Motivational Interviewing_Engaging the Patient

Motivational Interviewing

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Motivational Interviewing

and the Care

Manager

Building Rapport and Engaging the Patient

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Agenda

  1. The Spirit of Motivational Interviewing (MI)
    • MI is patient-centered
  2. The conversational skills utilized in MI
    • Open-ended questions, Active and Reflective Listening, Summaries, Guiding the conversation
  3. Sense making and practical reasoning
  4. Building Rapport
    • Creating and maintaining trust
    • Listening and empathic responding
    • Rolling with resistance

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The Spirit of MI

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MI and Your Role

Do you feel it is your job to motivate your patients?

MI is not about motivating your patients; it is concerned with assessing the patient’s motivation and exploring their ambivalence or resistance so that they are better equipped to make their own decisions.

If we shift our thinking from being in charge and feeling responsible for what a patient does, to becoming a caring and safe resource for the patient, change can happen.1

1 Berger, B. (2013) . Motivational Interviewing for Health Care Providers. American Pharmacists Association, 13

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The Spirit of Motivational Interviewing

MI is a collaboration between you and the patient. You may be the expert on clinical or social issues, the patient is the expert on self.

Collaboration

Your job is to "draw out" the person's own motivation and skills for change, not to tell him/her what to do or why he/she should do it.

Evocation

MI recognizes that the true power for change rests within the patient. Ultimately, it is up to the individual to follow through with making changes happen.

Autonomy

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MI is Member Centered

Motivational interviewing (MI) views the patient as a collaborative partner with expertise every bit as valuable as our own.

The patient is a person whose

thoughts and feelings matter, who have a

right to be heard and understood; a person who deserves our care and our unconditional positive regard.

MI is personalized care, finding out what is meaningful to our

patient.

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MI is Patient Centered

Respect for the patient– his/her concerns, thoughts and beliefs are not minimized, but accurately reflected and explored.

Genuineness – we want to understand the concerns of the

Patient and express this in a sincere manner.

Transparency – Information provided should be clear, objective, thorough, and transparent.

Shared decision making – be a resource and disclose to the patient things he/she can do to manage his/her illness.

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Summary The Spirit of MI

MI is a patient-centered, collaborative process between you and your patient. We move from information giving to information exchange.

It is a particular way of speaking that 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.

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Conversational Skills

Utilized in Motivational Interviewing

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Conversational Skills Utilized in MI

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Conversational Skills Utilized in MI

Clos e d -E n d e d Q u e s tions

Ope n -E n d e d Q u e s tions

1. Are you taking your medications

properly?

1. Tell me how you are taking your

medications.

2. Are you having problems with falls?

2. Tell me about your balance.

3. Why didn’t you go to the doctor like we talked about?

3. Tell me what happened to keep you from going to the doctor.

4. If you don’t use your walker, aren’t you likely to fall again?

4. What are the benefits of using your walker?

5. If you are already short of breath, why would you run after your grandchildren?

5. It sounds like you have fun playing with your grandchildren. How does playing with them affect your breathing?

6. You should put your husband in a nursing home. Obviously, it is a terrible strain on you.

6. You are doing well taking care of your husband. Tell me the effect that caregiving has had on your health.

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Conversational Skills Utilized in MI

Active Listening

  • Willingness to let other parties dominate the conversation.
  • Attentiveness to what is being said.
  • Care not to interrupt
  • Use of open-ended questions.
  • Sensitivity to the emotions being expressed.
  • Ability to reflect back to the other party the substance and feelings of what has been expressed.

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Conversational Skills Utilized in MI

Reflective Listening

Through skillful reflective listening, the care manager seeks to understand the patient’s feelings and perspective without judging, criticizing, or blaming.

Examples of Reflective Listening: “So what I hear you saying is…” “It sounds like you…”

“So you are feeling…”

This is what I am hearing, please correct me if I am wrong…”

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Conversational Skills Utilized in MI

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Expressing Empathy

Empathy is feeling ‘with’ that person, sharing the emotional experience with him/her and seeing it from his/her perspective.

It is a neutral process, there is no judgment or evaluation of the person or the feelings involved.

We do not have to agree with the patient’s perspectives but we do want him/her to know that he/she has been heard, understood, and respected on a deep level.

Don’t take sides when using empathy, just simply reflect back the

Patient’s understanding of how he/she is feeling.

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Conversational Skills Utilized in MI

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Conversational Skills Utilized in MI

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Conversational Skills Utilized in MI

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Conversational Skills Utilized in MI

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Conversational Skills Utilized in MI

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Summary of Conversational Skills Utilized in MI

When we utilize MI skills of open- ended questions, active and reflective listening, empathic listening, and guiding the conversation, we stand a better chance of helping our patients make changes that will benefit their health.

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Sense Making

And Practical Reasoning

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Sense Making and Practical Reasoning

Human beings are practical sense makers. We are constantly engaged in sizing up our situation and figuring out what we need to do to achieve our goals.

We adjust our practical reasoning as we

make sense of our changing circumstances.

The practical reasoning doesn’t mean the reason is correct or

incorrect, it just means that it makes sense to the patient.

What matters is the conclusion the patient draws.

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Sense Making and Practical Reasoning

When patients make conclusions based on the information they have at hand, these conclusions seem obvious and straightforward to them.

People make decisions about what needs to be done based on what is important to them; or whether they are confident they can do what is being proposed, or both.

Our patients are strongly motivated not only to defend these conclusions, but also to act on the basis of these conclusions.

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Sense Making and Practical Reasoning

If we want to have a positive influence on our patient’s sense making and practical reasoning, we have to do so in a way that avoids causing our patients to lose face. We can cause face loss:

  • If we start our interactions with the

Patient by telling him/her what to do.

  • If a patient shares his/her concerns and

issues with us but we don’t give any indication that we have heard and respected those concerns.

  • If we reflect back patient’s issues and concerns but move on to address other issues and concerns we consider more important.

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Sense Making and Practical Reasoning

We can also cause face loss by:

  • Reflecting back patient’s issues and concerns but moving on to give patient our standard ‘data dump’

or lecture.

  • If after hearing his/her practical reasoning and we tell the

Patient he/she is wrong or off base.

  • If we abruptly impose advice on the patient and suggest that we have solved his/her problems.
  • If we judge the patient’s practical reasoning as deficient or illogical and then tell him/her what he/she should be thinking.

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Summary of Sense Making and Practical Reasoning

The information we provide to the patient must affect his/her reasoning process. It cannot simply answer a question, it must guide the patient to rethink his/her line of reasoning or his/her sense making.

Unless the information we provide causes the patient to rethink his/her sense making, change will not take place.

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Building Rapport

And Engaging the Patient

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Building Rapport and Engaging the Patient

Developing rapport involves creating and maintaining a patient’s trust.

Your patients are observing and listening to you to determine “Can I trust this person?” “Do you have my best interests at heart?”

When rapport is built first, then the patient can hear the importance of the information provided without feeling threatened.

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Building Rapport and Engaging the Patient

  • Do NOT let patient feel that you are:
  • Just going through the steps.
  • Giving the patient your
  • standard lecture.
  • Running your own agenda.
  • Putting the patient down.
  • Blaming the patient.

Do let your patients feel:

  • My care manager really cares

about me.

  • My care manager really understands the issues and concerns I am struggling with.
  • My care manager has provided information that directly addresses my issues and concerns.

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Ways We Can Violate a Patient’s Trust

  • If we don’t pay attention to or listen to the patient.
  • If we consistently discount or judge what is important or meaningful to the patient.
  • If we scold or chastise a patient for ‘noncompliance’.
  • If we are consistently inaccurate in reflecting

the patient’s thoughts and feelings.

  • If we consistently imposes our ideas and goals

on the patient without the patient input.

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Listening and Empathic Responding

The process starts by making a determined effort to listen.

Generally, people don’t pay attention long enough to be good listeners.

Give your patients your full attention lets them know they are valuable.

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Listening and Empathic Responding

In order to be effective, we need to start understanding

more about the patient as an individual.

How does this patient make sense of his/her illness

and treatment?

Is he or she frightened, anxious, or overwhelmed?

We want to gather this information, understand it and

respond in a way that conveys caring.

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Listening and Empathic Responding

A full empathic response contains 3 elements, feelings, content, and reasons.

Example: You are frustrated (feelings) because you don’t feel that the doctor took you seriously (reason) when you told him how much your back hurts (content).

Often we cut it short, “you’re frustrated” or “he didn’t take you seriously”.

Be explicit so the patient knows exactly what you mean or what you understand.

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Barriers to Listening

We all tend to judge or evaluate the communication, problem, or feeling of the patient.

Understanding is different from evaluation of rightness or wrongness, goodness or badness.

To truly listen, we must temporarily give up our need to judge– give up the perspective that our frame of reference is the correct one. Hard to do!

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Barriers to Listening

  • When we hear our patients convey information or sense making that is faulty and we feel we need to correct it right away.
    • Respond with a non-judgmental reflection that reflects the patient’s perspective.
  • We try to fix a problem the patient is describing.

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Listening and Empathic Responding

Rapport is crucial for allowing information provided by the care manager to be accepted as an extension of caring. This can only happen when the perspective of the patient is acknowledged and respected without judgment.

Feeling understood strengthens the bond between the patient and care manager.

When effectively building rapport, we do not impose conclusions or draw conclusions for the patient. We allow the patient to draw his/her own conclusions.

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Listening and Empathic Responding

To be effective in helping to treat a patient’s illness, we need to start understanding more about the individual. It is important to ask the following questions:

  1. In the patient’s own words, how is he/she making sense of the illness? What does it mean to him/her?
  2. What does he/she think of the treatment? Does he/she

believe it is necessary?

  1. What is his/her understanding of what can happen if he/she doesn’t treat the illness?
  2. If he/she is committed to treating the illness, especially a chronic illness, what will keep him/her on track and what might get in the way over the long term?

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Rolling with Resistance

Rolling with resistance involves resisting the urge to push back at the resistance expressed by the patient and instead exploring that resistance.

Pushing back at the resistance only causes our patients to become more resistant and close to the door to future discussion.

Calmly accepting the patient’s resistance and exploring it keeps the door open to further discussion.

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Rolling with Resistance

If a patient is feeling angry, anger is born from a sense of powerlessness, helplessness, or a sense of injustice.

It is useful to think about what is making the patient feel that way.

Understanding a patient’s core concern allows us to make a more effective empathic response.

Stay separate, but present, and do not take the patient’s response personally.

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Rolling with Resistance

Example: the patient agreed to CCM services with the telephonic care manager and you’re calling to discuss the patients health care needs.

Patient: “I know I agreed to your calling but I have been rethinking that decision. I have so many provider visits. Adding another person who is here to ‘help’ me is too much! Im exhausted!”

Care Manager: You are overwhelmed with all the new medical professionals involved in your care and it is tiring for you. It also sounds like your not sure just how helpful they can be for you. Would it be ok if I gave you some information about our program and then you can tell me what you think? Ultimately, it is your decision whether to stay in the program.

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Rolling with Resistance

When we come across resistance,

  • Explore the sense making and reasoning that underlie the patient’s resistance.
  • Empathize with the patient’s sense making and reflect back his/her reasoning.
  • Ask permission to share information relevant to his/her reasoning.
  • Share the information in a clearly-focused fashion.
  • Then, invite the patient to tell us his/her thoughts about the information.

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Summary Rapport Building

To have rapport with another person means to be ‘on the same page’, or to be in-sync with that person. “My care manager ‘gets’ me.”

In a patient-centered relationship, it means the patient senses that he/she is genuinely understood and is not being judged or criticized.

When done correctly, the patient feels cared for and safe.

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Summary Rapport Building

The key elements of effectively creating rapport:

  • Empathy
  • Explicit, detailed reflections
  • Valuing and respecting the patient’s sense making

This means we listen to the patient without judgment and reflect our understanding in a way that says, “I fully hear your concerns or beliefs, I sense how important they are to you. I respect them and I want to help.

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Conclusion

Establish rapport with the patient by respecting the patient’s face and empathizing with the patient’s issues.

Address the patient’s issues by providing directly relevant information and inviting the patient’s response.