By Jeni Miller
Motivational interviewing has been used for decades in substance abuse counseling and is now growing in use in healthcare settings to provide better care for patients and encourage health behavior change.
Bruce Berger, PhD, president of Berger Consulting LLC, is an expert on motivational interviewing, which he defines as “a collaborative, person-centered form of information exchange to facilitate constructive sense-making by patients about their health.”
“The information exchange present in motivational interviewing helps a case manager determine how motivated their patient is to do something,” Berger explains. “For example, saying, ‘Tell me what having diabetes means to you,’ can help guide the discussion. Then, the case manager should talk in a way that respects how the patient is thinking and feeling. You show them that you are listening.”
Case managers can use motivational interviewing as a tool to provide patient-centered care that does not come across as judgmental, but rather supports and enhances a person’s motivation to change.
Motivational interviewing is “a form of counseling that helps patients to reason their way to the conclusion that they need to change their behaviors in order to achieve their goals,” Berger notes.
Using Motivational Interviewing
In the 1990s, motivational interviewing was adopted for healthcare. According to Berger, it changes the provider/patient dynamic completely.
“For us in healthcare, control is an illusion,” he says. “We think we’re in control, but truly the patient is in control. But motivational interviewing is all about voluntary behavior change — we don’t want to put ourselves in a parental role and the patient in a child’s role. Instead, we recognize that it’s a conversation or a dance that the patient is leading. It’s an exchange of information.”
While he recognizes that it may be a generalization, Berger acknowledges that of all healthcare providers, nurses tend to be the most caring and nurturing. However, they also tend to be the largest group of “fixers.”
“Understandably, nurses want to fix things,” Berger notes. “That means that they sometimes get anxious and say things like, ‘You can do this, you can quit smoking.’ But when we say those things, then we’re taking responsibility for something that is the patient’s job. We can’t be trying to fix or save our patients. But the relationship case managers have with their patients is what gives them the leverage to use their expertise as an extension of caring.”
This comes in the form of asking questions and ensuring that there is a genuine exchange of information between the case manager and patient. A case manager might ask, “What makes it difficult to take your blood pressure medication?” Berger shares that a typical answer might be, “I hate taking medicine,” or “Doctors prescribe too much medicine.” Reiterating what the patient said helps them to notice that the case manager is listening. The case manager might then continue the information exchange by asking, “What is your understanding of what can happen if you don’t take your medicine?”
“We tend to think that if we just educate the patient enough, they’ll make the change,” Berger says. “But it’s not just education. There’s more to it. We also need to admit that as healthcare professionals, we don’t always follow the education, either.”
Often, a patient will not take action until they feel unwell. “They might be ambivalent or resistant to change, and their sense-making might be corrupted by missing information or misinformation,” Berger shares. “But they don’t understand that damage is being done if they’re not treated immediately — and neither will they listen to ‘Do something now.’”
However, if a case manager asks, ‘Would you mind if I share a few thoughts with you about this and you let me know what you think,’ it paves the way for the case manager to be able to respectfully share new insight with the patient before asking, ‘Where does this leave you now?”
Aside from better patient care, motivational interviewing also can save case managers time — a sentiment that seems to run counter to a provider’s first impression of motivational interviewing.
“It doesn’t take more time, but they get to the issue faster,” Berger says. “Those who go through training in motivational interviewing say they’ll never go back to the way they used to talk to patients.”
This is because case managers are freed from the idea that they must fix their patients or their patients’ problems, he notes. It puts the problem back where it belongs — with the patient — while the case manager focuses on helping the patient treat the problem and explore barriers to that treatment.
“Motivational interviewing is not a manipulation,” Berger explains. “It’s not a maneuver. It’s a way of being with people that is patient-centered. If someone feels like they are being maneuvered, then you don’t know how to do motivational interviewing because we’re never trying to make a person do anything. We’re not trying to persuade. We’re trying to influence and explore their motivation, be a passenger on the bus, and guide them toward changing behavior for better health.”
This also helps to reduce frustration on the part of the case manager. After all, a case manager cannot, for example, make a person keep their blood sugar down. However, it can increase the possibility of helping the patient work on ways to keep their blood sugar down, their heart disease under control, or to quit smoking — all while respecting the person and the reality that it is their life.
“We never want to give the impression that we’ll only care about the patient if they do what we ask, like quit smoking or take a medication,” Berger says. “The patient isn’t being difficult, and we don’t want to jeopardize our ability to care for that patient. Being honest and simply saying, ‘I am concerned about your smoking and how it affects your heart disease, but in the meantime, can we talk about the other things you might be able to do to get the heart disease under control?’”
It is a challenge because healthcare professionals often are taught that they are the experts. “But we need to realize that we can’t use our expertise until we understand the patient’s expertise,” Berger explains. “We need to see that the way we’ve talked to patients hasen’t changed in 40 years — and the rate of medication adherence hasn’t gotten any better, either.”
Outcomes
Berger recalls a positive outcome from his experience with a large pharmacy chain. A patient was 30 days late on her 90-day supply of blood pressure medication.
“The woman was upset by the call and asked, ‘How dare you, this is between me and my doctor and I take my medication every day,’” Berger recalled. “What they needed to do was say, ‘I’m really glad you take your medication every day. Some patients are taking the same medication that you are, but because they feel OK, they skip doses and don’t realize they’re putting themselves at risk. What do you do to remember to take it every day, because I’d love to share with other patients?’ She no longer felt threatened, and ended up asking, ‘How many would I have to skip before it hurt me?’ We were able to educate without the person becoming defensive.”
Motivational interviewing is rigorously studied, with significant outcomes reported. Berger cites a study on motivational interviewing for patients taking medication for multiple sclerosis (MS). The patients in the motivational interviewing arm had a treatment discontinuation rate of 1.2%, compared to a rate of 8.7% in the standard care arm.1
“Using motivational interviewing, they taught providers to explore with their patients why they’d consider dropping out,” Berger says. “They learned that some were dealing with a needle phobia, others didn’t know that they could ice the area to reduce the pain, some didn’t know how to treat the flu-like symptoms, and some had flare-ups and didn’t understand that there is no treatment for MS — they’d assumed that the medication wasn’t working.”
By taking the time to use motivational interviewing with these patients and understand what they were thinking and feeling, the researchers addressed their concerns and helped them speak in a way that made sense.
“We take a simple but profound approach — human beings are sense makers,” Berger says. “We’re constantly deciding whether the other person makes sense.”
REFERENCE
- Berger BA, Liang H, Hudmon KS. Evaluation of software-based telephone counseling to enhance medication persistency among patients with multiple sclerosis. J Am Pharm Assoc (2003) 2005;45:466-472.
Motivational interviewing has been used for decades in substance abuse counseling and is now growing in use in healthcare settings to provide better care for patients and encourage health behavior change. Case managers can use motivational interviewing as a tool to provide patient-centered care that does not come across as judgmental, but rather supports and enhances a person’s motivation to change.
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