know how lets you know how important this issue(s) is to the important this issue(s) is to the patient, in the grand scheme of other patient, in the grand scheme of other important values in their lifeimportant values in their life

Confidence:Confidence: lets you know how able lets you know how able the patient feels he/she is to make the patient feels he/she is to make specific changes towards his/her specific changes towards his/her goal(s)goal(s)

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Readiness IndicatorsReadiness IndicatorsAssessing Importance and Assessing Importance and ConfidenceConfidence

ImportanceImportanceHow important is it to you to ____________?How important is it to you to ____________?On a scale of 0 to 10, with 0 being not important at all & 10 being very On a scale of 0 to 10, with 0 being not important at all & 10 being very important…important…

0 1 2 30 1 2 3 4 54 5 6 6 7 7 8 9 108 9 10Not a allNot a all Somewhat Somewhat Very Very

ConfidenceConfidenceHow confident are you that you could _____________, if you decided to? On a How confident are you that you could _____________, if you decided to? On a scale of 0 to 10, with 0 being not confident at all & 10 being very scale of 0 to 10, with 0 being not confident at all & 10 being very confident? confident?

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10Not at allNot at all Somewhat Somewhat Very Very

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Evaluating Evaluating Importance/ConfidenceImportance/Confidence

• ““What made you answer with a What made you answer with a (number patient gave) and not a (number patient gave) and not a zero?”zero?”

• ““What would it take for you to move What would it take for you to move from a (number patient gave) to a from a (number patient gave) to a (slightly higher number)?”(slightly higher number)?”

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Setting GoalsSetting Goals

SSpecificpecific MMeasurableeasurable AAchievablechievable RRealisticealistic TTimelyimely

Let’s see how we pull this Let’s see how we pull this together… together…

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ResourcesResourceswww.motivationalinterview.org

Clinical issuesClinical issuesBackgroundBackgroundSpecial PopulationsSpecial PopulationsGroup ApproachesGroup Approaches

The LibraryThe LibraryAbstractsAbstractsBibliographyBibliographyMINUET NewsletterMINUET NewsletterLinksLinks

TrainingTrainingUpcoming TrainingUpcoming TrainingMINT TrainersMINT TrainersTraining VideosTraining Videos

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MI BooksMI Books Miller, WR & Rollnick, S (1991). Motivational Miller, WR & Rollnick, S (1991). Motivational

interviewing: Preparing people to change addictive interviewing: Preparing people to change addictive behavior. New York: Guilford Press.behavior. New York: Guilford Press.

Miller, WR & Rollnick, S (2002). Motivational Miller, WR & Rollnick, S (2002). Motivational interviewing: Preparing people for change (2nd ed.). interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. New York: Guilford Press.

Arkowitz, H, Westra, HA, Miller, WR, Rollnick, S (Eds.) Arkowitz, H, Westra, HA, Miller, WR, Rollnick, S (Eds.) (2008). Motivational interviewing in the treatment of (2008). Motivational interviewing in the treatment of psychological problems. New York: Guilford Press.psychological problems. New York: Guilford Press.

Rollnick, S, Miller, WR & Butler, CC (2008). Motivational Rollnick, S, Miller, WR & Butler, CC (2008). Motivational interviewing in health care. New York: Guilford Press.interviewing in health care. New York: Guilford Press.

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MI ArticlesMI Articles Britt, E, Hudson, SM, & Blampied, NM. (2004). Motivational Britt, E, Hudson, SM, & Blampied, NM. (2004). Motivational

interviewing in health care settings. Education and Counseling, interviewing in health care settings. Education and Counseling, 53, 147-155.53, 147-155.

Emmons, KM, & Rollnick, S. (2001). Motivational interviewing in Emmons, KM, & Rollnick, S. (2001). Motivational interviewing in health care settings. American Journal of Preventive Medicine, 20, health care settings. American Journal of Preventive Medicine, 20, 68-74.68-74.

Greaves C, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Greaves C, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Steele A, Gale T, Hammerton F, Daly M (2008). Motivational Steele A, Gale T, Hammerton F, Daly M (2008). Motivational interviewing for modifying diabetes risk: a randomized controlled interviewing for modifying diabetes risk: a randomized controlled trial. British Journal of General Practice, 58(553), 535-40.trial. British Journal of General Practice, 58(553), 535-40.

Hecht, J, et al. (2005). Motivational Interviewing in community-Hecht, J, et al. (2005). Motivational Interviewing in community-based research: Experiences from the field. Annals of Behavioral based research: Experiences from the field. Annals of Behavioral Medicine, 29 Special Supplement, 29-34.Medicine, 29 Special Supplement, 29-34.

Resnicow, K, et al. (2001). Motivational interviewing in health Resnicow, K, et al. (2001). Motivational interviewing in health promotion: It sounds like something is changing. Health promotion: It sounds like something is changing. Health Psychology, 21, 444-451.Psychology, 21, 444-451.

Soria R, Legido A, Escolano C, and Yeste A (2006). A randomized controlled trial of Soria R, Legido A, Escolano C, and Yeste A (2006). A randomized controlled trial of motivational interviewing for smoking cessation. Br J Gen Prac, 56(531), 768-774.motivational interviewing for smoking cessation. Br J Gen Prac, 56(531), 768-774.

Moyers T, Martino S (2006). “What’s important in my life” The personal goals and Moyers T, Martino S (2006). “What’s important in my life” The personal goals and values card sorting task for individuals with schizophrenia.values card sorting task for individuals with schizophrenia.

Zygmunt A, Olfson M, Boyer A, Mechanic d (2002). Interventions to improve Zygmunt A, Olfson M, Boyer A, Mechanic d (2002). Interventions to improve medication adherence in schizophrenia. American Journal of Psychiatry. medication adherence in schizophrenia. American Journal of Psychiatry.

Possidente C, Bucci K, McClain W (2005). Motivational interviewing: A tool to Possidente C, Bucci K, McClain W (2005). Motivational interviewing: A tool to improve medication adherence? American Journal of Health-System Pharmacy, improve medication adherence? American Journal of Health-System Pharmacy, 62(12) 1311-1314.62(12) 1311-1314.

Swaminath G (2007). You can lead a horse to water… Indian Journal of Psychiatry, Swaminath G (2007). You can lead a horse to water… Indian Journal of Psychiatry, 49(4), 228-230.49(4), 228-230.

Cole S, Bogenschutz M, Hungerford D (2011). Motivational Interviewing and Cole S, Bogenschutz M, Hungerford D (2011). Motivational Interviewing and Psychiatry: Use in addiction treatment, risky drinking and routine practice. FOCUS, Psychiatry: Use in addiction treatment, risky drinking and routine practice. FOCUS, 9:42-54.9:42-54.

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