Stephen Rollnick MI presentation for MPS Feb2013

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Stephen Rollnick MI presentation for MPS Feb2013

  1. 1. Motivational InterviewingStephen Rollnick PhDCochrane Institute of Primary Care & Public HealthSchool of Medicine, Cardiff University, WALES 
  2. 2. What is good prac.ce?   Dr:   and I dont see why it ends up like this,  I’ve been   doing this job for 20 years and now apparently its        all my fault. I want this sorted just like you do, but I  don’t have the Ame for all this……  You:  ?    
  3. 3.              
  4. 4.   What’s the problem?               Behaviour change  is hard    professional prac.ce, addic.on, lifestyle,    communica.on style                                                       
  5. 5.   What’s the problem?               Behaviour change  is hard                                                 Your approach?             
  6. 6.     1. What triggers change?      2. Mo.va.onal Interviewing  
  7. 7.           What triggers change?    
  8. 8.  You would think that…..  having been disciplined twice for misconductwould be enough to persuade a man to do anythingpossible to protect his career and livelihood? 
  9. 9.  You would think that…..  having been disciplined twice for misconductwould be enough to persuade a man to do anythingpossible to protect his career and livelihood?hangovers, damaged relationships, an auto crash,and memory blackouts would be enough toconvince a woman to stop drinking 
  10. 10.  You would think that…..   very real threats of blindness, amputations andthe kidney failure from diabetes would be enough tomotivate weight loss and glycemic control
  11. 11.  You would think that…..   very real threats of blindness, amputations andthe kidney failure from diabetes would be enough tomotivate weight loss and glycemic controltime spent in the dehumanizing privations of prisonwould dissuade people from re-offending
  12. 12.   Does a direct approach trigger change?         
  13. 13. 80%20%
  14. 14.         Righ.ng reflex                     Ambivalence      
  15. 15.    Your role You don’t have to make change happen You can’tYou don’t have to come up with all the answers You probably don’t have the best onesYou’re not wrestling with patients You’re dancing 
  16. 16.         Consider yourself Imagine something in your life that you’ve oftenthought about changing, but havent.Imagine this: 
  17. 17.         Consider yourself Imagine something in your life that you’ve oftenthought about changing, but havent.Imagine this:You cant leave the room until you’ve made adecision to change! 
  18. 18.        How do people change?   We have inside us our own good reasons to change, and much of the strength to make it happen   Its how you draw out this mo.va.on and strength   that could improve outcomes      
  19. 19. “After all, when you seek advice from someone it’s certainly not because you want them to give it. You just want them to be there while you talk to yourself”. Terry Pratchett, 1948 – 
  20. 20.     1. What triggers change?      2. Mo.va.onal Interviewing  
  21. 21. COMMUNICATION STYLES     Direct   ‐   Guide   ‐   Follow  teach     draw out          listen  instruct            encourage       understand  lead                  mo.vate          go along with      Match the style to the problem         
  22. 22. The SPIRIT OF MI
  23. 23. CollaborationQUESTIONS ‐ OBSERVATIONS  Compassion Acceptance Evocation
  24. 24. Core Skills  OARS: Open questions Affirmation Reflection SummaryOffering Information and Advice
  25. 25. Goal of MI Quietly clarify ambivalence and elicit change talk  Defini.on … a person‐centered, goal oriented counseling style  for addressing the common problem of  ambivalence about change 
  26. 26. How you respond to change talk is key It flickers in a busy conversa.on  “... and I dont see why it ends up like this,  I’ve been doing this job for 20 years and now apparently there’s a problem. I want this sorted out just like you  do, but I don’t have the Ame for all this.” 
  27. 27. How you respond to change talk is key It flickers in a busy conversa.on  “... and I dont see why it ends up like this,  I’ve been doing this job for 20 years and now apparently there’s a problem. I want this sorted out just like you  do, but I don’t have the Ame for all this.” 
  28. 28. How you respond to change talk is key “... and I dont see why it ends up like this,  I’ve been doing this job for 20 years and now apparently there’s a problem. I want this sorted out just like you  do, but I don’t have the Ame for all this.”  If you respond with reflec.on:  Predicts better“Its frustra)ng yet you’d like to sort   outcome  this out”      More change talk will follow…..   “I need this off my back as soon as I can” 
  29. 29. You: Would you mind if we talked about your smoking?Patient: Well, OKYou: How do you really feel about it?Pt: I’m trying to cut back, but I cant say its easy with my job, youknow its stressful driving that truckYou: Its not easy for you yet you’d like to smoke lessPt: Oh if I could, definitely, I know its not good for my chest for a startYou: You can feel the effect for yourself and its not pleasantPt: That right, but its such a stress reliever its hard to let goYou: Its difficult for you to imagine being without smokingPt: yes, that’s exactly right, you got me.You: I don’t want to give you a lecture or hassle you about this, but I’mwondering what would be helpful for you?Pt: I just don’t know Doc.You: Tell me, deep down, how important is this for you right now?Pt: I feel sick and I’m tired, and this smoking wears me down….
  30. 30. Recent Changes in MI Motivational Interviewing: Helping People Change(3rd edition). NY: Guilford, 2012. Introduce compassion as a key element From “behaviour change” to “any change” Make it simpler & easier to apply in practice Include planning for action 4 Processes – let’s look!
  31. 31. New Four Process Model This is what happens in an effec.ve MI session 
  32. 32. PLAN  If they want to, support them to plan changes EVOKE    Draw out their own good reasons to change FOCUS    Find a useful direction  ENGAGE Settle into a helpful conversation
  33. 33. PLAN  If they want to, support them to plan changes EVOKE    Draw out their own good reasons to change FOCUS    Find a useful direction  ENGAGE Settle into a helpful conversation
  34. 34. “Settle into a helpful conversation”  ENGAGE  1. Just be nice and friendly?   2. You can get better & better   3. A service-wide challenge The 20% rule
  35. 35. PLAN  If they want to, support them to plan changes EVOKE    Draw out their own good reasons to change FOCUS    Find a useful direction  ENGAGE Settle into a helpful conversation
  36. 36. “Find a useful direction” FOCUS  1. Who’s direction?   2. Usually more than one direction   3. Agenda mapping as a skill  
  37. 37. PLAN  If they want to, support them to plan changes EVOKE    Draw out their own good reasons to change FOCUS    Find a useful direction  ENGAGE Settle into a helpful conversation
  38. 38. “Draw out their own good reasons to change”EVOKE  1. Defining heart of MI   2. Ear for language: change talk  
  39. 39. PLAN  If they want to, support them to plan changes EVOKE    Draw out their own good reasons to change FOCUS    Find a useful direction  ENGAGE Settle into a helpful conversation
  40. 40. “If they want to, support them to plan changes” PLAN  1. Righting reflex & other familiar challenges   2. Usually more than one possible plan   3. Path mapping as a skill  
  41. 41. Planning Evoking FocusingEngaging
  42. 42. Strategy 1: Informa.on exchange  
  43. 43. Style: that of a guide! Elicit: what pa.ent knows  Provide: informa.on  Elicit: what pa.ent might do 
  44. 44. Strategy 2: Importance & confidence ques.ons  
  45. 45. 1. Importance (Why?) “Why should I?” “I want to, but....” “What will I gain/lose?”2. Confidence (How?) “Will I be able to ?” “What skills do I need” “Will I cope in situations x, y & z?”
  46. 46.   Importance & Confidence Scaling 1. How important is it for you to …..… (I)2. How confident are you that you will succeed?(C)Summarize & check understanding
  47. 47.   Importance & Confidence Scaling How important is it for you right now to quitsmoking?On a scale from 0 - 10, if 0 was “not at all important” and 10 was“very important”, what number would you give yourself? 1. Why are you at x and not at 1? 2. What would need to happen, for you to get from x to (higher no.)? 3. How can I help you get from x to (higher no.)?Understanding answers increases motivation to change inactive patient
  48. 48.      Theory & Research 
  49. 49. Theory  1.  A linguis.c theory  your MI style – change talk – beaer outcome 2.  Self‐determina.on theory (SDT)       3 needs – Autonomy, Competence & Relatedness 
  50. 50. Research  Many meta‐analyses     Effec.ve in some areas, not in others    More effec.ve than advice giving   One example   
  51. 51. Meta‐analysis (in prepara.on)  50 studies in health care   Overall effect of MI = posi.ve  35/54 significant,  19/54 not significant  56% pa.ents improved with MI, 44% in comparison  Across 25 outcomes (interpret with care) …     
  52. 52.    Biomedical Markers                  MI        Comp.      Blood Glucose  (5)     OR 1.12*     52% vs  48%       Blood Pressure (1)    OR 1.65**   57% vs  43%    Cholesterol (3)           OR 1.09*     51% vs  49%    Heart failure (1)         OR 7.78**   75% vs  25%    Heart rate (1)             OR 0.91        49% vs  51%    Body weight   (11)   OR 1.15**    52% vs  48%    Dental (caries) (2)     OR 1.85**   58% vs  42%    HIV Viral Load (2)    OR 2.06*      60% vs  40%    Death rate (2)            OR 1.54         56% vs  44%       Mental health  (5)     OR 1.29**     54% vs  46%  
  53. 53. Health behaviors                        MI        Comp.    Health behavior     Eating healthy (7)        OR  1.08        51% vs 49%      Eating disorder  (6)     OR  0.79  47% vs 53%      Injury Prevention (1)  OR  1.76*      57% vs 43%   Alcohol              Amount (11)                OR  2.51**    62% vs 38%        Dangerous Use (3)     OR 1.94**  59% vs 41%     Smoking           Abstinence (8)        OR  1.25*   51% vs 49%  Marijuana               Amount (5)          OR   3.08**   65% vs 35%      Abstinence  (1)          OR   1.99   60%  vs 40% 
  54. 54.          MI         Comp. Adherence   Medication (6)               OR  1.17      52% vs 48%      Diabetes  (5)                  OR   2.36**       63% vs 37%    Exercise  (4)          OR  1.37**    52% vs 48%    General Health (3)        OR  1.55    52% vs 48%    A.R.T.  (1)           OR  11.56    78% vs 22%    Engagement   Keep appts (6)                OR 1.56**         57% vs 43%    
  55. 55. MI – Conclusions     No quick fix     MI shines a light on how you speak about change     Learning MI involves skill development       its not just client‐centred counselling: has direc.on    Do it well, outcomes should be beaer    
  56. 56.         People are generally better persuaded by thereasons which they have themselves discovered,than by those which have come into the mind ofothers.”Blaise Pascal, Pensées, (1670) 

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