A TOOL-BOX APPROACH TO
MOTIVATIONAL INTERVIEWING
PHARMACY COMMUNICATIONS
PROFESSOR MATT PERRI
OBJECTIVES
• Review the tool-box skills
• Identify reasons why we need to counsel and at
times go beyond traditional counseling methods
• Assess the role of the pharmacist in changing
patient behavior (medication adherence)
• Understand how to apply basic tool-box skills to
motivational interviewing (MI)
• Apply assertiveness and persuasion skills to improve
the care of our patients.
THE TOOL BOX
• Developing rapport (learning
names, respect)
• Respecting privacy
• Listening (summarizing,
paraphrasing, active listening)
• Empathic responding
• Attending to body language
• PAR (prepare, assess, respond)
• Open ended questions
• Use of silence
Awareness of perceptions
Stereotypes
Recognizing barriers
Respect
CLOSER
Verification
Interactive counseling, “filling in
the gaps”
• Assertiveness and persuasion
(soon to be added)
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Philosophy: Integrate these skills
into your own personal style of
communicating with patients.
THE TOOL BOX: MI
• Developing rapport *
(learning names, respect)
• Respecting privacy*
• Listening (summarizing,
paraphrasing, active
listening)
• Empathic responding
• Attending to body
language
• PAR (prepare, assess,
respond)
• Open ended questions
• Use of silence
Awareness of perceptions
Stereotypes
Recognizing barriers
Respect*
CLOSER*
Verification
Interactive counseling,
“filling in the gaps”
• Assertiveness and
persuasion
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• MI Uses these skills you
already know – * is
affirmation
PASSIVE, AGGRESSIVE AND ASSERTIVE
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Passive people tend to not respect themselves.
Aggressive people tend to not respect others.
Assertive people respect themselves and others.
People who are assertive tend to be more
persuasive.
• Do you agree?
• Why?
ASSERTIVENESS SKILLS
• Deal with confrontation, don’t avoid it.
• Inform the person by stating how you feel about their behavior.
• State the likely result of their behavior.
• Learn to say “No.” (Set personal limits in all areas, legal,
ethical, moral etc.)
• Remember, yes to something you don’t want is no to
something you do want.
• Do not fear asking for what you want, even when it
comes to the behavior of others.
• Do not fear expressing your opinion. Let others know
where you stand, this creates credibility.
• Initiate conversations, seeking opportunities to engage
others.
• Use an optimal level of self disclosure. Not TMI.
PERSUASION
• Assertive people tend to be more persuasive
• Related to perceptions of credibility
• Trustworthy
• Qualified
• Personal dynamism
• How could being more “persuasive” assist a
pharmacist in patient care, or you in dealing with
others?
• This is the essence of MI, but we want to be
persuasive not pushy.
PERSUASION
• MI is a technique designed to persuade patients to
engage lasting behavior change.
• Some skills are specific to MI, but, in general, to be
more persuasive:
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Find common ground
Be honest about your intentions
Be credible, admitting mistakes or knowledge deficit
Reinforce your messages over time (be patient)
Soften your appeals
Save most important points for last
THE MI TOOLBOX
• Everything you already know – applied differently
• Specific skills taught for MI
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Open ended questions
Affirmation (respect, reinforcement, praise, etc.)
Reflecting responses
Summarizing
Acronym: OARS
• MI is extended counseling to change behavior
• Medication adherence, smoking cessation, weight loss,
lifestyle change, diabetes, hypertension and many other
disease states.
THE KEY IS INTEGRATION
C O M B I N E WI T H Y O U R O WN P E R S O N A L S T Y L E
INTEGRATION OF METHODS WE KNOW
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PPCP/Prime Questions/Interactive Counseling
Verification
PAR Technique
RIM(next week)
Motivational Interviewing
MEDICATION ADHERENCE / MTM /
PHARMACOTHERAPY REVIEW
• Logical next step in patient counseling
• We can think about counseling for adherence
differently than the introductory counseling we do
with a new prescription.
• New Rx: Make sure the patient knows how to take the
medication, what its for and what to expect, how to deal
with bad effects.
• Refill: What is the experience? Is the patient taking the
medication correctly? Why? What you identify here could
lead you to decide MI is an appropriate step for a patient.
• Patient with complex regimen, polypharmacy, etc.
A DIFFERENT PERSPECTIVE ON
ADHERENCE
• Compliance
• Biomedical Model
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Practitioner centered
Information giving
Dictate behavior
Authority
Persuade / Manipulate
Argue
We are here to “save”
the patient
• Adherence
• Psychosocial Model
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Patient centered
Information for change
Negotiate behavior
Negotiation
Understand, accept
Address issues
The patient saves self
ADHERENCE SOME KEY POINTS
• Low adherence can result in treatment change
when its not needed!
• Patients may or may NOT be ready to change
behavior
• It is the patients job to manage disease
• Patients want more involvement
• We will look at 2 methods to improve adherence
• Motivational Interviewing and the RIM Technique
COUNSELING TO ENHANCE
ADHERENCE
USING MI
MI EXAMPLES
• Most are MD and behavioral therapists
• Relatively newer for pharmacy professionals
• Examples:
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Appropriate (MD example/CD)
Inappropriate (MD example/CD)
Heart Foundation Video and related videos
Bill Matulich: Introduction to MI
MI GROUNDED IN THE SCIENCE OF
BEHAVIOR CHANGE
Trans Theoretical Model of Behavior Change (TTM)
TTM EXAMPLE: PHARMACISTS BILLING FOR
COGNITIVE SERVICES
TTM
• Stages of change
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Pre-contemplation
Contemplation
Preparation
Action
Maintenance
• Self efficacy
• The extent or strength in ones belief to reach a goal.
• Decisional balance
• The balance of the pros and cons related to a behavior
change.
PATIENT READINESS TO CHANGE
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Change Process
Patient may be
completely
unaware.
Consciousness
raising
Re-evaluation
Self liberation
Stimulus control
Self-Efficacy (This will be good for me.)
Low confidence I
can do it or that
change will help
Increasing
confidence in the
positive aspect of
change
Increasing
confidence
High confidence
High belief
continued change
is good / continue
desired behavior
Decisional Balance
Cons > Pros
Cons ~ Pros
Cons < = Pros
Cons < Pros
Pharmacist Role in the Process of Change
Increase
awareness
Motivate, tip the
balance
Develop an action
plan
Assist and support
the patient
Provide reminders
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol 1992;47:1102–4, and Miller WR, Rollnick S.
Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991:191–202
MOTIVATIONAL INTERVIEWING
• MI is an effective (evidence based) way to talking
with people about change.
• We are focusing on the skills (toolbox approach) you need.
The process will come later with practice!
MOTIVATIONAL INTERVIEWING
• Begin by eliciting information from the patient
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Tell me about….?
What are your thoughts on…?
How much do you….?
Do you think you…?
So, where does not ______ leave you?
Do you think it will be hard to….?
What are the good aspects of….?
What are the less good aspects of..?
• KEY: The information from questions like these help us
understand where the patient is in terms of readiness for
change.
MI TOOLS
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Rolling with resistance
Expressing empathy
Avoiding argumentation
Developing discrepancy (dissonance = motivation)
Supporting (self efficacy, i.e., this change will be
good)
• READS (Roll, Express, Avoid, Develop, Support)
MOTIVATIONAL INTERVIEWING
• A partnership where we respect the patient, keeping their best
interest in mind and eliciting ideas for change from the patient.
• Seeks to enhance the patient’s motivation to change
• Focus on exploring awareness, problems, ambivalence /
resistance
• Aim: to create dissonance between goals and the non-adherent
behavior.
• Patients will reduce the dissonance by adopting the adherent behavior
• The process makes change a “good” thing
• But remember, dissonance creates motivation for change and as dissonance
decreases so can motivation which is one reason why we see relapse. The hope is
the new behavior is rewarding and creates its own motivation to maintain.
EXAMPLE: ROLL WITH RESISTANCE
• Ignore any antagonistic elements.
Antagonistic
Roll with it…
Look, I haven’t had any
problems with not taking this, so
don’t worry about it.
I hope things stay that way, but
maybe you should see your
doctor since the damage to
your kidneys caused by high
blood pressure doesn’t really
show up till much later when its
too late for the medication to
help.
I don’t have a cough. Smoking is
fine for me.
I hope that continues to stay
that way since many of the
diseases smoking causes don’t
have any early symptoms
EXAMPLE: EXPRESS EMPATHY
Statement
Response
Smoking is relaxing
But it’s bad for you.
Smoking is relaxing
It will be hard to give up
something that is so
relaxing.
Smoking is relaxing
So take up knitting or
something.
EXAMPLE: AVOID ARGUMENTATION
• We want the patient to feel we are on their side.
Argumentative
Avoid Argument
Your are late on your refill.
Mrs. Smith, I see you are getting
your medicine every 40 days or
so when its only a 30 day supply
You are supposed to take this
twice a day.
Taking this medicine twice a day
will help more to lower your
blood sugar.
Smoking is bad for you.
You may feel better if you smoke
less.
EXAMPLE: DEVELOP DISCREPANCY
• Dissonance = motivation
What’s good/not good
What are the good things and
less good things about change?
Pros and Cons
You may feel better if you take
your medication more regularly.
Your cough may decrease if you
smoke less.
Goals
Tell, what is your goal related to
your blood pressure medication?
Re-enforce discrepancy
That’s right. Your blood pressure
isn’t under control.
Not taking your medicine for
your diabetes is leading to high
sugar readings and eventually,
serious complications.
EXAMPLE: SUPPORT SELF EFFICACY
• A persons belief in the possibility of change
• And, the belief the change will be good for them
• Mrs. Smith, its terrific that you are taking the medication
every day as we’ve discussed.
• Your blood pressure today was excellent, your goal to take
this medication daily has really seemed to help.
MI EXAMPLES
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Diabetes counseling without MI
Diabetes counseling with MI
Cholesterol counseling with MI
Ineffective smoking counseling
Effective smoking counseling
• If you get bored, or are just a music fan, watch Tim
Lafolette’s video of motivational interviewing set to
the tune of Adele’s “Rolling in the Deep”
READINESS RULER
• Readiness ruler questions are informative
• How important is the change?
• Do you think you can do it?
• Example:
• On a scale of 1-7, where 1 is the lowest and 7 the highest,
how important is it for you to take you blood pressure
medication every day?
• If the patient answers “3” ask: why not a “1”
• What would it take for you to say “4” or “5”?
THE ENVELOPE
• Smoking:
• I just don’t want to quit smoking.
• If I were to hand you an envelope, what would the
message inside have to say in order for you to want to quit
smoking?
• Using too much pain medicine:
• I take more than the prescribed amount because I have
pain.
• If I were to hand you an envelope…..
MI: SUMMARY
• We use dissonance to create motivation
• Encourages patient involvement where they can
state their own concerns and goals
• Provides us with information we can use to effect
change
• Fills in gaps for patients
• Identifies barriers to good medication and habits
• Focus on how meeting your goals and changing
behavior will be good for you
• Emphasizes empathy in responding to patients.