Motivational Interviewing Sondra Adkinson, PharmD, DAAPM, CPE
Disclosure
Nothing to Disclose
Learning Objectives Review the background of motivational interviewing Describe at least four principles of motivational interviewing List three skills necessary for implementing motivational interviewing in Pain Management
Using a working definition Motivational interviewing is a particular method of clinical interviewing that is both collaborative and patient centered Motivational interviewing is an approach for behavioral change that builds on a patients empowerment
Background History – behavioral health roots Timeline 1983 - Dr. Wm. Miller, Psychologist 1995 – Miller and Rollnick 2002 – Miller and Rollnick –book 2007 – Rollnick, Miller & Butler 2009 - Miller and Rollnick
Can it Fit in Pain Management? Evidence based – MI outperforms traditional advice giving in the treatment of behavioral problems and diseases MI has been used and evaluated in alcohol abuse, drug addiction, smoking cessation, weight loss, adherence to treatment and follow-up, increasing physical activity, and in the treatment of asthma and diabetes Rubak, Sandboek, Lauritzen and Christensen, Motivational interviewing a systematic review and meta-analysis. British Journal of General Practice April 2005, 305-312.
Motivational Interviewing IS relatively brief a method collaborative patient centered
IS NOT a way of tricking patients to do what you want them to do a technique easy to learn a panacea Miller and Rollnick 2002
Spirit of MI Collaborative –positive, interpersonal, conducive and not coercive
Eliciting – drawing out motivation from the person and not imparting
Autonomy – affirm the patient’s capacity for self-direction and freedom
Principles of MI Express empathy – accepted and valued by respectful listening
Develop discrepancy – Aware of the pros and cons of current course
Role with resistance – Patient is primary resource
Support self – efficacy – Belief in own ability to succeed and change
Methods of MI Resist the righting reflex to fix it all Understand and explore patients motivation Listen with empathy Empower the patient by encouragement
Communication Styles
Core Skills
–Directing
–Asking
–Guiding
–Inferring
–Following
–Listening
Stages of Change Precontemplation Contemplation Preparation Action/willpower Maintenance Relapse ACHIEVE stable lifestyle change Prochaska and DiClemente (1983)
Process of MI Establish patient – provider relationship Set an agenda Assess Importance Establish confidence Continued Readiness Help patient and families with their action plan to effect the change/healthy behavior
MI in Pain Management Challenges –lack of interviewing skills –limited time for patient visit –differences in patient vs. clinician goals –inadequate attention to the patients –concerns
Pain Practitioner’s Ambivalence “I tell them what to do, but they won’t do it” “It’s my job just to give them the facts, and that’s all I can do” “These chronic pain patients are all the same, with this economy I understand why they are looking for drugs and disability” “Some patients are in complete denial about their drug and alcohol use”
Patient’s Ambivalence Poor self discipline
53.2%
Poor will-power
50.0%
Not scared enough
36.9%
Not intelligent enough
16.3% Polonsky, Boswell and Edelman, 1996
Benefits of MI in Pain Management More accurate identification of patients problems Increased patient adherence Decreased patient distress Higher patient satisfaction Improved healthcare provider well-being Decreased litigation
MI in Pain Clinic Practice Establish rapport Provide overview Use open-ended questions Use summary statements Active listening Aware of nonverbal communication
Patient - Centered Who is the person? What does the person want from the visit? How does the person experience pain? What is the person’s understanding of pain? What are the person’s feelings about pain?
Patient = Person = Focus
Interviewing the Pain Patient Greet the patient and establish a rapport Set the agenda Invite the patient to tell their story Expand and clarify the patients story Gather necessary information Generate a hypothesis Create a shared understanding Negotiate a treatment and follow-up plan
Case 56 yo female patient comes to the clinic for evaluation of “back pain” She is accompanied by her daughter and 3 year old granddaughter It is her first visit to your office
Case (cont’d) She reports back pain for two years with no trauma Severity has suddenly increased over last week She rates her pain as 9/10 now and is usually 5/10 with “pain med”
Pain Assessment and Tx Plan Location Duration Onset Characteristics Severity Aggravating/Relieving Associated symptoms Adverse side effects
Monitoring – UDS, PDM, Diary, Pill count, opioid agreement
Plan and Follow-up – Analgesia – Activity – Adverse side effects – Aberrant behavior – Adjunctive agents – Appointment
How would you begin the visit ? Interactive: role play demonstration –what else do you need to know?
Dilemma Patient reports: has doubled her dose of analgesics without pain relief Observe the role play demonstration Group input: what would you do?
Patient’s Concerns Needs to return to work –widowed and helping to raise –granddaughter while daughter has returned to school and has no job/income
Cannot live in this pain
Implementing Change talk Early method to enhance motivation Intension to change – what would you be willing to do
Disadvantages/advantages – what problems have you experienced in relation to your self medication for pain? – how do you think it should work for you?
Optimism/belief about capacity to change
Resistance/Ambivalence Normal: to be expected Alternative behaviors have + and – The costs of status quo with the costs of change The benefits of change with the benefits of status quo Resistance is a signal Acceptance facilitates change
Avoid the Righting reflex Most patients are going to be ambivalent about unhealthy behaviors Clinicians see an unhealthy/risky behavior and our natural instinct is to diagnose it and fix it or point it out and tell them to change The patients natural response is to defend the opposite – or no change
Roll with Resistance Avoid arguing for change Reflective responses Shift focus Reframing Agreeing with a twist Emphasizing personal choice
Enhance Motivation in Clinic Use open-ended questions: get the patients agenda
–Affirm: reinforce statements of actions that promote change –Reflective Listening: listen and reflect back what you think they’re trying to say –Summarize: condense down what the patient told you terms of change
What Could You Do? Explain what the patient could do differently in the interest of their health? Advise and persuade them to change their behavior? Warn them what will happen if they don’t change their ways? Take time to talk about how to change their behavior and refer them to a specialist? Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008
Results Patient increased sense of satisfaction Increased patient participation Adherence and compliance improved Realistic goal setting Improved healthy behavior change
References 1. Miller and Rollnick. Motivational Interviewing: Preparing people for change. Guilford Press. New York and London 2002. 2. Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press. New York and London 2008.
Q&A 1. Motivational interviewing is an approach for behavioral change that builds on a patients empowerment. True or False?
Q&A Which of the following is not a principle of motivational interviewing? a) refuse resistance b) reflective listening c) reinforce positive behaviors d) exploring ambivalence
Q&A What skills are necessary for implementing motivational interviewing? a) set an agenda b) assess readiness c) explore importance d) all the above