Motivational Interviewing
in Tobacco Cessation and Chronic Diseases
Physicians’ Institute
info@physiciansinstitute.org
Copyright Berger Consulting, LLC
bbergerconsulting@gmail.com
A Program of the Cease Smoking Today Partnership
www.ceasesmoking2day.com
.
The Problem
 Current models of care are paternalistic
 Communication is practitioner-centered, not
patient-centered
 Information giving vs information exchange
 Save the patient vs patients save themselves
 Labeling of patient: in denial, difficult, etc
 Compliance vs adherence
 Dictate rather than negotiate behavior change
The Problem (cont.)
 Resistance is dealt with as a flaw rather than
useful information that needs to be explored
 We don’t spend time identifying how patients
make sense of illness and treatment and how
we can helpwhat benefits do they derive
from tobacco?
 What do they know and understand about the
risk of not treating the illness?
 Schools teach HCPs that they are the expert
 New models of communicating with patients
are needed
Motivational Interviewing
Defined: Miller and Rollnick (1)
Motivational interviewing is a
person-centered (Rogers) directive (guided)
method of communication for enhancing intrinsic
motivation to change by exploring and resolving
ambivalence and resistance.
Note: focus on ambivalence and resistance
this is the key.
Key Points
 Motivational interviewing is concerned with
assessing a patient’s motivation for change,
not motivating the patient
 The skills used in motivational interviewing are
matched to the patient’s motivation (or readiness)
for change
 Create a climate that is safe to change and safe
to learn
 Assist the patient in making the argument
for change
 A look over the fence: smoker, weight loss
 What would have to change?
Key Points (cont.)
 Be honest and truthful with patients so they
can make informed choices
 BP of 160/110
 Be patient-centered
 Identify and respond to patient’s core
concerns and line of reasoning
 “Disease management”
 High cholesterol patient
The Spirit of Motivational Interviewing
 Agape
 Caring
 Collaboration
 Patient is the focus, not me
 Asthma patient, 27-year-old male smoker
 “You people”
 “I only signed up for the decrease in premiums
and no, I don’t want to quit smoking”
Key Concepts:
Decisional Balance
 Health behaviors involve voluntary behavior change
 Patients develop an internal decisional balance
about the change (pros and cons, benefits and
risks, etc)
 This balance may be subjective, but it must be
explored and “tilted” in favor of the benefits if
change is to take place
 The balance is quantitative and qualitative
 Exploring the decisional balance
 Benefits or pros
 Downside or risks or cons
Key Concepts:
Resistance and Ambivalence
 When people resist change, the worst strategy
is persuasionit forces them to defend the very
behavior you are trying to change
 When people are ambivalent, the pros=cons
 When they are resistant, the cons >pros
 When faced with ambivalence or resistance,
exploredon’t explain
 2 types of resistance
 Issue
 Relational
Issue Resistance
 “I am not ready to quit smoking. It relaxes me.”
 Strategy
 Empathize with the core concern (issue) and explore
the line of reasoning
Relational Resistance
 “I am so tired of you people hounding me
about my smoking. Everyone acts like it’s
so easy.”
 Strategy
 Respect the resistance, roll with it, apologize,
and, when appropriate, shift
2 Forms of Resistance
Relational
Resistance
Issue-Based
Resistance
What MI Does
Relational
Resistance
Issue-Based
Resistance
Info #1
Info #2
Info #3
Info #4
What MI Does: 2 Steps
Relational
Resistance
Issue-Based
Resistance
Commitment
Info #1
Change Talk
Info #2
Info #3
Info #4
Inappropriate Responses to Resistance
 Persuasion
 The Righting Reflex
 Produces paradoxical responses
 More information
Key Concepts:
Dissonance
 Anxiety or discomfort when goals, thoughts,
and behaviors don’t match up
 We want to create dissonance in our patients
between where they are now in their health
behaviors and where they need to be
regarding health
 Creating dissonance
 A look over the fence
 Realistic goals and then behaviors that don’t match
 Discrepancies in what patients say vs what they do
Key Concepts:
Face and Face Loss
 What do people do when they fear they are
losing face?
 2 types of face loss
 Autonomy face loss: Patient’s blood pressure is
still up. “You need to quit smoking (take your
medicine)…we have been over this before.”
 Competency, approval face loss: Patient doesn’t
think chew is as bad as smoking. “Do you think
I would tell you it was bad for you if it wasn’t?”
 Motivational interviewing does not cause
face loss
Other Key Concepts
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Importance, confidence, and readiness
Autonomy
Respect
Susceptibility or risk
Understanding of the illness and treatment
Treatment options: the menu
Core concern: what is the primary concern of the patient?
Line of reasoning: how does the patient make sense
of things?
 Core concern and line of reasoning must be addressed
or you will not move forward
F-I-G
 Follow (reflect)
 Reflect back your understanding of core
concerns and line of reasoning
 Inform (ask permission) and identify
 Ask permission to give information, make
suggestions, or clarify
 Identify the core concerns
 Guide: present a menu of options and
determine what the patient wants to work on
Case Study: Asthma
 Julie Stockton is a 37-year-old Caucasian female
 Her daughter, Sara, is 10 years old and has been
in the emergency room 4 times in the past year
 She has not been using her chronic inhaler for
her asthma
 When asked about this, Julie says defensively,
“I don’t want Sara using a steroid and don’t
bother to talk to me about my smoking.
I smoke outside so it doesn’t affect Sara.”
20
Motivational Interviewing Skills
 READS principles
 Roll with resistance
 Express empathy
 Avoid argumentation
 Develop discrepancy
 Support self-efficacy
 Importance, confidence rulers
 The envelope
 The insurance card
 A look over the fence
Roll With Resistance
Roll With Resistance
 Patient: I just don’t see how I can quit
smoking when my wife smokes too and
she won’t quit.
 HCP: You suspect that it will be much more
difficult for you to quit smoking if your wife
continues to smoke.
 Patient: Right…I just don’t see that working.
 HCP: How important is it for you to quit
right now?
Express Empathy
Empathy Starters
 “You seem_____”
 “In other words…”
 “You feel ___ because ___”
 “It seems to you…”
 “You seem to be saying…”
 “I gather that…”
 “You sound…”
Express Empathy
 Patient: Everyone makes it sound so
easy…just take the medicine, quit smoking,
change your diet, and exercise more!
 HCP: You sound frustrated. You have been
asked to make a lot of changes to control
your diabetes and blood pressure and
people don’t seem to appreciate how
overwhelming and difficult all of it can be.
Express Empathy (cont.)
 Patient: I know smoking is bad for me, it’s
just that all of my friends smoke and we
hang out together.
 HCP: You realize that smoking can have
harmful effects on your health, yet it has
been difficult for you to quit because your
friends smoke and they are important
to you.
Express Empathy (cont.)
 Expressing empathy to prevent face loss
 Patient: Other people have blood pressure that
is much higher than mine. Mine is not so bad.
 HCP: You are right…there are many people
whose blood pressure is quite a bit higher.
May I tell you what concerns me?
Ways to Express Empathy
 Repeating back the words with the feeling
 Slight paraphrasing
 Major paraphrasing
 Framing
To clarify the
motivational issue
Avoid Argumentation
Avoid Argumentation
 Patient: My doctor says I need to lose weight,
take the medicine, quit smoking, and reduce
the salt in my diet. I don’t think I need to quit
smoking, do you? How about cutting back?
 HCP: It sounds like a lot to do. It’s great that
you are willing to take your medicine and
watch your salt intake. Cutting back on your
smoking would be a great first step. Ultimately,
quitting smoking would be the healthiest thing
to do. What are your thoughts?
Develop Discrepancy
Develop Discrepancy
 Patient: I want to lower my blood pressure
and reduce my risk of stroke or heart attack.
 HCP: On the one hand, taking your medicine
as you do really supports your goal of lowering
your blood pressure. On the other hand,
smoking raises your blood pressure and
interferes with your goal.
Develop Discrepancy (cont.)
 HCP: On the one hand, you hate feeling
ashamed because you keep going back to
smoking. On the other hand, you actually
started to feel better when you quit, but
stress in your life triggers your smoking.
Develop Discrepancy
(A Look Over the Fence)
 “If you were to wake up tomorrow and you
were no longer a smoker, what would you
like about that? What would be the benefits
to you?”
 “If you could snap your fingers and be at
the weight you wanted to be at, what would
you like about that? What would you see as
the benefits?”
Supporting Self-Efficacy
Supporting Self-Efficacy
 Patient: I don’t think I am ready to walk
4 days a week, but I am willing to try
twice a week.
 HCP: That sounds like a great start and
will really help with your osteoporosis.
Supporting Self-Efficacy (cont.)
 Patient: I’ve thought a little more about
what you said about quitting smoking.
 HCP: Great. Tell me more about what
you have been thinking. What’s got you
thinking about it?
2 Forms of Resistance
Relational Resistance
Issue-Based Resistance
• Roll with resistance
• Express empathy
• Avoid argumentation
• Express empathy
• Develop discrepancy
• Support self-efficacy
Rulers
 2 concepts
 Importance
 Confidence
 Scale from 1 to 7 or 1 to 10
 How important is this change for you?
 How confident are you that you can make
this change if you want to?
 Why did you choose a ____, not a 1?
 Elicits change talk
The Envelope
 “If I were to hand you an envelope, what
would the message inside have to say for
you to
 Consider quitting smoking.”
 Take your medicine as prescribed.”
 Monitor your blood sugar twice a day?”
The Insurance Card
 Patient: We’ve all got to die some time.
Might as well go out doing something
I enjoy.
 HCP: You really enjoy smoking and no one
can live forever any way.
 Patient: Right.
 HCP: May I tell you what concerns me?
MI Summary Example
 Patient: I know smoking is bad for me.
I know I should quit.
 HCP: Then why don’t you? (biomedical)
Possible MI Responses
 It sounds like you know smoking is bad for you,
yet it is difficult for you to quit. If you were to
wake up tomorrow and were no longer a smoker,
what would you see as the benefits? What would
you like about that?
 You see long-term negative effects to smoking.
What concerns you the most?
 What would have to change for you to
consider quitting?
 What makes it most difficult for you to quit?
 On the one hand, you see smoking as bad for your
health, but on the other hand, you are not ready to quit.
Possible MI Responses (cont.)
 On a scale from 1 to 7, where 1 is not at all important
and 7 is very important, how important is it for you to
quit smoking?
 May I tell you what concerns me about your continuing
to smoke?
 You are certainly right about smoking being bad for you.
Tell me more about that.
 Earlier, you told me that you have a goal of reducing
your risk of stroke and heart attack. On the other hand,
smoking increases those risks. What are your thoughts
about that?
 It has been hard to quit smoking even though you are
concerned about its impact on your health.
Summary
 What does the patient know and understand
about the illness and its treatment?
 What is the patient’s understanding of
what can happen if the illness (behavior)
is not changed?
 What are the patient’s goals?
 What options are available to the patient?
 What does he/she want to work on first?
Summary (cont.)
 Explore the decisional balance
 Respond to the patient’s core concern(s)
 Focus on one issue at a time, based upon
what is of paramount importance to the patient
 Respond with empathy throughout (be explicit)
 Stay in the spirit
Suggested Readings
 Miller, WR, and Rollnick, S. Motivational
Interviewing. The Guilford Press, New York,
2002. 2nd edition.
 Rollnick, S, Miller, WR, Butler, CC.
Motivational Interviewing in Health Care.
The Guilford Press, New York. 2008.
 Berger, BA, APhA. Communication Skills for
Pharmacists. Washington, DC, 3rd edition.
 Rollnick, S, Mason, P, and Butler, C. Health
Behavior Change. Churchill Livingstone,
London. 2000.