using motivational interviewing to promote healthy weight · 2018. 12. 11. · help patients...
TRANSCRIPT
Using Motivational Interviewing to
Promote Healthy Weight
Melody Cole, MS, RDN, CD, CDEA Member of MINT- Motivational Interviewing Network of Trainers
Disclaimers
• SUCCESSFUL COMPLETION
• To receive contact hours, participants must sign in on the attendance form, attend the entire program and complete an evaluation for each presentation attended
• The evaluation will be sent to you via email. Once completed, you will receive your certificate via email.
• CONFLICTS OF INTEREST
• All activity planners for this program have reported no financial relationships with commercial interest.
• All presenters for this program have reported no conflicts of interest related to their presentation
Participants will be able to:
1. Compare and contrast the traditional advice
giving approach with the MI approach
2. Practice active listening with reflections
3. Share information in an MI consistent way
4. Apply the MI approach in clinical examples
Objectives
Definition of MI
• A collaborative
conversation
style for
strengthening a
person’s own
motivation and
commitment to
behavior changePage 1 Handout
MI Aligns with UW Health’s Mission,
Vision and Values
Motivational Interviewing
• Evidenced Based
• Best Practice
• Is helpful when
working with
patients needing or
wanting to change
behaviors
MI Is Evidence Based
Miller and Rollnick Over 800 Randomized Clinical Trials and 100 Systematic Meta-analyses Indicating that MI helps with:
• Better retention
• More patient satisfaction
• Better outcomes
• Takes less time
• More cost effective
Source: Miller, WR From the Desert. Available at http://www.motivationalinterviewing.org/forum/desert-july-2017-
bill-miller Accessed 4.26.18
160 Obesity Dental
n = 150
120
140 Asthma Violence Family
100Health Prom Psychiatric Diabetes Cardiac HIV/STD Risk Smoking/Tob Adh/Retention Eating Dis Offenders Gambling Dual Dx
n = 93
60
80
n = 54
20
40
n = 6
n = 36
01988‐94 1995‐99 2000‐02 2003‐06 2007‐09
AOD
Reference: www.motivationalinterviewing.org
Evidence: Number of MI Studies/Year
Number of Published Papers in
MI and Health Care
Courtesy: Chang Jun Kim, Member of the Motivational Interviewing Network of Trainers
MI Is Evidenced Based
A Systematic review of randomized controlled trials
concluded that medical providers can use MI to
help patients exercise more, lose weight, lower
blood pressure and lower cholesterol. The review
concluded:
• If medical providers can build relationships
and evoke change talk an expected 10 to 15%
improvement can be seen across a wide
variety of behaviors and medical outcomes.
Lundal, B., Moleni, Teena, Burke, Brian L., Butters, Robert, Tollefson, Derrik, Butler, Christopher, Rollnick, Stephen (2013). A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling, 93. 157-168.
A Continuum Of StylesD
IREC
T
• Administer
• Decide
• Order
• Prescribe
• Tell
GU
IDE
• Accompany
• Collaborate
• Elicit
• Offer
• Support
FOLL
OW
• Allow
• Listen
• Observe
• Understand
• Have faith in
What Our Training Teaches Us:
• Assess medical
condition
• Determine what
needs to change
• Cover all the
important points
The Righting Reflex
Righting Reflex
• Built in desire to set things “right”
• Identified by words such as:
• “You Should”….
• “You Must”……
• “You Need to”….
• “It’s important that you”….
Possible Results of the Righting Reflex
Agitated
• Patient gets defensive
• Patient says “Yeah, but”
Argumentative
• Patient gets angry
• Patient raises voice
Shuts Down
• Patient is quiet or disengaged
• Patient doesn’t come back or doesn’t answer the phone
Practice makes practice!
Traditional Advice Giving Approach
Person 1: ‘Patient’
Identify a change that you
are considering:
-Something you want, should, or need to
change
-A behavior that you might be struggling
with
-Pick something that you have been try
to change…
-But you haven’t changed yet
Person 2: Clinician
-Explain why this change
should be made:
-Give at least three benefits that would
result from making the change
-Give advice about how to do it
-Convince him/her about how
important it is to change
-Summarize the plan and ask for
agreement
You have 60 seconds for this. When finished, switch roles
Debrief- 3 minutes at your tables. Answer the following
questions. Select one recorder at your table.
1. What was it like to be the person on the
receiving end of the advice?
2. What is your overall motivation to make a
change?
3. Describe the characteristics of what the person
might feel like on the receiving end of this
conversation.
Beginning MI Approach
• Pushing Change
• Giving unwanted
information and advice
• Persuading
• Guilting
• Scare Tactics
• Premature Planning
Beginning MI Practice
Draw out the
individual’s
importance and
confidence to
change
Two Key Questions
• Ask the following questions. Listen with the
intent of understanding.
• Resist the “righting reflex” and give no
advice.
1. What are some of your reasons for wanting
to make this change?
2. What do you think you might do?
When finished, switch roles.
Two Question MI Approach
Person 1: ‘Patient’
Identify a change that
you are considering:
-Something you want, should, or
need to change
-A behavior that you might be
struggling with
-Pick something that you have been
try to change…
-But you haven’t changed yet
Person 2: Clinician
-Ask the following 2
questions, resist the
“righting reflex” and give
no advice.1. What are some of your reasons
for wanting to make this change?
2. What do you think you might do?
Debrief1. What was it like to be the person with the behavior
change in this conversation?
2. What is your overall motivation to make a change? Is it
lower, about the same or higher compared to the
traditional, direct, approach?
3. Describe the characteristics of the person or what the
person might feel like on the receiving end of this
conversation.
Debrief: 3 minutes at your tables. Answer the following
questions. Select one recorder at your table.
Large Group Debrief
Blaise Pascal French Philosopher 1623-1662
“We are usually
convinced more
easily by reasons we
have found ourselves
than by those which
have occurred in the
mind of others”
Behave in a way that will
reduce resistance (discord
and sustain talk) and
evoke change talk.
Primary Goal of MI
Change Talk
• CHANGE TALK:
–Any self expressed language
that is an argument for
change
Miller & Rollnick, 3rd ed. Pg. 159
Change Talk
www.boards.weddingbee.com
Common Types of Change Talk
• Desire- want, like, wish
• Ability- can, could, able to
• Reasons- If… then
• Need- need, have to , got to
_________________________
• Commitment- will, going to
• Activation- plan to, ready to
• Taking steps to change
Discord and Sustain Talk
Discord is about your
relationship with the
patient
Sustain Talk is about the
target behavior or
behavior change.
Change Talk and Sustain Talk
Two sides of the same coin
Possible Results of the Righting Reflex
DISCORD
Predictor of
poor clinical
outcomes
Worst Case Scenario
• Provider argues for
change while the
patient argues against
it.
• By simply reducing
discord, we increase
the odds of a good
clinical outcome.
Miller & Rollnick, 2002
Motivational Interviewing
EngageFocus
EvokePlan
-----------------MI SPIRIT-------------------Partnership Acceptance Compassion Evocation
ACTIVE
LISTENING
TARGET
BEHAVIOR
DARNCAT
SMART
GOALS
CHANGE TALK
O
A
R
S
--
E
P
E
Underlying Spirit & Style of MI
Partnership
Acceptance
Evocation
Compassion MI Spirit
Page 2 Handout
Accurate Empathy
A specific therapeutic skill that includes
commitment to understanding the client’s
personal frame of reference and the ability to
convey this heard meaning back to the client
via reflective listening.Carl Rogers, 1959
Clinician Empathy: A Strong Predictor
of Behavior Change
• U-Connect
• Search Motivational
Interviewing
• Key Articles
Acceptance versus Agreement
• Acceptance of who someone is and
acknowledgement of his/her perspective
IS NOT THE SAME AS
• Agreement or approval of his/her opinions
or actions
What does this show you about the
Spirit of MI?
Open Questions
Affirmation
Reflections
Summaries
Page 3 Handout
Reflections
• Validate the patient
• Let’s the patient know
you heard them
• Help prevent Discord
• Requires Active
Listening
• The patient relaxes
and is more receptive
to discussing change
Reflections
Reflections:
• Are statements, not questions
• Prevent the Q&A trap
• Prevent resistance
• Move the conversation forward
Reflections
• Patient feels listened to, heard and cared
about
• Patient speaks about what is on his or her
mind rather than just answering what’s on
Provider’s mind
• More truth from patient
Reflections
Simple:
Tip of the iceberg
Complex:
Underlying
Meaning or
Content
How to Reflect?
“I don’t have time to exercise.”
“You don’t have time to exercise.”
“You’d like to exercise if you could.”
You are a busy person and you are wondering
how to fit exercise in.”
How to Reflect?
“I’ve tried all the diets, I can’t lose weight”
“It’s hard for you to lose weight.”
“You are really wanting to find something that
works for you in the long run.”
“You’ve been working really hard at this.”
How to Reflect?
“I really hate exercise, but I want to lose
weight so I started exercising twice a week”
“You really want to lose weight.”
“You want to lose weight so badly that you are
willing to exercise.
How to Reflect?
“I forget to take my medication at night”
“You forget your medication at night”
“You are pretty consistent with taking your
medication in the morning”
“You’re trying to find a way to remember that
second dose at night”
MI Beginning Practice
A good beginning rhythm in MI is one question
followed by one reflection or a ratio of 1:1
RR
Active Listening
http://www.ourworkinglives.com/chinese-character-for-listening/
Page 6 Handout
Active Listening & Reflecting
Exercise
See one, do one
An Exercise in Listening:
Groups of 2 or 3
Person 1: Speaker
Role play for the next 1-
2 minutes the person
you see in the slide
– Put yourself in the
other person’s shoes
– Keep talking and relay
your issues and
concerns to your
listener
Person 2: Listener
Listen with the intent of
understanding. Do not
offer advice or try to “fix”
the situation.
- DO NOT ASK
QUESTIONS
- Reflections are okay
- Verbal tics are okay
If you finish early, please sit in silence until the time is up.
Speaker: Place yourself in this person’s shoes
Listener: Listen and REFLECT only. No Fixin’
• Overweight her whole
life
• Ridiculed for being
overweight by peers
• Physically abused from
a young age
Speaker: Place yourself in this person’s shoes
Listener: Listen and REFLECT only. No Fixin’
Esther: Accomplished
professional
Multiple fertility
treatments with weight
gain
Now pregnant with twins
Advanced maternal age
High Blood Pressure
Never had to watch what
she eats beforeImage from http://www.uconnruddcenter.org
Speaker: Place yourself in this person’s shoes
Listener: Listen and REFLECT only. No Fixin’
Regina: Stressful job
Recent divorce
3 grown children
Caregiver for her mom
Loves to garden and cook
Knee pain
Urinary incontinence
Type 2 diabetes
Multiple diets without
success Image from http://www.uconnruddcenter.org
Giving Advice or Sharing Information:
Elicit-Provide-Elicit
The person is more likely to hear
and follow your advice if you have
permission to give it
Dr. House
Providing or Sharing Information
• The goal is to share in a manner that
encourages individuals to receive
information and consider acting on it
• Advice giving and sharing of information is
used with permission
• We offer information or advice if» The person is asking for it
» You ask permission to give information
» You feel professionally obligated to give advice or
information
Exchanging Information in an MI
Consistent Way:
Facilitates:
• Engagement
• Rapport
• Trust
• Change Talk
• Empowerment
• A common direction
and focus
Avoids:
• Resistance =
discord +
sustain talk
• Disengagement
• Frustration
• Wasting time
Sharing Information:
Partnering and CollaboratingEsther:
• Tell me what you already know or would like to
know about healthy weight gain during
pregnancy?
• Would it be alright if we spent some time
discussing your blood pressure?
Regina:
• I have some information on healthy lifestyle habits.
Would it be okay if I shared them with you?
• I have the results of your assessment. Would it be
ok if we spent a few minutes reviewing it?
Sharing Information:
Stronger Language
Elicit: I have some information on alcohol use
during pregnancy that I would like to go over,
when I am finished, I would like to know what
your thoughts are.
Provide: Share the information
Elicit: What are your thoughts on what we just
discussed?
Sharing Information:
Stronger Language
May I tell you
what concerns
me?
EPE Practice
MI Guide
Focusing the Conversation:
Agenda Mapping
Beginning MI Practice
What matters to you?
What do you value?
What do you want your health for?
Reference: Berwick, D.M. Era 3 Medicine and Health Care JAMA. 2016;315(13):1329-1330.
Debrief
What Seems Useful So Far?
Resources for Learning MI
Motivational Interviewing Network of Trainers
www.motivationalinterviewing.org
Guilford Press: https://www.guilford.com/
References
• Miller, W. R. & Rollnick, S. (2013) Motivational Interviewing: Helping People
Change (3rd edition). New York: The Guilford Press.
• Miller, W. R. & Rollnick, S. Butler, C. (2008) Motivational Interviewing in
Healthcare: Helping Patients Change Behavior. New York: The Guilford Press.
• Rosengren, David B. (2017) Building Motivational Interviewing Skills: A
Practitioner Workbook. (2nd edition) New York: The Guilford Press.
• http://learning.bmj.com/learning/module-intro/motivational-
interviewing.html?moduleId=10051582 British Medical Journal Learning:
Motivational Interviewing in brief consultations
• www.motivationalinterviewing.org Motivational Interviewing Network of
Trainers Website
• http://www.kognito.com/changetalk/web/ An interactive MI learning experience
focused on childhood obesity and endorsed by the American Academy of
Pediatrics
Unless otherwise noted, all images from shutterstock or pixabay.com