Elena Petrova, PhD

LEARNING OBJECTIVES

•  Define motivational interviewing (MI).

•  Describe the core concepts of MI.

•  Describe the link between MI and the Transtheoretical Model of Change.

•  Define health behavior change and discuss its significance.

•  Explain the importance of health behavior change in disease management.

•  Discuss MI principles, microskills, and strategies and describe the “spirit of MI.”

•  Use MI in patient interactions to facilitate behavior change.

KEY TERMS

•  Motivational interviewing (MI)

•  Person-centered approach

•  Spirit of MI

INTRODUCTION

This chapter provides a detailed overview of the motivational interviewing (MI) approach to patient counseling. MI has been widely used as a counseling method in mental health counseling, and it can be a very effective approach in counseling pharmacy patients. The chapter not only introduces MI, but it also seeks to spark further interest in how MI can be used when interacting with patients. This chapter also explores the theory behind MI with how it can be applied to patient–pharmacist interactions.

According to its creators, William Miller and Stephen Rollnick, motivational interviewing (MI) is a client-centered, directive method for enhancing internal motivation in patients to change their behavior as they explore and resolve their own ambivalence to change.¹ In other words, MI is a communication approach that, when used by the pharmacist, can help the patient find internal motivators to change a certain behavior (i.e., low or no adherence to treatment) that may be contributing to a decline in health.

This chapter presents several important aspects of MI. First, MI is patient-centered in that its primary focus is on the patient’s perspectives and concerns about his or her own health and treatment. Second, MI involves a directive process for interviewing the patient, which means that the pharmacist is deliberate in selecting skills and strategies to help the patient move in the direction of behavior change. Third, MI is a counseling method. In other words, it takes more than using one specific sentence or word to communicate with the patient. MI involves the use of a communication skill set. Fourth, the focus of MI is to increase the patient’s internal motivation to change a behavior. This is because internal motivation, compared to external motivation, is a much stronger impetus of change. When motivation comes from within the patient (i.e., personal and meaningful reasons to change), the patient is more likely to change and continue engaging in the changed behavior (e.g., adherence to the prescribed treatment). In contrast, an externally motivated patient (i.e., a patient who decides to change a behavior because someone else wants him or her to) will likely briefly engage in the changed behavior and will then lose motivation to keep engaging in it. Fifth, MI is not coercive, meaning that the pharmacist does not force the patient into making a decision. The patient has to willingly make a decision to change a certain behavior or to engage in a new behavior, and that decision has to have a personal meaning for the patient.¹

THE SIGNIFICANCE OF MOTIVATIONAL INTERVIEWING

MI has been used extensively in the last decade, both nationally and internationally. Research in the area of MI demonstrates a significant impact of this approach on addiction management, lifestyle change, and adherence to treatment.² Adherence to prescribed or suggested medications, therapy, or lifestyle changes has often been used to determine the effectiveness of a medical treatment and has remained a focus of research over the last 40 years. Health, behavioral, and social scientists have tried to identify the variables behind poor adherence as well as possible interventions for improving it. Evidence suggests that human factors, such as motivation or attitude, are as important as healthcare provider and healthcare system factors. Adherence has been tightly linked to a patient’s need to engage in a certain therapy, course of treatment, or specific health behavior.³ Adherence optimizes clinical benefits and increases the effectiveness of the intervention not only for primary prevention and risk-reduction interventions, but also for the promotion of healthy lifestyles, such as diet modification, increased physical activity, smoking cessation, and safe sexual behaviors. Adherence also has a significant effect on secondary prevention and disease treatment interventions.³

Different behavioral approaches can be used to improve medication adherence. It has been demonstrated that MI significantly improves adherence in patients. Systematic reviews and a meta-analysis of randomized controlled trials about the effectiveness of MI in patient behavioral changes have found MI to be effective in 74% (53/72) of randomized controlled studies.⁴

MOTIVATIONAL INTERVIEWING AS AN APPROACH

Miller and Rollnick developed a counseling approach to increase a patient’s internal motivation to change a behavior; they named their approach “motivational interviewing.”¹ The term motivational means that motivation is the underlying element for behavioral change, and interviewing refers to the way in which the patient and the pharmacist interact, wherein the pharmacist interviews the patient in a caring, nonjudgmental, open-ended manner to help him or her find the internal motivation he or she already has and to build a cooperative relationship with the patient. MI has been defined as a “person-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”¹ Another definition describes MI as “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.”⁵ These definitions of MI stress that the relationship between the patient and the provider is collaborative.

This chapter describes what skills the pharmacist can use to facilitate a collaborative and patient-centered relationship to strengthen the patient’s motivation to change a behavior. The pharmacist can use MI to help patients increase their understanding of an illness and/or a treatment and to address patients’ concerns. During the patient interview, the pharmacist provides information to the patient in a patient-centered manner, determines whether the patient is ready to change a behavior through careful listening, talks to the patient about his or her motivators and barriers for behavioral change, and affirms the patient’s change talk about behavioral change. Change talk is defined as the patient’s commitment language; that is, the patient communicating his or her reasons for changing and the advantages of changing.¹ When the patient uses change talk, he or she is identifying and communicating one or more of the following: the pros of changing the behavior; a specific plan to change the behavior; positive feelings, such as excitement, about changing a behavior; and so on.

Note that the theory that guided the development of MI identifies ambivalence as one of the main barriers to a person’s readiness to change a behavior. Thus, in MI the pharmacist must determine if the patient is communicating ambivalence about changing and has to openly talk with the patient about his or her ambivalence to change. Ultimately, the pharmacist’s larger goal is to help the patient use his or her internal struggles with changing the behavior and looking at his or her own motivation.⁶ In MI, the pharmacist focuses on the patient’s concerns and problems. The pharmacist shows respect for the patient’s autonomy by respecting the patient’s decisions regarding and understanding of health.⁶

MI is a directive approach. During the interview, the pharmacist guides the patient toward change using different strategies to help change a certain behavior.¹ In MI, the pharmacist uses five MI principles and a variety of MI strategies and microskills. The five principles of MI can be described with the mnemonic READS: roll with resistance, express empathy, avoid argumentation, develop discrepancy, and support-self efficacy (Table 8.1).^6,7 The five READS principles are guiding principles for the pharmacist. They are the building blocks of MI and will be described in more detail later in the chapter.

The following MI microskills have been identified: open-ended questions, reflective listening, summarizing, and affirmation.⁸ The use of these communication skills by the pharmacist ensures a caring and patient-centered approach. A menu of MI strategies is used to determine the patient’s understanding of the illness and how the proposed treatment fits the patient’s goals.⁹ MI strategies include the following: talking about the person’s current lifestyle and sources of stress; exploring how unhealthy behavior affects the patient’s health; a typical day; the good things and the less good things; providing information; the future and the present; exploring concerns; and helping with decision making (Table 8.2).⁸

TABLE 8.1 The Five MI Principles

Originally, MI was developed as a counseling style for use by mental health providers in counseling patients with addiction problems.¹⁰ However, MI has also been found to be effective for brief interactions in the healthcare setting with the same purpose; that is, to elicit behavior change in patients. An example of this type of interaction is that between the pharmacist and a patient. Regardless of the setting in which MI is used, the terms counseling and interviewing are used interchangeably. However, it is important to differentiate between the use of MI in mental health counseling and in pharmacist–patient counseling. When the pharmacist interacts with the patient, he or she uses brief MI. Unlike mental health counseling, in which the counselor and the client generally meet for several 50-minute sessions, with brief MI the pharmacist has short encounters with the patient that last 5 to 10 minutes.^7,11 Thus, some of the strategies used in mental health counseling are not as applicable for brief MI interventions in healthcare settings.

MOTIVATIONAL INTERVIEWING FROM A THEORETICAL STANDPOINT

It can be difficult to understand MI without understanding its theoretical background. MI is based on the person-centered approach to counseling that originated from humanistic psychology. MI also incorporates elements from social psychology, such as attribution, cognitive dissonance, and self-efficacy. Additionally, MI is aided by the Transtheoretical Model of Change, which provides a framework for the change process, and MI provides a way to facilitate this process.¹² One MI principle, developing discrepancy, is related to the concept of cognitive dissonance. MI helps the patient resolve his or her ambivalence about change by creating cognitive dissonance in the patient. With the help of MI, the patient chooses to resolve the dissonance through behavior change.

TABLE 8.2 MI Strategies

Another important principle in MI is its support of self-efficacy. The concept of self-efficacy was first described by Albert Bandura as “the degree to which an individual develops the expectancy that they will be able to perform desired behaviors (i.e., self-efficacy) is an important factor in behavior change.”¹² In MI, the healthcare provider supports the patient’s self-efficacy by encouraging the patient in his or her ability to change a particular behavior. Other theories and models that have influenced MI include the theory of reasoned action, social cognitive theory, decisional balance, the health belief model, self-determination theory, the self-regulatory model, and the locus of control.¹²

Motivational Interviewing and Person-Centered Theory

The person-centered theory and the person-centered counseling approach have played a significant role in the creation of MI. To better understand the basic principles of MI, it is important to understand how human nature and change are viewed in person-centered counseling. The person-centered approach is founded on the belief that people are trustworthy, resourceful, capable of self-understanding, and capable of making constructive changes to live productive and effective lives.¹³ Thus, a patient is more likely to change a behavior when the pharmacist is genuine, caring, empathic, and nonjudgmental. The patient–pharmacist relationship is egalitarian. It is the patient who is the expert on his or her own life.

Guided by the person-centered approach, the pharmacist facilitates the communication with the patient and does not dominate it. Of central importance to this approach is the pharmacist’s attitude rather than the particular techniques used. A genuine, caring, and accepting pharmacist can serve as a role model and guide the patient toward greater self-care. When working with a person-centered pharmacist, patients quickly learn that they hold the responsibility for their own change and growth. Change and growth occur in a safe, nonjudgmental, and supportive environment.¹³ The focus of the person-centered approach is not to judge the patient’s behavior, but to help the patient accept his or her own behavior, values, and beliefs. The person-centered approach reduces resistance in the patient and increases the patient’s readiness to change. This approach is especially helpful when working with patients who are ambivalent toward change.

One of the similarities between MI and the person-centered counseling approach is the central importance of the patient. Both MI and the person-centered theory require the interviewer to be empathic and genuine and to support the patient’s self-efficacy in the interviewing process. The main difference between MI and the person-centered counseling is that MI is directive, whereas the person-centered approach is nondirective. In MI, the interviewer has a global goal (i.e., to help the patient find and strengthen the internal motivation to change) and uses strategies and skills to follow with that goal in mind.¹ In the person-centered approach, the provider allows the patient to determine the flow and the content of the helping interaction.

The Link Between MI and the Transtheoretical Model of Change

As mentioned previously, the Transtheoretical Model of Change is one that has influenced MI. As a matter of fact, MI is used along with the Transtheoretical Model of Change for the purpose of discovering the patient’s level of readiness to change a behavior. The Transtheoretical Model of Change proposes that changes in behavior and attitudes do not occur immediately but occur over time. People pass through several stages of readiness for change, and each stage differs based on how the patient thinks and feels about change.¹⁴ In order to use MI effectively, the pharmacist first has to identify the patient’s current stage of change to help the patient move along the change continuum.¹⁵

According to the Transtheoretical Model of Change, a patient can be in one of five stages: precontemplation, contemplation, preparation, action, and maintenance (Table 8.3). In the precontemplation stage, the patient does not see a problem with his or her current problem behavior and has no interest in behavior change. Thus, the patient may say “I do not see [the behavior] being a problem for me” or “I do not have a problem with [the behavior].” In the contemplation stage, the patient has had initial thoughts about the problem behavior, has contemplated changing the behavior, may have experienced ambivalence about change, but has taken no action toward change. In the preparation stage, the patient engages in emotional, behavioral, and intellectual preparation and planning about changing the problem behavior and engaging in healthy behavior. For example, the patient may enroll in a fitness club to start exercising and ask a friend to join to hold the patient accountable in continuing with the exercise. In the action stage of change, the patient engages in the healthy behavior. In the maintenance stage, the patient maintains the healthy behavior by continuing to engage in it and by overcoming obstacles that prevent him or her from maintaining the behavior. The patient’s level of motivation is different in each of the stages. The goal is to move the patient toward the stages of preparation, action, and maintenance, where the patient’s internal motivation is greater.

TABLE 8.3 The Stages of Change

The Significance of Health Behavior Change

Patients receive instructions, recommendations, and suggestions from their healthcare providers, including pharmacists, regarding their treatment, medications, diagnostic procedures, diet, and lifestyle. Patients receive instructions and recommendations when to take their medications, how to take them, what to eat, or how to increase their physical activity. Healthcare providers and patients have the same goal: to improve the patient’s health or to prevent illness from occurring. Often, following instructions and recommendations from the pharmacist requires that the patient change daily life activities and certain behaviors. Learning to manage and live with a certain condition or illness may pose many challenges. It is even more challenging when a patient is diagnosed with a chronic condition because the patient has to adjust to the possibility of managing the chronic condition for a long period of time or a lifetime. The management of a chronic illness may require taking a prescribed medication, changing dietary habits, implementing exercise regimens, following up with a healthcare provider, self-monitoring blood pressure or blood sugar, and so on. In the management of any illness, patients often have to acquire new behaviors of self-care and change old behaviors in order to implement the instructions and recommendations from the healthcare providers involved in their treatment.

Behavior change does not come easy for many patients. People differ in their ability to initiate and integrate behavior change; some are more readily able to embrace change, others see no benefits of behavior change for health improvement or illness management. The Transtheoretical Model of Change enables the pharmacist to better understand the patient’s level of readiness to change a behavior, and MI guides the pharmacist in facilitating that change.

MI PRINCIPLES, MICROSKILLS, AND STRATEGIES AND THE “SPIRIT OF MI”

MI Principles

In MI, the pharmacist addresses a patient’s ambivalence and resistance through the use of five principles and a variety of strategies. As discussed earlier, the five MI principles are described with the mnemonic READS: roll with resistance, express empathy, avoid argumentation, develop discrepancy, and support-self efficacy.^6,7 This section describes what each principle means and how a pharmacist can use it in an interaction with a patient.

The principle of roll with resistance truly shows the spirit of the interaction between the patient and the provider. The pharmacist is “rolling” with the patient’s resistance, meaning that the pharmacist is not confrontational or argumentative with the patient. The pharmacist moves with the patient in whichever direction the patient is ready to move.¹ The pharmacist addresses the patient’s resistance in a nonconfrontational way and communicates to the patient that the patient holds the freedom and autonomy in making any decision related to his or her health.

The principle of avoid argumentation

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