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