ERS Annual Congress Milan

09–13 September 2017

Professional development workshop

PDW3 Motivational interviewing for smoking

cessation

Sunday, 10 September 2017

14:30-16:50

Green 2 (North) MICO

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Professional development workshop : PDW3

Motivational interviewing for smoking cessation

Aims : Motivational interviewing is a patient-centred, collaborative, and goal-oriented method that is

designed to strengthen the personal motivation for and commitment to a specific goal by eliciting and

exploring the person’s own reasons for wanting a change within an atmosphere of acceptance and

compassion. In motivational interviewing, it is appropriate to provide information and advice, but only if

the patient gives permission to receive it. The goal of the healthcare provider is to understand the

patient’s perspective of the topic and their needs, and to help the patient to draw their own conclusion

about the relevance of any information provided.

Tracks: Chronic airway diseases

Tags: Clinical - Smoking prevention and cessation (HLfL)

Target audience: Allergologist - Cardiologist - Clinician - Educationalist - Epidemiologist - Fellow -

Junior member - Lung function technician - Nurse - Occupational therapist - Oncologist -

Otolaryngologist - Paediatrician - Patient - Physiologist - Physiotherapist - Psychologist - Public health

official - Pulmonologist - Resident - Respiratory physician - Respiratory therapist - Student - Trainee

Chairs : Paraskevi Katsaounou (Athens, Greece)

Introduction

Motivational interviewing: definition, objectives, and the transtheoretical model of

change Gian Paolo Guelfi (GENOVA, GE, Italy)

Motivational interviewing: principles Tim Anstiss (London, United Kingdom)

Motivational interviewing core skills: motivational strategies Lynne Johnston (Sunderland, United Kingdom)

Strategies for information exchange: play roles Paraskevi Katsaounou (Athens, Greece)

SELF-ASSESSMENT IN RESPIRATORY MEDICINE EDITED BY KONRAD E. BLOCH WITH ANITA K. SIMONDS AND THOMAS BRACK

Self-Assessment in Respiratory Medicine is an invaluable tool for any practitioner of adult respiratory medicine. Th e 261 multiple-choice questions cover the full breadth of the specialty, using clinical vignettes that test not only readers’ knowledge but their ability to apply it in daily practice. Th e questions were compiled and tested by the HERMES Examination Committee, making the book the perfect revision aid for candidates for the European Diploma, as well as any specialists in respiratory medicine and other fi elds who wish to improve their understanding.

To buy printed copies, visit the ERS Bookshop in the World Village at the ERS International Congress 2017.

Electronic: WWW.ERSPUBLICATIONS.COMPrint: WWW.ERSBOOKSHOP.COM

SELF-ASSESSMENT INRESPIRATORY MEDICINEhow do you measure up?

ISBN (print) 978-1-84984-077-4ISBN (ebook) 978-1-84984-078-1

€50 (ERS members)€60 (non-members)

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2017 by the authors

Professional development workshop : PDW3

Motivational interviewing for smoking cessation

Abstract Tim Anstiss will consider and contrast two different styles of interpersonal interaction within a smoking

cessation consultation. Using a practical exercise he will draw out the differences in these two styles and

introduce the workshop participants to the underlying philosophy and principles of Motivational Interviewing

(MI). This will set the scene for the next presentation.

Gian Paolo Guelfi will present the fundamentals of MI, and the reasons why it can be useful for professionals

in the field of respiratory problems. The presentation will discuss the origins of MI in the field of substance

abuse and alcoholism, and its evolution into other medical professions. The presentation will show how MI

can help in a difficult issue like smoking cessation. The Trans-Theoretical Model (Prochaska & DiClemente,

1983) will be presented, discussed and integrated into a Three-Factor Model of motivation. This will be used

to discuss the concept of motivation profiles.

Lynne Johnston will introduce some core practical skills in MI. Starting with the concept of ambivalence, her

presentation will discuss the rationale for the elicitation of ‘Change Talk’ and ‘Sustain Talk’. Focusing

specifically on practical skills she will consider how different types of questions can be asked to elicit either

‘Change or Sustain Talk’ from clients. She will consider why this can be helpful to either build motivation for

change or to help a client to explore their barriers to change (e.g. if this is then followed by further ‘solution-

focused’ evoking questions). Finally, Lynne will introduce two applied tools that can be used by practitioners

within a time-limited health behavior change consultation. Special attention will be given to how the

professional should help the client to elaborate on ‘Change Talk’ to strengthen and consolidate motivation for

change. Practical examples and exercises will be used throughout.

“MOTIVATIONAL INTERVIEWING: DEFINITION, OBJECTIVES,

TRANS-THEORETICAL MODEL”

Gian Paolo Guelfi, psychiatrist,Genova, Italy

Member of:Società Italiana TossicoDipendenze,

Associazione Italiana Colloquio Motivazionale, Motivational Interviewing Network of Trainers

Conflict of interest disclosure√ I have no, real or perceived, direct or indirect co nflicts of interest that relate to

this presentation.

This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation.Drug or device advertisement is strictly forbidden.

… and I quit smoking 35 years ago, at my age of 40 ….

Outline

�Definition: what is MI (and why it is relevant for problems with breathing)

� Objectives

�Trans-Theoretical Model and motivation profiles

� Conclusion

�Definition: what is MI (and why it is relevant for problems with breathing)

• a style of communication• collaborative and goal-oriented• with particular attention to the language of change• designed to strengthen personal motivation for andcommitment to a specific goal• by eliciting and exploring the person’s own reasonsfor change• within an atmosphere of acceptance andcompassion

Miller, Rollnick: Motivational Interviewing , 3°Edition,The Guilford Press, New York-London, 2013, p.29

Technical definition :Motivational Interviewing is

MI started in the Eighties, as a reaction to the confrontational style that was leading in the field of drug addiction and alcoholism.

Traditional / confrontational style

The professional knows the nature of the problem, the strategies to adopt in order to recover and the patient, who is deemed to be in denialabout his/her problem. The patient must rely on the skills and authority of the professional, accepting the confrontation as a prerequisite of a successful treatment.

The clinician dictates his/her stance against the client’s view. Such an attitude can generate blocks in communicationbetween clinician and client and raise resistance to change.

This compromises the therapeutic relationship, and displaces a great deal of the

energy of the client in defensive attitude rather than in the

change process.

Motivational/Reflective Style

The behavior problem was learned by the patient in order to cope with overwhelming difficulties in his/her adaptation and growth. The clinician helps the client to mobilize inner factors potentially useful to face ambivalence, and to find new ways to change behavior.

MI suggests that a useful therapeutic relationship be founded on empathy, on acceptance of clients concerns, fears, views, values as the starting point for a process of change.

The main instrument in such process is Reflecting listening

“placing weights on the positive change-seeking side of the scales,

and

perhaps, gently removing weights and obstacles from the negative, change-avoiding side of the balance”

Miller WR: Motivational Interviewing with Problem drinkers. Behavioural

Psychotherapy 1983, 11, 147-172

Bill Miller describes his job like this:

To what extent can this way of working be considered in the clinical work of doctors and nurses in the field of respiratory diseases?

MI started in the addiction field. But it quickly expanded to other fields, including behaviour changes related to health, and adherence to medical advice: taking medications, changing bad habits, including smoking of cigarettes.

Using MI in medical field involves giving advice and prescription. Doctor and nurses believe that the client should follow their advice and prescription in order to improve their health.

So it is generally useful to offer advice and prescriptions in a way that makes it more

likely that the clients accept them

From alcoholism and addictionto health behaviour problems

Yet this optimistic expectation is often disregarded, following the Latin expression

VIDEO MELIORA PROBOQUE, DETERIORA SEQUOR(I SEE WHAT IS GOOD, I DO WHAT IS WORSE )

Actually it is unlikely that a smoker quit smoking without a personal decision based on a strong motivational process.

Hence the importance that the doctor faces the problem in a way that can help the patient to develop such motivation.

Motivational interviewing can actually help the doctors to do so.

Quitting smoking is a difficult decision to make.

Van Eerd EAM, Bech Risør M, Spigt M et al

Why do physicians lack engagement with smoking cessation treatment in their COPD patients?

A multinational qualitative study

NPJ Primary Care Respiratory Medicine 2017 Jun 23;27(1):41

“… Smoking cessation is the only effective intervention to slow down the accelerated decline in lung function in smokers wit h chronic obstructive pulmonary disease ...

… physicians often do not routinely provide evidence- based smoking cessation treatment to their patients …

… a study with doctors in seven different countries … to assess barriers to smoking cessation …

… doctors' frustration with, and negative attitudes to wards patients who continued to smoke … a lack of experience with smoking

cessation techniques”

If the loop described in this paper is not brokenit brings about very bad effects

Negative attitudestoward patients whocontinue to smoke

Lack of experience with smoking cessationtechniques+

Lack of engagement with smoking cessation treatment

Frustration of doctors

Motivational Interviewing:Spirit, processes, and skills are aimed atgetting change talk from the client.

OBJECTIVES OF MI

The goal of MI is to evoke, reflect, support, and facilitate development of

change talk from the client

The components of MI: Spirit and Skills

are aimed at having the client voice change talk

PartnershipAcceptance

Compassion * Evocation

Autonomy SupportAffirmation

Absolute Worth of the Human Being Accurata

empatia

MI is done «for» and «with» a person.MI is not done «to» or «on» someone.

“Compassion” is a deliberate commitment to pursue the welfare and best interest of

the other.(Miller e Rollnick, 2013)

You have what you need, and together we will find it.

(Miller e Rollnick, 2013)

The components of the Spirit of MI

*Compassion: “Sorrow for the suffering or trouble of another or others, accompanied by an urge to help” (Webster’s New World Dictionary of American English. Third College Edition 1994

Accurate Empathy

From the Trans-Theorethical Model to athree-Dimension model

THE TRANS-THEORETICAL MODEL

The model that describes in detail the process of change is still the Transtheoretical Model of the Stages of Change (Prochaska and DiClemente 1982)

Contemplation

Determination Action

Maintenance

Relapse

Precontemplation

Termination

• Precontemplation, in which the person shows no intention to change;

• Contemplation, in which the person is ambivalent about change;

• Determination, the person makes up her/his mind to change;

• Action, in which change is getting started, (3-6 months);

• Maintenance, in which change stabilizes; • Termination, characterizes by the feeling that

the problem is gone

In more detail:

The model can be simplified like this:

Not ready … Uncertain … Ready

This model describes the sequence of the stages of change,

but what is needed is a model that identifiesthe factors that work

in the progress toward change.

Research done in the field showed that …

Many studies support the efficacy of MI, and adaptations deriving from MI, like MET – Motivational Enhancement Therapy used in Project MATCH; or BMI – Brief Motivational Interviewing

(Group of Project MATCH, 1997; Burke, Arkowitz and Dunn, 2002; Rosenhau, Monti,

Martin et al 2004.)

However, a controversy was started by Robert West (2005) suggesting to “put to rest” the Trans Theoretical Model (TTM). Other authoritative authors share this point (Bandura; Davidson).

EVIDENCE SUPPORTING THE MODEL, AND OPPOSING VIEWS …

We developed and validated a new instrument to measure motivation for change according to an integrated “three-dimensional model” including a profile of the Stages of Change (Readiness to change)

Beside the stages of change, other factors are relevant, particularly:

Importance/Discrepancy and Confidence/Self-Efficacy

and we also considered them in the MAC Questionnaire

MOTIVATION FOR CHANGE APPEARS …

…when people perceive contradiction between their usual behavior/condition and important objectives and personal values

WHEN THEY PERCEIVE

DISCREPANCY

Change is important to them

MOTIVATION FOR CHANGE WORKS …

When people feel sufficiently confident to achieve the result they are seeking

WHEN THEY HAVE HIGH LEVEL

SELF-EFFICACY

They are confident that change ispossible to them

MOTIVATION FOR CHANGE TAKES PLACE …

WHEN THEY AREREADY TO CHANGE

When people acknowledge the problem they have, When they express the will of facing and solving their problem

� Discrepancy/Importance� Self-Efficacy/Confidence� Readiness to change

Are the factors underlying motivation to change in a given problem area.

THE THREE FACTORS OF MOTIVATION

Readiness to change

Recognition of the problem,will to modify

a behavior or making a decision(Prochaska e DiClemente, 1986)

Self-Efficacy(confidence)

Confidence in one’s own abilityto bring about a definite behavior,

to reach a specific objectivein a definite time(Bandura, 1977)

Discrepancy(importance)

The painful perceptionof contradiction

between one’s own present condition, and important expectations,personal values and goals

(Festinger, 1957)

28/06/2017 28

Relevance of the three factor model isevident if we consider the motivation profiles of a person

The”motivational profile” of the client in a definite problem area can be explored by answering questions as:

SELF-EFFICACY (CONFIDENCE)

“How CONFIDENT are you to succeed with your problem?”

DISCREPANCY (IMPORTANCE)

“How IMPORTANT is for you to overcome the discomfort and to improve your situation?”

READINESS TO CHANGE

“How READY are you to change your problem?”

FOUR MOTIVATION PROFILES OF CLIENTSACCORDING TO THE VALUES OF

DISCREPANCY/IMPORTANCEAND SELF-EFFICACY/CONFIDENCE

FROM MILLER AND ROLLNICK, 2002, MODIFIED

PROFILE A: LOW IMPORTANCE, LOW CONFIDENCE

These people believe that change is not-important and they are also not- confident that they could make it, even if they try.

PROFILE B: LOW IMPORTANCE, HIGH CONFIDENCE

These people think that solving the problem is not important. Otherwise they are confident that if they try to change, they would certainly succeed.

PROFILE C: HIGH IMPORTANCE, LOW CONFIDENCE

These people deem it very importantto change, but they are not-confidentto be able to make the change

PROFILE D: HIGH IMPORTANCE, HIGH CONFIDENCE

These people believe that change is important, and they feel confident to be able to make it

PROFILES OF CLIENTS ACCORDING TO THE VALUES OF DISCREPANCY/IMPORTANCE

AND SELF-EFFICACY/CONFIDENCECLINICAL IMPLICATIONS (1)

PROFILE A: LOW IMPORTANCE, LOW CONFIDENCE

This profile requires discrimination about what comes first: if low importance comes first, it is better to work on Importance; if confidence comes first (the fox and the grape tale) let’s start with Confidence.

Ex.: Unaware Problem Drinker

PROFILE B: LOW IMPORTANCE, HIGH CONFIDENCE

The client is overlooking the problem, and the difficulties to deal with it. Importance has to be developed as a primary goal. Confidence could also be high as a result of previous good outcome experiences. The development of Importance still remains useful.

Ex.: Rebellious adolescent smoker.

PROFILE C: HIGH IMPORTANCE, LOW CONFIDENCE

This profile requires strong support of Self-Efficacy.

Warning: pressure on Importance could be counterproductive

Ex: Adult Smoker in a mood of Resignation

PROFILE D: HIGH IMPORTANCE, HIGH CONFIDENCE

This profile is generallyassociated to good levels of readiness to change. But not necessarily: a person can be willing, able, but not yet ready.

"I know it is important for me to change, and I feel confident I can do that. But not today.”

PROFILES OF CLIENTS ACCORDING TO THE VALUES OF DISCREPANCY/IMPORTANCE

AND SELF-EFFICACY/CONFIDENCECLINICAL IMPLICATIONS (2)

It helps the clinician to tailor the treatment on the patient’s actual needs and present capabilities.

And to stay with the patient while helping him/her to move forward.

The three-dimension model is also a stimulating tool for more research on motivation and change.

The three-dimension model of motivation and change turned out to be useful in clinical work.

Conclusion

MI is a style of communication with the client. Every experienced professional can feel she/he needs to improve her/his communication style with the client, and MI can help in this.

To use some of the skills of MI a professional doesn’t have to become an MI counselor, as MI spirit and skills can be incorporated into the professional style of a worker in the field of helping professions.

MI fits well with the medical and social work professions, and with many psychological approaches to behaviour change; MI is not intended to replace the communication skills of a professional, but just integrate them.

Motivational interviewing: principles

Dr Tim Anstiss

Academy for Health Coaching

London, United Kingdom

Conflict of interest disclosure

I have no real or perceived conflicts of interest that relate to this presentation.

I have the following real or perceived conflicts of interest that relate to this presentation:

Affiliation / Financial interest Commercial Company

Grants/research support:

Honoraria or consultation fees:

Participation in a company sponsored bureau:

Stock shareholder:

Spouse / partner:

Other support / potential conflict of interest:

This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosureis not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial productsor services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remainsfor audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of theseinterests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.

Resistance behaviours• Arguing • Interrupting• Ignoring• Looking away• Disagreeing• Blaming• Denying • Changing the subject• Discounting• Excusing• Sidetracking

• How often do you notice

these behaviours?

• Why do people behave

like this?

• Would you like to know

how to dramatically

reduce the emergence of

these behaviours?

• Would you like a quick

taste of the approach?

Exercise 1• Form pairs

• One of you be a clinician

• One of you be an overweight person with diabetes

– You are thinking about taking some exercise

– You are not stupid – you know it would be good for you

– But it is hard – you are busy, have work and family commitments, and are a little bit worried in case it makes you worse

Persuade

1. Explain why the patient should make this change

2. Give at least three specific benefits that would result from making the change

3. Tell the patient how to change

4. Emphasise how important it is for the patient to change –likely to include the negative consequences of not doing it

5. Persuade the patient to do it

And if you encounter resistance, repeat the above, but more emphatically

N.B. This is NOT Motivational Interviewing!

Person experience of“Evoke”

Person experience of

“persuade”

Clinician experience of “Persuade”

Clinician experience of“Evoke”

Exercise 2

• Form 3’s

• Agree who will talk about a real change they are thinking of making – but haven’t decided to yet. You are still thinking about it

Evoke

Listen carefully with a goal of understanding the dilemma.

GIVE NO ADVICE

Ask these 5 questions:

1. Why would you want to make this change?

2. What are the three best reasons to do it?

3. On a scale from 0 to 10, where 10 is very important, how important would you say it is for you to make this change?

4. And why are you at ____rather than a lower number of 0? Why is it important to you?

5. How might you go about it, in order to succeed?

Listener #1

Exercise: Evoke

Offer a short summary of the persons

• reasons for changing

• ideas about changing:

Then ask:

"So what do you think you'll do?"….and just listen with interest

(again, no advice giving)

Listener #2

Resistance

• Goes up and down

• Influenced by your behaviour

• You confront - it increases

Want to increase resistance?

• Take away control away

• Overestimate readiness to change

• Confront force with force

Optional

Ambivalence

+

+

+

_

_

_

+

+

+

_

_

_

Change(stop smoking)

No Change(continue to smoke)

Advantages of stopping

Advantages of smoking

Disadvantages of stopping

Disadvantages of smoking

They start telling you about advantages

They voice difficulties and disadvantages

You start lecturing them on bad things about

smoking

You tell them how great its going to be

Let people talk themselves into changing

“People are generally better persuaded by the

reasons which they themselves discovered,

than by those which have been discovered by

others”

Blaise PascalC17th French Mathematician / Philosopher

Reactance

Ambivalence

• Unsure

• In two minds

• Undecided

• Change or not change

• Very natural state

• Very common state

• People get stuck

• Can be ‘stuck’ for years

Help the person explore their ambivalence

Help them think it through for themselves

Help them decide

Motivational Interviewing:

Core Skills and Strategies

Lynne Halley Johnston PhD, DClin Psych, CBT Dip, AFBPsS

Halley Johnston Associates Limited, UK

www.halleyjohnstonassociates.co.uk

Motivational Interviewing Network of Trainers (MINT)

Conflict of interest disclosure I have no, real or perceived, direct or indirect conflicts of interest that relate to this

presentation.

This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation. Drug or device advertisement is strictly forbidden.

OVERVIEW

• Understanding Ambivalence

• Change Talk and Sustain Talk

• Skills in Motivational Interviewing: OARS

– Open Questions

– Affirmations

– Reflective Listening

– Summaries

• Some Simple Strategies to Evoke Change

– Open Questions

– Importance, Confidence, Readiness RULERS

– Two Possible Futures

AMBIVALENCE

– A conflict between two courses of action, each

of which has perceived costs and benefits

associated with it

– Unresolved ambivalence is often the reason

why people get stuck

– How you handle your patients’ ambivalence

influences outcome

CHANGE AND SUSTAIN TALK

Change Talk • Benefits of Change

• Cost of Staying the Same

Sustain Talk • Benefits of Staying the Same

• Cost of Change

Takes time, hard work, inconvenient, what else can I replace it with, may gain weight, pressure to never smoke again

Unhealthy, unfit, premature death, poor example for children, expensive, social outcast, worried about invisible damage, no willpower

CHANGE TALK

Cost of

Feel healthier, fitter, less breathless, more energy, self-esteem, live longer, better quality of life, save money, clothes smell better, less damage to teeth, lungs, etc

Easy, don’t have to find think about it, not stressful, no pressure on myself to do, no expectations/comments from others re success/failure

Benefits of

Changing Continuing to Smoke

CHANGE TALK SUSTAIN TALK

SUSTAIN TALK

CHANGE TALK AND SUSTAIN TALK QUIZ

• In pairs:

• Handout 1: Read through the list of statements

• Discuss which statements you think represent:

– ‘Change Talk’ or ‘Sustain Talk’

• Write you answers in the box provided under the heading of

either ‘Sustain Talk’ or ‘Change Talk’ (Handout 2)

• Answers (Handout 3)

O.A.R.S.

Open Questions • Invite the person to reflect and elaborate

• Example: What would be 3 good reasons

for you to stop smoking?

Summarising • A long reflection

• Collecting material up &

presenting it back

Affirmations: • Reinforce Strengths, efforts, resources.

• Making people feel bad does NOT help them

change their behaviour

Reflective Listening • Reflect meaning and emotion

QUESTIONS WHICH EVOKE

CHANGE TALK OR SUSTAIN TALK

• Discuss in Pairs each of the questions in Handout 4

– Decide which would evoke change talk and which would evoke

sustain talk?

– Put the question number in the relevant quadrant in the answer

sheet (Handout 5)

• Answers: Handout 6

TWO COMMON STRATEGIES TO EVOKE

CHANGE IN MI

• Rulers: Readiness, Importance and Confidence – Handout 7

• Two Possible Futures – Handout 8

RESPONDING TO CHANGE TALK

• Elaborating

• Affirming

• Reflecting

• Summarizing

Professional development workshop : PDW3

Motivational interviewing for smoking cessation

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