Insightful hints from behavioral health specialist Kristi Paguio, LMSW
Part I of a 3 Part Series: Motivational Interviewing
“The serious and chronic nature of diabetes, the complexity of its management, and the multiple daily self-care decisions that diabetes requires mean that being adherent to a predetermined care program is generally not adequate over the course of a person’s life with diabetes.” 1
Currently, several approaches exist when addressing behavioral change with people who live with diabetes and we all know some are more effective than others. To gain a better understanding of the best approaches, I’ve asked a colleague of mine, Kristi Paguio, LMSW, a behavioral health specialist with an expertise in diabetes, to lend her hand while writing this piece.
Most every educator I’ve met, whether it is in academia, primary education, or diabetes education, leads with a passion to help others learn and grow, achieve and succeed. Plainly stated it seems almost unnatural and maybe even uncomfortable for those in these positions to stop directing and advising rather than just listen. We have so much to share and such a strong will to do good, however, we are at risk to "fire-hose" our patients, dousing any glimmer of a chance to help them make the changes we know are so needed for their livelihood. Patients struggling with chronic illness, that require adherence to complex daily regimens, ie diabetes, appear to be only weakly motivated by other people’s suggestions as to what lifestyle and self-management issues they should focus on and improve. 2 This is truly why it’s called “Diabetes Self-Management Training.” Our role is to partner with our patients and work alongside them rather than direct and persuade them because the reality is, they can and often do, veto any advice we make. What we see as peppering them with our pearls can actually appear to them as unsolicited
advice.
When looking for ways to improve your effectiveness, understanding the marriage between motivational interviewing and patient empowerment are two visions with an obligatory place in diabetes education and the ideal chronic care model. Allowing the concepts of these two visions guide us becomes more of an art the more it’s practiced. It’s probably also safe to say that there’s really no endpoint in becoming better at it. It is an organic process by nature and one that is unique at every interval. In turn, we cannot start with our years of experience in diabetes when we look inward to assess ourselves and our need to change our rhetoric. This is a slippery slope because, in fact, the patient may have more years of experience than we do with diabetes. They for sure are the expert of their own lives and what motivates them. The years of experience we have doesn’t necessarily mean that the patient will find that valuable or applicable to where they are in their journey. It is of high importance to see the expertise the patient brings about themselves to this partnership. Once this is brought of the patient, we can offer what we know in our professional experiences. Basically, we may have relevant information to offer and feel we understand the patient, but unless they feel that way, the hoped gain is lost.
In reading this blog series, maybe you plan to glean a couple one-liners, refresh on or reaffirm what you do, print one of the reference papers listed, and/or use the video below to share with your diabetes care team. In whichever case, we hope you find it meaningful to your practice.
Start with Motivational Interviewing (MI)
Before reading any further, check out this example of what not to do. What did you think?
First off, let’s revisit the hallmarks of motivational interviewing. The goal of MI is to get patients to change by strengthening their personal motivations to do so. This naturally opens up a dialogue whereby the patient will be doing most of the talking. The environment necessary to do this is patient-centered; it’s one of compassion, trust and empathy. In other words, a therapeutic alliance becomes established where the patient is provided the opportunity to assess themselves for what might be important or possible to focus on when considering making a change.2 The art of doing this is dynamic, fluid and cannot be reduced to a set of algorithms. 3 The art of this practice involves the creativity, values and personalities of us, as diabetes educators, as well as our ability and willingness to respond to the unique needs and personality of each of our patients.” 3 Moving away from directing our patients on what they “should” be doing, we can instead work as facilitators in helping them find the next step they are motivated to make.
There are four essential elements to remember when practicing Motivational Interviewing:
• Express Empathy
• Develop Discrepancy
• Roll with Resistance
• Support Self-Efficacy
Allowing the patient to set the pace and direction of the conversation helps to assist in creating a safe environment where the patient in comfortable to explore his/her behavior. 3 We can help the patient by identifying ambivalence (develop discrepancy), providing support (express empathy and roll with resistance) and relaying evidenced-based information (support self-efficacy). 3 Instead of giving advice, we can be active listeners by practicing reflective listening throughout our time spent with patients.
Examples of Reflective Listening4
“It sounds like…”
“What I hear you saying…”
“So on the one hand it sounds like…And, yet on the other hand…”
“It seems as if…”
“I get the sense that…”
“It feels as though…”
Here is a lovely video by Brené Brown video that represents what empathy looks like: Brené Brown On Empathy.
Developing discrepancies involves discovering what the patient values in life and whether his/her current behavior is consistent with or counters those values. 3 To minimize eliciting a defensive response, inquire what the patient is struggling with in their contradictory behaviors utilizing empathy. Although you want to point out the discrepancy, it’s equally important to decrease risk of shaming/confrontation. Ask clarifying questions rather than make statements. For example, “It sounds like you would like to eat healthier and have struggled setting your environment up to make healthy choices easy, did I hear you right?” Partnering with your patient can permit for exploring the negative outcomes related to current behavior and experiencing a sense of discomfort can help foster an increasing motivation to change. 3 Allowing this process to unfold at the patient’s discretion is key. After all, it’s not us who bring the motivation for change; it is helping the patient to bring it out of themselves.
Rolling with resistance is ignoring that voice in our head that wants to advise or coerce the patient when they show reluctance to take action. 3 People don’t like being told what to do and instead prefer to be given choices when making behavior change decisions.4 Traditionally, health care practitioners are notorious for lines like, “If you continue using you are going to have (insert horrible health consequence here.)”4 Remember we are facilitators of change, we are not driving the change. Rather than directly confront the patient about his/her averseness, foster new ways of thinking about the situation remembering the patient is in charge of generating solutions. 3
Supporting self-efficacy reinforces the patient’s confidence in taking control and changing behavior.3 Promote an atmosphere of positivity that helps solidify the patient’s beliefs that they can perform the specific tasks they set out to accomplish.3 It can be a tremendous help to normalize what the patient is working through by reminding them they are not alone in their experience or in their ambivalence about change.4
If there appears to be an area that needs to be addressed, open the conversation on change by asking permission to talk about it. It’s also always helpful to provide affirmations during your visit with patients. Try to ask a question, wait for their response, and then try to reflect
2-3 affirmations.
Examples of Affirmative Statements4
“Your commitment really shows by [insert a reflection about what the patient is doing].”
“With all the obstacles you have right now, it’s [insert what best describes the patient’s behavior—impressive, amazing].”
“By the way you handled that situation, you showed a lot of [insert what best describes the patient’s behavior—strength, courage, determination].”
Now look at the difference in counseling techniques here.
What are two steps that you can take to support your diabetes practice in implementing and growing your use of motivational interviewing?
For more Motivational Interviewing Strategies and Techniques, click here.
References
- Funnell M, Anderson R. Empowerment and Self-Management of Diabetes. Clinical Diabetes. 2004; 22:123-127.
- Welch G, Rose G, Ernst D. Motivational Interviewing and Diabetes: What Is It, How Is It Used, and Does It Work? Diabetes Spectrum. 2006;19:5-11.
- Mensing C, ed. The Art and Science of Diabetes Self-Management Education Desk Reference. Chicago: American Association of Diabetes Educators; 2011.
- Sobell and Sobell. Motivational Interviewing Strategies and Techniques: Rationales and Examples. http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf. Update 2008. Accessed September 14, 2015.
- Anderson R, Funnell M, Carlson Saaleh-Statin N, Cradock S, Skinner C. Facilitating Self-care Through Empowerment. Psychology in Diabetes Care. 2000:70-96.
Disclaimer: This blog is a personal opinion and does not necessarily reflect the position of the American Association of Diabetes Educators. The intention of this blog is to do no harm. The writer is responsible for all content but the writer is not responsible for any blog comments.