Article originally featured in access™ 2018, volume II

Contributor: Patricia Shane, Ph.D, M.P.H.

Motivational interviewing and its importance to the pharmacy technician

As healthcare professionals, we do all we can to try to help our patients. But we can’t make our patients help themselves.

We can’t will them to quit smoking. Or force them to stop being so sedentary. Or make them prioritize sleep. And sometimes, an inner drive from the patient to make lifestyle changes is what is necessary in order to provide the lasting healing they need.

Although we can’t make lifestyle changes for them, we can help them arrive there on their own through a technique known as motivational interviewing.

What Is Motivational Interviewing?

Motivational interviewing engages patients through collaborative conversation. Instead of making demands of patients, patients can begin to make demands of themselves.

This person-centered approach addresses the common, but often unspoken, problem of ambivalence about change. It is designed to elicit and explore the person's own reasons for change within an atmosphere of acceptance and compassion, and can strengthen an individual’s own motivation and commitment to make healthier, adaptive changes—especially behavioral or lifestyle changes.

When & Where is it Used?

Treatment modalities ranging from addiction to complex medical care have seen success with motivational interviewing, which originated in a counseling context. Especially situations where patients are not necessarily in agreement about the need to change an unhealthy behavior, i.e. addiction problems with alcohol and other drugs. When evidence, information and education are simply insufficient to achieve improvement in a patient’s health, motivational interviewing can make an impact.

Why Patients Don’t Accept Treatment Recommendations

Traditional treatment approaches emphasize information and education as the key exchange between healthcare providers and patients. These approaches have an underlying assumption that patients are motivated to accept treatment recommendations.

And if patients always did what was suggested by their healthcare provider, there would probably be less repeat visits.  

But patients are human. And their beliefs, values and preferences have a significant influence on whether or not they will follow a medication regimen and their capacity for persistence in relation to adherence. Their beliefs often conflict with the “best” medical evidence. What you might see as fact they see as something that’s against what they believe in.

The answer is not to place blame on the patient. Blaming patients is a pervasive feature of medical encounters and can introduce mistrust—distancing patients from decisions that are not their own. The unintended consequences can negatively impact a patient’s identity and self-respect as well as their willingness to follow a treatment regimen.

 A Need for Change

In the United States, chronic disease conditions and the health risk behaviors that contribute to them account for most of the nation’s $2.7 trillion in healthcare costs. The Centers for Disease Control and Prevention estimate that 86% of all current healthcare spending in the U.S. is for people with one or more chronic medical condition(s).

Underlying these costs is the elevated risk contributed by unhealthy behaviors, which are considered preventable since these risks can be avoided. Four of these health risk behaviors—lack of exercise or physical activity, poor nutrition, tobacco use and drinking too much alcohol—cause much of the illness, suffering, and early death related to chronic disease conditions and the resultant illnesses. Overall, modifiable risk factors are largely responsible for each of the leading causes of death: Current estimates indicate that chronic diseases account for as much as 70% of all deaths in the U.S.**** 

The Evolving Role of the Pharmacy & the Importance of Following Medication Regimens

One of the changes taking place is the scope of pharmacy services shifting toward a greater emphasis on providing direct patient care and integration of pharmaceutical care*. This shift in focus makes motivational interviewing even more valuable, and the Accreditation Council for Pharmacy Education (ACPE) and the American Association of Colleges of Pharmacy (AACP) stress motivational interviewing as an essential skill for pharmacists and the delivery of pharmaceutical care.

If skillfully used, motivational interviewing can contribute to a much stronger therapeutic alliance by:

• Increasing a patient’s engagement in their treatment
• Reducing the potential for nonadherence
• Encouraging patients to fully participate in decisions affecting their health
• Non-judgmentally opening the conversation to consider their personal values and preferences—even if those values and preferences are at cross-purposes with the “evidence”
• Explicitly acknowledging and addressing ways to resolve ambivalence
• Encouraging behavior change to achieve better outcomes**

Working with patients in a way that is collaborative rather than prescriptive honors the person’s autonomy and self-direction, and is more about evoking than authoritative instruction. 

This involves a willingness to suspend an authoritarian or expert role, and to explore a patient’s capacity rather than incapacity, with a genuine interest in his or her experience and perspective. It also acknowledges the importance of an informed, activated patient for self management. And our patients’ capacity for self-management is fundamental to their ability to sustain adherence to a treatment plan.

We know that prescription medications are an essential component of treatment. But if prescription drugs are to fully realize their potential benefit and deliver improved health outcomes, then there need to better methods for ensuring that patients have the ability and support they need to actually follow the drug regimen in their treatment plan.

Unfortunately, overall, nearly 75% of adults are nonadherent in one or more ways, such as not filling a new prescription or taking less than the dose recommended by the physician.

When adherence is poor, worsening conditions can result—especially for those with chronic conditions.

Putting it into Action: Key Aims of Motivational Interviewing & Techniques

Motivational interviewing techniques involve establishing communication with (not to) patients and can ultimately shape a patient’s response to medications, including adherence and persistence with therapy and lifestyle choices. Specifically, motivational interviewing:

• Shifts the discussion to a patient-centered, rather than a disease-focused interaction.
• Systematically explores the ambivalence associated with a behavior.
• Better utilizes opportunities to discuss patients’ health related behaviors—diet, exercise, smoking, alcohol use and self-management of health problems.
• Encourages patients to express their own reasons for concern with their lifestyle behaviors or their prescribed treatment regimen.
• Builds patients’ intrinsic (internal) motivation to adopt and maintain treatment recommendations.
• Helps resolve patients’ ambivalence about behavior change and strengthen his/her ability to take responsibility.

There are five micro-counseling skills (AROSE) that are helpful when using motivational interviewing and each one helps to keep the communication grounded in a patient-centered framework.

Affirmations – Statements that recognize and reflect the patient’s strengths and efforts. These are used to rephrase a patient’s concerns or self doubts as evidence of positive qualities. These are ways to support a patient’s self-efficacy.

Reflective Listening – Conveying understanding, exploring a patient’s concerns, eliciting change talk.

Open-ended questions – Avoiding questions that can be answered with a yes/no response; promoting collaboration; inviting patients to explore their thoughts and feelings about a health-related issue.

Summaries – Brief recaps that reinforce the patient’s perception that his/her story has been listened to and understood as well as offering an opportunity to verify what has been said; highlight a patient’s perspective on their own ambivalence about change.

Elicit Change Talk – Getting the patient to tell you what the priority problem is from their perspective.

The five guiding principles of motivational interviewing can be remembered using a mnemonic device: READS. These are sometimes referred to as the “spirit” of motivational interviewing and are the skills and techniques that are used in working with patients. These techniques help to ensure that the encounter is experienced as caring and patient centered.

Roll with resistance – Rather than confrontation or asserting authority, one affirms that the patient has the autonomy to make their own health-related decisions. The conversation moves fluidly, in step with the patient’s perspective.

Express empathy – Experiencing the patient’s world as if it were your own. It is different from sympathy, and involves earnestly trying to understand and reflect the patient’s experience of managing life with his/her condition.

Avoid argumentation – Accept and acknowledge negative statements, but don’t set up an oppositional position.

Develop discrepancy – Highlighting the difference between actual and ideal behavior or actual behavior and ideal values.

Support self-efficacy – Affirm the patient’s strengths and ability to be effective on their own behalf.

While it may at first sound simple, developing proficiency in using and adapting this approach usually takes practice and evolves over time. 

As patients arrive at the pharmacy, the pharmacy technician may be the first person they meet. Motivational interviewing techniques have a valuable role to play in these experiences. Reflecting on ways to connect and incorporate motivational interviewing into one’s own professional practices and work environment offers opportunities to gain a better therapeutic alliance with your patients and have a rewarding contribution to the growing emphasis on patient-centered care.

References:

*National Governors Association. The expanding role of pharmacists in a transformed health care system. Available at: https://www.nga.org/files/live/sites/NGA/files/pdf/2015/1501TheExpandingRoleOfPharmacists.pdf

*** “Take as Directed: A Prescription Not Followed,” Research conducted by The Polling Company. National Community Pharmacists Association December 16, 2006.

**** Chronic Diseases the Leading Cause of Death and Disability in the United States. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. June 28, 2017 https://www.cdc.gov/chronicdisease/overview/index.htm