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Motivational Interviewing. Deborah L. Drew, Ed. D., LCPC and Evan Williams, PharmD Husson University HICHEP Presentation August 24, 2013. Agenda. Welcome and Introductions Hour 1: What is Motivational Interviewing? Hour 2: Components of Motivational Interviewing - PowerPoint PPT Presentation

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Motivational Interviewing

Motivational Interviewing

Deborah L. Drew, Ed. D., LCPC and Evan Williams, PharmDHusson UniversityHICHEP PresentationAugust 24, 2013Welcome and IntroductionsHour 1: What is Motivational Interviewing?Hour 2: Components of Motivational InterviewingHour 3: Tools and PracticeHour 4: Action Plan: Implementing Change inYour PracticeSummary and Evaluations

2Agenda3Welcome and IntroductionsDeb3Hour 1:

What is Motivational Interviewing?Clinicians can only provide patients with clinical knowledge and education

Patients make the ultimate decision to change

What can clinicians do to influence patient change?Scare tacticsLecture and educateMotivate the patient to changeOverview5Evan5Describe the development and evidence for the use of motivational interviewing

Implement components of the model for motivational interviewing

Develop an action plan to implement the elements and principles of motivational interviewing in practiceObjectives6Evan6Think of a bad habit you have tried to changeDietary habitsExercise habitsWorkplace habitsRelationship habitsHow long did it take to realize that this habit had a negative impact on you or others?Months? Years?Were you successful? Did you relapse? 7Self ReflectionDeb7Think about patients who have difficulty making change8Reflection on Your PracticeDeb8

Maslows Hierarchy of NeedsDeb910Stages of ChangePrecontemplation No intention of changing their behavior for the foreseeable futureNot thinking about changing their behaviorMay not see the behavior as a problemContemplation Aware a problem exists Seriously considers actionNot yet made a commitment to an actionPreparation Intent upon taking action soon Often report some steps in that directionAction Aware a problem exists Actively modifies their behavior, experiences and environment in order to overcome the problem Commitment is clear Great deal of effort to changeMaintenance Sustained change New pattern of behavior has replaced the oldBehavior is firmly established Threat of relapse becomes less intenseProchaska, J. O., & DiClemente, C. C.

Deb10Stages of Change

Deb11Motivational Interviewing (MI) is a collaborative, personcentered form of guiding to elicit and strengthen motivation for change.

Defined by the identification, examination, and resolution of ambivalence about changing behaviorAmbivalence: Feeling two ways about behavior changeDefining Motivational Interviewing12http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfhttp://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

12Method of communicationNot a techniqueIncreases mutual understanding

CollaborativeHonors patient autonomy

Strengthens a persons own motivation for and commitment to change Patient-centeredPrinciples of MI13http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfEvan

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

13William R. MillerMotivational Interviewing with Problem DrinkersBehavioral Psychotherapy - 1983 Stephen Rollnick and William R. Miller1991 articleOutlines clinical proceduresHas been revised and applied to many settingsDevelopment Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy. 1983, 11 (2); pp 147-17214Deb14Growing body of evidence6 references 1980-198978 references 1990-1999707 references 2000-2009Most studies show MI to be beneficialPublication bias?Most studies have limitationsSmall sample sizeWeak comparator groupsVarious providers offering MIProviders have differing levels of training in MIDifficult to assess the manner in which MI is usedEffectiveness of MI15Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan15Pattern of results show MI is likely To confer at least a 10% advantage in success rates versus weak comparatorsTo be as good or better than established treatments To take less time and resources

Best outcomes may be using MI pre-treatmentMI Meta Analyses16Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan

Integrate with other treatment strategies

Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312

16Effective regardless of gender or age

Training level does not significantly impact effectivenessVersatile

In what areas is MI most effective?17MI Meta AnalysesLundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan1718MI Meta Analyses

Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Evan1819MI Meta Analyses Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45

Evan19

MI Meta Analyses 20Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312Evan20Limitations Interventions ranged from 10-120 min (60 min most common)Variable follow up periods

UsefulnessProvides evidence that MI can elicit significant change Overall about 75% of studies show there was an effectMI Meta Analyses 21Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit J General Practice. 2005 April, pp 305-312Evan

Such heterogeneity can introduce skewedness where the longer intervention studies significantly more effective and changing overall results?2122Hour 2:

Components of MIKey Elements of MICollaborationEvocationAutonomy

Principles of MIExpress EmpathySupport Self EfficacyDevelop DiscrepancyRoll with Resistance

Components of MI23http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

Key Elements realized through principles of MI23CollaborationDismisses hierarchy

Builds rapport

Non-confrontational

Focus is mutual understandingKey Elements of MI24http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

This does not mean that the therapist automatically agrees with the client about the nature of the problem or the changes that may be most appropriate. Although they may see things differently, the therapeutic process is focused on mutual understanding, not the therapist being right.

24RG is a 57 year old male with hypertension and hyperlipidemia. On questioning it is revealed that he smokes about 1 pack of cigarettes daily. You would like him to quit smoking.

Example of Collaboration25Together

Which of the following shows the spirit of collaboration consistent with MI?A. You need to stop smoking now.B. What reasons do you have to stop smoking?C. If you continue to smoke, you are increasing your risk for having a heart attack or stroke.D. Let me help you to stop smoking.

Answer: B allows pt to reflect on his own reasons to quit. The other answers attempt to pressure the pt or in the case of D, violate his autonomy.

25EvocationPatients discover their own motivation and skills for change

Draw out the patients own thoughts and ideas

..lasting change is more likely to occur when the client discovers their own reasons and determination to changeKey Elements of MI26http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfEvan

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf26Pharmacist: Ive noticed you have been late filling these medications the last 2 months.

Patient: Yeah, Ive been having a hard time keeping up with things as I am moving to a new home across town in a few weeks. I know taking my medications is important but Ive been so busy lately that I forget sometimes.

Pharmacist: It sounds like you would like to take your medications but it has been a tough time dealing with the move.Example of Evocation27Evan Pharmacist; Deb - Patient

The final response allows the patient to elaborate on how he feels and possibly consider some of the reasons and motivation he has to change. 27AutonomyUltimately it is the patients decision to change

Empowers the patient and gives them responsibility

As clinicians, we can encourage patients to develop their own SMART goalsSpecific, Measurable, Achievable, Relevant, TimelyKey Elements of MI28http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdfDeb

http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

SpecificMeasurableAttainable/AchievableRelev

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