Motivational interviewing: Collaborating with patients about - PDF document

Motivational interviewing: Collaborating with patients about behaviour change Anthony Talbot Clinical Psychologist Alfred Cystic Fibrosis Service With thanks to Dr. Michelle Earle Principal Clinical Psychologist Victorian HIV Service, The Alfred Conversations about behaviour 1

Conversations about behaviour Conversations about behaviour 2

Person-environment system Person-environment system Knowledge and Behavioural understanding Deferral for “later” Gaps in specific knowledge Denial Suppressing information Avoidance (avoidant coping) Disorganisation Lack of time Forgetting Treatments Skill acquisition Poorer adherence when Habit/ momentum treatments are: Difficult or complicated Time consuming Offer no immediate feedback Offer no immediate benefit and Family and social environment (instead) negative consequences Climate of home life, family disagreements, over- involvement and poor communication Improved adherence with adults Illness can cause a centripetal effect: reliance on when treatments are: parents, parental anxiety and reluctance to hand- There is a degree of choice over responsibility Treatments yield immediate benefits Latchford, G.J., and Duff, A.J.A. (2011). A guide to adherence in CF. Jones, S., et al., (2015). Cochrane review on CF adherence. 3

Person-environment system Person-environment system Beliefs about illness What do I expect to happen? Health beliefs Perceived susceptibility (e.g., “it will be bad if I don’t change”) Perceived severity (e.g., “this is only mild”) Costs/benefits Psychological barriers Beliefs about what to do Beliefs How important is to me? What sort of person am I? Fear What are my values? Motivation Subjective norms/influences Confidence (e.g., “Mum and the doctor think I should Schemas (core memories do this”) beliefs) that filter Self-efficacy (e.g., “I can handle this”) interpretations and drive behaviour Mental ill health Beliefs about medicine Balancing necessity and Trauma/sensitisation concerns Do I need it? Will it work? Latchford, G.J., and Duff, A.J.A. What are the side effects? (2011). A guide to adherence in CF. 4

Person-environment system Patient Health professionals Collaborating with patients ❋ Giving advice tends to not work unless someone is ready to hear it. ❋ A conversation is still the best tool we have for helping patients ❋ Clinicians have a responsibility to update their communication skills. ❋ Effective conversations can elicit better information on which to base decisions and prescribing. Latchford, G.J., and Duff, A.J.A. (2011). A guide to adherence in CF. Atul Gawande, surgeon, on incremental care: “We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases… New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heart, transplanted organs, …heart attacks could be stopped; cancers could be cured…. Chronic illness …requires a more patient kind of Atul Gawande, The Heroism of skill ... steady intimate care”. Incremental Care, The New Yorker Jan 23, 2017 Incrementalism: “It’s no one thing we do. It’s all of it” 5

Collaborating with patients “Warren Warwick Principles” (Minneapolis CF Center) ❋ Collaboration: share the dilemma of managing treatment regimens, listen to patients and families, building patient’s confidence, informed decisions. Patient ❋ Consistently convey high expectations. Health professionals ❋ Careful listening and communication : patients and health professionals use words differently; avoid assumptions. ❋ Validating non-adherence: clinicians are honest about their own stance, while realistic about what patients will actually do. ❋ Reframing non-adherence as “experimenting” ❋ Expectation of a reciprocal relationship and collaboration Gawande, Atul. (2004). “You will need to work very hard to make this collaboration successful.” The bell curve. The New Yorker, December 6, 2004. The combination of an actively-listening clinician and Latchford, G.J., and actively-engaged patient leads to truly collaborative Duff, A.J.A. (2011). A guide to adherence in CF. relationships (Latchford and Duff, 2011). Motivational interviewing Motivational interviewing, n. collaborative, person-centred form of guiding to elicit and strengthen motivation for change Miller & Rollnick (2012) 6

Origins of MI — Bill Miller, psychologist and Stephen Rollnick, physician (Miller & Rollnick, Motivational interviewing: Helping people change. 3 rd ed., 2012) — Began in field of addictions (Britt et al., 2003) — Natural extension of Rogerian client-centred counselling e.g., warmth, genuineness, accurate empathy, unconditional positive regard (Rogers, 1951) — Empirical backing with psycholinguistic analysis of transcripts (Moyers, Miller and Hendrickson, 2005). — Research and publications http://www.motivationalinterviewing.org MI in Health Practice — Efficacy among primary care, acute medical and chronic illness populations. Schaefer and Kavookjian, 2017; Salimi, et al., 2016; VanBuskirk, et al., 2014. — Positive impacts on a range of outcomes: e.g., improved adherence, quality of life and symptom reduction for asthma, HIV, diabetes, dental cavities, cholesterol level, blood pressure, HIV viral load, alcohol and other substance misuse, body weight. Lundahl, et al., 2013 (review 48 RCT studies) — Small-modest-moderate effect sizes. Fidelity to MI? — Barriers to using MI: minimum 2-day practice workshop and ongoing coaching. 7

What can MI offer us in our quest for collaboration? Natural Language: Change and Commitment “ I wish I could ” “ I hope so ” “ I do ” “ I do ” 8

Change talk and commitment “ Yes, but… ” Change talk can predict commitment and actual change Examples “ I need to …” “ I will ” Readiness: stages of change model (Prochaska & DiClemente, 1983; 1994) 9

Basic MI Process Change talk Commitment talk Basic MI Process Change talk Commitment talk 3. Evoke: selectively elicit change and commitment talk 4. Plan 2. Focus – negotiate focus 1. Engage – build connection and trust 10

MI Defined … a method of communication rather than a set of therapeutic techniques… It selectively focuses on asking about the not-so- good side of a problem behaviour… … time-limited (i.e. one off intervention)… (Miller & Rollnick, 2002) MI in Health Practice MI can be used in a range of ways: — A stand alone, change-oriented intervention — Combined with another intervention (e.g., medical consult, cognitive-behavioural therapy, risk assessment, discharge process). — A way to engage the client to prepare for a different intervention — A way to handle loss of motivation or discord arising during the course of another intervention 11

Motivation How do you know if someone is motivated? • Not a personality trait • Open to influence from events - within a person (e.g., beliefs, tiredness, values, illness) - interpersonal events (e.g., objective information, personal advantage) • Open to influence of others (relationships). Motivation Motivation • It is normal to have mixed feelings. “ yes, but… ” • Conflict between different desires and reasons. Three ingredients of motivation: • Importance of change (willingness): more likely when change has a deeper meaning “ I want to change ” • Readiness: a matter of priorities “ I want to change now ” • Confidence (ability): perception of ability to change “ I can change ” 12

MI Framework Spirit Principles Micro-Skills OARS T arget Behaviour Spirit of MI Who was your favourite teacher? What qualities come to mind? 13

Spirit of MI Partnership Compassion MI Spirit Acceptance Evocation Spirit of MI Partnership Compassion Acceptance Partnership • Facilitate a relationship rather than direct or impose. • Honour clients’ experiences and perspectives. Evocation • Let go of the assumption that you supposed to have all the right answers or solutions. Acceptance • Absolute worth and potential of all human beings • Accurate empathy: a willingness to understand a client’s private personal meanings. • Autonomy: it’s their life, their choice. • Affirmation: seek out and acknowledge a person’s strengths and efforts Evocation • Potential for change lies within the person. • We try to draw out what is already there rather than inform, persuade or advise. Compassion • A deliberate commitment to the welfare of clients. • Having your heart in the right place. 14

Spirit of MI “ I learn what I believe as I hear myself talk ” (Miller, 1995) Spirit of MI Dr. Oliver Sacks, neurologist (1933-2015) “We speak not only to tell other people what we think, but to tell ourselves what we think. Speech is a part of thought” Seeing Voices “There is only one cardinal rule: One must always listen to the patient” 15

Therapeutic Principles of MI Express Empathy Skilful reflective listening is fundamental Empathy is not a feeling, it is a behaviour that must be visible to a client. 16