Abstract
Counselors and other clinicians are increasingly faced with treatment adherence issues particularly when counselling individuals and families dealing with medical conditions. Since motivational interviewing has proven to be effective in increasing patient motivation to change and in reducing nonadherence, it has become a valuable and necessary counseling intervention. The article describes motivational interviewing and its application as an adjunctive intervention with patients and their families who are dealing with medical conditions when treatment adherence is a concern. It illustrates this application with a clinical illustration.
Keywords
With rates of nonadherence to medical treatment as high as 80%, nonadherence, also called noncompliance, is a problem with significant consequences for patients and their families. Because it has significant psychosocial impact, counselors and psychotherapists are referred or asked to consult on such cases. Recently, motivational interviewing (MI) has been found to be an effective adjunctive treatment in dealing with nonadherence issues, particularly when delivered in a family context. Accordingly, those engaged in individual and family counseling would do well to develop competence in MI and utilize it in their work.
This article begins with a definition and description of MI and its principles and skill sets. Then, it describes nonadherence to medical regimens, the failure of conventional approaches, and the value of MI as an intervention delivered in a family context in increasing treatment adherence. A clinical example and session transcription illustrate this intervention.
MI: The Basics
MI was originally developed in the 1980s by William Miller, PhD, to help clinicians address patient’s problematic alcohol and substance use issues (Miller & Rollnick, 2002). Essentially, MI is a strategy for helping clinicians change what they say so that patients can change what they do. Evidence continues to mount that MI is a clinically effective and economically efficient intervention guiding patients toward change across a wide spectrum of health-related behaviors ranging from diet, medication compliance, and risky sexual practices, to self-management of chronic medical conditions (Rollnick, Miller, & Butler, 2008).
MI is defined as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25) and as a collaborative conversation that strengthen a patient’s motivation and commitment to change (Miller & Rollnick, 2009). These definitions reflect MI’s humanistic and client-centered roots and the three core ingredients that, together, represent the “spirit” of MI. These ingredients are (1) a collaborative partnership, a relationship built on shared understanding, caring, respect, and trust; (2) support of the patient’s autonomy, recognizing that the true power for change rests within the patient; and (3) an evocative approach to counseling, drawing out the patient's own motivations and capacities for change, in contrast to telling them what to do or why they should do it. MI is similar to other client-centered approaches, like health coaching and health counseling, in engaging and activating patients to take a more active role in their own self-care, self-management of chronic conditions, preventive care, and treatment of acute and chronic conditions.
There are four principles of MI, which are easily remembered with the acronym RULE: (1) resisting the urge to direct the patient with lecture, persuasion, or demands; (2) understanding the patient’s motivation by exploring the values, needs, aspirations, abilities, and ideas; (3) listening with empathy; and (4) empowering by exploring the patient’s past experience, setting achievable goals, and problem-solving to overcome barriers to change. These principles clearly reflect the collaborative, respectful, evocative spirit of MI (Miller & Rollnick, 2009).
Specific MI skills are related to these principles. The most basic and important MI skills are the OARS skills: open-ended inquiry, for example, “Tell me about your reasons for change”; affirmations for example, “I’m impressed with your efforts to try despite all the obstacles you are facing”; reflections as in reflective listening; and summaries. Reflection is considered the most useful MI skill. When using reflections, for example, “It sounds like you’re really frustrated,” a clinician can deepen rapport, particularly when patients express strong emotions or values. Clinicians can also strategically employ reflections to reinforce or affirm the patient’s expressed desire, reasons, ability, or need for change. Selective reflection of a patient's “change talk” has been shown to be a key ingredient of MI's positive effects. Summaries are a special type of reflection that recap of the patient's story and can help transition an interaction toward a specific action or plan. Other skills include developing discrepancies, rolling with resistance, and promoting change talk (Miller & Rollnick, 2002).
Research and clinical experience indicates that intensive training and follow-up supervision or coaching is essential in achieving proficiency in MI skills (Martino, Ball, Nich, Frankforter, & Carroll, 2008). For this reason, initial MI training should occur over at least two sessions with direct coaching, and the provision that participants practice skills between sessions and utilize a learning process that includes reflection, feedback, and additional skill practice. Thereafter, additional coaching can promote skill refinement (Rosengren, 2009).
Utilizing MI in Families Dealing With Nonadherence
Failure to follow advice from health care professionals, called treatment noncompliance or nonadherence, is a significant problem. Research indicates that 40–50% of patients in the United States do not comply with the health care plan for treatment such as medication, while nearly double that number fail to comply with dietary restrictions, exercise, or other restrictions of health-compromising behaviors (DiMatteo, Giordani, Lepper, & Croghan, 2002). Typically, health education was the approach or strategy most commonly used to increase treatment adherence.
Unfortunately, this approach is insufficient in changing patients’ behavior probably because it is persuasive, prescriptive, and focused on providing general advice. In contrast, a more collaborative, family-centered approach, which focuses on the family’s beliefs, values, and health behaviors and enhances the family’s self-efficacy and skills, is more likely to increase treatment adherence. Research comparing these two approaches showed a 64% success rate with knowledge or general advice alone and an 85% success rate for the more collaborative, family approach (Burke & Fair, 2003).
Because it is a collaborative approach that empowers patients, MI has become the intervention of choice in increasing treatment adherence to medical regimens (Rollnick et al., 2008). Furthermore, using MI with the patient’s family is noted to be superior to using MI with individual patients (Gance-Cleveland, 2005). In short, MI is a useful adjunctive intervention that augments both health education and other counseling interventions.
Illustration of Utilizing MI in Families Dealing With Nonadherence
Jeff W. is a 33-year-old married, Caucasian male who was diagnosed with moderate primary hypertension, that is, high blood pressure, 4 months ago. His physician was concerned with blood pressure readings in the range of 150/100. Jeff was insistent that he did not want to take medication, except as a last resort. Accordingly, his physician agreed to a treatment plan of diet modification, with a primary emphasis on salt reduction. The treatment target was to decrease blood pressure to at least 125/80. If this could not be achieved within 3 months, medication would be started. When they met and his readings were essentially unchanged, Jeff pleaded for another alternative to medication. It was mutually agreed that Jeff would work with the clinic’s health counselor, a mental health counselor with training in health issues, and MI, on adherence to diet and salt reduction. The counselor met briefly with Jeff and his wife to forge a treatment contract. Here is a transcription of their second meeting. (Key: patient = PT, wife = WF, counselor = CO.)
Please, tell me what you have noticed since we met last time. (focusing discussion)
I have to be honest. I have not done the salt reduction thing at all. There is no good excuse. I just haven't done it. I've done okay with the other goals, just not salt. (Brief mention of success embedded in “sustain talk” [opposite of “change talk”])
You're feeling pretty good about two of the three goals you set. (Selectively reflecting “change talk”)
Yeah, I've been good about my exercise. That's been easier than I thought it would be. I'm also doing pretty good at not overeating at home. Sometimes I overdo it, but not as much as before. (PT expanding on several areas of success)
You are persistent and you've found quite a bit of success so far. (Affirmation)
I guess so, except with the whole salt thing. (Sustain talk regarding salt-reduction goal)
I appreciate your honesty. Tell me more about reducing salt intake. What kind of things have gotten in the way? (Open-ended question)
I guess I'm just lazy. Not us using the salt shaker is not easy. Food doesn't taste right without it. And, it kills me when I'm eating lunch with my coworkers and they use salt like it's going out of style. (Sustain talk: PT. finds it hard to adjust; struggles when around salt users)
It's hard seeing others who apparently aren't on a low salt diet use it . Being around them makes you not want to use salt too. (Reflection: Expressing empathy and rolling with resistance)
Yes, exactly. I mean, later on I kick myself for salting everything because 1 know that raises my blood pressure. My hypertension is not silent like most people. I get strange sensation in my temples when my pressure is really high, like after salty meals. I guess I should really cut down and choose less salty foods. But that's mostly what the cafeteria serves. Maybe I should take a lunch to work. It could cut down on high salt foods. But I'd need help with that (looking over to his wife, Ginny). (Increasing change talk. Listing cons of not adhering to his treatment plan. Identifying barriers for success with possible solution involving wife)
So on a scale from 1 to 10, how important is it for you to reduce salt use? (Assessing importance of salt reduction goal)
Probably a 4 or so. Maybe a 7 or so when I feel that sensation. That's when wish I had the salt substitute with me. (Sustain talk and change talk)
What is it about that sensation that make it more important for you? (Open-ended question focusing on change talk)
It means that my pressure is way up and increases my immediate risk of stroke. Stroke runs in my family. Or, until I can reduce salt use maybe I could the salt substitute with me and use it in the cafeteria. (Reason to be serious about salt reduction. Acknowledges possibility of better choices)
So, you could choose to take a low salt lunch to work with you. Or, you could use the salt substitute at the cafeteria. Both are steps in the right direction, you are thinking about making different choices. (Summarize the two options. Affirming the effort)
Well, you were really good at dinner last night. You'd didn't roll your eyes when you used the salt substitute like you have in the past. That was great! (Wife expresses support)
Actually, I guess I'm getting more used to it. It doesn't taste like the real thing. But that alright. (pause) I really should take a lunch with me to work. But, I'm not really into packing one myself. Maybe, if Ginny could help. But I know it the past she wasn't keen on doing that. (More change talk, eliciting help from wife)
Now, I would be happy to pack your lunch for you. In the past it was different because I was trying to get 3 kids off to school so I just didn't have time to make a lunch for you too. But, I could do it now that the kids are on their own. (Supporting change talk)
It sounds like you are interested in taking your own lunch because you know it will be healthier for you. Ginny has agreed to pack you a low salt lunch. (Summarize)
Yeah. I think that can make a big difference. But, I'm going to need some seasoning too, at least until my taste buds adjust to less seasoning. And, I feel funny about taking a salt-substitute shaker to work with me. I know I'll get those looks from the guys. (Pt developing change plan, identifies another barrier)
So you feel good about taking a healthy lunch but not so good about the looks you might get from others if you take a salt substitute shaker with you to work. Still, you're open to to this option over eating high salted foods in the cafeteria. (Double-sided reflection ending with change talk)
Yes, I am (Change talk)
I just saw that our grocery now carries the salt substitute in small packets. I could put a packet or two in with your lunch. (Family generating change plan)
Yes, that could help make this whole thing a lot easier. (Strengthening plan)
So, on a scale of 1–10, how confident are you about your new lunch plan? (Assessing confidence of change plan)
10/10. I know this is going to work. (Change plan)
When do you think you can start? (Seeking commitment with start date)
Ginny, can we start this tomorrow? (Seeking help from wife)
Absolutely. (Support)
Looks like you two have a plan that you are excited about. (Reflection and summary)
Concluding Comment
This session transcription illustrates the application of MI as a powerful intervention for increasing treatment adherence in a family counseling context. Had Jeff’s response to the counselor’s scaling question had been 4 of 10 or so, rather than the reported 10 of 10, the counselor would have proceeded to process this with a response like “And what would need to happen for it to be 8 of 10?” and so on until a reasonable change plan was in place. In this case and many others, MI has proven to be an invaluable and necessary competency that all counselors and clinicians would do well to add to their therapeutic armamentarium.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.