Communication Skills to Better Pain Management: Motivational Interviewing Stephen R. Gillaspy, Ph.D....
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![Page 1: Communication Skills to Better Pain Management: Motivational Interviewing Stephen R. Gillaspy, Ph.D. Stephen-Gillaspy@ouhsc.edu Department of Pediatrics.](https://reader033.fdocuments.us/reader033/viewer/2022061305/551441b0550346494e8b4996/html5/thumbnails/1.jpg)
Communication Skills to Better Pain Management: Motivational
Interviewing
Stephen R. Gillaspy, [email protected]
Department of PediatricsUniversity of Oklahoma College of Medicine
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Learning ObjectivesLearning Objectives
1. Discuss common barriers to pediatric pain management.
2. Describe and discuss fundamentals of Motivational Interviewing (MI).
3. Describe and discuss specific motivational interviewing techniques.
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What are barriers?What are barriers?
1. Motivation– Patient– Parent / caregiver
2. Communication
3. Expectations
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Why Motivational Interviewing?
• Evidence-base– Hundreds of randomized trials– Several meta-analyses– MI > TAU, direct advice alone, education
• Practice Guidelines– Tobacco:
• USPHS Guidelines (“5 A’s”), American Academy of Pediatrics (2009), AMA
– Alcohol• Screening, Brief Intervention, Referral to Treatment
(SBIRT), American Academy of Pediatrics (2010), AMA
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Behavior change
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Why don’t people change?
procrastination
behavioral economics
avoidance
self-affirmation biases
habit-driven
reactance
biases toward downward comparison
reject labels
negative affect
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How do people change?
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What is “Motivational Interviewing”
• “…a client-centered, directive method for
enhancing intrinsic motivation to change by
exploring and resolving ambivalence.” (Miller &
Rollnick, 2002, p. 25)
• In MI, we attempt to:1. observe, respect, and avoid opposing sustain talk and;
2. elicit, amplify, and affirm change talk
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Style and Spirit of MI
• Relentlessly, radically patient-centered
• A way of being with people, characterized by:
Collaboration (vs. one-up, authoritarian relationship)
Evocation (vs. imparting or inserting knowledge)
Autonomy-supportive (vs. controlling)
Direction (vs. avoidant, distracted)
Empathy (vs. dismissive, disrespectful)
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Evocation
• Good practice:– Clinician works to proactively evoke patient’s own
reasons for change and ideas about if and how changes should happen.
• Poor practice:– Clinician actively provides his or her reasons why
the patient should change, or education about change, in the absence of attention or regard for the patient’s knowledge, ideas, or motivations
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Collaboration
• Good practice:– Clinician actively fosters and encourages power
sharing, shows respect for patient ideas, and allows client ideas to substantially influence conversation.
• Poor practice:– Clinician actively assumes expert role for majority
of interaction.
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Autonomy Support
• Good practice:– Clinician is accepting and supporting of patient
choice and autonomy and works to expand patient’s experience of control and choice.
• Poor practice:– Clinician actively detracts from or denies patient’s
perception of choice or control, assumes that client cannot move in appropriate direction without input from clinician
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Direction
• Good practice:– Clinician exerts influence on session and maintains
focus on topic of target behavior change.
• Poor practice:– Clinician does not influence topic of conversation,
and direction is entirely in hands of patient
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Empathy
• Good practice:– Clinician shows evidence of deep and sincere
understanding of patient’s point of view; demonstrates curiosity about patient; accurate reflections
• Poor practice:– Clinician has no apparent interest or curiosity in
patient’s worldview; may demonstrate indifference or dismissal of patient’s experiences or ideas; reflections, when present, are inaccurate or shallow
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Specific Behaviors
• Microskills – operationalize global ratings
• Prescribed Behaviors:– Seek permission to add target behavior to agenda
– Evocative questioning
– Empathic reflective listening
– Other MI-consistent behaviors
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Seek permission
• Demonstrate respect for autonomy and desire for collaboration immediately
• Ask for permission before transitioning to discussion of target behavior– Do you mind if we spend a few minutes today
talking about your child’s ……?
– If you don’t mind, I would like to spend a little time today visiting about Johnny’s ……..
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Evocative Questioning
• Use more open-ended questions than closed questions– Open-ended questions require elaboration, not quite
sure where answer might lead.• Can you tell me more about that?
• How did you make that decision in the past?
– Closed-ended questions require a simple answer and leave direction in the hands of the asker.
• How many times during the week do you ……….?
• Where does it hurt?
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Evocative Questioning (cont.)
• Scaled questions are very useful and highly recommended
• Can ask about readiness, importance, or confidence– On a 1-10 scale, how ready would you say you are
today to make changes to your ………..?– On a 1-10 scale, how important is it to you today to
get Johnny’s ………. under control?• Most important questions are follow-up
questions– Why did you say “3” and not “1”?– What would it take to move from “5” to “9” or
“10”?
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Role of Reflections
What the patient means
What and how the patient says
What the clinician hears and sees
What the clinician understands
Hypothesis Testing Model of Listening
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Empathic, Reflective Listening
• Respond to patient statement and ideas with reflective statements– Can include restatement, rephrasing, metaphor,
summary, etc.
– Try to reflect true meaning of patient expression
• Important for building rapport and enacting spirit of collaboration, empathy, autonomy support, and evocation
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Other MI-Consistent Behaviors
• Advise and educate, with permission– Ask for permission explicitly
• Do you mind if I share with you some information…
– Give permission to disregard• I’m not sure if this would work for you or not, but my advice
would be to…
• Collaborate on potential solutions or plans– Offer a menu of options for addressing the problem– Explore patient’s ideas for “goodness of fit” or “next
steps”
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Other (cont.)
• Affirm and support the patient– Reinforce good choices, ideas with praise and
encouragement
– Offer statements of compassion or sympathy
• Emphasize choice, autonomy, or control– Be explicit about your respect for the patient’s
choice• It is up to you, nobody can make this decision for you.
• You know yourself better than anyone.
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Proscribed Behaviors
• Confrontation– Avoid disagreeing, arguing, correcting, shaming,
blaming, criticizing, labeling, moralizing, ridiculing, etc.
– Often turn conversation into a wrestling match• Advising (without permission)
– Language usually includes words such as: should, why don’t you, consider, try, how about, etc.
• Over-directing– Commands, orders, imperatives– You should, you must, etc.
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Comparison of usual practice vs. MIComparison of usual practice vs. MI
Usual Practice• Clinician sets agenda• Tell patient what’s important• Clinician decides when to move ahead w/goals• Clinician is responsible for patient making changes• Clinician is instructor• Success measured by
clinician definition
Motivational interviewing• Patient sets the agenda• Patient decides what is
important, in line w/corevalues, beliefs and needs
• Patient sets pace for work• Patient is responsible for if,
what & when behavior change occurs
• Clinician is a guide• Success is measured by
patient’s own values and goals