©2011 MFMER | slide-1 Application of Motivational Interviewing in Primary Care Kristin S. Vickers...

©2011 MFMER | slide-1

Application of Motivational Interviewing in Primary Care

Kristin S. Vickers Douglas, PhD, ABPPAssociate Professor of PsychologyMayo Clinic Rochester

Minnesota Pharmacists AssociationFriday, November 16, 2012


DISCLOSURE

Relevant Financial Relationship(s)

None

Off Label Usage

None

Industry Acknowledgment

None

Learning Objectives

• After attending this application based activity, Pharmacists should be able to:• Review the four processes of motivational interviewing.

• Listen for and respond to "change talk“.

• Describe several practical applications of MI in the primary care setting.

• Identify a communication strategy that could be implemented immediately in clinical practice.


Motivational Interviewing

• A brief history


MI: Essential elements and definition

• MI is a particular kind of conversation about change

• MI is collaborative (person-centered, partnership, honors autonomy, not expert - recipient)

• MI is evocative, seeks to call forth the person’s own motivation and commitment


Is Motivational Interviewing Effective?

• Systematic review of 72 studies (Rubak et al., 2005)

• Motivational interviewing outperformed traditional advice giving in 80% of studies.

• Meta-analysis of 119 studies from last 25 years (Lundahl et al., 2010)

• MI produced statistically significant, durable results when compared to control conditions.

• Achieved comparable results (not significantly different) to other active treatments.


What is MI for?

• MI is a collaborative conversation to strengthen motivation and commitment for behavior change


Why would I use it?

MI is a person-centered counseling method for addressing the common problem of ambivalence about behavior change


How does it work?

• MI is a collaborative, goal-oriented method of communication with particular attention to the language of change.

• It is intended to strengthen personal motivation for and commitment to a target behavior change by eliciting and exploring an individual’s arguments for change (change talk)


Motivational InterviewingKey Principles

• R—Resist the righting reflex (resist fixing)

• U—Understand client’s motivation (ambivalence)

• L—Listen to your client (reflect)

• E—Empower your client (engage)

Rollnick (2008)

The Four Fundamental Processes of Motivational Interviewing Coaching

• Engaging

• Focusing

• Evoking

• Planning


Foundational MI skills: OARS

• Open-ended questions

• Affirmations

• Reflective listening

• Summarizing


Practice with Affirmations

Describe something you recently worked on (e.g., home project, new recipe, manuscript, vacation plan)

• Authentic observations about the person

• “You are the kind of person who can…”

• Attribute interesting qualities to the person

• Attend to non-problem areas

• Avoid using “I”

• Focus on behaviors vs. attitudes, goals


Practice with Reflection

• Double-sided reflection

• Feel two ways about something

• Follow with key question:

• Where does that leave you now?


Change Talk

• Desire to change

• Ability to change (optimism, I can do it)

• Reasons for change (benefits of change)

• Needs (problems with the status quo)


Commitment statements and taking steps

• I am going to…

• I will…

• I plan to…

• I intend to…

• I have already started to…


Eliciting Change Talk

• Ask the client how they feel about change

• Ask for elaboration—fan the flame when they are talking about change


Eliciting Change Talk

• Look back

• Is there a time that this was working? What has changed?

• Look forward

• What are your hopes for the future with this?

• Explore goals

• What do you want to accomplish with this?


Change talk exercise

• Train your ear to hear change talk


Responding to Change Talk

• Elaboration

• Affirmation

• Reflection

• Summary


When Providing Information or Options

• Elicit

• What do you already know about…?

• May I share a little with you about…?

• Provide

• Provide information, feedback, options in nonjudgmental manner

• Elicit

• What are your thoughts on that?

• How might that apply to you?


Expressing a concern

• Clinicians should feel empowered to offer concerns about a client’s decisions or positions, but should be thoughtful about how they approach this communication.

1. Direct report of concerns without judgment. Use client statement’s when possible.

2. Statement about client’s responsibility for choice and change.

3. Client’s view is solicited.


Expressing a concern

1. Direct report of concerns without judgment. Use client statement’s when possible.

2. Statement about client’s responsibility for choice and change.

3. client’s view is solicited.

I’m concerned about your decision to use the “extreme weight loss pills” you found on the internet. My concern is that we don’t know the ingredients and whether they might be dangerous. You’ve also told me that you thought the website looked questionable and that you worried when putting in your credit card information. Of course it is you who will decide what you’ll do with those pills. What do you think about these concerns?


Collaborative Goal Setting: Development of a Personalized Action Plan

Action PlanAction Plan


What is an Action Plan?

• Central feature of self-management

• Goals: Specific, realistic, set with confidence

• Client-centered and client-generated

• Short term: One to two weeks• “On a scale of 0 to 10, how confident are you that

you can achieve your goal?”


Personalized Action Plan

1. “What is a first step you are willing to take over the next few days?”

a. Concreteb. Patient-centeredc. Very specificd. Short-term

2. “How confident are you on a 1 to 10 scale that you will be able to carry out this goal?”

a. Must be 7 or b. Review barriers (develop solutions) or c. Revise goal

3. “Let’s arrange a way to check on how you are doing”


Reaffirm commitment and express optimism

• Secure client’s commitment to the plan

• Is that what you plan to do?

• If client is ambivalent:

• “It sounds like you aren’t quite ready to take this on now. As you look down the road, when can you see this happening? What would need to happen for that to occur?”


What can I do during a quick visit?

• Listen and respond to change talk

• Elicit Provide Elicit when giving information

• Collaborate in creating an action plan

• Have client rate confidence for next step

• Arrange follow-up when possible

• Connect desire for change and steps to change back to the person—values and strengths

• Recognize ambivalence and lapses are normal

• Reinforce all progress!


Motivational InterviewingTop 10 useful questions

• What changes would you most like to talk about?

• What have you noticed about . . .?

• How important is it for you to change . . .?

• How confident do you feel about changing . . .?

• How do you see the benefits of . . .?

• How do you see the drawback of . . .?

• What will make the most sense to you?

• How might things be different if you . . .?

• In what way . . .?

• Where does this leave you now?

BMJ 2010;340:c1900

Opioid pain medication— “lost my meds”

• Mary often presents at the pharmacy right before it closes on a Friday evening.

• She “left her bottle in the glove compartment of a rental car” and has gone to lengths to retrieve it, but no luck.

• Reports severe pain and concerns how she’ll make it through the weekend.

Applicable MI skills

• OARS:

• Reflect her pain and her concern.

• Without judgment or shame, express your own concern about this pattern and perhaps a problem with her management of this medication.

• Reflect ambivalence (double sided reflection) and key question

• On the one hand you have pain and are very uncomfortable, on the other hand you have people worrying about you and your medication. Where does that leave you now?

• Listen for change talk. Reflect what you hear.

• Affirm all that she has done right.

• Invite her to collaborate in a plan

Antidepressant Medication: “Here we go again”

• Bob’s primary care doctor prescribes an SSRI, again, for his depressive symptoms.

• Bob reluctantly fills prescription (never refilled last time). Makes a comment that his doctor “is starting to sound like my wife, harping on me about being cranky. Well, exactly what about being out of work is supposed to make me happy? I can’t fake it all the time you know?”

Applicable MI skills

• OARS:

• Reflect his frustration.

• Reflect ambivalence (double sided reflection) and key question

• Listen for change talk. Reflect what you hear.

• Use E-P-E if he has questions or concerns about the medication.

• What concerns you most about this kind of medication?

• Would you like to hear more about that?

• Provide information

• What do you make of what I said?

• What does this mean for you?


Motivational Interviewing Resources

• www.motivationalinterview.org

• Miller, B. and Rollnick, S (2012). Motivational Interviewing: Helping People Change. Third Edition. Guilford Press.

• Rosengren (2009). Building Motivational Interviewing Skills: A Practitioner Workbook (Applications of Motivational Interviewing Series).

• MI Training

• About training process and online training: http://www.motivationalinterview.org/quick_links/mitraining.html

• Training opportunities:http://www.motivationalinterviewing.org/training

Thank you!

©2011 MFMER | slide-1 Application of Motivational Interviewing in Primary Care Kristin S. Vickers...

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