Kelly N. Gable, PharmD, BCPP
Associate Professor, SIUE School of Pharmacy
Psychiatric Care Provider, Places for People
This year’s Pre-Meeting Workshop on Motivational Interviewing (MI) was a great success! Dr. Susan Butterworth, faculty at Oregon Health and Science University, led a 3-hour active learning session on Sunday morning to kick off the annual meeting. The workshop began with an ice-breaker for both introverts and extroverts in the audience, in an effort to demonstrate effective engagement and communication strategies. It allowed participants to critically think about their own approach to patient care in the face of ambivalence and resistance. A common misconception that clinicians have about patients that are not following their recommendations is that the patient just doesn’t know enough about the disease state/medication or they do not care enough to make a change. A natural response to this belief is to attempt to give the patient insight or knowledge through education or to scare them into wanting to change their behaviors. Dr. Butterworth reminded us that behavior change science tells us that simply providing a patient with information is not enough. The real reasons people change are because they think they can, their values support it, it is important to them, they have a plan and a good support system, and they are ready for it.1
This brings us to the heart of the workshop: Motivational Interviewing. The founders of MI, Miller and Rollnick, describe it as a collaborative, goal-oriented method of communication with particular attention to the language of change. It is intended to strengthen personal motivation for and commitment to a change goal by eliciting and exploring an individual’s own arguments for change.2 The basic skills of MI consist of asking open questions and providing affirmations, reflections, and summary statements. An acronym to best remember the core principles of MI is PACE:
P- partnership. The clinician-patient relationship is a collaboration, not an expert-recipient relationship.
A- acceptance. Accept that the patient has absolute worth and autonomy to make personal decisions.
C- compassion. See the world through your patient’s eyes and actively promote their welfare.
E: evocation. Evoke the patient’s own internal motivations for change.
A directive approach to care can often evoke the opposite of MI- sustain talk. Tension and resistance from the patient is a strong predictor of minimal to no change. The common responses you may get when you attempt to right someone’s wrong are “yeah….but,” a strong desire from the patient to justify their actions, or avoidance of the clinician altogether by not returning for a follow-up appointment.3,4 Dr. Butterworth provided the audience with 8 quick tips to improve MI skills:
Clinician: “On a scale of 1 to 10, with 10 being the highest level, how ready are you to quit smoking today.”
Patient: “I’d say that I’m about a 5.”
Clinician: “What makes you a 5 and not a 2 or a 3?”
This last statement allows the patient to verbalize their own internal motivation to quit smoking that is already present within.
Elicit information about what the patient already knows.
Provide information about the medication or disease state after first asking for permission.
Elicit a response from the patient on how they feel about the information you have provided.
At the close of the workshop, Dr. Butterworth provided the audience with a thoughtful quote from Miller and Rollnick: “watch a skillful clinician providing MI, and it looks like a smoothly flowing conversation in which the client happens to become increasingly motivated for change. In actual practice, MI involves quite a complex set of skills that are used flexibly in responding to moment-to-moment changes in what the client says. Learning MI is rather like learning to play a complex sport or a musical instrument.”2
If you are interested in expanding upon your own MI skills, seek out feedback from experts in the field, role play with colleagues, purchase a practitioner workbook5, and consider signing up for weekend workshops organized by a MINT-certified trainer. For workshop attendees, don’t forget to utilize your MI Quick Tips at the back of your Pre-Meeting Workshop booklet. The handout is perforated, allowing for easy removal and use at your practice site! Also check out one of the pre-meeting workshop readings for a better understanding of MI: Miller WR, Rollnick S. Ten Things that Motivational Interviewing Is Not. Behav. Cognit. Psychother. 2009;37(02):129.