Motivational Interviewing

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