Motivational Interviewing (MI) • “ ... method of communication rather than a set of techniques. It is not a bag of tricks for getting people to do what they don’t want to do; rather, it is a fundamental way of being with and for people - a facilitative approach to communication that evokes change. ” Miller & Rollnick 2002
Motivation – it’s complicated!
Why MI? • 80% of pediatricians report feeling "very frustrated" treating pediatric obesity 1 • Only 10% think obesity counseling is effective 2 • Only 37% feel "quite" to "extremely" comfortable providing obesity interventions to children 1 • One main reason for these negative attitudes regarding outcome is that practitioners perceive low patient motivation and poor behavioral adherence 2,3 1) Jelalian, Boergers, Alday, & Frank (2003) 2) Kolagotla & Adams (2004) 3) Story, Neumark-Stzainer, Sherwood, Holt, Sofka, et al. (2002)
Clinical Efficacy of MI • MI has been used extensively in the addiction field 1 • Numerous RCTs demonstrate clinical efficacy for addictive behaviors 2 • MI has been used to modify diet and physical activity in adults with overweight and obesity 3 1) Miller (1983) 2) Burke, Arkowitz, & Menchola (2003) 3) Armstrong, Mottershead, Ronksley, Sigal, Campbell, & Hemmelgarn (2011)
Effectiveness in Pediatric Practice • A RCT found that MI promotes physical activity in obese adolescents 1 • MI group compared to standard weight loss group reported greater autonomy support from medical staff at the end of the program, greater increase in integrated and identified regulations, and a decrease in amotivation • A single session of MI improves self ‐ determined motivation for healthy life ‐ styles during a weight feedback session to parents in recruitment to a family-based weight loss study 2 • Both MI and BPC were both successful in encouraging parents to participate in a family ‐ based intervention; with MI only increasing autonomy 1) Gourlan, Sarrazin, & Trouilloud (2013) 2) Dawson, Brown, Cox, Williams, Treacy, et al. (2014)
MI Style Influences Outcomes • Strong evidence provider style (the way they talk) influences outcomes 1 • When patients are motivated and express verbal commitments to change, they have better treatment outcomes 2 1) Miller & Rollnick 2002 2) Armhein et al 2004
Definition Motivational interviewing is a person- centered, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence.
MI is both a "Spirit" and a set of Skills
Spirit of MI
The Spirit of MI • Collaboration • Evocation • Autonomy
High Spirit of Collaboration • Clinician is not the “ expert ” • Willing to negotiate with the patient • Open to ideas from the patient • Avoids persuasion • Explores and support what the patient wants to do • Patient is the “ partner ” (e.g., dancing)
High Spirit of Evocation • Elicits the patients’ ideas about change • “ Curious and patient ” • Stays focused on whatever behavior change the patient is willing to do
High Autonomy/Self-efficacy • Accepts the patients may not choose to change • Are invested in behavior change but does not push it in order to maintain patient/professional alliance • Reinforces that ultimately any behavior change is within the realm of the patient
How is Spirit of MI different? • Not sympathy • No emphasis on expertise (on the part of the health provider) • Education of the patient is not considered effective (not to be confused with giving information) • Does not focus on skill-building • Does not analyze unconscious motivations • Not passive
Skills in MI
MI Skills • Explore ambivalence • Open-ended questions • Positive affirmations • Reflective listening • Summarize
Ambivalence • Explore the dilemma of change • You need to at least partially resolve ambivalence before moving towards change
Exploring Ambivalence What are the disadvantages What are the advantages of things staying just of things staying just the way they are now? the way they are now? What are the advantages What are the disadvantages of changing? of changing?
The Basic Skills of MI: OARS • O - Open-ended questions • A - Affirmations • R - Reflective listening • S - Summarize
Open-ended Questions • “ What brings you in today? ” • “ What can you tell me about that? ” • “ Tell me more about... ” • “ In what ways...? ” • “ What have you noticed…? ”
Questions • Closed questions • Result in “ yes ” or “ no ” response • Open questions • Allow for a wide range of information from the patient
Open or Closed Questions? • Don’t you think it’s time for a change? • What do you think would be better for you – walking to the grocery store or cutting down on fast food? • What do you like about exercising? • What do you already know about our program?
Eliciting change talk with importance/confidence rulers How important would you say it is for you to _________? On a scale of 0-10, where 0 is not at all important and 10 is extremely important, where would say you are? Follow-up: And why are you at __ and not zero? How confident would you say it is for you to _________? On a scale of 0-10, where 0 is not at all confident and 10 is extremely confident, where would say you are? Follow-up: And why are you at __ and not zero?
Instilling confidence with open questions • Listen carefully with a goal of understanding the dilemma, but give no advice. Ask these three open questions, and listen: 1) What is there about you (strengths, abilities, talents) that will help you do this? 2) How might you go about it in order to succeed? 3) What have you done successfully in the past that was like this in some way? • Reflect and summarize confidence statements
Elicit-Provide-Elicit • Elicit the patient's understanding and needs • What would you most like to know about ____? • What do you already know about _____? • Provide new information in a neutral manner • Information only not interpretation • Information in a manageable chunk • Elicit what the information means to them • What do you make of that? • What do you think of this information? • What more would you like to know? 57
Affirmations • Emphasize a strength • Notice and appreciate a positive action • Should be genuine, not cheerleading • Express positive regard and caring • Strengthen therapeutic relationship
Affirmations may include: • Commenting positively on an attribute • “ You’re a strong person, a really hard worker! ” • A statement of appreciation • “ I appreciate your openness and honesty today. ” • Catch the person doing something right • “ You're doing such a great job answering all of these questions! ” • A compliment • “ I like the way you said that! ” • An expression of hope, caring, or support • “ I hope this week goes well for you! ”
Reflective Listening • Form of hypothesis testing • "If I heard you right, this is what I think you're saying..." • "You seem like you're having trouble with..." • Goals: • Demonstrate you've heard the patient • Show you are trying to understand them • Affirm thoughts and feelings • Promote self-discovery
Reflective Listening • It should be a statement, with the inflection turning down at the end. • “ So, you mean that… ” • “ It sounds like you… ” • “ You're wondering if…. ” • Statements rather than questions • Make a guess about the patient's meaning (rather than asking) • Yield more information and better understanding • Often a question can be turned into a reflection
Summaries • Collect material that has been offered • “ So far you've expressed concern about your energy level and how you would like to get outdoors more. ” • Link something just said with something discussed earlier • “ That sounds a bit like what you told me early about how important it is to you to be a good soccer player. ” • Draw together what has happened and transition to a new task • “ Before I ask you more questions, let me summarize what you've told me so far, and see if I've missed anything important. You came in because you were feeling like you don't have as much energy as you would like, and it bums you out... ”
MI Clinical Practice • Obesity is not a behavior • A key task for clinicians is to work with the patient and their family to identify behaviors that contribute to the child's weight • Once behaviors are identified, MI strategies for each behavior can be implemented
MI Group Activity • Work in groups of 3 • One patient • One provider • One observer
Patient Come up with something about yourself that you... • want to change • need to change • should change • have been thinking about changing ...but you haven't changed yet (i.e., – something you're ambivalent about)
Provider • Listen carefully with a goal of understanding the dilemma • Give no advice • Ask as many open-ended questions • Examples of open-ended questions – Why would you want to make this change? – How might you go about it, in order to succeed? – What are the three best reasons to do it?
Observer • Listen carefully to the provider • Tally the number of open-ended and closed-ended questions the provider asks • If possible, write examples of helpful open-ended questions
Go! (15 minutes)
How Did the Patient Feel? How Did the Provider Feel? What Happened?
Clinical Tools for Pediatric Weight Management
UCLA Fit for Healthy Weight Clinic n Mean (SD) or % Clinic visits 309 3.13 (2.85) Time between clinic visits - 1.59 (1.12) (months) Age (years) 115 13.10 (3.81) <2 0 0% 2<x<9 19 16.52% 9<x<13 45 39.13% 13<x<16 22 19.13% 16<x<19 24 20.87% >19 5 4.35% Sex Male 57 49.57% Female 58 50.43%
UCLA Fit for Healthy Weight Clinic n Mean (SD) Height (cm) 115 157.09 (17.26) Weight (kg) 115 88.59 (33.29) BMI (kg/m 2 ) 115 34.68 (9.14) BMI percentile 115 97.8 (1.66)
UCLA Fit for Healthy Weight Clinic n Mean (SD) or % BMI Category Overweight 3 2.61% Obese 112 97.39% Blood Pressure Systolic BP (mm Hg) 113 117.92 (9.80) Systolic BP percentile 113 74.0 (24.2) Normotensive 79 69.91% Prehypertensive 11 9.73% Stage 1 hypertensive 17 15.04% Stage 2 hypertensive 6 5.31%
Barriers to Physical Activity 50 45 Percent of Patients 40 35 30 25 20 15 10 5 0 Barriers Selected
Barriers to Healthy Diet Percent of Patients 70 60 50 40 30 20 10 0 Barriers Selected
Change in BMI Values across Clinic Visits Figure 3. Change in BMI values across number of visits. Number of patients with an increase, decrease, or no change in BMI values over clinic visits. More patients saw a reduction in BMI across clinic visits than an increase or no change in BMI.
Prevalence of elevated blood pressure categories
Table 3. Identified comorbidities at the first visit of Fit Clinic patients (N=115) % with Not Reported a Comorbidity Present Not Present Identified Comorbidity Constitutional 112 3 0 97 Skin 90 21 4 79 Endocrine 80 31 4 70 Cardiovascular 60 52 3 52 Ears, Nose, Mouth, Throat 58 55 2 50 Psychiatric 48 66 1 41 Respiratory 42 71 2 36 Gastrointestinal 37 76 2 32 Neurological 33 80 2 28 Musculoskeletal 32 81 2 26 Female Specific 15 52 48 21 Eyes 20 92 3 17 Immunological 19 92 4 17 Genitourinary 16 97 2 14 Male Specific 9 54 52 14 Chest 13 100 2 11 Heme/Lymph 6 107 2 5 Average 5.8 identified comorbid systems at first clinic visit. a Missing data included in percentage calculations �
Registered Dietitian • Nutrition Assessment and Intervention • Physical Activity Assessment and Intervention
Initial Nutrition Assessment • 24-hour recall Source: ars.usda.gov
Target Nutrition Behaviors 1. Limiting consumption of sugar- sweetened beverages 2. Increasing fruit and vegetable consumption 3. Limiting eating at restaurants, particularly fast food restaurants 4. Limiting portion size 5. Avoid skipping meals
Target Physical Activity Behaviors • Incremental increase in physical activity with goal of 60 minutes per day • Limit television and other screen time to 2 hours per day
Intervention • Assess resources – Ability to purchase healthy foods – Access to safe spaces for exercise • Through motivational interviewing RD, patient and family determine – 2 to 3 nutrition goals – 1 to 2 physical activity goals • Support nutrition goals from specialists related to comorbidities
Nutrition Education My Plate My Snack Fruits Dairy Fruits Dairy Veggies Protein Dairy Grains
Nutrition Education
Nutrition Education
Nutrition Education
Psych • Assessment • Intervention • Referral (if necessary)
Assessment
Intervention • Brief psychological intervention targeting key psychiatric symptoms
Referral ?
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