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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).
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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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