Presenter Background - Infinity Rehab
An Introduction to Motivational Interviewing for Healthcare ProfessionalsContinuing Education Seminar for Physical Medicine & Rehabilitation ProfessionalsPresentation for Infinity Rehab, Denver Convention Center, Denver, Colorado, April 22nd, 2017.Presenter: Robert Scales, Ph.D., Director of Cardiac Rehabilitation & Wellness, Mayo Clinic-Arizona;Adjunct Associate Clinical Professor, Arizona State University, College of Health Solutions. Tel: (505)307-1142; Email: connect@robertscales.com; Website: www.robertscales.com.Background: Motivating patients to adopt a healthful treatment plan during brief office visits is amajor challenge facing healthcare providers. Therefore, effective communication strategies that canbe successfully employed during time-pressured consultations are worthy of consideration. Traditionalapproaches to patient care often rely on advice giving and direct persuasion. This can easily lead toconfrontation and may result in resistance (dissonance), particularly in patients who are ambivalent ornot ready to change behavior. Motivational interviewing is an alternate style of communication that hasdemonstrated success with clients that are recovering from drug and alcohol addiction. More recentadaptations of this approach to medical settings have been effective in improving a wide range ofhealth behaviors, including those that are promoted in a physical medicine and rehabilitation setting.This motivational approach is well suited to the daily practice of a busy clinic where improved patientcompliance is a priority. Skillful application by a clinician provides the platform for patients to talk aboutchange instead of exhibiting dissonance. Consequently, clinical consultations will not only be moreeffective, but also less frustrating for the provider.Purpose: To give a group of physical, occupational and speech-language therapists an introductionto motivational interviewing strategies for use in clinical settings.Objectives: The objectives for a 6.0-hour presentation are outlined as follows:Participants will be able to:1.Recognize ways in which patient resistance (dissonance) is exhibited during clinicalconsultations.2.Demonstrate an increased understanding of the research and theoretical framework uponwhich motivational interviewing is based.3.Identify the key components of motivational interviewing and how they can be used to lowerpatient resistance (dissonance) and promote behavior change.4.Explore options for incorporating motivational interviewing strategies into their own clinicalsetting.5.Identify tools that can be used to assess the communication skills of both students andpractitioners to provide feedback and ongoing skill development.References:1. Lundahl, B., Moleni, T., Burke, B. et al. (2013). Motivational interviewing in medical settings: Asystematic review and meta-analysis of randomized controlled trials. Patient Education & Counseling, 93:157-168.2. Miller, W. R. & Rollnick, S. (2013). Motivational Interviewing (3rd ed): Helping people change. New York,NY: Guilford Press.3. McKnight, K. M., McGowan, L., Dickens, C. & Bundy, C. (2006). A systematic review of motivationalinterviewing in physical health care settings. British Journal of Health Psychology, 11: 319-332.4. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helpingpatients change behavior. New York: Guilford Press.5. Scales, R., Miller, J. H. (2003). Motivational techniques for improving compliance with an exerciseprogram: Skills for primary care physicians. Current Sports Medicine Reports, 2, 3: 166-172.6. Scales, R., Inlander, R., Miller, J. H., Akalan, C., Thome, D., Castaldi, P., Humphrey, R. (2010). Aninvestigation of teaching methods to introduce motivational interviewing into a physical therapy schoolprogram. Physical Therapy Journal Online, Annual Conference Abstracts, 142-RR.7. Vong, S. K., Cheing, G. L., Chan, F, So, E. M. & Chan, C. C. (2011). Motivational enhancement therapyin addition to physical therapy improves motivational factors and treatment outcomes in people with lowback pain: A randomized controlled trial. Archives of Physical Medicine & Rehabilitation, 92, 2: 176-183.
An Introduction to Motivational Interviewing for Healthcare ProfessionalsContinuing Education Seminar for Physical Medicine & Rehabilitation ProfessionalsTeaching Methods:The seminar will incorporate handout material and a PowerPoint presentation that combines a didacticpresentation with an interactive discussion with attendees that is supplemented with videodemonstrations of motivational interviewing in the clinical setting. This will set the stage for willingattendees to practice some of the skills and strategies of motivational interviewing with structuredreal/role playing exercises in small groups.It should be noted that the standard 2-day workshop is the recommended format to teach motivationalinterviewing and improve competency. This usually involves a 1:16-20 Trainer: Attendee Ratio.Therefore, the 6.0-hour seminar will be an introduction to motivational interviewing in the healthcaresetting.Agenda:8:00 am – 10:15 am Pre-seminar self-evaluations, introductions, needs assessment and seminar goals. Motivational Interviewing: Background and Overview. The Stages of Readiness to Change: A theoretical model to help explain behavior change. What the research shows: Current review of the research involving motivational interviewing inhealthcare settings. What is Motivational Interviewing? Demonstrating the motivational style. Exploring a continuum of communication styles:What Goes Wrong with Persuasion? Pitfalls of Traditional Communication Tactics.Recognizing Resistance (Dissonance) and Using this as a Signal to Change Strategy.How to Have a Productive Conversation about Change: A Person-Centered Approach toConsultations. The Flow of Motivational Interviewing: The Four Processes.-Engaging-Focusing-Evoking-Planning. Integrating Key Components of Motivational Interviewing into a Routine Consultation in the Clinic.-Opening-History-Physical Evaluation-Education-Closure. Establishing a Respectful 'Opening' Conversation: Using the AIDES Acronym.-Acknowledge the Person with an Affirmation.-Introduce Yourself and Role within the Clinic.-Define the Duration of the Visit.-Explain the Expectations and the Flow of the Appointment.-Set a Collaborative Tone.10:15 am – 10:45 am (Break and Networking)
An Introduction to Motivational Interviewing for Healthcare ProfessionalsContinuing Education Seminar for Physical Medicine & Rehabilitation Professionals10:45 am – 12:30 pm Key Components of Motivational Interviewing (continued): The ‘History’ Building Motivation for Change with the Application of Fundamental Skills-Open-Ended Questions-Affirmations-Reflections-Summarizing (OARS) Help People Talk Themselves in Behavior Change: Identifying Change Talk. Practicing an initial discussion about behavior change. Transitioning to a 'Physical Evaluation'.-Affirmations, Structuring Statement and Informed Consent.-Body Awareness, Self-Discovery and Increasing Self-Efficacy. Expressing Optimism for Change.12:30 noon- 1:30 pm Lunch1:30pm – 2:30 pm Key Components of Motivational Interviewing (continued).-Transitioning to 'Education' Using the Motivational Style (Ask-Ask-Provide-Ask):Offering PM&R Related Information, Personalized Feedback and Advice. Recognizing Readiness to Change and Asking for a Commitment to Take Action.-Strengthening Commitment & Planning for Change.-Goal Setting and Negotiating a Behavior Change Plan in the Motivational Style2:30 pm – 2:45 am (Break and Networking)2:45 pm – 3:45 pm Transitioning to 'Closure':-Summarizing for Clarification and Direction.-Strengthening Commitment by Assessing Confidence to Change.-Closing Structuring Statement & Option of Follow-up. Integrating Motivational Strategies into the Clinical Setting and Overcoming Obstacles. Tips for Continued Learning of Motivational Interviewing: Self-Evaluation with Coding, Feedbackand Coaching. Questions, Evaluations and Adjournment.
Key Components of Motivational InterviewingEXPRESS APPRECIATION AND OFFER APPROPRIATE PRAISE WHENEVER POSSIBLE for the positivesteps being taken, for their honesty, for their willingness to consider change, for showing up . . .BEGIN WITH A STRUCTURING STATEMENT & SET A COLLABORATIVE TONE. During your introduction givea brief outline of what the patient can expect and step out of the expert role to let them know they will have a sayin any decisions about change. e.g. AIDES Acronym. They are the experts on what will work for them.SHARE OPTIMISM ABOUT THE POSSIBLITY OF CHANGE. Instill a belief that patients are capable ofchanging behavior, now or in the future, and that the patient’s health may improve as a direct result of thatchange.USE OPEN-ENDED QUESTIONS to build rapport and focus the discussion.SUPPRESS A WELL-INTENTIONED REFLEX TO ADVOCATE FOR CHANGE.RECOGNIZE THAT IT IS NORMAL TO HAVE MIXED FEELINGS ABOUT MAKING A CHANGE. Invitepatients to look at the pros and the cons of their current behavior as well as the pros and cons of making achange.AVOID ARGUMENTS. Arguments are hard work, counter-productive and a signal to use an alternativeapproach. Let the patient make the case for change. Provide opportunities for them to see the gap between theway things are now and the way they would like things to be.LISTEN WITH EMPATHY. Use respectful attention. Demonstrate a desire to gain mutual understanding bygiving short summaries of what you hear the person say, what you think it means, and, as appropriate, whatyou think the person is feeling.MATCH YOUR STRATEGIES WITH THE PERSON'S READINESS TO CHANGE. Assess the stages ofchange across multiple behaviors and use appropriate strategies.ASK EVOCATIVE QUESTIONS to encourage talk about change.RESPOND TO WHAT YOU HEAR WITH STRATEGIC REFLECTIVE STATEMENTS to highlight the thoughtsand feelings that reinforce the person’s own reasons for making a positive change.PROVIDE FEEDBACK & INFORMATION WITH PERMISSION and in a caring, collaborative manner. Let thepatient come to their own conclusions about how useful it is, if at all.GIVE ADVICE SPARINGLY and with respect for freedom of choice.USE SUMMARIES to clarify and to reinforce what the person is saying about making or maintaining a change.(“Let me make sure I’m getting this right.”)ASK FOR A DECISION TO CHANGE. “What would you like to do about ?”NEGOTIATE A CHANGE PLAN only when the person expresses readiness to change. Continue to invite thepatient to explore their own ideas and solutions.PROVIDE A MENU OF OPTIONS FOR CHANGE. Let the patient choose what they think will work best forthem.Adapted by Robert Scales and Joseph. H. (Bo) Miller (2016) from the following references:1.2.3.4.5.6.Miller WR, Rollnick S. Motivational interviewing: Helping people change. Guilford Press; 2013.Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictivebehaviors. American Psychologist, 1992;47:1102-1114.Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: Helping patients changebehavior: Guilford Press; 2008.Scales R, Miller JH. Motivational techniques for improving compliance with an exercise program: skillsfor primary care clinicians. Curr Sports Med Rep. 2003;2(3):166-72.Studer, Q. Hardwiring Excellence. Starter Publishing; 2003.White J, Levinson W, Roter P. “Oh, by the way ”: The closing moments of the medical visit. J Gen IntMed, 1994; 9(1):24-28.
GETTING PEOPLE TO TALK ABOUT CHANGESample of Open-ended Questions to Encourage Change-related StatementsThe questions fall into four areas. Keep in mind that these questions usually come after moregeneral open-ended questions have gotten the ball rolling and you have established some rapportwith your client (e.g., "Tell me what brings you here today." "How can I be helpful to you?""How have things been going for you?" etc.) Be aware that the interviewer's use of words like"problem" or even "concern" can sound confrontational to some clients. Take your cue from yourclients about how to describe their current situation.1. Disadvantages of the way things are now (problem recognition & concerns)What worries you about your current situation?What difficulties have you had in relation to your management of diabetes?What makes you think that you need to do something about your use of alcohol?How has your weight gain stopped you from doing what you want to do?What is there about your drinking that you or other people might see as reasons forconcern?In what ways does this concern you?What do you think will happen if you don’t make a change?2. Advantages of changeHow would you like for things to be different?What would be the advantages of making this change?The fact that you’re here indicates that at least part of you thinks it’s time to dosomething. What are the main reasons you see for making a change?If you could make this change immediately, by magic, how might things be better for you?3. Optimism about changeWhat makes you think that if you did decide to make a change, you could do it?What encourages you that you can change if you want to?What do you think would work for you, if you decided to change?When else have you made a significant change like this? How did you do it?What personal strengths do you have that will help you succeed if you decide to make achange?4. Intention to changeWhat makes you think that you may need to make a change?If you were 100% successful and things worked out exactly as you would like, whatwould be different?What things make you think that you should keep on with your diet the way it is now?And what about the other side? What makes you think it’s time for a change?What are you thinking about your smoking at this point?What would be the advantages of making a change?I can see that you’re feeling stuck at the moment. What’s going to have to change?Adapted by Bo Miller from Miller and Rollnick (1991; 2002)
GETTING PEOPLE TO TALK ABOUT CHANGE (CONTINUED)Nine Strategies for Evoking Change Talk1. Ask Evocative QuestionsAsk open questions, the answer to which is change talk. (See previous page.) Thequestions used in the “Taste of MI” exercise are also good examples:“Why would you want to make this change?” (Desire)“How might you go about it, in order to succeed?” (Ability)“What are the three best reasons for you to do it?” (Reasons)“How important is it for you to make this change?” (Need)“So what do you think you’ll do?” (Commitment)2. Ask for ElaborationWhen a change talk theme emerges, ask for more detail. “In what ways?” “Tell me moreabout that.” etc.3. Ask for ExamplesWhen a change talk theme emerges, ask for specific examples. “When was the last time thathappened?” “Give me an example.” “What else?”4. Look BackAsk about a time before the current concern emerged. How were things better, different?5. Look ForwardAsk what may happen if things continue as they are (status quo). “If you were 100%successful in making the changes you want, what would be different?” “How would youlike your life to be five years from now?”6. Query Extremes“What are the worst things that might happen if you don’t make this change?” “What are thebest things that might happen if you do make this change?”7. Use Change RulersAsk, “On a scale from zero to ten, how important is it to you to [target change] -- where zero isnot at all important, and ten is extremely important?” Follow up: “And why are you atand not zero?” “What might happen that could move you from to [higher score]?”Instead of “how important” (need), you could also ask “how much do you want” (desire), or“how confident you are that you could” (ability), or “how committed are you to ”(commitment). Asking “how ready are you?” tends to be a bit confusing because it combinescompeting components of desire, ability, reasons and need.8. Explore Goals and ValuesAsk what the person’s guiding values are. “What do they want in life?” Using a values cardsort can be helpful here. If there is a “problem” behavior, ask how that behavior fits in withthe person’s goals or values. Does it help realize a goal or value, interfere with it, or is itirrelevant?
9. Come AlongsideExplicitly side with the negative (status quo) side of ambivalence. “Perhapsis so important to you that you won’t give it up, no matter what the cost.”NOTE: With any attempt to encourage people to talk about making changes when you are usingthe motivational style, listen and reflect back what you hear them saying.Adapted by Bo Miller from: MI Training for New Trainers, Resources for Trainers; MotivationalInterviewing Network of Trainers: (2008), pp. 102-103.
The CARE Measure Stewart W Mercer 20041.Please rate the following statements about today’s consultation. Please check one box foreach statement and answer every statement.VeryGood ExcellentDoesNotApplyPoorFairGood How was the provider at .1. Making you feel at ease (introducing himself/herself, explaininghis/her position, being friendly and warm towardsyou, treating you with respect; not cold or abrupt)2. Letting you tell your “ story” (giving you time to fully describe your situation inyour own words; not interrupting or diverting you)3. Really listening (paying close attention to what you were sayings; notlooking at the notes or computer as you were talking)4. Being interested in you as a whole person (asking/knowing relevant details about your life,your situation; not treating you as “just a number”)5. Fully understanding your concerns (communicating that he/she had accurately understoodyour concerns; not overlooking or dismissing anything)6. Showing care and compassion .(seeming genuinely concerned, connecting with you on ahuman level; not being indifferent or “detached”)7 . Being Positive (having a positive approach and a positive attitude;being honest but not negative about your problems)8. Explaining things clearly .(fully answering your questions, explaining clearly,giving you adequate information; not being vague9. Helping you to take control (exploring with you what you can do to improve yourhealth yourself; encouraging rather than “lecturing” you)10. Making a plan of action with you (discussing the options, involving you in decisions asmuch as you want to be involved; not ignoring your views)Comments:
InformationThe Consultation and Relational Empathy (CARE) Measure is a consultation process measure has that beendeveloped by Dr Stewart Mercer and colleagues in the Departments of General Practice at GlasgowUniversity and Edinburgh University. It is based on a broad definition of empathy in context of atherapeutic relationship within the consultation. The wording reflects a desire to produce a holistic, patientcentred measure that is meaningful to patients irrespective of their social class, and has been developed andapplied in over 3,000 general practice consultations in areas of high and low deprivation in the west ofScotland.The scoring system for each item is ‘poor’ 1, ‘fair’ 2, ‘good’ 3, ‘very good’ 4, and ‘excellent’ 5. Allten items are then added, giving a maximum possible score of 50, and a minimum of 10. Up to two ‘NotApplicable’ responses or missing values are allowable, and are replaced with the average score for theremaining items. Questionnaires with more than two missing values or ‘Not Applicable’ responses areremoved from the analysis.The theoretical background and validation of the CARE measure can be found in:Mercer SW, McConnachie A, Maxwell M, Heaney DH, and Watt GCM. Relevance andperformance of the Consultation and Relational Empathy (CARE) Measure in general practice.Family Practice 2005, 22 (3), 328-334Mercer SW, Watt, GCM, Maxwell M, and Heaney DH. The development and preliminaryvalidation of the Consultation and Relational Empathy (CARE) Measure: an empathy-basedconsultation process measure. Family Pract
which motivational interviewing is based. 3. Identify the key components of motivational interviewing and how they can be used to lower patient resistance (dissonance) and promote behavior change. 4. Explore options for incorporating motivational interviewing strategies into their own clinical setting. 5.
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