Motivational Interviewing

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Motivational Interviewing

• Anne Mounsey

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Helping people to change behavior is a journey
not an event.
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Impact of Behavior on Health

• Half of U. S. deaths each year are attributable
  to behavior
• Substance abuse ( tobacco, alcohol, drugs)
  responsible for 550,000 deaths/yr.
• Unsafe sex responsible for 30,000 deaths/yr.

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Motivational Interviewing

• Information alone does not change behavior
• Attempts to persuade patients will increase
  resistance.

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Introduction

• Some patients may never have discussed exactly
  how they feel about smoking etc.
• Simply talking about the behavior can help
  clarify their thoughts
• Try not to get hooked on outcomes.

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Determine Stage of Change

• Are you thinking about quitting in the next six
  months?
• If no, precontemplator
• If yes, ask next question
• Are you thinking about quitting in the next 30
  days?
• If no, contemplator
• If yes, preparation

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Integrating the Behavioral Theories

• Ask
• Advise
• Assess
• Assist
• Arrange

Not Stage-dependent
Use Motivational Interviewing
Stages of Change Motivational Interviewing
Stage-based interventions Motivational
Interviewing
Local and national resources
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Aim of Motivational Interviewing

• The focus of the office visit is not to convince
  the patient to change but..
• To encourage the patient to come up with self
  motivational statements that help them move from
  one stage of change to the next.

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Interviewing Principles of MI (DARES).

• D Develop discrepancy
• A Avoid argumentation
• R Roll with resistance
• E Express empathy
• S Support self-efficacy

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Precontemplation

• Goal is to raise doubt, increase perception/
  consciousness of problem
• Personalize risks and rewards
• Explore decisional balance
• express concern
• state the problem non-judgmentally
• agree to disagree
• advise a trial of limited behavior change
• importance of follow-up (even if no change)

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Contemplation

• Goal is to tip the balance
• elicit and - aspects current behavior
• elicit and - aspects of new behavior
• summarize (patient could write these down)
• demonstrate discrepancies between
• values (what they say) and actions (what they
  do)
• advise a trial of new behavior
• Support self-efficacy

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Assessment of a patients readiness to change

• Overall goal is for the patient to think about
  change.
• This involves assessing
• importance
• confidence

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Strategy for Assessing Importance

• Scaling Questions How important is it to you to
  stop smoking? How would you rate it on a scale of
  0 to 10, 0 being unimportant and 10 being very
  important.

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Strategies for Exploring Importance

• 1. Do little more
• 2. Scaling questions
• 3. Examine the pros and cons
• 4. Explore their health concerns about the
  behavior
• 5. Advantages of changing their behavior.

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Assessment of Confidence.

• If you decided right now to stop smoking how
  confident do you feel about succeeding?
• Numerical Scale.

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Building Confidence

• Scaling questions
• Brainstorming
• Previous Successes

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The goal is to get the patient to think about
change
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High importance
Low importance
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Readiness

• However confident and important they feel the
  change is, now may not be the right time.
• Is now a good time for you to be thinking about
  making the change?

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Preparation (also called Determination)

• Goal is to help patient determine the best course
  of action
• working on motivation is not helpful
• supporting self-efficacy (review strengths,
  coming to doctor)
• help decide on achievable goals
• caution re difficult road ahead
• relapse wont disrupt relationship
• Recognizing danger signs
• Developing coping skills

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Action Stage

• Provide continued follow up and support.
• Studies show patients are more likely to succeed
  if given regular (weekly) follow up initially.
• Continue positive reinforcement of healthy choice.

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Maintenance

• Goal is to help prevent relapse
• anticipate difficult situations (triggers)
• recognize the ongoing struggle
• support the patients resolve
• reiterate that relapse wont disrupt your
  relationship

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Relapse

• Goal is to renew the process of contemplation
• explore what can be learned from the relapse
• express concern
• emphasize the positive aspects of what they
  accomplished temporariy and of current efforts to
  seek care
• support self-efficacy

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Assessment of nicotine replacement

• If the patient smokes more than 30 cigarettes a
  day he will need nicotine replacement.
• Or if he smokes within a few minutes of waking up

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Signs and Symptoms of Nicotine Withdrawal

• Irritability and anxiety
• Decreased heart rate
• Increased appetite
• Decreased concentration

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Nicotine Replacement

• Doubles the smoking cessation rate.
• Methods
• patch
• gum
• inhaler
• nasal spray
• lozenges

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Commit Lozenges

• 2 mg and 4 mg. Use the 4 mg if smoke within 30
  mins of getting up.
• Max of 20 lozenges a day.
• Let lozenge dissolve slowly usually takes about
  30 mins.
• Stop after 12 weeks.

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Nicotine Patch

• Regime
• 21mg/24hrs for 4weeks
• 14mg/24hrs for 2 weeks
• 7mg/24hrs for 2 weeks
• If patient smokes patch.

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Nicotine Patch

• 50 of people have local irritation from the
  patch.
• Apply above waistline and rotate site
• Remove at bed time.
• Studies of smokers with CAD using the patch have
  shown no increase in morbidity and mortality.

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Nicotine Gum

• Comes in 2mg and 4mg.
• If smoke 10 a day use 4mg strength a max of
  20/day.
• Chew gum slowly and when peppery taste emerges
  park between teeth and buccal mucosa.

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Adverse Effects of Gum

• Nausea and dyspepsia.
• Caused by swallowing nicotine.

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Nicotine Nasal Spray.

• Use 4 sprays per hour.
• Side effects of nasal and throat irritation,
  rhinorrhea and nausea.

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Nicotine Inhaler

• Primarily absorbed through oral cavity,
  oesophagus and stomach
• Need to use 4 inhalers a day to achieve adequate
  nicotine levels. Each inhaler contains 500 puffs.
• Works well for people who need to do something
  with their hands.

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Nicotine Replacement

• No data available comparing delivery systems.
• Be guided by patient preference.
• Gum costs least (80/month)
• Nasal spray costs most (200/month)

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Bupropion

• Has been shown to have similar effects on quit
  rates as nicotine replacement.
• Used with nicotine replacement has higher quit
  rate than either alone.
• Contraindicated in seizure disorders.
• Start with 150mg qd for 3 days then bid.
• Set quit date 2 weeks after therapy initiated.

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What happens

• Patient sees you as an ally and not a boss
• Patient works with you to consider an issue
• Patient feels comfortable and listened to
• Physicians self esteem is not dependant on
  patients change.

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To promote behavior change...

• Listening is far more important and effective
  than giving advice
• Asking questions is far more important and
  effective than giving advice.