Objectives – Section 1: Section Time 10 minutes

• Identify how to go through the e-learning course in the most effective and efficient manner.

• Describe the guidelines for passing each module and the entire course.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

• Formative evaluations

   

1. Introduction

   1. Welcome to this e-learning program

   2. How to learn from this program

   3. Receiving continuing education credit

      1. Passing all modules and summative evaluation

      2. Assessment questions

Objectives - Section 2: Section Time 20 minutes

• Explain why motivational interviewing was brought into health care from psychology.

• Elaborate on how training health care professionals in motivational interviewing is different than training psychologists.

• Distinguish between traditional approaches to motivational interviewing and the approach taken in this e-learning program.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

• Formative evaluations

                       

1. Background on Motivational Interviewing (MI)

   1. Origin in psychology and addiction

   2. Ambivalent and resistant patients

   3. Evidence of how MI works

2. Our New Approach to MI

   1. The context of the relationship

   2. Training of health care professionals (HCPs)

   3. The patient or client

   4. Sense making and practical reasoning

      1. Building rapport

      2. Addressing the patient’s issues directly

   5. A new definition

Objectives – Section 3: Section Time 25 minutes

• Differentiate between practitioner centered and patient centered care.

• Explain why MI is a patient centered approach to care.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

• Formative evaluations

   

1. Practitioner versus Patient-Centered Approaches to Care

   1. Problems with Practitioner-Centered Approaches

      1. Telling patients what to do

      2. I am the expert

      3. Educating the patient

      4. Motivating the patient

      5. Wrestling with patients

      6. Difficult patients or patients in denial

      7. Disease management

      8. Empowering patients

   2. Patient-Centered Approaches

      1. Respecting the patient as a whole person

      2. Honoring the patient’s right to decide

      3. Personalized care

      4. Facilitating the patient’s experience

      5. Genuinessness

      6. Transparency

      7. Shared decision-making

      8. A sense of safety and care

Objectives – Section 1: Section Time 25 minutes

• Discuss the relationship between the human brain, threat, patients who are ambivalent or resistant to behavior change and the use of motivational interviewing.

• Explain how social threat and face loss can result in patients discounting or dismissing health information.

• Differentiate between competence and autonomy face loss and their impact on relational resistance.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

• Formative evaluations

   

1. Introduction

   1. Brief review of Module 1

2. The human brain and threat

   1. Default position of the human brain is threat-avoidance

   2. Patients who are ambivalent or resistant to change are hypervigilant about threat – including social threat

   3. The amygdala and limbic system

      1. Fight, flee, freeze

      2. Patients only openly process information that is nonthreatening

   4. Persuasive strategies don’t work

   5. Examples

3. Social threat and face loss in patients

   1. Face loss

      1. Autonomy face loss

      2. Competency face loss

      3. Saving face

   2. Patient opts out of listening – distrust the health care professional

   3. Issue resistance remains

   4. Relational resistance is borne

Objectives – Section 2: Section Time 30 minutes

• Describe how threat experienced by the health care professional can undermine the relationship and behavior change.

• Explain how meaning creates feelings.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

• Formative evaluations

1. Threat and avoidance in health care professionals

   1. What do you do when you feel threatened?

   2. The limbic brain is not patient centered

   3. Health care professionals are “doers”

      1. What do you do when patients don’t want to do something?

         1. Suspend your need to do

         2. Fix them

         3. Do motivational interviewing

   4. Compassion and patient centered responses are impossible in the limbic brain

2. Feelings and meaning

   1. How do feelings occur?

   2. Anger and powerlessness

      1. Anxiety and blaming and labeling

   3. “Oh crap” moments and anxiety

   4. Introspection is critical

Objectives – Section 1: Section Time 20 minutes

• Explain how sense making creates motivation for change.

• Describe the relationship between a sense, the resulting conclusion and the decision about behavior.

• Based upon patients’ statements, identify the appropriate sense making of the patient, the patient’s reasoning, the concern(s) or issue(s) of the patient, and appropriate information to address the patient’s concern(s) or issue(s).

• Apply skills to patient cases.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

• Formative evaluations

1. Introduction – review of our new approach

   1. Problems with traditional acronyms

      1. READS, DARN, OARS

      2. HCP focused too much on remembering letters and not the patient

   2. Health care professionals are different than psychologists

      1. Training

      2. Time to spend with patients

   3. Delving more deeply into our approach

2. Sense making and practical reasoning

   1. Human beings are sense makers

   2. Reason our way through everything – practical reasoning

   3. Use our reasoning (and available information) to draw conclusions about things

   4. Reasoning about health behavior for ambivalent or resistant patients is often misguided

      1. Incomplete information

      2. Inaccurate information

   5. Example of patient sense making

      1. “I don’t know why I need this medicine. I feel fine.”

      2. Sense – I feel fine

      3. Conclusion – I am fine

      4. Decision about behavior – I’m not doing anything

      5. Unstated assumption – If I feel fine I am not at risk

      6. Information presented MUST address the issues and concerns (and unstated conclusions) if the patient is to move forward

   6. Our role in MI

      1. Listen and accurately identify how patient is making sense

      2. Reflect back our understanding in a nonjudgmental and caring manner

      3. Provide new information that directly addresses the sense making and reasoning

      4. Invite the patient to reconsider a new conclusion

   7. We ask patients to tell us how they are making sense of their illness and treatment

      1. Gives us an accurate understanding of how the patient views their illness

      2. Allows you to target your expertise to address their sense making

      3. Done with respect, care and concern

      4. Promotes collaboration

      5. Allows the patient to tell their story

      6. Increases the chance of behavior change

   8. Examples

      1. 2 Different patients with diabetes

         1. Inappropriate response

         2. Appropriate response – MI

            1. Patient’s sense is honored and reflected

            2. Their issues are addressed directly and respectfully

Objectives – Section 2: Section Time 15 minutes

• Based upon patients’ statements, identify the appropriate sense making of the patient, the patient’s reasoning, the concern(s) or issue(s) of the patient, and appropriate information to address the patient’s concern(s) or issue(s).

• Apply skills to patient cases.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• Learner participation (clicking on items)

• Formative evaluations

   

1. Case studies and module assessments

Objectives – Section 1: Section Time 25 minutes

• Explain why rapport is crucial to behavior change.

• Apply skills to patient cases.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

• Formative evaluations

1. Introduction

   1. Module 3 recap

   2. The critical importance of rapport

      1. Especially important with ambivalent and resistant patients

      2. Helps reduce threat so information can be heard, otherwise threatening

      3. Everything starts with rapport

      4. Must be woven throughout the process

      5. Rapport takes work and a conscious effort to help the patient

      6. Rapport is the leverage that opens up the patient to new information

   3. Becoming good at MI requires two fundamental processes

      1. Building and maintaining rapport throughout the process

      2. Directly addressing the patient’s sense making

      3. Doing both produces synergy

   4. Four examples of ways to respond to patients

      1. Low rapport; does not address the patient’s issues

         1. Creates face loss

         2. No change expected

         3. Relational resistance likely

      2. High rapport: does not address the patient’s issues

         1. No face loss or relational resistance

         2. High sense of safety

         3. No change expected

      3. Low rapport; addresses the patient’s issues

         1. Face loss and relational resistance likely

         2. Information seen as threatening

         3. Low likelihood of change

      4. High rapport; addresses the patient’s issues – MI

         1. No face loss or relational resistance

         2. Sense of trust and safety

         3. Information is considered

         4. Change is much more likely

Objectives – Section 2: Section Time 35 minutes

• Identify how to develop rapport in each step of the motivational interviewing process.

• Differentiate between appropriate and inappropriate rapport building

• Apply skills to patient cases.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

Formative evaluations

1. Introduction to the six steps of the MI process

   1. Explore and reflect the patient’s issues (sense making)

   2. Reframe the issues, if necessary

      1. Much like reframing a painting

      2. Helps patient see issues in a new light

   3. Ask permission to provide new information to address sense making

   4. Provide new information

   5. Ask the patient what he/she thinks of the new information

   6. Summarize next steps and plan for change

2. The use of rapport building in each step

   1. Step 1 - Reflecting the patient’s sense making

      1. Giving up our need to judge is crucial

      2. Patient’s reasons and sense making may be misguided but they must not be judged

      3. It is all valuable information to help us know what changes may need to be addressed

   2. The importance of listening

      1. An active, nonjudgmental process

      2. What are we listening for?

         1. How the patient is making sense

         2. What reasoning is the patient using

         3. How personally important is the behavior to the patient?

         4. How confident is the patient that he/she can do what is needed?

         5. What are the feelings involved?

            1. Feelings are not good or bad

            2. Empathy

            3. Empathic reflections are critical to building trust

         6. What is left unsaid by the patient that must be addressed?

      3. Sample dialogs

   3. Step 2 - Reframing

      1. “You’re wondering”

      2. Analogies

      3. Example

      4. More on reframing in Module 5

Objectives – Section 3: Section Time 40 minutes

• Identify how to develop rapport in each step of the motivational interviewing process.

• Differentiate between appropriate and inappropriate rapport building

• Explain the synergy of MI

• Apply rapport building skills to patient cases.

Presenter (Faculty) – Bruce A. Berger, PhD

Teaching Methods, Strategies

• PowerPoint slides

• Dialogs with analysis

• Learner participation (clicking on items)

1. Step 3 – Asking permission to share information

   1. Done with permission

   2. Exception to asking permission

      1. Violation of ethics

      2. What to do

2. Step 4 – providing information

   1. Must be understandable

   2. Directly address the patient’s issues

   3. Examples

3. Step 5 – What does the patient think of the new information?

   1. Don’t assume acceptance and understanding of the information

   2. Promotes collaboration

   3. Explore further if needed

4. Step 6 – Summarize and Plan for Change

   1. Provides closure and accomplishment

   2. Practitioner vs patient centered

1. Sample dialog illustrating rapport building in each step

   1. Analysis of dialog

2. The Synergy of MI

   1. Brief description of research supporting and defining the synergistic effects of MI

   2. Synergy occurs from:

      1. High rapport

      2. Directly addressing the patient’s issues

      3. Both are critical

   3. Conditions violating Synergy and results

   4. Conditions supporting synergy and results          

3. Why is MI still so challenging for HCPs

   1. Old language habits

   2. Past training

   3. Expect to learn MI a step at a time

   4. Be patient with yourself

   5. Notice the difference in your patients’ responses

   6. You will become more relaxed over time

   7. MI can be freeing

      1. No longer burdened with believing it is your job to convince, persuade or motivate your patients

      2. No longer driven by your own need to fix