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									                                                             Acknowledgements &
      Motivational                                           Thanks!
      Interviewing Strategies                                Motivational Interviewing Strategies
      in Health Care Settings                                 Jim Ellis, MSW, BCD, CDE
        May 10, 2008                                             Children’s Hospital of Wisconsin
                                                                 Diabetes Clinic

  Jessica C. Kichler, Ph.D.
  Pediatric Psychologist
                                                             S.H.A.R.E.D. Project
  Child and Adolescent Psychiatry & Behavioral                 Astrida Kaugars, PhD
  Medicine Center                                                Marquette University Department of
                                                                 Psychology




                                                             Disclosure of Financial
           Additional Thanks!
                                                             Relationships
Marquette University          Children’s Hospital of
                              Wisconsin                        I have no financial relationships to
Renee DeBoard, M.A.
                              Ramin Alemzadeh, M.D.            disclose with regard to this
Chris Fitzgerald              Diabetes Clinic Staff
Susan Heinze                                                   presentation. This talk is free of
Lauren Perazzo
                                                               commercial bias.
                              Milwaukee Area Child
Lisa Reinemann                Health Research
                              Initiative (MACHRI)




  Adolescent Quotes:                                            Theoretical
    I think when you’re first diagnosed, you really care        Framework of
    about it and then, like, as you get older, it’s just
    like…it just seems too routine and then you just,
    like, give up. You know you have to do it, but it just
                                                                Motivational
    takes a little extra push to do it, like testing your
    blood. I haven’t tested my blood sugar in, like, 6
    months.
                                                                Interviewing…
    I think sometimes people don’t check their blood
    because they just don’t want to know what it is. Like
    they’re afraid it’s going too high or something that
    they don’t want something recording that so other
    people will see that, I guess…So, I don’t check it
    and if don’t know, it can’t hurt me.




                                                                                                      1
         Transtheoretical Model (TTM)                              Motivational Interviewing
           (Prochaska & DiClemente, 1982)                                          (Miller & Rollnick, 1991)
                                                    A patient-centered, therapeutic style that incorporates:
“Readiness to Change”                                 Patient-provider relationship:
                                                        • collaborative partnership
                                                        • empathetic and non-judgmental
  1.   Precontemplation – not yet considering           • quiet and eliciting responses from provider
       change                                         Self-efficacy:
  2.   Contemplation – evaluating reasons for and       • Change in patient that is internally, not externally, motivated
       against change                                   • Maintains patient’s autonomy
                                                      Creating and resolving discrepancies:
  3.   Preparation – planning for change                • Between current behavior and future goals
  4.   Action – making the identified change          Advice giving:
  5.   Maintenance – working to sustain changes         • In a non-confrontational style
                                                        • Provide discussions on various methods of change




       Goals

         Provide an additional tool to                             Remember:
         professional staff to utilize as health
         counselors.
         Learn how to manage and direct
                                                                   “Readiness to
         encounters with patients to put the
         responsibility for change on them.
                                                                   change” is a state,
         Empower our patients to achieve
         greater success in Diabetes Self                          not a trait.
         Management Goals.




                                                                 Motivational Interviewing with
                                                                   Children & Adolescents
           Research on
                                                         Types of behaviors addressed:
           Motivational                                       Tobacco, Substance, Sunscreen Use
                                                              Weight Loss, Anorexia Nervosa
           Interviewing…                                      Cancer (exercise), Asthma (adherence)

                                                         Summary of research outcomes when MI
                                                         strategies were used in medical settings:*
                                                              Improved patient satisfaction with care
                                                              Increased disclosure of psychosocial concerns
                                                              Mothers demonstrated increased adherence to
                                                              treatment recommendations
                                                     *Sindelar, Abrantes, Hart, Lewander, & Spirito (2004).




                                                                                                                            2
        Motivational Interviewing in
          Adults with Diabetes
    Jones et al. (2003) – this intervention could
    help adult patients “move” to action stages of
                                                            The S.H.A.R.E.D.
    change.
    Trigwell et al. (1997) – did not find a
                                                            Project…
    relationship between HbA1c and the adult
    patient’s current stage of change using a
    general measure of stages of change.

    SHARED Project (Kaugars et al., in progress
    at CHW) – expanding this research to a
    pediatric diabetes population by looking at
    parent and child readiness to change specific
    to diabetes cares, adherence, and HbA1c.




      Readiness to Change
     Balance of Responsibility                           Purpose and Hypotheses
                                                     Purpose of the study is to examine whether a
A better understanding of the construct of           measure (DMSOCQ) assessing readiness to
“responsibility” involves a necessary shift to       change can be used to better understand the
understanding responsibility as dynamic and          balance of responsibility for diabetes management
                                                     among youths and parents.
interdependent.
                                                     It is hypothesized that parents’ and youths’
  Youth taking direct responsibility with parental   readiness to change will be related to theoretically
  supervision                                        relevant constructs:
                                                       Diabetes-related conflict
                                                       Diabetes task responsibility allocation
Measure needed to help treatment teams                 Reported and observed negative affect in youth-
assess families’ balance of responsibility             parent interactions
                                                       HbA1c and healthcare utilization




   Participants & Methods                                       Initial Findings
                                                      “Balance of Responsibility for Type 1 Diabetes
      71 adolescents (12-17 years old)                Management Responsibilities: A Measure Assessing
        67 maternal & 44 paternal caregivers          Mother, Father, and Youth Readiness to Change”
      Research visit before/after clinic visit
                                                        Great Lakes Conference on Child Health – Society of
        Completed questionnaires                        Pediatric Psychology
        Adolescent-parent videotaped                    Goal: To demonstrate the reliability and validity of a
        interaction                                     measure assessing caregiver and youth readiness to
        Medical record review                           change the balance of responsibility for T1DM
                                                        management – the Diabetes Management Stages of
                                                        Change Questionnaire (DMSOCQ).




                                                                                                                 3
           Results – Distribution of
           DMSOCQ Ratings                                                              Additional Results
                            Youtha         Maternalb          Paternalc
                         (Items 1-7)     (Items 1-12)       (Items 1-12)              Youths’ current age, age at diagnosis of T1DM,
                                                                                      length of T1DM duration, and HbA1c values were
Precontemplation             6%               0%                 5%                   unrelated to any of the DMSOCQ average ratings.
Contemplation               22%               2%                 5%
                                                                                      Eleven participants (16%) had one or more
Preparation                 25%              28%                21%                   diabetes-related emergency department visit
Action                      41%              59%                57%                   and/or hospitalization in the past year. Youth who
                                                                                      had >1 diabetes-related emergency department
Maintenance                  7%              12%                14%                   visit or hospitalization had significantly higher
                                                                                      DMSOCQ self-report ratings than the youth who
          Mean (SD) 3.63 (1.01)           4.26 (0.64)        4.13 (0.80)              did not utilize these services (t (28) = -3.72, p <
               Range 1.00 – 5.00          2.42 – 5.00        1.67 – 5.00              .01).
                                              an   = 69; b n = 65; c n = 44.




                                                                                        Health Behavioral Change Model
                                                                                         (Sindelar, Abrantes, Hart, Lewander, & Spirito, 2004)
                 Motivational
                                                                                      In brief, consultative encounters (10-20
                 Interviewing Strategies                                              min.) health providers can establish the
                 for Clinical Practice…                                               following:
                                                                                        Importance: how important is the change to
                                                                                        the patient?
                                                                                        • “How will I benefit,” “What will change,” “Will it
                                                                                          make a difference,” “Do I really want to?”
                                                                                        Confidence: how confident is the patient in
                                                                                        their ability to make the changes?
                                                                                        • “Can I change for good,” “How will I cope with
                                                                                          the urges to not change,” “How will I change?”




           Facilitators of Adolescents’                                                 Goals for Health Care Providers
           Successes                                                                     During a Clinic Appointment:
   Besides being educators, collaborators, and clinicians, nurses
   have the unique opportunity to serve as change agents,                      To Encourage Behavior Change:
   persons who intentionally promote the change process
   through partnering and empowering.                                            1.   Get explicit statement of patient’s willingness to
                                                                                      participate
   The goal is to create an atmosphere in which the client                       2.   Clarify and acknowledge patient’s ambivalence
   generates his or her own reason for change.
                                                                                 3.   Help patient create their own concrete, objective,
   An effective change agent shifts responsibilities from the                         and measurable goals
   health care provider to the client by engaging the client in                  4.   Problem-solve ways for patients to overcome
   what is termed change talk.
         Change talk involves spending time eliciting what is working for
                                                                                      obstacles
         the client, amplifying client expectations, and having clients          5.   Ask the patient for a statement of what they will do
         imagine hypothetical solutions.
                                                                                      to meet their goals (next steps).
   These strategies can be operationalized through motivational                  6.   Ask them to set time parameters, including a follow-
   interviewing (MI).                                                                 up visit




                                                                                                                                                 4
                  Strategies for Health Care Providers                                             Motivational Interviewing Strategies
                      During a Clinic Appointment                                                  for Children with Chronic Illnesses

    Build rapport --> develops a working alliance
         Make eye contact, say supportive statements, be                            Open-ended questions
         empathetic to situation, engage in active listening,                       Reflective listening
         involve patient in treatment decision-making
                                                                                    Advantages and disadvantages of poor adherence
    Agenda setting --> determines importance
         “What would you like to discuss today? We could discuss                    Draining
         X,Y, or Z, but I’d like to know what is important for you to               Rolling with resistance
         discuss.”
                                                                                    Affirmation
    Scaling Questions --> assesses confidence
                                                                                    Summarizing
         “How confident are you in being able to make these
         changes on a scale of 0-10? Why do you feel like your
         confidence is a 4? What would make it higher? Why isn’t                 *Lask   (2003).
         it even lower than 4?”
*Sindelar, Abrantes, Hart, Lewander, & Spirito (2004). – See attached article.




                Setting the Stage                                                            Opening the Encounter

                     Prepare for the interview.
                                                                                                   Identify yourself.
                     Assure privacy.
                                                                                                   Set time parameters in advance.
                     Be on time.
                                                                                                   Put patient at ease and establish
                     Attend to physical comfort.                                                   rapport.
                     Eliminate or minimize interruptions                                           Define your role.
                     and distractions.




                Positive Interactions                                                        Tell me about yourself

       Start out creating a positive environment                                                   Spend a few minutes getting to know
            You are interested in the patient’s issues,                                            them as a person.
            perspective                                                                            If follow up- “tell me what’s been going
            “Tell me why you are here today”                                                       on in your life since we last met”
            “How can I help you today”                                                               If they talk right away about the
            “What concerns do you have today”                                                        diabetes redirect them-”No what have
                                                                                                     YOU been up to”




                                                                                                                                              5
   Get Permission (Contract)                            Negotiate Agenda

     Get an explicit statement of patient’s              Focus on one thing, but leave door
     willingness to participate.                         open.
     Also, it is important to allow people               Let patient choose – patients who feel
     not to participate.                                 in control are more likely to initiate
                                                         “Change Talk.”
                                                         Ask open ended questions.
                                                         Allow silence and the tension it
                                                         creates.
                                                         Keep a positive focus.




   Opportunity for
                                                        Goal Setting
   collaboration
Once the concern, issue, task etc is identified the      Realistic
educator has the opportunity to collaborate or           Baby steps
negotiate
                                                         Reinforce positive changes, behaviors
  Eliminate barriers       - Fostering teamwork
  Focus on successes       - Educate                     Positive results make them eager for
  Improve ease             - Role definition             more improvement
  Decrease pain             -Role model                  Measure their effort (scale 1-10)
  Referrals                                              Work on improving consistency
  Fostering positive interactions




   Change Talk
  Patients talk about changes they are thinking
  about making.                                       The goal of “change talk” is
  Change talk includes reasons why (benefits)
                                                      to get the patient to make
  and reasons why not (disadvantages) to              the arguments for the
  change their behavior.
                                                      changes we hope they will
  Patient discovers the discrepancy between           make.
  stated goals and current behavior.




                                                                                                  6
        Ambivalence                                             Closing
•   All of us have reasons not to change our behavior
    even when or, perhaps especially when we know                    Ask the patient for a statement of
    we should to so.                                                 what they will do to meet their goals
                                                                     (next steps).
•   Change is easier when we can explore, clarify and
    resolve our ambivalence.
                                                                     Ask them to set time parameters,
                                                                     including a follow up visit.
•   It gives us the opportunity to be respectful of that
    part of us that doesn’t want to give up familiar
    behavior and habits.

•   “Yes” is meaningless, if we cannot also say, “no.”




        Tips for Success                                        Summary

          Patient does most of the talking.                Set the stage and build rapport
                                                             Positive interactions  “join” with patient
                                                             Focus on the specific patient and their successes
          Counselor does reflective listening.
                                                           Negotiate change with patient
                                                             Goal-setting
          Avoid lectures, they come across as                Problem-solving
          “Shoulds.”                                         Utilize “change talk” and explore ambivalence
                                                           Closing
                                                             What will the patient be willing to do
                                                             How to measure their successes




        Potential Benefits                                      More………

          Brief Intervention.                                        Helps create expectations of success.
          Structured interview may help us                           Potential to better outcomes,
          more effectively manage our growing                        especially with marginally motivated
          patient load                                               patients (a.k.a., the “non-compliant,”
          More efficacious use of face time and                      poorly controlled, and out-of-control
          phone time with patients.                                  ones).
          Patient-centered.
          Can be used individually or in groups.
          Can be used face-to-face and on
          phone.




                                                                                                                 7
On Change…                                                             References
                                                  Jones, H., Edwards, L., Vallis, T., Ruggiero, L., Rossi, S.R., Rossi, J.S.
                                                  et al. (2003). Changes in diabetes self-care behaviors make a difference
 If you want quick change, proceed                in glycemic control: Diabetes stages of change (DiSC) study. Diabetes
                                                  Care, 26 (3), 732-737.
 slowly.                                          Lask, B. (2003). Motivating children and adolescents to improve
                                                  adherence. Journal of Pediatrics, 143, 430-433.
                                                  Miller, W.R., & Rollnick, S. (Eds.). (1991). Motivational interviewing:
 A one second change in a symptom                 Preparing people to change addictive behaviors. New York: Guildford
                                                  Press.
 that exists 24 hours a day, you have             Patterson & Forgatch. (1985) Therapist behavior as a determinate for
                                                  client non-compliance: A paradox for the behavior modifier. Journal of
 made a major change.                             Consulting and Clinical Psychology, 53, 846-851.
                                                  Prochaska, J.O., & DiClemente, C.C. (1982). Transtheorectical therapy:
 If you want a large change, you                  Toward a more integrative model of change. Psychotherapy: Theory,
                                                  Research, and Practice, 19, 276-288.
 should ask for a small one.                      Sindelar, H.A., Abrantes, A.M., Hart, C., Lewander, W., & Spirito, A.
                                                  (2004). Motivational Interviewing in Pediatric Practice. Current Problems
                                                  in Pediatrics and Adolescent Health Care, 34, 322-339.
                                                  Trigwell, P., Grant, P.J., and House, A. (1997). Motivation and glycemic
                                                  control in diabetes mellitus. Journal of Psychosomatic Research, 43 (4),
       Jay Haley on the work of Milton Erickson   307-315.




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