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LMAP: Coaching, Motivational Interviewing and Brief Interventions Yoon Soo Park, 4 December 2022 ysp19@ic.ac.ukOutline of session 1. Health coaching and motivational interviewing A. Spirit of MI, OARS framework, 4 processes of MI B. Change talk and rolling with resistance C. Setting goals (& SMART goals) 2. Brief interventions and screening tools A. VBA and IBA B. Audit-C, SADQ, CIWA-Ar, GPPAQ, MUST, Scot-PASQ 3. Smoking A. Assessing smoking addiction level B. Psychobiology of nicotine addiction C. Treatment of nicotine addictionHealth coaching Why? • Many long term health conditions are associated with modifiable risk factors • A very time efficient method • Opportunistic • Making every contact count • Cost effective How? • Referral to health coach for series of health coaching sessions • Opportunistically during consultationsHealth coaching Key coaching principles and issues to consider: 1. The patient’s assumed resourcefulness - Can the patient understand and retain the information + weigh up the pros and cons? 2. A relationship based on mutual trust and respect - Is the patient being manipulative/dishonest or do they not respect/trust you? 3. Coaching is about change and action - The patient must want to address their issue and be prepared to explore itEffective coaching questions Important things to remember: Open and short questions Solution-oriented questions Pause Avoid double, triple questions Start with ‘what’, ‘how’ rather than ‘why’Useful questions to help set goals and explore motivation • What is the issue? • What makes this an issue now? • What is important to you about this issue? • How motivated are you to address this issue? • What part will be most useful to focus on in the next few minutes? • What do you want ideally?Motivational interviewing (MI) Definition: A collaborative, person-centred form of guiding to elicit and strengthen motivation to change ß Spirit of Motivational interviewingMotivational interviewing skills - OARS framework O pen questions: • ‘What are your thoughts on this?’ • ‘How confident do you feel about this?’ A ffirmations: positive statements or gestures emphasising strength and abilities • ‘I really appreciate that you have made the time to focus on this’ R eflective listening • ‘You mentioned that work has been very stressful, can you tell me more about that?’ S ummaries • ‘Can I just check I’ve understood what you are saying?’The ‘Four Processes’ of MI 4. Planning: Supporting patients identify possible options/opportunities/resources 3. Evoking: Supporting patients in exploring their situation further 2. Focusing: Identifying a health behaviour-related goal 1. Engaging: Building connection and rapportRapport building techniques Involves full attention, mutual respect, empathy and a curious, non-judgemental mindset Tips on building rapport: 1. Active listening 2. Tone of voice 3. Non-verbal communication (eye contact/nodding/leaning forward) 4. If meeting patient for first time: spend more time with introduction 5. Clear, slow speech with pauses between sentences (call consultations) 6. Emphasise non-verbal communication and look into the camera for video consultationsChange talk and ‘rolling with resistance’ Change talk = positive language • What is stopping you from achieving your ideal outcome? • What needs to happen for this change to become possible? • What part of this do you have control over? • What would be different and better for you if you make this change? • How will you know when you are ready to make this change? • What is going well/right? Key skill: ‘Rolling with resistance’ • Allow patients to express resistance without feeling judged or pressuredNext steps Useful questions to help the patient plan next steps include: • What are your options? • How will you decide which option(s) to follow? • What are your next steps? • What might get in the way of your plans? • How could you adapt your plan if need be? • What resources can you access to help you? • Who can help support you in your plan of action? • What would really make a difference to achieve success? • When will you make a start? • How will you review your progress?Setting expectations/goals with the patient 1. Practicalities a) Location? timing? 2. Approach to confidentiality a) Discuss with patient – may have to be broken in certain Important situations aspects to consider 3. Expectations of the roles of practitioner and patient a) Be clear from the start to reduce any misunderstandings b) Healthcare practitioner’s role = from expert to enabler 4. Boundaries of work a) Limits of competence 5. Keeping a recordSMART goals Other factors to consider for effective S pecific goal-setting: - Importance of goal M easurable - Motivation - Alignment with situation A chievable/attainable - Control R elevant T imelyCOM-B model of behaviour change The model suggests that behaviour is a result of: 1. Capability (ability – physical and psychological) 2. Motivation (reflective and automatic) 3. Opportunity (environment – physical and social)MENTI CODE - 2971165SBA 1 Which of the following is a key principle of health coaching? A. The practitioner must come up with the behaviour changing solutions for the patient. B. The patient must come up with their own solutions without any help from the practitioner. C. The patient must want to address their health behaviour. D. A health coaching relationship is based on how well the practitioner knows the patient.SBA 1 Which of the following is a key principle of health coaching? A. The practitioner must come up with the behaviour changing solutions for the patient. B. The patient must come up with their own solutions without any help from the practitioner. C. The patient must want to address their health behaviour. D. A health coaching relationship is based on how well the practitioner knows the patient.SBA 2 Which of the following is NOT an aspect of the spirit of motivational interviewing? A. Compassion B. Evocation C. Persuasion D. AcceptanceSBA 2 Which of the following is NOT an aspect of the spirit of motivational interviewing? A. Compassion B. Evocation C. Persuasion D. AcceptanceSBA 3 The starting point for health coaching conversations is to look at the… A. Past B. Present C. FutureSBA 3 The starting point for health coaching conversations is to look at the… A. Past B. Present C. FutureSBA 4 A health coaching approach starts with the assumption that… A. The patient has failed in making any changes to their health behaviours. B. The patient is resourceful and is an expert in their own life situation. C. The patient is going to be unable to think of health behaviour changing solutions themselves. D. The patient will be able to successfully make the recommended changes to their lifestyle after the conversation.SBA 4 A health coaching approach starts with the assumption that… A. The patient has failed in making any changes to their health behaviours. B. The patient is resourceful and is an expert in their own life situation. C. The patient is going to be unable to think of health behaviour changing solutions themselves. D. The patient will be able to successfully make the recommended changes to their lifestyle after the conversation.SBA 5 Which one of these is the most ideal question to ask during a health coaching conversation? A. Do you walk often? How about running? B. What does eating better look like for you? C. Why have you been exercising less recently? D. Don’t you think it’s really important for your health to be more physically active?SBA 5 Which one of these is the most ideal question to ask during a health coaching conversation? A. Do you walk often? How about running? B. What does eating better look like for you? C. Why have you been exercising less recently? D. Don’t you think it’s really important for your health to be more physically active?Brief interventions and screening toolsBrief interventions = a collective term for giving advice to help them change a variety of harmful behaviours Opportunistic High-impact skill Why? Cost efficient Time efficientStructure of a brief intervention 1. Identification of behavioural risk factor A. Eg: smoking, physical inactivity, poor diet 2. Explain best method to change this behaviour A. Eg: regular exercise, smoking cessation, 3. Signposting: how to obtain help Commonly: - Smoking - Alcohol use - Physical activityExample #1 of a brief intervention Smoking = VBA (very brief advice) <30 seconds 3 step structure of VBA: 1. ASK A. Establish and record patient’s smoking status (do you smoke?) 2. ADVISE A. ‘We found that the best way for people to stop smoking is with a combination of support and medical treatment’ 3. ACT A. Offer or signpost support and treatment (mention in detail)Example #2 of a brief intervention Alcohol: IBA (identification and brief advice) Structure of IBA 1. Identification: who is at risk? A. U singscreening tools (AUDIT-C) 2. Brief advice A. Motivational interviewing skills B. Implementation intention: not just vague commitment (what, where, when and how) 3. Support: self help or referral to a specialised alcohol service A. Patient info resources, apps, trackers for alcohol consumptionMECC (Making Every Contact Count) = An approach to behaviour change that aims to give everyone in an organisation the tools to promote positive health messages to everyone they encounter Advantages Disadvantages - Patients felt there was less of a - Increased workload for staff barrier when engaging with non- - Requires more training professional staff - Flexible approach - Low cost - Straightforward - Improves patient healthAudit-C Alcohol use disorders identification test = alcohol screen Scoring: 0-12 1-4 = Low risk (sensible drinking) 5-7 = Increasing risk (hazardous drinking) 8-10 = Higher risk (harmful drinking) 11-12 = Potentially addicted or dependentSeverity of alcohol dependence questionnaire (SADQ) Recommended by NICE - determine severity of someone’s alcohol dependence https://www.smartcjs.org.uk/wp-content/uploads/2015/07/SADQ.pdf SADQ questions cover: Scoring: • Physical withdrawal symptoms 31 or higher = severe alcohol • Affective withdrawal symptoms dependence • Relief drinking 16-30 = moderate dependence • Frequency of alcohol consumption < 16 = mild physical dependency • Speed of onset of withdrawal symptoms A chlordiazepoxide detoxification regime is usually indicated for someone who scores 16 or over.Clinical Institute Withdrawal Assessment for Alcohol – revised (CIWA-Ar) Used to assess severity of acute, unplanned alcohol withdrawal Scoring: <8: mild withdrawal (pharmacological tx not necessary) 8-15: moderate withdrawal (pharmacological tx may be appropriate to prevent progression) >15: severe withdrawal (pharmacological tx strongly indicated)General practice physical activity questionnaire (GPPAQ) Used in general practice to gain an objective view on how active someone is (takes approx 30s) Questions on: - Type & amount of physical activity involved in work - How many hours spent on certain activities during the last week - Describe usual walking pace (slow, brisk, steady average, fast) questionnaire-gppaqgovernment/publications/general-practice-physical-activity-Malnutrition Universal Screening Tool (MUST) 5-step screening tool to identify adults who are malnourished, at risk of malnutrition, or obese. Step 5: Management guidelines - Low risk: routine clinical care - Medium risk: Observe - High risk: Treat https://www.wales.nhs.uk/documents/MUST%20Nut ritional%20Screen.pdfScottish Physical Activity Screening Questionnaire (Scot-PASQ) Has up to 3 questions depending on answers given after each one. If patient is adequately active: positive reinforcement If patient wants to be more active: brief advice and/or brief interventions If patient isn’t interested: recommendations and patient leafletMENTI CODE - 2971165SBA 6 What are the 3A’s of VBA (very brief advice)? A. Affirm, Act, Amend B. Ask, Act, Affirm C. Ask, Advise, Act D. Aim, Advise, AdjustSBA 6 What are the 3A’s of VBA (very brief advice)? A. Affirm, Act, Amend B. Ask, Act, Affirm C. Ask, Advise, Act D. Aim, Advise, AdjustSBA 7 Which of the following is NOT an alcohol screening tool? 1. Audit-C 2. Scot-PASQ 3. SADQ 4. CIWA-ArSBA 7 Which of the following is NOT an alcohol screening tool? 1. Audit-C 2. Scot-PASQ 3. SADQ 4. CIWA-ArSBA 8 What severity of smoking addiction would a patient have if their time to first cigarette is <30 mins from waking? 1. Low addiction 2. Moderative addiction 3. High addiction 4. Very high addictionSBA 8 What severity of smoking addiction would a patient have if their time to first cigarette is <30 mins from waking? 1. Low addiction 2. Moderative addiction 3. High addiction 4. Very high addictionSmokingSmoking Why people might keep smoking: • Habit • Boredom • Stress • Social • Taste • Weight control • Nicotine addiction After stopping… - 24-48h for nicotine to leave body - 8-12w for nicotine receptors to down-regulateSmoking addiction level Assessing addiction level: Time to first cigarette (TTFC) after waking Number of cigarettes smoked Wakes at night Very high per day > 20 High addiction to smoke addiction <30 mins from High addiction 10-20 Moderate waking addiction 30mins – 2hours Moderate <10 Lower addiction from waking addiction >2 hours from Lower addiction wakingCompensatory smoking Fewer cigarettes may NOT mean less smoke inhaled Research: The more heavy smokers reduced their smoking, the more exposure they had to toxicants per cigarette due to more frequent puffs or deeper and longer inhales.Psychobiology of nicotine addiction Nicotine has the highest binding affinity at the α4β2 nicotinic receptors - Smoke takes 7-10 seconds to reach this area - Leads to rapid release of dopamine (feel-good NT) Ventral tegmental area (VTA) Effect of regular smoking on this dopamine release - Increase in receptors (long term effect) – enhances addictive effect ‘For most smokers, smoking is a chronic relapsing organic brain disease and not a lifestyle choice’Treatment of nicotine addiction Key to management: Examples of NHS trained stop smoking 1. Good support AND advisers: - Practice nurses 2. Evidence based treatments - Hospital nurses Goals of behavioural support: - Healthcare assistants 1. Reduce motivation to smoke - Pharmacists or pharmacy assistants 2. Commitment to abstain - Specialist stop smoking advisers 3. Enhance ability to cope with cravings 4. Ensure effective use of (Standard support regime = 4-6 pharmacotherapy appointments over 6-12 weeks)Evidence based treatment for smoking 3 licensed pharmacotherapy for smoking cessation 1. Nicotine replacement therapy (NRT) A. Available in many different forms: skin patches, gum, lozenges, mini lozenges, inhalator, oral spray, oral film and nasal spray 2. Bupropion (Zyban) A. Works by modifying dopamine levels and noradrenergic activity B. Reduces craving and withdrawal symptoms 3. Varenicline (Champix) - most effective All 3 should be consideredVarenicline mode of action Works at α4β2 nicotinic receptors in the brain Part-stimulating - Relieves craving and withdrawal symptoms Part-blocking - Blunts pleasurable effects of smoking - Reduces risk of full relapse after temporary relapseAlternative Unorthodox Treatment: E-Cigarettes Considered because: - Far safer than smoking (95%) - As effective as NRT for smoking cessation BUT: - Long term safety not known - Half of users also smoke - Controversial and many misconceptions When is it recommended? If patients won’t use varenicline, bupropion and combination NRTs for cessationMENTI CODE - 2971165SBA 9 Which receptor does nicotine have the highest binding affinity to? 1. α7 nicotinic receptors 2. α4β2 nicotinic receptors 3. α3β4 nicotinic receptors 4. α6β2 nicotinic receptorsSBA 9 Which receptor does nicotine have the highest binding affinity to? 1. α7 nicotinic receptors 2. α4β2 nicotinic receptors 3. α3β4 nicotinic receptors 4. α6β2 nicotinic receptorsSBA 10 What is the most common reason why people keep on smoking? 1. Habit 2. Nicotine addiction 3. Social 4. StressSBA 10 What is the most common reason why people keep on smoking? 1. Habit 2. Nicotine addiction 3. Social 4. Stress Thank you! Please fill the feedback form to receive the slides for this tutorial! Your feedback will be incredibly useful for future sessions. https://imperial.eu.qualtrics.com/jfe/form/SV _a5b5xJ4MaBihCNE
