Helping patients reduce sexual health risk using a Motivational

Interviewing approachSTIF workshop

15.9.08

Objectives

• Summarise the NICE recommendations for reducing STI/HIV

• Consider the primary HCW role in helping people reduce sexual health risk

• Introduce Motivational Interviewing (MI) (Miller 1983)

• Introduce the Stages of Change model (Prochaska & DiClemente 1986)

• Consider feasibility of integrating into practice• Review local service provision

Prevention of STI and under 18 conceptions (NICE 2007)

• Recommendations 1 & 2• One to one structured discussions with

individuals at high risk of STIs… • structured on the basis of behaviour change

theories. …• address factors that can help reduce risk-taking

and improve self-efficacy and motivation. • each session …15–20 minutes. • The number of sessions will depend on

individual need.

Challenges with risk reduction

• What difficulties have you encountered?

• What has worked well?

• Have you avoided such discussions – if so, why?

Process of Change ModelAdapted from Prochaska & DiClemente (1986)

Stable, ‘safer’ lifestyle

Pre-contemplative

Preparation

Action Maintenance

Relapse

Contemplation

What is MI?

“A person-centred, goal-orientated approach for facilitating change by exploring & resolving ambivalence”Miller (2006)

“a skilful clinical style for eliciting the patient’s own good

motivations for .change” (Rollnick, Miller & Butler 2008)

The spirit of MI

• “Dancing rather than wrestling”• Collaborative

– conversation between equals; working together; joint decision making

• Evocative– Elicits patients own motives and resources for change

• Honouring patient autonomy– Emphasise patient choice and control– Avoid creating resistance through coercion

RULE Guiding Principles

• Resist the righting reflex

• Understand your patient’s motivations

• Listen with empathy

• Empower your patient

Opening strategies - OARS

• Open questions

• Affirmations

• Reflective listening

• Summarise

Exploring ambivalence

• Good things / not so good things

• ‘Decisional Balance’ demonstration– Good things about unprotected sex– Not so good things about unprotected sex – Good things about condom use – Not so good things about condom use

Decisional balance demonstration

Patient

18 year old female

Presents with PID symptoms

2 previous episodes of chlamydia

3 casual partners in past 6 months

All unprotected vaginal sex

Assessing readiness to change

Importance Confidence (self-efficacy)

IMPORTANCE

CONFIDENCE

10

101

1

Giving information

• Wait for client to ask or / seek permission

• Offer choices / what other do

• Elicit- provide- elicit

Roll with resistance

• Avoid arguing - may increase resistance to change

• Resistance cue to change strategies • It is for the client to make decisions about

change• The client is the primary resource in finding

answers and solutions

Group practice exercise

Patient18 year old femalePresents with PID symptoms2 previous episodes of chlamydia3 casual partners in past 6 monthsAll unprotected vaginal sex

What would you not say?What might you say, in the spirit of MI?

MI in practice

Let me explain just how serious chlamydia /PID is, and why you need to avoid it in future!

You need to start using condoms!

I know you are in a hurry but this won’t take long!

What do you know about chlamydia / PID? Would it be helpful if I gave you a bit more information?

How do you feel about using condoms?

You seem in a hurry. ..is there anything you need to talk about before you go ?

What next?

• Goal setting: “What could you do to reduce your risk for

STDs/HIV/pregnancy?” (Examples of goals: condom use, reducing

number of sexual partners, safer sex, contraception, partner testing.)

• Action Plan: “How would you go about that?” “What would be the difficult thing about that?” “How would you overcome it?”

Summary

• Spirit of MI - collaborative, evocative, respect for autonomy

• RULE- Resist the righting reflex, understand, listen with empathy, empower

• Information giving - elicit – provide – elicit

• Exploring ambivalence – decisional balance (pros and cons)

• Importance and confidence• Roll with resistance

Further reading

• Rollnick, Mason and Butler (1999)

Health Behaviour Change: A Guide for Practitioners.

• Rollnick, Miller and Butler (2008) Motivational Interviewing in Health Care

• Miller & Rollnick (1991) Motivational Interviewing