Motivational Interviewing: Improving Communication For .

Motivational Interviewing:Improving CommunicationforBehavior Change4th BIENNIAL WISCONSIN HEALTH LITERACYSUMMITApril 13, 2011Celeste Hunter, MS, CRCDoctoral CandidateDepartment of Rehabilitation PsychologyUniversity of Wisconsin-Madison

Overview Understanding “Literacy” acquisition:o Theories and perspectives from a (K-12) reading teacher Communication Styles Health Literacy and Connections to MotivationalInterviewing (MI) Engagement is is a primary issue in to attaining healthliteracy Motivational Interviewing (MI) is designed specificallyto enhance patient engagement Applications of MI in across client settings to enhancehealth literacy and engagement.

Todays Learning Objectives Refresh understanding of the fundamental principles andspirit of MI Learn the basic tenants of motivational interviewing to helpelicit positive behavior change most relevant to enhancinghealth literacy and engagement in underserved populations Observe and practice empathic counseling skills Gain understanding of communication styles and theirrelevance to culturally competent MI practice. Practice applying MI principals within a variety of healthliteracy case scenarios commonly experienced by healthpractitioners.

“Whole-language” Model of Literacy LearningRespect for the Developmental LevelExpect that learning will occurFocus on StrengthsDisplay of “joyfulness’Encourage “Languaging’Process OrientationOngoing EvaluationFoster IndependenceFoster life-long learningTeacher as facilitator and co-learnerNegotiation of curriculum: The importance of choiceModel the behaviorSharingValue timeCollaboration and social interaction

Three Communication Styles

The Problem of Non-adherence Simply giving patients advice to takemedications or make lifestyle changes isoften not effective. For example, rates of adherence:oooooAnti-hypertension drugs: 50%MS disease modifying therapies: 55%Chronic schizophrenia treatment: 24-63%Antibiotics: 73% (qd), 52% (tid), 42% (qid)Rule of one-third (Meichenbaum & Turk, 1987)

Health is Hard Work!The only way to keep your health isto eat what you don’t want,drink what you don’t like,and do what you’d rather not- Mark Twain

Rehabilitation is hardwork!In PC or other rehabilitation, we often askpatients to make significant changes in theirbehavior:o Adhere to self-care, medication, & therapy i.e. OT,PT, Speecho Exercise & eat righto Show up to all appointments on timeo Stop or curb substance useo Use “appropriate” behavior

Motivation & Rehab Outcomes“Client motivational problems are a primary barrier tosuccessful rehabilitation outcomes”.Thoreson, et., al 1968 How successful people are towards rehab goals whatthey do Clients are often ready, willing, and able to makechange Most clients seeking treatment or change are ambivalentabout it:. They want it and they don’t

Current Knowledge?What do you already knowabout MotivationalInterviewing?

Motivational Interviewing: A DefinitionMotivational Interviewing is acollaborative, person centeredform of guiding to elicit andstrengthen motivation forchange.

Assumptions About BehaviorChange Attitude is everything: Impart belief in thepossibility of change Empathy: Create an atmosphere in which theclient safely explores

Motivation:Traditional Clinicians Perspective Motivation is the patientsproblem The patient “just isn’tready to change The patient is getting“something”out of statusquo: i.e.; social security,attention, relaxedlifestyle, etc.or

Motivation: MI’s Perspective Motivation is theprobability that a personwill change* Motivation is influencedby clinician responses Low patient motivationcan be thought of as aclinician deficit*Miller & Rollnick, MotivationalInterviewing: Preparing people tochange addictive behavior. New York:Guilford Press, 1991.

MI is Theoretically SoundMI strategies are theoretically & empiricallybasedo Substance abuse (Miller & Rollnick, 2002)o Chronic pain treatment (Jensen, 2002)o Exercise and MS (Bombardier et al, in progress)Focus on Ambivalence: Feeling 2 ways aboutsomething:o Wanting to change, but not wanting to

Theoretical Basis of MICognitive Dissonance Theory (Festinger):-‘If I say it and no one has forced me to say, Imust believe it.’Client-Centered Therapy (Rogers): Accurate empathy, warmth, and genuinenesspromote change.Belief System Theory (Rokeach): Awareness of a discrepancy between behaviorand core values creates change.

Theoretical Basis of MI (continued)Learned Optimism (Seligman): Optimism and hope facilitate change.Importance of Choice (Sanchez-Craig): Choice enhances adherence.Reactance Theory (Brehm): Threats to freedom elicit resistance.

Stages of Change:Transtheoretical Model of Change Prochaska & Velicer, 1997Transtheoretical model of change: Explains or predicts a person's success or failure in achieving aproposed behavior change, such as developing different habits. It attempts to answer why the change "stuck" or alternatively whythe change was not made.

Efficacy of MI: RCTsHIV risk reduction- Increased condom use (Belcher et al., 1998)Diet and exercise- Increased physical activity (Harlan, 1999)- Better treatment adherence (Smith, 1997)Public health- Increased sales of water disinfectant (Thevos, 2000)

What do we know with reasonableconfidence about MI? Individual MI improves treatment retention,adherence, and outcomes across a range of problembehaviors MI generalizes fairly well across cultures Outcomes vary widely across providers, programs,and research sites Therapeutic relationship matters So do client change talk and resistance Mi is learnable MI skill is reliably measurable and predicts betterclient outcomes

STRATEGIESSKILLSSPIRIT“Spirit” is the foundationof MI practice

The Spirit ofMotivational Interviewing3 main concepts:o Collaborationo Evocationo Autonomy

Spirit Underlying assumption thatclients can develop in thedirection of health and adaptivebehaviorEssential for the full andeffective use of MI

Spirit: UnderlyingAssumption:oClients can and will developdirection of health and adaptivebehaviorEssential for the full and effective use of MI

Introspective Exercise #1 Think of a behavior you have tried tochange and write it down Think about how long it took you tomake an earnest attempt at change afternoticing the behavior Who was helpful in that process andwhy?

MI: Four GeneralPrincipals#1: Express empathy:(using short reflections)Acceptance facilitates changeJudgment changeAmbivalence is normal #2 Develop discrepancy: (good things/not so goodthings)ooClient (rather than counselor) argues for changeChange when perceived discrepancies in present behavior importantpersonal goals & values

MI: Four General Principals#3: Roll with Resistance: giving advice change and resistanceNew perspective are invited-- with permissionResistance Signal- DO SOMETHING DIFFERENT!#4: Support Self-Efficacy: Person’s belief in possibility of increases initiation &persistence of adaptive behavior

CollaborativeDancingvs.Wrestling

Accepting &Non-judgmentalThe paradox of change: when people feel accepted for who they areand what they do - no matter what

Eliciting Encourages the other person to do mostof the talking Your ability to support the other personin doing most of the talking

Honoring Autonomy Respects the other person’s:-freedom of choice-personal control-perspective-ability to make decisions

Please remember. Just because MI seems SIMPLE,that doesn’t mean it is EASY Just because it seems likeCOMMON SENSE, that doesn’tmean it is COMMONPRACTICE!

Motivational Interviewing:2 PhasesPhase #1Phase #2Increase Motivation to ChangeConsolidating CommitmentCounselor evokes client’s: Strength of language (not frequency) change Low level “I’ll try" or “I’ll think about it” High Level “I promise” or “I will!”DesireAbility ReasonsFinal min of session strongest predictor ofbehavior change (Amrhein et al. 2003)“I will do it!” Need for changeBy responding with reflective listening

Applications Lecturing provides little in the way ofmotivationUsual response Annoyance or guiltJensen, 2005“Information is to behavior changeas wet noodles are to bricks”-Wilbert Fordyce

Applications (continued)If you find yourself lecturing orarguing Stop!

Applications (continued)There are many things you can do to increasemotivation #1 LISTEN!

Listen for Meaning!What to listen for Is this person ready to change?Identifying stage of changeWhat does this person value?Link health outcomes to the person’sown goalsWhy would this person want toparticipate?Use the person’s own arguments for change

Change TalkChange-talk is client speech that favorsmovement in the direction of change

What do we know about change talk?Change talk.Predicts behavior changeIs suppressed by confrontationIs enhanced by listeningIs under the control of thecounselor

Preparatory Change Talk:Four KindsDESIRE to change (want, like, wish . . )ABILITY to change (can, could . . )REASONS to change (if . . Then)NEED to change (need, have to, got to . .)

Ask for DARN to get DARN! Why would you want to make this change?(Desire)How might you go about making this change?(Ability) What are the three best reasons to do it?(Reasons)On a scale of 0-10, how important would you sayit is for your to make this change? And why aren‘tyou at a (2 points lower)? (Need)

CAT Commitment: What do you intend to do?Activating: What are you ready or willingto do?Taking steps: What have you already done?

Listening Practice to get DARN!OARS

Key MI Skills Open-ended questions Affirmations Reflective listening Summarize

Exercise #2 Choose a behavior you areinterested in changing and willing toshare with a partner in this room Review the “DARN” principles asthey relate to this change Role play with a partner as“counselor” and “client”

When do you know it is working?- The patient keeps talking- The patient is talking more than you- You are following and understanding- The patient is working hard andseeming to come to new realizations- The patient is asking for information oradvice

Persuasion Exercise: Debrief- Did the clinician observe movementin the direction of positive change?- Did the speaker feel like makingpositive change?- What are the underlying messagesconveyed by advice giving andlecturing?

In Conclusion Motivational issues are central to enhancinghealth literacy We cannot make patients change behaviorWe can help to motivate patients in thedirection of positive changes by: 1. Listening rather than lecturing2. Identifying the stage of change3. Matching our response to the stage toencourage movement to the next stage

For more information.Contact info: cahunter@wisc.edu

Health Literacy and Connections to Motivational Interviewing (MI) Engagement is is a primary issue in to attaining health literacy Motivational Interviewing (MI) is designed specifically to enhance patient engagement Applications of MI in across client settings to enhance health literacy and engagement.