Motivational Interviewing: Helping People Change Problem Behaviors Using Smoking Cessation as the Model Andrée Aubrey, MSW, LCSW, CTTS Director, Area Health Education Center FSU College of Medicine Department of Family Medicine and Health Affairs [email protected] 850-645-6439 At the end of this training, learners will be able to: • Articulate the key components of MI interventions; • Demonstrate competence in an evidence based and practical approach to behavior change counseling; • Focus the assessment interview on identifying and/or enhancing the client’s own reasons for wanting to quit tobacco or make other health related changes; • Use reflective listening skills to more fully understand clients’ perspectives about “the problem” and potential strategies to address those problems; • Enhance client self-efficacy for making a change. What would you say to this patient? • Video slide here Typical Tobacco Cessation Counseling • Video slide here Problems with Traditional Approach • Focuses on “fixing” the problem • Assumes knowledge and information are keys to motivating behavior change • “Teaches” patients how to make the desired change • Often leads to a “Yes, but…” tug of war Motivational Interviewing is NOT a treatment for tobacco dependency. It is an evidence-based intervention for tobacco users WHO ARE NOT YET READY TO QUIT. You can lead a horse to water but you cannot make him drink…. The most effective treatment for tobacco dependency is a combination of …. 1. Practical Counseling 2. Pharmacotherapy 3. Systems level interventions MI “salts the oats” TX for Tobacco Dependency Practical Counseling Pharmacotherapy Systems Interventions • Problem Solving: compulsions to use, triggers to smoke, changes in lifestyle • Coping Skills: developing or enhancing other coping mechanisms • Nicotine Replacement Therapy: Patch, gum, lozenge, nasal spray, inhaler • Bupropion: Wellbutrin SR • Verenicline: Chantix • ASKING every client at every visit about tobacco use – paper screening like a vital sign OR electronic health record (EHR) prompt • ADVISING about the benefits of quitting • REFERRING for treatment if not able to provide on-site • Reminder systems which prompt clinicians to do the 2A/R intervention What is Motivational Interviewing? • A collaborative, person-centered form of guiding to elicit and strengthen motivation for change • Empirically validated approach for helping people change addictive or other problematic behaviors • www.motivationalinterviewing.org MI • A consumer-centered, yet guiding style of counseling that is shaped by a guiding philosophy and understanding of what triggers change. • Involves the conscious and disciplined use of specific communication strategies to evoke the person’s own motivations for change. Three Essential Elements of MI • MI is a particular conversation about change • MI is collaborative (person-centered, not expert-recipient; partnership; honors autonomy and self-determination) • MI is evocative – seeks to call forth the person’s own motivation and commitment Persuasion Exercise: Part 1 • SPEAKER: Talk about something you’d like to change. May be a behavior, attitude, or habit but something it would be good to change. • COUNSELOR #1: – Explain why he/she should make this change – Give at least 3 benefits of making the change – Tell him/her how to do it – Emphasize how important it is to make the change Persuasion Exercise: Part 2 COUNSELOR #1 • Why would you want to make this change? • If you do decide to make this change, how might you go about it in order to succeed? • What are your three best reasons to do it? • On a scale of 0 to 10, how important is it for you to make the change? *Why are you at___ and not 0? Persuasion Exercise: Part 3 COUNSELOR #2 • Give a short summary of the speaker’s motivation for change: – Summarize desire, ability, reasons, need for change – Then, ask “So what do you think you will do?” – Affirm strengths of the speaker TO BE DOING MI THERE MUST BE… • a Target such as a health related behavioral change; attitude; decision (forgiveness); habit • Change Talk • Without these, there may be great rapport building and patient-centered listening, but not MI Underlying Theory of MI • People are ambivalent about making changes • When the clinician advocates for change, it will evoke resistance from the person • Resistance predicts lack of change • Getting the person to talk about making the change makes it more likely that he/she will do it Change Talk Lost Cause! Resistant Refuses to take care of herself Non-compliant Unwilling to change Non-adherent Difficult person Doesn’t understand Waste of my time Where do we start? • Understanding basic principles of MI • MI skills: – Open ended questions – Affirmations – Reflective listening – Summaries and • Informing/ Advising Open Ended Questions • Open questions – Encourages patient speech – More efficient for gathering information – Builds relationship – patients perceive clinician as caring and showing personal interest • Closed questions – Effective for gathering information, if you ask the right questions! • Question-answer trap – A series of questions (lends itself to quantification focus) Open-ended Questions Video Example of MI in action! Video slide here Affirmations • Statement of appreciation and understanding – Builds rapport and conveys respect for their struggles, feelings, achievements, humanity – Reinforces open exploration – Promotes self-efficacy for change • The point is to notice and appropriately affirm the person’s strengths and efforts Affirmations • “I am sure that when you do decide to quit, you will figure out a way that works for you.” • “You are clearly a resourceful person, to cope with so many difficulties for so long.” • “If I were in your position, I would have a hard time dealing with so much stress.” • “I know this is not easy to hear.” • • • • Clinician Keep the person talking and thinking Avoid a premature focus on solutions Improve “adherence” Enjoy your interactions more Reflective Statements Person • Listen to one’s own reasons • Hear how the behavior fits into one’s life • Freedom to explore the desire or reasons for change in a safe environment Reflective Listening • Use a down-turn in inflection • Make statements, rather than asking questions • Focus on change talk • ROLL with RESISTANCE Practice Simple Reflections • Tobacco user: “All my friends smoke, and I feel like I wouldn’t belong anymore if I quit.” – Instead of: “Would you rather die from lung cancer?” – Try: “Smoking helps you fit in.” • Tobacco user: “I know I need to quit, but I don’t know how I would deal w/ my depression without smoking.” – Instead of: “We’ve got a great medication that will help you quit and help w/ your depression at the same time. Let’s get you a prescription and I’ll sign you up for one of our Quit Smoking now classes.” – Try: “You have had some thoughts about quitting.” – Try: “You’ve been using smoking as a coping mechanism for a long time.” – Try: “It’s kind of scary to think about quitting.” Janine has been at the detox program for three days and has an appointment with you this morning, before being discharged. “Well, I’ve ben wearing the patch since I got admitted and haven’t really been craving cigarettes. But I am just not sure what is going to happen once I get home. “ • You were not expecting to give up smoking when you got admitted for alcohol detox. • It’s surprising to you that the cravings have been pretty manageable. • Your experience with the NRT patch has been positive. • Not smoking or drinking while at detox has been a positive experience and you are wondering how your home environment is going to influence your sobriety. Double-sided Reflections • May be used to highlight ambivalence • “On one hand, there are some things about smoking that you really enjoy like socializing with your friends, and yet you are worried about the health effects of continuing to smoke and the impact it has on your children.” Yes….but • People usually are ambivalent about change • Comfortable w/ status quo and disadvantages to change • Arguments on either side of the ….but… cancel each other out. “You would like to cut down on your drinking and you are concerned about fitting in with your friends.” Reflective Listening Skills TALKER: •Discuss something you’ve been thinking about changing LISTENER: •Respond with reflective listening STATEMENTS Remember, you don’t have to hit a home run, just put a little wood on it! Summaries: Putting it all together • Effective transitions when moving from the “building motivation” phase to the “goal-setting” stage • Useful if the person starts to get off track • Focus on the person’s own motivations for change Help Get Person Back On-track • "So far you've listed three reasons to keep smoking; and three reasons to quit. And you found that quitting for your daughter's sake was the most important of all these reasons." Possible Responses? • Video slide here Possible Responses? • Video slide here Video slide here Is it change talk? • I want to quit smoking so I’ll be here for my grandchildren. • My boss told me I had to join this QSN class or my insurance costs will double. • No one can tell me what to do! • I wish my life was different. • It took me 12 years to get off cocaine. I am not using any drug, not even NRT! Questions?