By APRIL BOYKIN, MSW, LCSW and MARY-CATHERINE SEGOTA, Psy.D.
One of the most challenging aspects of working in the medical field is dealing with patients who don't follow medical recommendations and end up sick, suffering, or worse off than when they originally sought care. These days the healthcare industry is expected to provide high-quality, cost-effective, patient-centered care that will improve overall health outcomes. Healthcare professionals are increasingly turning to health outcome research for the evidence-based guidance they need to improve care. Much of the research on health outcomes focuses on patient behavioral responses to changes in healthcare delivery. Additionally, research on chronic disease prevention has also focused on patient behavioral changes (e.g., smoking cessation, weight loss, increase in physical activity). Because these health behaviors are such predictors of increased compliance, improved health, and decreased risk, the ability to create a behavioral change is an essential indicator of improved health outcomes.
Non-compliance is complex and is usually based on a layering of behavioral factors, including health literacy, forgetfulness, cost, misunderstanding, fear, confusion, absence of symptoms, mental illness, complicated regimen, side-effects of medications, apathy, and previous negative experiences. The healthcare industry has created protocols to overcome some of these obstacles, such as education and the well-informed diagnosis process, employing the "teach-back" model, reminders and technology, packaged medications, genetic testing, etc. But nothing is as effective as a patient being motivated to achieve the desired health outcome. Motivational Interviewing is a tool medical professionals can integrate into their everyday interactions that can help increase patient buy-in and compliance.
Motivational Interviewing (MI) is a patient-centered approach that is gathering increased use in healthcare settings. Created by William Miller in 1983 to treat substance abuse, MI has since grown into a successful model for achieving lasting behavioral change. MI provides a method of working with patients who may not seem ready to make changes that are considered necessary by the provider. MI allows patients to be active rather than passive by insisting that they choose the treatment and take responsibility for changing. The provider does not impose his or her views or goals on the patient.
Motivational Interviewing's main principles include building rapport, demonstrating empathy, identifying discrepancy, avoiding arguing and confrontation, recognizing resistance as a part of the process, and supporting self-efficacy. Implementing these simple and effective principles can drastically shift interactions with patients and improve medical compliance.
Rapport creates a close, helpful relationship between the provider and the patient. Effective rapport can overcome many obstacles because the patient feels connected, which increases confidence and trust. Even in limited time together, we can build rapport by making eye contact, nodding, affirming that you are listening, getting on the patient's level (sitting instead of standing over), showing empathy, showing curiosity, and actively listening to the patient.
Empathy is essential to build a bridge between the provider and the patient to guide them to successful care. Empathy is how we express that we see and recognize the patient and his or her struggle. Building empathy starts with acknowledging how someone feels without judgment. Even if the expression is dramatic or incongruent, empathy allows the patient to feel cared about and will often reduce distress. A few examples of empathy are:
"I'm sorry you are going through this. I imagine you are feeling overwhelmed."
"It looks like you feel awful, and what you are doing is not making you feel any better."
"That must have been frightening for you, but it looks like you were able to navigate it successfully."
Discrepancy is the act of building an awareness of the difference between the patient's current behavior and desired behavior and building a plan from there. Highlighting the differences can allow the patient to assess for themselves what needs to happen. Discrepancy is accomplished by having the patient make a pro and con list or scaling their readiness, with follow-up guiding questions that can lead to the steps to make a change.
"What will happen if you continue to smoke? What will happen if you stop smoking? Which reflects where you want to be? What do you think you might do from here?"
"On a scale of 1 to 10, how ready are you to lose weight? What would need to be in place for you to be at a 10? What changes are you thinking about making?"
Avoid arguments and confrontation; if these worked, the change would have already happened. MI is based on the premise that providers are not there to force change but instead facilitate change.
Recognizing resistance, resistance is a normal part of change. Change can feel uncomfortable, and resistance is an indicator that the patient is not ready, and something else needs to happen to achieve the change. In a profession typically defined by “advice giving,” it is important to recognize that unwelcomed advice creates resistance. It is important to focus on the collaborative nature of the relationship when dealing with behavioral change. When resistance is considered part of the process, we more quickly identify what will get in the way of identifying solutions.
"Many people feel apprehensive about change. What apprehensions are you having?"
"It is not uncommon to be resistant to change. What obstacle might get in the way of you making this change?"
Supporting self-efficacy is essential for the patient taking responsibility to change. Our role as providers is to remind the patient that the change is up to him (or her), but we can facilitate a sense of confidence by helping them explore past success. For example;
"Tell me about a time when you were successful at (losing weight)."
"What strengths do you have that will help your make this change?"
“Motivation to change is not a personality trait, but is affected by interpersonal interaction.” Miller & Rollnick, 1991
When patients are facing a behavioral change, it is important to assess the stage of change they are in. Prochaska & Diclemente identified the following Stages of Change. In working with behavioral change, it is critical to understand which stage a patient is in, and that your expectation of patient change should align with what stage of the change the patient is in.
- Precontemplation - do not intend to take action in the foreseeable future (defined as within the next 6 months)
- Contemplation - intending to start the healthy behavior in the foreseeable future (defined as within the next 6 months), but are ambivalent, “on the fence.”
- Preparation (Determination) - ready to take action within the next 30 days (0-3 month). start to take small steps toward the behavior change.
- Action - have recently changed their behavior (3-6 months) and intend to keep moving forward with that behavior change.
- Maintenance - have sustained their behavior change for a while (6+ months) and intend to maintain the behavior change going forward.
- Relapse – the behavior returns and the re-evaluation of where process begins again.
Techniques that help in the MI process include OARS.
O: Open Ended Questions
A: Affirming
R: Reflective Listening
S: Summarizing
Open ended questions can’t be answered with “yes” or “no.” Remember to ask one question at a time, and use the patient’s own words, when possible. For example:
“Tell me about…..?”
“Help me understand…..?”
Affirming includes a combination of “reframing” and “validating” the patient. For example: “That must have been really hard for you…” (validation)
“You are being really honest with yourself…” (affirming)
Reflective listening affirms and validates your patient’s experience. When they feel understood, they are more likely to go deeper and say more, and you are less likely to appear judgmental. For example:
“It sounds like you are unsure about …”
“It sounds like you have had a lot of success with…”
Summarizing - Focus on your patient’s statements regarding 1) recognizing the problem, 2) their reason for change, and 3) their optimism or confidence about the change. For example:
“Let me see if I understand what you’ve told me so far…”
Improving health outcomes is dependent upon many factors, including patients being willing to do their part. The Motivational Interviewing model helps patients find motivation for doing what is best for themselves. There is much more to MI than discussed here, but this is a significant first step in noticing the language we use and the process we engage in for helping our patients take steps towards better health outcomes.
April Boykin is a Licensed Clinical Social Worker and cofounder of Counseling Resource Services (CRS). Established in 2013, CRS is a community-based in-home integrated behavioral health agency serving the aged and disabled population in Central Florida. As a mental health counselor, she has provided individual, family and caregiver counseling to children, teens and adults. She can be reached at april@counselingresourceservices.com
With a doctorate in clinical psychology and over 20 years of experience in the field, Dr. Segota has conducted university-based behavioral medicine research, acted as a consultant to professionals and organizations, and worked with a diverse number of psychological and medical conditions. By identifying unique needs, the source of distress, and what’s perpetuating the problem, she will help develop the tools to overcome seemingly insurmountable circumstances. Visit www.CounselingResourceServices.com
