evan williams, pharmd assistant professor of pharmacy practice husson university school of pharmacy

An Introduction to Motivational Interviewing

Evan Williams, PharmDAssistant Professor of Pharmacy Practice

Husson University School of Pharmacy

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I have no financial disclosures

Disclosures

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Clinicians can only provide patients with clinical knowledge and education

Patients make the ultimate decision to change

What can clinicians do to influence patient change?◦ Scare tactics◦ Lecture and educate◦ Motivate the patient to change

Overview

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Describe Motivational Interviewing (MI) and its components

Identify tools pharmacists and pharmacy technicians can use to help implement Motivational Interviewing in their practice setting

Review literature that supports the effectiveness of Motivational Interviewing

Objectives

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MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change. MI is a style of communication, not a technique.

True or False?

Pre-Test Questions

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OARS in MI stands forA. Open Communication, Active

listening, Reasoning with the patient, and Seeking change

B. Oral arguments, Active listening, Rolling with Resistance, and Summaries

C. Open-Ended Questions, Affirmations, Reflective Responses, and Summaries

D. Ongoing dialogue, Affirmations, Resisting the Righting Reflex, and Seeking change

Pre-Test Questions

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Developing discrepancy involves:A. The patient discovering how current

behaviors conflict with personal values or goals

B. Telling the patient the negative results of current behaviors

C. Allowing the patient to choose between two treatment options

D. None of the above

Pre-Test Questions

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Think of a “bad” habit you have tried to change◦ Dietary habits◦ Exercise habits◦ Workplace habits◦ Relationship habits

How long did it take to realize that this habit had a negative impact on you or others?◦ Months? Years?

Were you successful? Did you relapse?

Self Reflection

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“Motivational Interviewing (MI) is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change.”

Defined by the identification, examination, and resolution of ambivalence about changing behavior– Ambivalence: Feeling two ways about behavior

change

Defining Motivational Interviewing

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

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Method of communication◦ Not a technique◦ Increases mutual understanding

Collaborative◦ Honors patient autonomy

Strengthens a person’s own motivation for and commitment to change ◦ Patient-centered

Principles of MI


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William R. Miller◦ Motivational Interviewing with Problem Drinkers

Behavioral Psychotherapy - 1983 Stephen Rollnick and William R. Miller

◦ 1991 article◦ Outlines clinical procedures

Has been revised and applied to many settings

Development

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy. 1983, 11 (2); pp 147-172

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Key Elements of MI◦ Collaboration◦ Evocation◦ Autonomy

Principles of MI◦ Express Empathy◦ Support Self Efficacy◦ Develop Discrepancy◦ Roll with Resistance

Components of MI


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Collaboration◦ Dismisses hierarchy

◦ Builds rapport

◦ Non-confrontational

◦ Focus is mutual understanding

Key Elements of MI


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RG is a 57 year old male with hypertension and hyperlipidemia. On questioning it is revealed that he smokes about 1 pack of cigarettes daily. You would like him to quit smoking.

Which of the following shows the spirit of collaboration consistent with MI?◦ A. You need to stop smoking now.◦ B. What reasons do you have to stop smoking?◦ C. If you continue to smoke, you are increasing your risk for having a heart attack or stroke.◦ D. Let me help you to stop smoking.

Example of Collaboration

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Evocation◦ Patients discover their own motivation and skills

for change

◦ Draw out the patients own thoughts and ideas

◦ “..lasting change is more likely to occur when the client discovers their own reasons and determination to change”

Key Elements of MI


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Pharmacist: “I’ve noticed you have been late filling these medications the last 2 months.”

Patient: “Yeah, I’ve been having a hard time keeping up with things as I am moving to a new home across town in a few weeks. I know taking my medications is important but I’ve been so busy lately that I forget sometimes.”

Pharmacist: “It sounds like you would like to take your medications but it has been a tough time dealing with the move.”

Example of Evocation

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Autonomy◦ Ultimately it is the patient’s decision to change

◦ Empowers the patient and gives them responsibility

◦ As clinicians, we can encourage patients to develop their own “SMART” goals Specific, Measurable, Achievable, Relevant, Timely

Key Elements of MI


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DK is a 44 year old patient newly diagnosed with diabetes. After discussion, it is revealed that he eats desserts for relaxation. When asked how he thinks this impacts his diabetes, he states he does not know.

The response that best exemplifies autonomy consistent with MI is:◦ A. “May I tell you some information about how sweet foods impact your blood sugars?”◦ B. “Sugary dessert foods increase your blood sugar and negatively impact your diabetes.”◦ C. “Here is a pamphlet about how foods impact blood sugar.”

Example of Autonomy

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Express Empathy◦ See the situation from the patient’s perspective◦ Gain perspective on what the patient’s motivation

may be “It sounds like this has been tough for you” “It seems like this situation has been

difficult for you to accept”

Principles of MI


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Support Self Efficacy

◦ Focus on strengths and skills patient already has

◦ Highlight previous successes

◦ Patient needs to believe that change is possible

Principles of MI


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Develop Discrepancy◦ Patients identify their values and goals◦ Patients evaluate their current behaviors◦ Ambivalence is discovered when conflict between

values/goals and behaviors is identified◦ Change is more likely when patients realize their

behaviors are in conflict with their self‐identified values or accomplishment of goals

◦ “On the one side, you feel unhappy that you cannot keep up with your grandkids because of your COPD, but on the other hand, you feel that smoking is one of the only ways you can relax.”

Principles of MI


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Roll with Resistance◦ Do not challenge resistant statements

Confronting resistance promotes defensiveness and diminishes the likelihood of a patient finding their own reasons to change

◦ Use the resistance as an opportunity to further explore the patient’s views

◦ Be aware of when a patient is becoming frustrated Closed body language Negative verbal responses Shortened verbal responses

Principles of MI


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BG is an overweight veteran recently discharged from the Air Force. He has gained much of this weight since his discharge 14 months ago. The pharmacist suggested that BG enroll in clinic sponsored program for weight loss. BG declines enrollment. BG states that he is just not willing to exercise for 30 minutes 5 days a week because he is just too exhausted after work.

Which response best exemplifies the spirit of MI? ◦ A. If you don’t lose weight, you are putting yourself at risk for other serious problems.◦ B. Could you try to exercise just a few days a week?◦ C. How much are you willing to exercise?◦ D. Why don’t you want to be healthy?

Example of Rolling with Resistance

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OARS◦ Open-Ended Questions◦ Affirmations◦ Reflective Responses◦ Summaries

RULES of Motivational Interviewing◦ Resist the righting reflex◦ Understand the patient’s motivation◦ Listen with empathy◦ Empower the patient

Tools to Help Implement MI

Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov

http://www.tms.va.gov/

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Elicit better responses from patients Make a conversation less one-sided Are not answerable with a simple yes or no

Open-Ended Questions

Open-Ended Question Words

Closed-Ended Question Words

How?Why?Tell me more about...When?What kinds of…

Do you?Have you?Can you?Will you?



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Statements that recognize a patient’s strengths

Help support self efficacy◦ Tries to help patient believe change is possible

despite past failures

Affirmations


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Words the patient uses

Words clinician hears

What the clinician

thinks the patient meant

What the patient meant

Reflective Responses

Restate how the provider perceives the patient

Allows for increased clarity

Allows the listener to affirm the patient’s feelings

Patient feels understood



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Reflection that recaps visit and highlights important areas

Can clarify ambivalence and discrepancies

Summaries


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“I know what is best”◦ Removes autonomy from the patient by

insinuating the patient does not know what is best for themselves

◦ Re-establishes hierarchy◦ Can undermine the patient’s motivation for

change◦ Can create conflict

Resist the righting reflex



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Patient’s reason for change is more important than the clinician’s

Explore importance of changing◦ Ask for a scaled answer◦ Why is it that number and not another?

Understand patient’s motivation



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Use reflective responses ◦ Allows patient to tell you more◦ Clarifies patient’s concerns◦ Confirms mutual understanding

Be aware of body language◦ Eye Contact◦ Nodding◦ Posture

Do not “understand”

Listening with empathy



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Patients must believe change is possible

Failures can be demoralizing

Focus on previous successes◦ Even small victories can be uplifting

Encourage the patient

Let the patient know that they are in control of the change

Empower the patient



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DARN-CAT◦ Desire (I want to change)◦ Ability (I can change)◦ Reason (It is important to change)◦ Need (I need to change)◦ Commitment (I will make changes)◦ Activation (I’m ready and prepared to change)◦ Taking steps (I am doing specific things to

change)

Eliciting Change Talk


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Ask questions that will elicit answers that are consistent with DARN-CAT◦ Developing discrepancy

Desire Reason Need

◦ Change ruler Ability Activation

◦ SMART Goal Setting Ability Activation Taking steps

Change Talk

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Examples of MI in Action

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Example #1

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What went wrong?

What could the pharmacist have done instead?

Discussion of Example #1

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Example #1- Revisited

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Example #2

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What principles of MI were used by this pharmacist?

How well did the change ruler work?

What else could the pharmacist have done?


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Example #3

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What went right?

What examples of change talk did the patient give?

What could the pharmacist have done to improve?


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Evidence for Use of MI

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Growing body of evidence◦ 6 references 1980-1989◦ 78 references 1990-1999◦ 707 references 2000-2009

Most studies show MI to be beneficial◦ Publication bias?

Most studies have limitations◦ Small sample size◦ Weak comparator groups◦ Various providers offering MI◦ Providers have differing levels of training in MI◦ Difficult to assess the manner in which MI is used

Effectiveness of MI

Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

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Effectiveness of MI on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study

N=109 officers ◦ 67 officers completed the program (13 women, 54 men)

◦ Previously completed a “high performance training seminar” 10-week program

◦ Goal to improve fitness, nutrition, and lipids◦ Weekly meetings with health coach

MI included to help the officers identify and achieve goals 10-week endpoints were compared to baseline

Example: Police Officer Fitness

Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare. 2008 14:48

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Pre and Post intervention Measurements

Variable Pre Test Post Test Difference p-value

SBP 127 119 8 (6%) <0.001

DBP 82 75 7 (9%) <0.001

% Body Fat 24.8 21.5 3.3 (13%) <0.001

Total Cholesterol 188 175 13 (7%) <0.001

HDL 49.5 56.8 7.3 (15%) <0.001

LDL 113 96 17 (15%) <0.001

Triglycerides 138 123 15 (11%) <0.001


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Significant improvements in physical fitness, blood pressure, and lipids for those who completed the 10-week course◦ Baseline values already at BP/Lipid goals

Unknown cardiovascular/diabetes risks◦ Changes in lipids comparable to low dose statin◦ Changes in BP comparable to addition low dose ACEi

• Average Adherence to fitness regimen:• 80% for cardiovascular activity• 75% for strength training


http://summaries.cochrane.org/CD003823/ace-inhibitors-for-the-treatment-of-high-blood-pressure

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Limitations ◦ large drop out rate (42%)◦ Selection Bias

Those who completed study were likely more motivated and active prior to study

◦ Results likely only reflective of increased exercise◦ Short follow-up

Were benefits maintained Is MI beneficial for long term lifestyle changes?


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Pattern of results show MI is likely ◦ To confer at least a 10% advantage in success

rates versus weak comparators◦ To be as good or better than established

treatments ◦ To take less time and resources

Best outcomes may be using MI pre-treatment

MI Meta Analyses


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Effective regardless of gender or age

Training level does not significantly impact effectiveness◦ Versatile

In what areas is MI most effective?

MI Meta Analyses


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MI Meta Analyses


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MI Meta Analyses


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MI Meta Analyses

Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312

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Limitations • Interventions ranged from 10-120 min (60 min most

common)• Variable follow up periods

Usefulness• Provides evidence that MI can elicit significant

change • Overall about 75% of studies show there was an

effect

MI Meta Analyses

Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312

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Online resources or live classes

Begin small◦ Try only adding one component at a time◦ Reflective responses are a great starting point

Keep working at it◦ It may feel uncomfortable the first few times

Add components as you become more adept

Application Strategies

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MI is a useful technique to help people change

It is useful in combination with other techniques for eliciting change

MI should not replace your method of patient interaction, but enhance it

Conclusions

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Motivational interviewing is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change.

Key Elements◦ Collaboration◦ Evocation◦ Autonomy

Summary

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Principles ◦Express Empathy◦Support Self Efficacy◦Develop Discrepancy◦Roll with Resistance

Summary

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Strategies for implementation ◦ OARS

Open-Ended Questions Affirmations Reflective Responses Summaries

◦ RULE Resist the righting reflex Understand the patient’s motivation Listen with empathy Empower the patient

Summary

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MI is a collaborative, person‐centered form of guiding to elicit and strengthen motivation for change. MI is a style of communication, not a technique.

True or False?

Post-Test Questions

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OARS in MI stands forA. Open Communication, Active

listening, Reasoning with the patient, and Seeking change

B. Oral arguments, Active listening, Rolling with Resistance, and Summaries

C. Open-Ended Questions, Affirmations, Reflective Responses, and Summaries

D. Ongoing dialogue, Affirmations, Resisting the Righting Reflex, and Seeking change

Post-Test Questions

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Developing discrepancy involves:A. The patient discovering how current

behaviors conflict with personal values or goals

B. Telling the patient the negative results of current behaviors

C. Allowing the patient to choose between two treatment options

D. None of the above

Post-Test Questions

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Questions?

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Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare. 2008 14:48

Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov Burke B, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta analysis of

controlled clinical trials. Journal of Consulting and Clinical Psychology 2003; 71, 843-861 Hettema J, Steele J, Miller W. Motivational Interviewing. Annual Review of Clinical Psychology 2005;

91-111 http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&

%20Approach%20V4%20012911.pdf Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych

2009;65(11) 1232-45 Lundahl B, Tollefson D, Kunz C et al. Meta analysis of motivational interviewing: twenty five years of

research. Research on Social Work Practice 2009 Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983;

11(2),147-172 Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York:

Guilford Press. Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of

controlled clinical trials. Brit J General Practice 2005; April, 305-312 Vasilaki E, Hosier S, Cox W. The efficacy of motivational interviewing as a brief intervention for

excessive drinking: a meta analytic review. Alcohol and Alcoholism 2006; 41, 328-35

References

evan williams, pharmd assistant professor of pharmacy practice husson university school of pharmacy

Documents

patient change

motivational interviewing

settings miller

miller wr

pharmacy technicians

open communication

active listening

method of communication