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Motivating Patients to Make Change Ann Landes, Ph.D. alandes@zoho.com Slide 2 Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation. Slide 3 Objectives 1. Introduce the model of Motivational Interviewing (MI) 2. Provide an overview of the concept of "Stages of Change" and its application to patient self-management 3. Explain how MI can be employed by medical providers to encourage collaboration between the patient and the medical provider, as they work toward positive behavior change and improved quality-of-life Slide 4 SUPPORT FOR MOTIVATIONAL INTERVIEWING Slide 5 Hettema, Steele, and Miller (2005) Found significant support for the efficacy of MI across 75 randomized controlled trials (RCTs). Adding MI to the beginning of treatment led to sustained outcome improvements. Outcomes were better when no manual was used. * (e.g., focus more on the alliance/relationship between provider and patient) Slide 6 Applications Alcohol abuse HIV risk reduction Illicit drug use Smoking Treatment adherence Diet/exercise Gambling Intimate relationships Eating disorders Water purification to promote health Slide 7 Beach, Keruly, & Moore, 2005; Schneider, et al., 2004 Patient-Centered Communication from Provider Effective Patient-Physician Relationship & Communications = Greater patient satisfaction in medical care Greater improvements in general medical condition Increased adherence to medical treatments Slide 8 WHAT IS MI? Slide 9 Motivational Interviewing is a method that has been found to be successful in increasing intrinsic motivation to change by exploring and resolving ambivalence collaborative effort between the provider and patient (Miller & Rollnick, 2002) Slide 10 Motivational Interviewing helps patients identify and address roadblocks to change (i.e., fears, lack of skills/information, needed supports, etc.) focuses on the way we as providers can inspire positive change in the lives of patients (Miller & Rollnick, 2002) Slide 11 The Spirit of MI Autonomy Focusing on patient choice Asking permission to provide assistance, info. Collaboration Coming along side; nonjudgmental Viewing the patient as the expert Evocation Exploring what motivates the patient Making no assumptions Appreciation of Ambivalence Slide 12 Notes about Ambivalence When an individual feels two ways about something Normal to the process of change Trap If we argue for change, the patient may argue for the status quo, leading to decreased likelihood for change. Slide 13 Motivational Interviewing is a method that 1.works to create collaboration between the provider and the patient 2.focuses on patient choice/autonomy 3.sees ambivalence as pathological 4.Answers 1 and 2 5.None of the above Slide 14 The Individual and Change Slide 15 Patients with HIV/AIDs and Change Adherence to current medication schedule Maintaining regular medical appointments Making healthy choices about use of alcohol, tobacco, illicit drugs Attending to self-care needs, such as diet and exercise Practice consistent precautionary behaviors to reduce transmission (prevention) Enlisting social support(s) Slide 16 Prochaska and DiClementes Stages of Change Model Pre- contemplation ContemplationPreparationActionMaintenanceRelapse Slide 17 Pre-contemplation I see no problem(s) to address at this time. I know theres a need for change, but I dont want to right now. ( has not given much thought to change) Provider Role Bring awareness to the issue Encourage engagement of the patient Slide 18 Tell-Tale Signs Im not ready Argues/disagrees with the providers diagnosis or suggestions Resists offers of assistance Expresses denial of problems/concerns Communicates a sense of hopelessness about the situation Slide 19 Contemplation Yeah, Ive thought about my health needs, but Im just not ready yet to change. (ambivalence) Provider Role Increase awareness about the options for and benefits of change * Keep the patient thinking about positive change. Slide 20 Preparation/Determination OK, Im prepared to make some changes, but, Im not really sure I can or know how to do it. Provider Role Decrease barriers to change by providing resources, information & offering assistance Address issues of self-efficacy Slide 21 Action/Will Power I know I need to make some changes; I have had to make changes before and did it. Provider Role Encourage movement by helping to develop realistic goals and a plan-of-action Offer resources and support Slide 22 Maintenance Wow! I have made some impressive changes! How can I continue on this path? Provider Role Help maintain positive focus and reduce opportunities for relapse Slide 23 Relapse I was doing really well, I thought, but then I got tired of having to focus so much energy on caring for my health. So, I just quit. Provider Role Normalize that relapse is OK (reduce shame) Encourage honest discussion about what led to relapse Assist in re-exploration of personal goals Help develop strategies for re-engagement Slide 24 Tips To Remember It is not about us. Responsibility lies with the individual patient and what they feel they need in their life. Our role is to be active, caring observers who are present to help the patient. Because individual behaviors can change over time, we need to remain vigilant about checking-in at each encounter (Metsch, et al., 2004). Slide 25 INSTRUMENTS OF CHANGE The Health Care Provider & Motivational Interviewing Slide 26 Provider Stance Guiding or coaching (versus directing) and supporting Respecting individual autonomy & empowerment Expressing belief in the patients ability to make decisions Resisting the reflex to make it right or to label actions as good versus bad Slide 27 Slide 28 Four Processes of MI 1.Engaging: listening to understand OARS 2.Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, offering information and advice 3.Evoking: selective eliciting, responding, summaries toward change talk 4.Planning: moving toward commitment and change Slide 29 Change Speak DARN-C Desire: I want to get healthier. Ability: I can do this if I set my mind to it. Reasons: My heavy drinking is causing me many health problems. Need: My family worries about me too much; it is not fair to them. Commitment: I will start getting more regular health check-ups. Slide 30 Engaging: Building a therapeutic alliance Step 1 OARS O pen ended questions A ffirmations R eflective Listening S ummaries http://motivationalinterview.org/clinical/interaction.html www.mpaetc.org/downloads/motiv_interv_09.pdf Slide 31 O-A-R-S O pen ended questions to elicit change talk: What are some of your reasons for decreasing your alcohol intake? (desire) How might you go about decreasing your drug usage? (ability) What do you see as some benefits to lowering your alcohol usage? (reasons) Slide 32 O-A-R-S O pen ended questions to elicit change talk: How important is it for you to decrease your usage? (need) What might you do to start reducing your alcohol consumption? (commitment) Slide 33 O-A-R-S A ffirmations: Use to encourage people to see their resources Make them personal and genuine Explore partial successes and attempts and intentions Highlight patient attributes, effort Im really glad you decided to come in to see me today. Slide 34 O-A-R-S R eflective Listening (paraphrasing pt comments): It sounds as if you are a bit concerned about how to make healthier choices in your life. S ummaries (restating patients main points): Let me make sure I heard you correctly. You do want to address your drug usage and you want information about how to take more precautions in your sex life. Slide 35 O.A.R.S. is an acronym for the skills that can be used to engage patients in treatment; it stands for 1.O-offer assistance; A-ask questions; R-refer out; S-summarize 2.O-operationalize; A-attend; R-request tests; S-start goals 3.O-open ended questions; A-affirmations; R-reflective listening; S-summaries 4.O-open up discussion; A-attend to; R-reflect; S-shorten session Slide 36 Focusing: Target one area step 2 Identify a strategic focus (agenda setting) Explore patients motivation, while listening for change talk Offer and share information - ask permission, Elicit-Provide-Elicit Slide 37 Example Target behavior: use of condoms Agenda setting: Hello, Sandy, its nice to see you. The last time we met, we spoke about your goal to begin using condoms more regularly. Id like to start with that topic, unless you have something more pressing to discuss. Sandy: I didnt do too well - I do want to do better. Possible Reflections: You found it more difficult than you thought. Youre still committed to change and you found it challenging. Slide 38 Example (cont.) Sandy: My partner doesnt like using condoms. He wont even talk to me about it. Reflections: Its been difficult to make the change, especially since your partner doesnt agree with the change. Sandy: Yeah, I guess; I dont really see the need either, since I am monogamous. Reflections: You have questions about the importance of using condoms, since you are having sex with just your partner. Slide 39 (cont.) Sandy : Yeah, its such a big change; Im not sure its worth it. Reflection: You feel a bit unprepared for making this change and uncertain about whether using condoms is what you want to do. Sandy : Yeah. I do and I dont want to make the change. Reflection: You have some motivation to change. We can work on this together. I have some ideas and information. Can I share them with you? Sandy: Okay. Slide 40 Conversation continues Transitional Summary: Alright, if I can summarize what we have spoken about: You are confused about the reasons for using a condom, its been difficult to make the change since your partner does not agree with it, and you feel unprepared. So, you would like more information and some ideas that may work for you. Key Question: Where do you want to begin with information about condom use, ways to make the change, or how to approach your partner? (autonomy) Slide 41 Elicit, Provide, Elicit (information sharing process) ELICIT readiness and interest What do you know about the effects of What concerns do you have about? PROVIDE clear information or feedback What happens to some people is that The results of your tests suggest that As your doctor/counselor/nurse, I strongly urge you to ELICIT the interpretation or reaction What do you think? How do you think you might? Slide 42 Evoking pulling for change talk step 3 Encouraging, nurturing, reinforcing change talk Guiding towards change finding alignment (and discrepancy) between current behavior and goals and values Rolling with resistance Summarizing where you are Slide 43 Approaches for Evoking Change Talk Ruler for importance Querying extremes Goals and Values Typical day Looking forward Coming alongside Slide 44 Importance Ruler On a scale of 0 to 10, how important is it to you to _________? What is the reason its (x) and not (a lower number)? (If number is less than 8), What would it take to move it up in importance just one number? {Listen, reflect} What do you think you might do next? Slide 45 Querying Extremes What are the worst things that could happen if you dont make this change? Whats the best thing that could happen if you make this change? Slide 46 Goals and Values Lets, for a moment, move away from this ____ issue and focus on the things that are most important to you, your life dreams, goals, and values. Tell me the most important areas for you. Listen, then say: So being here, healthy, is important. How does your (behavior) fit in with that? Relate to values, bigger issues. May be useful to prompt or have visual aides that reflect common values and goals (family, work, country, spirituality, community) (Miller and CdeBaca, 2001) Slide 47 Rolling with Resistance o Affirm and accept patients fears, concerns: I can understand your worries about the side effects of all you medications. Lets spend some time discussing this. o Reflect others concerns: I hear you saying that you dont care about maintaining a healthy diet; but, how does this impact your partner? o Reframing patient concerns to positive movement So what youre saying is that you desire to quit smoking and (instead of BUT) you realize this may be hard to do. o Offer assistance How can I help you move towards making positive change? What is needed? Slide 48 Assessment and Planning step 4 Summarizing where the patient is with regard to making change Developing a goal and action plan Exploring, building patients confidence/self-efficacy (affirmations) Addressing real and perceived barriers, challenges Scheduling follow-up Slide 49 Assess Stage of Change How confident/ready are you in making changes to your lifestyle? How do you feel about the requirements of maintaining your health? What do you hope with regard to your health diagnosis for the future? What concerns do you have about your risk-reduction practices? Slide 50 Pre-contemplation Listen and help address any patient concerns It sounds as if you want to reduce your alcohol intake, but your partner does not want to change his/her lifestyle. Maybe we can brainstorm ways that you can address this with your partner. Encourage information sharing from patient What is your opinion or belief about using condoms? Tell me how you have been able to manage your medication requirements. Express interest and empathy The decisions you have to make are very difficult. I know you can make the decision on your own, but I would like to assist you in learning more about your options. Slide 51 Planning for Change (Contemplation Stage) Attend to ambivalence I hear that part of you wants to make some positive changes, but a part of you is also hesitant. reflect intention Foster Self-efficacy and Autonomy Elicit current knowledge: What do you know about __? Provide information: If I may, let me provide some information. Elicit Pt reaction: What are your reactions to this information? Ultimately, it is your decision to make about ___. Slide 52 Movement Towards Change (Preparation and Action ) What do you think would be a do-able first step towards your goal that you can do today? What do you plan to do between now and next week? When do you think you will be able to start? What strategies have you employed in the past to achieve goals? What will we be looking for that indicates success? Slide 53 Addressing Barriers to Change & Enlisting Support What can I do to assist you? Can I provide you some resources? Who can you ask to be a support for you during this time? Slide 54 Maintaining Positive Change Normalize any possible set-backs (reduce shame) Its OK if you dont always meet your goals of ___. Help patient develop a plan to ensure success What other things can you do to encourage your progress towards ____. What might be some barriers or temptations that hinder you? Provide Continued Support I would you like to meet again to check-in and see how you are doing. How does that sound? Slide 55 When Relapse Happens Normalize relapse Relapsing is a normal part of any change process. Assist patient in remaining engaged I believe you are quite capable of continuing on toward your goals you did it before and you can do it again! What lessons can be learned from this relapse to help you remain focused on ___. What might you do differently? Where do you think we should go from here? Slide 56 Case Study H.A., a 42-year-old, Caucasian, divorced male is referred to your care after he was found to be HIV-seropositive. H.A. is currently unemployed and homeless and though he has a long history of abusing drugs and alcohol he states that he is trying to get clean. H.A. states that he is really concerned about his deteriorating physical and mental health. When asked about social supports, HA replies that he has a brother and a sister who live close by. He adds that he also receives great support from his case manager, a social worker at the community-based recovery program for homeless persons with addictions. Slide 57 What is the patients stage of change and how would you nurture his change talk? 1.Precontemplation Stage; provider would express empathy and encourage info. sharing 2.Contemplation Stage; provider would attend to patients ambivalence and foster his self-efficacy and autonomy 3.Preparation Stage; provider would help patient set goals and develop action plan 4.Maintenance Stage; provider would normalize relapse Slide 58 Remind yourself that even if the patient does not choose to change, the intervention is not a failure. Any discussion or talk about change is planting a seed. Slide 59 References Beach, M., Keruly, J., & Moore, R. D. (2005). Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV? Journal of General Internal Medicine, 21, 661. Metsch, L. R, Pereyra, M., del Rio, C., Gardner, L., Duffus, W. A., Dickinson, G., et al. (2004). Delivery of HIV prevention counseling by physicians at HIV medical care settings in 4 US cities. American Journal of Public Health, 94(7), 1186. Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York: Guilford. Slide 60 References Miller, W. R., & CdeBaca, J. (2001). Quantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives. New York: Guilford Press. Schneider, J., Kaplan, S. H., Greenfield, S., Li, W., & Wilson, I. B. (2004). Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. Journal of General Internal Medicine, 19, 1096. Slide 61 References Cook, P. F., Bradley-Springer, L., & Corwin, M. A. (2009, August). Motivational interviewing and HIV: Reducing risk, inspiring change. Retrieved July 2, 2010, from www.mpaetc.org/downloads/motiv_interv_09.pdf Motivational interviewing [resources for clinicians, researchers, and trainers.](n.d.) Retrieved July 2, 2010, from http://motivationalinterview.org/clinical/interaction.html Family Health International. (2007). Nursing care of patients with HIV/AIDS. Retrieved August 19, 2010, from http://www.fhi.org/NR/rdonlyres/erwyyfde6xm6oxea3vg46q5fpg7lo ttczgkru5ymvykflcipkasb3jkqkfomo3ybedwpeis5z6sxlp/NursesCar ePatientsParticipantsGuideHV.pdf Slide 62 Questions? Contac Office: 352-376-1611 (x-4745) Slide 63 Disclosure of Financial Relationships This speaker has no significant financial relationships with commercial entities to disclose. This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.