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Enhancing Life Enhancing Life

© 2010 Cherokee Health Systems

Enhancing Motivation to Change:

Motivational Interviewing in an Integrated Primary Care Clinic

Suzanne Bailey, Psy.D.Suzanne Bailey, Psy.D.Licensed Clinical PsychologistLicensed Clinical PsychologistBehavioral Health ConsultantBehavioral Health Consultant

Cherokee Health SystemsCherokee Health Systems

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session G1bOctober 28, 201110:20 AM




Faculty DisclosureFaculty Disclosure

I I have nothave not had any relevant financial relationships had any relevant financial relationships during the past 12 months. during the past 12 months.




Need/Practice Gap & Supporting ResourcesNeed/Practice Gap & Supporting Resources

• www.motivationalinterview.orgwww.motivationalinterview.org

• Rollnick, S., Mason, P., & Butler, C. (1999). Health Behavior Change: A guide for practitioners. NY: Churchill Livingstone.

• Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping patients change behavior. NY: Guilford Press.

• Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change (2 ed.). NY: Guilford Press.

• Prochaska, J.O., & DiClemente, CC. (1984). The transtheoretical approach:

Crossing traditional boundaries of therapy. Homewood, IL: Dow/Jones Irwin.




ObjectivesObjectives

1. Describe motivational interviewing as a conceptual model for enhancing patient motivation

2. Identify why the use of highly confrontational interventions are less likely to evoke behavior change

3. List the basic concepts and techniques of motivational interviewing

4. Implement a method to train providers to use motivational interviewing in integrated care




Expected OutcomeExpected Outcome

• Participants will utilize motivational interviewing as a Participants will utilize motivational interviewing as a conceptual tool to enhance patients’ ability to engage in conceptual tool to enhance patients’ ability to engage in behavior changebehavior change

• Participants will implement a model of training providers to Participants will implement a model of training providers to use motivational interviewinguse motivational interviewing




Cherokee Health Systems’ Cherokee Health Systems’ Integrated Care ModelIntegrated Care Model

• Embedded Behavioral Health Consultant (BHC) Embedded Behavioral Health Consultant (BHC) on the Primary Care teamon the Primary Care team

• Real time behavioral and psychiatric consultation Real time behavioral and psychiatric consultation available to PCPavailable to PCP

• Focused behavioral interventions in primary careFocused behavioral interventions in primary care• Behavioral medicine scope of practiceBehavioral medicine scope of practice• Encourage patient responsibility for healthy livingEncourage patient responsibility for healthy living• A behaviorally enhanced Healthcare HomeA behaviorally enhanced Healthcare Home




Poor Treatment AdherencePoor Treatment Adherence

• A systemic problemA systemic problem

• Management of chronic disease requires Management of chronic disease requires behavior change interventionsbehavior change interventions

• Directly impacts treatment efficacyDirectly impacts treatment efficacy

• Frustrates providersFrustrates providers““I’ve told him a thousand times. He just doesn’t care.”I’ve told him a thousand times. He just doesn’t care.”




Why don’t patients change?Why don’t patients change?

• Our focus on overall health may not be the Our focus on overall health may not be the patient’s priority.patient’s priority.

• AmbivalenceAmbivalence““I don’t want to change, I just want to feel better.”I don’t want to change, I just want to feel better.”

• Decisional Balance- Costs vs. BenefitsDecisional Balance- Costs vs. Benefits

• Stage of ChangeStage of Change




Stages of ChangeStages of Change• PrecontemplationPrecontemplation

I don’t have a problem. I don’t have a problem.

• ContemplationContemplationI have a problem, and might change someday.I have a problem, and might change someday.

• PreparationPreparationI think I will change soon. I think I will change soon.

• ActionActionI’m taking action to change.I’m taking action to change.

• MaintenanceMaintenanceI’m working to maintain the changes I’ve made.I’m working to maintain the changes I’ve made.

Prochaska and DiClemente Prochaska and DiClemente (1984)(1984)




Ready for Action?Ready for Action?

• Providers are in the action stage.Providers are in the action stage.

• Are patients?Are patients?




Common PitfallsCommon Pitfalls

• Give a lecture Give a lecture

• Give them a hard timeGive them a hard time

• Give upGive up




Why it doesn’t work…Why it doesn’t work…

• Creates resistanceCreates resistance

• Causes patients to become defensiveCauses patients to become defensive

• ““Yes, but…”Yes, but…”




Changing our thinking about changing Changing our thinking about changing our patientsour patients




Imperative for MI TrainingImperative for MI Training

• Implementation of SBIRTImplementation of SBIRT

• PCPs “close the sale”PCPs “close the sale”

• Introduction of the BHCIntroduction of the BHC




The MI The MI InformedInformed PCP PCP

• Training Goals-Training Goals-1.1. Become familiar with the core concepts and Become familiar with the core concepts and

principles of MIprinciples of MI2.2. Learn fundamental MI skills Learn fundamental MI skills 3.3. Practice using MI skills and applying key Practice using MI skills and applying key

conceptsconcepts




Providing MI Training For PCPsProviding MI Training For PCPs

• Episodes of TrainingEpisodes of Training

• Training LengthTraining Length

• Training Intensity Training Intensity

• Follow-upFollow-up




Introduction to Motivational Introduction to Motivational InterviewingInterviewing

• Duration: 45 minutesDuration: 45 minutes• ObjectivesObjectives– To be familiar with the core components of MITo be familiar with the core components of MI– To be acquainted with theoretical background and To be acquainted with theoretical background and

evidence of efficacyevidence of efficacy

Adapted from Sample Training Agendas provided by motivationalinterview.orgAdapted from Sample Training Agendas provided by motivationalinterview.org




What is Motivational InterviewingWhat is Motivational Interviewing• ““Motivational Interviewing is a collaborative, Motivational Interviewing is a collaborative,

person-centered form of guiding to elicit and person-centered form of guiding to elicit and strengthen motivation for change.”strengthen motivation for change.”

(Miller & Rollnick, 2009)(Miller & Rollnick, 2009)

• Style of InteractingStyle of Interacting

• A A collaborativecollaborative conversation about changeconversation about change that that elicitselicits motivation and commitment from the motivation and commitment from the patient.patient. (Miller & Rollnick, 2010)(Miller & Rollnick, 2010)




MI EfficacyMI Efficacy

• Well-researchedWell-researched• Research conducted in settings providing Research conducted in settings providing

direct caredirect care• Substance use, smoking cessation, obesity, Substance use, smoking cessation, obesity,

diabetes, hypertension, adherence, and many diabetes, hypertension, adherence, and many moremore




Motivational Interviewing: Core Motivational Interviewing: Core ComponentsComponents

• Develop DiscrepancyDevelop Discrepancy• Express EmpathyExpress Empathy• Roll with ResistanceRoll with Resistance• Support Self-EfficacySupport Self-Efficacy





Motivation and Confidence RulersMotivation and Confidence Rulers

• On a scale of 1-10 how important is it for you On a scale of 1-10 how important is it for you to make the change?to make the change?

• On a scale of 1-10 how confident are you in On a scale of 1-10 how confident are you in your ability to make the change?your ability to make the change?




Example of Motivational InterviewingExample of Motivational Interviewing




Application of MIApplication of MI

• Duration: 1 hourDuration: 1 hour• ObjectivesObjectives– To learn basic MI skillsTo learn basic MI skills– To practice an MI style of patient interactionTo practice an MI style of patient interaction

Adapted from Sample Training Agendas provided by motivationalinterview.orgAdapted from Sample Training Agendas provided by motivationalinterview.org




OARS AlgorithmOARS Algorithm

• OO – Open-ended Questions – Open-ended Questions• AA – Affirmations – Affirmations• RR – Reflective Listening – Reflective Listening• SS – Summaries – Summaries





O – Open-ended QuestionsO – Open-ended Questions

• Cannot be answered with “yes” or “no”Cannot be answered with “yes” or “no”

– ““What changes have you considered making to What changes have you considered making to your diet?”your diet?”




A - AffirmationsA - Affirmations

• ReinforceReinforce• Recognize Recognize • EncourageEncourage

– ““I can see that your health is important to you and I can see that your health is important to you and you would like to feel better.”you would like to feel better.”




R – Reflective ListeningR – Reflective Listening

• ListenListen• RestateRestate• Ask for clarification and confirmationAsk for clarification and confirmation

– ““I hear you saying that you’d like to stop smoking, I hear you saying that you’d like to stop smoking, but you worry that it would be difficult.”but you worry that it would be difficult.”




S - SummariesS - Summaries

• Restate with emphasisRestate with emphasis

– ““So, what you have said is that… Did I understand So, what you have said is that… Did I understand you correctly?”you correctly?”




Change TalkChange Talk

• Listen for itListen for it• Guide the conversationGuide the conversation• Don’t elicit resistanceDon’t elicit resistance– Say it firstSay it first

• Strengthens commitment to changeStrengthens commitment to change




PracticePractice

• Provider generated scenariosProvider generated scenarios• Role-playingRole-playing• FeedbackFeedback




Follow-UpFollow-Up

• HandoutsHandouts• E-mail “Tip of the Week”E-mail “Tip of the Week”• ““Curbside consultation” with BHCCurbside consultation” with BHC




Lessons LearnedLessons Learned

• Brief training can be beneficialBrief training can be beneficial

• ““It’s not really that different.”It’s not really that different.”

• Planning and prioritizationPlanning and prioritization




Contact InformationContact Information

Suzanne Bailey, Psy.D.Suzanne Bailey, [email protected]@cherokeehealth.com




Session EvaluationSession Evaluation

Please complete and return thePlease complete and return theevaluation form to the classroom monitor evaluation form to the classroom monitor

before leaving this session.before leaving this session.

Thank you!Thank you!

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