Brief Motivational Interviewing SLIDES(1).pdf

UNIVERSITY OF PRETORIA Behavioural “I believe that every human Change has a finite amount of Counselling heartbeats. I don't intend to...

UNIVERSITY OF PRETORIA Behavioural “I believe that every human Change has a finite amount of Counselling heartbeats. I don't intend to waste any of mine running around doing exercises.” K Mostert Neil Armstrong 1 2 Health behaviour change Guiding principles Common concerns, conditions and  Expressing empathy complaints?  Developing discrepancy between client goals  Whose problem is it? and current problem behaviour by use of Health Professional / Client reflective listening and objective feedback;  Practitioner can make matter  Avoiding argumentation by assuming that the client is responsible for the decision to change  Worse OR  Better  Rolling with resistance, rather than confronting  Vignettes of two scenarios or opposing it; and (Rollnick, Mason and Bulter 1999: 7,8)  Supporting self-efficacy and optimism for change  Evidence? 3 4 1 Emotions Emotions Get ready a folio of paper and a In 30 s write down as many emotions as pen/paper you can think of Or note function on an electronic device 5 6 Counselling skills Fundamental approach Reflect content and emotions  Collaboration  Partnership that honours client’s experiences and Others? perspectives  Evocation  Intrinsic motivation enhanced by drawing on the clients own perceptions, goals, and values.  Autonomy  Client’s right and capacity of self-direction facilitated by informed choice 7 8 2 The process Be your own first “case” Rollnick et al 1999: 12 Fig 1.1  Establish rapport  Set agenda  Think of a health habit that you either  Talk about a single behaviour (But open for other issues)  want to start with  Asses (1) Readiness and Importance and  Maintain (2) Confidence  Improve Take up again  Explore importance (Why?)  Explore confidence (How? Can I?)  Exchange information AND Reduce resistance 9 10 Readiness: Stages of Change Pre-contemplation  Pre-contemplation Presentation – Minimal awareness (or  Contemplation active denial) of the existence of a  Preparation problem.  Action Time frame - No intention to change in the foreseeable future (in next 6 months).  Maintenance “What problem?” Progress Relapse “Who me?” “Give me a break!” “Whatever…” 11 3 Contemplation Contemplation (Cont.) Presentation – Awareness of a problem but AMBIVALENCE ambivalent to make a change – “I want to, but I don’t want to…” Time Frame – Considering a change in the – “Between a rock and a hard place.” next 6 months – “I know I should stay on my meds, but …” “It’s not really that bad.” “Sure I could stand to lose a few pounds, – Patient “resistance” ??? doesn’t everybody?” Preparation Maintenance Presentation - Actively planning or taking Presentation – Continuing new behaviour; initial steps toward a goal. solidifying change and actively resisting Timeframe - Intends to change in the next relapse. month Timeframe – Maintained behaviour for six months “I’m tired of this…” “It is so hard to remember my meds in the “After the holidays, I’m going to get back morning, but I do.” in shape!” “Even though my husband keeps bringing home ice cream, I limit my intake because of diabetes.” 4 Relapse Termination Presentation – Engaging in old behaviour; Presentation – New behaviour has become associated with feelings of guilt and a solid habit; not at risk for relapse distress; Trigger event may have that Timeframe – Indefinite period after occurred before relapse maintenance Timeframe – Current; can occur at any “I have absolutely no desire to smoke, and stage it’s been five years since I even held a “I stopped the PT exercises, because my cigarette.” back felt better.” “Checking my glucose levels is the first “I was tired of feeling ‘so normal’ so I thing I do every morning…” backed off on my mood stabiliser.” Stages of Change Model Motivational Interviewing (MI) Pre-contemplation Precontemplation – Understand the patient’s perspective – Provide information especially about pros of new Contemplation Progress behaviour and cons of old behaviour – Demonstrate positive regard and empathy Relapse Preparation Contemplation – Tip the balance of ambivalence Action – Develop discrepancy – Avoid arguments Maintenance – Support self-efficacy Based on Miller WR, Rollnick S. Figure based on information from Prochaska JO, & Motivational interviewing: Preparing people DiClemente CC. Stages and processes of self-change of to change addictive behavior. Guilford smoking: Toward an integrative model of change. J Press: NY, NY, 1991. Chapters 5,6 Termination Consult Clin Psychol. 1983:51;390-5. 5 Motivational Interviewing (MI) Motivational Interviewing (MI) Preparation Maintenance – Review options – Reduce likelihood of relapse – Enlist help (others, materials) – Discuss possible relapse antecedents or triggers – Anticipate problems – Inquire about progress at follow-ups – Rehearse plan (Relapse) Action – Acknowledge pt’s possible feelings of guilt or disappointment – Reinforce steps taken – Consider factors contributing to relapse – Assist in problem solving – Encourage resuming plan or developing a new plan Based on Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. Guilford Based on Miller WR, Rollnick S. Motivational interviewing: Press: NY, NY, 1991. Chapters 5,6 Preparing people to change addictive behavior. Guilford Press: NY, NY, 1991. Chapters 5,6 Motivational Interviewing (MI) Health Professional’s Actions Ask open-ended questions (Termination) – Reinforce pt’s ongoing commitment (follow-up) Listen reflectively – Prompt pt to consider other problematic behaviors Affirm Summarise Elicit self-motivational statements Based on Miller WR, Rollnick S. Based on Miller WR, Rollnick S. Motivational interviewing: Preparing people Motivational interviewing: Preparing people to change addictive behavior. Guilford to change addictive behavior. Guilford Press: NY, NY, 1991. Chapters 5,6 Press: NY, NY, 1991. Chapters 5,6 6  Eliciting Self-Motivational Good rapport Statements (MI)  Avoiding arguments Importance and Confidence  With skills such as Decisional balance (pro’s and con’s)  reflective listening  shifting focus and reframing Elaboration Looking forward Looking back Exploring goals Based on Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. Guilford 26 Press: NY, NY, 1991. Chapters 5,6 Agenda Setting Stott et al 1996 Talking about the issue More than one issue to address  ELICIT personal views and feelings What sort of things make you smoke more? How does it affect you? How does it affect your every day life? Tell me about your smoking?  Provide explanation It’s normal. Talk about causes, symptoms and solutions Stott et al (1996) 27 28 7 Ingredients of Readiness to change Importance: Why? Importance (Why should I change?)  Is it worthwhile? (Personal values and expectations of the  Why should I? importance to change)  Who will benefit?  What will change? PLUS  Do I really want to?  Will it make a difference? Confidence (How will I change?) (Self-efficacy) 29 30 Assessing Readiness for Establishing importance Change (MI) If, on a scale of 1 to 10, 1 is not at all “How important is this change to you?” motivated to give up smoking and 10 is 0—1—2—3—4—5—6—7—8—9—10 100% motivated to give up, what number Not at all Extremely would you give yourself at the moment?’ Important Important Exploring importance “How confident are you in making this change?” Why did you select this number? 0—1—2—3—4—5—6—7—8—9—10 Not at all Extremely Confident Confident 31 Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London, Churchill Livingstone,1999. 8  Decisional Balance for Importance: Explore Ambivalence (MI)  Do a little more (or less) Maintaining the current behaviour  Scaling questions – Advantages – “What do you like about…”  Why so high? (6 and not 1) – Disadvantages – “What worries you about …”  How can you go higher? (You gave yourself a 4/ Initiating a new behaviour 10, e.g. What would have to happen for your score – Advantages – “What would you like about …” to move up from 6 to 6). – Disadvantages – “What would concern you about …”  Examine the pros and cons | benefits and costs  If behaviour change vs If not  Explore concerns about the behaviour  A hypothetical look over the fence 33 Confidence: How? What? Decisional Balance (MI) Maintain current behaviour Initiate new behaviour  Can I?  How will I do it? (Advantages) (Advantages)  Ho w will I cope with x, y and z?  Will I succeed if … ? (Disadvantages) (Disadvantages)  What change … ? 36 Based on Janis IL, Mann L: Decision-Making: A Psychological Analysis of Conflict, Choice, and Commitment. New York, Free Press, 1977. 9 Establishing confidence Building confidence If you were to decide to give up smoking  Goals now, how confident are you that you  Strategies would succeed?  Targets If, on a scale of 1 to 10, 1 means that you are not at all confident and 10 means that you are 100% confident you could give up  Do a little more and remain a non-smoker, what number  Scaling questions would you give yourself now?  Brainstorm solutions Exploring confidence Why did you select  Past successes and failures this number? 37 38 Common Clinician Traps (MI) Two ongoing tasks to AVOID Question-answer trap  Gathering information Qx, answer, qx, answer, qx, answer, …  E.g. A typical day Expert trap  Reduce resistance Clinicians assumes best course; pt becomes passive Emphasise personal control and choice Clinicians prescribes solution; pt minimizes problem Reassess readiness, importance and Premature-focus trap confidence Clinicians focuses on a problem or aspect of a problem that may not be relevant to pt Don’t meet force with force Labeling trap Limits options; creates all-none scenario Diabetic; lazy; “the liver disease in room #314” 39 Based on Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. Guilford Press: NY, NY, 1991. Chapters 5,6 10 Inappropriate assumptions Ethical reminder  This person ought to change  Be honest with the patient about what  This person wants to change you are planning  This patient’s health is the prime motivating  Watch for resistance. If your are going factor of him/he further than the patient wants, he/she will  If he/she decide to change, the consultation has resist failed  Patients are either motivated to change or not  Understand the patient’s point of view.  I’m the expert. He/she should follow my advice Empathy is your protection. Let the  A negotiation-based approach is best patient be your guide.  ‘If in doubt, leave it out’. There might be very good reasons not to change 41 42 Health behaviour change Spirit of MI  Its about Creativity Readiness to change is not a client trait, but  and NOT slavish adoption a fluctuating product of interpersonal interaction The therapeutic relationship functions best as a partnership THE SPIRIT is more important than the Rather than an expert/recipient relationship. steps!! Motivation to change should be elicited from the client, not imposed by the counsellor. 43 44 11 Spirit (cont) Other evidence  It is the client’s task, not the counsellor’s,  Flattum et al (2009) : School-based to articulate and resolve his or her obesity programme for adolescent girls ambivalence.  Channon et al (2007) Teenagers with Self-directed persuasion, in which rational Diabetes 1 arguments for change are presented to the client by the expert, is not an effective method for resolving ambivalence The counselling style is generally a quiet and eliciting one 45 46 Outcome measures References  Motivational Interviewing Treatment Refer to the syllabus and Integrity (MITI) – Coding sheet Goniewicz, ML, Kuma, T, Gawron, M, Knysak, J & Kosmider, L 2013 Nicotine Levels in Electronic  Behavioural Change Counselling Index Cigarettes. Nicotine & Tobacco Research 15(1): (Becci) 158-66. Pokhrel, P, Fagan, P, Little, MA, Kawamoto, CT & Herzog, TA 2013 Smokers Who Try E- Cigarettes to Quit Smoking: Findings From a Multi-ethnic Study in Hawaii. American Journal of Public Health 103(9): e57-e62. 47 48 12