Welcome to the COPE Webinar Series for Health Professionals! November 19 th webinar: Time: Moderator: 12 1 PM EDT Rebecca Shenkman, MPH, RD, LDN Program Manager, MacDonald Center for Obesity Prevention and Education MacDonald Center for Obesity Prevention and Education (COPE) Goals Provide Continuing Education Partner with agencies and organizations Handouts of the slides are posted at: www.villanova.edu/cope Participate in Research Enhance Education 11/19/13 Webinar: Presenter: Julie C. Michael, PhD Post-Doctoral Fellow, Divisions of Endocrinology and Behavioral Health Children s Hospital of Pittsburgh of UPMC Objectives: Learner will be able to: 1. Discuss behavioral needs of youth with diabetes 2. Discuss principles of motivational interviewing (MI) 3. Discuss how principles of MI can relate to meeting behavioral needs of youth with diabetes Credits: This webinar is approved for 1 contact award awarded by ANCC and 1 CPEU awarded by CDR. Suggested CDR Learning Need Code: 5000, 5190, 6000; Level 2. Notice: Neither the webinar planners or the presenter have any conflicts of interest to disclose for this presentation. Villanova University College of Nursing Continuing Education is an accredited provider of nursing education by ANCC. Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). MOTIVATIONAL INTERVIEWING FOR YOUTH WITH DIABETES: GUIDING INDIVIDUALS TO MAKE HEALTHY LIFESTYLE CHOICES Julie C. Michael, Ph.D. Children s Hospital of Pittsburgh of UPMC Post-Doctoral Fellow, Divisions of Behavioral Health and Endocrinology michaeljc@upmc.edu Overview Motivational Interviewing (MI) and Health Behavior Change Motivational Interviewing for Youth with Diabetes Processes of Motivational Interviewing The Method of Motivational Interviewing Common Challenges of Motivational Interviewing What is Motivational Interviewing? Began with William Miller and Stephen Rollnick (1992) Initial model used for patients with substance abuse disorders Growing research base for adaptation to other disciplines Final Summary 1
MI Definition A collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring a patient s own reasons for change within an atmosphere of acceptance and compassion (Miller & Rollnick, 2013). Differences from Typical Medical Model Patient-centered approach Work with the patient or family Focus on patient autonomy and changes made when ready Clinician takes a guiding approach Focus on gradual changes Spirit of MI Motivational Interviewing and Health Care Collaboration Wide applications Reducing health risk behaviors Evocation SPIRIT Acceptance Promoting positive health behaviors Improving self-management Enhancing treatment follow through Compassion Current Research Completed primarily with adolescents Motivational Interviewing for Youth with Diabetes Positive effectiveness of MI with adolescents and health behavior change (Suarez et al., 2008) Of three diabetes studies reviewed (Christie & Channon, 2013), MI interventions associated with: Improved perception of diabetes Reduction of HbA1c Sustained changes in quality of life and HbA1c after 1-year follow up 2
Common Behavioral Demands of Youth with Diabetes Medication adherence (insulin, metformin, etc.) Checking blood sugar Dietary considerations Physical activity Logging and reviewing blood sugar numbers Checking for ketones www.typeonederful.com Why is MI a good fit for this population? Most have diabetes education In MI, patients are not taught how to. Rather, the MI approach relies on the patient s own natural change processes and resources (Miller & Rollnick, 1991). Increased risk for mental health issues as compared to youth without diabetes Most youth can identify clear physical, social, and psychological reasons for change Helpful to facilitate positive changes in youth to assist with long-term management Developmental Perspective for Youth with Diabetes Age and development matter! Need to consider: Age of Diagnosis Cognitive Development Social Development Emotional Development Family System Level of Independence and Supervision Processes of Motivational Interviewing: What are the different components of patient-provider interactions? 3
Processes of Motivational Interviewing Engaging Evoking Planning Foundation of work together Develop therapeutic alliance Discussion of health-related or non-health related topics Focusing Time frame is variable Engaging Beware: Assuming patient is there for obvious reasons and using that as a starting point Miller & Rollnick, 2013 Focusing Target what the person is there to discuss Develop a specific direction for the rest of your conversation Patient, parent, and clinician agendas may be different Beware: Losing focus of the patient s agenda Evoking Elicit motivations for change May feel unnatural because it is contrary to the medical model Have the person voice their own motivations for change Beware: Assuming health is the main motivation for change Planning When the patient is ready, make a plan! Often needs to be reassessed as changes are made Consider incremental changes towards long-term goal Beware: Making a plan of what you think works for everyone Key Points about Processes of MI Patients need to be ready to make their own changes based on their own reasons for change Health behavior change is not a one-size-fits-all model The clinician is the guide towards behavior change, and it is a privilege to be on the journey. Engaging, focusing, evoking, and planning are components to cover along the way. 4
Core Skills of Motivational Interviewing The Method of Motivational Interviewing: How do you do it? Open ended questions Affirmations Reflective listening Summarizing Informing and Advising Open Ended Questions Used to encourage reflection and elaboration Invites the patient to do most of the talking Examples What are some things you like to do for fun? (Engaging) How do you manage your blood sugar while you play basketball? (Focusing) What are some reasons that it s important for you to improve your diabetes control while you play? (Evoking) What would be the next step that you would need to take to check your blood sugar at basketball practice? (Planning) Open Ended Questions that Promote Change Disadvantages of Negative Behavior (Status Quo) What does it feel like when your blood sugar is high? Advantages of Positive Behavior How do you typically feel when your blood sugar is within the target range? Assess optimism for change What makes you think you re ready to make these changes now? Assess intentions to change What would be different about your day to day life when you re ready to make these changes? Affirmations Respect and honor the patient as a person of worth Accentuate the positive Enhance rapport through empathy and validation Be careful of cheerleading! Example: Even despite not meeting your goals like you had hoped, you really worked hard to stay positive and come to our session. Reflections Used for hypothesis testing of patient s intentions and behavior. Goal is to elicit more talking and clarification from the patient Try to selectively reinforce and reflect change talk When in doubt, reflect! 5
Type of Reflections Patient: My parents are always on my back about recording my numbers. If they would just stop bothering me so much, I d probably do it on my own. Simple reflection: It bothers you that your parents constantly remind you about logging your numbers. Complex reflection: Your parents constant reminders make it challenging for you to be as independent as you would like. Double-sided reflection: You have been having trouble writing your numbers down lately, and at the same time, you want to find a way to log your numbers independently without your parents reminders. Summaries Collection of reflections to provide back to the person what they have been saying Possible uses To suggest links from one session to another To recap information before going to another topic area To recap plan before ending a session Provide an opportunity to ask if anything is missing What else? Summaries Example You came in today because your doctor told you that you have to bolus insulin more often before eating. Although you think it s a hassle to give insulin before you eat, you recognize that having your sugar better controlled would likely give you more energy and you d feel less thirsty all the time. Informing and Advising Appropriate to offer information or advise, especially when the patient asks for it Information is offered with permission Patient is free to reject the information and it is often useful to acknowledge this fact Elicit provide elicit format Informing/Advising Example Clinician: Tell me what you know about how your average blood sugar and A1c is related to your overall health. (Elicit). (Patient responds) Clinician: Would it be OK if I added to that information? (Patient says yes). A1c is a measure of average BG in a 3 month period, and it represents a percentage of glucose carried on your blood cells. Your A1c of X at last clinic visit means Y. (Provide) Clinician: What do you make of that information? How does it relate to you? (Elicit) Key Points about the Method of MI The goal is for the patient to talk more than the clinician! Affirmations are used to strengthen rapport through empathy and validation. Reflections are useful to strengthen alliance as well as selectively reinforce change talk towards desired behavior. Summaries help to consolidate information, reinforce important points, and gather any missing information. Information may be offered with permission using the elicitprovide-elicit framework. 6
Righting Reflex by Clinician Common Challenges of Motivational Interviewing: How do I work around them? Patient expresses an issue and clinician wants to make it right and fix them Righting done by telling information they know and why they should do the positive behavior Typically leads to resistance If you notice this occurring: Acknowledge what you re doing Emphasize autonomy of the patient Patient Ambivalence about Change How to work around this? Keep ears open for change talk and selectively reflect Patient Motivation for Change is Unclear Assess motivation using rulers to gauge ability, confidence, importance, or desire for change Preparatory change talk Desire: I want to have more energy. Ability: I can check my sugar more often. I did it last summer. Reason: I would like to keep all my limbs when I m older. Need: I need to stop all this fighting in my family. Mobilizing change talk Commitment: I promise I ll check my sugar 5 times tomorrow. Activation: I m willing to talk to my mom about going out to eat less often. Taking Steps: I checked after I treated any low blood sugars this week. Example: On a scale from 1 (least important) to 10 (most important), how important is it for you to check for ketones each week? Probe about number choices Reflect responses and continue to ask, What else? Key Points for Navigating through Challenges Stay with your patient and resist the urge to fix Work with patient to make a plan they are willing to do not what you think they should do Final Summary Be aware of change talk, and continue to selectively reflect this information Rulers are tools used to quantify ability, confidence, importance, or desire for change. Use core skills to gather qualitative data. 7
Key Points Motivational Interviewing is an empirically supported style of working with patients to help them make health changes of their choice. There is promising initial evidence for positive outcomes related to use of MI with youth with diabetes. Keep in mind factors that underlie the spirit of MI collaboration, acceptance, evocation, and compassion and work to avoid common pitfalls. Practicing core skills are typically a helpful way of developing the spirit of MI. Acknowledgments Special thanks for contributory ideas from colleagues on the MI curriculum advisory group as part of Children s Hospital of Pittsburgh of UPMC, Western Psychiatric Institute and Clinic, and University of Pittsburgh Medical Center: Dana Rofey, Melanie Gold, Anne Marie Kuchera, Nasuh Malas, Antoine Douaihy, Katrina Fletcher, Justin Schreiber, Sarah Homitsky, Roberto Ortiz-Aguayo, Dena Hofkosh, Jon Pletcher, Gina Sucato, Via Winkeller Evaluations and CE Certificates Everyone who has completed the webinar will be emailed a link to the evaluation within 2 business days. The email will be sent to the email address that you used to register for the webinar. Once the evaluation is completed, the CE certificate will be emailed separately within 2 business days. Title: Date: Time: CE Credit: COPE s December Professional Webinar (it s free!) Presenter: Angie Hasemann, RD, CSP Clinical Dietitian University of Virginia Children s Hospital & Morrison Management Specialists Weight Based Bullying: The Silent Culprit Complicating Pediatric Obesity Wednesday, December 11 th 12:00PM 1:00PM EDT 1.0 contact hour, 1.0 CPE To register, go to villanova.edu/cope or https://www3.gotomeeting.com/register/622872326 Questions and Answers! Moderator: Rebecca Shenkman, MPH, RDN, LDN Email: rebecca.shenkman@villanova.edu Web site: villanova.edu/cope To receive monthly emails on upcoming COPE events, please join COPE s Contacts on the web site. Thank you for your time and interest. 8