Engaging Your Engaging Your Patient in Patient in ChangeChange

Care Coordination Summit Alicia M. Ellis, LPC-MHSP

April 4, 2014

Defining Motivational Defining Motivational Interviewing Interviewing

• Motivational Interviewing focuses on exploring and resolving ambivalence and centers on motivational processes within the individual that facilitate change.

• “a collaborative, person–centered form of guiding to elicit and strengthen motivation for change (2009)

• A collaborative conversation to strengthen a person’s own motivation for and commitment to change.

-Miller and Rollnick

Style and SpiritStyle and Spirit• A client centered approach• Motivation is a state or stage, not a character

trait• Client’s resistance to change and change talk• Client’s defensiveness or resistance can facilitate

the education process• Respect for client’s autonomy and choice• Educator’s style significantly impacts client’s

behavior: collaboration, not confrontation

Spirit of Motivational Spirit of Motivational InterviewingInterviewing

• Collaborative- a partnership, honors person’s expertise and perspectives

• Evocative – resources and motivation presumed to reside within the individual

• Empowering – honors individual’s autonomy and self-direction, facilitates informed choice.

Underlying PrinciplesUnderlying Principles• Express empathy- seeing the world through the

client’s eyes• Develops discrepancy-”where they are and where

they want to be”• Rolls with resistance, avoiding argumentation-

work to de-escalate and avoid a negative interaction.

• Support self-efficacy-client’s have within themselves the capabilities to change successfully.

Three Critical Components of Three Critical Components of

MotivationMotivation

• Ready – a matter of priorities

• Willing – importance of change

• Able – confidence to change

Why do people Why do people change?change?

Client motivation is key to change……..

And client motivation is greatly influenced by the provider.

Provider behavior that tend to elicit or Provider behavior that tend to elicit or

increase resistance:increase resistance:• Arguing for change

• Assuming the expert role• Criticizing, shaming, blaming

• Labeling• Being in a hurry

• Paternalism

A thought….A thought….“People are not resistant to change; they resist being

changed.” – Kevin Eikenberry

Micro-skills (OARS)Micro-skills (OARS)• Open-ended questions – not easily answered with

a “yes/no”

• Affirmations – statements that recognize client strengths.

• Reflective listening – Careful listening and reflective responses

• Summaries – recap of what occurred in all or part of the session

AskingAskingAsk ample open-ended questions Ask ample open-ended questions

to:to:• Establish rapport, gather information, Establish rapport, gather information,

increase understanding (assess)increase understanding (assess)

• Elicit what is important to person (agenda-Elicit what is important to person (agenda-setting)setting)

• Demonstrate respectDemonstrate respect

• Affirm autonomy and self-directionAffirm autonomy and self-direction

• Plant seeds (guiding)Plant seeds (guiding)

AskingAskingPractical SuggestionsPractical Suggestions• Ask twice as many Ask twice as many openopen questions questions

as closed questionsas closed questions

• Keep questions clear and briefKeep questions clear and brief

• Avoid negating open questions Avoid negating open questions with closed ones – e.g. How is it with closed ones – e.g. How is it going? going?

AskingAskingPractical SuggestionsPractical Suggestions• Ask questions that generate change Ask questions that generate change

talktalk

DDesire esire – “What do you want, wish…?”– “What do you want, wish…?”AAbility bility – “What can or could you do?”– “What can or could you do?”

RReasons easons – “Why would you make this – “Why would you make this change?”change?”

NNeed eed – “How important is this – “How important is this change?”change?”

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AskingAskingCCommitment ommitment – “What will you do – “What will you do next?”next?”

AActivation – “ What are you ctivation – “ What are you prepared to do?”prepared to do?”

TTaking Steps – “What steps aking Steps – “What steps can you take?”can you take?”

AskingAskingPractical SuggestionsPractical Suggestions• Ask hypothetical questions for Ask hypothetical questions for

clients who are less ready to clients who are less ready to change change – “What might it take…” “If – “What might it take…” “If you were to…” “Suppose you you were to…” “Suppose you continue as is…”continue as is…”

• If you are going to ask, then listenIf you are going to ask, then listen

ListeningListeningReflective statements:Reflective statements:• Show you are actually listening – Show you are actually listening –

key to patient-centered carekey to patient-centered care

• Are used to check rather than Are used to check rather than assume you know what the assume you know what the patient meanspatient means

• Require Require thinkingthinking reflectively reflectively

• Appear deceptively easy to use, Appear deceptively easy to use, but take practicebut take practice

ListeningListeningSIMPLE REFLECTIONSSIMPLE REFLECTIONS

Repeating or rephrasing Repeating or rephrasing – stay close to – stay close to what person saidwhat person said

COMPLEX REFLECTIONSCOMPLEX REFLECTIONSParaphrasingParaphrasing – major restatements that – major restatements that infers or guesses the clients’s meaninginfers or guesses the clients’s meaning

Reflection of feeling Reflection of feeling – infers or guesses – infers or guesses clients’s feelings; deepest form of clients’s feelings; deepest form of listeninglistening

ListeningListeningForming Reflective StatementsA statement, not a question; voice turns down at endA statement, not a question; voice turns down at end

• Common word is “you”Common word is “you”

• Complete the paragraphComplete the paragraph

You…You…So you…So you…It sounds like you…It sounds like you…You’re wondering…You’re wondering…That would be…for youThat would be…for you

ListeningListening

General considerations• Listening, even if for just a brief time, Listening, even if for just a brief time,

has no agenda except to understandhas no agenda except to understand

• An invitation, opening the door, An invitation, opening the door, attendingattending

• Asking is not listeningAsking is not listening

• Asking and listening fit naturally Asking and listening fit naturally togethertogether

InformingInformingGuidelines for informingGuidelines for informing• Ask permission Ask permission – “Would it be all right if – “Would it be all right if

I tell you one concern I have about this I tell you one concern I have about this plan?”plan?”

• Offer choices when possible Offer choices when possible – “One – “One option is to…, another is to…which do option is to…, another is to…which do you prefer?”you prefer?”

• Talk about what others do – “Some Talk about what others do – “Some patients in your situation…”patients in your situation…”

• Acknowledge the decision is the Acknowledge the decision is the patient’s to make patient’s to make

Let’s PracticeLet’s Practice

QuestionsQuestions