Creating Conversational Flow With MI

Copyright Berger Consulting, LLC1792 Overton RdAuburn, AL 36830

334.444.3160bbergerconsulting@gmail.com

baberger.shutterfly.com

These materials may not be duplicated or used without permission.

Creating Conversational Flow

We’ve presented the MI “toolbox”

What do you do with these tools? Frustrating to be told, “Go build a house!” Awkward lack of direction; hesitation

We want to provide a sense of how these MI tools work together to form a smooth conversational flow What prominent problems to avoid What strategies work well

Basic MI Processes

Developing the relationship with the patient Reduce relational resistance

Engaging the patient’s reasoning Address issue resistance

Basic MI Processes (cont.)

Developing the relationship with the patient Express empathy Support self-efficacy

Engaging the patient’s reasoning Establishing global premises

Assessing patient’s understanding of disease and treatment

Establishing risk and susceptibility Establishing patient’s long-term goals

Addressing the patient’s specific lines of reasoning

Basic MI Processes (cont.)

Developing the relationship with the patient

Objective is to develop rapport

Patients should not feel a need to defend themselves

Patients are willing to talk openly and honestly because they are not losing face and they are being given choices

Consequently, patients are willing to “push the envelope” of their thinking

Basic MI Processes (cont.)

Engaging the patient’s reasoning

Identify the patient’s core motivational issues

Reflect and empathize with these issues

Explore the line of reasoning for each issue

Address the weak point of each line of reasoning

Invite the patient to draw a new conclusion

Basic MI Processes (cont.)

Developing the relationship with the patient

Engaging the patient’s reasoning processes

Both processes occur simultaneously and are thoroughly interdependent!

Typical MI Progression

Early emphasis on developing a solid relationship with the patient Less relational work required later

Later emphasis on engaging the patient’s reasoning Allows you to speed up because patient is not

defensive and argumentative Saves time by precisely targeting the patient’s

thinking: rifle vs shotgun

Example #1

Developing the relationship with the patient

Engaging the patient’s reasoning processes Identify the patient’s core motivational issues

Reflect and empathize with these issues

Explore the line of reasoning for each issue

Address the weak point of each line of reasoning

Invite the patient to draw a new conclusion

Creates rapport

Example #1 (cont.)

Patient: I’ve tried to quit smoking for a while. But I always come back to it again. So, I don’t see the point in trying any more.

HCP: It feels pointless to try to quit one more time if you are just going to smoke again anyway.

Patient: You got it!

HCP: Now, you said that you’ve been successful in quitting previously, but then you start back again. When you quit initially, what worked for you?

Example #1 (cont.)

Reflecting and empathizing with the patient’s core motivational issues Helps to create early rapport with the patient Helps to initiate the process of engaging the

patient’s reasoning process

If the patient feels that you haven’t heard and haven’t respected their issues, the patient will become defensive and/or aggressive The patient is no longer listening to you

Rapport Phone Audio

Example #2

Developing the relationship with the patient

Engaging the patient’s reasoning processes Identify the patient’s core motivational issues Reflect and empathize with these issues Explore the line of reasoning for each issue Address the weak point of each line

of reasoning•Invite the patient to draw a new conclusion

Example #2 (cont.)

Developing the relationship with the patient

Engaging the patient’s reasoning processes Identify the patient’s core motivational issues Reflect and empathize with these issues Explore the line of reasoning for each issue Address the weak point of each line

of reasoning•Impose your own conclusion on the patient

Decreases rapport

Example #2 (cont.)

HCP: Given that you don’t want to have a stroke or heart attack, what are you going to do to lower your blood pressure?

Patient: I don’t think that I can handle dieting, exercise,or quitting smoking. So, I’m going to rely on just taking the medicine.

HCP: It’s great that you are going to take your medicine. But the medicine alone won’t get your blood pressure down to a safe level without diet and exercise and quitting smoking. Your blood pressure is just too high.

Patient: Look, there’s no way I’m going to diet or exercise or quit smoking! And I really don’t like the idea of taking the medicine.

Example #2 (cont.)

If you make the argument for why you think the patient needs to change, the patient loses face and becomes resistant

READS: Avoid argumentation

MI is a facilitated reasoning process whereby the HCP assists the patient in making the argument for change

Must avoid reasoning steps that lose face for the patient

Establishing Global Premises

Some aspects of the patient’s thinking are global because they are the foundation for many lines of reasoning

Assessing patient’s understanding of disease and treatment

Establishing risk and susceptibility

Establishing patient’s long-term goals

Example #3

Patient: I had no idea my blood pressure was that high. RPh: You were surprised to find out you had high

blood pressure? Patient: Yeah…I feel fine. RPh: What’s your understanding of what can happen if your

blood pressure remains high…even if you feel ok? Patient: I’m not sure…I just know it’s bad for you. RPh: That’s right..may I share with you some of the risks

of it remaining high? Patient: Ok. RPh: If it remains elevated, you greatly increase your risk of

stroke or heart attack. What are your thoughts about that?

Example #3

Sometimes a patient may not process the implications of generalized concepts such as “stroke” or “heart attack”

If you push the patient, you create relational resistance

One option is to personalize the consequences

Engaging the Patient’s Reasoning on a Specific Motivational Issue

1. Empathize With the Motivational Issue

Reflect back and empathize with the patient’s motivational issues Feeling + content + reasons

Empathize fully and explicitly

Create a solid mutually acknowledged foundation that all subsequent reasoningis built upon Give clear explicit evidence that you have

heard the patient’s issues

1. Empathize With the Motivational Issue (cont.)

Avoid semantic reductions “I’m shocked” “You’re concerned”

Avoid generalized references “I’m shocked that my blood pressure is still

so high.” “That would be disturbing.”

Avoid pronouncing “understanding” “I understand that…” Instead, use “I sense that…,” “I hear that…,”

“I get the impression that…”

1. Empathize With the Motivational Issue (cont.)

Empathize with the central motivational issue Not with a superficial detail

Patient: It’s really hard to cut back on my smoking when I’m stressed out about things. Right now it’s the holidays…trying to get everything done before Christmas.

HCP: Preparing for the Christmas seasonis very difficult for you.

1. Empathize With the Motivational Issue (cont.)

Empathize with the central motivational issue Not with a superficial detail

Patient: It’s really hard to cut back on my smoking when I’m stressed out about things. Right now it’s the holidays…trying to get everything done before Christmas.

HCP: Christmas is really stressing you out. And when you get really stressed, you find that it’s harder to cut back on your smoking.

1. Empathize With the Motivational Issue (cont.)

Combine supporting self-efficacy with empathy Supporting self-efficacy and ignoring the

motivational issue often leads to a dead end

Patient: I’m shocked that my blood pressure didn’t come down a lot more because I’ve been really cutting back on my smoking and eating less salty foods.

HCP: It’s great that you’ve been cutting back on your smoking. Tell me how you’ve managed to accomplish that.

1. Empathize With the Motivational Issue (cont.)

Combine supporting self-efficacy with empathy Supporting self-efficacy and ignoring the motivational

issue often leads to a dead end

Patient: I’m shocked that my blood pressure didn’t come down a lot more because I’ve been really cutting back on my smoking and eating less salty foods.

HCP: Because you’ve worked hard to cut back on your smoking and decreased the salt in your diet, you were shocked and disappointed to find out that your blood pressure didn’t come down as much as you had expected.

2. Frame the Motivational Issue

Framing can make explicit what is implied by the patient

Framing can subtly introduce new possibilities that patients are inclined to accept because They feel understood The new possibilities are attributed to them

Framing can help generate a verbal commitment from a negative expression of doubt and concern

2. Frame the Motivational Issue (cont.)

Patient: I don’t see myself quitting smoking with all this stress in my life.

HCP: You seem to be saying that if you were less stressed or had less stress in your life, you would be much more likely to consider quitting.

3. Create an Explicit Transition to Exploring and Informing

Failing to set the context for clinical inquiry

After empathizing with patient’s core motivational issue, HCPs often move too quickly to perform clinical steps required to address the patient’s issue

HCPs assume patients will understand why they are asking these questions

Patients can easily misunderstand the HCP’s questions as accusatory in nature

3. Create an Explicit Transition to Exploring and Informing (cont.)

HCP needs to affirm desire to address the patient’s concern

Then, HCP needs to create explicit connection back to shared understanding of the patient’s issue

3. Create an Explicit Transition to Exploring and Informing (cont.)

Patient: I’m shocked that my blood pressure didn’t come down a lot more because I’ve been really cutting back on my smoking and eating less salty foods.

HCP: You’re surprised that your blood pressure did not come down more especially since you have worked so hard on making lifestyle changes. In order for me to address your concern about your blood pressure, I need to ask you some questions. Would that be ok?

Patient: Sure.

Summary

Empathize with the motivational issue

Frame the motivational issue

Create explicit transition to exploring and informing

4. Explore the Patient’s Line of Reasoning

Explore and reflect back the patient’s line of reasoning

Identify potential points of influence in the line of reasoning What parts of the patient’s reasoning can be

targeted precisely? Where’s the weakness in the reasoning?

How can you address the line of reasoning?

5. Address the Patient’s Line of Reasoning

Add new information Correct mistaken information Surface unstated assumptions: “I feel fine.” Personalize abstract benefits/losses Create discrepancy Share what other patients have done The insurance card: “May I share with you

my concern?”

6. Invite the Patient to Draw the Conclusion

After addressing the patient’s line of reasoning, many HCPs put the pressure on the patient by Implying that there is a correct conclusion:

“That’s why we want you to…” Reverting to a yes/no question: “Would you

be willing to try…?”

“How do you feel about this information?”

“What are your thoughts about how this information applies to your situation?”

6. Invite the Patient to Draw the Conclusion (cont.)

Crucial objective is to avoid creating new relational resistance by your drawing the conclusion

Intent is to assist patients in making their own argument for change

If they aren’t ready to draw a new conclusion, back off

7. Assess Changes in Willingness, Readiness, and Confidence

Reinforce any change talk and especially any changed conclusions

Explore what the patient is willing and ready to do

HCP: “Cutting back on your smoking will help to reduce your asthma attacks. How do you think you can go about cutting back on your smoking?”

8. Close the Deal

Provide a final summary of the patient’s line of reasoning

Express the desire to assist in reaching the patient’s goal

Affirm self-efficacy of any change proposed by the patient

Look forward to future interaction with the patient

Questions?

Comments?