I) BACKGROUND AND DEFINITIONS
- Motivational interviewing (MI) is important
- Motivational interviewing is a theory-based communication skill set with an established evidence base for its potential to affect patient outcomes in comprehensive disease management, even during brief encounters.
- Motivational interviewing is a patient-centered process used to gauge a patient's readiness to act on a target behavior and to apply specific skills and strategies that respect the patient's autonomy and facilitate confidence and decision-making.
- Transtheoretical model of behavior change
No intention to change behavior, and may be unaware of the need to change
Aware of the problem and seriously considering change, but no commitment to take action
Intends to take action within one month and makes small behavioral changes
Patient has changed their behavior within the last six months
Patient has changed their behavior more than 6 months ago
- Supporting Self efficacy (SE): defined as one's confidence to engage in a particular target behavior, higher self-efficacy predicts action for change on a target behavior.
- Overall goal: Move patient to a state of change or action by nonjudgmentally exploring ambivalence and resistance with the preaction patient
II) THE SPIRIT OF MI
- Spirit of MI: A way of being that is foundational to MIadherent intervention. The spirit of MI is collaborative, caring, nonjudgmental, and includes support of patient autonomy in treatment decision-making.
o The most important thing to remember about MI is that the first priority is building and preserving the relationship, even if the patient leaves without a commitment for change.
o Be direct and assertive
III) INTERNAL VERSUS EXTERNAL MOTIVATION
- Each patient contemplating change internally weighs the pros and cons of the decision
- Decisional balance: pros must outweigh the cons for a patient to move forward with changing their behavior
- In MI, the process helps the patient think of/voice their “pros” rather than the provider lecturing the patient on the pros.
- We want to elicit the patient’s internal motivation
- More likely to be sustained
- In MI, internal motivation > external motivation
- “External motivation” may do more harm than good
IV) MAINTAINING PATIENT AUTONOMY
- Skills that support patient/autonomy
- Open-ended questions
- Also illicit more information than close-ended questions
- Instead of asking “Did you miss taking any of your doses?” – try asking “About how many doses did you miss last week?”
- Agenda setting
- Give the patient a choice about which topic to discuss first
- Patients may have a topic they want to discuss and may become anxious about forgetting to ask their question or unable to focus
- Helps to organize and structure the encounter
- Asking permission before giving advice or information
V) 5 MAIN COMMUNICATION PRINCIPLES
- Express empathy
- Helps the patient feel the provider is listening and trying to understand
- Empathy is not sympathy (e.g., “I am sorry… ”), instead, empathy focuses on the patient and the underlying effect: “It is unfair that your mother died of a heart attack at such a young age.”
- Examples of proper phrases such as “you seem ____, you sound____”
- Develop discrepancy
- Meant to be thought provoking
- Can help a resistant patient begin to think about change
- Some things that may help
- Repeat pros/cons that the patient has already stated
- Ask about behaviors that do not support the goals that the patient states
- Ask thought provoking questions
· What would have to happen to have to get you from a 5 to 6 on the readiness ruler?
- Remember to always use compassion and nonjudgement tone!
- Support self-efficacy
- Praise the behavior, not the person
- “Mr. Y it's great that you have been taking your blood pressure medication regularly”
- b. Can simply involve noticing, encouraging, and supporting patient attempts, or even thoughts, about change.
- Roll with resistance and avoiding argumentation
- Treat resistance as information that can be explored
- Patient may expect pharmacist to engage in an argument...then this does not happen, it leaves opportunity for thought-provoking behavior to occur
VI) CHANGE TALK
- Definition: a form of intention to change, or intention to think about changing
- May include the patient expressing acceptance or movement regarding a target behavior
- Eliciting Change Talk
- We can illicit change talk by asking the patient open-ended (thought-provoking) questions
- "What do you see as the benefit of taking your diabetic medication more regularly?
- " If I were to ask you to write down your pros for monitoring you blood sugar more regularly, what would be your top two?”
- Another strategy is to have the patient talk about previous successes
- “When you brought your A1C down previously, what were you doing that helped you achieve this success?”
- Have patients talk about how they felt during previous successes
- "How did it make you feel when your A1C fell by half a point?"
- Get the patient to visualize how their life may be different after the change
- "How would it feel to you if taking X medication regularly brought down your Y lab, reducing your risk of Z disease?"
- Readiness ruler: a tool used to measure a patients readiness, importance, or confidence for engaging in a target behavior
- Scale of 1 to 10: 1 being not at all ready/confident and 10 being completely ready/confident
- When the patient responds, ask follow-up questions to elicit change talk
- "6 is great! Why a 6 and not a 7?"
- "What would have to happen for it to be a 7 or 8?"