Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

39
Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014

Transcript of Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Page 1: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Motivational Interviewing for Busy Residents

PBL SESSION 3

KEN SAFFIER, MD

JULY 18, 2014

Page 2: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Disclosures

Still nothing to disclose

Member, Motivational Interviewing Network of Trainers (M.I.N.T.)

www.motivationalinterviewing.org

Page 3: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Learning ObjectivesBy the of this session, you will be able to:

1. Recognize and use O.A.R.S. microskills in patient visits.

2. Use reflections to “roll with resistance” in challenging situations.

3. Apply MI tools to evoke change talk in patient interviews.

4. Develop an individual MI learning plan.

Page 4: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Spirit of MI

Collaboration

Acceptance

Evocation

Compassion

Page 5: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Eight Stages of Learning MI

1. Spirit of MI – evocative, collaborative, respectful of client autonomy

2. OARS – Client-centered counseling skills

3. Recognizing and reinforcing Change Talk – DARN CAT

4. Eliciting & strengthening Change Talk

Miller, WR, Moyers, TB, 2006

Page 6: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Eight Stages of Learning MI

5. Rolling with Resistance – Reflections: simple, amplified, double- sided

6. Developing a Change Plan – moving from Change Talk to Commitment

7. Consolidating Client Commitment – moving from “I can”/”I’d like to” … to “I will”

8. Switching between MI and other Counseling Methods

Miller, WR, Moyers, TB, 2006

Page 7: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Four Processes in MI

Miller and Rollnick, 2013

Engaging

Focusing

Evoking

Planning

Page 8: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

8Building Motivation: OARS(the microskills)

•Open-ended Questioning

•Affirming

•Reflective Listening

•Summarizing

•O

•A

•R

•S

Page 9: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Reflective Statements Levels

Repeating. The simplest reflection simply repeats an element of what the speaker has said.

Rephrasing. Here the listener stays close to what the speaker said, but substitutes synonyms or slightly rephrases what was offered.

Paraphrasing. This is a more major restatement, in which the listener infers the meaning. Continues the paragraph.

Reflection of feeling. Deepest form of reflection, a paraphrase that emphasizes the emotional dimension through feeling statements

Page 10: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Recognizing Change Talk

Page 11: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

and Elicit – ChangeTalk

D A R N - CAT

Desire to change:

Page 12: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

D A R N – C A T

Ability to change:

“ I could …”

Page 13: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

D A R N – C A T

Reasons to change:

Page 14: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

D A R N – C A T

Need to change:

Page 15: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

D A R N – C A T

Desire Ability Reasons Need

C: commitment—Will, intend to, going to

A: activation—Ready to, willing to (w/o specific commitment)

T: taking steps—Report recent specific action

toward change

Amrhein et al., 2003

Page 16: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Which Style Do You Prefer?

Dancing Wrestling

Page 17: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Motivation is particularly sensitive to Interpersonal Communication Styles

Counsel in a directive, confrontational manner—Resistance increasesChange talk decreases

Counsel in a reflective, empathic manner—Resistance decreasesChange talk increases

Miller & Rollnick, Motivational Interviewing, 2002

Page 18: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Rolling with Resistance Strategies:

“Well, I over do it sometimes, but I don’t have a problem with meth.”

Coming alongside: You feel mostly in control with your meth use and don’t see it as an issue.

Amplified reflection: Your meth use has never really caused any problems or unpleasant effects in your life.

Double-sided reflection: You think you use too much at times, but you also don’t think of yourself as a problem user.

Page 19: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Roll With Resistance/Sustain Talk

Avoid arguing for change.

Resistance is not directly opposed.

New perspectives invited, not imposed.

A sign to respond differently.

Miller and Rollnick, Motivational Interviewing, 2002

Page 20: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.
Page 21: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

“Batting Practice”

Write down one or two examples of resistance from your experience what your patients have said.

We all get to take turns “batting” one or two examples to practice “rolling with resistance” (or sustain talk).

Page 22: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Expert Demonstration

Listening for:

O.A.R.S.

and change talk:

D.A.R.N. - C.A.T.

Page 23: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

A Brief Review of MI Tools

Pros and cons Pros and cons squared

Explore – Offer – Explore (Elicit – Provide – Elicit aka Ask – Tell – Ask)

Decisional (importance and confidence) rulers Strategic summary statements followed by an

evocative question.

Page 24: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Pros and Cons

What’s good about _______________? What’s not so good about __________?

For contemplative and pre-contemplative stages of change.

Page 25: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Tools for Contemplation

Pros & Cons squared

“good” and “not so good”

DON’T CHANGE

CHANGE

PROS

CONS

Page 26: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Valuable MI Tools

Elicit – provide – elicit (Ask – Tell – Ask)

E What is your understanding about _______?

(May I share some information about this?)

P Information shared…

E What do you think about this?

Importance and confidence rulers to elicit change talk.

Page 27: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Assess Readiness to Change Once you identify a problem….where do

you go?

“On a scale of 1 to 10, how important is it for you to make a change, to ___?

“Why did you pick ___, and not 1 or 2

(a lower number)?”

“On a scale of 1 to 10, how confident are you that you can ________

“What would it take to go from ___ (lower #) to ___ (higher)?

Page 28: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Summarizing Statement Special form of reflection Pick a bouquet of flowers

Focus on change talk or underlying dilemmas

Reassures that you heard the personMoves the conversation along

MJ relaxes you & it’s a way to socialize with your friends. But you want to limit your MJ use, because its interfering with school and it takes a big bite out of your budget.

Page 29: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Evocative Questions

Why would you want to make this change? If you did decide to make this change, how would

you go about it in order to succeed? What are the 3 best reasons to do it? So what do you think you’ll do? How important would you say it is for you to make

this change, on a scale of 0 to 10, and 10 is extremely important? And why are you at __ and not a lower number or 0?

Page 30: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Demonstrations

http://www.youtube.com/watch?v=80XyNE89eCs “Not so good”

http://www.youtube.com/watch?v=URiKA7CKtfc “Good”

Page 31: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Time to Practice

Page 32: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Exercise – Pass the Stethoscope

Your patient has ___________________.

One provider opens the visit, learns what is important to the patient, and after 2 interactions, passes the stethoscope to another, who continues the interview, using OARS, and MI tools.

Pick a card from the table and practice with that tool. Then pass the stethoscope.

Page 33: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

MI is Effective Across Cultures

• Based on broad generalizable principles of human behavior.

• Cultural competence = cultural humility, respectful listening, learning, appreciating and understanding differences = “Spirit” of MI.

• Evidence: increased effect sizes in studies with predominantly minority populations.

(Hettema, Steele and Miller, 2005)

Page 34: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Eight Stages of Learning MI

1. Spirit of MI – evocative, collaborative, respectful of client autonomy

2. OARS – Client-centered counseling skills

3. Recognizing and reinforcing Change Talk – DARN CAT

4. Eliciting & strengthening Change Talk

Miller, WR, Moyers, TB, 2006

Page 35: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Eight Stages of Learning MI

5. Rolling with Resistance – Reflections: simple, amplified, double-sided

6. Developing a Change Plan – moving from Change Talk to Commitment

7. Consolidating Client Commitment – moving from “I can”/”I’d like to” … to “I will”

8. Switching between MI and other Counseling Methods

Miller, WR, Moyers, TB, 2006

Page 36: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Learning MI – consider:

Attend a training workshop (CME)

Read: Miller, Rollnick, others.

Tape record your real plays or a clinic visit (after consent obtained) and then:Rate yourself.Have a colleague or mentor provide feedback, return the favor.

Develop a learning plan and a timetable www.motivationalinterviewing.org

Page 37: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Your Individualized Learning Plan

1. What you will practice in the coming week?

2. Where will you try out these tools?

3. With whom will you practice?

4. When will you do this?

5. How will you do this?

Page 38: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Recommended Reading

Page 39: Motivational Interviewing for Busy Residents PBL SESSION 3 KEN SAFFIER, MD JULY 18, 2014.

Many Thanks to:

Sharone Abramowitz, MD Karena Franses, LCSW Tom Freese, PhD Jennifer Hettema, PhD Steve Berg-Smith, MS, CWP