Motivational Interviewing:Encouraging Patients to Change

Unhealthy Behavior

CAPA2015Ian Jones, MPAS, CCPA, PA-C

College of Medicine, University of ManitobaAdapted from Michael Vallis, PhD R Psych, 2013 and Ingrid Toews

PhD

Changing Behaviors

Image - Canadian Obesity Network.

www.2011rrdc.com

Fitafterfifty.com

Identify opportunities to integrate motivational interviewing in the practice setting

Identify patient cues for readiness to move towards change planning

Define empathetic counseling skills Describe motivational interviewing as a

style for meeting resistance

Objectives: Teach the Teacher

What is the best predictor of future behavior?

Why is changing behavior difficult?

What is the best predictor of changed behavior?

Predictors of . . .

“A person’s confidence to perform a specific behavior in a specific context for a specific time period and in the face of specific barriers”

Bandura, 1977

Self-Efficacy

Based on relevant theoretical models from psychology

A style is used to engage with patients, target their strengths and hopes, elicit their own reasons to change, and encourage autonomy in decision making.

Related to Patient-Centred Clinical Method – IFFE and Finding Common Ground

Rollnick et al, 2010Lussier et al. 2007

Miller & Rollnick, 2008

Motivational Interviewing Theory

Results

Concerns Goals Resources

As Teachers we model the practice

Meta-analysis by Burke, Arkowitz, & Dunn (2003) looked at 30 controlled clinical trials of motivational interviewing

Overall, motivational interviewing is effective with alcohol use, drug use, diet, exercise, and academics.

Apodace & Longabaugh (2009) found that the most consistent evidence of effectiveness was: client change talk and client experience of discrepancy

Decisional balance had the strongest association

with better outcomes.

Evidence

Smoking, poor diet, physical inactivity and alcohol misuse may account for 38% of annual US deaths (Woolf, 2008)

Estimates that less than 5% of the population do not smoke, have a healthy weight, are physically active and eat 5 or more fruit/vegetables a day

Lifestyle choices are integral to chronic disease occurrence. In 2005, the WHO estimated that Canada would lose

US$500 million in national income from premature deaths due to heart disease, stroke, and diabetes yearly.

As people die each year, losses accumulate; financial losses due to these premature deaths will skyrocket to an est. US$1.5 billion by 2015, (http://www.conferenceboard.ca/hcp/details/health.aspx)

Epidemiology

How one interacts with patients appears to be as important as the approach

Empathy impacted 6 month drinking outcomes Confrontational counselling has been

associated with a higher drop out rate Change talk and resistance has been found to

be significantly influenced by counselling style

Rollick et al, 2010

What are the barriers to teaching or practicing – motivational interviewing?

Motivational Interviewing

Instead of: “I am the expert listen to me” i.e.

“Let me tell you what you need to do” “Let me tell you what you need to

know”

To: “We both have a role to play”

“I understand that you will make your own decisions and I respect that. Can we have a conversation about your health?” Vallis, 2013

Change-Based Relationship

Positive reinforcement:◦ Work an extra 60 min per day for 2 weeks and then

I will give you $1000.00

Negative reinforcement:Work an extra 60 min per day for 2 weeksAt the end I will Not throw you down a flight of stairs.

Long-term behavior change requires positive source of motivation in addition to negative reinforcement

Vallis, 2013

Motivation for Health Behaviors

Asking questions, minimizing statements

Empathy Nonjudgmental curiosity Avoiding argument Rolling with resistance Building self-efficacy

Motivational Skills

1. Is this behavior a problem for you?2. Are you distressed by this problem?3. Are you interested in making a change?4. Are you ready to change now?

Vallis, 2014

Readiness Questions

Not Ready Ready AmbivalentPersonal meaning Go right to Expanding on readinessSeriousness, Behavior Personal/meaningful reasonsresponsibility, Modification to changecontrollability, Willingness to work hard –optimism connect to principles

Delay of gratification

Decisional Balance – Pros/Cons Self-Efficacy

Barrier/Temptations Especially social, cultural and environmental

Vallis, 2013

Readiness Assessment

https://youtu.be/CDjnYTOkjaY

5 A’s of Obesity Management

Express concern Ask for permission – nonjudgmental, to screen for

specific behaviors Assess – readiness to change, whether behavior has

become a problem for patient Advise – “Given that it is harmful to your health

would it be ok if I recommended…” Assist – make suggestions (realistic goals) and check

how patient feels about, “anything that has helped you in the past?”

Arrange – “We’ll follow up. I think those changes will help”. “What would help you make changes?”

Preventioninhand.ca

Supporting Behavior Change

Relevance: In what way relevant to patient Risks: Any downside of not changing, reflect

dilemma to patient◦ Ask what next steps might be, if you have

permission to help ◦ Rewards: “What’s good about staying the same?”

Roadblocks: “If try to change any obstacles?” Repeat: Explored and reviewed consistently

Preventioninhand.ca

5 R’s

Goal Setting – Building confidence◦ Specific◦ Measurable◦ Achievable◦ Relevant◦ Timely

◦ Behavior Shaping Doable – specific Start small and build – accept approximations Respect pace of change Keep number of behaviors under 3

Modifying Behavior

Stimulus Control◦ Identify the events, situations and people that elicit

the unhealthy behavior◦ Take control of these events, situations and people,

to whatever extent possible◦ Look for alternatives◦ Identify barriers/temptations and make a plan◦ Reinforcement management Identify positive reinforcements that can be administered by the patient contingent on specific behaviors Plan for relapse

Behavior Modification

Normalize emotions Chronic disease – part of emotional burden

of living with “How can I support you? I know it’s hard

work.” Self-Efficacy, Social Support Stress – Identify emotional issues and

search for opportunities to replace the function of unhealthy behaviors

Emotion Management Skills

Patient may need to try several or many times, the best chance of success is in making continued efforts (not giving up).

Physician continues to support the patients’ efforts to change and provides continuing encouragement.

Ambivalence can resurface

Lussier & Richard, 2007

http://im4us.org/Behavior+Change+Teaching+Materials

We use SP – Standardized Patient exercises◦ Or Provide students with case then role play◦ Video tape and then review

Exercises

Relationship skills

Motivational skills – asking questions, minimizing statements, empathy, nonjudgmental curiosity, avoiding argument, rolling with resistance and building self-efficacy

Behavior change skills - goal-setting, behavior shaping, stimulus control, reinforcement management

Emotion management skills – identifying function served by unhealthy behaviors, stress management

Summary - Change Skills

Identify opportunities to integrate motivational interviewing in the practice setting

Identify patient cues for readiness to move towards change planning

Define empathetic counseling skills Describe motivational interviewing as a style

for meeting resistance

Michael Vallis www.behaviourchangeinstitute.ca

Objectives

http://www.obesitynetwork.ca/ http://rethinkingdrinking.niaaa.nih.gov/ http://www.exerciseismedicine.ca/ http://

www.hc-sc.gc.ca/hc-ps/tobac-tabac/quit-cesser/index-eng.php

Resources

Apodaca, T.R. & Longabaugh, R. (2209) Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence, Addiction, 104 (5): p. 705-715.

Bandura, A. (1977). Self-Efficacy: Toward a unifying theory of behavior change. Psychological Review, 84, 191-215.

Burke, B.L., Arkowitz, H., & Dunn, C. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71, 843- 861.

Lussier, M. & Richard, C. (2007). The Motivational Interview, Canadian Family Physician, 53, p. 2117 – 2118.

Lussier, M. & Richard, C. (2007). The Motivational Interview, Canadian Family Physician, 53, p. 1895-1896.

Prevention in Hand, College of Family Physicians of Canada and the Public Health Agency of Canada. Preventioninhand.ca

Reeves, MJ, Rafferty AP. Health lifestyle characteristics among adults in the United States, 2000. Arch Intern Med 2005; 165:854-7.

Rollick S. et al. (2010). Motivational Interviewing, BMJ2010;340:c1900. Tamakoshi A, Tamakoshi K, Lin Y, et al. Healthy lifestyle and preventable death: Findings

from the Japan Collaborative Cohort (JACC) Study. Prev Med 2009;48:486-92. Vallis, M. V. 2009 Appreciating the Challenge: Motivation and Change. Association of

Faculties of Pharmacy of Canada 66th Annual Meeting and Conference.

References

Vallis, M. Workshop for the Manitoba Psychological Society, October, 2013, Winnipeg, MB

Vallis, M. Behavior Change Counselling-How Do I Know If I Am Doing It Well? The Development of the Behavior Change Counselling Scale (BCCS), Canadian Journal of Diabetes, 37, 18-26.

Woolf, S.H. (2008). The power of prevention and what it requires. JAMA, 299:2437-9.

References (cont’d)