Presented by Primary Care Development Corporation & Reverend Julie L. Barnes, LMHC, Same Boat Consulting

Strategies for Healthy Behavior Change:A "Speed Date" Session on Motivational Interviewing

About the Primary Care Development Corporation (PCDC)

Founded in 1993, PCDC is a nonprofit organization dedicated to expanding and transforming primary care in underserved communities to improve health outcomes, lower health costs and reduce disparities.

• Certified as a Community Development Financial Institution (CDFI) by the U.S. Treasury.

• Offices in New York City and Los Angeles County.• Three Programs:

– Capital Investment– Performance Improvement– Policy & Advocacy

About PCDC’s HIP in Healthcare Program• PCDC is currently funded by the U.S. Centers for Disease Control and

Prevention (CDC) to provide High Impact HIV Prevention (HIP) capacity building services to healthcare organizations across the country.

• PCDC’s HIP in Healthcare program provides training and technical assistance at no cost to healthcare organizations (i.e. direct service providers) and brings its expertise in patient-centered medical home and chronic care management to improve HIV testing, care coordination and care management services.

High Impact HIV Prevention StrategiesHIV Testing

Prevention with PositivesPrevention with High Risk Negatives

MOTIVATIONAL INTERVIEWINGSession Goals:

• Help clinic staff better understand how/why patients get stuck in the process of behavior change

• Offer an overview of Motivational Interviewing principals and techniques that can facilitate more efficient, productive, patient-centered dialogue about behavior change

Case Example

• Alicia, Latina, pregnant, 21 years old, HIV+• Newly diagnosed, off meds, afraid• Newly in recovery, living in halfway house,

heroin use since adolescence, past sex work• Two older children: older one living with child’s

father, one placed by DCF with a relative. • Isolated, lots of shame, unskilled as parent,

significant trauma history

How to Help Alicia?

• Build trust & relationship with CHW with similar life experience

• Foundation of active listening• Look for her strengths: resilience, determination,

strong survival skills care for her baby• Start with what she’s ready to do: methadone

program, primary care, parenting classes, supportive housing

• Respect what she’s not ready for: HIV treatment and disclosure

What makes unhealthy behavior hard to change for everyone?

• Fear• Stress• Habit• Payoffs of current behavior: it’s easy, familiar, feels good,

avoids something worse• Shame• Feeling pressured• Feeling powerless• Lack of support• Environmental factors (family, neighborhood)

Where do our patients get stuck?• Negotiating safer sex• 100% Adherence to HIV meds• Coming regularly to clinic for care• Making needed changes in diet, exercise, lifestyle• Reducing or ending substance use (including

cigarettes & alcohol)• Feeling isolated & not super motivated about health• Not dealing with underlying Mental Health issues

(especially depression, anxiety, PTSD)

Behavior change is…

• A long process over time of small changes, setbacks, returns to old habits, and re-starting again

• Challenging for all of us in different ways

• May be stressful, scary, overwhelming, and difficult without support.

• Easier with a non-judgmental, consistent network of providers and community.

Staff

Harm ReductionAn approach focused on reducing negative impact

MotivationalInterviewing

A tool to help build desire & willingness for positive change

Stages of Change

A tool to assess readiness & make practical plans

Anansi Health 2014

Why Stages of Change?

It’s a way of understanding someone’s level of motivation to make change

Can be used in different situations: addiction, med issues, diet, exercise, etc.

Can help provider recognize why someone is or isn’t taking action on an issue

Anansi Health 2014

Stages of Change

• Pre-contemplation: Not even thinking of it– “I’ve got enough to deal with already”

• Contemplation: Planning to do it someday– “I know I should and I want to, but just not right now.”

• Preparation: Taking steps– Cutting back, getting rid of triggers, telling friends, etc

• Action: Doing it!• Maintenance: Sticking with it

– Part of my life• Relapse: Falling off & trying to get back on track

– Natural part of the cycle

Anansi Health 2014

Precontemplation Contemplation

Preparation

Action

Maintenance

Relapse

Precontemplation

Contemplation

Preparation

Action

MaintenanceRelapse

Precontemplation

PreparationMaintenance

Contemplation

Action

Relapse

Anansi Health 2014

Motivational Interviewing (MI)

• client-centered

• goal-directed (behavior change)

• helps resolve ambivalence

• affirms client’s autonomy

• collaborative

• elicits client’s intrinsic motivation & reasons for change

What is MI?

• An end to trying to convince, persuade, beg, insist, scare, or bribe people into changing

• Sometimes thought of as “helping people talk themselves into changing”

• Assumes that all of us have reasons to change and reasons to stay the same, which leads to ambivalence

Principles of MI• Express empathy

respectful understanding and warmth

• Develop discrepancybetween present self and ideal self

• Support self-efficacyempowering them to make change

• Roll with resistanceavoid confronting/arguing

Patient is the Expert in Her Own Life

“People are generally better persuaded by the reasons they have themselves

discovered, than by those whichhave come into the mind of others.”

Blaise Pascal, Pensees17th century philosopher

Evoking Change

• Ask about pros of the status quo What do you like best about your current situation?

• Ask about cons of the status quoWhat are the hardest/worst parts of

your current situation?

Let them make the argument for change

• If you follow the “righting reflex” and make the argument for change, the other person will instinctively defend the status quo!

The Status Quomy current behavior: not using condoms, staying out of care,

drinking

_________________________________________Pros Cons

Not taking HIV Meds

PROS CONS• Avoid side effects• Save money• No hassle at clinic or pharmacy• Avoid having to think about my

illness• Protect privacy (i.e.: living with

family who doesn’t know status)• Don’t have to worry about

remembering or planning• I don’t feel sick!• My life is too chaotic/stressful to

start now.

• May get sicker or get an OI• Higher risk of infecting

partners• Spotty adherence may lead

to meds not working anymore

• May get hospitalized• Weak immune system is

slow to recover• Risk of Death

What do we notice about these reasons?

• Pros and Cons are nearly equal!• Pros are short-term and more emotional• Cons are longer-term and more grave• There are rational reasons on both sides.• For a person who is stressed & feeling fine, the pros may

legitimately outweigh the cons of not taking meds.• As providers, we need to understand a person’s

individual pros and cons to help them make the health decisions they are ready for and feel right to them.

How do we practice MI?

• The principles are pretty straightforward, but hard to do.

• We have to put our agenda aside & meet our client in their ambivalence!

• Requires we stop trying to solve the patient’s problems for her.

• Like any art form, it gets easier with practice.• OARS= tools to make this concrete

OARS: Closed v.s. Open Questions

OPEN

What worries you

most about your

current situation?

What changes have

you noticed?

How so?

CLOSED

Are you worried about

your current situation?

Have you noticed

changes?

Do you care

about your health?

• OARS: Affirming– Giving credit for small steps– Appreciating aspects of someone’s

character, something they accomplished, or supporting an idea they have

– Not shaming or blaming, labeling, or stereotyping

– Work best when they are both specific and genuine

OARS: Affirmations

Anansi Health 2014

Communication ModelFrom Thomas Gordon

The Words the Listener Hears

What the Listener Thinksthe Speaker Means

The Words theSpeaker Says

What the Speaker Really Means

2

OARS: Reflective Listening3 Levels

• Simple - restate using the same words• Complex – paraphrase, extrapolate• Feeling – infer meaning behind the words or

emphasize emotional aspects

Client: “I wish I could quit smoking and I’ve tried so many times, but I really need it to help manage my stress and not feel crazy.”

Practitioner: “You want to quit, and there are a lot of reasons that you feel like you depend on cigarettes.”

OARS: Summaries• Transition or ending statements• Collect “change talk” statements• Present bouquet of patient’s own

reasons for change

Summary Intros:

“Here is what I’ve heard so far…..What did I miss?

“We’ve gone over quite a bit. Let me make sure I am understanding you…”

Applying the tool

• How might MI fit into your work with “stuck” patients?

• What challenges might arise in using this approach?

• How could you use MI in communicating across the care team?

• What questions do you have?

Want more?

• This session scratched the surface of what’s out there in MI

• Understanding the principles is the first step, but mastery comes through practice and ongoing reinforcement of learning.

• PCDC offers free training sessions tailored to your site’s existing skills and needs for qualified health centers

• For more information, contact: P: (212) 437-3970 E: hip@pcdc.org

Thank You!

• For the work you do & your willingness to keep learning in service to your patients.

• Be in touch with questions or to learn more:Rev. Julie Barnes, LMHCSame Boat Consulting, Boston, MAsameboatconsulting@gmail.com