MI May 31 Session WORLD NO TOBACCO DAY

MOTIVATING CHANGE!
Dr. Peter Selby MBBS, CCFP, FCFP, MHSc, Dip
ABAM
Clinical Director, Addictions Program
Head, Nicotine Dependence Clinic
Centre for Addiction and Mental Health
Associate Professor
Departments of Dalla Lana School of Public Health
Family and Community Medicine, and Psychiatry
University of Toronto
The Fourth Annual Ottawa Conference: State of the Art Clinical Approaches to Smoking Cessation on February 3rd – 4th, 2012
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Disclosures
Grants/Research Support:
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Health Canada, Smoke Free Ontario, MHP, CTCRI, CIHR
•
Alberta Health Services (formerly Alberta Cancer Board),
•
Vancouver Coastal Authority, Pfizer, OLA, ECHO, NIDA, CCS
Speakers Bureau/Honoraria:
•
Schering Canada , Johnson & Johnson Consumer Health Care Canada
•
Pfizer Inc. Canada, Pfizer Global Sanofi-Synthelabo Canada,
•
GSK Canada, Genpharm Canada, Prempharm Canada, NABI Pharmaceuticals
Consulting Fees:
•
Schering Canada , Johnson & Johnson Consumer Health Care Canada,
•
Pfizer Inc. Canada, Pfizer Global, Sanofi-Synthelabo Canada, GSK Canada,
•
Genpharm Canada, Prempharm Canada, NABI Pharmaceuticals,
•
V-CC Systems Inc., eHealth Behaviour Change Software Co., AstroZeneca Canada Inc.
Research Funding: Schering Canada (Buprenorphine training 2000)
NO TOBACCO or ALCOHOL or FOOD INDUSTRY FUNDING
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Objectives
•
•
•
•
Determinants of change
Motivating change
Communication style
Elements of MI
You should
just quit!
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ADVICE HAS A SHORT HALF LIFE
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So how do I get people to change?
PUSHING EXERCISE
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Increase self efficacy
through empowerment
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LIMBIC LOCKING
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Three Communication Styles
Direct
Follow
Guide
Directing
• You take charge
• Uneven relationship with
regard to knowledge,
expertise, authority or
power
• Patients often appear to
and want this kind of
take-charge approach
from you
Following
• A truly good listener
suspends his/her
own “stuff” to give full
attention to
understanding the
other’s experience
• Only agenda is to
understand and
follow the client’s
lead
Guiding
•
•
•
Providing
information, acts
as a resource,
tutor
Helps someone
find their own way
Client becomes
his or her own
therapist
Guiding:
Motivational Interviewing
Solution-focused therapy
(Asking)
Following:
Psychodynamic
Psychotherapy
Rogerian Therapy
(Listening)
Directing:
Behavioural Therapy
CBT
Reality Therapy
Dr. Phil
(Informing)
So when do I use a
Motivational
Interviewing?
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Motivational
Interviewing
THREE DEFINITIONS
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What’s it for?
Motivational interviewing is a
collaborative conversation to
strengthen a person’s own motivation
for and commitment to change
HCP
Pt
change
Why would I use it?
Motivational interviewing is a
person-centered counseling
method for addressing the
common problem of ambivalence
about change
It has a small to medium effect size
How does it work?
Motivational interviewing is a collaborative,
goal-oriented method of communication
with particular attention to the language of
change. It is designed to strengthen an
individual’s motivation for and movement
toward a specific goal by eliciting and
exploring the person’s own arguments for
change
Saunders’ Law of Behaviour Change:
People only change when the pain
of change is less than the pain of
staying the same.
What’s the analgesic????
“A Psychological Law”
I learn what I believe as I hear
myself speak.
- Bill Miller
WHAT HELPS PEOPLE CHANGE
“People are generally better persuaded
by the reasons which they have themselves
discovered, than by those which have
come into the mind of others.”
(Pascal, 1670)
Change as a Process
Elements of
Interviewing
Motivational
Change
Talk
OARS
Principles
Spirit
The Underlying Spirit of MI
ACE
Autonomy
V
E
Collaboration
R
S
Evocation
U
S
• Authority
• Coercion
• Education
Autonomy
In the end, it is your choice
where would you like to go
from here?
Collaboration
How do you think I could be helpful to
you?
Evocation
I’m interested in your ideas on how you
want to tackle this
The Four Principles of
Motivational Interviewing
RULE
Resist the Righting Reflex
Understand patient motivations
Listen to your patient
Empower your patient
YOU MAY ALREADY HAVE
MANY SKILLS TO MOTIVATE
LETS EVOKE!
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INSTRUCTIONS
• PAIR UP PLEASE
• INTERVIEWEE: THINK OF A BEHAVIOUR CHANGE
YOU
– DESIRE TO
– HAVE THE ABILITY TO
– HAVE REASONS TO
– NEED TO
• BUT ARE FEELING AMBIVALENT ABOUT.
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INTERVIEWER:
INTRODUCE YOURSELF
ASK THE FOLLOWING QUESTIONS
1. “Given we have only 10 minutes today, What would you
like to discuss today?”
“listen”
(WHEN YOU HEAR “DARN)
2. AFFIRM IT: EMPHASIZE A STRENGTH
3. “TELL ME MORE”
4. REFLECT WHAT YOU HEARD
1. CONTENT
2. MEANING/FEELINGS
NO “WHY” questions
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THEN ASSESS READINESS
• IMPORTANCE
– Given everything going on in your life right
now, on a scale of 0 to 10, how important
would you say it is for you to <INSERT
BEHAVIOUR CHANGE>?
• CONFIDENCE
– On a similar scale of 0 to 10, how confident
do you feel about being able to <INSERT
BEHAVIOUR CHANGE>? BY WHEN?
EXPLORING AMBIVALENCE
• “Help me understand what is
good about <staying the same>?”
• “What else?”
• Reflect
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EXPLORING AMBIVALENCE
• “Help me understand what is NOT
SO good about <staying the
same>?”
• “What else?”
• Reflect
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Summarize what you heard
• check your understanding of the person’s
situation as a whole
• reflect back key components of what the
person has discussed especially the
ambivalence
• To signal a transition to another topic or the
end of the session/consultation
• To highlight change talk
OARS
Open ended
questions
Affirmation
Reflection
Summarize
ELICIT CHANGE TALK
•Readiness
•Rewards
•Risks
Interviewer?
• “ so what do you think you
will do next?
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Cat
Commitment
Action
Taking Steps
What if it appears this person is making
reasons not to change?
Change Talk and Sustain Talk
Opposite Sides of a Coin
Exploring Roadblocks
• “What might come in the way of you being
successful?”
– Environment
– Biology
– Behaviour ( Attitude, Knowledge, skills)
• Ask permission to give Advice
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FLU SHOT
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MI Hill
(Pre-) Contemplation
Preparation
Action
Summary
• Determinants of behaviour are multiple
• The ability to change is dependent on the interactions
between the opportunities and constraints in the
environment currently and embodied modulating the
biological and psychological abilities of individuals to
exercise choice
• Motivational interviewing is one way to guide the
DARNCAT by rowing with OARS through the choppy
waters of AMBIVALENCE.
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