Motivational interviewing enhances care

No matter how hard they work at it, pharmacists cannot persuade, browbeat, shame, or cajole patients into following their drug regimens. The patient alone makes the decision whether to comply with his treatments. But there is a way to plant seeds in the patient's mind that can bloom into adherence to therapy. It's an approach called motivational interviewing (MI) that helps patients find their own internal motivation for engaging in healthful behavior.

Motivational interviewing is a process healthcare practitioners can use to help patients overcome ambivalence or resistance to change, such as taking a new medication, stopping harmful behaviors, or adopting healthful ones, according to Bruce Berger, Ph.D., professor and head of the pharmacy care systems department, Auburn University. But the decision remains with the patient.

"We're talking about readiness to change," Berger told attendees at the 2005 annual meeting of the American Pharmacists Association in Orlando. "What we do is explore the patient's ambivalence or resistance. Why does it exist? What has to change? Motivational interviewing requires that you not explain, you explore. We don't try to persuade people who are ambivalent or resistant to the behavior."

Take, for example, the patient who isn't ready to quit smoking. Using traditional counseling, a pharmacist might try to convince the patient to quit by using scare tactics about the harmful effects of tobacco. The MI method doesn't try to persuade the patient; instead, the counselor explores the patient's readiness to change and what would make him more likely to change. The idea is to shape the patient's decision without forcing that decision.

If the patient says smoking relaxes him, for instance, the pharmacist agrees that it would be hard to give that up and asks whether the patient would like to discuss other activities that might also be relaxing. If not, she backs off after having raised the idea that something else relaxing might substitute for smoking. At the same time, she makes it clear that she's worried about the health fallout from smoking but it's up to the patient to decide what to do about it.

"When patients are not ready to change, the worst strategy we can use is persuasion, and yet that's the No. 1 method of communication in health care," observed Berger. "A lot of people in health care believe that if you provide people with enough information, that should do it. My response is that if information were enough, no one would smoke."

Done correctly by a practitioner familiar with the process, MI takes about five minutes per session. Research shows MI is more powerful than 10 or 15 minutes of the traditional practitioner-centered, information-giving intervention model, said Berger.

At the heart of MI is the pharmacist's caring attitude, Berger said. If the patient does not perceive that the pharmacist really cares about his or her well-being, it will not work. "Caring does not mean you're trying to fix them," he added. "It means 'I care about what happens to you.' You cannot fake that. Without that, MI just becomes a technique."

Motivational interviewing resources include Berger's book, Communication Skills for Pharmacists from the American Pharmacists Association and the book Health Behavior Change by Stephen Rollnick and colleagues. Pharmacists can also request a two-CD set on MI by Berger and W. A. Villaume from their Pfizer clinical education consultant.