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Motivational Interviewing

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A facilitative style of interviewing designed to promote healthy behavior change ... Conviction (importance) of behavior, of its potential harm, and of perception of ... – PowerPoint PPT presentation

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Title: Motivational Interviewing


1
Motivational Interviewing
  • Mark Publicker, MD FASAM
  • Medical Director
  • Mercy Recovery Center

2
Motivational Interviewing
  • Grounded in a patient-centered approach
  • A facilitative style of interviewing designed to
    promote healthy behavior change
  • Humanistic, non-confrontational
  • Solid research support for its effectiveness

3
Motivational Interviewing
  • Prochaska-Diclementes transtheoretical model of
    the Stages of Change
  • Observational study of thousands of individuals
    attempting weight loss and smoking cessation
    without professional help

4
Stages of Change Model
  • Precontemplation
  • Contemplation
  • Determination (negotiation)
  • Action
  • Maintenance
  • Extinction
  • (Relapse)

5
Stages of Change Model
  • Precontemplation
  • Absent conscious awareness of problem
  • Defeat by failed prior attempts to change
  • Perception that change would be too difficult to
    contemplate

6
Stages of Change Model
  • Contemplation
  • Ambivalence
  • Feeling stuck
  • Decisional balance
  • Price of change vs price of maintaining the
    status quo
  • Cognitive dissonance

7
Stages of Change Model
  • Determination
  • Resolution of ambivalence
  • Readiness to embark on behavioral change
  • Menu of choices

8
Stages of Change Model
  • Action
  • Daily implementation of new behavior(s)
  • Requires conscious work
  • Duration 6 to 18 months
  • Example
  • 90 in 90

9
Stages of Change Model
  • Maintenance
  • New behavior becomes self-sustaining, carries its
    own momentum
  • New behavior becomes second nature
  • Attention to relapse risk

10
Stages of Change Model
  • Extinction
  • Old behavior has low likelihood of recurring
    (relapse)

11
Assessment
  • Conviction (importance) of behavior, of its
    potential harm, and of perception of need for
    change
  • Confidence Self-assessment of ability to change
    behavior
  • Conviction x Confidence Commitment

12
Assessment
  • C
  • O
  • N
  • V
  • I
  • C
  • T
  • I
  • O
  • N
  • C O N F I D E N C E

13
Assessment
  • Ask
  • On a scale of 1 to 10, how important is it that
    you stop drinking, smoking, lose weight, etc?
  • On a scale of 1 to 10, how confident are you
    that you could change your behavior if you wanted
    to?
  • On a scale of 1 to 10, how ready are you to
    change now?

14
Motivational Interviewing
  • Understanding change
  • Change happens naturally
  • Formal interventions produce changes that mirror
    natural change
  • Behavioral change after interventions happens in
    the first few sessions total dose doesnt make
    much difference
  • The style of clinician intervention is a major
    determinant of retention, adherence and outcome

15
Motivational Interviewing
  • Understanding change
  • Empathetic style increases change
  • Confrontational style impedes it
  • People who believe that they are likely to change
    to do.
  • People whose counselors believe they are likely
    to change do so.
  • People told they are not expected to change
    indeed do not

16
Motivational Interviewing
  • Understanding change
  • What people say about change is important and
    reflects what they will do
  • Arguments against change (resistance) produce
    less change
  • Both can be influenced by counseling style

17
Motivational Interviewing
  • Empathy
  • Accurate empathy reflection of patients
    thoughts
  • Reflective listening techniques are the core of
    MI
  • Empathic quotient of practitioner predicts
    positive outcome
  • Ratio of reflective responses to direct questions

18
Motivational Interviewing
  • Match intervention to patients stage of change
  • Precontemplation
  • Assess conviction/confidence
  • Provide feedback measurement (lab, etc) and
    meaning of symptoms

19
Motivational Interviewing
  • Contemplation
  • Ambivalence towards change
  • Ambivalence is normal
  • Acceptance facilitates change
  • Avoid argumentation
  • Roll with resistance
  • Express empathy
  • Augment discrepancy

20
Motivational Interviewing
  • Contemplation
  • Patient defense of the status quo diminishes the
    likelihood of change
  • Confrontation causes the patient to defend the
    problem behavior
  • Help the patient become the change agent

21
Motivational Interviewing
  • Determination
  • Provide a menu of choices
  • Support self-efficacy
  • Advice

22
Motivational Interviewing
  • Action
  • Support self-efficacy
  • Reinforce change
  • Risk reduction
  • Responsibility

23
Motivational Interviewing
  • Maintenance
  • Relapse prevention/risk reduction
  • Reinforce behaviors that resulted in change and
    identify old behaviors that will compromise it

24
Motivational Interviewing
  • FRAMES
  • F feedback
  • R responsibility
  • A advice
  • M menu
  • E empathy
  • S self-efficacy

25
Motivational Interviewing
  • Reflective responses
  • Simple reflection good response to resistance
  • Example
  • If my wife would just get off my back I would do
    better.
  • Response Its really frustrating to have people
    lecture you.

26
Motivational Interviewing
  • Amplified reflection
  • My kids are always exaggerating my drinking.
  • Response You really dont have any problem with
    alcohol at all.

27
Motivational Interviewing
  • Double-sided reflection
  • Emphasizes the sides of the dilemma
  • On the one handand on the other hand

28
Motivational Interviewing
  • Research support
  • Across a wide variety of medical and behavioral
    disorders
  • i.e. Diabetes, weight loss, HIV, medication
    adherence, smoking cessation, alcohol and drug
    addiction

29
Motivational Interviewing
  • Larry Genitello, MD, Trauma Surgeon, Parkland
    Memorial Hospital, Dallas
  • April 2005 Annals of Surgery Vol 241
  • Alcohol interventions for trauma patients
    treated in emergency departments and hospitals a
    cost-benefit analysis

30
Motivational Interviewing
  • Brief alcohol interventions using MI in trauma
    centers have been shown to reduce injury
    recidivism
  • Estimate of 27 of injured patients are
    candidates
  • Cost savings of an intervention is 330 per
    patient, for cost saving of 3.81 for each 1.00
    spent
  • If interventions were routine, national savings
    of 1.82 billion annually

31
Motivational Interviewing
  • Summary
  • Express empathy
  • Avoid confrontation
  • Roll with resistance
  • Augment discrepancy in ambivalence
  • Support self-efficacy
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