Motivational Interviewing: A Guide for Medical Trainees [2 ed.] 0197583873, 9780197583876

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Motivational Interviewing: A Guide for Medical Trainees [2 ed.]
 0197583873, 9780197583876

Table of contents :
Motivational Interviewing
About the Editors
1. Motivational Interviewing in Medical Training
2. The Style and Spirit of Motivational Interviewing
3. The Processes, Skills, and Strategies of Motivational Interviewing
4. Ambivalence, Decisional Balance, and Equipoise
5. Motivational Interviewing in Practice
6. Motivational Interviewing in Challenging Encounters
7. Brief Interventions
8. Motivational Interviewing in Primary Care Settings
9. Motivational Interviewing, Cardiovascular Health, and Diabetes Care
10. Motivational Interviewing and Dietetics
11. Motivational Interviewing and Obesity
12. Healing Justice Frameworks and Motivational Interviewing: Supporting Survivors of Intimate Partner Violence
13. Motivational Interviewing for Substance Use
14. Motivational Interviewing and Psychiatric Disorders
15. Integrating Community Psychiatry and Motivational Interviewing
16. Addressing Healthcare Access and Disparities Using Motivational Interviewing
17. Motivational Interviewing in Pediatric Settings
18. Motivational Interviewing in Family Settings
19. Integration of Motivational Interviewing with Mindfulness and Other Integrative Health Modalities
20. Integration of Motivational Interviewing into the Electronic Health Record and Electronic Communication
21. Motivational Interviewing in e-​Health and Telehealth
22. Learning and Experiencing Motivational Interviewing
23. Integration of Motivational Interviewing in Medical Training
24. The Ethical Practice of Motivational Interviewing in Healthcare Settings
Appendix 1: Video Clips of Clinical Encounters

Citation preview

Motivational Interviewing

Motivational Interviewing A Guide for Medical Trainees Second Edition Edited by

Antoine Douaihy University of Pittsburgh School of Medicine

Thomas M. Kelly University of Pittsburgh School of Medicine

Melanie A. Gold Columbia University Irving Medical Center

Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2023 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. CIP data is on file at the Library of Congress ISBN 978–​0–​19–​758387–​6 DOI: 10.1093/​med/​9780197583876.001.0001 This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-​to-​date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/​or application of any of the contents of this material. Printed by Sheridan Books, Inc., United States of America

Contents Foreword  Preface  Prologue 

ix xi xiii

Jared Kopelman

Acknowledgments  About the Editors  Contributors 

xv xix xxi

PART I .  FO UNDATIONS OF MOTIVATIONAL INTERVIEWING 1. Motivational Interviewing in Medical Training 


Sarah Minney and Julie Childers

2. The Style and Spirit of Motivational Interviewing 


Antoine Douaihy, Melanie A. Gold, Gail Gutman, and Dina Romo

3. The Processes, Skills, and Strategies of Motivational Interviewing 


Amelie Meltzer, Morgan Faeder, and Thomas M. Kelly

4. Ambivalence, Decisional Balance, and Equipoise 


Mark D’Alesio, Thomas M. Kelly, and Antoine Douaihy

5. Motivational Interviewing in Practice 


Miriam Rosen and Julie Kmiec



Areej Ali and Erin Smith

7. Brief Interventions 


Janice Pringle and Mara Rice-​Stubbs

8. Motivational Interviewing in Primary Care Settings  Carolyn Windler and Brianna Rossiter


vi Contents

9. Motivational Interviewing, Cardiovascular Health, and Diabetes Care 


Daniel Salahuddin and Esa Matius Davis

10. Motivational Interviewing and Dietetics 


Antoine Douaihy, Thomas M. Kelly, Augusto Bermudez, and David Bell

11. Motivational Interviewing and Obesity 


Lindsay Leikam, Dana Rofey, and Melanie A. Gold

12. Healing Justice Frameworks and Motivational Interviewing: Supporting Survivors of Intimate Partner Violence 


Lauren Auster, Judy Chang, and Elizabeth Miller

13. Motivational Interviewing for Substance Use 


Antoine Douaihy, Jody Glance, and Estelle Hirsh

14. Motivational Interviewing and Psychiatric Disorders 


Elliot Collins and Tina Goldstein

15. Integrating Community Psychiatry and Motivational Interviewing  245 Joshua T. Morra, Daniel Cohen, Melinda Armstead, and Antoine Douaihy

16. Addressing Healthcare Access and Disparities Using Motivational Interviewing 


Vivianne Oyefusi and Jeanette South-​Paul

17. Motivational Interviewing in Pediatric Settings 


Katelin Blackburn and Pamela Burke

18. Motivational Interviewing in Family Settings 


Thomas M. Kelly and Meghan Keil

19. Integration of Motivational Interviewing with Mindfulness and Other Integrative Health Modalities 


Jessica J. Stephens and Melanie A. Gold

20. Integration of Motivational Interviewing into the Electronic Health Record and Electronic Communication 


Jordon Post and Jessica Gannon

21. Motivational Interviewing in e-​Health and Telehealth 


Elizabeth Hovis and James Latronica

22. Learning and Experiencing Motivational Interviewing  Cassandra Boness and Antoine Douaihy


Contents  vii

23. Integration of Motivational Interviewing in Medical Training 


Laura Marengo and Neeta Shenai

24. The Ethical Practice of Motivational Interviewing in Healthcare Settings 


Lisa Forsberg, Isra Black, and Mariel Piechowicz



Patrick H. Driscoll

Appendix 1: Video Clips of Clinical Encounters 


Mark D’Alesio and Amelia Cuevas



Foreword It is hard to think of a request to write a foreword for a book as captivating as this one. The case for using Motivational Interviewing (MI) in routine practice is well-​made. It is one thing to locate and describe research evidence and another to bring it to life. MI is illustrated in so many ways in this book that it is hard to put it down. Clinical scenarios, calls from the hearts of experienced clinicians, illustrative dialogue, quizzes, literature reviews, hot topics like health disparities and ethical practice, specialist applications in different medical settings, and the list goes on. In the end, the book is a call to consider what kind of person and doctor you would like to be. Showing that MI directly helps medical trainees to answer this question is a considerable achievement by this diverse group of authors. The skills for improving your well-​being and practice are here for the taking. The more experienced clinicians will also find this one of the most useful handbooks to keep close to one’s desk. Stephen Rollnick, PhD Cardiff University William R. Miller, PhD The University of New Mexico

Preface Building on the pioneering work of Drs. William R. Miller and Stephen Rollnick, Motivational Interviewing: A Guide for Medical Trainees, Second Edition is a 24-​chapter volume that guides medical trainees which is used interchangeably with practitioners on the practice and applications of Motivational Interviewing (MI) in a variety of healthcare settings. Much has happened in the MI field since the first edition of this book. The number of clinical research trials and studies of MI-​based interventions has exploded exponentially, and those studies now clearly demonstrate the effectiveness of MI for a wide range of medical practices, including the treatment of psychological disorders, and patient populations. The current edition of this guide attempts to distill the extensive research findings to what is most meaningful and important in real-​life clinical encounters for practicing medical trainees. The contributors of this book are medical trainees, mentors, and specialists who offer their unique collaborative perspective as they implement MI in their daily practice of patient care. This is essentially a guide by trainees for trainees. This guide is arranged into two parts. To lay the groundwork for incorporating MI into clinical encounters, Part I provides an overview of its foundations, skills, and strategies of MI, and the role of ambivalence and processes of change in MI. Part II focuses on the clinical applications of MI in diverse healthcare settings and patient populations. The fundamentals of MI are presented as they relate to a particular medical setting and specialty, such as using MI in pediatric populations or psychiatric care. The guide also includes a couple of chapters addressing challenges related to integrating MI in the context of the latest technological advances in medicine, such as tele-​ medicine and electronic medical record utilization. Chapter 16 is devoted to the intersection of MI and social justice and particularly the role of MI in addressing healthcare access and disparities. A new chapter covers the issues related to the ethical practice of MI in healthcare settings. This clearly written book is augmented by clinical vignettes of patient-​ trainee interactions, which are followed by detailed explanations of the clinical rationale for using MI, with a specific emphasis on its spirit and method, in each vignette, which provides a dynamic guidance to trainees on how to implement MI-​adherent practices with the ultimate goal of improving patients’ health-​related outcomes. This volume also incorporates video clips of clinical

xii Preface

encounters conducted by two medical trainees, illustrating the mindset and “heartset” of practicing MI. A coding sheet for every video the trainees watch is included to help with assessing adherence to MI spirit and skills. Each chapter offers the trainees’ personal reflections on their experiences with doing and being MI as well as how they came to realize its value in the healing process for their patients. A question-​and-​answer section at the end of each chapter allows the readers to assess their knowledge of the concepts and strategies presented. A challenge in the writing and editing of this guide has been about maintaining a consistent vision as we offer a wide range of experiences and perspectives from many contributors. With humility, we have made every effort to give a pragmatic and unified voice to the spirit of MI. This guide has been conceptualized and designed for medical trainees. At the same time, it will serve as an invaluable resource for all healthcare professionals who wish to learn about the foundations and applications of MI across healthcare settings and its impact on patient outcomes.

Prologue Jared Kopelman

I used to think I was a good listener. After all, I could talk to patients, hear the words they said, and write them down to present later or use to formulate a differential diagnosis. What else is there to listening? When I started to learn and practice Motivational Interviewing (MI) this month, I realized the answer to that question: a lot. MI requires more than just silence and eye contact while a patient is speaking; it requires you to formulate active reflections of what the patient is saying. These reflections require a type of listening I had rarely practiced before, and I was initially frustrated at how difficult I found it. When you are practicing this type of listening, there is no hiding. You cannot “zone out” for even the briefest period. To be able to accurately reflect what patients have said back to them, you have to truly understand the meaning behind the patients’ words. An example of both the difficulty and strength of this approach arose when I was working with one of my first patients on the dual diagnosis service, KS, a 34-​year-​old woman with alcohol use disorder. Our discussion revolved around a particular medication, aripiprazole (antipsychotic medication used to treat psychotic and bipolar disorders), which she had taken in the past. In this conversation, I was tasked with informing her that we would not be prescribing her this medication when she left the hospital, as there was no indication for her to be on it. She had demonstrated no signs of bipolar disorder, and her history of symptoms was not consistent with this disorder. Rather, we believed she carried the diagnosis of severe alcohol use disorder, which included periods of binge drinking lasting days, where she would sometimes only sleep for an hour or two a night. I recognized this conversation as potentially perilous. I was telling her that I did not believe she carried a diagnosis that she believed she did, a direct challenge to a longstanding part of how she identified herself and explained her behavior. Further, I was telling her that we would not be prescribing her a medication that she endorsed as helpful in the past, which could be seen as undermining her experience and, therefore, disempowering. Previously, I would have approached this conversation nervous about the potential for conflict, but confident that I was armed with the facts—​facts that she would accept if I could just make my case persuasively enough. I could

xiv Prologue

rattle off the diagnostic criteria for bipolar disorder, which she did not meet; I could explain that there was no evidence aripiprazole would treat people with her diagnosis; I could even explain away her belief that this drug had helped her because her taking aripiprazole coincided with her period of abstinence from alcohol, which was likely the larger contributor to her improved mood. I had approached a prior discussion with her (about the duration of her hospitalization) just this way, and the conversation ended with her saying, “we have nothing more to discuss,” and walking out angrily. Determined not to replicate this conversation and equipped with some rudimentary and recently acquired MI skills, I approached the conversation differently. The issue of her diagnosis and the possibility of us discontinuing her aripiprazole had been touched on briefly in a prior session. I started by simply asking her what she thought of that previous discussion. She said she was surprised when she first heard this and then described some of her previous symptoms and behaviors, including an inability to regulate her emotions (which led to her drinking), as well as rapid shifts in her mood. I reflected to her the difficulty of these mood swings and how they affected her life and then related them to some of the skills she had developed during her hospitalization. Coping strategies that we had discussed in our sessions, that she had worked on in group sessions, and that she had worked through in workbooks could all be applied to these situations. As we discussed different strategies for how she could deal with her emotions when she left the hospital, the label of her illness became less important. Rather, what was important was her experience of the symptoms of her illness, the recognition of the distress it caused her by her practitioner, and our shared goal of giving her the skills she would need to better deal with these emotions in the future. By reflecting her distress and her difficulty coping with the stressors that led to her alcohol use, I was able to help her understand her disorder and empower her to use the tools that she had been working on to mitigate those stressors. What my experiences with KS, and my experiences with MI more broadly, have taught me is that there can be no true listening without empathy. Reflective listening allows you to support patients by acknowledging their feelings and experiences, and it allows you to develop a nonjudgmental, collaborative patient-​practitioner relationship. Further, empathy, when thought of like this, is not simply something you have. It is not a finite resource that can be used up at the end of a stressful day (or week or month or career). Rather, it is something that we can cultivate and use to empower our patients and collaborate with them to reach their goals.

Acknowledgments First of all, I want to express my gratitude and appreciation to my coeditors and collaborators, Tom and Melanie, and all contributors for their work, encouragement, guidance, and wisdom in helping shape and refine this project. I have been privileged to learn and contribute to the learning experience of medical trainees who have provided me intellectual engagement and inspiration. I am also deeply indebted to my patients of diverse backgrounds, who trusted me with their minds and hearts, and who have taught me the true meaning of empathy and compassion. A special word of appreciation goes to Dennis Daley. As a mentor, collaborator, and friend, Dennis has played a major role in the development of my personal and professional identity. This book was made possible because of the work, inspiration, generosity, and influence of many pioneers of Motivational Interviewing (MI) who developed and researched the practical approaches in this guide, including Bill Miller, Steve Rollnick, Terri Moyers, and many others. In the preparation of this work, the members of the Motivational Interviewing Network of Trainers (MINT) have contributed tremendously to systematically consolidating my perspectives and publishing them. Finally, I am especially grateful to Senior Editor Andrea Knoblock and Project Editor Katie Lakina at Oxford University Press for guiding us through another enriching editorial experience and production process. Antoine Douaihy First, I acknowledge my coeditors, Antoine and Melanie. This work was created because of Antoine’s vision of its significance for the field, and I thank him for persuading me of its importance. Melanie’s breadth and depth of experience brought an enlightened perspective to every chapter. Second, the group of practitioners involved in writing this volume provided most of the inspiration for its content. Their experiences as specialists brings a truly unique perspective to learning how MI is effective with patients in all healthcare fields. A subgroup of these young practitioners provided exceptional creativity and technical expertise in creating the illustrations and videos. I want to thank Dennis Daley for mentoring me and for the ongoing support he has provided me as a faculty member, clinician, and as a specialist in applied addiction research. John E. Donovan was also instrumental in my postdoctoral training as

xvi Acknowledgments

a clinician-​researcher. My early training in individual and family therapy was critical because I was taught by an outstanding group of clinicians, especially Tom Saunders. Later, at Western Psychiatric Hospital, the late Carol Anderson helped me to recognize the overarching influence of the family system as a model for diagnosing and addressing problems in family therapy. Similarly, William Cohen widened my knowledge of psychotherapy. Under his tutelage I came to recognize that each patient, or family, requires both a treatment plan and an individualized therapeutic strategy. Paul Soloff helped me to understand the critical integration of intrapsychic and interpersonal dynamics that exist in the treatment of all patients. These are the influences that I try to combine with the relational style that is the core of MI. I have learned that a strong therapeutic alliance provides the best opportunity for treating psychological and behavioral maladies, and that MI is the best way to establish such an alliance. My hope is that the perspectives expressed in this volume will stimulate medical trainees to integrate the content of their medical training with Bill Miller’s and Steve Rollnick’s invaluable process for establishing truly therapeutic relationships. Thomas M. Kelly Editing a book is never a solitary effort. This guide would have been impossible without the hard work, support, and collaboration of my two amazing coeditors and colleagues, Antoine and Tom. Antoine’s vision and perseverance initiated and kept the ball moving on completing this second edition. Tom’s clinical insights and wealth of experience improved every chapter. This guide was inspired by and written by medical trainees, including medical students, residents, and fellows in various fields of medicine. Their collaboration on this guide makes it a true reflection of the “MI spirit.” First and foremost, thanks go to my mother, Rona Beth Fisher, who taught me from the time I could speak, the importance of listening to language, of communication skills, of respect for people and their different perspectives, and of all the other key aspects of MI. It was not until my early years as a faculty person in 1998, when I realized that what my mother had taught me was called MI. I also must thank my friend, colleague, co-​investigator, and teacher, Allan Zuckoff, who introduced me to MI and provided me with numerous hours of one-​on-​one supervision when I was first learning. There is no one who has taught me more about MI than Allan. I would also like to express my appreciation to Bill Miller and Terri Moyers for many years of support in learning and doing research on MI, and especially to Bill Miller and Steve Rollnick for reviewing our second edition of the guide and for agreeing to write the foreword for it. Others I wish to acknowledge, who played critical roles in my

Acknowledgments  xvii

learning to use, teach, and study MI include Carlo DiClemente, Christopher Ryan, and Bill Cohen. Each one played a unique and important role in my development. Finally, I wish to thank the patients, medical students, residents, and fellows at the University of Pittsburgh and at Columbia University; the student-​patients, nurse practitioners, health educators, and mental health providers at the NY Presbyterian School Based Health Centers; and all the research staff and research participants from whom I always learn new ways to listen and reflect. You have all enhanced the quality of my MI skills and more importantly brought me great joy and gratitude from our interpersonal relationships. Melanie A. Gold

About the Editors Antoine Douaihy, MD, is a professor of Psychiatry and Medicine at the University of Pittsburgh School of Medicine. He serves as the senior academic director of Addiction Medicine Services and director of the Addiction Psychiatry Fellowship at Western Psychiatric Hospital of the University of Pittsburgh Medical Center. Dr. Douaihy has been a member of the Motivational Interviewing Network of Trainers (MINT) since 2002. He has focused his career on patient care, education, mentoring of medical trainees, and research in the areas of psychology of behavior change, Motivational Interviewing (MI), substance use disorders, and HIV Psychiatry. Dr. Douaihy has been a champion in the implementation and dissemination of MI across healthcare settings and has been the recipient of multiple teaching and mentoring awards, including the Leonard Tow Humanism in Medicine Award and The Charles Watson Teaching Award, recognizing him for the qualities of a masterful clinician, academician, caretaker of his patients, educator, mentor, and contributor to the medical school community and community at large. Thomas M. Kelly, PhD, began his career as a licensed clinical social worker at the Western Psychiatric Hospital of the University of Pittsburgh Medical Center in 1982. Dr. Kelly received his doctoral degree in social work in 1996 from the University of Pittsburgh and served as the director of the Adolescent Substance Abuse Treatment Service until 2014. Dr. Kelly’s other work focused on teaching, consultation, and research. He was a coinvestigator with the National Institute on Drug Abuse Clinical Trials Network and has published over 50 peer-​reviewed publications. Dr. Kelly has been a MINT member since 2005, and has conducted training workshops, lectures, and seminars, locally and nationally. Dr. Kelly retired from full-​time practice as an associate professor of Psychiatry in 2014. He continues to publish on psychiatric treatment. Melanie A. Gold, DO, is a former Professor and current Special Lecturer in the Department of Pediatrics in the Division of Child and Adolescent Health, Section of Adolescent Medicine at Columbia University Irving Medical Center. She is a former Professor and current Special Lecturer in the

xx  About the Editors

Department of Population & Family Health at the Mailman School of Public Health at Columbia University. She served as medical director of New York Presbyterian’s School Based Health Centers (SBHCs). Dr. Gold is an osteopathic pediatrician who is board certified in Adolescent Medicine. She trained in MI in 1998 and became a MINT member in 2000. MI has become an integral and critical component of her work as a clinician, researcher, educator, and administrator.

Contributors Areej Ali, UT Southwestern Medical Center Melinda Armstead, Erie County Medical Center, Buffalo, New York Lauren Auster, University of California at San Francisco David Bell, NY Presbyterian Hospital-​Columbia Augusto Bermudez, NY Presbyterian Hospital-​Columbia Isra Black, University College London Katelin Blackburn, Boston Children’s Hospital Cassandra Boness, University of New Mexico Pamela Burke, Boston Children’s Hospital Judy Chang, University of Pittsburgh Medical Center Julie Childers, University of Pittsburgh Medical Center Daniel Cohen, University of Pittsburgh Medical Center Elliot Collins, University of Washington Affiliated Hospitals Amelia Cuevas, University of Pittsburgh School of Medicine Mark D’Alesio, University of Pittsburgh School of Medicine Esa Matius Davis, University of Pittsburgh Medical Center Antoine Douaihy, University of Pittsburgh Medical Center Patrick H. Driscoll, University of Pittsburgh Medical Center Morgan Faeder, University of Pittsburgh Medical Center Lisa Forsberg, University of Oxford Jessica Gannon, University of Pittsburgh Medical Center Jody Glance, University of Pittsburgh Medical Center Melanie A. Gold, Columbia University Irving Medical Center Tina Goldstein, University of Pittsburgh Medical Center Gail Gutman, Columbia University Irving Medical Center Estelle Hirsh, University of Pittsburgh Medical Center Elizabeth Hovis, Medical College of Wisconsin Meghan Keil, University of Pittsburgh Medical Center

xxii Contributors Thomas M. Kelly, University of Pittsburgh Medical Center Julie Kmiec, University of Pittsburgh Medical Center Jared Kopelman, University of California at San Diego James Latronica, University of Pittsburgh Medical Center Lindsay Leikam, University of Pittsburgh Medical Center Laura Marengo, MGH McLean Amelie Meltzer, University of Pittsburgh School of Medicine Elizabeth Miller, University of Pittsburgh Medical Center Sarah Minney, University of Rochester Joshua T. Morra, Horizon Health Vivianne Oyefusi, UT Southwestern Medical Center Mariel Piechowicz, University of Pittsburgh Medical Center Jordon Post, University of Illinois Chicago Janice Pringle, University of Pittsburgh School of Pharmacy Mara Rice-​Stubbs, University of Pittsburgh Medical Center Dana Rofey, University of Pittsburgh Medical Center Dina Romo, Columbia University Irving Medical Center Miriam Rosen, University of Pittsburgh Medical Center Brianna Rossiter, University of Pittsburgh Medical Center Daniel Salahuddin, University of Pittsburgh Medical Center Neeta Shenai, University of Wisconsin Erin Smith, The University of British Columbia Jeanette South-​Paul, University of Pittsburgh Medical Center Jessica J. Stephens, University of Pittsburgh Medical Center Carolyn Windler, Tacoma Family Medicine, MultiCare Health System



1 Motivational Interviewing in Medical Training Sarah Minney and Julie Childers

We think we listen, but very rarely do we listen with real understanding, true empathy. Yet listening, of this very special kind, is one of the most potent forces for change that I know. —Carl Rogers, Empathic: An Unappreciated Way of Being, 1975.

PERSONAL REFLECTION (Sarah Minney) (PART I) Already sweating through my freshly ironed short white coat, I held my breath while I raised my hand to knock twice on the “standardized” patient’s door as instructed. “Come in” said the patient gruffly. All I knew about the patient was the short blurb which was posted on the door. She was here to follow up on some routine liver testing her primary care doctor had ordered. Did I already do or say something wrong? I thought, as I entered the room and registered a look of frustration and a flash of anger in the patient’s eyes. “I’m not really even sure why I’m here, the doctor said they were just routine lab tests and now for some reason they’re not?” she inquired. We just finished our Gastro-​ Intestinal (GI) module in school, I thought to myself, so it must be a GI problem I am supposed to diagnose. I ran through a litany of yes-​or-​no questions about symptoms, the patient’s medical history, social history and medication history, and the patient just grew more and more irritated. “I do not understand why you’re asking me all these questions the doctor already asked me last time. Why can’t you just tell me what is wrong with my liver? This is a waste of time.” Why am I getting nowhere? I thought, and I wished the overhead bell would just ring already and tell me it was time to leave the room. What do you do when there is a communication breakdown between you and your patient? I wrapped up the visit and stepped out of the exam room feeling frustrated and defeated. On reviewing our interactions in our feedback session, I came

4  Motivational Interviewing, 2E

to realize that with my urge to correctly diagnose the patient, I had missed the crucial step of listening to the patient. She had been struggling with increased alcohol use and was worried it was the cause of her abnormal liver function. Yet, she was too ashamed to discuss her concern with her doctors. Behind what I had viewed as defensiveness and impatience was really the patient’s fear. As you will come to learn as you continue to read this book, active listening is essential to Motivational Interviewing (MI), and it can transform your interactions with patients.

THE ORIGINS OF MOTIVATIONAL INTERVIEWING: FILLING A NEED Despite the innumerable biomedical and technological advancements over the past century, the County Health Rankings and Roadmaps model demonstrates that clinical care contributes only 14.9% to 32.5% of health outcomes, and health behaviors contribute 26.5% to 31.6%; this makes health behaviors just as significant, if not more so, compared to medical care in terms of overall health (Park, Roubal, Jovaag, Gennuso, & Catlin, 2015). And as a trainee I spent the majority of my first two years of medical school learning the pathophysiology of disease states rather than how to address the health behaviors that can trigger them. Therefore, it is essential that medical trainees not only learn how to communicate with their patients about health behaviors, but also how to do so efficiently and effectively. We cannot improve the health of our patients without ensuring their success in modifying their desired health behaviors, and thanks to the work of Drs. William “Bill” R. Miller and Stephen “Steve” Rollnick and their development of MI, we have an approach to do that. Miller stated that developing MI was completely unplanned and unanticipated. It originated initially from an inspiration which came from his own data, whereby he noted that accurate empathy is the therapist skill that best predicts patient reductions in alcohol use (Miller, Benefield, & Tonigan, 1993). Leaving on a sabbatical from the University of New Mexico, Miller started working in an “alcoholism” clinic in Bergen, Norway, in 1982, lecturing on cognitive-​behavioral treatment and teaching a group of Norwegian psychologists about reflective listening through role playing with patients and discussing challenging clinical situations. These experiences helped Miller conceptualize some clinical principles and decision rules. This is how MI emerged. Miller reasoned that direct argumentation was an ineffective way to change someone else’s behavior. Instead, he focused on the principle that any person is more likely to be committed to a position that he or she

Motivational Interviewing in Medical Training  5

defends verbally. He pointed out that the patient, not the counselor, argues for change. The MI approach is designed to evoke these arguments. Miller’s first description of MI was published in 1983, in the British journal Behavioural Psychotherapy. In the period after, Miller began doing research and evaluating the approach through working with individuals with alcohol use disorder, who were then referred to as “problem drinkers.” He proposed an approach rooted in the tenets of social psychology, namely cognitive dissonance, and internal attribution (Miller, 1983). Seven years later, he met Rollnick in Australia, who had been teaching MI in addiction treatment programs in the United Kingdom. In collaboration with Rollnick, Miller wrote a more detailed description of MI and its associated clinical processes in the book Motivational Interviewing: Preparing People to Change Addictive Behavior (Miller & Rollnick, 1991).

THEORETICAL UNDERPINNINGS AND ASSOCIATED MODELS When an individual did not engage in treatment or change a particular behavior, it was attributed to a lack of motivation or a “denial” of their condition. Confrontation is, therefore, the natural therapeutic response, rather than empathy and collaboration. A central tenet of Miller’s approach is the psychological principle that individuals commit more strongly to opinions and arguments when they voice them. Miller proposed that therapists should work to elicit statements from individuals regarding their concerns about their negative behaviors and reasons why they believe they should change their behaviors. This allows the creation of statements that reflect dissonance. These statements, then called “self-​motivational statements” and now better known as “change talk,” are then reinforced by the therapist along with an atmosphere that promotes reflection on behavior change. The use of these statements comprise the four “key principles of motivation” that Miller outlines in his 1983 article: 1. De-​emphasis on labeling, meaning the focus is not on labeling an individual with a problem but rather having the individual describe their own problems. 2. Individual responsibility, meaning a person can define for themselves if their behavior is a problem and why. 3. Internal attribution, meaning the responsibility to change is placed on the individual rather than the external environment.

6  Motivational Interviewing, 2E

4. Cognitive dissonance, reflecting that in order for a behavior change to occur, individuals must recognize the discordance between their thoughts and beliefs versus their behaviors. As opposed to being fundamentally grounded in psychological theory, the concept of MI arose from intuitive clinical experience. Nevertheless, Miller drew upon several prevailing theories in his descriptions of MI, including the following (Miller & Rose, 2009): • Leon Festinger’s formulation of cognitive dissonance: that when faced with an internal contradiction, we tend to change our thoughts and beliefs in order to resolve the conflict (Festinger, 1962). • Daryl Bem’s reformulation of self-​perception theory: that just as we are influenced by our observations of our own behaviors, so too are we influenced by what we ourselves say aloud (Bem, 1972). • Albert Bandura’s self-​efficacy theory: that the stronger individuals believe they will succeed in performing a given task, the more likely they will attempt to finish that task (Bandura, 1997). MI follows Carl Rogers person-​centered approach to therapy that is based upon building empathy, congruence, and the positive regard “necessary and sufficient [to establish] interpersonal conditions [which foster] discussion about behavior change.” (Rogers, 1975). However, unlike classic Rogerian therapy, MI is more goal-​driven and directional, meaning that there is a clear, positive behavioral outcome. More recently, self-​determination theory (SDT) has been identified as a de facto model for understanding why and how MI works (Deci & Ryan, 2012). SDT postulates that all behaviors may be understood as occurring along a continuum ranging from external regulation to true autonomy, or self-​regulation. Both SDT and MI view the concept of motivation as theoretically central to each model and emphasize the importance of patients developing “intrinsic” motives, in addition to assuming responsibility for change. Another similarity is that both models are person-​centered and endorse engaging with patients in a safe atmosphere of genuine empathy and unconditional positive regard as a prerequisite for the success of behavioral interventions. SDT emphasizes the core needs of autonomy, competence, and relatedness as relevant to motivating behavior change. Likewise, autonomy support is central to MI and is promoted though reflective listening, eliciting the patient’s perspectives and values, providing a menu of choices, and the marked lack of persuasion

Motivational Interviewing in Medical Training  7

throughout a clinical encounter. Clearly, many of the tenets of SDT provide a theoretical framework to guide an MI approach, and in many ways, MI may be considered as “the interventional method of SDT” (Deci & Ryan, 2012; Resnicow & McMaster, 2012).

THE SPIRIT OF MOTIVATIONAL INTERVIEWING It is the spirit of MI that allows it to transcend from a counseling style to a tool of equity and social justice. While MI can be characterized by conversational strategies and techniques, it is more accurately defined as a way of being with others. At its core is empathy (as alluded to in this chapter’s epigraph), as the creation of MI largely drew on Miller’s training in Carl Rogers person-​ centered therapy. With the central tenet of empathy comes a natural positive regard for all-​comers, regardless of race, ethnicity, gender identity, sexual orientation, origin of birth, religion, educational level, socioeconomic status, or physical ability. Miller wrote about the relationship between MI and social justice in a plenary published in 2013, which outlined the values inherent to both: compassion, respect, fairness, human potential, prizing of differences, and collaboration. MI allows for these values to be placed into action on an individual level with a natural extension to the family unit, community level, and national level. The spirit of MI will be discussed in detail in Chapter 2.

DEFINITIONS OF MOTIVATIONAL INTERVIEWING The book Motivational Interviewing: Helping People Change (3rd ed.) (Miller & Rollnick, 2013) offers the following definitions of MI for laypersons and practitioners, along with a more technical definition. MI is: 1. “A collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p.12). 2. “A person-​ centered counseling style for addressing the common problems of ambivalence about change” (p.24). 3. “A collaborative, goal-​oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for, and commitment to, a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” (p.29).

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Trainee burnout

defensiveness, cynicism

spirit of MI


Figure 1.1  Guarding against burnout.

GUARDING AGAINST COMPASSION FATIGUE The spirit of MI allows practitioners to navigate emotionally taxing conversations with patients and may even reduce the risk of compassion fatigue (Figure 1.1) (Douaihy, Kelly, & Gold, 2014). As compassion and a belief in human potential and autonomy drive MI, practicing it allows practitioners to let go of the common belief that they have control over or total responsibility for patients’ behaviors and outcomes. This “righting reflex,” which is the desire to “fix,” meaning telling patients what to do, is counter to the MI spirit of supporting patient autonomy and is a known internal risk factor for compassion fatigue and moral injury. By being with patients instead of confronting them, we support their own journeys without judgment, and their own choices without criticism. MI’s unconditional positive regard for others is also a balm to the compassion fatigue many practitioners face and is another high-​risk factor for burnout. When we approach patients with curiosity and empathy, the urge to label or categorize patients is diminished. Labels like drug-​seeker, vasculopath, sickler, alcoholic, diabetic, poor historian, demented . . . . the list goes on, result in automatic negative thoughts by practitioners as well: they just want drugs, they’ll never stop smoking, they’ll just go home and drink anyway, I can’t determine how to treat them. The conversation changes from how am I going to fix you? to what is your story and how can we work together on what you would like to change? Rollnick and Miller note that the essence of MI can free us from the burden of failure and defeat that often accompanies the unpleasant realization that we cannot make our patients change. By fully embracing the spirit of MI, we become intentional in our perceptions of patients and conscious of our role in our relationships with them.

THE EVIDENCE: APPLICATIONS OF MOTIVATIONAL INTERVIEWING From its origins as a therapeutic style and treatment modality for addiction, MI has grown and expanded and is put to use for a wide variety of health

Motivational Interviewing in Medical Training  9

behaviors across treatment settings and practitioner types. Because MI is a clinical style with communication skills as its foundation (as will be discussed in subsequent chapters), it can be taught to practitioners across disciplines and requires little in the way of materials. Further, the success of MI in modifying a variety of health behaviors is well-​established. Miller and Rose review the dissemination of MI across healthcare settings in a journal article published in 2009; this review is a comprehensive outline of Rollnick’s work in MI in health care as well as that of other practitioners. The success of MI has been proven in numerous health challenges including cardiovascular rehabilitation, diabetes management, hypertension, gambling, smoking, and many others (Douaihy, Kelly, & Gold, 2014; Rubak, 2005). Even brief encounters of 5 to 15 minutes, especially multiple encounters over time, are effective in creating behavior changes (Westra, Aviram, & Doel, 2011). Lastly, as a style rooted in verbal communication, MI can be implemented in telemedicine, which became a necessary component of healthcare in the era of COVID-​19 (Chapter 21).

PERSONAL REFLECTION (Sarah Minney) (PART II) A few months ago, I had a follow-​up with a clinic patient of mine who had recently started a beta-​blocker for treatment of an essential tremor. Our conversation meandered from its original start to the health effects of alcohol; my patient seemingly out of the blue asked if alcohol use could be contributing to a new hip pain she was having. I thought back to the case I shared with you at the beginning of this chapter; back then, without a working knowledge of MI skills and practice, I struggled to walk alongside my patients rather than in front of my patients and had missed the opportunity to truly listen. This time, I instead approached her questions with openness, curiosity, empathy, and reflective listening, and I came to learn she was struggling with increasing alcohol use but had not known how to ask me for help. I elicited her ambivalence about her drinking pattern—​she did not think abstinence made sense because, “I don’t want to lose the fun part of me,” but also stated that “I had a fall so now I know it’s getting dangerous.” This led to change talk regarding her desire to modify her drinking, “I could start with not drinking during the week and going to more of my Jehovah’s meetings,” and her confidence in her ability to change her patterns, “I’ve cut back before and can do it again”—​ all of these strategies you will learn about through the course of this guide. Rather than leaving the encounter frustrated and defeated, I left feeling fulfilled, and the patient left stating she felt “relieved” and “hopeful.” Clearly, MI strengthens our ability to withstand the very real threat of disillusionment and

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emotional exhaustion during medical training. While the process of learning MI requires a meaningful commitment of time and energy, it is an investment with great potential to bring about better outcomes for our patients, and to improve our effectiveness, our time management skills, and the satisfaction we experience in our work as medical trainees.

SELF-​ASSESSMENT QUIZ True or False 1. MI is an evidence-​based framework that addresses unhealthy behaviors. 2. MI is a trainee-​directed conversation in which trainees assume the role of experts who provide guidance toward a desired behavior change within a patient. 3. Dr. Miller incorporated elements of contemporary psychological theories and adapted them into a goal-​driven therapy based on collaboration and respect for patient autonomy. 4. Directly confronting patients regarding their unhealthy behaviors is a cornerstone of MI. 5. Long-​term therapy is essential to MI’s success as a clinical intervention. 6. An essential element of the spirit of MI is that trainees must relinquish a sense of having the power to change or control patient behavior.

Answers 1. True. There is an expanding body of scientific literature validating the effectiveness and efficacy of MI for numerous health-​related behaviors. Research continues on the use of MI among patients with substance use, anxiety, depression, eating disorders, and chronic medical conditions such as diabetes, heart disease, HIV, and obesity. 2. False. MI is a collaborative conversation between trainees and patients, rooted in the principles of egalitarianism and empathy. It is patient-​ centered and oriented toward strengthening a patient’s motivation and commitment to targeted behavior change. 3. True. In the 1980s, Dr. Miller was inspired by Festinger’s formulation of cognitive dissonance, Bem’s reformation of self-​perception theory, Bandura’s self-​efficacy theory, and Rogers person-​centered approach.

Motivational Interviewing in Medical Training  11

4. False. MI is based on the observation that argumentative and confrontational approaches compromise trainee–​patient relationships and lead to poor outcomes. MI-​based interactions are defined by a patient-​centered focus, empathy, and support, which have been demonstrated to improve outcomes. 5. False. While MI is effective over the course of long-​term practitioner–​ patient relationships, 64% of studies investigating the use of MI in brief encounters demonstrate positive patient outcomes. 6. True. The false sense of power that some trainees believe they possess to change a patient’s behavior is contrary to the principles of MI. MI focuses on patient-​centered care and affirms patient autonomy. Unfortunately, trainees are subject to feelings of failure and defeat when they realize they are unable to force patients to change. Consequently, some trainees are at risk for profound cynicism, burnout, and a pervasive sense of therapeutic nihilism. MI reminds trainees that the responsibility for behavior change rests with patients.

REFERENCES Bandura, A. (1997). Self-​efficacy: The exercise of control. W H Freeman/​Times Books/​Henry Holt & Co. Bem, D. J. (1972). Self-​perception theory. In L. Berkowitz, (Ed.), Advances in experimental social psychology (Vol. 6, pp. 1–​62). Academic Press. Deci, E. L., & Ryan, R. M. (2012). Self-​determination theory in health care and its relations to motivational interviewing: a few comments. International Journal of Behavioral Nutrition and Physical Activity, 9(24), 24. Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational interviewing: A guide for medical trainees. Oxford University Press. Festinger, L. (1962). Cognitive dissonance. Scientific American, 207(4), 93–​106. Miller, W. R. (1983). Motivational Interviewing with problem drinkers. Behavioural Psychotherapy, 11(2), 147–​172. Miller, W. R. (2013). Motivational Interviewing and social justice. Motivational Interviewing: Training, Research, Implementation, Practice, 1(2), 15–​18. Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455–​461. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. Guilford Press. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Miller, W. R., & Rose, G. S. (2009). Toward a theory of Motivational Interviewing. American Psychologist, 64(6), 527–​537. Park, H., Roubal, A. M., Jovaag, A., Gennuso, K. P., & Catlin, B. B. (2015). Relative contributions of a set of health factors to selected health outcomes. American Journal of Preventive Medicine, 49(6), 961–​969.

12  Motivational Interviewing, 2E Resnicow, K., & McMaster, F. (2012). Motivational Interviewing: moving from why to how with autonomy support. International Journal of Behavioral Nutrition and Physical Activity, 9, 19. Rogers, C. R. (1975). Empathic: An unappreciated way of being. The Counseling Psychologist, 5(2), 2–​10. Rubak, S. (2005). Motivational Interviewing: A systemic review and meta-​analysis. British Journal of General Practice, 55(513), 305–​312. Westra, H. A., Aviram, A., & Doell, F. K. (2011). Extending Motivational Interviewing to the treatment of major mental health problems: Current directions and evidence. Canadian Journal of Psychiatry, 56(11), 643–​650.

2 The Style and Spirit of Motivational Interviewing Antoine Douaihy, Melanie A. Gold, Gail Gutman, and Dina Romo

As trainees, we have good intentions and we want to help our patients make healthy choices. And, as you may have learned through personal experience when you have tried to convince someone to make a change, helping other people change their behaviors is not easy. Our instincts are to lecture, warn, scold, beg, plead, or even nag. But that is usually not effective. We offer another way to help your patients make health behavior changes; that way is Motivational Interviewing (MI).

THE STYLE OF MOTIVATIONAL INTERVIEWING Core Communication Skills and Styles Communication Skills There are three core communication skills in clinical encounters. They can be used in varying degrees, depending on the type of communication style necessary at the time of the conversation. The first is informing. Informing in a healthcare setting is defined as conveying knowledge about a condition or medical treatment, or even the results of a laboratory or radiologic test by providing facts, diagnoses, prognosis, and recommendations to the patient. The second communication skill is asking, especially asking questions that develop an understanding of patients’ problems and perspectives. This is best accomplished using open-​ended questions. This is a skill that is different than the usual asking of predominantly closed questions that result in answers of a few words (e.g., yes/​no, twice last week). Closed questions are often numerous and consecutive and are asked for the sole purpose of generating a differential diagnosis and treatment plan that is then told to the patient. The third communication skill is listening, which is an active process beyond just nodding

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your head and saying, “Uh huh” or “I see.” You demonstrate you are actively and mindfully listening and that you are working to understand patients’ experiences, feelings, and meanings by using “reflections,” also called listening statements, a fundamental skill we will discuss in more detail in Chapter 3. Communication Styles We present three core communication styles: directing, following, and guiding. A directing communication style communicates that “I know what you should do and here is how to do it.” This communication style implies that the practitioner is the expert who will “fix” the patient with their knowledge and expertise. A following communication style implies that “I trust your own wisdom, I will stay with you, and I will let you work this out in your own way.” When you use a following communication style, you listen and demonstrate that you hear the patients’ perspectives and follow them wherever their conversation takes you, without any guidance in any particular direction. A following style is often used by psychologists who practice client-​centered counseling in the style of Carl Rogers (1951). A guiding communication style combines listening well, conveying empathic understanding, and suggesting thoughts and feelings for the patient to explore, while offering advice with permission when needed; it is in-​between directing and following. MI uses a guiding communication style. When it comes to communication style, no single one is a particularly effective or ineffective style. All three styles are needed, and skillful medical trainees shift flexibly among these styles as appropriate to the patient and the clinical encounter. For example, when a patient has collapsed in a waiting area, a directing style is most appropriate until you have completed your ABCs (or airway, breathing, and circulation) and stabilized the patient. In this situation, you need to take charge and not have a conversation that is following or guiding. Likewise, early on in a mental health evaluation or when a therapist is practicing pure client-​centered psychotherapy in a Rogerian style, one might use a following communication style to better understand a patient’s experiences and perspectives. MI is a guiding communication style that uses specific techniques and strategies, such as reflective listening, shared decision-​ making, and eliciting change talk. MI is defined as a “person-​centered method of guiding to elicit and strengthen personal motivation for change” (Miller & Rollnick, 2009). Considering how communication skills and communication styles align, in a directing style, one informs a lot, asks a little, and does not use reflective listening much (Figure 2.1). In a following style, one performs reflective listening a lot, asks a bit, and does not inform much. In a guiding (MI) style, one informs, asks, and provides reflective listening in equal parts. There

Proportion of skills used

The Style and Spirit of MI  15

Directing Following Informing


Guiding Listening

Figure 2.1  Communication styles.

is an important role for informing as much as there is for reflective listening and asking in a guiding style.

THE RIGHTING REFLEX The righting reflex is a natural human tendency, an “impulse,” that healthcare practitioners experience, and the term refers to “a built-​in desire to set things right” (Miller & Rollnick, 2013). Simply put, it tells our patients what to do using unintentionally a derogatory tone of voice. For instance: “Why don’t you start eating healthy?” “You need to stop hanging out with people who use alcohol.” “You should start taking your medications as prescribed.” “When are you going to focus on yourself?”

The righting reflex can damage the therapeutic relationship and cause patients to feel unheard, dismissed, disconnected, disempowered, and helpless. Discord in the clinical encounter often contributes to patients blaming themselves for not making the change. The message to the practitioner is clear: “You do not understand what I am going through.” As a result, patients respond by recalling and reasserting their arguments for maintaining the same behavior and may become more rigid about maintaining the status quo and not changing. While the righting reflex is normally driven by a well-​intentioned desire to help and “fix,” quickly offering unsolicited solutions and “expert advice” can set up a dynamic in the clinical encounter where the trainee is arguing for change and the patient is arguing against it. Learning MI requires quelling your desire to fix, suppressing the righting reflex, and exploring patients’

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individual motivations for change. Rather than reflexively trying to fix the problem or offer unsolicited information, you first find out how patients feel and think about the problem, and then elicit their own ideas and resources about how to address it. Instead of the above statements, consider the following: “What are your thoughts about changing your diet?” “How do you feel about being around people who use alcohol?” “What are some challenges related to taking your medications and what do you think you need to do to help yourself take them as prescribed?” “What do you think you could do to start focusing more on yourself?”

AMBIVALENCE Ambivalence is when you feel two ways about a behavior change, such as whether you should start exercising on a regular basis. On the one hand, you do not feel like going to the gym and getting all sweaty today. On the other hand, you know you should do it for your health because it will help you stay strong and trim, and you will feel better if you do it. You are already dog-​ tired, and you hardly have enough energy to drag yourself home after a day of classes or rotations. You just want to go home, eat something satisfying, veg out in front of the TV, and then go to bed. You feel two ways about it—​you are ambivalent about exercising (Figure 2.2) (Douaihy, Kelly, & Gold, 2014). It is like having a devil on one shoulder and an angel on the other, each telling you different things to do, think, or feel. Ambivalence is a normal process in behavior change. However, when someone tries to push you one way or another when you are ambivalent, you will naturally push back. If I start to argue with you about why you really need to go work out, you will probably counter with how exhausted you are and that I do not understand how hard your day has been. When I demonstrate my understanding using reflective listening statements that you had a rough day and you feel you deserve to go home and relax because exercise is not really a big deal right now while you are in medical school or residency, you might disagree with me. You might say that you really need to exercise and that you will feel so much better afterward and that it is worth the time to go to the gym. Patients are often ambivalent and feel two ways about making health-​related behavior changes that we suggest they do, especially lifestyle changes that are hard and require a lot of ongoing effort and commitment.

The Style and Spirit of MI  17

Figure 2.2 Ambivalence.

Regarding your patients, you decide—​do you want to push them away from healthy changes by arguing with them or telling them what to do when they are ambivalent, or do you want to help them move toward change by learning to evoke from them their own reasons for change and how they feel about it? Because ambivalence is a universal human experience (Miller, 2021), it is at the heart of the clinical framework of MI (Miller & Rollnick, 2013), “a normal step on the road to change” (p. 157). One goal of MI is to assist individuals to work through their ambivalence about behavior change and explore discrepancies between current behaviors and broader life goals and values. Practitioners must establish a nonconfrontational, empathic, and safe atmosphere in which patients feel comfortable opening up and expressing both the positive and negative aspects of their current behavior before moving toward discussing change. In MI, ambivalence is subsequently understood as patient statements in favor of behavior change (change talk and commitment language), which often co-​occur with patient statements in favor of status quo (sustain talk) (Miller & Rollnick, 2013) (e.g., “I know I need to take my medications, but they make me feel groggy!”). We will discuss how to address ambivalence in Chapter 4.

THE SPIRIT OF MOTIVATIONAL INTERVIEWING Perhaps the most concise way to think about MI is as a person-​focused way of engaging people in a conversation about changing problematic

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ac ce p





part ners


behaviors. The underlying mindset and “heartset” or “spirit” of MI is not itself behavioral—​it is humanistic and it prioritizes value and autonomy of the individual person over the purely rational and empirical. As trainees, we receive extensive training concerning the content of questions and methods to gather information that determine a differential diagnosis and treatment plan. However, we all struggle with competing priorities whenever we encounter opportunities to address problem behaviors that cause patients to seek treatment. Should we go back and collect more data, or should we tell patients how they ought to change? Should we focus on making a diagnosis immediately or should we listen to patients discuss the issues that they believe are important to focus on? One way to imagine the spirit of MI is the outer rim and tire on the wheel of a bicycle (Figure 2.3) (Douaihy, Kelly, & Gold, 2014). The spokes of the MI wheel are the many processes and skills that support this approach. Together, they have the potential to help us better engage with our patients. Similarly, learning to ride a bicycle takes time, effort, balance, and perhaps a dose of risk-​taking and courage. Learning MI requires the same approach. Let us take a moment to consider another image: that of a skilled and highly experienced mountaineer seeking to guide a novice climber who wishes to











ga ng




Figure 2.3  Conceptualizing MI.






in riz

a mm







a mp


The Style and Spirit of MI  19

scale their local peak (Figure 2.4) (Douaihy, Kelly, & Gold, 2014). The seasoned mountaineer has the expertise to climb virtually any summit but has not previously visited this particular hill. The student climber has visited few other mountains and has spent long hours observing the geography and wildlife of the pinnacle they approach together. The student’s life has been spent on this hill, yet many of its contours and cornices remain unknown and unmapped. Sometimes the student has ventured beyond the confines of the family settlement, but not often enough to feel confident in their ability to explore further afield; the decision to attempt an ascent now has taken both time and courage. The professional mountaineer works closely with the new climber to uncover two sorts of paths: those that require both climbers’ careful attention to small topographic subtleties, and those that are clear to the experienced eyes of the accomplished climber alone, being too well hidden or treacherous for the novice to notice. Any new ascent is fraught with physical, psychological, and emotional challenges, and so it is on this climb.

Figure 2.4  The spirit of MI.

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Despite the inexperienced climber’s doubt and uncertainty, the expert actively supports and encourages the beginner in the unfamiliar position of leading the way up the mountain. This in itself is tacit recognition of the worthiness of the journey and acceptance of the new climber’s intrinsic value and ability. The mountaineer feels many things: empathy, which arises from an ability to perceive the mountain with the fear and trepidation that the new climber experiences; compassion that comes from understanding the profound vulnerability the new climber must overcome in order to complete the climb; and the willingness to allow the student to chart the course. The mountaineer’s goal is to awaken and reinforce the student’s inner confidence, strength, and wisdom, and, in so doing, increase the prospect of success. As the master shares the skill and finesse gleaned from a lengthy career, so too the novice reveals local secrets known only to one whose life has been spent on this hill.

FOUR ELEMENTS OF MI SPIRIT The spirit of MI, which is defined as a therapeutic “way of being” with a patient, is comprised of four key elements: (1) equal partnership or collaboration, (2) acceptance, (3) compassion, and (4) evocation (Miller & Rollnick, 2013).

Partnership The conventional medical model confines practitioners to the role of feeding advice, information, and directives into patients, who are viewed as passive recipients of information and advice. Equal partnership, also known as collaboration, is the opposite of the conventional medical approach, meaning that the practitioner and the patient work together toward a shared patient goal. MI is done with the patient, not to, on, or for the patient. Our role as trainees is to explore patients’ experiences and point of view to better understand the circumstances that have caused them to seek care and to evoke their reasons for change. As partners in the process, we learn to attend to the nuances of our voices and body language, for these elements play a significant role in establishing the tone of the relationship. Encounters based on MI have been compared to dancing a waltz, in that each partner is highly receptive to the subtlest motions of the other in an activity that is demanding but exhilarating. Imagine that your patient has just expressed concern about a recent medical diagnosis. You realize that this is not the time for false optimism or a detailed summary of treatment options.

The Style and Spirit of MI  21

Here is how you might reinforce a collaborative style: • “May I share my perspective on this news? We could discuss the pros and cons of different treatment options based on what makes the most sense for you.” • “You raise very important concerns that we can examine and weigh together. Help me understand more about how you see it.” Explicit in the spirit of MI are trainees who are able to give up the expert role, who support patients’ autonomy and expertise in decisions about change, and emphasize accurate empathy in their interactions with patients.

Acceptance Accepting our patients means that we recognize and respect all that each individual brings to the encounter. It is profound and unconditional. Acceptance is not the same as approving of a patient’s behaviors or actions. Acceptance consists of four components:

• Absolute worth • Accurate empathy • Autonomy support • Affirmation

Absolute Worth Carl Rogers termed the phrase unconditional positive regard against an attitude of judgment and placing conditions on worth. At the heart of unconditional positive regard is hope. “An acceptance of this other individual as a separate person, a respect for the other as having worth in his or her own right. It is a basic trust—​a belief that this other person is somehow fundamentally trustworthy” (Rogers, 1980). This aspect of acceptance requires that we acknowledge and respect the absolute value of each patient as an individual human being. The concept of absolute worth assumes that no patient is completely devoid of goodness and trustworthiness, and that uncovering these qualities is a critical element of behavior change. In the absence of this view, therapeutic nihilism—​that is, the conviction that a patient is incapable of change—​ pervades treatment. Unconditional acceptance commits us to searching for each patient’s intrinsic goodness, even in situations when patients believe they lack this quality.

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In accepting our patients, we resist judging them or their behaviors, realizing that sometimes this will be especially challenging. Although acceptance and behavior change may not seem related, the two form two halves of an exciting dynamic. When patients feel accepted and learn to accept themselves and their inevitable vulnerabilities, they are free to make the changes that help them gain the lives they seek. Philosophers and humanistic psychologists have described this process as one of self-​actualization: becoming all that we may be by realizing our full potential. When we model patient acceptance, we facilitate our patients’ acceptance of themselves, which in turn, facilitates the process of implementing and sustaining change. Keep in mind that acceptance is an active process; it is not always easy. In the following scenario, a patient presents to the emergency department feigning severe flu symptoms, until he shares, with shame, that he is experiencing acute opioid withdrawal. Some ways of demonstrating absolute worth include the following: • “You have been struggling a lot and you weren’t sure whether you felt safe and trusting about how to be open about that struggle.” • “What is it like for you to be honest and share what you’ve been keeping inside for so long?” • “You sometimes wonder who could possibly really understand all that you have been through and what this has meant for you as a person. How do you feel about working together to better understand your experiences?” Accurate Empathy Accurate empathy refers to a genuine interest in discovering and attempting to understand patients’ perspectives. We communicate empathy by using thoughtful reflections that demonstrate our belief in the unique value of each patient’s experiences. As described by Carl Rogers (1986), it is “to sense the patient’s inner world of private personal meanings as if it were your own, but without ever losing the ‘as if ’ quality.” Comprehending patients’ frame of reference also acknowledges patients’ independence and the validity of their point of view. Take care to avoid either overidentifying with your patients’ experiences or imposing your own values or perspective on what they share. Be careful not to dismiss elements of your patients’ narratives, however insignificant or irrelevant they may appear at first. The following patient has suffered much loss and hardship over the course of her illness, and she has yet to share her feelings of this struggle and the

The Style and Spirit of MI  23

changes she wants to make. As she begins to confide in you, here are some ways to empathically elicit more of her story:

• • • •

“How was that [experience] for you?” “You’ve really been fighting for your life.” “What was it like to struggle through that experience on your own?” “You know what will work best for you to get back on the right track with taking care of your diabetes.” • “It surprised you to find out how much you were loved and cherished by so many family members and friends during your last hospitalization.” Another tip regarding accurate empathy is to pay attention to your own tone of voice and manner of expression: stay in the moment and attend to the essence of what you hear from your patient. Remember that most patients know when we are “faking” interest in them, especially when we respond with feeble clichés or forced optimism. Autonomy Support Supporting autonomy is central to MI. It is reinforced through skills and strategies such as eliciting and acknowledging (or reflecting) patient perspectives and value system, providing a menu of choices for the relevant behavior discussion, and focusing on goals identified by the patient through agenda mapping. Avoiding coercion and direct persuasion throughout the encounter are of utmost importance. MI also facilitates autonomous behavior change by linking change to the patient’s broader goals, beliefs and value system, and sense of self. We support our patients’ autonomy by acknowledging their right to self-​determination and their capacity to choose what they believe is right for them. Recall that conventional medical models tend to view patients as objective medical conditions, devoid of the independence and volition that are essential to the humanistic view that each individual person is a unique human being. As discussed previously, a traditional medical encounter highlights patients’ pathology at the expense of exploring their strengths, resiliencies, and abilities to enter into the process of change, which culminate in a successful plan of action. The authoritarian “expert” attitude of some practitioners assumes that patients are unable to be involved in the brainstorming process of resolving their problems. Remember that a key component of the spirit of MI is recognizing and accepting that patients themselves are the agents of change. This principle is the basis for self-​efficacy that MI fosters and supports. Here are some examples of some evocative and reflective statements that reinforce the

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autonomy of an individual who has managed his diabetes very well for years until he recently experienced a mild form of diabetic ketoacidosis: • “What did you draw from within yourself to manage your diabetes for so long?” • “What inside you allowed you to manage your diabetes for many years without having complications?” • “No one can decide for you or force you to change your eating lifestyle.” • “I’m not here to tell you what to do, or to try to make you do anything you don’t wish to do. You are the expert on yourself. You’ll decide when and if you wish to change anything regarding your diabetes management and if you want, I can help facilitate the process for you.” Affirmations These statements acknowledge our patients’ strengths and their past and present efforts to initiate or maintain behavior change. Affirmations show patients that we have listened closely to their experiences. Affirmations are more about the person than the behavior. They are not praise or cheerleading. They are an effective means of communicating acceptance and reinforcing autonomy. Patients often face major struggles over the course of an illness. Examples of possible affirmations include the following: • “You’ve been able to meet the challenges that were once so frightening to you.” • “You’ve persevered, despite circumstances that many others would not have been able to meet head-​on as you have.” • “Sometimes you show a determination that surprises even you.” As we all know, it is easy to forget about past success when we’re in the midst of present difficulties. Used appropriately, affirmations help our patients remember the resilience they already possess.

Compassion Compassion is widely understood as the feeling of being moved by another’s suffering, accompanied by a desire to end it. It highlights the essence upon which MI is conceptualized. MI holds that compassion is more than an emotional response: It is a stance that places another person’s perspective ahead of one’s own. While partnership, acceptance, and evocation may be part of

The Style and Spirit of MI  25

many professional relationships, compassion is the principal component that distinguishes therapeutic relationships. By definition, MI prioritizes a patient’s welfare over the practitioner’s. MI cannot be used to exploit or take advantage of a patient in any way; such behavior would constitute a serious breach of professional ethics. Furthermore, acceptance and the compassionate spirit of MI may provide a safe and wholesome atmosphere for the cultivation of self-​ compassion, defined as a healthy conceptualization and attitude toward the self (Pastore & Fortier, 2020; Neff, 2003a). The following encounter is about a patient experiencing significant pain who demands immediate pain relief. An effective way to avoid escalating the situation is to avoid a confrontational reaction and instead respond with compassion: • “It’s frustrating for you to have to wait even a moment for pain medication when you’re suffering like this, and you need it now.” • “How can we work together to address your pain?” • “You have reached your limit in terms of tolerating the pain and you can’t understand why the nurse didn’t respond more quickly when you need help.”

Evocation MI diverges from conventional medical encounters in the way that patient information is collected. Instead of relying solely on a series of consecutive closed questions, MI uses a process of evocation through which we assist patients to explore how their experiences and perspectives contribute to building motivation for change. In MI, we use collaborative engagement as the means by which a patient’s intrinsic motivation is elicited and strengthened. A major premise in MI is the belief that individuals already have what they need within them and are resourceful and our role as practitioners is to evoke their resourcefulness. We have sometimes found ourselves in the role of reluctant and unwilling “expert,” stuck in a trap of asking yes/​no questions. One way to break this cycle is to switch to open-​ended, evocative questions: • “Help me better understand [your illness] and how it has affected your life.” • “How has your struggle with [your illness] affected your sense of yourself?”

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• “What has been the most challenging part of coping with this illness, physically and personally?” • “Describe for me how you manage to keep your spirits up in the face of [this illness].”

PERSONAL REFLECTION (Gail Gutman) I had heard about MI for years—​in college and medical school—​before I realized exactly how useful of a therapeutic approach it is. It was always somewhere in the back of my mind, seeing it as a way of being with patients and an empathic style of communicating with patients that I could employ if I needed or if communicating with patients became too challenging. It was not until I was in my second year of residency training, finding my own career path toward adolescent medicine and longing to find the most therapeutic ways to engage my patients and provide counseling interventions, that I really reflected on how important the MI approach is and delved into what it means to intentionally use MI in my clinical encounters with patients. All of the sudden, something clicked—​as I worked to understand the true spirit of MI, my patient encounters became more humanistic and less focused on purely rational science. What surprised me most about learning MI is how its spirit awakened the notion of true patient-​centeredness within me. I discovered that the more capable I became at helping my patients make their own choices about treatment, the better I felt about my ability to provide sound care. As I have advanced throughout my training, working with more challenging patients, and encountering scenarios that feel newer by the day, I have consistently relied on embracing the MI spirit. Knowing how to also learn and integrate the MI skills and strategies to help my patients articulate what they want for themselves has been an exceptionally fulfilling experience. Another epiphany was learning to view challenging patients with compassion, realizing that these individuals have much to teach me. I know now that when I am able to stay person-​centered, I feel more confident in my ability to put my patients first. This has made a huge difference in the way I practice medicine. Ultimately, MI has been a complete lifesaver for me throughout my training—​and I believe for my patients as well.

CONCLUSION The essence of MI lies in its spirit, defined as an egalitarian “way of being.” The professional attitude describing the MI spirit is referred to as equanimity,

The Style and Spirit of MI  27

meaning composure, patience, and balance. The MI approach uses specific skills, strategies, and techniques, such as reflective listening, evoking, and reinforcing change talk. The four components of the MI spirit, partnership, acceptance, compassion, and evocation, are integrated throughout the clinical encounter.

SELF-​ASSESSMENT QUIZ True or False 1. The four key elements of the spirit of MI are partnership, acceptance, compassion, and evocation. 2. In MI, trainees are seen as experts who provide answers and a clear course for patients to follow in order to achieve change. 3. The four A’s of acceptance include absolute worth, accurate empathy, autonomy support, and affirmation.

Answers 1. True. In a collaborative relationship, trainees do not function as directive sources of advice and information, but rather as equal partners in the behavior changes patients wish to bring about. Trainees accept patients for who, and where, they are, with regard to exploring or implementing change. Compassionate medical trainees place patients’ perspectives and welfare ahead of their own. Evocation encourages patients to explore how their experiences and perspectives contribute to their motivation for change. 2. False. The trainee’s role is not to offer or even try to identify all the answers; rather, trainees aim to help patients determine which course of action would work best for them. Autonomy support is central to the MI practice. 3. True. In MI, acceptance is the ideal standard that implies that trainees accept patients for precisely who they are, regardless of their degree of interest or motivation for changing unhealthy behaviors. Acceptance is embodied by appreciating the absolute value of each patient, expressing genuine interest in understanding a patient’s worldview, supporting each patient’s right to self-​determination, and acknowledging each patient’s strengths and efforts for change.

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REFERENCES Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational interviewing: A guide for medical trainees. Oxford University Press. Miller, W. R. (2021). On second thought: How ambivalence shapes your life. Guilford Press. Miller, W. R., & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural & Cognitive Psychotherapy, 37, 129–​140. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Neff, K. D. (2003a). Self-​compassion: An alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2(2), 85–​101. Pastore, O., & Fortier, M. (2020). Understanding the link between Motivational Interviewing and self-​compassion/​comprendre le lien entre la technique d’entrevue motivationnelle et l’autocompassion. Canadian Journal of Counselling and Psychotherapy, 54(4), 846–​860. Rogers, C. (1951). Client-​centered therapy. Riverside Press. Rogers, C. (1980). A way of being. Houghton Mifflin Company. Rogers, C. R. (1986). Carl Rogers on the development of the person-​centered approach. Person Centered Review, 1, 257–​259.

3 The Processes, Skills, and Strategies of Motivational Interviewing Amelie Meltzer, Morgan Faeder, and Thomas M. Kelly

Many healthcare-​related interactions take place in circumstances where the patient seeks assistance, and the patient and medical trainee agree about the patient’s need for treatment and what must be done to achieve a positive health outcome. Other interactions occur that are unexpected, for example, medical emergencies and accidental injuries. These encounters develop quickly out of circumstances that cannot be foreseen, and treatment demands rapid judgment and decision-​making. As a result, these interactions often include consideration of conditions that are occurring coincidently with a “primary problem.” Trainees and patients may or may not agree about treatment goals and recommendations in these situations. Finally, some medical conversations occur in situations where the trainee and the patient disagree about many things, including whether there is a need for treatment, the cause of the need for treatment, what condition(s) need treatment, and even the objectives of treatment. One commonality among all these health-​related encounters is that the trainee should maintain the same even-​tempered, emotional, and behavioral approach. Trainees should relate in a conversational manner that includes paying attention to their own verbal and nonverbal behaviors such as smiling, making eye contact, and showing that they are paying attention to the patient throughout the visit. They also need to respond to the patient’s presentation in ways that reduce negative mood and cognitive states such as anger, frustration, or confusion. Establishing rapport by approaching each patient with respect, compassion, and confidence is crucial to establishing a therapeutic alliance, which is essential to working together effectively. Trainees learn to develop their communication style as they become increasingly comfortable with a particular routine of engaging and moving through the interview while maintaining an inquisitive and conversational atmosphere, without pressure. Using a consistent tone and manner of speaking demonstrates self-​assurance

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and indicates nonverbally that a trainee has experience with interviewing and treatment. It is important to note that projecting confidence does not mean pretending to know everything. In fact, trainees admitting openly that they do not know all the answers can aid in establishing a collaborative and comfortable therapeutic relationship with their patients. When confronted with a difficult situation, trainees can acknowledge their uncertainty, and provide assurance that they, their supervisor, and the patient will work together to find the best way to assist the patient in reaching their health-​related goals. This chapter is a guide to the processes, skills, and strategies that you can use to accomplish this.

PROCESSES OF MOTIVATIONAL INTERVIEWING There are four processes within Motivational Interviewing (MI): (1) engaging, (2) focusing, (3) evoking, and (4) planning (Miller & Rollnick, 2013). Note that the open-​ended questions, affirmations, reflections, and summaries (OARS) skills, described later in the chapter, are used in each of these four processes. Engaging occurs as we establish working partnerships with patients that are collaborative in nature. From the first moment of contact, our goal must be to demonstrate understanding, compassion, patience, and acceptance of wherever our patients are in terms of readiness to change their behaviors. Focusing requires us to identify, develop, and maintain a specific direction in our conversations with patients about change. As with all aspects of MI, the process of establishing an agenda for a discussion must be a shared objective with each patient. Evoking involves eliciting a patient’s own motivations and arguments for change. This dialogue is described as “change talk,” and it refers to the words, phrases, statements, and expressions that are unique to each person. Several structured questions help elicit change talk and link these questions to various phrases that patients may use to express different aspects of making behavior change. The acronym DARN-​CAT summarizes these types of preparatory and mobilizing change talk (Table 3.1), where the letters represent: desire, ability, reasons for change, need to change, commitment to change, activation language, and taking steps toward change. While the early psycholinguistic work of Amrhein (Amrhein, Miller, Yahen, Palmer, & Fulcher, 2003) suggested only commitment language and DARN leading to commitment language predicted behavior change, further research has since shown that any change talk predicts behavior change and that change

Processes, Skills, and Strategies of MI  31 Table 3.1  Examples of Change Talk: DARN-CAT Desire: “I really want to find a way.” Ability: “I could do that.” Reasons: “My family is counting on me.” Need: “I just can’t keep doing this.” Commitment: “I must—​no, I will make a change.” Activation: “I set my quit date.” Taking steps: “I joined a gym last week.”

talk improves outcomes in the context of substance use (Magill, et al., 2014; Moyers, Martin, Houck, Christopher, & Tonigan, 2009). Most people have the capacity to talk themselves into changing behavior, and we are all more likely to succeed in doing so when we express this intention aloud. It takes time to help your patients give voice to their hopes and aspirations for different ways of behaving, but keep in mind that this process has a better chance of achieving long-​term, sustainable change than anything a practitioner might say or do. The final step of planning develops and refines our patients’ commitment to change and specific action plans. This may or may not occur over the course of a single conversation; often the planning process requires fine-​tuning to the realities of a patient’s circumstances, and this can be accomplished through continued contact. Much like a flight of stairs, the processes of MI build upon one another, each step relying on the foundation that precedes it (Figure 3.1). We need to engage each patient to develop the rapport and trust that are essential in

Planning. making plans for change

Evoking. eliciting patient’s own motivations

Focusing. collaboratively developing direction

Engaging. establishing trust and a working relationship

Figure 3.1  The four processes of MI.

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assisting them to focus attention on whatever target behaviors may be subject to change. Once these are identified, evoking a patient’s reasons for change helps build commitment to the process; this is especially important in confronting the inevitable difficulties and challenges that lie ahead. Patients must feel a certain degree of confidence in their ability to succeed before we begin the planning process, in which together, we look ahead to our patient’s “new” life that includes a new set of behaviors. Note that this process does not always follow the tidy, linear course we have used to outline the steps. Sometimes progress will occur in a seemingly horizontal fashion, zigzagging through each phase, and if, for example, engagement is lost in the midst of focusing or evoking, one will need to return to engaging before moving on. No matter. What is important is that you and your patient determine the course you will follow. Whether you move slowly or briskly through the steps is of no consequence whatsoever. What matters is that you and your patients determine the most effective way to promote enduring behavior changes.

INTEGRATING THE PROCESS AND CONTENT OF MOTIVATIONAL INTERVIEWING All patients have at least one reason for coming in for an evaluation, even if it is only because someone else wants them to be there. Finding out about the reason(s) for the visit must be the first order of business because it must be addressed to engage the patient. Engaging the patient so they want to talk with you, no matter what brought them there initially, is the foundation of therapeutic alliance. An example of this is patients who come because their spouse wants them to. They may not see that their behaviors are having a negative effect on their relationship but have agreed to come for an evaluation out of respect for their spouse (or to maintain peace in the household). Establishing rapport will begin by accepting the patients’ viewpoint and exploring ways that they may find a therapeutic relationship to be beneficial to them. In accepting their reluctance, the trainee gives the patient space to explore their feelings about their behavior without pressure from their spouse being the driving factor. Patients can explore their own motivations for change and begin an authentic reckoning with their behaviors and the effects of these behaviors on themselves and on the people around them. Motivation for change begins with motivation to engage with an evaluation of the circumstances that brought the patient and the trainee together. As noted earlier, all interactions during the evaluation require paying close attention to patients’ nonverbal behaviors from the outset, especially in circumstances

Processes, Skills, and Strategies of MI  33

where discord is already created by the situation that brought them to the encounter. In these interactions, it is important to pay attention to what the patient is saying, and even more critical to respond to nonverbal cues. The nonverbal cues often provide information about how the patient is feeling about the evaluation and the trainee. It is necessary to first establish an atmosphere wherein the patients feel comfortable and safe revealing themselves without fear of judgment or manipulation. Whether patients are honest will be based on their perception that you are trustworthy and nonjudgmental, and that you want to work with what they want to achieve in their interaction with you. It is critical to recognize that patients will be honest with a medical trainee if they believe the medical trainee is being genuine and transparent, even if they believe that the trainee does not agree about the focus of treatment.

ESTABLISHING SAFETY Establishing safety has two main facets. One is primarily related to ensuring that a patient’s healthcare information is kept confidential. This means that patients must be interviewed in private, and it is your responsibility to establish a safe environment in which patients can disclose their behaviors, feelings, and opinions. This could involve taking steps to stop patients or staff from talking about a patient’s drug use or any other medical issues in public areas when confidentiality may be compromised. Another aspect of establishing safety is assuring patients that what they say to you will be kept confidential, and that unless they disclose intent to harm themselves or others, you will not share anything they say with individuals outside their treatment team without their permission. You should also establish that you are not there to judge patients, no matter what they share. Once you have established a safe and secure interview locale and set the emotional tone for your encounters, you can explain what will happen during the time you and the patient are together. An example of this is given in the clinical scenario below, just after the trainee asks the patient if he is willing to work together to sort out the medication issue.

DR. Jones’ PATIENT (PART I) TRAINEE: Dr. Jones referred you to me to talk about your treatment with painkillers. Is that right? PATIENT: Yeah, she thinks I am using too much. So that is why I am here. I believe in following doctor’s orders.

34  Motivational Interviewing, 2E TRAINEE: So, you are only here because Dr. Jones said you should call me. [one-​sided reflection undershooting the reason for referral] PATIENT (smiling): Yes, I told her I was only taking what I needed to stop the pain. There is no way I want to end up like my cousin. He started out with a back injury and took oxycodone for it, but then his doctor cut him off and he started using heroin instead. I do not want that to happen to me. Dr. Jones said to try physical therapy, but I do not see how working out is going to help. Even walking hurts. How is doing more exercise going to make things better? I have tried heating pads, ice packs, lying flat on my back, but every time I try to do anything it starts hurting again. So, I think the physical therapy could make it worse. I have got to work. I cannot afford to take time off. Anyway, she said that I could overdose, and that I should talk to you, and I thought, well she is the expert. TRAINEE: You did not think the dose was too much because it stopped the pain and, at the same time, your doctor said the amount you are taking is dangerous. [double-​ sided reflection] Have you shared your perspective with her? [closed-​ended question] PATIENT: I think I tried to once, about 3 months ago. But I remember that she cut me off and said something about getting physical therapy if I still had pain. I remember that was the day she found out I was taking more of the medication than she expected. She seemed angry and I do not remember much of the discussion that day. She reduced the strength of the pills I got after that. When I saw her after that visit, I always told her everything was fine. But I started taking some old medications that my wife had after surgery. I thought that talking to Dr. Jones about medication would lead to an argument and I do not like arguing, especially with doctors. I mean you guys went to school for all these years so you must be right about these things. Anyway, I just kept taking more of it until last week when she told me that she will not give me any more medication unless I agreed to see you. TRAINEE: Your doctor suggested a combination of medication and physical therapy about 3 months ago, but you did not go to physical therapy. Also, you were not honest with your doctor about how much painkiller you were taking. Now, you are concerned your relationship with her has not been going smoothly and you do not feel comfortable sharing with her openly about your medication use. [collective summary] PATIENT: Yes, now I remember, her nurse gave me the number of a physical therapy clinic, but I never called them. And yes, I am really frustrated that I cannot have a good conversation with her. TRAINEE: You have a lot of real concerns about what treatment you can get for your pain, and you are worried you might end up like your cousin who is dealing with an addiction [complex reflection]. Dr. Jones wants you to start physical therapy, and you have doubts about how that could make your pain worse, which would make

Processes, Skills, and Strategies of MI  35 it hard for you to work. Dr. Jones reduced your medication when she found out you were taking your wife’s medications. You did not want to argue with Dr. Jones, so you just kept taking your wife’s medications and what she was prescribing. When your wife’s medication ran out you finally confided in Dr. Jones. She agreed to keep treating you, but she insisted that you come here. [summary] PATIENT: That sounds about right. I feel like I am stuck. I need the medications to function, and I also do not want to end up like my cousin. If Dr. Jones would listen to me, I feel like she would understand. TRAINEE: Before we discuss more, how do you feel about working together to figure out the situation with the medication? [closed-​ended question and invitation to work together] PATIENT: Yes, it makes sense. You seem to understand my concerns. TRAINEE: We do not have to argue just because we may have a difference of perspective. We can agree to disagree, and I won’t get angry, and I may even end up agreeing with you about some things, if I have enough information to understand your point of view. If we do see something differently, we will talk about it until we better understand each other’s perspectives. Usually, when that happens, we can find another way to work on the problem or negotiate a compromise. Most importantly, I believe you are the expert on you and your pain. You are the only one who knows what you are experiencing and what you think will work and what will not help you. How does that sound to you? [complex reflection, autonomy support, and collaboration followed by an open-​ended question]

In this clinical scenario, the patient is giving the trainee several inconsistent verbal and nonverbal cues about treatment. This behavior is due to what had previously been described as “resistance,” and is now considered “discord” in the relationship between the patient and practitioner. Practitioner–​patient differences regarding perspective on symptoms and coping behaviors have been historically described by practitioners as “patient resistance,” which implies pathology that lies within the patient. However, Miller and Rollnick (2013) discuss how an objective view suggests that these differences are more specifically related to discord in the relationship between patient and practitioner based on each other’s prior experiences in relationships, views on the objectives of treatment, and patient ambivalence, all of which are “normal.” In order to reduce discord in the relationship with the patient, the practitioner must address it early in the encounter. The critical issue is that the patient perceives the referring practitioner (Dr. Jones) as being angry with him, and this triggered his unwillingness to talk openly with her about his medication usage. What is needed is an empathic communication to reduce the chance that this will occur in the present therapeutic relationship. Empathic

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communication can only occur if trainees can differentiate their approach from Dr. Jones who seemed to become angry or disappointed with the patient when he told her things that he and Dr. Jones disagreed about. In the current encounter, forming a partnership rather than continuing the expert/​recipient roles (i.e., refraining from persuasion and confrontation by the trainee) will be more likely to allow the patient to share concerns and work collaboratively with you. This is a good example because it outlines both the content of what will be discussed (the medication overuse) and sets the tone for their sessions (respect and unconditional positive regard). Remember that the patient will ultimately decide exactly what information they choose to share and emphasize during your encounters, and your providing structure and clearly outlining your role helps make the most of your time together.

CORE MI SKILLS: OARS The essence of MI lies in its spirit. Built upon the foundation of MI spirit are the four processes we outlined. To carry out the four processes, there are four core therapeutic skills (Douaihy, Kelly, & Gold, 2014; Miller & Rollnick, 2013). They are summarized by the acronym OARS and are largely derived from the person-​centered approach. The primary goal in MI is to elicit change talk (statements made by the patient in favor of changing the behavior in question), and the skills to be discussed are designed to achieve that purpose. It is important to remember that OARS does not describe a linear process of conducting the clinical encounter. Rather, these communication skills are used throughout a clinical encounter to promote engagement, establish trust, focus on a patient-​chosen agenda, evoke motivation for change, and, when appropriate, develop a treatment plan. These are defined and described in the following sections.

Open-​Ended Questions “An open-​ended question is like an open door”—​one that opens the door of conversation and invites patients to consider their thoughts carefully before answering. When asking an open-​ended question, think about it as a request to explore the issues that patients find most important or most emotionally

Processes, Skills, and Strategies of MI  37

Figure 3.2  Open-​ended questions.

significant. It is an invitation for patients to “tell their stories.” And most important, when asking open-​ended questions, the trainee must be willing to listen carefully to the patient’s response (Figure 3.2). Tips • Rhythm: start by asking one open-​ended question, followed by one or two reflections based on the patient’s answer to the question, and then follow with another open-​ended question. Aim for a 1:2 or 1:3 ratio of questions to reflections. • Avoid asking several questions in a row. Even when they are open-​ended; too many questions in a row can lead to patient defensiveness or settling back into a passive role. • How and what are the best question stems with which to start open-​ ended questions. They help us avoid asking close-​ended questions such as those that start with can, do, have, will, when, could, and did (and they help us to avoid using the word why, which can carry a judgmental tone and create defensiveness and potentially some discord). • Ask the patient to elaborate more by saying, “Tell me more about that” or “Describe for me . . . ” or “Walk me through a typical day” or “Paint me a picture of . . . ” or “Help me understand. . . .” These statements function like open-​ended questions by inviting the patients to elaborate more about their experiences or perspectives. • Avoid or limit your use of close-​ended questions that either shut down interaction or result in a one-​or two-​word answer, except for those that ask for permission such as “Is it OK if. . . ?” or “May I share with you. . . ?”

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Open-​Ended Question Starters • “What is that like for you?” (a simple, powerful question that suggests that you want to know about another’s experience from their own frame of reference—​an empathic question by definition). • “What is your understanding of. . . .” • “What is your understanding of the events that led to your seeking help?” • “What is your understanding of what contributed to your not taking medications. . . ?” • “What are your thoughts regarding. . . ?” • “What are your thoughts regarding your drug use?” • “What are your thoughts about how you have handled stress in the past?” • “What are you like when (problematic behavior). . . ?” • “What are you like when you drink?” • “In what other circumstances do you see yourself . . . (problematic behavior)?” ■ “In what other circumstances do you see yourself acting out of anger?” ■ “In what other circumstances do you see yourself messing things up?” • “What would you need to change in order for you to . . . (positive behavior/​goal)?” • “What would you need to change in order for you to live the life you want?” • “What would need to change for you to feel good about yourself?” • Examples of open-​ended question stems using how: • “How do you feel about . . . ” ■ “How do you feel about your drinking?” • “How were you able to . . . ?” ■ “How were you able to exercise more in the past?” ■ “How were you able to handle stress without drinking in the past?” • “How do you see A . . . to be related to B. . . ?” ■ “How do you see your depression to be related to your substance use?” ■ “How do you see your poor relationship with your children to be related to drinking?” There are also some open-​ended questions you can ask that direct the patient to acknowledge their own sense of agency and autonomy: • “What was in you that changed?” • “What did you draw on within yourself to make that different decision?”

Processes, Skills, and Strategies of MI  39

• “How were you able to gather the courage to make that change within yourself?” • “How have your inner strengths helped you in the past in tough situations?” Avoid using words that start close-​ended questions: • Can you? Could you? Do you? Have you? Did you? Will you? Should you? Where did you . . . ? How long or how many? When did you . . . ? Who? Except to ask permission to give information or advice. This will be discussed further later in this chapter in the “Exchanging Information” section. Examples of open-​ended questions in contrast to close-​ended questions: “I understand you are struggling with your drinking; how has it been affecting you?” Versus “Does drinking affect you?”

Another example: “What has your relationship with your children been like?” Versus “Do you have a good relationship with your children?”

Affirmations To affirm is to accentuate the positive by being supportive and encouraging personal goals. Affirming overlaps with empathy in two ways: by being genuine and by meeting people where they are through understanding their personal frames of reference. Affirmations can comment on an inner strength or personal attribute, a positive past step or behavior, or an attempt to change behavior. A well-​formulated affirmation puts into words what you have found is “right” with your patient, rather than what is wrong and reinforces unconditional positive regard.

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Tips • Start statements with you rather than I. For example, instead of saying “I am proud of you,” say “you have a lot to be proud of.” Placing I in statements takes the focus away from the patient and makes the statement more about ingratiating than affirming. Examples of affirming statements focusing on a patient’s “specific efforts”: • “Despite how hard it is, you have worked hard to do the right thing.” • “You have been successful in sharing your thoughts and being truthful about your emotions.” • “You feel proud of yourself for being able to control your diabetes.” Examples of affirming statements focusing on a patient’s “specific qualities”: • “You have had some significant setbacks in following through with your goals. At the same time, you continue in treatment. You are very determined.” • “You have been through a lot of struggles in your life. You are a survivor.” • “When you set your mind to something, you make it happen.” Examples of affirming statements communicating a “genuine value” of a person: • “You have shared so many strong feelings with me.” • “Thank you for sharing your struggles with me.”

Reflections Reflective listening is a core component of MI. The goal of reflecting is to make a best guess at the underlying emotion or meaning in a patient’s statement. It can be conceptualized as a way of testing a hypothesis. It is the primary method of building “accurate empathy.” Relatedly, reflective listening functions to deepen communication between the trainee and the patient and to deepen patients’ self-​understanding of the many aspects of what contributes to their struggle with change. It may appear to be misleadingly easy. In fact, it is likely the most difficult MI skill for trainees to master. If reflections are

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done appropriately and genuinely as statements, they tend to reduce discord in the therapeutic relationship, making the patient more likely to open up. However, even when reflections are not accurate, through the process of correcting the trainee, patients may clarify their perspective and emotions without negatively affecting the therapeutic relationship. Reflections involve different levels of complexity and depth. Broadly speaking, there are two types of reflections: simple and complex. Simple Reflections • Repeat or rephrase in different words the same meaning or emotion of a patient’s statement. • While useful in establishing rapport with the patient, simple reflections do not add to the content of the conversation, and this tends to yield slower progress within the engagement process. Complex Reflections • Add to the underlying meaning or unexpressed emotions that the patient might be meaning or feeling. • Reflect feelings and behaviors that are verbally expressed by the patient, such as saying, “You feel ashamed” or “You are feeling depressed,” after a patient has said, “I feel so embarrassed about this” or “I feel really down.” This is a deep form of listening. • Complete the paragraph with what you think the patient would say next. • Reflect two sides of what the patient is feeling or thinking and convey that you heard the reasons for and against change (double-​sided reflection): strategically, start with reflecting the patient’s reasons against change and end with her reasons for change. • Focus and emphasize the underlying emotion and the unspoken content of the conversation. • Can be used to amplify or reinforce desire for change. • They help the patient view their effort, even if not resulting in major success, as a positive step forward indicative of a commitment rather than failure. This is an example: “You mentioned working out in the gym as your only physical activity and at the same time you have also been walking back and forth to work and working in your yard three times a week.” • Accurate complex reflections help to move the therapeutic conversation forward.

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Tips • Start reflections with you. Reflections beginning with the generic phrases of it sounds like . . . or it seems like . . . or what I hear you saying . . . can be annoying if they are repetitive. • Name the emotion. Even if you get it wrong, patients appreciate that you are putting effort into understanding them and their perspective. • Be brief. In general, reflections should not be longer than the statement it follows. • Be selective. Emphasize content or process that would be helpful for the patient in self-​understanding and evoking change talk. • Take risks. Make an educated guess regarding the underlying reasons for patients’ experiences and their current readiness for change. • Do not be afraid to be wrong in offering a reflection. Choose the reflection from a point of empathy and desire for more understanding. We have found that even when we are wrong, patients will correct us and continue forward. Either way, we understand more and continue to move forward with the patient. • Establish rhythm: Follow reflective statements with an open-​ended question, such as, “What do you think about that?” or “What is your perspective?” or “What do you make of that?” At the same time, it is helpful to give space, in the form of silence or a pause, for patients to think about what you have said after you reflect, before jumping in with a question. • Pay attention to your tone of voice. A deflection in the tone of the reflection keeps it as a reflection. An inflection in tone is often a question masquerading as a reflection. • Avoid letting your lack of confidence or certainty about the content of your reflection result in your tone drifting upward at the end of the reflection, which can turn a well-​formulated reflection into a question. Examples of simple reflecting statement stems and how to advance them to complex reflecting statements: PATIENT: “I am concerned about my diabetes not being well controlled after I got my blood work today. I have changed my diet and I take my medications as I am supposed to, but I am not sure what else I could do.”

Possible reflections: • You are . . . Simple: “You are worried about your diabetes.”

Processes, Skills, and Strategies of MI  43 Complex: “You are frustrated about not being able to have better control over your diabetes despite doing your best.” Simple: “You are not sure what else to do.” Complex: “You are struggling with figuring out what else you could do to improve your diabetes.”

• You feel . . . Simple: “You feel concerned.” Complex: “You feel frustrated about not being able to see your diabetes controlled after you made changes in your diet and you’re taking your medications appropriately.”

Examples of more complex reflections: • “On one hand, you feel you have done all you could do to control your diabetes and on the other hand, you want to figure out what else you need to do.” [double-​sided reflection] • “You care about controlling your diabetes and you want to figure out what else you could work on changing to help you better control it and live a healthier life.” [collective summary]

Troubleshooting Related to Reflections Going Around in Circles Sometimes it feels like the conversation is going around in circles and getting nowhere. It is likely that the reflections are too simple and not assisting the conversation in moving forward. Tips • Use more complex reflecting statements. • Acknowledge openly that the patient may find it a challenge to share thoughts or emotions. Overshooting/​Undershooting It is common to either overshoot or undershoot when learning how to accurately reflect. Use these techniques when you want the patient to be confronted with discrepancies between their thoughts and behavior (i.e., create ambivalence).

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Tips • Do not get frustrated. • Be a careful listener. If a patient disagrees with your reflective statement, this is a perfect point to ask for further clarification by saying, “Help me understand this from your perspective.” • It is generally better to undershoot than to overshoot, because undershooting invites correction and more elaboration of a problem, while overshooting tends to generate sustain (or status quo) talk. For example, reflecting statements such as “This is becoming a little bit of a problem in your life” or “This is a bit annoying to you” are more likely to evoke a response about how much of a problem a behavior is than to say, “This is a huge problem for you” or “This is the worst thing that ever happened to you,” as the latter two examples may evoke a minimizing response.

Summaries Summarizing is essentially a collection of reflections that pulls together a number of points made during the clinical encounter. They are special applications of reflective listening. The goal of summarizing is to foster the therapeutic relationship, to help patients organize their thoughts, to expand the ongoing conversation, and to move the conversation forward by setting the stage for evoking change. Essentially, to make a good summary statement, think about conveying to the patient: “I have heard what you have said, here is how I understand it, and I want to continue to understand more.” There are three types of summaries: collecting summaries, linking summaries, and transitional summaries. Collecting Summaries Collecting summaries are a list of interrelated items that the patient shared. They usually occur in the midst of a clinical encounter. “You have shared about a number of issues you would like to work on in your life. You want a better relationship with your children and to be a happier person. You also talked about going back to school and finishing your degree.”

Tips • Simple and complex reflections can be followed by “emptying questions,” such as asking “What else?” repeatedly, with alternating reflections until

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the patient’s exploration of the topic is fully exhausted. This serves as an invitation to keep adding to the collecting summary list. • Collecting summaries can be combined with affirmations by listing personal qualities and attributes as well as past efforts at behavior change that evoke patients’ confidence for future change: “You have talked about yourself as a stubborn person, one who sticks to his guns when it comes to challenges in your life. At the same time, you see yourself as a good person who cares a lot about other people. You are also a hopeful person who sees the positives in others.”

Collecting summaries such as this can be followed by an emptying question, for example, “What other strengths do you see yourself having?” Linking Summaries Linking summaries are statements that link the current conversation to something else that the patient has previously said at this or at a prior clinical encounter. Linking summaries further strengthen change talk by finding overarching themes and core values in the patient’s path of change. “You find joy in life’s little moments, such as drinking a cup of coffee with your wife. That is not unlike something else that you shared earlier in our conversations; you talked about how much you enjoyed reading a good book. You really value life and you have missed finding satisfactions, great and small, in your life.”

Tips • Anatomy of simple linking summary: Reflect-​link-​reflect. Begin with a brief reflection of the present conversation, follow with a linking statement, and then another reflection of a past conversation. Examples of linking statements: “What you said reminded me of something you shared earlier.” “The way you feel now about (current topics) is similar to the reaction you had with another experience you shared.”

• Can conclude with a statement that synthesizes the overarching theme. • Can be followed by a statement that emphasizes a patient’s core values. • Can be combined with an open-​ended question to evoke further change talk.

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Transitional Summaries Transitional summaries are a collection of statements and reflections that emphasize the key points of the present conversation while signalizing a shift to a new framework of conversation. This type of summary promotes therapeutic progress and at the same time provides the patient with the option for further discussion before moving on from the current conversation. Tips • Anatomy of simple transitional summary: orient-​reflect-​empty. • Begin with an orienting statement/​question, signaling/​seeking permission to pull things together. “Before we talk about . . . , is it OK if I share with you my understanding of. . . ?” For example, “Before we talk about the next step you might like to take in your treatment, is it OK if I share with you my understanding of your current struggles with smoking?” • End with an emptying question, inviting the patient to bring up anything that has not been mentioned thus far. “What else would you like to talk about before we discuss. . . ?” “What other thoughts do you have regarding what we have talked about thus far?”

Another type of transitional summary can end with a key question to signal a change in direction, perhaps toward change: orient-​reflect-​use transitional open-​ended question. • Begin with an orienting statement/​question, followed by a grand summary of important motivating points and with signaling a change in direction. “Before we move on to discussing what you might want to do next, I would like to review what I think I heard you say thus far and find out from you whether I have it right. . . .” Summarize key points, wait for any response, and then say, “So where do you want to go from here?” or “What is your next step?”

DR. Jones’ PATIENT (PART II) Below is the vignette of the follow-​up session for Dr. Jones’ patient whom the trainee previously treated on the pain management service. This encounter

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illustrates the OARS skills of MI with a follow-​up discussion on the challenges in the clinical encounter: TRAINEE: It is good to see you today. Thank you for coming on time. [simple reflection on punctuality] PATIENT: Well, I have always been good about keeping my appointments. I realize the world runs on a schedule, whether I like it or not. TRAINEE: It is a strength you have that you respect other people’s time. [affirmation] PATIENT: Yeah. Well, I went to physical therapy last week. When I left here the last time, I was not sure if I would go because I didn’t think it would work. It seemed like everyone was telling me what to do about my pain. Then I remembered you saying that I am the “expert” on my pain. I thought about that and realized, yes, I know the medications work but it just makes sense to try both at the same time. And if it does not work, I can just stop going. I was still concerned that all that working out they make you do would make my pain worse. TRAINEE: Even though you did not want to go to physical therapy you recognized that it is an option that may work. You looked at it objectively because you came to understand that you are free to choose how you deal with pain [double-​sided reflection]. No one else is responsible for the decisions to start or stop different treatments. It is your judgment of whether or not they are helping. [complex reflection emphasizing autonomy] PATIENT: Yeah, that is right. I sort of felt free to decide for myself. TRAINEE: How do you want to proceed from here? [open-​ended question] PATIENT: I am not sure. TRAINEE: Would you like to talk about how you did with physical therapy? [closed-​ ended question, asking permission] PATIENT: Sure. The people there were nice, but it was like I expected it to be. The therapists made me do things that really hurt. And my back felt pretty bad even the next morning. They had told me that I need to do this two, or three times a week for at least a month. In addition, they gave me instructions on exercising at home. So, they scheduled me for another treatment three days from the first appointment. TRAINEE: So, you were right about what it would be like during the treatment and even after it was over. It seems like it was not a positive experience for you. [complex reflection] PATIENT: Well, I was not going to go back but I saw Dr. Jones and she said, if I stayed with it for a week, she would give me a limited supply of painkillers. Another thing, even though I had a lot of pain the day after the first treatment, the second day after the treatment my back felt pretty good. So, I went to the second appointment.

48  Motivational Interviewing, 2E TRAINEE: Your decision to go along with trying physical therapy seems to have paid off because you are now doing what you said makes sense. You are using both methods of treating your back pain. [complex reflection] PATIENT: Yes. But I still do not think I can get into the kind of trouble using oxycodone that my cousin has now. I think I was handling things pretty well, even before Dr. Jones said she would stop prescribing for me. TRAINEE: You were not having any real problems related to your medications. Your reliance on them didn’t cause you any problems in your daily routine and so you didn’t see any reason to decrease your use of them. And no one else was concerned about your use. You only started the physical therapy to satisfy Dr. Jones so you could keep on using pain killers. [complex reflection, undershooting] PATIENT: Well, I do not know if I can agree with all that. I did miss a couple of days on the job because I was hungover. I knew it would be better not to go at all because, if they thought I was using on the job they would have ordered a pee test and I would have been fired. When I told you at our first session that I could not afford to miss work it was partly because my supervisor told me I would be suspended if I missed any more days. Also, my wife was starting to get on me because I was not helping around the house. TRAINEE: So, your medication use was causing some problems in your life, even though you were still able to function OK, for the most part. You believe you could have gotten along alright even if you had not started the physical therapy for your back. Is it OK we talk about how this affects your motivation to stay with the physical therapy? [complex reflection; asking permission] PATIENT: Well, it seems funny to think about it when you put it the way you did. You might think I would quit, but I really want to stay with the physical therapy now. I need to get back on track. I notice that I feel better in the morning, since I have not been taking so much of the medication. I have noticed that I can even skip days and not take any medicine. My back still hurts but it is different now because my head feels clearer. Maybe I am handling the pain better. Also, I told you before that I do not like arguing and that goes for arguing with my wife. We have been getting along a lot better since I have been going to physical therapy.

Note that the trainee builds on the trusting relationship that began at the first session. The session starts by offering an affirmation about the patient’s punctuality and frames it as a strength. Later the trainee offers a reflection that emphasizes the patient autonomy in the decision-​making process. Later, in response to the patient reverting to his statement that he functions well while

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overusing opioid medication, the trainee uses a reflection that agrees with the patient while clearly overemphasizing patient’s ability to function well during bouts of drug overuse. This confrontation brings to the forefront the discrepancy between what the patient said and the reality of his true functioning. Remember, the patient now values the trainee’s input which, in turn results in the patient feeling ambivalent about the erroneous observation made by the trainee. The patient now feels compelled to clarify that he really does not function well while overusing pain medication. This leads to change talk at the end of the vignette, whereby the patient reinforces that he sees physical therapy as a valuable adjunct to pain medication.

AGENDA MAPPING Now that we have learned how to engage through using OARS, the next step is to learn another tool, which is agenda mapping (“What to change?”). Agenda mapping through the process of focusing allows the trainee to enter the patient’s world and understand the patient’s internal frame of reference while balancing the need for therapeutic progression. While thinking about agenda mapping through the process of focusing, it can be helpful in thinking about the process of agenda mapping as operating via agenda sources, styles of focusing, and focusing scenarios.

Agenda Sources At any point in a clinical encounter, there are three agenda sources at work. While the focus should always be on the patient, these are sources that the trainee must consider in the process.

Patient The critical content here is that patients bring their own internal frame of reference to all therapeutic encounters, and without exploring and entering the patient’s world, it would be impossible to find common ground for therapeutic communication. The content often includes a blending of patients’ agendas with their feelings about the encounter and the trainee.

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Setting The setting refers to where the interaction is occurring and may depend on the specific predetermined focus of the setting, such as a smoking cessation program or family planning clinic. This includes how the request for service may be affected by agency or clinic policy. For example, parents who take their child to an emergency department to address a child’s injury may become concerned about the trainee’s decision to report the injury to Child Protective Services.

Clinical The overt agenda here is that the trainee’s expertise may help the patient explore other changes necessary to achieve the patient’s stated goals. This may also include a blending of the trainee’s agenda with his feelings about the clinical encounter and the patient.

STYLES OF FOCUSING There are three focusing styles that medical trainees can use to facilitate agenda mapping.

Directing • The trainee directs the focus of the conversation by essentially dictating and teaching a therapeutic curriculum, which suggests to the patient that the trainee has power in this therapeutic interaction and decision-​making. • While effective in establishing a focus and particularly effective in establishing a focus consistent with an agency’s “agenda,” “directing” has limited effectiveness in enhancing a patient’s sense of self-​efficacy and evoking change. It is best utilized in an emergency medical encounter where the trainee needs to take control of the situation to ensure that the patient gets urgent care, such as when a patient loses consciousness or requires an urgent medical procedure or is actively suicidal and safety needs to be assured first.

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• This style has a limited role within the MI practice because of its lack of person-​focused empowerment.

Following • The trainee uses a nondirective therapeutic approach and asks many open-​ended questions such as: • “What do you think is most important to talk about today?” • “What concerns do you have today?” • “What is the most important priority you would like to engage about today?” • The trainee follows the natural movement and momentum of the conversation as directed by the patient’s agenda and does not influence the direction. • This method of focusing yields the slowest progress in therapeutic progression.

Guiding This style is the most congruent with the spirit of MI. Tips for this style to be successful include:

• • • •

Tolerate uncertainty and ambivalence. Share control with the patient. Identify the patient’s personal strengths, goals, values, and beliefs. Look for and enhance openings for change.

Focusing Scenarios There are three broad spectrums of the patient’s possible perspectives on agenda mapping at any point during the therapeutic encounter. Clear Direction Sometimes the focus and agenda of the therapeutic encounter can be clearly defined by the patient from the onset, and this is the case in several scenarios. The patient is highly motivated and focused on changing a specific behavior and asks for guidance starting at the beginning of treatment. The therapeutic

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encounter occurs within a narrowly defined field, such as a smoking cessation program or a family planning clinic. If the agenda is clearly delineated from the onset, the next step would be to move toward treatment planning and management. Choices in Direction: Agenda Mapping Sometimes there may be several possible directions to take a specific therapeutic encounter. For example: patients may be motivated to find ways to manage their anxiety; however, they might feel overwhelmed by the various facets of anxiety in their lives, such as panic attacks, substance use, deteriorating relationships with family members, and difficulty managing professional life. If there are myriad possible directions, the three goals at this point are to assist the patient in structuring thinking, considering options, and choosing a focus. Utilizing tools for agenda mapping can be particularly useful in achieving these goals.

TOOLS FOR AGENDA MAPPING Questions to Promote Structured Thinking Start with either, “What makes the most sense for you to focus on right now?” or you can be more directive and ask, “Would it be OK if we talked about. . . ?” or “Based on what I know about you so far, may I suggest that we talk about some things in your life that relate to your . . . (e.g., weight, depression, alcohol use, risk of pregnancy, or uncontrolled diabetes)?” After obtaining permission and giving some suggestions where to focus the discussion, end with an open-​ended question and autonomy support statement such as “What do you think? You are the best judge of where you want to focus your attention and our discussion.”

Tips to Aid in Considering Options • Be comfortable with silences. Allow patients time for thought and reflection. • Be generous with summarizing statements. • Invite more options and new ideas by using emptying questions, such as: “What else can you think of?” or “What else might work for you?”

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Questions to Encourage Choosing a Focus • “Of all the things you mentioned that contribute to your . . . (expressed behavior), what do you think has the biggest influence and in what ways?” • “Of all of the things you listed, what worries you the most?” • “Of the topics you have come up with thus far, which one is the most difficult for you to face?” Agenda mapping is particularly helpful when more than one health behavior may benefit from change because it helps you and the patient prioritize and focus on the one behavior that the patient agrees to target. It is important to be open and honest about your own agenda while still respecting and understanding the patient’s agenda. Whenever possible, it is better to let the patient’s agenda take precedence over your own agenda, even when you believe it is not in the patient’s best interest. People are more likely to make successful change in the areas that they, not you as the practitioner, are most interested in changing. The goal of agenda mapping is to help the patient select a behavior to discuss and to encourage the patient to decide what to talk about, assisted by you. It can be helpful to use a visual aid such as a chart with circles on it that is either prepopulated with possible topics to discuss, as well as some open



managing my depression

Figure 3.3  Agenda mapping. In this example, a patient is concerned about managing depression.

54  Motivational Interviewing, 2E take my medicine every day

limit my alcohol intake join a gym, start exercising 30 minutes a day, 3 times a week discuss possible new strategies with my therapist check in at my follow-up appointment to reassess consider daily journaling

Figure 3.4  Agenda mapping timeline. The patient from Figure 3.3 has now identified a series of behavioral targets. The trainee can guide the patient in developing a timeline and priorities.

circles in which to enter new, unanticipated topics the patient identifies.; or a diagram with all open boxes or circles for the patient and trainee to fill in as possible topics on which to focus (Figure 3.3) (Douaihy, Kelly, & Gold, 2014). Introduce the chart, discuss readiness to think about change, and elicit what the patient wishes to discuss. Example: “On this sheet are some of the topics we can discuss. We could talk about contraception, ways to prevent sexually transmitted infections, smoking cessation, taking medications, physical activity, eating, or drinking alcohol. You are the best judge of what to consider changing. Which of these do you wish to talk about?” “These blank spaces are for adding any other topics you think might be of greater concern to you today. What would you include in these spaces?” “What do you think? What would you like to focus on today?” Other than the chart mentioned earlier, another visual aid that could be particularly helpful in providing a literal overview of the agenda mapping is a drawing of a timeline (Figure 3.4) for temporal organization.

EXCHANGING INFORMATION Studies of MI emphasize the importance of reflective listening during the process of giving personalized feedback of test results. How information is shared

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with the patient can also affect how it is received. The main reason simple advice does not work is that most people do not like being told what to do: for example, a statement such as, “If you continue smoking, you are going to have a heart attack,” would likely cause patients to feel that they are being told what to do. Rather, most patients would prefer to be engaged in a decision-​ making process, particularly when they are considering making a choice about changing problematic behaviors. Offering healthcare-​related information to the patient should not happen unless the patient gives you permission. Remember that some patients may not be interested in having you provide information. When you use scare tactics, lecture, preach, ridicule, moralize, or coerce, you risk creating discord in the relationship and jeopardizing the therapeutic work. A preferred approach to this type of encounter would be to acknowledge and respect the patient’s perspective and autonomy: “I respect your decision about not being interested in discussing your behavior today, and we can come back to it in the future if you want.” Inviting the patient to reflect on the information you shared facilitates the discussion. Bombarding the patient with a barrage of data that we feel pressured to deliver can overwhelm the patient and negatively affect therapeutic communication. Sharing information and recommendations with a patient is consistent with the guiding style and spirit of MI: that is, elicit-​provide-​elicit (E-​P-​E) is the appropriate framework. E-​P-​E involves a collaborative mindset when the goal is health behavior change (Miller & Rollnick, 2013; Rosengren, 2017). This approach can also be helpful in working through ambivalence related to change, agenda mapping, and treatment planning.

ELICIT-​PROVIDE-​ELICIT The E-​P-​E framework starts with asking patients what they know already or are interested in knowing about a specific topic (elicit). Once patients share what they already know, you can build on it (provide). This approach allows you to then reflect on the patient’s view of what is offered (elicit).

Elicit Explore prior-​knowledge examples of question stems: • “What do you know about. . . ?” • “What is your understanding of. . . ?”

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Elicit Existing Emotions Examples of question stems: • “How do you feel about. . . ?” • “What do you feel when you think about. . . ?”

Querying Interest Now is a time when using close-​ended questions may be appropriate to ask permission to share information: Examples of question stems: • “May I share my thoughts about . . . with you?” • “Would it be OK if I told you about. . . ?”


• Engage first (through first eliciting before providing!). • Use statements sparingly and keep them short and focused. • Emphasize personal choice. • Offer a menu of options, preferably three, and add, “You know yourself the best, what do you think?” or “Perhaps you know of other options that would work best for you.”

Elicit The goal of the second elicit is to get feedback from patients on their thoughts, questions, interpretation, or understanding of the information just provided. Examples of questions to ask for the second elicit include the following: • “What do you make of this information or these suggestions?” • “What is your reaction to the effects of alcohol on your liver?” • “What do you think about these strategies I shared with you to help you take your medications regularly?” • “What do you think about what we just talked about?” • “What do you think is the next step for you?”

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• “How might what we just talked about apply to you?”

Examples of Putting It All Together with E-​P-​E TRAINEE: What do you know about the effects of drinking alcohol on your liver? [elicit] PATIENT: I know it will help to understand how my hepatitis C is affected if I continue to drink. TRAINEE: You are concerned about how drinking can affect your liver and having hepatitis C. [complex reflection] Would it be OK with you to share what we know about the impact of alcohol on people with hepatitis C? [asking permission] PATIENT: Yeah. TRAINEE: Drinking alcohol on a liver that is already injured by hepatitis C could damage your liver more and lead to serious consequences such as liver failure. What are you thinking now? [provide then elicit] PATIENT: So, I do not think I should drink at all. TRAINEE: Would you be interested in some strategies that other people who have hepatitis C like yourself have used to help them not drink. [elicit] PATIENT: I think I do not want to destroy my liver, so yes what are these strategies?

CHUNK-​CHECK-​CHUNK This is a variation on the E-​P-​E framework that fits more under the directing style. It is more practical when the trainee must deliver a lot of information, at the same time keeping the patient engaged in the conversation. The trainee starts with providing a “chunk” of information. After delivering the chunk, the trainee stops to check in with the patient about the information. This exchange is followed by another chunk of information. This framework helps you detect and correct misunderstanding that occurs in the clinical encounter. The following is an example of this framework: TRAINEE: You have shared your struggles with remembering to take your medication consistently, and you have been more depressed recently. You have been worried about your high HbA1c. Let me share with you the sort of treatment we can provide for your diabetes. We will get to know you better in the clinic. We will discuss your medication regimen and your lifestyle and explore with you what changes you want to make to help you better control your diabetes. How does that sound so far? [chunk]

58  Motivational Interviewing, 2E PATIENT: It makes sense. I know we discussed my concerns about controlling my diabetes? [check] TRAINEE: That is not surprising to you. PATIENT: Not at all. TRAINEE: And we will also discuss strategies to address your depression and how it affects your ability to manage diabetes. I would like to see if you would be willing to involve your wife in your care. This will help us get a better perspective on your challenges in coping with diabetes. [chunk] PATIENT: Clearly it is important to talk about that, and sure we can talk with my wife. TRAINEE: We can figure out how to work together so you are better able to care for yourself. [collaboration] PATIENT: Yes, sure.

This illustrates the chunk-​check-​chunk approach, where a lot of information is provided along with periodic short check-​ins. The patient’s responses are brief and reflected. MI skills are used throughout the exchange. At the end of the exchange, the patient is engaged and willing to work with the trainee.

PERSONAL REFLECTION (Amelie Meltzer) The processes of MI may seem tightly structured and even unnatural when discussed in the abstract, but when practiced effectively, they are extremely impactful clinical tools that can be used to connect and build an alliance with patients. On an especially busy afternoon during my internal medicine clerkship, we admitted a patient in his fifties with pancreatitis. A quick review of his chart revealed a long history of hospitalizations for pancreatitis, falls, and frostbite. One of the residents told me he had almost left the emergency room against medical advice and that he said he hated doctors and hospitals. I entered his room to do a history and physical, I felt nervous. He grudgingly let me examine him but told me he did not need to be in the hospital. “All these docs ever do is boss me and scold me,” he said. When we reached the social history section and I asked about alcohol use, he bristled. “Listen,” he said, “I know I drink, but I’ve had a long hard life, and it’s mine to do with what I like.” I was not sure what to say next. I did not want to destroy the fragile rapport we had started to build, or to make him feel scolded or judged. Cautiously, I said, “You’ve been through a lot, and drinking is how you get by.” He looked up at me for the first time. “Damn right,” he said. I continued, “At the same time, you value your independence and want to stay out of the hospital.” He nodded. “How does drinking fit in to that?” I asked him. He was quiet for a

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minute, and I thought I might have upset him. Then he said, “I guess it doesn’t fit with that.” This encounter was not a magic bullet that changed everything, but it established a relationship through which we could explore together the role alcohol was playing in his life. By acknowledging that drinking was the most effective tool he had at that time to cope with pain and escape from dealing with his “hard life,” I signaled that I was not there to judge or lecture him and I validated his struggles. That acknowledgment allowed me to challenge him with a question that highlighted the conflict between the life he wanted and the life his drinking was allowing him to live.

SELF-​ASSESSMENT QUIZ 1. Write 3 “What” open-​ended questions. 2. Write 3 “How” open-​ended questions. 3. Write 2 complex reflections for the following statement: “I take pills sometimes to help me relax and have fun, but I can stop if it becomes a problem. I do not know why everyone is acting so worried.” a. Example answers: i. Complex: “You’re confused at how your loved ones are reacting to your pill use.” ii. Double-​sided complex: “Taking pills helps you enjoy yourself and at the same time it is concerning to your loved ones.” 4. Improve these affirmations and avoid cheerleading: a. “I’m proud of you for cutting back to 1 pack a day.” i. Example answer: “Cutting back on cigarettes is difficult, and you made a significant change.” b. “Great job for remaining sober for 1 week.” i. Example answer: “You have abstained from drinking for longer than you ever thought possible, even though it was hard for you.” 5. Write a collecting summary and a transitional summary for the following:

“I guess I have been drinking more lately, but I am under a lot of stress. Alcohol really does help me relax. It is causing a lot of tension with my partner, and I do not like feeling hungover all the time.” a. Example answers: i. Collecting: “You shared that your alcohol intake has increased because you are under stress, and that alcohol is a way you cope.

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You also mentioned this has caused conflict with your partner and resulted in feeling hungover.” ii. Transitional: “Before we talk about the next step in treatment, can I share with you my understanding of how drinking has impacted your life?” 6. For each of the following statements/​questions, state whether it is most consistent with a directing, following, or guiding focusing style: a. “You have told me that you think it would be helpful to find some new hobbies instead of going to the bar every night and that you would like to spend more time with your grandchildren. Let us focus on how you might get involved in some new activities.”—​Following

b. “We have talked a lot about the changes you’d like to make in your life. When you think about your goal of maintaining sobriety, which of the strategies that we have discussed feel possible for you to work on now?”—​Directing c. “Which of your priorities would you like to work on now?”—​Guiding 7. You are working with a patient who is having difficulty adhering to their insulin regimen. During your conversations, you have found out that they have a limited understanding of the role of medication, diet, and exercise in controlling their diabetes. You have come to the point in your work where you think you can provide education and start to plan for behavior change. Using the Elicit-​Provide-​Elicit framework, write three questions to elicit more information from the patient to help you move forward, for example: “What is your understanding of the role of insulin in managing your diabetes?” “What is your understanding on how your diet can affect your control of diabetes?” “How do you see the role of physical activity in managing your diabetes?” 8. You elicit from the patient above that they would like to understand more about why they need to take insulin several times daily. They also feel frustrated and hopeless about needing to limit their diet because they must feed their family on a limited income and do not have money for “special food” just for them. How might you go provide them with information to address these concerns?

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REFERENCES Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 71, 862–​878. Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational interviewing: A guide for medical trainees. Oxford University Press. Magill, M., Gaume, J., Apodaca, T. R., Walthers, J., Mastroleo, N. R., Borsari, B., & Longabaugh, R. (2014). The technical hypothesis of motivational interviewing: A meta-​analysis of MI’s key causal model. Journal of Consulting and Clinical Psychology, 82(6), 973–​983. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Moyers, T. B., Martin, T., Houck, J. M., Christopher, P. J., & Tonigan, J. S. (2009). From in-​ session behaviors to drinking outcomes: A causal chain for motivational interviewing. Journal of Consulting and Clinical Psychology, 77(6), 1113–​1124. Rosengren, D. B. (2017). Building motivational interviewing skills: A practitioner workbook (2nd ed.). Guilford Press.

4 Ambivalence, Decisional Balance, and Equipoise Mark D’Alesio, Thomas M. Kelly, and Antoine Douaihy

As Miller and Rollnick observed, ambivalence about change is completely normal and is a part of the process of change (2013). Patients can feel torn between what they consider to be two distasteful options. If we reflect on the term ambivalence, we may be reminded of the cliché “stuck between a rock and a hard place.” In fact, however, ambivalence is more emotionally and cognitively intense than is implied by this cliché. The cliché relates to the perceived need to decide when neither option is desirable. Ambivalence, however, is generated by frustration over confrontation with having to choose between one option that is gratifying and at the same time clearly unhealthy, possibly life-​threatening, and another one that is very difficult to initiate and would potentially reduce or eradicate the threat to one’s well-​being (Miller, 2021). The “unhealthy” alternative is attractive because it is a behavior that has become ingrained in one’s lifestyle as the primary manner of experiencing pleasure or coping with stress. Sustaining an unhealthy behavior allows for the comfort of sameness rather than the anxiety of doing something new, with the accompanying worry about the unknown or the possibility of failure. It also allows for continued control over one’s own life, rather than responding to or giving in to the demands of others. The “better” or healthier alternative is also made up of multiple facets, including better physical health, progress toward achieving an ideal self-​image, secure finances, enhanced relationships, and all-​around improved functioning. For patients, change is hard in these instances in part because of the uncertainty that the “good” decision will actually result in an improved lifestyle. On the other hand, at least maintaining the status quo provides a view of what the future will look like. The behavioral result of this intense intrapsychic conflict is “sustain talk” (Figure 4.1) (Douaihy, Kelly, & Gold, 2014); arguments for the status quo versus and “change talk” arguments for the need to behave in a different way.

Ambivalence, Decisional Balance, Equipoise  63 S U S T A I N T A L K

. Righting reflex . Trying to “break through denial” . Arguing for change . Being in a hurry . Scare tactics . Pep talks or “cheerleading” . Simple reflections . Affirmations . Amplified reflections . Reframing . “Coming alongside” . Double-sided reflections


Figure 4.1 Discord.

The emotional and cognitive nature of ambivalence is manifested in the fact that these two types of “talk” will often occur in the same conversation (or even in the same sentence). People can talk themselves out of change as easily as they can talk themselves into it. Taking a person-​centered empathic approach demands that we recognize both sides of the ambivalence.

HOW DO WE RESPOND TO SUSTAIN TALK? Inherent in Motivational Interviewing (MI) is the expectation of facilitating movement toward the resolution of ambivalence, beyond the realms of thinking and talking about change, and in the direction of “tipping the balance” toward behavior change. This is accomplished by practitioners reflecting “sustain talk” and shifting the strategic focus to evoke and strengthen patient change talk. In fact, the ratio of change and sustain talk in treatment sessions, when favoring change talk, is associated with positive behavioral outcomes (Borsari, et al., 2015). To engage patients in the process of moving in the direction of change: 1. Do not overreact to sustain talk by looking for it or fishing for it. When patients tell you they do not want to change, it is not important to ask or explore why this is so. In fact, it is likely that most patients have already talked about why they are attracted to the status quo. Find an element in patients’ statements that allows you to move the discussion toward change talk:

64  Motivational Interviewing, 2E PATIENT: My wife tells me that I have to start paying attention to my cholesterol and triglycerides, but I really do not know what I will eat. I mean, I grew up eating eggs, hamburgers, and pizza five or six times a week, doc. I do not know anything else. Besides, cannot I just take one of those “statin” drugs to lower them? TRAINEE: You developed your eating habits in childhood, and it is hard to even think about changing what you eat. While you were describing what you eat just now, you are sharing that you think you must give up all the foods you like. [complex reflections] PATIENT: Well, won’t I? Everything I see on TV or read online talks about how the American diet is loaded with all the bad stuff, you know, the stuff that clogs our arteries and raises our blood pressure. TRAINEE: Actually, you will find that you can make excellent progress improving the health of your heart when you consider making small changes in your eating habits along with other parts of your lifestyle. For example, you probably know that getting regular physical activity helps, and, yes, medications can help, too. The idea is to put together a routine that is made up of small changes in whatever areas you feel ready to make and that are really not that hard to live with. What specific changes in your activity level, diet, or medications could you imagine would work successfully for you? [complex reflections; open-​ended evocative question]

2. Resist the “righting reflex.” Responding to patients’ dilemmas or distress with the righting reflex generally involves two elements. The first element is the desire to help. It is almost an instinct to try to correct patients’ statements that their behaviors are not damaging. Here are examples of the righting reflex and what not to say: PATIENT: Smoking relaxes me! TRAINEE: But it is terrible for your health! PATIENT: I do not think my drinking affects me that much. TRAINEE: Of course, it does. You have been arrested for drunk driving, and you said you have gone to work hung over at least several days a week for the past month. PATIENT: I feel fine. Why should I take my diabetes medications? TRAINEE: Because you do not want to end up blind and with an amputated leg.

These types of trainee’s responses are generally counterproductive because they generate anxiety, frustration, or anger in patients. When patients are confronted with an unwanted reality in this manner, it causes discord in your therapeutic relationship with them. These types of responses are not collaborative, empathic,

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compassionate, or supportive. In fact, they come across as condescending, pushy, and rude and they put patients in the position of arguing for the status quo, which precludes any discussion of change. The second element of the righting reflex is to suggest potential answers to problems or to give advice about how to stop engaging in unhealthy behaviors. Without exploring patients’ perspectives and past experiences, we cannot even know what behaviors the patients are willing to change, and whether they want to follow through on any suggestions we may offer, with their permission. Furthermore, it is quite possible that patients have already tried those suggestions without success. Conversely, the practice of MI assumes that the patient will be making the arguments for change, and the role of the trainee is to skillfully cultivate these arguments from patients. Rather than making suggestions, it is best to ask patients to tell you about the history of their behavior in response to the problem, as they define it. In so doing, you will come to understand the range of behaviors and changes that have been attempted and, more importantly, the behaviors that have the potential for being successful. This process involves emphasizing self-​efficacy, which entails reviewing past successes each patient has experienced in addressing the problem, as well as behaviors each patient believes would help, even if they have not attempted them yet.

ADDRESSING AMBIVALENCE USING MI Reflective listening can be a powerful strategy. Amplified reflections often move patients from sustain talk to change talk because, as practitioners exaggerate reasons for not changing, patients are prompted to vocalize the other side of their ambivalence (i.e., reasons to change) (Miller & Rollnick, 2013). TRAINEE: Your health is exactly where you would like it to be right now, so you see no reason to worry about your blood sugar. [amplified reflection]

Amplified reflections offer a more exaggerated form of a reflective statement. While the technique is a straightforward reframing of what was said, such a reflection must be done with particular attention to nonverbal behavior. To avoid coming across as sarcastic or condescending, it is important to make a statement that implies your understanding that the patient is simply forming a perspective. Your response will come across as sarcasm if your statement is made with inflection in your voice, implying disbelief that the patient is being honest. Your tone is critical in making amplified reflections, and the tone should be understanding and flat rather than judgmental and questioning.

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In regard to accurate reflections, it is noteworthy that, reframing sustain talk so the meaning is a positive reflection has been found to stimulate more change talk (Barnett, et al., 2014). Note the example below. PATIENT: I feel fine. Why should I take my diabetes medications? TRAINEE: You feel well physically, and it is understandable that you don’t want to take medications you don’t need. And you are open to following a treatment plan if you see the importance of it. [complex reflection emphasizing willingness to make changes] PATIENT: Yeah, if I can understand why you’re telling me I should do something for my health, I’ll do it.

Strategically, these reflections are more effective when you place the part of the ambivalence that supports change last, rather than first. TRAINEE: You feel you are healthier than you would expect to feel if diabetes were a major problem. At the same time, it is very important to you to stay active and independent, and you would like to take whatever steps are necessary for that to happen. [double-​sided reflection]

On a related note, it can sometimes be helpful to “come alongside” by agreeing with patients’ arguments for the status quo. Coming alongside can be used when patients argue very strongly for the status quo. Again, the effectiveness of the reflection relies on how it is framed. It is, of course, counterproductive to actually agree with patients that they should continue unhealthy or risk-​ taking behavior. Coming alongside is indicated when unhealthy behavior can be contrasted against another goal that the patient has indicated to be at least as important as continuing the status quo. This clinical scenario below demonstrates how the trainee developed a collaborative relationship with the patient using the spirit, skills (OARS: open-​ ended questions, affirmations, reflections, and summaries), and strategies of MI to address ambivalence by softening sustain talk and cultivating change talk in an effort to facilitate behavior change. PATIENT: I really do not see why it is anyone’s business how much weight I gain or how healthy I am. That is my business. That is what I tell my wife when she nags me about eating too much or drinking too much beer. And that is what I am telling you. As long as I am getting to work every day and keeping the roof over our heads and food on the table, I think I have the right to eat and drink whatever I want.

Ambivalence, Decisional Balance, Equipoise  67 TRAINEE: You are making a valid point. It is up to you to decide what is right for you. You work hard because you value providing for the family, and you take it very seriously. You have the right to decide what you eat and drink. [complex reflections; autonomy support; affirmation] PATIENT: Yeah, that is the way I see it. I am a responsible guy. Taking care of the family is the most important thing. But after that I should be able to enjoy myself if I want to. TRAINEE: No argument here. As long as you are not doing anything that hurts your family, you should be able to do as you please. [coming alongside; autonomy support] PATIENT: Yeah, and I know a lot of people who think that way. TRAINEE: I noticed that you were in the hospital last year. [simple reflection] PATIENT: Yeah, I had to have my right knee replaced. The orthopedic guy says the other one is not as bad. I really only have pain in it in the morning. It is stiff, you know, but once I get going, it loosens up. He is another one who told me I need to lose weight—​that is what caused my right knee to give out. When I was in there, I told the guy I was waking up at night with chest pains and they checked my heart, turned out to be acid reflux. I am on medication for that now and have not had any problems with that. And they told me my blood pressure was high because I am overweight. That is what started my wife on this health kick. TRAINEE: That must have been a difficult experience for you dealing with these health concerns. How long were you laid up with all that? [complex reflection followed by closed-​ended question] PATIENT: It was almost 3 months before I could go back to work. TRAINEE: That must have been hard on you and the family. [complex reflection] PATIENT: Yeah, I got short-​term disability, but that does not pay what I usually get, and I missed a lot of overtime. I have three kids. I can tell you; it was not easy at all. We almost had to go into our retirement savings, and there is not much there either. TRAINEE: You have gone through a rough time as a result of not being able to work and you have experienced a bit of anxiety related to the uncertainty about your future. [complex reflections] PATIENT: Oh yes! So painful to go through this. TRAINEE: What do you think would happen if you had another episode like that? How would your family get by? [open-​ended questions] PATIENT: I got to admit, I did think about it back then. For 6 weeks all I could do was lay around and so, yeah, I thought about it. I could not wait to get back to work and once I did, I got back into the routine of making regular money and it did not seem like there was any need to worry about that anymore. TRAINEE: You are really a responsible person who wants the best for his family. You feel proud of yourself. I see a lot of patients who struggle with taking their

68  Motivational Interviewing, 2E responsibilities seriously. So, as you talk about it now, you would want to avoid having another time like that. [affirmations] PATIENT: Yeah, who would not? I know it would be better if I could be healthier. But I just cannot do all those things they told me to do. TRAINEE: They suggested you do too many things at once and this is overwhelming to even think about it. [complex reflection] PATIENT: They gave me this three-​page list of all the things I should do. It seemed like they expected me to give up everything I like. And the guy there told me I should start swimming for exercise because it would help me lose weight and be easy on my knees. I can swim, but, hell, I have not done that since I was a kid. It seemed like a lot. I tried to do some of the things they wanted me to do, but after a while it got too hard to keep up. TRAINEE: You have made as much effort as you could to follow through with their recommendations and you prefer to set more realistic goals in terms of change you can make. [affirmation] PATIENT: Yes, that would be easier for me to do. TRAINEE: What if we take another look at that list? You will find that you do not have to do all those things all at once. There is a way we can come up with a few things that you can live with that can help you get healthier. I have done this before, and it has worked for many of my patients. How do you feel about it? [complex reflection; open-​ended questions] PATIENT: Sure, when you put it that way, it is worth a shot.

Some patients remain stuck in a pattern of sustain talk and demonstrate little, if any, interest in change. In our experience, we find these clinical situations especially difficult because they challenge every aspect of an encounter with a patient. The running “head start” is designed to prompt movement away from a perspective that sees the current situation as desirable; paradoxically, it works by focusing precisely upon the arguments in favor of the status quo (Figure 4.2). In practical terms, this means acknowledging that, in some situations, changing behavior is too difficult, too demanding, and, in short, not worth the effort. Counterintuitive as it appears, this approach has the potential to become a creative—​and yes, collaborative—​way of inspecting the status quo from a distance, much as one studies a sculpture in an art gallery. PATIENT: I do not know why my parents made me come here. I do not need to see a doctor. TRAINEE: There is no reason for you to be here. [complex reflection] PATIENT: That is right! I get into fights, so what? Who cares? It is because those other kids bug me. They make me mad. I am allowed to be angry, right? That is who I am. TRAINEE: You like being angry. [complex reflection]

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Figure 4.2  Running head start.

PATIENT: You bet I do! TRAINEE: What do you like about being angry? [open-​ended question] PATIENT: I like feeling excited! I like yelling, and I like feeling something rather than nothing. TRAINEE: So, you do not feel numb when you are angry. What else do you feel when you are mad? [complex reflection followed by an open-​ended question] PATIENT: It is weird, some of the kids at school are kind of scared of me; they watch what they say and do when I am around. TRAINEE: You feel that people respect you. Sometimes it seems that making a big noise and getting into fights is one way to make everyone notice who you are. What are some other reasons why kids might notice, or even look up to you? [complex reflections followed by open-​ended question] PATIENT: Well, I am on the football team. People like me for that.

This strategy has the dual benefit of building rapport and engagement while potentially evoking change talk. The trainee acknowledges and validates the patient’s anger, including the possible benefit that being angry causes others to take notice of him. Instead of being critical of seeking attention in this fashion, the trainee opens an avenue of discussion that may lead away from sustain talk: specifically, what it means to be on the football team, how football players are supposed to act, and whether this young man is likable.

CAPTURING AMBIVALENCE WITH DECISIONAL BALANCE The term decisional balance (DB), conceptualized by Janis and Mann (1977), is described as a technical tool to measure the relative weight of pros and cons and of the benefits and costs of change. Miller and Rollnick (1991) described DB as a “clinical procedure” to have patients discuss both negative and

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positive aspects of change. When using a DB approach for resolving ambivalence, the practitioner elicits and explores both the benefits and the costs of the status quo and the potential benefits and costs of change. There has not been any clear theoretical or empirical examination demonstrating that using DB would necessarily increase the likelihood of making behavior change. DB has the potential to result in fishing for sustain talk, intentionally eliciting, and reinforcing it. This can make people more ambivalent about change. A review of outcome research (Miller & Rose, 2015) found that DB is counterproductive in clinical exchanges with ambivalent individuals showing low motivation for change. In fact, DB decreases commitment to change by strengthening sustain talk and maintaining status quo, with the end result of a reduced subsequent behavior change (Krigel, Grobe, Goggin, Harris, Moreno, & Catley, 2017; Miller & Rose, 2015). However, reinforcing, intensifying, and igniting change talk are essential active ingredients of MI, and at the same time, softening, reframing, and not dwelling on sustain talk are crucial elements of MI (Barnett, et al., 2014; Miller & Rollnick, 2013; Resnicow, Gobat, & Naar, 2015). DB tool is indicated and helpful when a patient has moved beyond ambivalence and made a willful decision to change, at which point it can target sustain talk, rectify discord in the relationship, and/​or review and address challenges interfering with the change process. Clearly, it is not recommended to include DB as a therapeutic strategy in an MI intervention targeting patient ambivalence and promoting behavior change. So, what if the strategic focus is not to resolve ambivalence by tipping the balance in one direction or another?

EQUIPOISE IN MOTIVATIONAL INTERVIEWING Equipoise is defined as a conscious decision to remain neutral and not intentionally steer a patient toward making a specific choice, direction, or change. Often practitioners do not pay much attention to this situation, which is frequently encountered in health care settings. Equipoise refers to a particular goal or choice the person is considering. Counseling with equipoise requires being aware of your own values and opinions and can be appropriately practiced using a nondirective approach for choosing and maintaining neutrality (Miller, 2012; Miller & Rollnick, 2013; Miller & Rose, 2015). Examples of equipoise situations include whether to: • Enroll in a research study. • Discuss treatment options for a patient diagnosed with cancer.

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• Stay in or leave a relationship. • Have and raise a child, have an abortion, or choose adoption, especially when deciding about an unintended pregnancy. • Donate an organ, such as a kidney or liver segment, to another person who needs it. To counsel with neutrality requires, from the outset, that we inform patients of our intention to explore both sides of the decision equitably, and that we will do so from an impartial perspective. Our role in these situations is clear: help patients choose whichever option best suits them and their circumstances and goals. Counseling with neutrality may be difficult, especially in those situations in which we may, consciously or inadvertently, be tempted to argue for one particular position over another. Some patients will ask “what would you do, if you were me.” Do not attempt to “dodge” this question. It should be addressed in a straight-forward manner by providing the information requested. However, the practitioner should point out that the patient and practitioner are different people, and it is best that the patient make their decision based on their personal information and life circumstances. While DB is not indicated in ambivalence, as previously mentioned, it could be a useful tool in situations where maintaining neutrality is imperative. The focus here is to guide patients, using MI conversational style, to reflect and explore the pros and cons in a balanced way. This allows patients to make decisions with which they feel satisfied and comfortable, in a way that minimizes postdecisional regret (Dew, et al., 2012; Miller & Rollnick, 2013; Miller & Rose, 2015). Here is how this tool might be structured to apply to the process of deciding whether to donate a kidney to a relative with severe kidney failure (Box 4.1). This grid helps organize and summarize the content of therapeutic conversations concerning any difficult decision. The key point to remember is that your role is to help your patients arrive at a decision: not a particular decision, but their decision. The following is a clinical scenario between a trainee who is an oncology fellow and a patient who was recently diagnosed with cancer of the

Box 4.1  Decisional balance. Pros Donating a kidney Not donating a kidney


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prostate and presenting to the office to discuss treatment options. This scenario demonstrates an equipoise situation and using the strategy of discussing options and their benefits and harms. This method engages the patient in decision-​making and helps the patient clarify his values and preferences. Note that the patient, through his statements, indicates he has resolved any ambivalence about the need for treatment. He actually requests information and support for implementing treatment, indicating he is a good candidate for a DB tool. TRAINEE: Thanks for coming today. How have you been doing since we had the conversation about your diagnosis? [open-​ended question] PATIENT: Well, it has been rough. Still trying to process how my life is going to change now that I have to cope with cancer and the uncertainty about what is next. TRAINEE: You have been overwhelmed and worried about the impact of living with cancer and the next steps with treatment options and dilemmas. [complex reflection] PATIENT: Yes, I am concerned how it is going to affect my family, my financial situation, and my everyday life. TRAINEE: We are here today to work together and provide you with the resources you need through your journey of dealing with cancer and its impact on your quality of life. How do you feel about having a conversation about treatment options? [collaboration followed by an open-​ended question] PATIENT: I would appreciate your support throughout the process and love to hear about different treatment options to choose from. TRAINEE: First, is it ok with you to explain the process? [asking permission] PATIENT: Of course. TRAINEE: We will review different treatment options based on the clinical studies and discuss some concepts such as time without decision progression, benefits and harms, median life expectancy, and treatment implications for your family members. How does that sound? [providing followed by open-​ended question] PATIENT: Makes sense. It feels a bit overwhelming at this time. TRAINEE: You are making a valid point. My intention is not to overwhelm you with too much information. We can discuss any issues and you can ask any questions that comes to your mind. [complex reflections] PATIENT: Yes, I like that. TRAINEE: While reviewing treatment options, you can interrupt me anytime you feel you need any clarification. I can make recommendations based on validated research studies and it is up to you to choose what suits you the best. [providing; collaborating; autonomy support]

Ambivalence, Decisional Balance, Equipoise  73 PATIENT: So, are you saying that the responsibility for choosing the particular treatment falls on me? TRAINEE: Yes, you decide based on our discussion of pros and cons/​benefits and costs of every treatment option that you think would be the most appropriate for you to consider. I am here to facilitate the discussion and brainstorm with you. [autonomy support and maintaining neutrality] PATIENT: OK. So, what are my treatment options? Pros and cons?

DB is utilized to facilitate values-​based decision-​making regarding treatment options. MI clinical style and skills are maintained throughout the session. Having realistic expectations of the potential outcomes (both the benefits and the harms), providing patients with more time for discussion with the healthcare team, and involving concerned significant others and family members may help patients resolve “decisional conflict” or ambivalence about the course of action to take. One final note. Unlike the example above, whereby the expected outcomes are based on physical changes, equipoise is especially important for formulating and presenting change plans based on behavioral outcomes. As noted by Miller and Rollnick (2013), treatment plans are only a piece of change plans, which are much wider in scope in the patient’s life. Practitioners can help formulate change plans by offering suggestions or conducting “brainstorming” sessions (with patient permission). However, patients must ultimately be responsible for carrying out any plan. Suggestions by the patients must never be rejected. They should be accepted and explored as to how the patients view their fitting into a plan for change. The patient should be affirmed for coming up with them with emphasis on the likelihood that they will be helpful because the patients are the best judge of what will work for them. No matter how a change plan comes about, the practitioner should express neither excessive optimism nor pessimism about it. It is best to affirm the patient for the work that went into the plan and the opportunity for change, while pointing out that the plan has yet to be tested in the real world. Miller and Rollnick (2013) indicate that change plans should be reviewed with an eye toward what could go wrong, and suggest that screening for problems may produce change talk, which increases the potential for success. Of course, no specific “Plan B” should be discussed at this time. However, by following these guidelines, the practitioner communicates ongoing support for the patient and leaves the door open to modifying the plan as needed. As important as equipoise is for developing change plans, it is critical to remain neutral to the outcomes associated with them. The practitioner’s emotional stance toward the patient must remain unfluctuating with regard to

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both good and bad outcomes. This does not mean that practitioners cannot show satisfaction when patient’s successfully implement change. Such satisfaction should be expressed while providing affirmations to the patient and giving credit to them for their success. On the other hand, communicating dissatisfaction in the face of unsuccessful outcomes will likely result in compromising trust and creating discord in the therapeutic relationship. Furthermore, even when patients reveal that they have not successfully made changes, it is likely that they are overlooking aspects of their efforts that can be framed as positive. Just as larger goals must sometimes be broken down into more readily achievable steps, patients’ experiences during their efforts to change should be closely explored to guide the practitioner in helping the patient restructure their efforts toward change.

PERSONAL REFLECTION (Mark D’Alesio) Appropriately addressing ambivalence as a trainee is a difficult task. Working in healthcare, we have the desire to help others. When a patient comes to us asking for help with deciding between a seemingly deleterious behavior and a seemingly beneficial behavior, we are tempted to assume a paternalistic role and simply tell patients what they should do. We want to share with our patients our knowledge and expertise; however, that is often not what patients need or want. They likely already know the information we would provide; instead, their ambivalence is often secondary to barriers that are preventing them from making this change. In giving this unsolicited information we often do more harm than good, effectively telling patients that we expect them to make a certain decision while failing to show concern for or understanding the reasons that they are struggling to do so. This isolates patients and risks harming the therapeutic relationship. I have worked with many patients struggling with ambivalence and have seen how the incorporation of MI can support individuals in deciding what they ultimately feel comfortable with and confident in doing. For example, I had one patient who was struggling with adherence to his medication for schizophrenia, which was resulting in an increased frequency of hallucinations. As somebody who has never been on schizophrenia medication, I felt that it would be a simple decision: if you want to reduce your symptoms related to schizophrenia, take your medication. I could have focused our sessions on discussing how the medication works, how effective it is at reducing symptoms, and discussing skills to remember to take the medication every day. However, I instead used MI skills and strategies to learn more about his experiences with the medication. I used OARS

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skills to engage the patient and better understand what was causing his ambivalence about taking the medication and learned that he was discontent with the side effect profile. Through affirmations and complex reflections, I learned more about his struggles and gained more details regarding which side effects he was most concerned about and how they have impacted his well-​being. In talking through and processing these challenges and normalizing his ambivalence, he was able to recognize that he values control of his schizophrenia more than he values not experiencing side effects from his medication. This not only reinforced his commitment to taking his medication without the need for me to give my input, but also opened the door to an additional conversation on how to address the side effects appropriately.

SELF-​ASSESSMENT QUIZ True or False 1. Sustain talk consists of arguments for the status quo, while change talk argues for the need to change. 2. The technique of “coming alongside” is used when patients engage in sustain talk. 3. The DB tool works best in clinical exchanges with ambivalent individuals showing low motivation for change. 4. DB is not MI. 5. MI is a useful approach when trying to convince patients to choose a particular treatment option for cancer or enroll in research studies.

Answers 1. True. Sustain talk and change talk result from the intense emotional and cognitive intrapsychic conflict patients experience as they work through ambivalence; this process demands that they explore arguments in favor of maintaining the status quo as well as those in favor of change. Patients often engage in sustain talk because they lack experience with either the positive aspects of implementing behavior change or success in doing so. Sometimes patients are far removed from a healthy lifestyle and do not recognize that change is an achievable viable alternative. The goal of MI is to help guide patients to express more change talk and less sustain talk.

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2. True. Trainees “come alongside” when they acknowledge a patient’s arguments for the status quo of maintaining unhealthy behavior; this is contrasted against positive goals and aspirations that the patient has stated as desirable as preserving the status quo. 3. False. DB is contraindicated in ambivalent individuals with low motivation for change since it has the tendency to reinforce sustain talk and decrease commitment to change. MI through evocation helps patients resolve their ambivalence in the direction of change. 4. True. DB, as an MI component, is inconsistent with recent conceptualizations of MI, which focus on “eliciting and exploring the person’s own reasons for change” (Miller & Rollnick, 2013) and discourage the balanced exploration of ambivalence. 5. False. There are many situations in which it is neither appropriate nor ethical for trainees to choose the direction of change for a patient. In these equipoise situations, trainees must counsel with neutrality and guide patients toward making their own decisions. These scenarios include whether to enroll in a research study, remain in a relationship, continue a pregnancy, or have an abortion, choose a treatment option for cancer or other medical illnesses, or donate an organ.

REFERENCES Barnett, E., Spruijt-​Metz, D., Moyers, T. B., Smith, C., Rohrbach, L. A., Sun, P., & Sussman, S. (2014). Bidirectional relationships between client and counselor speech: The importance of reframing. Psychology of Addictive Behaviors, 28(4), 1212–​1219. Borsari, B., Apodaca, T. R., Jackson, K. M., Mastroleo, N. R., Magill, M., Barnett, N. P., & Carey, K. B. (2015). In-​session processes of brief motivational interventions in two trials with mandated college students. Journal of Consulting and Clinical Psychology, 83(1), 56–​67. Dew, M. A., Zuckoff, A., DiMartini, A. F., DeVito Dabbs, A. J., McNulty, M. L., Fox, K. R., Switzer, G. E., Humar, A., & Tan, H. P. (2012). Prevention of poor psychosocial outcomes in living organ donors: from description to theory-​driven intervention development and initial feasibility testing. Progress in transplantation (Aliso Viejo, Calif.), 22(3), 280–​293. Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational Interviewing: A guide for medical trainees. Oxford University Press. Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict, choice, and commitment. Free Press. Krigel, S. W., Grobe, J. E., Goggin, K., Harris, K. J., Moreno, J. L., & Catley, D. (2017). Motivational interviewing and the decisional balance procedure for cessation induction in smokers not intending to quit. Addictive Behaviors, 64, 171–​178. Miller, W. R. (2012). Equipoise and equanimity in motivational interviewing. MITRIP, 1(1), 31–​32. Miller, W. R. (2021). On second thought: How ambivalence shapes your life. Guilford Press.

Ambivalence, Decisional Balance, Equipoise  77 Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. Guilford Press. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Miller, W. R., & Rose, G. S. (2015). Motivational interviewing and decisional balance: Contrasting responses to client ambivalence. Behavioral and Cognitive Psychotherapy, 43 (2), 129–​141. Resnicow, K., Gobat, N. H., & Naar, S. (2015). Intensifying and igniting change talk in Motivational Interviewing: A theoretical and practical framework. European Health Psychologist, 17, 102–​110.

5 Motivational Interviewing in Practice Miriam Rosen and Julie Kmiec

The fundamental encounter in any healthcare setting occurs between an individual seeking care and the person whose duty it is to alleviate suffering and promote health. During Motivational Interviewing (MI), each of these two individuals assumes a significant role in the context of a highly dynamic process for initiating behavior change. Respect for patient autonomy is at the core of this process. A paramount tenet of MI is to affirm the patient’s ability to identify problematic behaviors in their own life and determine and choose an approach to bring about and sustain healthy alternatives. This chapter incorporates the core behaviors discussed in previous chapters and expounds on what is expected of MI-​experienced trainees: a patient-​centered approach, the clear expression of clinical empathy, use of collaborative language, and evocation of goal-​directed communication. The chapter concludes with a discussion of common challenges faced when beginning to use MI, and presents methods to address these obstacles.

A PATIENT-CENTERED APPROACH The concept of patient-​centered care assumes that each patient is a unique individual (Epstein & Street, 2011). Indeed, MI views patients as the true “experts” of their lives. Integrating MI into everyday practice demands that we listen, respect, inform, and involve our patients throughout the course of care. As discussed in earlier chapters, this approach is not without its challenges, particularly those situations in which trainees believe that patients’ decisions might not be in the best interest of their own health. Patient-​ centered care fits perfectly with evidence-​ based medicine (McMillan, et al., 2013; Robinson, Callister, Berry, & Dearing, 2008) and allows trainees to relinquish the authoritarian style of the past in favor of a more collaborative approach. An essential component is to learn to be mindful of our own subtle verbal and nonverbal cues, as well as those of our patients;

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equally important is to actively engage and encourage each patient to become a full participant in their care. Sharing information with patients should be designed to facilitate meaningful deliberation and shared decision-​making and be tailored to each individual’s needs. Although the specific mechanisms by which patient-​ centered care contributes to improved outcomes are not yet clear, MI has demonstrated significant positive effects with regard to adherence to treatment regimens and self-​management plans (Palacio, et al., 2016; Smith, Heckemeyer, Kratt, & Mason, 1997). Many patients express reduced anxiety and greater interest in collaboration when MI is used (García-​Llana, Remor, del-​Peso, Celadilla, & Selgas, 2014). Some trainees worry that collaborating with patients implies a reduction in the importance of clinical judgment, but this is not the case. Situations remain in which practitioners must assume control, as in an emergency situation when a patient loses consciousness during a seizure or is in extreme pain from a gunshot wound. MI allows trainees to use a panoply of therapeutic communication skills that, in combination with clinical judgment, provide for the greatest likelihood of significant and long-​ lasting behavior change.

CLINICAL EMPATHY Clinical empathy is an essential element of the high-​quality care that is associated with improved patient satisfaction and adherence to treatment recommendations (Kim, Kaplowitz, & Johnston, 2004; Mercer & Reynolds, 2002; Pollak, et al., 2011); it is a hallmark of a strong practitioner–​patient relationship. Despite some overlap with other caring responses, particularly sympathy, empathy is a unique concept. Sympathy involves sharing emotions between an impartial observer and a person who is suffering. In contrast, clinical empathy is defined as the effort of a skilled observer to genuinely understand the world from the perspective of a person who is suffering, which in turn, leads to a sensitive, attuned response from that observer. What differentiates this response from how one might react to family and friends is that it occurs within a therapeutic framework characterized by specific goals and outcomes. To accurately understand our patients’ experiences, we must listen and be present with them in their distress and suffering. Caring and understanding are among the words most commonly used to describe ideal practitioners, and they indicate the high priority most people place upon a practitioner’s bedside manner. We begin to approach this standard of care by expressing

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genuine curiosity and interest in learning and understanding how our patients have struggled. This desire to learn about and understand another person’s perspective is central to an empathic encounter. Active listening enables us to offer astute reflections and, in doing so, demonstrates that we understand not only what our patients express but also how they feel. Participants in any meaningful exchange of information—​whether between family members, friends, business partners, or romantic partners—​are reassured to know that their statements have been validated and understood, and our patients are no different in this regard. Moreover, by creating an atmosphere of empathy and support, we enhance the development of trust with our patients, which in turn fosters increasingly honest discussions about complex thoughts, behaviors, and beliefs. Many practitioners and trainees struggle with identifying and responding to “empathic opportunities” in which difficult emotions are expressed. In response to patients with advanced cancer expressing emotions such as fear, anger, or depression—​for example, “I’ve got absolutely nothing to look forward to”—​a group of oncologists responded in an empathic way only 22% of the time, using “a continuer” to allow patients to keep expressing their struggles. Rather than acknowledging these challenging emotions, most of the specialists in this sample chose to redirect the discussion to other aspects of medical care, such as potential changes in therapy, using a “terminator” that could make the patient less open about emotional experiences. When oncologists demonstrated improved empathy, patients reported greater satisfaction with individual visits and with the overall patient–​doctor relationship (Pollack, et al., 2007). In any specialty area of medicine, accurate empathic responses in the form of reflections can direct conversations forward, even in the absence of asking further questions. Remaining nonjudgmental is essential to seeing a situation through the eyes of a patient and to understanding how a particular set of behaviors has evolved. The following exchange is representative of scenarios in which medical trainees either cannot or will not understand a patient’s reasons for not taking medications as prescribed.

SCENARIO 1 TRAINEE: Hi, Jamie, how can I help you today? PATIENT: Um, I do not know, but I’ve had a hard time breathing, and I cannot walk like I used to.

Motivational Interviewing in Practice  81 TRAINEE: How long has this been going on? [closed-​ended question] PATIENT: For the past couple of weeks. TRAINEE: How long are you able to walk without stopping because of shortness of breath? [closed-​ended question] PATIENT: Maybe I can go one block or two, but I just cannot play with my grandkids like I used to. TRAINEE: Have you been taking your lung medications? [closed-​ended question] PATIENT: Well, not really, my schedule has just been so hectic. TRAINEE: Do you think you could make a commitment to taking those medications since doing so would help with your breathing trouble? [closed-​ended leading question] PATIENT: Yeah, I think I could try.

In Scenario 1, the trainee does not even attempt to understand the patient’s reasons for struggling to adhere to their medication regimen, making it nearly impossible to address the root cause and establish appropriate adjustments in the treatment plan. In Scenario 2, reflective listening facilitates empathic understanding of the patient’s struggles to take their medication and leads to a productive conversation and a negotiated approach concerning recommendations.

SCENARIO 2 TRAINEE: Hi, Jamie, what made you decide to come in today? [open-​ended question] PATIENT: Well, doc, I have had a hard time breathing lately, and I cannot walk like I used to. TRAINEE: Your trouble breathing has made it hard for you to do activities that you usually enjoy. [complex reflection] PATIENT: Yeah, I mean, I cannot even go two blocks like I used to, and I cannot play with my grandkids for as long. TRAINEE: Playing with your grandkids is something you really love doing and your trouble breathing is making that hard for you. I understand you were doing better for a while. What are your thoughts about what might be contributing to this now? [complex reflections followed by an open-​ended evocative question] PATIENT: Well, it has really just been the last two weeks, since I have not been taking my lung medications. TRAINEE: You have noticed it is getting worse since you stopped taking your medications and you think there may be a connection. [complex reflection]

82  Motivational Interviewing, 2E PATIENT: Yes. Everything has just been so hectic at home, and I have not been able to pick them up. TRAINEE: You have been so busy that remembering to pick up and take your medications has been challenging. Help me understand what has affected your ability to do so. [complex reflection followed by an open-​ended question] PATIENT: There is a lot going on, but the main problem is that I lost my job, and I just do not have the money to pay for them. Not to mention that I babysit my grandkids, so it is not easy to just find another job. And I love being with the kids, but I just do not have the wind in me anymore. TRAINEE: You have not been able to afford your medications and it has been hard to find another job with your grandkids at home. At the same time, you see the importance of finding a way to get your medications because without them, you are not able to do some of the activities you enjoy. So, you decided to come in so we can figure out a solution together. [summary] PATIENT: Exactly, I do not have the money, but I know I need them; otherwise, I can’t enjoy the things that mean the most to me. TRAINEE: You want to be able to participate actively in some aspects of your life that are most important to you. What ideas did you have about getting your medications? [complex reflection; open-​ended question] PATIENT: Well, maybe there is some kind of financial aid, in the short term. TRAINEE: We do have some options. Would you mind if I share what I think could be helpful? [asking permission] PATIENT: No, of course I appreciate your help. TRAINEE: We have “Option A,” which I understand you have tried before. There is also “Option B” and “Option C.” What do you think about these possibilities? [giving information followed by eliciting] PATIENT: Well, I guess I could probably try “Option B.” TRAINEE: OK, you know what would work best for you. If you like, we could schedule an appointment for you to see the social worker today to explore more about “Option B.” How does that sound? [autonomy support reflection; asking permission, followed by an open-​ended question]

COLLABORATIVE LANGUAGE Naturally, learning to incorporate MI into our usual, everyday approach to patient care takes practice, which requires consciously intending to bring MI skills to patient encounters. This attitude helps us focus our thoughts on working collaboratively with patients in the moments leading up to our initial meeting. Regardless of the considerable knowledge we bring to each

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encounter, believing solely in our own expertise is an invitation to patient defensiveness and dissonance that will impair our efforts. We cannot overstate that patients are the experts when it comes to their stories and lives. Patients have insight into what has contributed to their behaviors, and listening closely to their perspectives permits us to understand their circumstances and collaboratively formulate an individualized treatment plan. Our goal is to assist our patients in tapping into the knowledge, awareness, and resourcefulness that they already possess, and building upon these elements is crucial to maintaining long-​term behavior change. In practice, we have discovered that once a patient permits us to offer treatment suggestions, having several available options provides a greater degree of choice. Being open to modifications increases this variety even further. Questions such as, How do you feel about these suggestions? or What do you think is most important for us to work on? foster and reinforce a collaborative spirit. By contrast, statements such as “How can I help you today?” or “Let me tell you what I think you should do” impairs an atmosphere of collaboration and trust. In the early stages of MI training, we must consciously suppress the urge to impose our own ideas on our patients (the righting reflex) (Miller & Rollnick, 2013). Instead, as we learn to elicit our patients’ ideas, we discover that their suggestions are much more personalized and likely to be successful. While we may sometimes believe that our ideas are better, patient-​ generated input is associated with greater levels of engagement. Moreover, by affirming and valuing our patients’ collaboration, we reinforce their sense of self-​determination. The following clinical conversation demonstrates the use of collaborative language: PATIENT: Doc, I just get so anxious. Pot is the only thing that seems to calm me down. TRAINEE: Your feelings of anxiety can be very overwhelming for you and smoking marijuana helps you find relief and comfort. [complex reflection] PATIENT: Yeah, exactly. I have been smoking weed for so long that I really cannot remember other ways to deal with the anxiety. TRAINEE: This has been your lifestyle for quite a while, and imagining any other way is a challenge for you. [complex reflection] PATIENT: Yes, it is . . . but I am tired of living this way. I do not have the energy or motivation to be there for my son and to be the role model I want to be for him. TRAINEE: Deciding to use marijuana has been your way of dealing with your anxiety and comforting yourself. At the same time, you see that it is reducing your motivation and preventing you from being the example you wish to be for your son.

84  Motivational Interviewing, 2E You cannot be the father you imagined yourself to be, which in turn, increases your anxiety even more. [summary] PATIENT: (Becomes tearful; allow a few moments of silence and wait for him to process the information). I have to; I just have to be there for him. TRAINEE: You have made the decision to break that cycle. What other strategies could you use to help cope with the anxiety? [complex reflection followed by an open-​ ended question] PATIENT: I don’t really know. I just don’t know. TRAINEE: You mentioned to me earlier that you had a period of not using pot in the past. In what ways were you able to cope with your anxious feelings at that time? [simple reflection followed by an open-​ended question] PATIENT: Well, actually I used to listen to music. I’d go for a drive, put the window down, and just listen to some jazz. TRAINEE: This is a strategy you found useful at that time; how do you feel about using it again? [complex reflection followed by an open-​ended question] PATIENT: I guess I could do that. TRAINEE: It was useful before and you are deciding to explore how well it will work for you now. What other ideas do you have? [complex reflection followed by an open-​ ended question] PATIENT: I just can’t think of anything right now. TRAINEE: Would you mind if I share some other skills that have been useful for other people dealing with these feelings? [asking permission to give information] PATIENT: No, not at all, that’s why I’m here. TRAINEE: It can be helpful to understand the sources of your anxiety, identify the thoughts associated with it, how you cope with it, and learn how to control it. This can be done sometimes by writing them in a journal. Other strategies could be helpful in reducing anxiety such as meditation, relaxation, and breathing techniques. How do you feel about considering those suggestions? [summary followed by an open-​ended question] PATIENT: Journaling is something I’ve done before; I’d be willing to give it a try. TRAINEE: There is a “How to Journal Workbook” available; would you like to start working on that together? [closed-​ended question]

EVOCATION OF GOAL-​DIRECTED COMMUNICATION Evoking goal-​ directed communication is a way of encouraging and strengthening our patients’ intrinsic motivations to change behaviors that interfere with optimal health. We accomplish this by engaging them in a dialogue intended to guide awareness of the problematic behavior and by

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identifying the discrepancy between that behavior and the goal(s) they wish to achieve or the values and beliefs they hold important. So, how can you, as a trainee, help patients develop a sense of incongruence of values and behavior without creating a defensive response? Establishing rapport includes engaging patients and providing validation. During this period of engagement, patients often divulge their reasons for change. Even if it is not readily offered, it is appropriate to ask whether they mind sharing this information. Often the reasons are related to their values, which is something that is important to them. When we hear a value expressed, we either pursue it immediately or place it in “our pocket” for the appropriate time. Exploring values often leads to the expression of painful emotion and refocuses attention on the areas of patients’ lives that are most important to them. Asking patients what change would mean for them, for their values (e.g., health, autonomy, honesty, self-​control, responsibility, family, job, pets, and respect), and for their lives often paints a picture of how they see their future. This very naturally leads into a conversation on the ideas they have about how they might reach this goal. This approach leads to less discord compared to other approaches because it is based on eliciting their thoughts and feelings about what is important to them and how they might address their behaviors. You could imagine if you told them all the reasons why they should change, how they might give you argument opposing change (i.e., sustain talk). This is because both sides exist, and they are ambivalent about change. It is the goal of MI to strengthen change talk. This can be assisted by allowing patients to recognize the discrepancy between present behaviors and future goals, values, and belief system. As a patient engages in discussing their current problems, we use an array of MI skills to guide the conversation toward future goals and whether the present behaviors are, in effect, obstacles to those goals. This approach helps us avoid behaving judgmentally. Two clinical scenarios follow:

SCENARIO 1 PATIENT: I mean, I don’t take my diabetes medications, but it really hasn’t been a big deal. TRAINEE: You have not experienced any problems from your diabetes. [complex reflection] PATIENT: Well, I would not say that. I mean, I do have trouble with the nerve pain in my feet and that is affecting my ability to play with my grandkids.

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Here, the patient makes contradictory statements regarding the effects of nonadherent behavior. Asking about the perspective of a concerned significant other is a helpful way to introduce discrepancy: “What might your partner/​children be concerned about?” This has the potential to open a dialogue that evokes values and helps establish patient-​determined goals, including strengthening motivation for change.

SCENARIO 2 PATIENT: I tried to quit smoking, but I just can’t. I can’t deal with all the stress I’m going through. TRAINEE: You have had a difficult time stopping smoking because you use cigarettes as a way to deal with stressful times. [complex reflection] PATIENT: Yes . . . and I’ve been doing this for 20 years! And now is just not a good time. TRAINEE: That has been tough for you to deal with. I can tell you have been putting in an effort to stop. What does your family think about you quitting? [complex reflections followed by an open-​ended question] PATIENT: My wife quit a long time ago and she really wants me to stop because my daughter keeps having asthma attacks. I know I need to do it; it just seems so hard right now. TRAINEE: You’ve seen your wife quit, and your daughter has been having some health problems. You want to stop, and at the same time you’re having a hard time doing it. How do you think stopping might affect your family? [summary followed by an open-​ended question] PATIENT: Well, for one, I’m sure my daughter wouldn’t have so many asthma attacks. I have to figure this out because I just feel so bad that I’m hurting her. Also, my wife would get off my back and quit bugging me. TRAINEE: It does not feel good when you see your daughter suffering or have your wife nagging you. You have been struggling with stopping for a while, and at the same time, you see it as important for you to help improve your daughter’s health and have a happy marriage. [summary] PATIENT: Yeah, I think I need to try something different. What else could we do, doc?

Early in the conversation about smoking, the patient discusses two aspects of smoking: how it helps him deal with stress and how it negatively affects his family. Through a series of reflections followed by open-​ended questions, the trainee is able to guide this patient to explore his feelings about how smoking has both positive and negative effects on his life. The process demonstrates empathy for the patient’s expressed need to choose between the varying effects

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smoking has on his life. The trainee then explores the patient’s ambivalence concerning the behavior without diversion. The critical element in eliciting change talk is the trainee’s selective reflection in the latter part of the exchange. At this point, the trainee has heard the patient say that smoking is his primary way to relax, and at the same time, that it adversely affects his daughter’s recovery from asthma and creates discord with his wife. Instead of asking how smoking helps the patient relax, the trainee affirms the effort the patient has made to stop smoking and then asks the patient to reflect on his family’s perspective concerning his smoking. The remaining conversation focuses on the patient expressing various reasons to stop smoking, whereupon the trainee summarizes these reasons. The change talk culminates with the patient’s willingness to consider quitting and exploring treatment options. Putting it all together, we have examined the process of taking a patient-​ centered approach to behavior change. The approach includes recognizing patients as equal partners in identifying changes that will be effective for them to lead a healthier lifestyle. The patient-​centered approach solidifies the working relationship and allows patients and trainees to work collaboratively toward goals patients identify as they resolve ambivalence. Plans to reduce health-​related risks are developed as the practitioner–​patient team uses the same straightforward, collaborative style that led to the patient’s original decision to change to improve their quality of life.

COMMON CHALLENGES IN MOTIVATIONAL INTERVIEWING Reading this guide might convince you that MI is not so hard after all. Many of the patients in these scenarios struggle initially to identify their problems, and with help from the trainee, these patients can acknowledge their desire for change and figure out a few next steps. MI can feel quite natural and easy when faced with a highly introspective person. However, when working with patients who are not as psychologically minded, MI can be more of a challenge. The most difficult encounters in MI are those in which you are working with patients who lack “insight.” The following clinical scenario is based on a real interview with this type of patient. In the following example, a man presented voluntarily to an inpatient psychiatric facility because of a recent suicide attempt by overdosing on heroin. TRAINEE: Yesterday, you were talking more about your family and how you struggle to be the father figure you want to be in your daughter’s life. How do you think

88  Motivational Interviewing, 2E your heroin use affects your relationship with your daughter? [summary followed by open-​ended question] PATIENT: I don’t know. I don’t think it does. TRAINEE: You do not think your heroin use has had any effect on your 9-​year-​old daughter. [amplified reflection] PATIENT. Like I said, no. TRAINEE: OK. What do you think have been the greatest consequences of using heroin? [open-​ended question] PATIENT: It’s really expensive. That’s about all I can think of. TRAINEE: So, it is costing you a lot financially. How do you think your dad and daughter would feel if you stopped using heroin? [complex reflection followed by an open-​ ended question] PATIENT: I don’t know. Maybe it would help us get along better. I guess I might be more available to my daughter. But she doesn’t seem to need me anyways, so what’s the point? She’s fine living with my dad and his wife. TRAINEE: You feel that your daughter does not need you, so it does not really matter if you stop using heroin. At the same time, you think that your relationship with your daughter might improve if you stopped using. You are worried that if you try and things do not change right away, it will mean that you have failed at doing something that’s important to you. [summary followed by complex reflection]

While some patients will be able to identify their values with ease, others have lost a sense of who they are, their goals, and what they value. This patient has become so disconnected because of his substance use that he struggles to see how his heroin use affects his family relationships. Working with patients who lack this degree of insight will be more challenging, and progress can still be made. Patients, like this one, will sometimes make statements indicating that their behaviors do not present difficulties, either for themselves or for their families and friends. Even with the use of an amplified reflection in the previous scenario, the patient continues to deny the serious consequences of his heroin use. That type of reflection used early on clearly backfired because the patient was not able to talk about both sides of his ambivalence yet and increased discord in the encounter. To help patients recognize their values, it’s sometimes necessary for the trainee to go out on a limb when forming a reflection. In the last complex reflection of the scenario, the trainee summarizes what the patient has said in the first two sentences and then makes a reflection of meaning in the third. This reflection of meaning was one of the hardest things to learn. Making this sort of statement feels like a risk because the patient has not said this

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explicitly. At the same time, it is a solid inference: the patient wants to improve his relationships but is ambivalent about changing anything because he does not know if it will make any difference in the end. What likely sits at the root of his ambivalence is a fear of failing. It is alright to make your best guess at what is going on in the patient’s head—​many times you will be right. Sometimes though, you will miss the mark. When you do, it is still an opportunity for patients to explain their perspective and clarify what they think, feel, or mean, if you have developed enough rapport for them to care enough that you understand them. One of the most valuable things we have taken from MI is that it is OK to make an inaccurate reflection. If we do, the patient will very quickly tell us “No, that’s not how it is.” Ironically, that inaccurate reflection may help the patient put us back on track: “this is how it really is.” For patients who struggle to articulate their feelings, making an inaccurate reflection can sometimes prompt them to share their thoughts and feelings. A complex reflection, whether it does or does not accurately reflect the patient’s feelings, indicates that the trainee is truly present with the patient and enables the conversation to move forward. A final thought on how to stay calm when the interview is difficult: embrace silence pausing! In traditional medical interviewing, silence or pausing can be viewed as unproductive since you are not asking questions or receiving information. In fact, the opposite is often true of silence. If your question is followed by silence, that usually means they are taking time to consider their response—​this is good. Allow what a patient says to sit for a few moments before jumping to respond. I have many a time been too quick to respond to what my patients say, only to realize later that they would have offered a lot more if I had only given them the space. MI is not a magic tool that will enable every patient encounter to proceed seamlessly. It takes a lot of practice (Rosengren, 2017), and you may feel more or less successful with MI depending on the patient you’re working with. If you use every interaction as a learning experience, you are doing it right.

PERSONAL REFLECTION (Miriam Rosen) My first experience with MI went nothing according to plan. I had put a great deal of effort into preparing for the patient encounter: I had read the MI manual, watched my colleagues use MI the day before, and reviewed my patient’s history ahead of time. In addition, I considered medical interviewing to be my strong suit.

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The patient had come to the hospital voluntarily because of a recent suicide attempt with heroin. Once the patient and I were both seated, I proceeded to do what I was used to doing during patient interviews. Like bullets, my questions propelled forward with voracious speed. Only after the interview did I realize that I knew little about him and his story. He had been willing to share about himself, but I was unwilling to listen. I did not yet understand what it meant to be present with a patient. During my first couple of days practicing MI, I began to consider how accustomed I had become to setting a specific agenda for my patient interactions. Prior to this point, my goal for patient interviews was to get the answers to my questions. One of the hardest parts of practicing MI is learning how to be comfortable with uncertainty. It is scary to enter a conversation with a patient and not know exactly where it’s going. But when we actively listen to a patient’s story, we can take advantage of what each patient offers instead of ploughing through with our own predetermined set of questions. This not only allows us to form a stronger relationship with each patient but also enables us to access deeper roots of a patient’s behavior that we would not have known to ask without their help. As I progressed through my MI rotation, I continued to set goals for each session, and I learned how to remain flexible so that I would not miss the opportunities that each patient gave me. MI has taught me that, if I know how to listen well, I do not need to ask many questions to elicit a meaningful history. MI holds a basic tenet that patients are the experts on themselves. I have learned how to rely on each patient to develop an effective treatment plan. I believe this genuine reliance builds a high level of trust between patient and practitioner and improves patient adherence. MI has informed the way I plan to practice as a future psychiatrist and has helped me see the patient and practitioner as equals, each of whom comes with a different area of expertise. While being present with and actively listening to a patient is no easy feat, I am comforted knowing that most of what I need to help my patients is sitting right in front of me.

SELF-​ASSESSMENT QUIZ True or False 1. The core behaviors expected of proficient MI trainees include: a patient-​ centered approach, clinical empathy, the use of collaborative language, and the evocation of the reasons in support of change.

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2. A patient-​centered approach challenges the historically authoritarian style of the trainee–​patient relationship. 3. “Clinical empathy” is the sharing of emotions between trainees and suffering patients. 4. “Let me tell you what I think you should do about quitting smoking” is an example of collaborative language. 5. Establishing rapport with a patient and exploring that patient’s values lend themselves to conversations about which goals the patient wishes to achieve.

Answers 1. True. MI is a collaborative process through which trainees and patients work together to identify problematic behaviors and to explore and strengthen a patient’s motivation for change. To this end, a patient​centered approach, clinical empathy, use of collaboration language, and evocation of the reasons for change are vital to effective MI. 2. True. Historically, relationships between trainees and patients were defined by a power differential that placed trainees in an authoritative role above their patients and that promoted the sharing of expert advice and opinion to those who were expected to accept it without question. MI challenges such a power differential and views trainee–​patient relationships as a collaborative meeting between equal partners. 3. False. Sympathy is the term used to describe the sharing of emotions between an observer and an individual who is suffering. Clinical empathy requires attention and effort on the part of a skilled observer who wishes to understand the world from the perspective of the patient who is suffering; it is expressed using reflections and a wide variety of subtle nonverbal cues. 4. False. This type of statement is the antithesis of collaborative language. By placing I at the center of the statement, the speaker references an outdated trainee–​patient relationship in which practitioners tell patients what to do. A more collaborative approach is to pose a question, such as, “Would you be interested in exploring options that could be helpful as we approach your goal of stopping smoking?” 5. True. By exploring a patient’s values and aspirations, trainees identify incongruities between the moral and ethical principles a patient upholds vis-​à-​vis his or her present behavior(s). Highlighting such discrepancies in a nonjudgmental and empathic fashion facilitates a smooth transition

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into a discussion regarding how maladaptive or unhealthy behaviors might be altered to better reflect the patient’s sense of integrity.

REFERENCES Epstein, R. M., & Street, R. L. (2011). The values and value of patient-​centered care. Annals of Family Medicine, 9(2), 100–​103. García-​Llana, H., Remor, E., del Peso, G., Celadilla, O., & Selgas, R. (2014). Motivational interviewing promotes adherence and improves wellbeing in pre-​dialysis patients with advanced chronic kidney disease. Journal of Clinical Psychology in Medical Settings, 21(1), 103–​115. Kim, S. S., Kaplowitz, S., & Johnston, M. V. (2004). The effects of physician empathy on patient satisfaction and compliance. Evaluation & the Health Professions, 27(3), 237–​251. McMillan, S. S., Kendall, E., Sav, A., King, M. A., Whitty, J. A., Kelly, F., & Wheeler, A. J. (2013). Patient-​centered approaches to health care: A systematic review of randomized controlled trials. Medical Care Research and Review, 70(6), 567–​596. Mercer, S. W., & Reynolds, W. J. (2002). Empathy and quality of care. British Journal of General Practice: The Journal of the Royal College of General Practitioners, 52(Suppl), S9–​12. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Palacio, A., Garay, D., Langer, B., Taylor, J., Wood, B. A., & Tamariz, L. (2016). Motivational interviewing improves medication adherence: A systematic review and meta-​analysis. Journal of General Internal Medicine, 31(8), 929–​940. Pollak, K. I., Alexander, S. C., Tulsky, J. A., Lyna, P., Coffman, C. J., Dolor, R. J., Gulbrandsen, P., & Ostbye, T. (2011). Physician empathy and listening: Associations with patient satisfaction and autonomy. Journal of the American Board of Family Medicine, 24(6), 665–​672. Pollak, K. I., Arnold, R. M., Jeffreys, A. S., Alexander, S. C., Olsen, M. K., Abernethy, A. P., Sugg Skinner, C., Rodriguez, K. L., & Tulsky, J. A. (2007). Oncologist communication about emotion during visits with patients with advanced cancer. Journal of Clinical Oncology, 25(36), 5748–​5752. Robinson, J. H., Callister, L. C., Berry, J. A., & Dearing, K. A. (2008). Patient-​centered care and adherence: Definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners, 20(12), 600–​607. Rosengren, D. B. (2009). Building Motivational Interviewing skills: A practitioner workbook. Guilford Press. Smith, D. E., Heckemeyer, C. M., Kratt, P. P., & Mason, D. A. (1997). Motivational interviewing to improve adherence to a behavioral weight-​control program for older obese women with NIDDM: A pilot study. Diabetes Care, 20(1), 52–​54.



6 Motivational Interviewing in Challenging Encounters Areej Ali and Erin Smith

Challenging patient encounters occur across all healthcare settings. From outpatient clinics to inpatient wards, and from operating suites to emergency departments, we cannot imagine a setting in which the potential for unnerving patient encounters do not exist. As medical trainees, we are at the forefront of patient engagement, but at times, it seems as though we are also in the direct line of fire of strongly expressed human emotions. Often, the most difficult aspect of engaging with challenging patients is the array of negative feelings that stir within us regarding our capabilities and our perceived areas of vulnerability. In this chapter, we present a Motivational Interviewing (MI)–​ informed therapeutic approach that will help you recognize and manage challenging patient encounters.

DISCORD AND HARMONY IN CONVERSATIONS Disharmony can be a natural component of discussing ambivalence. Nonetheless, by recognizing the signs of discord and maintaining a collaborative and guiding approach, trainees can minimize strain on their therapeutic alliance. As Drs. Bill Miller and Steve Rollnick stated in Motivational Interviewing: Helping People Change (2013), “discord is about a practitioner’s relationship with a patient, and inherently requires two people.” In order to successfully navigate moments of disharmony, one must be able to:

(1) (2) (3) (4)

Recognize signs of discord Appreciate factors that lead to discord Own and address your own contribution Reflect and respond appropriately

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Although frustrating to experience, moments of discord are ultimately moments of opportunity—​both to understand our patients and to grow as trainees. Harmony is, therefore, best thought of as an alliance with an appropriate response to discord rather than the lack thereof.

A CHALLENGING ENCOUNTER The following case illustrates many of the features common to challenging patient encounters: A 38-​year-​old woman presents with anxiety, type 2 diabetes, alcohol use disorder, and ischemic heart disease. She has been prescribed ten different medications, including insulin. She has not been functioning well. She is managing her diabetes poorly and her hemoglobin A1C is 11 (above the normal range, which suggests poor glycemic control). She does not exercise and drinks alcohol five times a week, on average, eight standard drinks daily, though intermittently. She is angry with her husband for not understanding her struggles with anxiety. At the outpatient appointment, she demands a benzodiazepine, “because nothing else works for my anxiety.” When the medical trainee tries to explain the reasons for not prescribing it, she becomes very angry and screams, “I am suffering. You don’t understand and you don’t care about me! I am not coming back here again!” We usually expect clinical encounters to conclude with a sense of mutual satisfaction: We anticipate that our treatments will prove effective and consequently, that our patients will feel better. Yet, as we know, this is not always the case, and, as it turns out, the challenge of “difficult” clinical encounters has been discussed in medical literature for decades. In 1949, the International Journal of Psychoanalysis published a paper entitled “Hate in the counter-​ transference,” written by the pediatrician D. W. Winnicott (1949). In it, he acknowledged having experienced outright hatred for patients under certain circumstances. Later the psychiatrist J. E. Groves (1978) wrote extensively about these encounters in his article “Taking care of the hateful patient,” in which he notes that, in dealing with “difficult” patients, physicians have the capacity to experience intensely “negative feelings, as well as malice and, at times, [a]‌‌ secret wish that the patient will ‘die and get it over with.”” We even attach disparaging labels to patients whose needs we believe we cannot satisfy, such as “heart sink,” “train wreck,” “rock,” or “borderline.” Countertransference is the word Freud coined to describe the emotional reactions that a practitioner feels regarding the patient. Freud believed that countertransference reactions are caused by a physician’s or therapist’s own

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unconscious conflicts; more recently, countertransference has come to be understood as reactions that arise from our own experiences. Some of the unwanted negative emotional responses that may present in these encounters can range from mild annoyance to frustration, anger, exasperation, helplessness, resignation, or downright spite and malice. Trainees encounter challenging patients in everyday practice, including the management of common clinical presentations. For instance, an emergency medicine resident may feel annoyed or angry at having been requested to examine a patient described by the triage nurse as a “frequent flyer.” Similarly, psychiatry residents may experience feelings of dysphoria or “heart sink” when dealing with patients who engage in self-​injurious behaviors or nonadherence to prescribed treatments. Upon graduating from medical school, most of us are very well trained in the straightforward management of patients who have diabetes, but we feel lost when dealing with patients who have diabetes and are demanding, angry, or not following their prescribed treatment plans. Often, our emotional reactions are reflections of patients’ underlying pathologies, complex inner struggles, or conflicts with interpersonal relationships. What is important here is to see our reactions as portals for empathy and understanding, and not judgment, labeling, or categorization. Further evidence suggests that these problems do not lie exclusively with our patients. Some individuals are labeled “difficult” by physicians as a result of frustration with the way in which a patient sought care, or with the relationship itself. Some evidence suggests that patients presenting with multisystem signs and symptoms, and those who physicians perceive as “difficult,” are more likely to possess poorer functional status, engage in greater utilization of healthcare services, and have a greater sense of unfulfilled expectations, as compared to a less complicated, more “likable” cohort (Jackson & Kroenke, 1999). The notion of “heart sink” has recently been re-​examined, with the conclusion that this phenomenon or “difficulty” likely results from ineffective “doctor–​patient communication” that, in turn, leads to discord within the relationship. To understand how this experience occurs, and how it might be avoided, three areas must be considered (Box 6.1): (1) characteristics we bring to an encounter, (2) characteristics patients bring to the encounter, and (3) factors relating to the healthcare system itself. The first group of characteristics is familiar to all medical trainees: lack of experience and professional identity, poor communication skills, and an (over-​)eagerness to assume the role of expert or authority. Other factors can also come into play at any stage of our careers: fatigue, gaps in knowledge

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Box 6.1  Factors contributing to challenging patient encounters.

Practitioner Factors Lack of experience Poor communication skills Desire to be the expert or authority Burnout Overcommitment Clashes with professional identity Cultural gaps Time management Undermining of patient autonomy Lack of trust in the patient

Patient Factors Depression Anxiety Personality disorders Impulse control disorders Multiple physical symptoms Nonadherence to medical advice Poor response to treatments Mistrust in the medical system Bad experiences in the past Ambivalence toward change or fear of change

System Factors Language and cross-​cultural issues Time pressures during visits Patient and staff conflict Lack of continuity of care and access Systemic racism Sexism Socioeconomic factors

concerning cultural habits and practices, difficulties with time management, a tendency to undermine patient autonomy, failure to trust a patient, and emotional or professional burnout. Important patient characteristics include the following: psychiatric disorders such as depression, anxiety, personality

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disorders, or impulse control disorders; multiple symptoms involving multiple organs; failure to adhere to medical advice; and poor response to treatment. Finally, healthcare system features include language and other cultural barriers, time pressures, structural racism, conflict between patients and staff, and a lack of continuity of care. Not surprisingly, these three categories of factors often intertwine. For example, the diagnostic process is rife with confusion for patients who present with multiple vague but intense physical symptoms and who are also experiencing anger and despair. If such individuals present for treatment at a time when a trainee is feeling pressured, fatigued, and overcommitted, a challenging encounter is more likely to occur. Identifying, understanding, and managing the contributing factors to difficult clinical encounters will lead to more effective and satisfactory experiences for both trainee and patient. As an egalitarian, empathic therapeutic approach, MI is well suited to fostering a collaborative relationship that facilitates shared decision-​making between patients and trainees. This helps prevent discord in the relationship and resolve difficulties that have already arisen, and it yields higher satisfaction with the encounter for both parties. Chances are high that many other trainees have been in your shoes. When empathy begins to wane, a helpful response can be to remind oneself of the myriad painful life events and unpleasant circumstances that have contributed to your patient’s coping skills, including those that may be perceived as “maladaptive.” You may sense that your patient is pushing you away; however, by maintaining the spirit of MI in the encounter and consciously developing compassion, you may succeed in keeping the patient engaged and help break a repetitive cycle of “difficult” encounters. At this point, you may feel that maintaining the spirit of MI is idealistic, if not downright impossible, especially at two o’clock in the morning with a patient who threatens “road rage” if you do not immediately provide x, y, or z. But remember that skillful maintenance of a collaborative, evocative, and person-​centered approach will be far more therapeutic and efficient in the long run than an authoritarian and confrontational manner.

STRATEGIES FOR WORKING WITH CHALLENGING PATIENTS The “Angry” Patient Key Skills (a) Reflective statements that acknowledge and validate anger, (b) autonomy statements to support a patient’s sense of self-​efficacy, and (c) open-​ended

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questions to explore the situation in greater depth and discover what might be required to resolve the conflict. Tips Regulate your affect and be aware of your body language. Avoid becoming defensive and resist the need to justify your decision-​making when it is questioned in a mocking or sarcastic manner. Stay aware of the “expert trap” or desire to rationalize. When you feel an impulse to justify a decision under these circumstances, think about framing your perspective such that you clarify your intent to promote adaptive coping behaviors. A communication style geared toward shared decision-​making is another way to remain person-​centered. One morning, one of my colleague’s patients stormed into the interview room before we had a chance to call him by name and he began an angry tirade, claiming that we had discontinued one of his “as-​needed” medications last night and “tricked him.” He was yelling, pointing fingers, and at one point, he angrily dismissed the trainee saying, “I don’t care what you have to say, I need to talk to the real doctor.” This came out of the blue, in the wake of three or four good MI sessions with the same patient. Here are some examples of my colleague’s responses: • “You’re really pissed off right now and feel really disrespected.” [reflection of emotion] • “It’s difficult for you to trust people and you feel like the team has let you down.” [linking past information to the reflection to reinforce rapport] • “What is anger like for you?” (The patient did not understand this question.) “I mean, what’s that like for you?” [an evocative open-​ended question; it is very useful to focus on the underlying emotion when you feel stuck] • “Yesterday you shared with me how you were able to manage your emotions during an argument in the kitchen. How were you able to do that so skillfully?” Or “What made that successful?” Or “What has helped you cope/​be effective in the past when you have been really angry? [supporting and reinforcing self-​efficacy] • “We’re not doing anything for you . . . what is your idea of treatment?” [repeating the patient’s last statement, clarifying, and exploring] • “Anthony, do you mind if I share my perspective with you? (She waited for permission.) “You have mentioned that no one listens to you, and no one is helping you. Personally, I find it very difficult to hear you and appreciate what you are feeling when you yell. I wonder if people shut down

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when you start to yell . . . communication breaks down and your needs are not met. What do you think about that?” [sharing a personal perspective; always ask permission first and be very careful to adopt an empathic, nonjudgmental tone]

Key Point Reflecting emotion with an angry patient is a key skill that enables “coming alongside the patient.” This particular patient responded very well to my colleague’s personal disclosure. He sat down, lowered his voice, and agreed that yelling was not the most effective way to communicate. Later in the interview the patient explored further the roots of his tendency to always think the worst in people and how he could act differently in the future. It is worth emphasizing that the trainee maintained a neutral but concerned affect throughout the encounter. Her body language was relaxed, and she did not focus on content (e.g., which medication, why it had been stopped, and that he had been told it was going to be discontinued). She focused on the process of interpersonal relatedness while maintaining a person-​centered approach using MI skills and strategies and successfully defused what had the potential to be an aggressive exchange. She also avoided the expert trap and the implication that “I am the expert and I know which medications you need.” This approach likely would have elicited defensiveness on the part of the patient. The root of discord in this instance arose in part from the patient’s tendency to mistrust others.

THE “OVERWHELMED” PATIENT Key Skills (a) Reflections, (b) affirmations, and (c) supporting self-​efficacy.

Tips Acknowledge tears. Stay in the emotional moment. Adopt a neutral affect. Choose tones that resonate with the patient’s emotions. This approach diminishes discord in the relationship. Evocative questions help patients continue to explore their emotions.

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I used to be extremely uncomfortable whenever patients became overwhelmed and began to cry. Do you tend to ignore it? After all, most people seem embarrassed to cry in front of a stranger. Do you offer a supportive moment of pausing and then move on with the session? In one particularly cringe-​worthy situation, a patient was sobbing while intermittently apologizing for not being able to “get a hold” of herself. My response was, “Don’t be sorry,” and this response was both empathic and effective. Following is an example in which I found myself in a similar situation: PATIENT: (Starting to tear up) TRAINEE: I can see that your eyes are starting to fill with tears . . . what are the emotions you are feeling right now? [acknowledge tears, stay in the emotional moment, and explore with an evocative question] PATIENT: Scared, ashamed . . . my life is ruined. I can’t recover. TRAINEE: You feel like you have passed the point of no return. [complex reflection] PATIENT: Yes. I’m sorry, I need to stop crying and get it together. TRAINEE: You feel embarrassed. [reflection of the underlying emotion, instead of responding to the content] PATIENT: Very embarrassed. I’ve tried to stop drinking so many times before, but this time is different. I want to recover. TRAINEE: You want to learn how to start coping with feelings in a different way that does not involve alcohol, and you see yourself being determined this time. . . . What does it mean to you to recover? [transitional summary followed by an evocative question that guides the patient forward] PATIENT: I believe I can do it . . . but I’m scared. TRAINEE: On one hand, you are afraid to try again, and on the other hand, you are determined in a way you have not been before. [double-​sided reflection; always end with the emotion that will mobilize the session instead of creating a roadblock, which is what might have occurred if the sentence was structured the other way around; and use language that builds self-​efficacy] TRAINEE: You mentioned earlier that 2 years ago you had a period where you did not use substances for 8 months. How did you successfully stop for those 8 months? [this affirms self-​efficacy and continues to move the encounter forward; also note that, although it is in our common parlance, the word clean is judgmental, whereas the phrase not using substances, as a behavior, is not]

By making the effort to acknowledge this patient’s obvious emotions, and by exploring what they meant right now, this patient and I were able to extend this understanding to the bigger concerns in her life, namely, those related to alcohol use.

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THE “DISENGAGED OR WITHDRAWN” PATIENT Key Skills (a) Acknowledge patient autonomy, (b) astute reflections, and (c) affirmations.

Tips If a patient says he or she does not want to talk, it is worth respecting this autonomy and negotiating another time to engage. It may be less convenient for you, but it furthers rapport and provides a good foundation on which to base the next encounter. Consider voicing understanding and acceptance of why it may be too difficult for a patient to engage at this particular time. For example, the patient is experiencing significant withdrawal symptoms from drugs or alcohol or is exhausted after having just been admitted following a long night in the emergency department. Acknowledge that the patient is struggling and revisit the session later. Depending on the context, you could attempt to engage your patient by reflecting that he or she has really been struggling lately and follow this observation with an open-​ended question as to how he or she was able to walk into the room and reach out despite these struggles. You can resist feeling uncomfortable by either pausing a bit or slowing down your pace. MI is about meeting patients where they are, both in the content of your reflections and the pace of the encounter. This can be particularly challenging in a medical setting in which we are under intense time pressures. However, slowing down and using carefully chosen, effective language will actually save you time and better serve your patient in the end. An older gentleman with a long history of alcohol use was involuntarily admitted to our hospital after making homicidal and suicidal statements in front of police officers. At first, I was caught off guard because I thought he would present as angry and not willing to engage in the session. Here is an excerpt from our second session: TRAINEE: Hi, John. How have you been feeling since we last talked? JOHN: Fine, I got some rest. TRAINEE: (pause) Some rest . . . [simple reflection, echoing his words] JOHN: I’ve been gathering my thoughts. TRAINEE: (pause) You have had a chance to rest, to be still, and reflect on what has happened as a result of your actions. [I specifically used the phrase your actions, instead of recent events or What brought you in?, because my goal was to maintain

104  Motivational Interviewing, 2E a person-​centered approach and place subtle emphasis on the fact that it was his actions and not “the alcohol” that led to his admission. Recall that MI aims to evoke a sense of autonomy within patients, rather than implying or assuming passivity] JOHN: Yes. TRAINEE: When you say, “gathering your thoughts,” what do you mean? [evocative question] JOHN: I realize that when I’m depressed, I shouldn’t drink. I should make a phone call instead or try a different vice. [the patient is presenting reasons for change elicited by the open-​ended question] TRAINEE: Drinking is not something you want to do in the future . . . you really see a connection between your depression and drinking alcohol. [reflection emphasizing how depression and alcohol use are linked] JOHN: Yes. TRAINEE: John, how were you able to conclude that your drinking is affecting you? [open-​ended question] JOHN: Well, take smoking [cigarettes], for example. I can go for 2 days [that is, since admission to the unit] with no nicotine patch and be fine. Why can’t I do that with drinking? TRAINEE: You are drawing a comparison between smoking and drinking. You realize that you are coping without cigarettes and want to do the same with drinking. John, help me understand, what drives you to drink? [transitional summary statement followed by an evocative question] JOHN: Well, sometimes it’s the taste, but other times I don’t like the taste. I want to drink because I’m angry or depressed. Sometimes it’s because my friends will be in the bar, playing pool, shooting darts, you know. . . . TRAINEE: There is the social aspect of being out with friends, as well as some of the characteristics of alcohol . . . at the same time there are also times where negative emotions drive you to drink. [double-​sided reflection linking in past information] JOHN: Yes. Some people blame alcohol for their actions or say it caused their depression, but I know I drink because I’m depressed, period. TRAINEE: John, I really appreciate you sharing this with me; it is not easy to sit in that chair. You pride yourself on being strong for others and you are realizing now that you need to be strong for yourself too by being honest and open about your struggles. [affirmation, encouraging the patient without “cheerleading” responses, such as “That’s great,” “That shows good insight,” or “Good for you”]

Reflecting on this encounter, I remember how challenged I felt to remain quiet within myself, while remaining fully attentive and present to this patient’s reserved, subdued manner of speaking. Had I not been able to

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respond to his stillness, I wonder now whether I might have missed the remarkable insights we gleaned together over the course of this session.

THE “MANIPULATIVE OR ENTITLED” PATIENT Key Skills (a) Address thought process rather than content, (b) complex reflections such as amplified and double-​sided reflections, (c) autonomy statements and affirmations to communicate that they are in control of their emotions and their behaviors, particularly when loss of control is suggested or threatened.

Key Point Stress autonomy with a patient presenting as “entitled” to further establish therapeutic alliance.

Tips A neutral/​relaxed or pleasant/​concerned affect is ideal, as is relaxed body language. During a medical rotation I was called to the floor because a patient on the ward was “freaking out”: TRAINEE: Hi, Jessica. Help me understand what the situation is? [open-​ ended question] JESSICA: I’ll tell you what’s going on—​it’s you people and this place. I come here in agony, somehow am able to reach out for help, and then I get nothing in return! Tylenol® isn’t going to cut it. I told you this and I’m not stupid, you know! Only Norco® works for my chronic pain! TRAINEE SAMPLE RESPONSE 1: Well, Jessica, as we spoke about earlier, Norco® is not indicated for your pain as we cannot find a pathological cause of your pain. [defensive, directly responds to content and intellectualizes] TRAINEE SAMPLE RESPONSE 2: Jessica, I can see how frustrated you are right now . . . it took all your energy to come here, and you feel that coming here was a waste of time because you are still in excruciating pain. [complex reflection that addresses thought process and not content]

106  Motivational Interviewing, 2E TRAINEE SAMPLE RESPONSE 3 [should the patient continue to be riled up]: It is hard to communicate when you are yelling. Would you like me to give you a couple of minutes to cool off? Let us see what is happening right now. I am a little confused because this morning you were much calmer. [setting boundaries and allowing the patient a degree of control because, internally, the patient feels stripped of it; acknowledging some personal emotion makes you more of a real person and less of a threat]

The risk of responding directly to content is that such a stance will likely place you in opposition to your patient, thereby sending you into what I call “interview purgatory,” that is, a never-​ending debate about your medical management versus their reality versus your credentials versus what they know is true, and so on. Direct insults, sarcasm, rhetorical questions, and challenges to medical decision-​making are situations rife with potential content traps. Addressing your patient’s thought process puts the focus back on the patient in a therapeutic and nonconfrontational manner. It is perfectly reasonable to share a personal opinion, similar to sample 1; however, it is better to preface this activity by first seeking permission to do so and then asking for feedback on your opinion after you have shared it. Another useful strategy is to offer the patient a list of available options. Shea (1998) describes seven “core pains” that interviewers should keep in mind when assessing and understanding how the patient’s “manipulative” behavior, or any form of observable resistance, comes about:

1. Fear of being alone 2. Fear of worthlessness 3. Fear of impending rejection 4. Fear of failure 5. Fear of loss of external control 6. Fear of loss of internal control 7. Fear of the unknown

“Manipulative” or “entitled” patients have learned to fill these voids and insecurities by manipulating and controlling their environments, thereby also serving to protect their fragile sense of self. How do they achieve this? They attack your sense of self . . . along with everyone else’s. What a shock it is when you respond in a steady, controlled manner designed to deescalate the situation. Similar to delirium, manipulation can present in either a quiet fashion or a very obvious one. However, unlike delirium, these interactions seem to

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pierce right into our core, our very sense of self. They shake us up enough to ruin a morning, a call shift, or even longer. “Flight” is not an option; so instead, we prepare ourselves to “fight.” The defense we often use is to put up an emotionless wall that has a twofold benefit: our countertransference cannot get out, and the patient’s enraging words, or behaviors cannot get in. We quickly learn that this is not a sustainable coping mechanism when phrases such as “Who cares if she leaves, I’ll be glad!” dare to creep into our minds or when we dread the thought of another challenging patient. This still happens from time to time when we are tired or having a difficult day. Yet it takes all of 10 seconds to remind ourselves that no one wins this way: it is a lose-​lose situation. Remember that when we view our interactions with patients as a battle with winners and losers, then we have the MI approach to use. Once you feel confident using MI strategies, your options for dealing with “manipulative” or “entitled” patients will consist of “fight,” “flight,” or “use MI.”

THE “NONADHERENT” PATIENT Key Skills (a) Explore beliefs and underlying ambivalence; (b) develop discrepancies, that is, how the individual’s current behavior or consequences contradict his or her values, beliefs, or goals for the future; and (c) respond to discord.

Tips Why is a word best avoided when incorporating MI into encounters with our patients. It is perceived as subtly judgmental and can limit patient engagement, rather than evoke more change talk. Instead of asking “Why?” pose questions such as “What leads you to. . . ?” or “What makes it difficult for you to. . . ?” Remember that the dyad formed through MI, the interpersonal process itself, is what helps to bring about motivation for change.

Key Point Avoid questioning a patient engaging in nonadherent behaviors with the pejorative why?

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Patients with concurrent psychiatric and substance use disorders often sense that these issues get in the way of the person they would like to be, whether mother, father, son, daughter, significant other, or perhaps even the person a now-​deceased relative had wanted them to be. These feelings are an extremely powerful conduit for change. Religion and culture may also prove very important. Family members of patients who do not adhere to medication or treatment regimens, or who fail to attend medical appointments, are often upset about this behavior, and their reactions can also become a stepping-​ stone to exploring ambivalence and developing discrepancies. Consider the following summary, in which the arrows mean “leads to”: Discrepancy or conflict between behavior and core values → ambivalence about continued sustained versus changed behavior → through MI, discrepancy increases, and ambivalence is guided in the direction of change → the process of change is mobilized, and soon the patient is expressing change talk → further mobilize to commitment language (Figure 6.1) (Douaihy, Kelly, & Gold, 2014). As mentioned in other chapters in this guide, the process of change is more effective when our patients, and not us, come up with the reasons for change.

Elicit values and explore conflict between core values and behaviors

Patient ambivalence about maintaining problematic behaviors

Use OARS skills within the context of the spirit of MI to build discrepancy

As ambivalence is guided toward the direction of change, change talk emerges

The continued use of MI adherent discussion further mobilizes the patient

Commitment talk emerges

Figure 6.1  Mobilizing patients by developing discrepancy.

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Our role is to engage, guide, and evoke reasons for, and commitment to, change. “Nonadherent” patients are patients we may feel frustrated with, sometimes prompting dramatic statements and scare tactics such as, “Mr. Smith is going to die if he doesn’t take that medication or make those lifestyle changes or keep those outpatient appointments.” More often than not, we as trainees make a grave mistake in thinking that confronting ill patients with the certainty of a negative health consequence, severe pain, or even death will be sufficient to bring about the desired change. It is not. In fact, we have treated countless individuals in our inpatient psychiatric setting who tell us that their drug and/​or alcohol use or lack of medication adherence actually increases following stern warnings from practitioners in starched white coats. In many cases patients’ lives may be in jeopardy; but, however ardently we tell them this, when we fail—​for even a few minutes—​to explore the thoughts and feelings that have prevented adherence in the first place, we are much less likely to bring about meaningful change.

THE CHALLENGING ENCOUNTER OF DELIVERING “BAD NEWS” Breaking “bad news” is a challenging encounter for any medical trainee. Bad news may be defined as any situation in which “there is either a feeling of no hope, a threat to a person’s mental or physical well-​being, a risk of upsetting an established lifestyle, or where a message is reality which conveys to an individual fewer choices in his or her life” (Bor, Miller, Godman, & Scher, 1993). It is crucial to consider the cultural context of these scenarios since some cultures have different perspectives of delivering and receiving bad news. Bad news delivered poorly can negatively affect a patient’s responses. Delivering bad news may be very distressing to us because it elicits a profound fear that we will be unable to respond adequately to strong emotional reactions. Taking the time to carefully review the clinical situation, to prepare yourself emotionally, to ensure an unhurried discussion that respects your patient’s privacy while encouraging family members to be present as desired by the patient, will help these difficult situations go as smoothly as possible. Once the consultation is initiated, use the spirit and skills of MI to engage with the patient. The elicit-​provide-​elicit (E-​P-​E) framework can be a helpful approach to information-​sharing, and it honors autonomy by asking patients permission to share additional information (in the “P” of E-​P-​E.) and eliciting feedback from them. It is crucial to pay close attention to a patient’s emotional

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reactions when sharing bad news. Support can be offered in an empathetic approach by reflecting and validating patients’ emotions and experiences and summarizing the discussion. Discuss the implications of the news, elicit patient questions, offer resources and options as appropriate, negotiate the next steps, and arrange for follow-​up.

AN MI APPROACH TO VACCINE HESITANCY Key Skills (a) Reflections, (b) autonomy, (c) explore ambivalence, and (d) avoid the expert trap (use the E-​P-​E framework). Vaccine hesitancy is a common occurrence and can be influenced by distrust in the medical system, a lack of proper communication of scientific information, or overt misinformation. There are many reasons why patients may not feel comfortable getting vaccinated, many of which involve an element of fear. Interventions that are focused solely on providing practical information have not been shown to be successful (Kaufman, et al., 2018). Our “righting reflex” might really flare up in these conversations yet falling into the expert trap in these instances is likely to backfire and lead to further sustain talk on the part of the patient. Sustain talk is about the target change, and it often reflects a person’s desire to maintain the status quo (Miller & Rollnick, 2013). This is not to say that patients do not want health information. Practitioners should be mindful of the need to contextualize conversations with deference given to a patient’s own belief system. Relying purely on vaccine logistics and facts may come across as judgmental and cause patients to double down on their position, whereby furthering sustain talk, increasing ambivalence, or generating frank discord. As Miller and Rollnick describe, every conversation can be viewed as the analogy of two chairs in a room, one for “change” and the other for “maintaining” the current behavior. If we as practitioners occupy the “change” chair, it only leaves the opposing chair—​or rather, viewpoint—​open. In a similar manner, by aggressively defending vaccines, practitioners may actually be furthering vaccine hesitancy. As the authors describe in “Motivational Interviewing Strategies for Addressing COVID-​19 Vaccine Hesitancy,” violating neutrality by taking a position can create “resistance” and is especially likely to backfire in situations when practitioners are unable to stay neutral or with patients who are highly ambivalent or express a high amount of distrust in the medical system (Boness, Nelson, & Douaihy, 2022).

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MI skills and techniques have been successfully utilized in this arena to help patients process their own vaccine deliberation. Specifically, the E-​P-​E framework can be especially useful. This same concept was demonstrated during a clinic rotation in my final year of medical school when I came across Charles. TRAINEE: Charles, I know you said you were not interested in any vaccinations for you or your son today. Help me understand what you have been told and learned about this vaccine? [elicit with open-​ended question] CHARLES: I do not trust it. I heard it gives children autism. I do not want my son to get it. [sustain talk] TRAINEE: Thank you for sharing that. You are very worried about your son’s health and how your decisions impact him. [complex reflection] CHARLES: Yes, I don’t want him suffering because of something I did. TRAINEE: You take your role as a father very seriously, and you do not want to feel guilt for causing him harm. It is not unusual for people to be suspicious of medical interventions. Some people feel like they are being controlled, as if it takes your autonomy away. [complex reflections] CHARLES: Yeah, with the government and the schools. So many people pushing you to take this vaccine and I look like a crazy person just because I am not jumping to the front of the line to get you to stick a needle of who-​knows-​what in my son? I have heard too many troubling stories. TRAINEE: You have heard a lot of conflicting information about vaccinations and the diseases that they prevent, at the same time, you would like to keep your son safe. [double-​sided reflection; avoiding the expert trap; focusing on the patient’s underlying motivation; and highlighting aspects favoring behavior change] CHARLES: His safety is my number one priority. TRAINEE: Would it be ok to share my understanding of what we know about the vaccine? [asking permission to provide information] CHARLES: Sure. TRAINEE: In a lot of ways, a vaccine is similar to any medication you take. Instead of treating an illness after the fact, it helps your body fight before you get sick. It helps you achieve your goals so that it is easier for your son to live his life. I am not saying that rare side effects do not occur. By and large, they are as safe, if not safer, than many of the medications we have today. How do you feel about us talking through some of your concerns more specifically? [providing information then eliciting via open-​ended questions] CHARLES: OK, we can do that.

It is important not to assume that vaccine hesitancy comes solely from a place of ignorance or lack of judgment. Often addressing a patient’s fears

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and ambivalence early on can lead to a more productive discussion down the road.

“END OF THE ROAD” ENCOUNTERS Key Skills (a) Decisional balance and (b) avoiding the righting reflex. In spite of our best attempts, we can reach an impasse with patients’ behavior change that can feel insurmountable. There will inevitably be moments where you think, “I have tried everything I can, and nothing works.” In these moments, it can be helpful to take a step back and refocus on the principles guiding your collaboration: partnership, acceptance, collaboration, and evocation. Ask yourself, “Are my priorities in line with my patient’s?” It is crucial to be honest with yourself about your own opinions, motivations, and aspirations. “What is causing me to be so frustrated with this interaction?” Every partnership has its differences but forcing or pushing unwanted behavior change is antithetical to the spirit of MI. In these instances, it can be helpful to remind yourself of the underlying principles of MI. One of these involves the principle of absolute worth, or unconditional positive regard (Rogers, 1957). It does not matter whether a patient is continuing to use illicit substances, refusing a vaccine, or engage in risky behaviors—​they are inherently valuable human beings. Allow yourself to take a step back from the conversation if you are too exhausted or frustrated to approach your patient in a manner consistent with absolute worth. It is only through this acceptance that we can provide our patients with autonomy support, or the freedom to make their own decisions. When you feel yourself starting to argue with a patient, consider asking more open-​ended questions instead. If your goal entering a conversation is to create or generate behavior change, you will inevitably be frustrated with an alternative outcome. MI is helpful in exploring ambivalence around a target behavior or change. If there is little to no ambivalence on the part of a patient, forcing the conversation will undoubtedly backfire. When there is ambivalence, it is because of opposing “pro” and “con” arguments that the patient already has in their mind. Reinforcing a patient’s own pro-​change motivations is much more likely to be successful than providing your own. Absolute worth, empathy, and autonomy support decrease patients’ defensiveness and allow them to express their ambivalence to you in a way that can move the conversation forward. These principles also free trainees from the burden that comes with tying “success” (ours or the patient’s) to a particular

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outcome. Success, at the end of the day, is having created a safe place for the patient to begin to think about what change could be like. CINDY: I need Klonopin® (Clonazepam) right now. My anxiety is out of control. None of you care about me! I am sick of this! TRAINEE: You are very upset this morning and I am not sure what to make of this because yesterday you felt confident, and we covered a lot of ground together. Help me understand what you are going through. [complex reflection followed by an open-​ended question] CINDY: I told you—​I keep telling you. I NEED my Klonopin®. I cannot function without it. You are not listening. I have been trying and trying but I cannot handle this anxiety. TRAINEE: You cannot manage your life without Klonopin®, at the same time, you want to learn how to start coping with your anxiety in a different way. [double-​sided reflection] CINDY: I do but it’s too hard. TRAINEE: This is an ongoing struggle for you. Do you mind if I share my perspective since we have been working together? [complex reflection followed by asking permission] CINDY: Yes, tell me. TRAINEE: I am concerned about the degree you are focusing and relying on Klonopin®, and you’re not giving yourself enough credit for the skills you learned that helped you cope better with anxiety. [complex reflection and affirmation]

Using the MI spirit, skills, and strategies, Cindy’s emotions are addressed and acknowledged in a way that shifts the focus of the conversation in a more positive direction.

ACKNOWLEDGING INJUSTICE AND CULTURAL ADAPTATION There are many reasons why patients mistrust the medical system. Patients may additionally have experienced racism, sexism, homophobia, xenophobia, or generally abuse of trust in their lives. Acknowledging historical traumas or past discrimination can go a long way in building a therapeutic alliance with your patient. A compassionate approach prioritizes the welfare of our patients. Moreover, MI approaches can be used to explore ambivalence surrounding the healthcare system. Open-​ended questions can be helpful to explore the patient’s experiences such as: “What was it like the last time you were hospitalized?” or “How do you feel about us working together?” Racism can

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and should be treated like any other source of trauma—​with openness and listening, and without forcing an undesired conversation (Saha & Cooper, 2021). If you make a mistake or a cultural misstep, apologize instead of getting defensive. Similarly, remain open to the possibility that some of the topics patients bring up may make you uncomfortable. Some MI approaches may need to be adapted for patients who come from a collectivist culture, as opposed to an individualistic one. Suggestions that clash with cultural norms can inadvertently reinforce sustain talk (Oh & Lee, 2016). In these situations, it is important not only to highlight the effects of a certain behavior on the individual, but also on their family. For instance, “What are challenges you foresee for yourself?” becomes “What are challenges you foresee for yourself and your family?” Lastly, it is important to assertively address racism and bigotry in the clinical encounter. Absolute worth and empathy can go hand in hand with setting boundaries with patients who transgress inappropriate boundaries. For instance, “Mr. Zad, at our hospital we pride ourselves on mutual respect. We do not use that kind of language. It is harder for us to help you when you talk like that. [firm limit; then redirect] Tell me about your understanding of the events that led you to coming to the hospital?” (Goldenberg, et al., 2019).

PERSONAL REFLECTION (Areej Ali) The first time I saw my mentor engage a patient about their substance use, I braced myself for what I anticipated would be a stormy and tense conversation. Instead, I found that their discussion bent and flowed like a river around points of resistance. I was hooked. Finally, I was being shown a way to navigate conversations that I had previously dreaded and, admittedly, avoided. Throughout the rest of medical school, I worked hard to build on my MI skills. Each week, I would work on one aspect—​even if it were something as small as, “I am going to try to consciously remove pejorative words such as ‘relapse’ from my conversations with patients.” Eventually I felt more confident about my ability to apply these skills after graduation and beyond. Unfortunately, what I thought would be one of the most exciting times of my life was marred by a ruptured appendix, multiple hospitalizations, procedures, and weeks of antibiotics. Because of a 1-​month gap in insurance between the end of medical school and the beginning of residency, I was also stuck with thousands of dollars in medical bills. I started my residency hundreds of miles away from my family—​exhausted, physically deconditioned and often in pain, broke, and in the midst of a surging pandemic. Disillusioned with the

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medical system I was entering, I began to have a deeper understanding of the difficulties many of our patients face. Surprisingly, MI was the very thing that prevented me from burning out. Early on, a lot of my difficult conversations centered on vaccine deliberation and pain medication. These conversations certainly were not easy, and many of them provided the inspiration for some of the examples in this chapter. However, I felt that the conversations weighed less on me when I approached them through the lens of MI. It helped me avoid viewing patients’ successes or setbacks as my own. In this way, I could be proud of a patient for the hard work it took to recognize a developing opioid use disorder while also not beating myself up because another patient did not get vaccinated after we talked about it. I often borrow and adapt Aristotle’s view of mirroring when I describe MI (Pigliucci, 2012). Through MI, we hold a mirror up to our patients and allow them to see themselves in ways that would not otherwise be accessible to them, thereby helping them change their behaviors. However, the very process of mirroring fundamentally changes you as a physician and a person. I did not expect to personally benefit from MI, but utilizing this collaborative approach allowed me to have some of my most meaningful conversations with patients and kept my disillusionment with the system from turning into disillusionment with my patients. Many of you may be eager to jump in, as I was when I was first exposed to MI. Some of you may feel closer to the version of myself at the beginning of residency—​exhausted and skeptical of your ability to add another “to do” to your already full list. For this reason, I have offered you a reflection from the highs and lows of my own journey. In the end, learning MI was more than worth it for me, as I hope it will be for you.

A CLOSING THOUGHT We work under extreme time pressures on top many other stresses and strains unique to this time in our lives. The following anecdote from Father Gregory Boyle’s book Tattoos on the Heart, The Power of Boundless Compassion (2010) is a fitting end to this chapter on engaging with challenging patients. The next time you find yourself annoyed by an ill-​timed page or a seemingly difficult individual, it may be helpful to recall this scenario. This woman in her thirties walks through the door. I immediately glance at the clock hanging on the wall. I check how much time I have left before the baptism and am already lamenting that I most probably won’t get to all the mail. I find out later

116  Motivational Interviewing, 2E that the woman’s name is Carmen. . . . Carmen is a heroin addict, a gang member, street person, occasional prostitute, and . . . she is often defiantly storming down the street usually shouting at someone. . . . Now I have seven minutes until the baptism. . . . Carmen plops herself into one of the chairs in my office and cuts the fat out of her introductory remarks. “I need help,” she launches right in. . . .“I’ve been at like fifty rehabs. I’m known all over . . . nationwide. . . . I went to Catholic school all my life. Fact, I graduated from high school even. Fact, right after graduation, is when I started to use heroin.” Carmen enters some kind of trance at this point and her speech slows to deliberate and halting. “And I . . . have been trying to stop . . . since . . . the moment I began.” Then I watch as Carmen tilts her head back until it meets the wall. She stares at the ceiling, and in an instant her eyes become these two ponds, water rising to meet their edges, swollen banks, spilling over. Then, for the first time really, she looks at me and straightens. “I . . . am . . . a . . . disgrace.” Suddenly, her shame meets mine. For when Carmen walked through that door, I had mistaken her for an interruption (p.61).

SELF-​ASSESSMENT QUIZ True or False 1. MI offers helpful techniques and strategies to challenging clinical encounters. 2. Exploring the emotion behind tears is encouraged in MI. 3. When patients refuse to talk, respecting their autonomy may help build rapport. 4. “Why?” questions are a helpful means to engage patients and evoke change talk. 5. The phenomenon known as “heart sink” or a “difficult” encounter may be understood by examining the characteristics both trainees and patients bring to the encounter, in addition to complex factors within healthcare systems.

Answers 1. True. The spirit of MI is one of collaboration, absolute acceptance, and compassion, making it an ideal framework to approach challenging

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encounters. Developing compassion and accepting a patient’s perspective helps break the unproductive cycle that often accompanies challenging encounters. 2. True. Acknowledging a patient’s obvious emotion and exploring the nature of what is being expressed validates the experience and is one way of demonstrating compassion and empathy. Such explorations may lead to meaningful discussions of topics or perspectives that are fundamental to patients’ progress toward change. 3. True. By respecting a patient’s wishes, we affirm autonomy and demonstrate respect. Acknowledge that the patient is uncomfortable, perhaps struggling with emotion, and suggest that you meet at another time to begin a therapeutic conversation. 4. False. “Why” should be avoided most of the time in all MI-​based encounters; these questions are often perceived as judgmental and limit patient engagement. More relevant questions include, “What leads you to. . . ?” or “What makes it difficult for you. . . ?” These questions are value-​neutral and more likely to encourage further change talk. 5. True. “Heart sink” or “difficult” encounters result from a combination of a trainee’s level of expertise and ability, a patient’s previous experience with health services, and factors intrinsic to the healthcare system. Important practitioner characteristics include lack of experience and professional identity, gaps in knowledge, weak communication skills, an inability to manage time effectively, and fatigue. Patient characteristics include mental health issues, personality disorders, a lack of willingness to engage with treatment, and previous experience with ineffective practitioners and treatments. Finally, healthcare system characteristics include language and cultural barriers, time pressures, and lack of continuity of care.

REFERENCES Boness, C. L., Nelson, M., & Douaihy, A. B. (2022). Motivational interviewing strategies for addressing COVID-​19 vaccine hesitancy. Journal of the American Board of Family Medicine, 35(2), 420–​426. Bor, R., Miller, R., Goldman, E., & Scher, I. (1993). The meaning of bad news in HIV disease: Counselling about dreaded issues revisited. Counselling Psychology Quarterly, 6 (1), 69–​80. Boyle, G., Fr. (2010). Tattoos on the heart: The power of boundless compassion. Free Press. Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational Interviewing: A guide for medical trainees. Oxford University Press.

118  Motivational Interviewing, 2E Goldenberg, A., Garcia, D., Halperin, E., Zaki, J., Kong, D., Golarai, G., & Gross, J. J. (2020). Beyond emotional similarity: The role of situation-​specific motives. Journal of Experimental Psychology General, 149(1), 138–​159. Groves, J. E. (1978). Taking care of the hateful patient. New England Journal of Medicine, 298, 883–887. Jackson, J. L., & Kroenke, K. (1999). Difficult patient encounters in the ambulatory clinic: Clinical predictors and outcomes. Archives of Internal Medicine, 159 (10), 1069–​1075. Kaufman, J., Ryan, R., Walsh, L., Horey, D., Leask, J., Robinson, P., & Hill, S. (2018). Face-​to-​ face interventions for informing or educating parents about early childhood vaccination. Cochrane Database of Systematic Reviews, 5(5), CD010038. Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Oh, H., & Lee, C. (2016). Culture and motivational interviewing. Patient Education and Counseling, 99(11), 1914–​1919. Pigliucci, M. (2012). Answers for Aristotle: How science and philosophy can lead us to a more meaningful life. Basic Books. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–​103. Saha, S., & Cooper, L. A. (2021). Talking about racism with patients. Journal of General Internal Medicine, 36(9), 2827–​2828. Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Saunders. Winnicott, D. W. (1949). Hate in the countertransference. International Journal of Psychoanalysis, 30, 69–​74.

7 Brief Interventions Janice Pringle and Mara Rice-​Stubbs

Motivational Interviewing (MI) is an evidence-​based therapeutic approach that is compatible with a wide range of brief interventions (BIs). In this chapter, we review and describe several widely used frameworks or organizing structures designed to deliver BIs using the MI interactional style and spirit. BIs may vary considerably in their communication style and underlying modality, or theoretical framework used to facilitate change. Several types of BIs have an emphasis on strengthening motivation for change and rely on the spirit, skills, and strategies of MI and share common elements of being person-​centered, structured, time-​limited, and goal-​focused (Libby, 2009). BIs can be effectively implemented in various contexts, including primary care practice, medical specialty clinics, emergency and trauma services, employee assistance programs, college health services, and treatment settings for drug and alcohol use disorders (Miller & Wilbourne, 2002; Rollnick, Miller, & Butler, 2008).

OVERVIEW OF BRIEF INTERVENTIONS It is common to see well-​meaning trainees and other practitioners prematurely push patients to make behavioral or lifestyle changes. As a result, patients can become defensive to the point of rejecting advice they might otherwise have considered. The nature of the interaction causes them to focus on defending their position rather than on communicating with trainees and other practitioners about their health and quality of life. Trainees may express frustration with patients who refuse to take the necessary steps to improve their medical conditions. They want to help their patients to help themselves but may lack the tools necessary to engage with patients in a way that is likely to result in success. The practitioner’s directive role in healthcare is based on a history of medical practitioners treating acute physical conditions which respond to

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treatment primarily without regard to patients’ experiences. In an inpatient setting, pneumonia may be treated with antibiotics and acute appendicitis resolved with surgery. Practitioners thereby diagnose, treat, and discharge patients with acute conditions without paying much attention to considerations beyond the disease process itself. In these scenarios, patients are unlikely to object to this approach because they and their practitioners share the objective of simply reducing symptoms. Modern medicine, however, has gone through an evolutionary process that has redefined the focus of medical care and the role of practitioners. Chronic diseases now dominate the healthcare landscape. This new paradigm recognizes the dire consequences of four chronic, life-​threatening behaviors: tobacco use, unhealthy diet, physical inactivity, and excess alcohol consumption. These four behaviors alone cause up to 40% of mortality in the United States (CDC, 2014). These chronic conditions can be modified but cannot be remedied by practitioners simply dictating to patients acute care plans. Patients ultimately must be responsible for changing these lifestyle-​ based behaviors, and practitioners must rely on evidence-​based methods for helping them accept this responsibility and engage in making behavior change. Many terms have been used to describe BIs, such as brief advice, minimal interventions, brief opportunistic encounters, and brief counseling (Barry, 1999). BIs may range from a few minutes of advice and counseling to a mélange of various elements delivered in one or more sessions of 10–​30 minutes. There is no clear theoretical perspective on the selection and use of different ingredients in the BIs (Barry, 1999). BI becomes even more important in primary and secondary prevention efforts. BI lends itself to a reframing as an “opportunistic intervention,” a sometimes-​unexpected chance for trainees to influence health behavior change. BIs can be a freestanding event targeting motivation for change or integrated into general or specialty care settings such as primary care or emergency services. BI has been used to address substance use, childhood bullying, domestic violence, and other risk factors and have been implemented in a wide range of settings, including primary care, emergency rooms, trauma units, and college health services (Hettema, Wagner, Ingersoll, & Russo, 2014; Pringle, Nowalk, Howard, & Taylor, 2020; Rollnick, Miller, & Butler, 2008). Earlier studies and numerous systematic reviews and meta-​analyses have reported beneficial outcomes of BI, compared with control conditions, in terms of reductions in alcohol use and its related health and social problems, improvement of mental health, and utilization of health services (McCambridge & Cunningham, 2014; Kaner, et al., 2009; Moyer, Finney, Swearingen, & Vergun, 2002). An example of a framework for delivering BIs is

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the screening, brief intervention, and referral to treatment (SBIRT) approach to addressing tobacco, alcohol, illicit, and prescription drug use and mental health (Bray, Del Boca, McRee, Hayashi, & Babor, 2017). Here are some clinical encounters where BI is indicated and beneficial: • Medical care delivered when a practitioner has time for only a short interaction with a patient: for example, in an emergency department with a patient whose injury is alcohol-​related or during a preoperative visit where multiple factors affecting outcome might need to be addressed (e.g., tobacco use, diet, postoperative care). • Medical care during which a circumscribed behavior can be targeted: for example, in a primary care office with patients who are not taking medications as prescribed for hypertension, or at a dentist’s office where poor dental hygiene results in gum disease. • During routine treatment for another condition where a risk-​related behavior is uncovered but is not the focus of treatment: for example, risky sexual practices or drug use revealed while doing an evaluation. During consultation services where evaluation is generally considered the primary role of the practitioner: for example, a consultation liaison psychiatrist may find a patient who accidently overdosed judged to be safe for discharge but would still benefit from a risk-​related intervention to prevent future overdoses. BIs as adaptations from MI across behavioral domains (Bogenschutz, et al., 2014; Dunn, Deroo, & Rivara, 2001; Goldstein, et al., 2020; Gonzalez & Dulin, 2015; Ismail, Ondersma, Jedele, Little, & Lepkpwski, 2011; Mello, et al., 2005; Pringle, Boyer, Conklin, McCullough, & Aldridge, 2014; Riper, et al., 2009; Shahab & McEwen, 2009) have been used in different settings, such as:

• Hospital • Primary care • Dental • Prenatal care • Alcohol and drug use treatment • Inpatient and outpatient care for tobacco use • Psychiatric • Emergency departments • Trauma centers • Pharmacy encounters • Telephone consultations, text messaging, and computer-​based encounters

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FRAMEWORKS AND STRUCTURES OF BRIEF INTERVENTIONS This section discusses the rationale, styles, techniques, and evidence-​base for a variety of frameworks for delivering BIs, including FRAMES, POLAR*S, BNI, and SBIRT.

FRAMES Several key components of effective BIs for risky or harmful alcohol use have been identified (Bien, Miller, & Tonigan, 1993; Miller & Sanchez, 1993). These components corresponded to the mnemonic acronym FRAMES: • F: Provide personalized feedback related to alcohol use and its consequences. Example: “I would like to review your score on the alcohol screening scale, is that ok with you?” (after patient gives permission) “You’ve scored high on the screening, which indicates that you are at high risk of potential harm from your current pattern of drinking.” • R: An emphasis on the patient’s personal responsibility for change. Example: “How concerned are you about scoring high on the screening?” “It is up to you to decide if, when, and how you might want to change drinking alcohol.” Using importance and confidence rulers could be helpful tools to determine what “intervention” best matches patient readiness for change. • A: Give advice regarding behavior change. “Would it be ok to share some advice regarding your pattern of drinking and then you can let me know what you make of the advice?” “The best approach to reduce your risk of harmful consequences from your drinking, such as fatal motor vehicle crash, is to cut down or stop completely. What do you think?” • M: Provide a menu of options if the patient is willing to consider change. With permission, the trainee provides several options to reinforce the patient’s sense of personal responsibility for making behavior change together with optimism in having a range of choices. For example: “Keep track of your alcohol use and reflect on it; identify high-​risk situations that lead to increased drinking and develop strategies to cope with them; and reach out to your support system when you need help to change your drinking pattern.” Then add. “You are the best judge of what will work for you, what ideas do you have?”

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• E: Use an empathic nonjudgmental and supportive interactional style. FRAMES is delivered using a supportive and nonconfrontational approach based on listening to each patient’s concerns and perspectives and respecting their autonomy. • S: Support patients’ self-​efficacy. It’s particularly useful to elicit patients’ self-​efficacy statements and review prior experiences in making changes and affirming them. Enhancing self-​ efficacy has been based on social cognitive theory (Bandura, 1986) that individuals’ belief that they are capable of change increases the probability that they will follow through with attempting and succeeding at change. Moreover, practitioners’ expectations and their beliefs in their patients’ ability to change may significantly influence self-​efficacy and has been found to be predictive of positive outcome (Leake & King, 1977). A single session of FRAMES is likely to produce significantly better results than no intervention at all (Barnett, et al., 2010; Landy, Davey, Quintero, Pecora, & McShane, 2016). The elements of BI based on FRAMES using MI spirit and OARS skills (open-​ ended questions, affirmations, reflections, and summaries) facilitate the process of change by supporting autonomy and reinforcing motivation for change. One theoretical explanation for how it works is the activation of the person’s self-​regulatory processes, by pointing out discrepancy and mobilizing the person’s resources and desire to change (Miller & Brown, 1991; Vohs & Baumeister, 2011). During the encounter, identifying and validating ambivalence when facing potential behavior change is crucial and may require using MI strategies to address it and help the patient move in the direction of change.

POLAR*S Another organizing structure for BIs is described by the mnemonic POLAR*S. POLAR*S is pronounced the same as “Polaris,” the North Star. The components of POLAR*S are the following: asking permission, open-​ended questions, listening reflectively, affirmations, rolling with ambivalence, and summary. POLAR*S was first developed for use in a pharmacy setting to improve medication adherence and has since been applied in numerous settings (e.g., primary care, emergency departments, university health centers) for behavioral health concerns (Pringle, Boyer, Conklin, McCullough, & Aldridge, 2014). The Pennsylvania Project demonstrated that the screening and BI

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processes based on POLAR*S significantly improved medication adherence across five major chronic disease medication classes (Pringle, Boyer, Conklin, McCullough, & Aldridge, 2014). Moreover, pharmacist-​provided intervention is a cost-​effective tool that may be applied in community pharmacies and across patient populations.

Brief Negotiated Interview The Brief Negotiated Interview or BNI, a specialized “brief intervention” for the medical setting, contains major components of MI. It was originally created for the emergency department in collaboration with Dr. Steve Rollnick, the co-​founder of MI. The BNI has been showed to be effective at facilitating a variety of health behavior changes. (D’Onofrio, Bernstein, & Rollnick, 1996). The BNI focuses on eliciting and strengthening intrinsic motivation. The five elements of BNI are: • Build rapport (engaging process) Skills: ask permission to discuss the [health behavior], raise the subject, and use open-​ended questions. • Personalized feedback with objective data about the [health behavior] Strategy: Elicit-​Provide-​Elicit (E-​P-​E). • Assess and build readiness for change Strategy: importance and confidence rulers [health behavior]. • Negotiate an action plan [health behavior] Skills and strategy: OARS, provide appropriate resources and support (always after asking permission) based on the patient’s readiness for change, and use E-​P-​E.

SBIRT Many trainees are familiar with BIs in the context of Screening, Brief Intervention, and Referral to Treatment or SBIRT (Agley, Gassman, DeSalle, Vannerson, Carlson, & Crabb, 2014; Young, et al., 2014). The SBIRT model has continued to evolve and has been adapted for a number of culturally diverse populations. It has been primarily practiced in primary care and family medicine settings, federally qualified health centers, school-​based health centers, and emergency departments (Manuel, et al., 2015). SBIRT efforts focus on MI approaches of various lengths (Pringle, Kowalchuk, Myers, & Seale, 2012).

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The US Substance Abuse and Mental Health Services Administration’s SBIRT demonstration program was adapted successfully to the needs of early identification efforts for hazardous use of alcohol and illicit drugs in primary care and general medicine (Babor, Del Boca, & Bray, 2017). Many barriers have been identified that interfere with the implementation of the SBIRT model. Lack of practitioners advocating for SBIRT practice, inadequately trained staff in terms of skills and knowledge for delivering SBIRT, or insufficient resources to support training and implementation (Hargraves, et al., 2017) are among some of those barriers. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes the three components of SBIRT (SAMHSA, 2017) as follows: • Screening quickly assesses the severity of substance use and identifies the appropriate level of intervention. • BIs focus on increasing insight and awareness regarding substance use and its impact and motivation toward behavioral change. • Referral to treatment provides those identified as needing more extensive treatment with access to specialty care. SBIRT aims to prevent patients from experiencing harms caused by illness progression via early intervention. This intervention is focused on those who are not seeking help for a particular health-​risk behavior and are identified via screening (SBIRT). For example, a positive screen for heavy drinking should trigger a BI (SBIRT), even though the patient did not intend to talk about her drinking during the medical visit. Patients continue to engage in risk-​related behaviors for a variety of reasons—​ they may not be aware that their behaviors are putting them at risk, they may lack knowledge or resources to change, or the behaviors may have a perceived benefit (e.g., using alcohol to decrease anxiety, manage insomnia, or numb negative emotions). The concomitant risks and benefits of these behaviors creates ambivalence about discontinuing them. This ambivalence is a natural step in the change process, and it creates a challenge to maintaining motivation for change. Trainees who struggle to appreciate this internal conflict and who convey an interest in keeping interactions short and directive cause patients to feel that they are not being heard or understood about being conflicted about making change. This dynamic must be changed if trainees are to be effective in treating behavioral conditions, a realization reflected in the decision by the Accreditation Council for Graduate Medical Education, to designate a focus on patient-​centeredness and interpersonal skills as core competencies.

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Screening (S) Efficient screening means having a working knowledge of at-​risk populations. While dependent on the specific nature of the presentation, the following conditions prompt screening as noted: • Trauma: substance use and intimate partner violence • Gynecologic or genitourinary complaints: engaging in sexual behaviors that increase risk for unintended pregnancy and/​or sexually transmitted infections or sexual abuse • Esophageal bleeds: alcohol use (variceal) or eating disorders (Mallory-​Weiss) • Electrolyte imbalance: eating disturbances, diuretic or laxative use, alcohol use, or misuse of supplements or herbal medications • Elevated glycemia or hemoglobin A1C, intravenous drug use (IVDU), or dental caries Use of inclusion criteria that is less restrictive, combined with clinical judgment is a more conservative treatment approach and increases the number of patients screened using BI (i.e., greater sensitivity). Conversely, giving emphasis to exclusion criteria results in fewer people being screened because they do not meet a particular threshold for risk (i.e., greater specificity). For example, a patient with tricuspid valve vegetations warrants discussion of IVDU (Intravenous Drug Use), even if preconceived biases regarding age, gender, ethnicity, or socioeconomic status suggest a low likelihood of a positive screen. A 70-​year-​old woman with a urinary tract infection should be asked about her recent sexual history. Similarly, a young man in his twenties with an electrolyte imbalance should be asked one or two general questions about his eating habits and body image. More detailed explorations should be reserved for patients after brief screening verifies the possible existence of a diagnosable disorder. It is essential to adopt the spirit of MI to ensure the quality of the data, as well as to engage and build rapport and therapeutic alliance. Further, it is crucial to convey empathy with reflective listening during the entire process of reviewing screening assessments and obtaining a history and physical exam or other assessments.

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Brief Intervention BIs follow the screening and assessment process. Placing the BI at the end of the assessment maximizes the time spent on building a therapeutic relationship. The goal of the BI is to increase the patient’s awareness of the consequences of substance use, and assist the patient in exploring ambivalence, not necessarily resolving it, and to determine whether the identified issue is even concerning or deserving of treatment to the patient. Patients’ screening scores determine their level of risk and, subsequently, the most appropriate type of BI. Regardless of the level of risk, the BI is always patient-​centered and guided by MI spirit, skills, and strategies. A successful BI should result in patients recognizing discrepancies between their behaviors and broader values and goals. In fact, BI can engage patients who would not otherwise consider traditional services. Small doses of intervention in the form of a BI, with an emphasis on patient’s autonomy for deciding about change, is often the best strategy, and, for some patients, it may be all you have time to, or need to, offer. Further, an effective BI can enhance the chances that the patient will follow through with an outpatient treatment referral and, thereby, takes advantage of an opportunity for significant behavioral change. The do’s and don’ts of BI are outlined in an SBIRT adherence card (AETC MidAtlantic, HRSA, HIV/​AIDS Bureau of Training and Capacity Development, Grant # U10HA29295).

Referral to Treatment (RT) RT in SBIRT is short-​hand for a well-​planned process through which a trainee provides an active referral to specialty treatment for patients who screen positive (e.g., high-​risk opioid use) and indicate a willingness/​desire for such services during the BI. Whether the process includes internal health practitioners and/​or external referral sources, engaging patients using the MI spirit and skills is crucial. Explaining the referral process, involving concerned significant others, and providing support are critical to the RT component to facilitate engagement in treatment. Assisting patients in navigating barriers to care is an essential part of the RT process. It is important to know specific resources that patients may not be aware of and, with permission, offer them to patients who wish to receive them. These may include the following: • The patient’s pre-​existing or new primary care practitioner • Pain management practitioners

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• Substance use disorder treatment services • Hotlines • Web sites • Organizations or meetings • Access to specialty care • Therapists, social workers, and case workers

INTERPERSONAL STYLE, THERAPEUTIC RELATIONSHIP, AND MOTIVATION FOR CHANGE While support for BI’s efficacy is building, the extent of its effectiveness has not been definitively determined. MI has been well established as a “highly effective psychotherapeutic approach for establishing a therapeutic alliance” (Kelly, Daley, & Douaihy, 2012). Learning to perform BI is critical to learning how to conduct MI because it challenges trainees to maximize use of MI skills. Embracing MI is more of a style than a set of techniques. Reflective listening, affirming patients’ strengths and behaviors, and supporting their autonomy are at the heart of forging a strong therapeutic alliance. Brief interactions with patients can efficiently form a therapeutic alliance. The sooner in their careers that trainees learn to naturally engage in an MI-​style of communication, the more effective they will be as practitioners.

COMMON PITFALLS IN THE DELIVERY OF BI Using the MI framework, BI is defined as patient-​centered, nonjudgmental, empathic, and goal-​oriented. BIs can create several pitfalls that trainee must consciously avoid, most arising directly from time constraints. Trainees frequently urge patients prematurely to focus on what trainees consider to be the focus of behavior change of problematic behaviors while their patients engage in sustain talk and express ambivalence about change. Common pitfalls might include: • Limited time, which makes a very direct approach seem reasonable. Trainees may feel a strong urge to be directive, activating the “righting reflex,” and simply begin dictating to patients what they must do to reduce health-​related risk or negative outcomes.

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• Trainees apply direct pressure and persuasion, which induces immediate discord during the encounter in the form of arguing, ignoring, interrupting, and/​or being “overly compliant.” • Disrespecting patients’ rights to self-​determination through failure to explore their perspective or offer a menu of options. • Arguing with patients when they express a lack of desire to change or ambivalence about change or hesitation about implementing suggested advice. It is critical to avoid such pitfalls because it may not be possible to establish or recover a therapeutic relationship undermined or damaged by the practitioner’s righting reflex during the BI. Practitioner use of autonomy statements can help minimize or address discord when it emerges during a BI. Autonomy statements can reflect patients’ strengths, including self-​determination for their well-​being, as well as their past efforts to make behavior change, regardless of outcome. Remember that it is always up to patients to decide whether they want to consider change, and practitioners should give voice to this in the form of autonomy support statements. When offering advice, it can be helpful to state that you do not necessarily expect the patient to agree with you or use your advice, and that it will not affect your patient–​trainee relationship or any treatments you provide to them. This stance makes it clear that your objective is to help patients, and you will not withhold treatment or otherwise punish patients if they disagree with you or your recommendations. Engaging in a successful BI means having reasonable expectations of what can be accomplished in 5 to 30 minutes. Some reasonable expectations include: • Establish a realistic goal for the encounter based on the patient’s current readiness for change and emotional state. • Engage a patient who is not yet ready to enact change in thinking about the behavior of concern and the possibility of change. • Understand concerns and potential fears that accompany thinking about change and recognize that even life-​threatening experiences may not inspire unwavering motivation to achieve lasting change. • Identify important windows of motivational opportunity to help patients see discrepancies between their current behaviors and their values and goals. • Avoid using “scare tactics” to pressure patients to change.

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Example of a Brief Intervention in a Medical Setting Setting: 5–​20 Minute BI in the Neurology Intensive Care Unit During a rotation in the Neurology Intensive Care Unit, a trainee encountered a patient that was admitted following a seizure. The patient has a history of severe alcohol use disorder, a seizure disorder, and several episodes of pancreatitis. The attending physician suggested that a beer be delivered to his room because alcohol-​withdrawal monitoring is time-​intensive, and he stated, “there is no way he is going to quit.” The trainee used this opportunity to discuss the patient’s alcohol use and how it fits into his medical conditions. TRAINEE: Good afternoon. Your team had a conversation about your situation and I’m here to see how you are doing. How are you feeling? [open-​ended question] PATIENT: Not great. The last doctor said he was going to get me a beer. Do you have that for me? TRAINEE: I do not have a beer with me at the moment. I would like to hear a little bit more about your situation and see how we can work together during your hospitalization. [engaging, invitation to collaborate] PATIENT: Thanks, but I don’t really need help. If you’re trying to talk me into quitting drinking, I’ve heard it before, and I’m not interested. I don’t have a drinking problem—​I have a seizure problem. TRAINEE: Your top priority at this time is your seizure problem. [complex reflection] Would it be OK if we talk a little bit about your seizure problem? [asking permission] PATIENT: I guess so. TRAINEE: Thanks. How did you end up in the hospital? [open-​ended question] PATIENT: I have been having stomach pains the last few days and have been throwing up whenever I try to eat. I haven’t been able to hold down much of anything including my medications. I don’t remember what happened, but my daughter told me I was shaking uncontrollably, and so she called Emergency Medical Services. The last thing I remember was sitting down on the couch with a drink. This same thing happened to me a year ago. TRAINEE: It is unsettling not to remember what happened. [complex reflection] PATIENT: Yeah, it kind of freaked me out. TRAINEE: It was scary for you and your family. [complex reflection] PATIENT: Yeah, it’s not good. And the fact that it happened before worries me. I don’t want it to happen again. I’m all my daughter has. TRAINEE: You daughter means a lot to you. You care so much about your family, which makes it important for you to be healthy and take care of them. [complex reflection, emphasizing values, and affirmation] PATIENT: Yeah. I just need to get this figured out.

Brief Interventions  131 TRAINEE: You feel very strongly about taking charge and managing you medical problems. [complex reflection] Would it be OK if I gave you some information about what is going on with your health right now, particularly your stomach pains? [asking permission] PATIENT: Sure. TRAINEE: You are having an episode of pancreatitis which is a type of inflammation of the pancreas, which can often be caused by alcohol. That is what is causing you to vomit and have stomach pains and it has prevented you from keeping your seizure medications down. When you were vomiting, not only were you losing your medication, but you were also losing the alcohol that you drank. The vomiting caused you to miss doses of your seizure medications and reduced your alcohol intake, causing you to have a seizure. [providing information] What do you think about what I shared? [eliciting feedback] PATIENT: So, I’m in the hospital because of the vomiting? TRAINEE: The vomiting is what led to your seizure, but the vomiting is caused by pancreatitis. [providing information] What do you think? [eliciting feedback] PATIENT: I am concerned about my drinking causing pancreatitis and messing up my seizure medications. TRAINEE: You are seeing the negative consequences of your drinking on controlling your seizures. [complex reflection] Would it be OK if I give you some information about the causes of pancreatitis and how to prevent future episodes? [asking permission] PATIENT: Yeah, that’s fine. TRAINEE: Pancreatitis is inflammation of the pancreas. It is commonly caused by drinking large quantities of alcohol over a long period of time. This happens because the pancreas helps to digest the alcohol but releases toxic byproducts in the process that damage the pancreas. The pancreas will then begin to digest itself, and this process is what leads to your stomach pain and vomiting. You could prevent these episodes of inflammation and pain by decreasing alcohol consumption, and this would also decrease the risk of having a seizure because of vomiting causing you to miss your seizure medication. [providing information] What does this mean to you? [eliciting feedback] PATIENT: So, the only way to avoid this in the future is to quit drinking? That’s bad news—​I’ve quit in this past and I don’t see that happening again any time soon. TRAINEE: You want to avoid future pancreatitis episodes and you are concerned that you are not considering quitting drinking at this time. [complex reflection] PATIENT: Yeah. Is there any other way to prevent them? TRAINEE: Not really. Reducing your alcohol use is a critical step to preventing pancreatitis. [complex reflection] PATIENT: It looks like I have no other choice except to at least decrease my alcohol use. I don’t think I want to stop completely.

132  Motivational Interviewing, 2E TRAINEE: You are leaning toward considering making some change in your alcohol use. The option that makes most sense to you is decreasing it. [complex reflections] Is it OK if we talk about your drinking? [asking permission] PATIENT: What do you want to know? TRAINEE: What have you done or considered doing in the past to decrease drinking alcohol? [open-​ended question] PATIENT: I was in the AA fellowship (Alcoholics Anonymous), and I was sober for 2 years, but it took so much of my time. I went every day during the week and checked in with my sponsor weekly. I just have too many responsibilities to do that again. TRAINEE: You worked really hard during those 2 years to not drink. [affirmation] You are hesitant to work on reducing your drinking now because you do not have enough time in your day for AA. You also want to avoid having another seizure and coming back to the hospital. [summary] PATIENT: That’s right. I’m just not sure this is something I want to deal with right now. TRAINEE: Thank you for sharing all of this with me. You don’t have to decide now. [roll with ambivalence] You are the best judge of when is the right time to make a change. [autonomy statement] We have talked about your desire to find strategies to prevent future health complications. You mentioned that you’ve been involved in AA in the past, which is just one of many options you have to support you when you decide to reduce drinking. You’re committed to being there for your daughter. I will be available all day and will check back in with you around 4:00. We can discuss more if you desire. [summary] PATIENT: Yeah, that’s fine. Thanks. I’ll think about it. I know that something needs to change.

The trainee reported to the team that the patient progressed from no interest in stopping alcohol to considering making a change. Shortly after the encounter, the trainee was notified by nursing staff that the patient wanted to learn more about alcohol withdrawal management options and treatment services. Throughout this encounter, the trainee demonstrated that a person-​ centered, goal-​directed BI using MI-​consistent skills and strategies can help to move the patient in the direction of change. By asking permission and using the E-​P-​E, the trainee demonstrated respect for the patient’s autonomy. In particular, the trainee employed this strategy when switching topics in the conversation and at the same time highlighting how the patient’s health behaviors are connected to each other. The trainee used OARS to engage the patient in the conversation and to learn more about their experiences. Reflective listening enabled the trainee to demonstrate collaboration, compassion, and genuine understanding; reduced discord; and

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foster a strong therapeutic alliance. Affirmations helped to highlight patient strengths and past successes, thereby supporting self-​efficacy. When the patient demonstrated ambivalence, the trainee did not push the patient in the direction of change. Rather, by meeting the patient with an open mindset, the trainee supported the patient’s exploration of potential intrinsic motivation for change through eliciting the patient’s value system. The trainee’s summary at the end of the BI included highlights of the patient’s change talk and clear next steps to support change. BIs are a critical skill for both trainees and seasoned practitioners alike. The MI style and its therapeutic approach has been used within the context of a variety of BI frameworks and structures. Use of BI removes the excuse we give ourselves for not working to intervene when time is short or problems seem daunting. It is also a skill that all practitioners have the greatest number of opportunities to practice. It is the rare patient who would not benefit from greater adherence to a treatment regimen. Accordingly, trainees have myriad windows of opportunity to practice and implement their BI skills with patients and develop them in diverse clinical settings throughout their medical careers.

PERSONAL REFLECTION (Mara Rice-​Stubbs) My first experience with MI occurred on an inpatient psychiatric unit specializing in dual diagnosis (patients with substance use and co-​occurring psychiatric disorders). I had the luxury of experiencing MI from a medical student perspective, which meant I was only responsible for two patients and had significant time to invest in getting to know each patient. The process was time-​ intensive, and I was struck by patients’ remarkable transformation. Prior to my experience as a medical student, however, I was an ICU nurse. The practical side of me thought it would be difficult for a medical hospital to engage in something as time-​intensive as MI. As I left my psychiatry rotation and started on inpatient medicine, I challenged myself to incorporate skills and strategies of MI into my patient interactions and I completed a training on SBIRT for substance use. I was surprised by how little time BIs guided by MI spirit and strategies added to patient encounters. As I integrated BIs into my patient encounters, I noticed that patients were more satisfied with their care as I was able to avoid discord and collaborate with them on more effective plans of care. Ultimately, this led to better outcomes for the patient and improved my experience as a practitioner, including preventing burnout. Many practitioners are seeking that spark that

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re-​energizes them to keep going and keep giving. Witnessing improved health-​related behavior outcome in my patients reminds me often of why I entered the medical profession.

SELF-​ASSESSMENT QUIZ True or False 1. BIs are targeted therapeutic conversations in which trainees begin the process of helping patients explore the relationship between unhealthy behavior(s) and current health concerns. 2. BIs based on the MI framework and structures have been shown to be beneficial only when addressing substance use. 3. SBIRT is a public health initiative that involves three steps: screening, BIs, and RT. 4. Since BIs are time-​limited, trainees should use a more directive style with patients, especially in terms of suggesting the specific steps that will reduce health-​related risks. 5. Emergency departments, inpatient hospital wards, pharmacy encounters, and outpatient clinics are settings in which BIs such as SBIRT, FRAMES, BNI, and POLAR*S are appropriate approaches.

Answers 1. True. BIs are indicated in those encounters in which trainees have time for only short interactions with patients, as in an emergency department with an individual whose injuries are related to alcohol use. Another example, from a primary care setting, occurs among patients with hypertension who are nonadherent to medications as prescribed. BIs are also indicated when high-​risk behaviors are identified during routine interactions or treatment for another condition, such as discussing high-​risk sexual practices during a standard history and physical examination. 2. False. BIs based on the MI style, spirit, and skills have been tested and validated in many settings, including acute medical settings, dentistry, drug and alcohol programs, emergency departments, prenatal care, primary care, tobacco cessation programs, telephone consultations, and trauma centers.

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3. True. Screening should occur as a function of trainees knowing about possible conditions and recognizing at-​risk individuals or populations; realistically, it is impossible to screen everyone for every health-​related risk. A prime example is to screen patients injured in motor vehicle accidents for alcohol use. If the screening for alcohol use is positive, a BI is used, and RT depends on the severity of the patient’s substance use behavior and willingness to engage in treatment. 4. False. Given the time restrictions associated with BIs, using a directive style and approach may seem reasonable, but at the same time, it can backfire and create discord in the therapeutic alliance. Maintaining a guiding style using the spirit and skills of MI, even in short and isolated encounters, is vital to the success of the BI. 5. True. A variety of BI frameworks including SBIRT, FRAMES, BNI, and POLAR*S are utilized in diverse clinical settings.

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Brief Interventions  137 Pringle, J. L., Kowalchuk, A., Meyers, J. A., & Seale J. P. (2012). Equipping residents to address alcohol and drug abuse: The national SBIRT residency training project. Journal of Graduate Medical Education, 4(1), 58–​63. Pringle, J., Nowalk, A., Howard, A., & Taylor, M. (2020). Approaches to brief interventions. In M. D. Cimini, & J. L. Martin (Eds.), Screening, brief intervention, and referral to treatment for substance use: A practitioner’s guide (pp. 85–​101). American Psychological Association. Riper, H., van Straten, A., Keuken, M., Smit, F., Schippers, G., & Cuijpers, P. (2009). Curbing problem drinking with personalized-​feedback interventions: A meta-​analysis. American Journal of Preventive Medicine, 36(3), 247–​255. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care. Guilford Press. Shahab, L., & McEwen, A. (2009). Online support for smoking cessation: A systematic review of the literature. Addiction, 104(11), 1792–​1804. SBIRT Adherence Card: AETC MidAtlantic, HRSA, HIV/​AIDS Bureau of Training and Capacity Development, Grant # U10HA29295 (2018). Vohs, K. D., & Baumeister, R. F. (Eds.). (2011). Handbook of self-​regulation: Research, theory, and applications (2nd ed.). Guilford Press. Substance Abuse and Mental Health Services Administration. About screening, brief intervention, and referral to treatment (SBIRT) (2017). https://​www.sam​​sbirt/​about. Young, M. M., Stevens, A., Galipeau, J., Pirie, T., Garritty, C., Singh, K., Yazdi, F., Golfam, M., Pratt, M., Turner, L., Porath-​Waller, A., Arratoon, C., Haley, N., Leslie, K., Reardon, R., Sproule, B., Grimshaw, J., & Moher, D. (2014). Effectiveness of brief interventions as part of the screening, brief intervention and referral to treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: A systematic review. Systematic Reviews, 24(3), 50.

8 Motivational Interviewing in Primary Care Settings Carolyn Windler and Brianna Rossiter

This chapter reviews the application of Motivational Interviewing (MI) in the primary care (PC) settings and focuses on some of the most common chronic health behavior problems encountered by primary care practitioners (PCPs). MI has a crucial role in healthcare generally, and in the individual treatment of people with common, yet often chronic and even fatal, conditions (Rollnick, Miller, & Butler, 2008). We describe the application of MI in the context of medication adherence, chronic pain management, and tobacco cessation, as well as health maintenance screenings. The goal is to increase the broad utility of MI throughout PC medicine, to maximize its effectiveness, and strengthen practitioner experience and confidence with this clinical approach.

ROLE OF MOTIVATIONAL INTERVIEWING IN PRIMARY CARE An overall review (Morton, et al., 2015) of MI in PC concluded, “MI can be an effective intervention (or intervention component) for use within PC settings” (p.16). MI is an evidence-​based, patient-​centered approach to empower patients to self-​manage their health. This is a strategy well-​suited to PC given that health behavior change is the cornerstone of managing most chronic illnesses. MI supports patient confidence and autonomy in controlling medical issues, resulting in increased motivation for change and improving outcomes. We will focus on the role of MI for managing common health issues addressed in the PC setting using clinical scenarios. In the PC setting, MI is particularly useful for promoting preventive medicine and healthy behaviors, such as treating chronic hypertension or promoting healthy diet and physical activity. These healthcare behaviors are often more challenging for patients to

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adhere to compared to symptomatic treatment measures, such as antacids to treat gastroesophageal reflux or analgesics to manage chronic pain. In PC, MI helps integrate concrete physical behavior modification with mental behavior modification. Physical behavior modification involves making a measurable change in an activity or behavior. Mental behavior modification involves shifting the framework or belief system surrounding an activity or behavior. Often, the initial step in making a physical change is to mentally process the need and desire for change. MI helps elicit an individual’s intrinsic motivations to begin mental behavior change, which can ultimately facilitate physical behavior change. MI is a practical frontline approach that improves the patient–​practitioner relationship and rapport by promoting shared decision-​making, ultimately leading to better health outcomes (Palacio, Garay, Langer, Taylor, Wood, & Tamariz, 2016; Rubak, Sandbaek, Lauritzen, & Christensen, 2005). MI fosters activation and empowerment compared to the traditional approach, which promotes passivity and paternalistic management in PC settings (VanBuskirk & Wetherell, 2014). This chapter will review and discuss the most common ways that MI can be integrated into PC and provide specific guidance on how to do so.

MI WITHIN EXISTING EMPIRICAL MODELS Chronic Care Model The Chronic Care Model (CCM) is an evidence-​based model of care for patients with chronic diseases that are commonly addressed by PCPs. The CCM focuses on supporting patients to self-​manage their medical needs by providing evidence-​based guidance, care coordination, monitoring, and resources. In doing so, this model promotes “better informed and activated patients” so that they may develop goals and establish plans to improve their health. MI is well-​suited to facilitate patient–​practitioner conversations that support patient autonomy and self-​management of their health (Coleman, Austin, Brach, & Wagner, 2009).

Information-​Motivation-​Behavioral Skills Model The Information-​ Motivation-​ Behavioral Skills Model purports that health promotion information and intrinsic motivation both contribute to

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development of skills to facilitate health behavior change. MI can foster acquisition of information and nurture motivation for patients to work toward adopting healthy behaviors. A core strategy of MI is the “Elicit-​Provide-​Elicit” or E-​P-​E for exchanging information or advice. For example, when discussing hypertension with a patient, the practitioner may first “elicit” by asking an open-​ended question: “What do you know about how high blood pressure affects one’s health?” If the patient does not mention the relationship between high blood pressure and stroke, then ask permission to share information. If the patient accepts the offer, the practitioner “provides” brief evidence or scientific data, such as: “High blood pressure often does not cause daily symptoms, and at the same time when it continues for years, it is the greatest risk factor for stroke.” Then, the practitioner “elicits” again by asking an open-​ended question: “What do you think about that?” or “What does this mean to you?” The practitioner is both offering data-​driven information and eliciting the patient’s perspective and supporting autonomy in decision-​making around accepting and processing information. Thus, the E-​P-​E strategy and MI communication-​style fit well into the IBM model of health care and behavior change (Fisher, Fisher, & Harman, 2003). .

MEDICATION ADHERENCE Patient adherence to prescribed medication regimens, or lack thereof, is a challenge most PCPs face daily. Based on the World Health Organization (WHO) reports, up to 50% of patients do not take medications as prescribed (Brown & Bussell, 2011). When patients do not take prescribed medications, treatment often fails. We frequently prescribe medicine to treat health problems, when equally important is addressing behavior change and attitudes to treating chronic medical conditions. According to the WHO, “Increasing adherence may have a greater effect on health than improvements in specific medical therapy” (Brown & Bussell, 2011). There are many nuanced reasons, both psychological and practical, why medication adherence may be challenging for patients: • Imperceptible benefits (“I do not feel different when I take my medicine.”) • Lack of patient autonomy in medical decision-​making (“I do not want to take medications.”) • Suboptimal medical literacy (“I do not understand why I should take medication.”)

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• It is difficult to adopt new behaviors (“I forget.”) • Side effects of medications • Cost of medications • Other values, goals, beliefs, or priorities that are perceived by the patient to outweigh the benefits of treatment

Addressing the reasons for nonadherence to a medication regimen is best accomplished in an MI-​adherent manner (Table 8.1). First assessing patients’ motivation for change then eliciting their thoughts and feelings about adhering to medications before initiating a conversation about changes and next steps they are willing to take. The following clinical scenario is an

TABLE 8.1  OARS Skills in the Context of Medication Adherence Open-​Ended Questions • “What do you find most challenging about getting or taking your medications as prescribed?” • “How did you feel when you realized you’d missed a dose of your medication?” • “What are some things you can do to help yourself take your medications as prescribed?” • “What ideas do you have for how to improve your consistency with taking your medications?” • “What might make it easier to take your medication as prescribed?” Affirmations • “You have a lot of great ideas about how to improve the way you take your medication.” • “You’ve put an incredible amount of work into trying different methods for taking your medications regularly.” • “Thank you for being so honest about how hard it has been for you to take your medication.” • “You work hard to make sure you take your medication regularly despite your mixed feelings about taking them every day.” Reflections • “You’re concerned about the effects that taking multiple medications may have on you.” • “You don’t think this approach is going to be affordable for you.” • “It’s not easy making changes to your daily routine so you can take your medication.” • “Sometimes it just does not seem worth it to take all these medications when you already have (add condition here). You feel like the damage is done.” Summaries • “You find it difficult to take your medications on time, you’re struggling with some side effects, you’re feeling pressured by your family to take them consistently, and you don’t want to depend on the medications.” • “You worry about the costs of medications and cannot afford the co-​pay, you see the importance of not missing any doses, and at the same time you are conflicted about how to deal with this situation.”

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illustration of using MI with a patient who has diabetes and is not well informed about managing it: PATIENT: I have been using herbal remedies to treat my blood sugars. TRAINEE: You are clearly taking steps to work toward improving your health and you recognize that fluctuating levels of your blood sugar can be harmful. [affirmation] PATIENT: Exactly. I feel much better after using the herbs and I know my sugar level are lower and better controlled. TRAINEE: You believe that the herbs are making you feel better. And I can see you are very invested in your health. [affirmation]

Always ask permission before offering information about other strategies. This approach respects the right of patients to decline receiving information and gives patients autonomy in deciding to change. If a patient does say “no” to an offer to provide information or advice, there are several therapeutic options. First, the trainee shows curiosity about understanding the patient’s perspective about not being interested in getting more information: “You are the best judge of when and if you want information about this. Help me understand what makes you not interested in hearing more about it? Or what is a higher priority for you right now?” “What would be more important for you to know at this time?” Alternatively, the practitioner can choose to delay the conversation to a future time when the patient may be more ready to change. In the PC setting, practitioners and trainees have the benefit of longitudinal relationships with patients, where a good patient–​practitioner relationship is key to long-​term quality health care. In this case, it is reasonable for the practitioner to say, “I appreciate your honesty and telling me that you do not want to talk about this today. We can discuss it at a future visit if you like, but for now let’s move on if that is OK with you.” When discussing solutions to medication adherence, elicit patients’ ideas first, and then with permission, offer a menu of options so patients can consider which is best instead of why one idea or the other might not work. It is a good strategy to give three options and a fourth option of “or whatever suggestions you think would work best for you.” Suggestions may include pill boxes, cell phone alarms, automated e-​mail reminders, support from family, and selecting particular drugs based on cost or number of doses needed per day. Example: A 50-​year-​old man presents for an outpatient appointment for a routine follow-​up and consistent with similar readings from his last several visits, has an elevated blood pressure of 154/​86. He was prescribed daily lisinopril 10 mg 3 months ago for these elevated blood pressures. He reports that he takes his

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lisinopril approximately half of the time and forgot last night. You decide not to change the dosing of his blood pressure medication and instead have a conversation about medication adherence. The following open-​ended questions might be a good place to start a conversation about medication adherence: • What is your understanding of how lisinopril works to treat high blood pressure? • What makes it challenging for you to take your medication as prescribed? • What makes it easier for you take it daily as prescribed?

CHRONIC PAIN Chronic pain is a challenging health issue that involves the interplay of mind and body contributing to debilitating symptoms for many patients. Unlike acute pain, which is managed by addressing the cause of pain, chronic pain management focuses on addressing the effects of pain and improving overall quality of life. Chronic pain creates a feedback loop of persistent pain, oftentimes leading to catastrophizing, which can contribute to maladaptive responses to pain (i.e., decreased exercise). This in turn leads to worsening pain and increased ambivalence to change (Douaihy, Jensen, & Jou, 2005). Often, the best approach to chronic pain is to offer affirmations with empathy. Patients need their experience of pain to be heard and validated. Chronic pain is invisible, subjective, and debilitating. Patients may often feel like a practitioner does not fully appreciate or understand the pain they experience. Affirmations in an MI style can improve the therapeutic alliance. For example, a practitioner might say, “You have invested so much time and energy into finding solutions to cope with your pain.” Or “You have been so resilient to have dealt with this pain while still going on with your daily activities.” The second important strategy when discussing chronic pain is expectation management. Managing chronic pain should focus on rehabilitation, improvement, and better functioning, rather than on cure or complete control of pain. It is important to increase chances for good outcomes by asking the patient the following evocative questions: • What are your expectations of working together to help you manage your chronic pain? • Help me understand how much you are capable of managing your pain.

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Example: A 44-​year-​old woman presents for an outpatient appointment for follow-​up of persistent back pain. Her pain originally began after a car accident 3 years ago and decreased initially but then plateaued and now has been slowly getting worse. She takes 5 mg oxycodone nightly before bed, which is the only thing that takes the edge off so she can sleep. She says her sleep is still of poor quality because of pain. She has gained 30 lbs. in the last 3 years because of inactivity and decreased mobility. The OARS skills can facilitate chronic pain conversations and move the patient toward considering change by eliciting change talk: TRAINEE: What would your life look like without this pain? [open-​ended question] PATIENT: I would be able to get back to gardening. I would see my friends more. My whole life would be different. I do not even leave my house now; I just sit on the couch all day. I have tried so many things and nothing works—​I do not know what to do. TRAINEE: You have put a lot of time and thought into how to get through these challenges. You are committed to finding a way to live the life you want. [complex reflection; affirmation] PATIENT: Yeah, I really have put all my energy into dealing with this pain. I just want to get back to the life I had before the accident. TRAINEE: This pain has been all-​consuming. It has taken over your life, and you are feeling overwhelmed and sick of it. [complex reflections] PATIENT: I am overwhelmed. I want to be more active and do the things I enjoy, but I just cannot bring myself to move. And now I have gained so much weight because all I can do is sit around. TRAINEE: You recognize that gaining weight and not being active are limiting your ability to heal, and at the same time, the pain makes it hard to address those issues. You are invested in improving your health and at the same time you feel hopeless at times. [summary; double-​sided reflection] PATIENT: Yes, that is how I feel. I want to figure out how to change, but it has been difficult.

TOBACCO USE Traditional behavioral therapy is a common strategy used for tobacco cessation that focuses on giving advice, providing information, and building skills. In contrast, MI elicits patients’ intrinsic motivations to initiate and adopt change. Instead of giving advice directly, the MI style and skills can be used

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with the Five As approach. This has been shown to be more effective than only giving information and advice (Hettema & Hendricks, 2010). The Five As are: • Ask (ask about tobacco use at every visit: “Tell me about your tobacco use.”) • Advise with permission (“I strongly recommend you quit smoking because it puts you at a much higher risk of having a stroke.”) • Assess (“What have your past experiences with quitting been like? How do you feel about talking about quitting today?” • Assist with permission (“We have different tools such as medications and counseling, that we could discuss to best support you when you are ready to quit.”) • Arrange with permission (“I am going to message you via the virtual chat in 2 weeks to see how you are doing. And then I would like to see you back in the office in 1 month. How does that sound to you?”). Example: A 27-​year-​old man presents for an outpatient appointment for a medication refill of citalopram and albuterol inhaler. He notes that he smokes 1–​2 packs of cigarettes per day on his intake form. When you ask about smoking, he says “I know I should stop smoking, but I just cannot. All my friends smoke, work is really stressful, and I have been smoking since I was a teenager. Maybe one day, but not right now.” Patients may be at different levels of readiness to quit smoking. It is crucial to understand where they are on the continuum of motivation to be able to better guide the session. Importance and confidence rulers (Table 8.2) can be used to do this. The following excerpts are relevant to the above vignette: TRAINEE: We have been talking about your smoking, and you have brought up the point that you’re thinking about quitting. On a scale of 0 to 10, with 0 being not important at all and 10 being most important, how important is it for you, right now, to quit smoking? PATIENT: Hmm, I guess . . . 6? TRAINEE: I am curious . . . what makes you say it is a 6 and not a 2? PATIENT: Well, I guess it’s because I realize that smoking affects my health in a bad way, and I’m tired of waking up with this cough every morning. I mean, I know it can cause lung cancer, so I guess that’s important too. TRAINEE: You noticed smoking is already affecting your lungs and worry about it damaging it more in the future. What are some of the other ways smoking affects you?

146  Motivational Interviewing, 2E TABLE 8.2  Importance and Confidence Rulers for Medication Adherence Importance Ruler • “On a scale of 0 to 10, where 0 is not at all important and 10 is the most important, how important is it to you right now to take your medications the way you have been instructed?” • “Why are you at a 3 and not a 0 (or 1–​2 points below whatever number they pick)?” Reflect and explore by asking, “What else?” until the patient has exhausted all the reasons he or she can think of and says, “That’s all.” Then summarize what you have heard. If the patient starts to explain why the number is not higher, redirect them back to why the number is as high as it is. • “What would need to happen to increase the importance 1 or 2 points higher?” Reflect and explore by asking, “What else?” until the patient has exhausted all the reasons and says, “That’s all.” Then summarize what you have heard starting with why the number is as high as it is and ending with what would need to happen to make the number higher. Confidence Ruler • “On a scale of 0 to 10, where 0 is not at all confident and 10 is the most confident, how confident are you right now that you could take your medications the way you have been instructed?” • “Why are you at a 5 and not a (pick a number 1–​2 points lower)?” Reflect and explore by asking, “What else?” until the patient has exhausted all the reasons and says, “That’s all.” Follow up by summarizing what you have heard. If the patient starts to explain why the number is not higher, redirect them back to why the number is as high as it is. • “What would need to happen to increase your confidence 1 or 2 points higher?” Reflect and explore by asking, “What else?” until the patient has exhausted all the reasons and says, “That’s all,” and then summarize what you have heard starting with why the number is as high as it is and ending with what would need to happen to make the number higher.

PATIENT: Sometimes I notice that my clothes have that stale, smoky smell . . . it’s really pretty awful now that I think of it. And I do not want to end up with a heart attack and die. I want to be there for my grandchildren and see them growing up.

By asking the open-​ended question “What makes you choose that number and not something lower?” we elicit change talk by prompting the patient to express why it might be important to change an unhealthy behavior and open up the possibility of discussing it in further detail. It is critical to avoid asking the opposite question, that is, “Why did you select a 6 and not a 10?” In all likelihood, this strategy will result in eliciting more sustain talk regarding why the status quo should be maintained and, in doing so, serve only to make the task of behavior change much more difficult. Even without being asked, some patients tend to focus on why they don’t rank the importance of change as closer, or equal, to 10; should this happen, gently redirect your patient to the subject at hand: “I understand there are reasons why the number you selected is less than 10; what I’m curious about is why the number you chose is as high

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as it is, and not something lower on the scale.” The importance ruler serves as a guide to patients’ perceived longing, need, and reasons for change. Remember to use this scale in a nonjudgmental, empathic way that invites patients to respond with a number of their choosing; maintain this neutral and engaged tone throughout your follow-​up questions. Should your patients respond by choosing 0, it’s fair to ask whether they would even consider making a behavior change that seems completely unimportant. After asking your patient why the number is as high as it is, pursue this line of thought by asking, “What else?” or “Help me understand why the number isn’t lower,” and reflect what you hear until you sense that all possible reasons have been exhausted. You will recognize that you have reached this point by comments such as “That’s it” or “That’s really all I can think of.” At this juncture, summarize everything you have heard your patient say and then ask, “What would need to happen for the importance level to move up one or two points?” As before, reflect what you hear, asking, “What else?” in order to extend the discussion until its logical conclusion, and finish by summarizing what you’ve heard and understood. The ruler metaphor may also be used to explore a patient’s level of confidence to follow through with specific changes in behavior. As with the importance ruler, ask what makes your patient’s confidence level is as high as it is and discuss what would be needed to make it even one or two points higher. Another advantage of this tool is that it may easily be modified to evoke change talk relating to one’s readiness, commitment, or hope for sustained change. The confidence ruler helps evoke a patient’s level of certainty that they will be able to carry through with the proposed changes, and it subtly taps into their sense of hope regarding success. TRAINEE: If you were to decide to quit smoking at this time. How confident are you that you could quit smoking on a scale of 0-​to-​10? 0, not confident and 10 very confident. [confidence ruler] PATIENT: Probably a 3. TRAINEE: How come you are a 3 and not a 0 or 1? PATIENT: I guess I feel like there’s a chance it could work. And my mother really wants me to quit, so she would help me out.

Additionally, always be sure to validate experiences and feelings regarding tobacco use. Here are some strategies to do that: • Accept ambivalence and address it using MI skills and strategies. • Be nonjudgmental. • Listen reflectively.

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Remember that the trainee’s role is not to convince or persuade patients to stop using tobacco but instead to help them understand and give voice to their own individual motivations for change. Using MI can support patient’s internal locus of control for change. The practitioner must avoid challenging resistance, arguing for, or giving advice unless the patient seeks it. Only give advice after asking permission and receiving the patient’s willingness to accept it. Often patients feel or express low confidence in their ability to quit, even when it is important, and they want to quit. MI offers a mechanism to support patient self-​efficacy. When a patient says, “I just cannot quit,” you may reflect back, “you feel some pressure to quit, and you also feel tremendous barriers to doing so.” Other reflections could include: “you are not ready to quit right now and that is OK. What do you think would help you feel more ready?” Or “What are some of the things that make it difficult to even think about quitting right now?” Then, in some situations it is best to give patients space and return to the conversation at the next visit. You might say, “I can tell this is not the right time to talk about quitting. If it is OK, I would like to talk about it at our next visit.” Finally, a useful tool when it comes to tobacco cessation is addressing discrepancies. You can use reflections to help patients see inconsistencies between their current behaviors and their lifestyle goals, values, and beliefs. For example, you might say, “You know that smoking makes it hard for you to stay on your feet for very long without feeling tired, and, at the same time, you really want to be able to work in your garden again because it brings you great joy and satisfaction.”

HEALTH MAINTENANCE SCREENING Some patients are willing to participate in general wellness health maintenance. But for many patients who have no symptoms, screening exams may feel like an unnecessary burden. One way to use MI to address this ambivalence is with the E-​P-​E model. Example: A 57-​year-​old woman presents for an outpatient appointment for recurrent atopic dermatitis. She has not seen a physician in many years and often misses follow-​up visits. She has a family history of colorectal cancer in her father documented in her chart. You ask if she has ever been screened for colorectal cancer via a colonoscopy or stool test for blood. She replies she has never been screened and says she does not think she is interested.

MI in Primary Care Settings  149 TRAINEE: What made you not consider having a colonoscopy? [eliciting] PATIENT: I just don’t want to have to drink all the laxative stuff and spend the day getting it done. I would have to take time off work. Plus, I’m fine, I’m good, I don’t need it. TRAINEE: Getting a colonoscopy feels like a hassle when you do not have any signs or symptoms you are worried about right now. Would it be OK if I told you a little bit more about screening for colon cancer? [complex reflection followed by asking permission] PATIENT: Yeah, I guess. TRAINEE: There are a few options, including a kit you take home to test for blood in your stool. If that is negative, you only have to do it once per year and no colonoscopy. Only if it is positive would we want you to follow up with a colonoscopy. I saw in your chart that your father had colon cancer. In some cases, it can be hereditary, so I think getting a screening test is important. [providing] What do you make of that information? [eliciting] PATIENT: Oh, I didn’t realize all that before. The home kit sounds much easier, so I guess I could do that. But it is scary to think I could have colon cancer. TRAINEE: Colon cancer is a serious condition and is also treatable. Luckily, we have great screening tests available, so we are now able to identify and treat colon cancer more successfully the earlier we find it, which makes it much less dangerous. Would you be comfortable doing the home screening test? [providing, followed by closed-​ended question] PATIENT: Yes.

TIME MANAGEMENT IN THE PCP’S OFFICE Outpatient visits are short and often quite busy. MI is well-​suited for brief interventions, usually less than 5 minutes, that emphasize patient autonomy in behavior change. Here are several strategies for using time well during a busy outpatient setting while still integrating MI.

Prioritize What Is Most Important for the Patient Often patients come in with a long list of concerns, and you only have 15 minutes. Behavior change can take a lot of energy and effort. It is best to address one issue and maybe only one subset of an issue at a time.

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Agenda mapping at the beginning of an outpatient visit is tremendously helpful for utilizing time efficiently and preparing the patient for what they can expect during your time together. Be sure to include the topic of focus, such as vaccinations or tobacco cessation during this agenda mapping. A good strategy for agenda mapping is to ask patients what they see as important to discuss in the session today. Keep a strategic focus. Once you have all the patient’s priorities identified, reflect what you plan to discuss and make sure that you are on the same page (see Chapter 3).

Address Incongruencies Whenever there is a mismatch between what you want patients to do and what they say they want (or do not want) to do, make sure to address the discrepancy and support patients’ autonomy, through explicitly communicating that any decision is ultimately up to them.

Assess Patient’s Motivation for Change The MI nonjudgmental tone and core clinical strategies (reflective listening and evoking change talk) encourages patients to work through their ambivalence about behavior change and to explore discrepancies between their current behavior and broader life goals and value system. Patients generate the rationale for change and ambivalence is addressed prior to moving toward change. If the patient is considering change and wants your medical opinion, this is a great opportunity to provide information or advice using the E-​P-​E approach. MI works better among people who are “resistant,” angry, or demonstrate low motivation to change a particular health behavior (Heather, Rollnick, Bell, & Richmond, 1996). With highly motivated patients expressing significant change talk with low degree of ambivalence, particularly at the beginning of the session, MI may be counterproductive, and a more active approach may yield better outcomes (Bertholet, Faouzi, Gmel, Gaume, & Daeppen, 2010; Forman, Moyers, & Houck, 2022).

Use MI in Brief Interventions Even brief MI has demonstrable impacts, such as improved medication adherence, fewer hospitalizations, increased physical activity, and reduced stress (Funderburk, et al., 2018; McNeil, Addicks, & Randall, 2017).

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PERSONAL REFLECTION (Carolyn Windler) I went into Medicine because being a patient-​facing physician allows me to work at the junction of scientific data and human connection. When I learned MI, I embraced it for the same reasons. I have always prioritized building relationships with patients and earning their trust to improve their experience with health care. But, while lending a sympathetic ear may show respect for patients, it does not inspire them to make meaningful change. Additionally, I may know the evidence-​based medication the patient needs, but if they do not care to take it, what good am I doing? With MI, I can use a data-​driven approach to break through the barriers to behavior change, while still using my empathic listening skills that allow me to connect with patients. As a medical student, with the luxury of time, I got to engage patients in long sessions identifying core goals and building a therapeutic relationship, seeing the full impact of MI. Now, as a Family Medicine resident trainee, I may not always have the benefit of time, at the same time I do have the tools and strategies of brief MI interventions. Even in a short clinic visit, I can use MI to work collaboratively with my patients, develop an achievable action plan, and ultimately do what I went to medical school to do: help my patients.

CONCLUSION MI is a proven and practical frontline approach in PC settings (Anstiss, 2009). The interactional style of MI establishes a safe, nonconfrontational, and supportive climate in which patients feel respected and comfortable discussing their struggles with managing health behaviors and initiating the process of change. In MI, patients themselves do much of the work, and the practitioner guides them to think and express openly how their current health behaviors may affect their goals or go against their values and belief system. MI fully supports patients to make their own fully informed decisions, even if the decision is to not consider change. A recent study showed that using MI in PC is less a matter of convincing practitioners about its importance, but rather a clear intent to implement it into ongoing practice. This will likely require investment in training, skills practice, coaching, and in vivo feedback and perhaps adding motivational incentives for busy practitioners (Hershberger, Martensen, Crawford, & Bricker, 2021; Saddawi-​Konefka, Schumacher, Baker, Charnin, & Gollwitzer, 2016; Schwalbe, Oh, & Zweben, 2014).

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SELF-​ASSESSMENT QUIZ Questions 1) What is the best MI-​adherent skill in responding to a patient with chronic obstructive pulmonary disease (COPD) who tells you they are not interested in quitting smoking? a) “Quitting smoking is one of the biggest ways you could improve your overall health.” b) “Smoking has been a part of your life for a long time. In what ways does smoking impact your life?” c) “I understand you do not want to talk about this today, maybe next time.” d) “Your COPD is really bad, and I think if you quit smoking, you would see dramatic changes. Let me give you resources in your check out paperwork.” 2) Your patient tells you they are not going to get the shingles vaccine. Select the response that best demonstrates trainee language using the E-​P-​E strategy. a) Have you heard about how bad shingles can be for patients? It is very debilitating and often can have long-​term effects that cause chronic pain. Are you interested in getting the vaccine? b) You are not interested in the vaccine because you never get vaccines. Tell me more about the reasons you’ve chosen not to get vaccines in the past. Why do you not want to get the shingles vaccine? c) What do you know about shingles? Do you mind if I share some information about patient experiences with shingles? What are your thoughts about the vaccine knowing this information? 3) Which of the following patients with type 2 diabetes would most benefit from MI regarding their adherence to their insulin regimen? a) A patient who has decided not to use insulin and has 2 admissions in the last month for hyperosmolar hyperglycemic syndrome. b) A patient who reports occasional missed doses of insulin and whose A1c has been steadily increasing during the last year. c) A patient who takes insulin as prescribed and reports no missed doses but still has a high A1c. d) a & b. e) All of the above.

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Answers 1) b—​First offer a reflection that helps the patient see that you understand what they are going through. Then ask an open-​ended question that will lead the patient to explore their own motivations for continuing to smoke or quitting smoking. 2) c—​Asking open-​ended questions instead of closed-​ended questions is key to eliciting information from patients. When providing information to patients it is always essential to ask permission first, which supports patient decision-​making autonomy. 3) d—​Patients who are not considering change or have high degree of ambivalence about change are most likely to benefit from MI. Patient c would benefit more from a change of medication regimen.

REFERENCES Anstiss, T. (2009). Motivational interviewing in primary care. Journal of Clinical Psychology in Medical Settings, 16(1), 87–​93. Bertholet, N., Faouzi, M., Gmel, G., Gaume, J., & Daeppen, J. B. (2010). Change talk sequence during brief motivational intervention, towards or away from drinking. Addiction, 105(12), 2106–​2112. Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceedings, 86(4), 304–​314. Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Affairs, 28(1), 75–​85. Douaihy, A. B., Jensen, M. P., & Jou, R. J. (2005). Motivating behavior change in patients with chronic pain. In B. McCarberg & S. D. Passik (Eds.), Expert guide to pain management (pp. 217–​232). American College of Physicians. Fisher, W. A., Fisher, J. D., & Harman, J. (2003). The Information‐Motivation‐Behavioral Skills Model: A general social psychological approach to understanding and promoting health behavior. In J. Suls, & K. A. Wallston (Eds.), Social psychological foundations of health and illness (pp. 82–​106). Blackwell. Forman, D. P., Moyers, T. B., & Houck, J. M. (2022). What can clients tell us about whether to use motivational interviewing? An analysis of early-​session ambivalent language. Journal of Substance Abuse Treatment, 132, 1–​6. Funderburk, J. S., Shepardson, R. L., Wray, J., Acker, J., Beehler, G. P., Possemato, K., Wray, L. O., & Maisto, S. A. (2018). Behavioral medicine interventions for adult primary care settings: A review. Families, Systems, & Health, 36(3), 368–​399. Heather, N., Rollnick, S., Bell, A., & Richmond, R. (1996). Effects of brief counselling among male heavy drinkers identified on general hospital wards. Drug and Alcohol Review, 15(1), 29–​38. Hershberger, P. J., Martensen, L. S., Crawford, T. N., & Bricker, D. A. (2021). Promoting motivational interviewing in primary care: More than intention. PRiMER, 5, 7.

154  Motivational Interviewing, 2E Hettema, J. E., & Hendricks, P. S. (2010). Motivational interviewing for smoking cessation: A meta-​analytic review. Journal of Consulting and Clinical Psychology, 78(6), 868–​884. McNeil, D. W., Addicks, S. H., & Randall, C. L. (2017). Motivational interviewing and motivational interactions for health behavior change and maintenance. Subject: Psychology, Health Psychology. Oxford Handbooks Online, Scholarly Research Reviews, 1–​42. doi: 10.1093/​ oxfordhb/​9780199935291.013.21 Morton, K., Beauchamp, M., Prothero, A., Joyce, L., Saunders, L., Spencer-​Bowdage, S., . . . & Pedlar, C. (2015). The effectiveness of motivational interviewing for health behaviour change in primary care settings: A systematic review. Health Psychology Review, 9, 205–​223. Palacio, A., Garay, D., Langer, B., Taylor, J., Wood, B. A., & Tamariz, L. (2016). Motivational interviewing improves medication adherence: A systematic review and meta-​analysis. Journal of General Internal Medicine, 31(8), 929–​940. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. Guilford Press. Rubak, S., Sandbaek, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-​analysis. British Journal of General Practice, 55(513), 305–​312. Saddawi-​Konefka, D., Schumacher, D. J., Baker, K. H., Charnin, J. E., & Gollwitzer, P. M. (2016). Changing physician behavior with implementation intentions: Closing the gap between intentions and actions. Academic Medicine, 91(9), 1211–​1216. Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). Sustaining motivational interviewing: A meta-​ analysis of training studies. Addiction, 109(8), 1287–​1294. VanBuskirk, K. A., & Wetherell, J. L. (2014). Motivational interviewing used in primary care: A systematic review and meta-​analysis. Journal of Behavioral Medicine, 37(4):768–​780.

9 Motivational Interviewing, Cardiovascular Health, and Diabetes Care Daniel Salahuddin and Esa Matius Davis

This chapter reviews the application of Motivational Interviewing (MI) in primary care settings, with a specific focus on diabetes management and primary, secondary, and tertiary prevention of cardiovascular disease (CVD). We provide an overview of MI strategies that are useful to prepare medical trainees for engaging with patients to improve self-​management of their health. We provide examples of using MI strategies to address complex common primary care conditions. CVD and diabetes mellitus (DM) contribute to a significant degree of morbidity and mortality in our society. MI is well suited to addressing these conditions as they can be effectively treated with lifestyle and behavior modification. Additionally, use of MI can help leverage the intrinsic motivation within patients to optimize their overall health outcomes. MI has been shown to be effective for improving dietary behaviors, increasing physical activity, and tobacco cessation, each of which contribute to CVD (primary prevention) (Lee, Choi, Yum, Yu, & Chair, 2016; Thompson, et al., 2011; VanBuskirk & Wetherell, 2014). Data supporting the use of MI for behavioral change in CVD has been equivocal (Ismail, et al., 2020; Ismail, et al., 2019; Mifsud, Galea, Garside, Stephenson, & Astin, 2020). This may be due to the dynamic nature of human behavior and change taking time. Many studies have attempted to quantify the specific effect of MI on CVD-​related behaviors, but they are not longitudinal and capture moments in time. Such studies cannot tell the full story. However, one study found that MI leads to long-​term increases in walking and lower cholesterol levels among patients diagnosed with obesity and hypercholesterolemia (Hardcastle, Taylor, Bailey, Harley, & Hager, 2013). Additionally, MI helps patients make modest improvements in

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physical activity and improves medication adherence for the treatment of hypertension in the context of secondary prevention (O’Halloran, et al., 2014; Hedegard, et al., 2015). A systematic review examining the effects of primary care physician (PCP)-​delivered MI on lifestyle modification for patients with Type 2 DM found significant improvements in various outcome measures including total cholesterol, low-​density lipoproteins, fasting blood glucose, HbA1c, body mass index, blood pressure, waist circumference, and physical activity (Thepwongsa, Muthukumar, & Kessomboon, 2017). A subsequent systematic review examining the effects of MI on behavior change outcomes and resultant clinical outcomes among patients with Type 2 DM revealed that MI had a positive impact on both dietary behaviors and on weight loss (Ekong & Kavookjian, 2016). Given the significant promise of MI in behavioral change, it will be important to continue studying the impact of MI on health outcomes. While there is enormous potential for the use of MI to assist in promoting lifestyle changes to optimize both CVD and DM outcomes, the trainee must be aware of many practical and unique challenges within the primary care setting. First, primary care outpatient visits are usually 15–​20 minutes in duration. This time constraint can be intimidating when trainees consider how to address the many patient health issues in this short time. A common struggle is achieving a balance between time spent addressing the patient’s agenda and the practitioner’s agenda, which usually involves prioritizing chronic care management and other health maintenance topics. Another challenge that trainees might encounter is that CVD and DM often present without symptoms. Therefore, patients may not be as concerned about managing their blood pressure or cholesterol because it is not something that is actively bothering them, compared to an irritating rash or an upper respiratory tract infection. Lastly, trainees need to be mindful of the inherent power dynamic that exists between trainee and patient and be able to tailor their approach to encourage collaboration and shared decision-​making to support patient autonomy. Use of a collaborative approach is, therefore, more likely to produce a therapeutic alliance with the patients. In turn, patients feel more empowered and comfortable sharing their experiences, struggles, and barriers that may conflict with their intrinsic motivation for behavior change. This chapter will provide various scenarios illustrating how trainees can establish harmony in the clinical encounter and create a safe, empathic, and collaborative atmosphere conducive to address lifestyle behavior change.

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CARDIOVASCULAR HEALTH AND MOTIVATIONAL INTERVIEWING CVD is a heterogenous disease that has significant impact on overall morbidity and mortality. Management of CVD involves managing multiple risk factors (Table 9.1) and improving lifestyle factors (Table 9.2). The consistent management of the many facets involved in the prevention of CVD can, at times, be overwhelming, and often feel like an insurmountable task, particularly for trainees. The complex interplay between the reduction of risk factors and optimization of lifestyle factors influencing CVD highlights the importance of using shared decision-​making with patients. Shared decision-​making TABLE 9.1  Risk Factors for CVD Modifiable (Can Be Changed by the Practitioner and Patient)

Nonmodifiable (Not Changeable by the Practitioner and Patient)

Diabetes Care Goals/​parameters: HbA1c range between < 6.5 and < 8–​8.5, depending on age and/​or comorbidities (ADA)

Family history of CVD

Hypertension Goal: < 130/​80 (ACC/​AHA)

Genetics (i.e., familial predisposition) to CVD and risk factors; these conditions being seen in first-​degree relatives

Hyperlipidemia Goal: LDL levels, < 100 –​< 160; HDL > 50 based on risk factors (AHA)

Epigenetics (Environmental predisposition) on genes that results in CVD and CVD risk factors

Alcohol Goal: nondrinking, or 1 drink or less per day for women, or 2 drinks or less per day for men (CDC) Tobacco Goal: complete cessation of all tobacco and alternative tobacco products (CDC) Other substance use Goal: blend of cessation and harm reduction (CDC, SAMHSA) Obesity Goals: weight loss > 5% and sufficient improvement in health targets, including comorbidities (AHA/​ACC/​TOS) Note: ADA, American Diabetes Association; ACC, American College of Cardiology; AHA, American Heart Association; CDC, Centers for Disease Control and Prevention; SAMHSA, Substance Abuse and Mental Health Services Administration; TOS, The Obesity Society.

158  Motivational Interviewing, 2E TABLE 9.2  Lifestyle/​Environmental Factors Contributing to Risk Factors of CVD Diet Goal: 2.5 cup equivalents of vegetables, 2 cup equivalents of fruit, 6-​ounce equivalents of grains with greater than 50% being whole grains, 3 cup equivalents of dairy, 5.5 cup equivalents of protein foods, 27 grams per day of oils per day (USDA) Physical Activity Goal: 150 minutes of moderate-​intensity aerobic activity and at least 2 days of muscle strengthening activity per week (CDC) Sleep Goal: age-​dependent, 7–​9 hours per night for adults (CDC) Stress Management • Interpersonal stressors • Psychosocial stressors/​Social Determinants of Health (SDoH)* o Neighborhood safety o Housing insecurity o Food insecurity o Financial instability o Access to daycare/​childcare issues o Educational and employment opportunities o Transportation Medication adherence Note: USDA, United States Department of Agriculture. * While SDoH are listed in the table as stressors that contribute to the risk factors causing CVD, it should be noted that they may also directly influence other aspects of health as well.

enables the practitioner and patient to focus on factors most important to the patient that have the best chance of being addressed or changed. Additionally, shared decision-​making will allow the trainee to gain insight into the patient’s ability to create change. Conversations surrounding CVD risk factors and lifestyle optimization typically take place within the 15–​20-​minute primary care clinical encounter. Proficiency to address patient concerns, perform an exam, and provide counseling improves throughout medical training and career experience. However, the time constraints of the medical encounter can feel daunting for trainees, especially when the patient’s and trainee’s agenda are different. Agenda mapping (see Chapter 3) can be useful to better align agendas between patient and practitioner. During this process, it is important for trainees to understand that priorities for visits should not come from the them. Practitioners tend to prioritize based on urgency of the health issue; however, the patient’s perspective, goals, values, and priorities are most important as they determine what is most feasible for patients to achieve, which may differ from the practitioners’ priorities. This clinical scenario illustrates how agenda mapping fits into MI:

MI, Cardiovascular Health, and Diabetes Care  159 Mr. H is a 74-​year-​old man with a history of type 2 diabetes (HbA1c 10.1), hypertension (blood pressure 150/​88), tobacco use disorder (one pack/​day), and a stroke 5 years ago with no residual deficit who was recently discharged from the hospital following a myocardial infarction (i.e., heart attack), requiring the placement of three stents. He presents to the clinic for a hospital follow-​up visit, where he is expressing disappointment and frustration over new changes that were made to his medication regimen. Additionally, while he was treated for tobacco use disorder in hospital with counseling and nicotine patches +​gum, he has since started smoking again and is ambivalent about whether he wants to restart wearing a nicotine patch. TRAINEE: Good afternoon, Mr. H. I understand you recently had a heart attack and were discharged from the hospital last week and are here today for follow-​up. You may be working on getting back to your normal routine since being home and have some concerns about your recent heart issue and hospital stay, what do you think makes the most sense for us to focus on today? [summary statement followed by an open-​ended question/​agenda mapping] Mr. H: Doc, I don’t understand why I need to take all these extra medicines. I was doing just fine before my heart attack, and now I am on all this new medicine. I don’t know why all this is needed and everything now is more complicated. TRAINEE: You’re feeling overwhelmed and frustrated with all these new changes in your life that have happened relatively quickly. [complex reflection] Mr. H: Yeah, these doctors at the hospital gave me a lot of information about what happened to my heart. They gave me some new medications, some of which I have to take two times a day, told me to quit smoking, change what I am eating, and exercise; they didn’t even bother to ask me how I felt about all of this. It just feels like a lot. I want to be healthy and do not want to have another heart attack, but this is causing me more stress, and when I am stressed, I smoke more. TRAINEE: You have a lot on your plate, and while you want to do what is best for your health, you are finding it difficult to manage all the different aspects that will help keep you healthy. [complex reflection acknowledging challenges in making changes] Mr. H: Exactly! At this point I’m feeling like I don’t know where to turn and I don’t really know what the path forward for me looks like. TRAINEE: You are feeling lost and frustrated [affirmation] with no direction and are questioning your ability to do what you need to do to keep yourself healthy. [complex reflection] Given your understanding of what you need to do to prevent another heart attack, what do you think has the biggest influence and in what ways? [open-​ended evocative question] Mr. H: Well, I understand that as annoying as it is, I need to take my pills. Lucky for me the pharmacy sends them in blister packs, so I don’t forget to take them, even though I don’t know what they’re for. Aside from that I’m most concerned with how stressed I’ve been lately. I remember reading that stress can also cause heart attacks.

160  Motivational Interviewing, 2E TRAINEE: You have been sharing your concerns about your medication regimen and you are feeling frustrated about not being well informed about the rationale for taking them and what they are indicated for. [complex reflections] How about having a brief conversation about it [asking permission]? Mr. H: Yes, please help me understand why I need to take them. TRAINEE: Sure. Let’s review your medication regimen. One medication is indicated to control your diabetes, another one is to control your high blood pressure, and one to help prevent another heart attack and the last one is to help control your cholesterol level. [providing information] What are you thinking now? [eliciting] Mr. H: That makes total sense but it’s still not easy for me to take them consistently. TRAINEE: You are aware that it is going to be a major challenge for you to stick to the medication regimen, at the same time, you see the importance of doing so to prevent another heart attack and manage your medical conditions. [double-​sided complex reflection] And you are feeling also stressed from all the new changes that have suddenly come into your life. [complex reflection] Mr. H: Yes, and the more stressed I feel, the more I start doubting my ability to keep myself healthy, which causes me to smoke more. It’s a vicious cycle that’s driving me crazy. TRAINEE: You are able to see the connection between how stressed you get and how it contributes to smoking more. Based on your desire to be as healthy as possible, would it be OK for us to discuss how your smoking fits into your health and managing your medical conditions? [complex reflection followed by asking permission/​closed-​ended question] Mr. H: I was afraid you would mention that, but yes, we can talk about it.

As illustrated in this example, agenda mapping is particularly helpful when more than one health behavior may benefit from change, because it helps the trainee and the patient to prioritize and focus on the one behavior that the patient agrees to address. The trainee in the scenario above skillfully and strategically used open-​ended questions, affirmations, reflections, and summaries (OARS) to engage and listen to the patient’s concerns about his medication regimen while setting the stage to discuss the patient’s ongoing tobacco use in the context of managing his medical conditions.

MOTIVATIONAL INTERVIEWING AND BEHAVIOR CHANGE As discussed in previous chapters, optimizing the chance for behavior change with MI consists of eliciting the patient’s understanding of their

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medical condition, how their behavior influences their illness, and how changing that behavior improves their health. It is important to elicit optimism, which instills patients with confidence in their ability to make behavior change. Every patient brings their unique context to a given clinical encounter, and trainees must gain an understanding of a patient’s perspective and motivation before being able to elicit any sort of change talk or behavior change. Trainees, while building rapport with a patient, need to remember:

• What is important to the patient? • What does the patient value? • What matters to the patient? • What are the patient’s motivations for change or manage their risk factors, lifestyle factors, and overall health?

Useful approaches that may help trainees answer these questions and gain a deeper understanding of patient’s motivations include OARS and Elicit-​ Provide-​Elicit (E-​P-​E). Once motivation has been established, the trainee can then begin to focus on eliciting behavior change through the Desire, Ability, Reasons, Need, Commitment, Activation, Taking Steps (DARN CAT) framework, which summarizes both preparatory (DARN) and mobilization (CAT) change talk. It is important to highlight the fact that these MI frameworks are applicable to virtually every aspect of CVD risk factor management including improvement in diet, exercise, sleep, medication adherence, and smoking cessation. The following clinical scenario demonstrates the use of these various strategies and techniques: Ms. F is a 44-​year-​old woman with a history of type 2 diabetes (HbA1c 11.2), hypertension (blood pressure 162/​96), obesity, and hyperlipidemia, who presents for a follow-​up visit after having been off all her medications over the last 6 months after wanting to incorporate more lifestyle changes to manage, and potentially reverse, her chronic conditions. TRAINEE: Hello, Ms. F, I want to make sure that we take some time today to address your concerns that you shared earlier. You have been making lifestyle changes which I want to hear all about, and I am wondering if you could share how you decided to stop taking your medications? [complex reflections followed by an open-​ ended question] Ms. F: I honestly didn’t feel like they were doing anything for me, and I read about how many of the conditions I was taking pills for could be addressed with simple lifestyle changes, plus I didn’t want any side effects if I could avoid it.

162  Motivational Interviewing, 2E TRAINEE: You have really taken it upon yourself to learn more about your health because you want to feel as healthy as possible. [affirmation; complex reflection] Ms. F: Yeah, not to mention any side effects that I can be avoiding by not taking the medication. TRAINEE: You are concerned about the effects that taking multiple medications may have on you. [complex reflection] Ms. F: Yeah, if I truly don’t need these medications, what’s the point? TRAINEE: You are really taking your health seriously and after weighing the benefits of taking medications and comparing it to the risk of possible side effects, you feel that you are able to manage your diabetes and high blood pressure without any medication. [summary] Ms. F: Exactly. TRAINEE: Would it be ok if we talked about you no longer taking medications for your diabetes and high blood pressure? [asking permission] Ms. F: Sure, although I’m not really sure what there is to talk about. TRAINEE: What do you know about the effects of uncontrolled diabetes and high blood pressure on your body? [open-​ended question; eliciting] Ms. F: Well, I had a friend who had to get a couple of toes amputated because their diabetes got really bad. Matter of fact, that same friend has also had to get a couple laser treatments for their eyes because doctors said that the diabetes was affecting those too. TRAINEE: Your friend has had several of the harmful effects of uncontrolled diabetes. [complex reflection] Ms. F: Friends! I had another friend with really high blood pressure who ended up getting a stroke. TRAINEE: You have had more than one person in your life have devastating life-​ changing events as a result of uncontrolled diabetes and high blood pressure. [complex reflection] Ms. F: You’re telling me! I know what you’re getting at though. I’m not going to change my mind about taking medications for these conditions if I don’t need them. TRAINEE: On one hand, you feel very strongly that you do not need to take any medications for these conditions, and on the other hand, you see the harmful and potentially deadly effects that uncontrolled diabetes and high blood pressure can have on the body. [complex double-​sided reflection] Would it be ok to share what we know about other effects of uncontrolled diabetes and high blood pressure, and the importance of preventing these complications? [asking permission; eliciting] Ms. F: Yeah sure, why not. . . . TRAINEE: The combination of uncontrolled diabetes and blood pressure can damage your kidneys and could lead to your kidneys failing and the need for dialysis or transplant. What are your thoughts about that? [providing information then eliciting]

MI, Cardiovascular Health, and Diabetes Care  163 Ms. F: My thoughts are that my grandma was on dialysis a long time ago and she always had to be there. I’d never want to have to do such a thing because I have too many things to do. TRAINEE: You have seen many of these severe complications firsthand and know that you would not want that for yourself. I wonder if you would be interested in some more information about the medications you were previously prescribed, and the role of both medications and lifestyle in being able to manage your diabetes and high blood pressure? [complex reflection followed by eliciting through asking permission] Ms. F: Maintaining a healthy lifestyle, preferably without medications, is very important to me, but yes, I would be willing to hear more about how I can best take care of myself.

The scenario above uses both OARS and E-​P-​E to help elicit the patient’s intrinsic motivation that may be leveraged to elicit behavior change. In this example, the trainee may opt to have the patient return for shorter, more frequent “check-​in” visits to be able to adequately address her concerns and manage her conditions and assess her progress.

STRESS AND CVD MANAGEMENT Stress management is an important consideration for trainees using MI in a primary care setting to address CVD risk and lifestyle factors. Trainees should assess whether patients seen in the primary care setting are acutely stressed and what is causing their stress because being stressed may distract patients from focusing on previously expressed goals. For example, a patient seen 3 months ago may acutely present with an exacerbation of an interpersonal or psychosocial stressor that has hindered them from achieving their previously stated goals of reducing tobacco use and incorporating more exercise into their daily routine. Stressful situations are typically perceived with a great degree of uncertainty and inability to change; therefore, trainees equipped with MI skills, strategies, and techniques can help refocus, hear, express empathy toward, and engage the patient. Additionally, trainees may opt to employ mindfulness techniques during the process of refocusing and engaging with the patient (see Chapter 19). Mindfulness has been theoretically and empirically associated with psychological well-​being, and it emphasizes awareness and nonjudgmental acceptance of one’s moment-​to-​moment experience (Keng, Smoski, & Robbins, 2011). Questions to consider asking patients to help them become more centered and engaged include the following:

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• • • •

What emotions are you feeling? Where do you feel stress in your body? What do you see as options moving forward? What do you intend for yourself in the future?

Another helpful strategy for trainees caring for patients who are acutely stressed is to support the patient’s internal locus of control by empowering patients to choose how they will respond to given situations. For example, if a patient was hospitalized and receives a shut-​off notice for gas, it would be appropriate for the trainee to first acknowledge the patient’s stress, followed by empowering the patient to take actions such as connecting with the social worker or calling the utility company to explain and rectify the situation. Once a patient who is acutely stressed appears to have regained a greater sense of ease, it would then be appropriate to proceed with MI to address whatever the patient deems as his top priority or goal in that moment amidst active stressors. The next scenario highlights the interplay between a patient whose stressors conflict with efforts toward meeting goals for primary prevention of CVD: Ms. T is a 32-​year-​old woman with a history of obesity and prediabetes (HbA1c:6.0), who presents to the office for a pre-​employment physical. She appears very overwhelmed during the visit, wanting the form to be signed immediately so she can leave. She reports that she has been very stressed with childcare, which has had a detrimental effect on her diet and exercise, stating that she does not have time to think about these things. TRAINEE: Good morning, Ms. T, I understand that you are here for a physical. What concerns do you have today? [open-​ended question] Ms. T: You said it all . . . I need to have my form filled out so I can be on my way. I have three children, a 9 month old and a 3 and 5 year old, at home with my neighbor who I need to get back to as soon as possible. It’s nonstop for me. TRAINEE: It has been really stressful for you to arrange childcare and take time for yourself. [complex reflection] Ms. T: Take time for myself?! I don’t even know what that means anymore. You doctors say I need to watch what I eat, lose weight, and exercise but I don’t have time for any of that stuff. I’d like to have the doctor who told me that to try it for themselves with my life. Not possible. I’m just trying to survive and figure out this childcare situation for when I start my new job. TRAINEE: You are feeling really stressed because you are balancing many things that are important, and they also seem to be at odds with one another. [complex reflection; affirmation]

MI, Cardiovascular Health, and Diabetes Care  165 Ms. T: You got it, but there’s nothing you can do about it. Now can I go? TRAINEE: You are understandably eager to get back to your family; however, I’m wondering what your thoughts are about spending 5 more minutes working to come up with a plan to help you take care of your own health while you’re taking care of your children. [complex reflection followed by an invitation to engage through negotiating] Ms. T: I can do that, but only 5 minutes.

This vignette highlights the importance of meeting the patient where they are as the first step in building a therapeutic alliance. While there are many external factors contributing to the patient’s presentation, the trainee focused on achievable goals that could be accomplished within the appointment limits being set by the patient. An interdisciplinary approach that helps to address both lifestyle and social need would be most beneficial in this case to establish a feasible plan that could work for the patient. Additionally, while this scenario focuses largely on social determinants of health as a driver for the patient’s stress, these factors should be assessed at every clinical encounter.

MI AND PERSONAL GROWTH: A TRAINEE’S PERSPECTIVE (Daniel Salahuddin) I was first introduced to the practice of MI while working on a dual diagnosis inpatient psychiatric unit. What I was unaware of was how the intentionality and the skills I gained in MI during that time would become so seamlessly integrated with the rest of my residency training in both family medicine and psychiatry. MI has assisted me in creating meaningful therapeutic relationships with countless patients like the patients described in the clinical scenarios. Additionally, I have witnessed its powerful role in helping to empower patients to take control of various aspects of their health. The aspect of MI that I appreciate the most has been the core tenet of empathic listening. Patients commonly express frustration over not feeling heard and their needs often not being met. The process of taking a moment to be present with the patient and reflecting back what they have shared about their unique experience can create an incredible connection that is not often achieved in healthcare settings. As we described strategies and techniques to help refocus patients, I end this reflection by encouraging all trainees to take time before starting any given encounter to ensure that you are truly present with the patient. It’s about first and foremost being MI, not just doing MI.

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SELF-​ASSESSMENT QUIZ True or False 1. Trainees must be sure to address all of a patient’s concerns and any outstanding health maintenance issues during a single office visit. 2. Focusing on emphasizing behavioral change for the potential to prevent is more effective than focusing on the dangers and negative consequences of not changing a behavior. 3. Useful approaches that may help trainees gain a deeper understanding of patient’s motivations include OARS and E-​P-​E. 4. It is not possible to engage patients with MI when they are acutely stressed or worried about other external factors. 5. MI is an appropriate framework for addressing CVD in a primary care setting.

Answers 1. False. Primary care visits are typically limited to 15–​20 minutes; therefore, it is best to agree on a specific agenda for the visit alongside the patient so that expectations are appropriately managed. If there is a pressing need for follow-​up, or if the patient has many aspects that need to be addressed, it is reasonable to have the patient seen more frequently until all pressing issues have been addressed. MI is particularly well suited for brief interventions that trainees have to incorporate in this setting. 2. True. Trainees should focus on positive outcomes, such as preventing illness or predictable consequences. Most people prefer to move toward healthy, positive goals rather than away from negative health repercussions. 3. True. Asking evocative open-​ended questions and using reflections to elicit a patient’s understanding of their condition promotes patient success by supporting patient autonomy and empowering patients to unveil their underlying motivations for behavior change. Once motivation has been established, the trainee can then begin to focus on eliciting specific behavior changes. 4. False. Patients who present to the office acutely stressed by various life circumstances are still able to be engaged in MI; however, there may need to be additional time spent to engage, refocus, and empathize with

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patients about what is bothering them so that they feel heard. Only after establishing this therapeutic alliance can the process of MI effectively take place. 5. True. MI is particularly well suited for CVD management, given the heterogenous nature of this disease entity and the various risk factors and upstream modifiable lifestyle factors that must be addressed in an effort to optimize health outcomes.

REFERENCES Ekong, G., & Kavookjian, J. (2016). Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review. Patient Education and Counseling, 99(6), 944–​952. Hardcastle, S. J., Taylor, A. H., Bailey, M. P., Harley, R. A., & Hagger, M. S. (2013). Effectiveness of a Motivational Interviewing intervention on weight loss, physical activity, and cardiovascular disease risk factors: A randomised controlled trial with a 12-​month post-​intervention follow-​up. International Journal of Behavioral Nutrition and Physical Activity, 10, 1–​16. Hedegaard, U., Kjeldsen, L. J., Pottegård, A, Henriksen, J. E., Lambrechtsen, J., Hangaard, J., & Hallas, J. (2015). Improving medication adherence in patients with hypertension: A randomized trial. American Journal of Medicine, 128(12), 1351–​1361. Ismail, K., Bayley, A., Twist, K., Stewart, K., Ridge, K., Britneff, E., Greenough, A., Ashworth, M., Rundle, J., Cook, D. G., Whincup, P., Treasure, J., McCrone, P., Winkley, K., & Stahl, D. (2020). Reducing weight and increasing physical activity in people at high risk of cardiovascular disease: A randomised controlled trial comparing the effectiveness of enhanced Motivational Interviewing intervention with usual care. Heart, 106(6), 447–​454. Ismail, K., Stahl, D., Bayley, A., Twist, K., Stewart, K., Ridge, K., Britneff, E., Ashworth, M., de Zoysa, N., Rundle, J., Cook, D., Whincup, P., Treasure, J., McCrone, P., Greenough, A., & Winkley, K. (2019). Enhanced Motivational Interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-​arm RCT. Health Technology Assessment, 23(69), 1–​144. Keng, S. L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6), 1041–​1056. Lee, W. W., Choi, K. C., Yum, R. W., Yu, D. S., & Chair, S. Y. (2016). Effectiveness of Motivational Interviewing on lifestyle modification and health outcomes of clients at risk or diagnosed with cardiovascular diseases: A systematic review. International Journal of Nursing Studies, 53, 331–​341. Mifsud, J. L., Galea, J., Garside, J., Stephenson, J., & Astin, F. (2020). Motivational interviewing to support modifiable risk factor change in individuals at increased risk of cardiovascular disease: A systematic review and meta-​analysis. PLoS One, 15(11), 1–​21. O’Halloran, P. D., Blackstock, F., Shields, N., Holland, A., Iles, R., Kingsley, M., Bernhardt, J., Lannin, N., Morris, M. E., & Taylor, N.F. (2014). Motivational interviewing to increase physical activity in people with chronic health conditions: A systematic review and meta-​ analysis. Clinical Rehabilitation, 28(12), 1159–​1171. Thepwongsa, I., Muthukumar, R., & Kessomboon, P. (2017). Motivational interviewing by general practitioners for Type 2 diabetes patients: A systematic review. Family Practice, 34(4), 376–​383.

168  Motivational Interviewing, 2E Thompson, D. R., Chair, S. Y., Chan, S.W., Astin, F., Davidson, P. M., & Ski, C. F. (2011). Motivational Interviewing: A useful approach to improving cardiovascular health? Journal of Clinical Nursing, 20(9–​10), 1236–​1244. VanBuskirk, K. A., & Wetherell, J. L. (2014). Motivational Interviewing with primary care populations: A systematic review and meta-​analysis. Journal of Behavioral Medicine, 37(4), 768–​780.

10 Motivational Interviewing and Dietetics Antoine Douaihy, Thomas M. Kelly, Augusto Bermudez, and David Bell

Unhealthy lifestyle behaviors such as insufficient physical activity and unhealthy diet are major risk factors for mortality and morbidity (Cecchini, Sassi, Lauer, Lee, Guajardo-​Barron, & Chisholm, 2010). Specifically, unhealthy dietary habits, such as a low intake of fruit and vegetables and a high fat intake, carry serious health risks, including an increased risk of various types of cancer, cardiovascular disease, type 2 diabetes, and depression (Cecchini, Sassi, Lauer, Lee, Guajardo-​Barron, & Chisholm, 2010). Motivational Interviewing (MI) is a person-​centered, goal-​oriented therapeutic approach based on the spirit of collaboration and compassion, with a focus on strengthening intrinsic motivation and aligning personal values with behavior change (Miller & Rollnick, 2013). The American Heart Association evaluated interventions that promote physical activity and dietary lifestyle change (Artinian, et al., 2010) and found MI to be an effective approach for initial weight loss for up to 6-​months, for increasing physical activity, reducing caloric intake, and decreasing body mass index (BMI) (Befort, Nollen, Ellerbeck, Sullivan, Thomas, & Ahluwalia, 2008; Bennett, Lyons, Winters-​ Stone, Nail, & Scherer, 2007; Britt, Hudson, & Blampied, 2004; Carels, Darby, Cacciapaglia, Konrad Coit, & Harper, 2007; Hardcastle, Taylor, Bailey, & Castle, 2008; Rubak, Sandbaek, Lauritzen, & Christensen, 2005).

STATE OF RESEARCH ON MOTIVATIONAL INTERVIEWING AND DIETETICS MI, as a form of dietary intervention, is relatively new to the field of dietetics (Hollis, Williams, Collins, & Morgan, 2014). Traditionally, dietitians and medical trainees were trained using a directive, unilateral communication style that was practitioner-​centered and included giving nutrition advice and establishing goals for patients, instead of working collaboratively with patients on setting their own goals and supporting patient autonomy (Douaihy, Kelly,

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& Gold, 2014; Hollis, Williams, Collins, & Morgan, 2014). This approach typically leads to discord in the therapeutic relationship, which can negatively affect patient outcomes. MI aligns with the scope of practice and competency standards for Registered Dietitian Nutritionists and is well supported as an approach in clinical practice (Hollis, Williams, Collins, & Morgan, 2014). An increasing body of research demonstrates that MI-​based interventions improve certain nutrition-​related outcomes among patients (Bowen, et al., 2002; Britt, Hudson, & Blampied, 2004; Campbell, et al., 2009; Neumark-​Sztainer, et al., 2010). MI, as a component of a dietary modification intervention, is effective. People who received MI via the telephone or face to face reported an increase in fruit and vegetable intake (Ahluwalia, Nollen, Kaur, James, Mayo, & Resnicow, 2007; Blackford, Jancey, Lee, James, Howat, & Waddell, 2016; Resnicow, et al., 2001). Behavioral interventions targeting obesity through changes in diet and/​ or physical activity have been shown to be effective in producing clinically significant reductions in weight (Avenell, et al., 2004; Shaw, Rourke, Del, & Kenardy, 2005). At the same time, such interventions tend to be intensive and time-​ consuming and require considerable resources to disseminate and implement, which make them impractical for most primary care medical settings (West, DiLillo, Bursac, Gore, & Greene, 2007). Further, using guidelines or recommendations to prompt behavioral change related to diet is more likely to focus on extrinsic motivation, which may not yield positive long-​term behavioral change. With its broad applicability to and efficacy in improving health behaviors, MI has been found to be effective, whether delivered as a low-​level intervention consisting of a single face-​to-​face session and five brief follow-​up telephone contacts or a high-​level intervention of six face-​to-​face sessions, at least in the short-​term and up to and beyond 2 years of the intervention (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Martins & McNeil, 2009). A more recent study showed that a low-​intensity MI intervention (standard exercise and nutrition information plus up to five face-​to-​face sessions), delivered in a primary care setting over a 6-​month period, contributes to a reduction in cholesterol and a significant increase in walking at both 6-​and 12-​months postintervention, compared to an information-​ only intervention, with participants who had high levels of obesity (Hardcastle, Taylor, Bailey, Harley, & Hagger, 2013). Interventions based on the self-​determination theory (SDT), discussed in an earlier chapter in this book, and MI synergistically promote healthier eating. SDT postulates that the autonomous forms of motivation, particularly intrinsic motivation, are more likely than extrinsic forms to result

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in sustained behavior change (Teixeira, Carraca, Markland, Silva, & Ryan, 2012; Teixeira, Patrick, & Mata, 2011). Several studies have shown that intrinsic motivation has been associated with healthier eating patterns and engagement in physical activity (Verstuyf, Patrick, Vansteenkiste, & Teixeira, 2012). Strengthening the basic psychological needs of autonomy, relatedness, and competence as defined by SDT, leads to the development or the maintenance of autonomous forms of motivation that subsequently results in behavior change (Markland, Ryan, Tobin, & Rollnick, 2005; Sheeran, et al., 2020). Using the skills and strategies of MI to support patients’ basic psychological needs as defined by SDT has the potential to strengthen change talk and enhance more autonomous or intrinsic forms of motivation for behavior change (Markland, Ryan, Tobin, & Rollnick, 2005; Miller & Rollnick, 2013). Personalized eHealth interventions have the potential to promote lifestyle behavior changes such as a healthy diet (Kohl, Crutzen, & de Vries, 2013). A recent two-​arm randomized controlled trial based on SDT +​MI investigated whether a combined diet and physical activity (PA) web-​based computer-​tailored intervention, called MyLifestyleCoach, was effective in promoting dietary and PA behaviors. Only participants in the intervention condition had access to MyLifestyleCoach. The waiting list control condition had access to the intervention after completing the 12-​month follow-​up questionnaire. Overall, the intervention was not effective in changing dietary and PA behavior. However, moderation analyses suggest that the intervention was effective in improving dietary behavior for those participants who used the intervention more intensively, meaning completing more sessions in the dietary module (Coumans, Bolman, Friederichs, Oenema, & Lechner, 2022). The authors discussed whether using more “genuine SDT+​MI strategies,” such as empathy skills or promoting self-​efficacy, from early on in the intervention could have yielded better dietary outcomes (Coumans, Oenema, Bolman, & Lechner, 2021; da Silva, Kavanagh, May, & Andrade, 2020; Shingleton & Palfai, 2016). Practitioners may need to engage patients in multiple MI sessions, either in a face-​to-​face intervention format, or a computer-​tailored approach, and provide individual feedback that matches personal characteristics and needs. These sessions address fluctuations of motivation and ambivalence about making changes in dietary pattern and other health-​related behaviors such as PA and help re-​engage patients when they disconnect from treatment. Since emphasizing autonomy and personal choice are central precepts in MI, the sessions should be flexible and allow patients to determine which particular health-​related behaviors they see as a priority to work on. For people who are already intrinsically highly

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motivated with a low degree of ambivalence, combining MI with a menu of tools and strategies to choose from to develop a change plan of action could produce positive outcomes.

INTEGRATING MOTIVATIONAL INTERVIEWING WITH NUTRITION INTERVENTIONS First and foremost, MI is not a set of clinical techniques, or tools, or a protocol that is done to patients; rather, it is a “way of being” with people through the spirit of the entire conversation (Miller & Rollnick, 2009). The challenge of incorporating MI into interventions and conversations about dietary patterns of behaviors is mostly related to maintaining a person-​centered, collaborative approach that aligns with patients’ goals and values (Clifford & Curtis, 2016). Four categories of nutrition interventions are internationally recognized by the International Dietetics & Nutrition Terminology Reference Manual (Academy of Nutrition and Dietetics, Chicago, IL, 2013): food and/​ or nutrient delivery, nutrition education, nutrition counseling, and coordination of nutrition care. Nutrition counseling and nutrition education can be delivered in an MI-​adherent approach using MI guiding style and spirit while working collaboratively with patients on setting the agenda, priorities, and goals. Resisting the “righting reflex,” avoiding the expert opinion trap, engaging in self-​monitoring activities, and tailoring the dietary intervention based on patients’ readiness for change level are aligned with a MI counseling framework. In the MI model, using the collaborative information exchange strategy of the Elicit-​Provide-​Elicit (E-​P-​E) technique instead of the traditional advice-​giving models makes the dietetics consultations more congruent with MI. Below are some clinical tips on how the MI construct of partnership and acceptance, its OARS skills (open-​ended questions, affirmations, reflections, and summaries), and strategies can be incorporated into nutrition encounters includes: • Allowing patients to choose which behaviors to focus on first (proper nutrition, PA, and other lifestyle changes), by doing an agenda-​mapping exercise. • Reminding patients that every dietary or activity change affects their health in many ways. • Avoiding the righting reflex and scare tactics.

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• Emphasizing personal choice and autonomy. • If changes in diet are overwhelming, assisting patients in taking small steps and waiting to discuss PA recommendations until progress is made elsewhere, unless the patient wants to focus on PA first. • Affirming all progress and improvements in behaviors, even small ones, regardless of whether they have large impacts on overall outcomes such as losing weight. • Developing discrepancy between actual and desired behavior by helping patients identify their personal goals and values. • Paying attention to how patients express change talk, commitment language, or sustain talk. • Responding collaboratively and mindfully and focusing on evoking change talk and softening sustain talk. • Remembering that, when discussing change, a patient’s arguments are not always logical or based on factual information. They often include a great deal of intense emotion and distress. In these circumstances, recognizing and appreciating the intense stress that internal struggles present and responding by acknowledging, validating, and normalizing uncertainty and fears with equanimity and empathy is crucial. MI and its briefer adaptations have been used to address a wide range of conditions and behaviors, including diet and PA. Whereas the essence of MI resides in its spirit, there are specific strategies that, when used effectively with fidelity, help ensure that such spirit is activated. In the context of clinical nutrition encounters, the MI construct and skills have been found to improve intrinsic motivation with a focus on personal values, reducing ambivalence, and modifying certain nutrition-​related outcomes. An example of using the tips above can be seen in this vignette of a 15-​year-​old adolescent boy with a BMI of 30 who says he wants to live a healthier lifestyle and feel better physically. He says his parents struggled when immigrating to the United States from their South American country, and he does not want his parent’s plight to go unnoticed. He wants to be healthier and feel better able to support them when they are older. Although the topic of wanting to be a better son does not seem to connect at first glance with feeling physically and psychoemotionally better, notice how open-​ended questions and reflections are used to get to the root cause of a desired behavior change. This is a good example of using OARS to explore other domains in a patient’s life, domains with which he ultimately connects.

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This is the second session between the trainee and the patient: TRAINEE: Hi Mike. It’s good to see you. How you have been doing since we last met? [open-​ended question] PATIENT: Well, I told you how I had been feeling sort of tired, not having energy, especially in the afternoon. When I saw you last week we talked about my daily routine and I realized I could use some of my lunch break to walk around school, rather than sit in the cafeteria. It’s really easy for me to just sit there and “veg out” until I have to go to class. There are always snacks like chips sitting around and, if I stay there, I just keep eating. Anyway, for the last four days I have been pushing myself to spend about twenty minutes taking a walk around school, and I feel better. I’m not as tired later in the day. TRAINEE: You made a major change! From the way you describe it, you can really feel the difference this change has made. I know we didn’t discuss anything like this last time so you must have come up with the idea between sessions. You are really working hard on your goals. [complex reflection; affirmation] PATIENT: Yeah. It just came to me when I was in the cafeteria at school the day after we met. I thought about how much time I was wasting just sitting there. Now I realize how much I like walking. It sort of clears my head and I can better understand what I want to do with my life and the things that are important to me. TRAINEE: What you are telling me shows that you can work through problems in your life without necessarily seeing a counselor. You have ideas that spontaneously come to you because you are making such a good effort. And you’re finding other benefits, such as being able to order your priorities in life. Is it OK if we talk about that? [complex reflection emphasizing autonomy; asking permission] PATIENT: Sure. When I walk, I think about what I am doing now, and about what I want to do. But since I have been exercising like I described, I realize there are things that are more important to me than just feeling better physically. I mean, yes, I feel better but now I also want to pay more attention to being in good physical condition, maybe lose some weight. I think I might even take up running on a regular basis. TRAINEE: You see how this one change, walking at lunch, leads to you extending your commitment to taking better care of your body. What other things do you want to change about what is going on in your life now? [summary; open-​ended question] PATIENT: I know my parents have struggled to get where they are and I want to be able to help them, especially when they get older. They deserve that. And if I am going to be able to do that, I need to work on bringing my grades up. I mean I’m getting Bs and Cs in my classes. I can get by on that, but I want to be a better student and get a good job, so there’s no doubt I will be able to take care of my parents when the time comes. TRAINEE: You want to make a lot of changes. Do you have any concerns about moving too fast with all of this? [simple reflection; closed-​ended question]

Motivational Interviewing and Dietetics  175 PATIENT: Well yeah, I’ve thought about that, and I know it won’t be easy, but I know I can do it. TRAINEE: Your commitment to being successful is strong. I want to ask you to think of a scale from 1 to 10. Choose the number that most represents your confidence to change, where 1 is having very little confidence to make these changes and 10 is the highest level of confidence to make these changes. [affirmation; confidence ruler] PATIENT: I feel like I’m at an 8. TRAINEE: That’s very high on the scale. Tell me why it isn’t lower, like 5 or 6. [open-​ ended question] PATIENT: Well, like I said, I have already been successful at making changes in my daily routine. And that feels so good, compared to where I was. I know I am on the right track. TRAINEE: Eight is very high but it is not the highest. What would you need to do to bring that to a 9 or even a 10? [open-​ended question] PATIENT: The hardest thing I need to do is bring my math grade up. Math doesn’t come easily to me. I have to work hard now to get a C. Still there is more I can do. I need to improve my study habits. For example, I have two study periods a day. We are allowed to go to the library, if we want, but I usually stay in the room. Of course, people are always “goofing off” there. I know I concentrate better in the library. And, if I need help, I have friends who will tutor me.

Notice in this clinical vignette that the trainee opens by asking the patient to decide how the session will begin and the patient immediately discusses his success with his walking regimen. As the tips above suggest, the trainee resists the righting reflex to offer advice on how he might motivate himself to take a walk. Instead, the trainee focuses only on Mike’s statements related to his satisfaction with his new routine. The practitioner takes the opportunity to affirm Mike’s success and to reaffirm his autonomy and responsibility for the changes. This is in line with research on SDT (discussed earlier), which shows that strengthening intrinsic motivation improves dietary and PA outcomes. Similar to the tips discussed above, the practitioner emphasizes how making small changes in one area of one’s life often leads to others. Finally, by paying attention to Mike’s change talk about his success with his exercise regimen, the practitioner suggests he talk more about making changes in other areas of his life. This opens the door for a discussion of the importance of Mike’s commitment to helping his parents, and it allows the practitioner to use the confidence ruler to help the patient develop discrepancy with where his grades are now and how he will go about improving them.

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PERSONAL REFLECTION (Augusto Bermudez) One of the highlights of this chapter on the applications of MI in dietetics is not assuming that you know what is “best” for the patient, meaning you are the “expert,” no matter how strongly you feel about doing it. Consequently, you are inclined to conduct the session in an instructing expert-​recipient manner. What I am referring to is the righting reflex that can be easily activated in discussions about dietary patterns of behaviors. You might have some thoughts and suggestions that if the patients sticks with what you want to recommend it will “fix” whatever they might be experiencing and struggling with, and you might be completely right. Instilling insight, dismantling maladaptive beliefs, and giving direct advice do not facilitate behavior change. Another alternative approach that I have learned and applied is to carry out the session in the spirit of MI and accept the change in my role from expert to facilitator. Precisely, my approach is to incorporate MI-​consistent skills and strategies and assist patients in working through their ambivalence about behavior change. I have learned to prioritize establishing a nonconfrontational empathic and supportive climate in which patients feel comfortable expressing both the positive and negative aspects of their current behavior, always maintaining equanimity and a nonjudgmental listening attitude. I have seen the positive impact of guiding patients to think about and verbally express their own reasons for and against change and explore how their current behavior or health status may impact their ability to achieve their life goals or align with their core personal values. Using MI helped me facilitate the process of evoking what intrinsically motivates my patients to change a particular behavior, thereby empowering them, instead of coercing them or trying to motivate them through fear of failure, guilt, shame, or external pressure.

SELF-​ASSESSMENT QUIZ True or False 1. “My doctor told me I have high cholesterol and I could be at risk for a stroke. It sort of freaked me out because my father just recently had triple bypass surgery. I realized that I need to make drastic changes to my eating habits. I want to be there for my grandchildren.” This patient statement is an example of which of the following? A. Change talk B. Sustain talk C. Discord

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2. Which of the following would be the most MI-​adherent way to respond to this patient statement? “I’ve been eating pizzas and burgers at least few times a week, and my diabetes is all over the place. I am having a hard time changing my eating habits and being physically active.” A. “Yes, you really shouldn’t have too many of those. You are putting yourself at risk for serious problems.” B. “Why not just eat pizzas and burgers just twice a week?” C. “You are struggling to make changes in your eating habits and staying physically active and you are worried about losing control over managing your diabetes. 3. True or False? In the context of clinical encounters that focus on discussing dietary patterns, the therapeutic approach of MI used in conjunction with the SDT framework fosters the development of intrinsic motivation and reinforces the need for patients to take responsibility for change.

Answers 1. A. The patient statement is an example of change talk and refers to the need for change in the DARN acronym. A core tenet of MI is that individuals are more likely to accept and act upon arguments that they voice. MI practitioners guide patients and encourage them to express their own reasons for change, using skills and strategies such as reflective listening and eliciting change talk. Expression of change talk, particularly a strong crescendo of commitment, appears to be a good predictor of future change, and a key mediator of the MI process (Miller & Rose, 2009). A related strategy is to help patients develop and experience any discrepancy between their current behavior and their personal core values or life goals. 2. C. This is an example of a complex reflection of feeling/​ meaning acknowledging the distress and emotional intensity associated with being “stuck,” which is a powerful way to engage the patient and provide a safe atmosphere to continue sharing their thoughts and feelings. The other responses are not aligned with MI since they use scare tactics and are judgmental. 3. True. For MI practitioners, an awareness of SDT’s core needs of autonomy, competence, and relatedness can provide a theoretical framework to guide their MI sessions with the goal of strengthening all elements of the change process.

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REFERENCES Academy of Nutrition and Dietetics (2013). International dietetics & nutrition terminology (IDNT) reference manual (4th ed.). Academy of Nutrition and Dietetics. Ahluwalia, J. S., Nollen, N., Kaur, H., James, A. S., Mayo, M. S., & Resnicow, K. (2007). Pathway to health: Cluster-​randomized trial to increase fruit and vegetable consumption among smokers in public housing. Health Psychology, 26(2), 214–​221. Artinian, N. T., Fletcher, G. F., Mozaffarian, D., Kris-​Etherton, P., Van Horn, L., Lichenstein, A. H., Kumanyika, S., Kraus, WE, Fleg, J. L., & Burke, L. E. (2010). Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation, 122(4), 406–​441. Avenell, A., Broom, J., Brown, T. J., Poobalan, A., Aucott, L., Stearns, S. C., Smith, W. C. S., Jung, R. T., Campbell, M. K., & Grant, A. M. (2004). Systematic review of the long-​term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment, 8(21), 1–​182. Befort, C. A., Nollen, N., Ellerbeck, E. F., Sullivan, D. K., Thomas, J. L., & Ahluwalia, J. S. (2008). Motivational interviewing fails to improve outcomes of a behavioural weight-​loss program for obese African American women: A pilot randomised trial. Journal of Behavioral Medicine, 31(5), 367–​377. Bennett, J. A., Lyons, K. S., Winters-​Stone, K., Nail, L. M., & Scherer, J. (2007). Motivational interviewing to increase physical activity in long-​term cancer survivors. Nursing Research, 56(1), 18–​27. Blackford, K., Jancey, J., Lee, A. H., James, A., Howat, P., & Waddell, T. (2016). Effects of a home-​ based intervention on diet and physical activity behaviours for rural adults with or at risk of metabolic syndrome: A randomised controlled trial. International Journal of Behavioral Nutrition and Physical Activity, 13, 13. Bowen, D., Ehret, C., Pedersen, M., Snetselaar, L., Johnson, M., Tinker, L., Hollinger, D., Ilona, L., Bland, K., Sivertsen, D., Ocke, D., Staats, L., & Beedoe, J. W. (2002). Results of an adjunct dietary intervention program in the Women’s Health Initiative. Journal of American Dietetic Association, 102(11), 1631–​1637. Britt, E., Hudson, S. M., & Blampied, N. M. (2004). Motivational interviewing in health settings: A review. Patient Education and Counseling, 53(2), 147–​155. Campbell, M. K., Carr, C., Devellis, B., Switzer, B., Biddle, A., Amamoo, M. A., Walsh, J., Zhou, B., & Sandler, R. (2009). A randomized trial of tailoring and motivational interviewing to promote fruit and vegetable consumption for cancer prevention and control. Annals of Behavioral Medicine, 38(2), 71–​78. Carels, R. A., Darby, L., Cacciapaglia, H. M., Konrad Coit, C., & Harper, J. (2007). Using motivational interviewing as a supplement to obesity treatment: A stepped-​care approach. Health Psychology, 26(3), 369–​374. Cecchini, M., Sassi, F., Lauer, J. A., Lee, Y. Y., Guajardo-​Barron, V., & Chisholm, D. (2010). Tackling of unhealthy diets, physical inactivity, and obesity: Health effects and cost-​ effectiveness. Lancet, 376(9754), 1775–​1784. Clifford, D., & Curtis, L. (2016). Motivational interviewing in nutrition and fitness (1st ed.). Guildford Press. Coumans, J. M., Bolman, C. A., Friederichs, S. A., Oenema, A., & Lechner L. (2022). The effects of a web-​based computer-​tailored diet and physical activity intervention based on self-​determination theory and motivational interviewing: A randomized controlled trial. Internet Interventions, 28, 100537.

Motivational Interviewing and Dietetics  179 Coumans, J. M. J., Oenema, A., Bolman, C. A. W., & Lechner, L. (2021). Use and appreciation of a web-​based, computer-​tailored diet and physical activity intervention based on the self-​ determination theory: Evaluation study of process and predictors. JMIR Formative Research, 5, e22390. da Silva, J. G. G., Kavanagh, D. J., May, J., & Andrade, J. (2020). Say it aloud: Measuring change talk and user perceptions in an automated, technology-​delivered adaptation of motivational interviewing delivered by video-​counsellor. Internet Interventions, 21, 100332. Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational interviewing: A guide for medical trainees. Oxford University Press. Hardcastle, S. J., Taylor, A. H., Bailey, M. P., Harley, R. A., & Hagger, M. S. (2013). Effectiveness of a motivational interviewing intervention on weight loss, physical activity, and cardiovascular disease risk factors: a randomised controlled trial with a 12-​month post-​intervention follow-​up. International Journal of Behavioral Nutrition and Physical Activity, 10, 40. Hardcastle, S. J., Taylor, A. H., Bailey, M., & Castle, R. (2008). A randomised controlled trial on the effectiveness of a primary health care-​based counselling intervention on physical activity, diet, and CHD risk factors. Patient Education and Counseling, 70(1), 31–​39. Hollis, J. L., Williams, L. T., Collins, C. E., & Morgan, P. J. (2014). Does motivational interviewing align with international scope of practice, professional competency standards, and best practice guidelines in dietetics practice? Journal of Academy of Nutrition and Dietetics, 114(5), 676–​686. Kohl, L. F., Crutzen, R., & de Vries, N. K. (2013). Online prevention aimed at lifestyle behaviors: a systematic review of reviews. Journal of Medical Internet Research, 15(7), e146. Lundahl, B. W., Kunz, C., Brownell C., Tollefson, D, & Burke, B. (2010). A meta-​analysis of motivational interviewing: Twenty-​five years of empirical studies. Research on Social Work Practice, 20(2), 137–​160. Markland, D., Ryan, R. M., Tobin, V. J., & Rollnick, S. (2005). Motivational interviewing and self-​determination theory. Journal of Social and Clinical Psychology, 24(6), 811–​831. Martins, R. K., & McNeil, D. W. (2009). Review of motivational interviewing in promoting health behaviours. Clinical Psychology Review, 29(4), 283–​293. Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioral and Cognitive Psychotherapy, 37(2), 129–​140. Miller, W. R, & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed). Guilford Press. Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527–​537. Neumark-​Sztainer, D. R., Friend, S. E., Flattum, C. F., Hannan, P. J., Story, M. T., Bauer, K. W., Feldman, S. B., & Petrich, C. A. (2010). New moves-​preventing weight-​related problems in adolescent girls a group-​randomized study. American Journal of Preventive Medicine, 39(5), 421–​432. Resnicow, K., Jackson, A., Wang, T., De, A. K., McCarty, F., Dudley, W. N., & Baranowski, T. (2001). A motivational interviewing intervention to increase fruit and vegetable intake through Black churches: Results of the Eat for Life trial. American Journal of Public Health, 91(10), 1686–​1693. Rubak, S., Sandbaek, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-​analysis. British Journal of General Practice, 55(513), 305–​312. Shaw, K., Rourke, P., Del, M., & Kenardy, J. (2005). Psychological interventions for overweight and obesity. Cochrane Database Systematic Reviews, 2, CD003818. Sheeran, P., Wright, C. E., Avishai, A., Villegas, M. E., Lindemans, J. W., Klein, W. M. P., Rothman, A. J., Miles, E., & Ntoumanis, N. (2020). Self-​determination theory interventions

180  Motivational Interviewing, 2E for health behavior change: Meta-​analysis and meta-​analytic structural equation modeling of randomized controlled trials. Journal of Consulting and Clinical Psychology, 88(8), 726–​737. Shingleton, R. M., & Palfai, T. P. (2016). Technology-​delivered adaptations of motivational interviewing for health-​related behaviors: A systematic review of the current research. Patient Education and Counseling, 99(1), 17–​35. Teixeira, P. J., Carraca, E. V., Markland, D., Silva, M. N., & Ryan, R. M. (2012). Exercise, physical activity, and self-​determination theory: A systematic review. International Journal of Behavioral Nutrition and Physical Activity, 9(1), 78. Teixeira, P. J., Patrick, H., & Mata, J. (2011). Why we eat what we eat: the role of autonomous motivation in eating behaviour regulation. Nutrition Bulletin, 36(1), 102–​107. Verstuyf, J., Patrick, M., Vansteenkiste, E. A., & Teixeira, P. J. (2012). Motivational dynamics of eating regulation: A self-​determination theory perspective. International Journal of Behavioral Nutrition and Physical Activity, 9(21), 1–​16. West, D. S., DiLillo, V., Bursac Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care, 30, 1081–​1087.

11 Motivational Interviewing and Obesity Lindsay Leikam, Dana Rofey, and Melanie A. Gold

Obesity is an increasingly common and serious health problem in the United States. Current CDC data estimate a recent prevalence of obesity in 42.4% of US adults (Hales, Carroll, Fryar, & Ogden, 2020) and 19.3% of US children and adolescents (Hales, Carroll, Fryar, & Ogden, 2017; Ogden, et al., 2016). Obesity in childhood and adolescence leads to physical health risks, including cardiovascular abnormalities, metabolic abnormalities (including insulin resistance and hyperlipidemia), and chronic inflammation. In addition to the negative physical health impacts, obesity in childhood and adolescence increases the risk of psychosocial stressors, including increased risk of bullying by peers and being subject to negative bias by peers, teachers, and family members. Children with increased body mass index (BMI) often become obese adults, and obesity in adulthood is associated with ongoing physical and psychological health risks, including cardiovascular disease, type 2 diabetes, various forms of cancer, depression, anxiety, and overall higher mortality. In one study, researchers found that over 30 units of BMI, each one-unit BMI increase was associated with an additional healthcare cost of $253 per person. Among adults, obesity was associated with $1,861 excess annual medical costs per person, accounting for $172.74 billion of annual expenditures. Severe obesity was associated with excess costs of $3,097 per adult. Among children, obesity was associated with $116 excess costs per person and $1.32 billion of medical spending, with severe obesity associated with $310 excess costs per child (Ward, Bleich, Long, & Gortmaker, 2021). Given the physical, psychological, and financial burden of obesity among children, adolescents, and adults, effective weight management interventions are necessary to prevent and treat obesity. Interventions have also shifted over recent years to focus especially on primary prevention of obesity, which involves behavioral change at its core.

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EFFECTIVENESS OF MOTIVATIONAL INTERVIEWING FOR OBESITY IN ADULTS AND ADOLESCENTS Lifestyle interventions are often the first approach for both youth and adults who are overweight or obese. These interventions include modifications targeted at diet, physical activity, and behaviors, but they are often more complex in practice than in theory. As a result, implementing interventions can be overwhelming and frustrating to patients. Weight loss may be further complicated by mixed messages received from social media, news sources, and friends or family. Many patients are genuinely interested in discussing their weight or strategies for weight loss but find it difficult to approach the topic for fear of being told what to do. In turn, practitioners often may not want to discuss it out of fear of offending and increasing weight bias for their patients. Eliciting behavior change in relation to obesity is a sensitive topic. It is imperative to establish a comfortable space with patients where you can collaborate and empower them to be autonomous in working toward their goals. Motivational Interviewing (MI) is highly relevant to patients working toward weight management and is applicable as a primary communication style to address the challenges of behavioral change in healthcare settings where obesity is treated (Reims & Ernest, 2016). There are many specific behaviors that can be targeted toward reducing obesity using MI. The positive effects of MI-​based interventions on weight loss in overweight adults have been supported by many systematic reviews and meta-​analyses. Two MI sessions, when incorporated in behavioral weight-​loss interventions, helped to support preparation for behavior change and maintenance of progress within weight-​loss settings through increasing motivation, raising self-​efficacy, and improving adherence to treatment (Moss Tobin, Campbell, & von-​Ranson, 2017). A study that identified 15 randomized controlled trials using MI within telehealth settings for weight loss in adults living with overweight and obesity found that MI performed better than no treatment in around 54% (6) of 11 occasions, but in the majority of cases using an active comparator, MI performed better than active comparator on only one of seven occasions (Patel, Wakayama, Bass & Breland, 2019). A meta-​analysis of randomized controlled trials recruiting adults with overweight and obesity identified an overall significant, moderate effect of MI to improve weight loss over comparator interventions such as treatment as usual and advice from non-​MI trained practitioners (Armstrong, et al., 2011). Another review of studies utilizing MI with adults with overweight and obesity drew similar conclusions to the earlier findings, with 13 (54.2%) out of 19 included studies reporting clinically significant weight loss of at least

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5% initial body weight; although this review did not quantitatively synthesize findings using meta-​analytic technique (Barnes & Ivejaz, 2015). In addition, within the obesity management context, MI can be integrated with the use of techniques such as goal-​setting, self-​monitoring of behavior, review of behavioral goals, feedback on performance, and action planning which are proven effective for weight-​loss outcomes (Falko Sniehotta, Bunten, Coulton, Blackshaw, & Tedstone, 2017). Recently, a taxonomy of techniques and components specific to MI has been developed which can be used to clarify what is occurring within MI implementation (Hardcastle, Fortier, Blake, & Hagger, 2017). However, there is currently no clear understanding of the influence of strategies within MI interventions for obesity-​related outcomes. Most recent systematic reviews and meta-​analyses evaluating the effectiveness of MI among adults with obesity did not contribute to additional evidence for the effectiveness of MI, and at the same time, they yielded a better understanding of methodological issues that needed to be addressed to help better identify the MI intervention effects on obesity-​related outcomes (Makin, Chisholm, Fallon, & Goodwin, 2021). In adolescent populations, although existing data demonstrate the positive effect of MI-​based interventions on lifestyle modification and disease control (Cushing, Jensen, Miller, & Leffingwell, 2014; Gayes & Steele, 2014; Jensen, Cushing, Aylward, Craig, Sorell, & Steele, 2011), its efficacy on the weight management process in those with excessive weight remains questionable (Cushing, Jensen, Miller, & Leffingwell, 2014; Gayes & Steele, 2014; Vallabhan, et al., 2018). Findings from a meta-​analysis of 15 studies targeting multiple behaviors, such as diet, physical activity, and BMI status in adolescents, indicate small but significant aggregate effects of MI interventions to improve behavioral patterns and weight status among participants (Cushing, Jensen, Miller, & Leffingwell, 2014). A more recent meta-​ analysis reviewed the impact of MI-​ based interventions on the weight management process and showed minor effects on reducing sugary beverage intake in adolescents and at the same time a reduction in central obesity was observed predominantly among girls. The age of participants, MI fidelity assessment, parental involvement, and duration of interventions are the main characteristics influencing goal achievement in MI-​based interventions (Amiri, et al., 2022). In the context of obesity management, MI can be integrated with the use of techniques such as goal-​ setting, self-​monitoring of behavior, review of behavioral goals, feedback on performance, and action planning, which are proven effective for weight loss outcomes (Falko Sniehotta, Bunten, Coulton, Blackshaw, & Tedstone, 2017).

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These findings suggest that MI can be an effective intervention for helping patients control their weight. However, it is clear that more research is needed to determine the specific techniques and conditions necessary to improve outcomes related to obesity.

CLINICAL APPLICATIONS OF MOTIVATIONAL INTERVIEWING Initial Discussion Given that obesity is a sensitive topic, it is important to first assess each patient’s level of concern about their weight. Depending on the situation, the practitioner can initiate the conversation with the patient by using open-​ended questions—​the O in the OARS skills (open-​ended questions, affirmations, reflections, and summaries)—​or could lead with a statement followed by a close-​ended question asking permission to discuss the topic. Questions and statements should be direct, and at the same time, not authoritarian. Examples of open-​ended questions: “How much is weight a concern for you?” “What is your understanding of how your weight affects your health?”

An example of a statement followed by a close-​ended question asking permission: “I would like to talk about how your weight may be affecting your health. Would it be OK if we talk about it today?”

If a patient is engaging in sustain talk (e.g., the status quo side of ambivalence, or not interested in change at all), it is appropriate to provide an autonomy statement that the patient is the best judge of when is the right time to discuss weight management and shift conversation to a topic the patient wishes to discuss rather than pushing an agenda. Your response in this situation can still empower the patient to consider future discussion and affirm your shared goals. For example, you can use a support statement such as, “I respect your decision to hold off today, and I am always here to discuss this in the future when you are more interested.” It may be worthwhile exploring patients’ reasons for being unwilling to engage in further discussion (barriers), as some patients simply are not concerned because they are not

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informed about the consequences of obesity on their health. With patient permission, the practitioner can offer to share education or information related to the impact of obesity on health and then assess the patient’s feedback about this information. TRAINEE: Is it OK if I share with you some concerns I have about the effect your weight may be having on your blood pressure? [asking permission; closed-​ended question with personalized feedback] PATIENT: Sure, but I’m not concerned at all. High blood pressure runs in my family anyway. TRAINEE: It is true, genetics can have a big influence on blood pressure. At the same time, weight gain can also contribute to higher blood pressure, and often weight loss alone can help lower your blood pressure. [providing information; complex reflection] PATIENT: Oh really? I didn’t realize my weight was such a big deal. But my blood pressure isn’t THAT high, so losing weight might not even make a difference. TRAINEE: Is it OK if I provide you with some information? [asking permission] PATIENT: Yes. TRAINEE: Weight loss could help lower your blood pressure without medication, and it could also give you more benefits such as lowering your cholesterol and decreasing your joint pain. Achieving a healthier weight in general would have a positive effect on multiple aspects of your overall health, not just your blood pressure. What are your thoughts? [providing information; eliciting feedback with open-​ended question]

In the above scenario, it is important to portray weight management as a positive change for the patient. Highlighting additional potential benefits of weight loss reframes it in a positive light for the patient, instead of focusing on risks and adverse outcomes. You set yourself up to be lecturing the patient if you focus only on the negative aspects of weight gain and obesity, which takes away from the collaborative aspect of MI. Further, the exchange above is consistent with the MI-​based strategy of Elicit-​Provide-​Elicit (E-​P-​E), which helps continue the conversation in a manner that shows the patient the importance of their input. Some patients may express more sustain talk based on failed past attempts and are not motivated to change out of fear they will again not be successful in their goals. In this case, it is important to use the “importance” and “confidence” rulers to assess where they are in terms of making changes. Using these rulers, the trainee can differentiate what value patients place on behavior change, as well as their beliefs about their abilities to actually make changes.

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Lower scores on confidence often exist in the context of a high rating on importance. Once the trainee understands where the patient stands on making changes in relation to their past struggles and failures, it may be important to discuss past successes, which can highlight patients’ strengths and resourcefulness. This can open the door to additional discussion about how to apply previously successful strategies to a new weight loss goal. Using reflective listening (the R in the OARS) in these scenarios can also enhance motivation as patients feel heard and validated for their past efforts. PATIENT: I’ve tried so many different diets and exercise plans in the past, and nothing has worked. I don’t think this time will be any different. TRAINEE: You have already attempted to lose weight multiple times, and each time has ended in frustration instead of feeling good about yourself. At the same time, you are determined to not give up and are willing to explore other strategies. [affirmation; double-​sided reflection] PATIENT: Yes, absolutely. It’s so frustrating to stick to a diet and exercise plan and then still not see any results. TRAINEE: You mentioned you were successful at quitting smoking a few years ago, which is very difficult for most people. What were some tricks that were helpful to you back then? [affirmation; open-​ended question]

Discussing a Change Plan Once you have established a collaborative relationship with patients and they have demonstrated strong commitment (via expressing more change talk and commitment language) to making changes, you can begin the conversation about determining a focus on establishing specific goals and plans for how to reach those goals. Remember that you are planning with patients, and not for them; being too authoritarian can make patients feel that change is a punishment instead of a shared goal that they are invested in making a reality. It is also important to note that the patient’s commitment is fluid, and ambivalence can emerge unexpectedly. Patients often wax and wane in their commitment to a certain goal or topic throughout treatment. This is a normal process of behavior change and should be regarded as such. OARS skills guide the session. PATIENT: After 3 months of going to the gym, I just am not motivated to continue to go every day. TRAINEE: Going to the gym feels unmanageable right now. [complex amplified reflection]

Motivational Interviewing and Obesity  187 PATIENT: I wouldn’t say unmanageable. I just don’t feel like doing it anymore. TRAINEE: You feel you’ve lost interest in doing it any longer and at the same time you believe it’s not a lost cause. [double-​sided reflection] PATIENT: Yeah, I am still hopeful I can regain some of my motivation one way or another. TRAINEE: You want to figure out how you can get yourself more motivated and consistent with it. [complex reflection] PATIENT: Yes, I would like to at least try to work on it. TRAINEE: Let’s get a better picture of your schedule. How many days did you go last week? [closed-​ended question] PATIENT: Zero. TRAINEE: You are disappointed you didn’t go at all. You used to go everyday not so long ago. And last week, it was challenging to get there at all. [complex reflection; affirmation] If you wanted to restart going to the gym, what would feel more manageable? [open-​ended question] PATIENT: I guess I could go on days that I don’t have band practice. TRAINEE: And you feel able to give it a try. Are there particular days that would work best for you. [complex reflection; closed-​ended question] PATIENT: Maybe Mondays, Wednesdays, and Fridays. TRAINEE: Three times a week seems manageable to you right now. [complex reflection]

Patients often have their own ideas for targeting weight loss, while other are at a loss or feel as if they have already tried many methods. When considering a specific target behavior, offering patients a variety of choices (e.g., a menu of options, Table 11.1) empowers them to choose their own path. At the same time, it is important not to make too many suggestions, as this can be overwhelming. Another key aspect of planning for change involves making only one or two changes at a time; focusing on small, realistic, sustainable changes is more likely to lead to success. Eliciting from patients what they know about the positive aspects of change, such as beneficial impact on their overall health and wellbeing, can elicit ongoing motivation to pursue change. Implementing and sustaining goals noted above will include utilization of a variety of skills including behavioral and cognitive strategies discussed below, using an E-​P-​E strategy. TRAINEE: Would it be OK if I shared some suggestions of where other people I work with on weight management have started? [asking permission] PATIENT: Sure, that’s why I am here. TRAINEE: (Add some examples and then say) Where do you think you may be interested in starting? [providing options; eliciting]

188  Motivational Interviewing, 2E TABLE 11.1  Menu of Options Menu of Options for Weight Management Targets •  Dietary Modifications o  Portion control o  Substitution of calorie-​free/​sugar-​free beverages o  Healthy snack choices o  Meal prepping o  Grocery lists o  Creating a budget •  Increasing Physical Activity o  Exploring gym memberships or classes o  Online exercise videos o  Finding an “exercise buddy” o  Pedometer use to set step/​distance goals • Accountability o  Use of calendar or visual aid o  Use of apps or wearable devices for tracking progress

PATIENT: When I go to the grocery store and I’m hungry, I end up buying lots of snacks. It’s expensive, and then I’m frustrated because I can’t make many dinners. TRAINEE: Would it be OK if I provided some additional information on how to potentially address this challenge? [asking permission] PATIENT: Yes. TRAINEE: Stimulus control is the best way to change your diet. If you go to the grocery store with a list of high protein, low sugar foods that fall within the 5/​10 rule that we discussed last week, you’re more likely to succeed. What do you think about this information? [providing information then eliciting feedback] PATIENT: That would probably be a good place to start.

Integration of MI with Cognitive Behavioral Therapy Despite the small number of high-​quality randomized trials, a recent meta-​analysis found that that integrated MI-​cognitive behavioral therapy (CBT) leads to modest improvements in lifestyle mediators of overweight and obesity such as physical activity and body composition among community-​ dwelling adults (Barrett, Begg, O’Halloran, & Kingsley, 2018). The integrated intervention can be delivered by a range of healthcare practitioners and can be incorporated readily into clinical practice addressing weight management issues. The following will review some of

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these behavioral and cognitive strategies that can well be integrated with the MI approach. Behavioral Strategies Self-​monitoring is a skill that includes tracking both dietary intake and physical activity expenditure. It encourages patients to have an accurate portrayal of their baseline ratings and allows them to objectively monitor change over time. These behavioral strategies can be combined with the clinical style of MI and OARS skills: goal setting, stimulus control, relaxation training, and behavioral activation. Goal-​setting is an important component of weight management to achieve success and overcoming challenges involves setting realistic goals that can be monitored over time. Short-​term, reasonable weight-​loss goals are encouraged to promote a series of successes over time, instead of repeated failures stemming from unrealistic expectations. The setting is the Outpatient Pediatric Clinic. The patient is a 17-​year-​old girl with no chronic past medical history, who presents for an annual well-​ child visit. Her BMI has been increasing yearly since age 12 years, and at her last visit 1 year ago was in the obese range. Her mother, who typically attends appointments with her, is also obese and on medication for hyperlipidemia. Screening bloodwork was completed at her visit one year ago because of elevated BMI and showed mild dyslipidemia. The physician who saw her at that visit discussed dietary modifications and increased physical activity. At that visit, the patient’s lab results were reviewed with her and her mother, and they expressed understanding. However, she and her mother did not attend the scheduled follow-​up appointment 6 months ago. Repeat labs today show continued elevated LDL, total cholesterol, and triglycerides. You reviewed the new results with the patient and her mother. Goals: Elicit concern about obesity and identify ways to improve her lifestyle that will prevent further weight gain. Promote healthy weight loss using both MI approach and behavioral strategies. TRAINEE: What do you think about your cholesterol level? [open-​ended question] PATIENT: I see it’s still high. I just don’t understand what the big deal is. I’m not going to have a heart attack tomorrow, and I’ve been feeling fine. I obviously don’t want to keep gaining more weight, but at least I don’t feel sick. TRAINEE: You are not worried at the moment that your health will be hurt by your cholesterol level, and at the same time, you do not want to gain more weight. [double-​ sided reflection]

190  Motivational Interviewing, 2E PATIENT: Right. But losing weight is hard. It seems like my mom is always on a diet, but it doesn’t work for her. And I don’t have time for exercise.

Stimulus Control: Modifying environments to promote and sustain behaviors consistent with desired weight management goals can be influenced by multiple cues. Increasing the availability of healthy foods in the environment and decreasing the availability of unhealthy foods is one example of stimulus control that can influence dietary modifications. As another example, decreasing sedentary behavior may be influenced by limiting sedentary activity or placing sneakers/​workout clothes in high-​traffic environments to increase visibility and serve as a cue to become physically active. Relaxation training: Diaphragmatic breathing, guided imagery, and progressive muscle relaxation are strategies that may be taught to patients to manage negative affect and subsequently aid in making healthy lifestyle choices (see Chapter 19 on MI and mindfulness and other integrative health modalities). Behavioral Activation: Prior to attempting a new behavior, practitioners should elicit from the patient any cognitive, emotional, or logistical barriers to successfully initiating new behaviors as part of the collaborative style of MI. After implementation of a new behavior, practitioners should inquire about expected barriers and compare with actual barriers to behavior change. Let us continue the clinical encounter with our 17-​year-​old girl.

INTEGRATING THE MI CLINICAL STYLE AND OARS WITH BEHAVIORAL STRATEGIES (SELF-​ MONITORING, GOAL-​SETTING, STIMULUS CONTROL, RELAXATION TRAINING, AND BEHAVIORAL ACTIVATION) The setting is the outpatient pediatric clinic. The patient’s mother is attending the visit. MOTHER: I feel like we’ve tried so many things—​I buy healthier food at home, but she just gets a bunch of fast food with her friends. She’s so busy with school and work that she does not have time to exercise either. TRAINEE: Weight loss is a difficult task that takes dedicated attention, and it must be overwhelming to think about that when you are so busy. [complex reflection; affirmation]

Motivational Interviewing and Obesity  191 PATIENT: Exactly! And I do try to eat healthy, but it’s just easy to eat fast food with my friends on the weekends. I’ve tried some of my mom’s diets and there are just too many rules to keep track of. TRAINEE: It is definitely hard to make a bunch of changes all at once. I wonder if you can make one small change at a time, like substituting water instead of soda when you are out with your friends. [complex reflection; advice-​giving; goal-​setting] PATIENT: I could try that. I’d save money if I got water. TRAINEE: So maybe some of these changes would be beneficial in multiple ways! What do you think will be difficult about making one change at a time? [complex reflection; open-​ended question; behavioral activation; discussing barriers to implementation of new behaviors] PATIENT: Well, it will definitely be annoying to see all my friends drinking soda when that’s what I am craving and what I really want. TRAINEE: You will feel jealous and might give in to that craving. [complex reflection] What are other beverage options when you go out with your friends? [open-​ended question] PATIENT: I’m not sure. Sometimes they have flavored waters available; I do like the fizziness and carbonation. It might make it a little better when they’re all drinking soda. TRAINEE: You have already come up with some excellent healthy alternatives that you could choose to drink besides just water. [affirmation] What else might make this difficult? [open-​ended question] PATIENT: I am just forgetful; I can’t keep track of things in my head. TRAINEE: A visual tool might help instead of having to just remember to do this in your head. [complex reflection] PATIENT: Yeah, I can make a list in my phone. I am a visual person anyways; I need things written down. TRAINEE: You know yourself and what will work for you. [affirmation] Sometimes people find it is easier to eat healthy when they have access to healthier foods, or actually see the healthy food sitting out on the counter. MOTHER: I buy plenty of fresh fruit and vegetables, but she goes straight for the chips when she gets home. PATIENT: They’re just so easy to get to. I don’t have the time to cut up fruits and vegetables before I head to work. TRAINEE: It would be easier to eat the fruits and veggies if they were already washed and cut up. [complex reflection] PATIENT: Well, yeah, of course. MOTHER: We could wash and cut the fruits and vegetables right after I bring them home from the grocery store on the weekends. She sometimes comes with me anyways.

192  Motivational Interviewing, 2E TRAINEE: That could be a great way to make snacking on fruits and veggies more practical for you. What do you think of that idea? [complex reflection; evocative open-​ ended question] PATIENT: I might do that some of the time. I mean, chips are just so good! MOTHER: I should stop buying them, so they aren’t even around the house. It would help me out too and she gets plenty of junk food out with her friends. TRAINEE: Removing the chips and having healthy snacks ready-​to-​eat is a healthier way that you both can take control of your snacking. [complex reflection; stimulus control] PATIENT: I’m just worried I am going to forget to do all of this. I am not super organized like some of my friends. TRAINEE: You mentioned that you are a visual person and like to see things written down. What do you think about incorporating that into your plan for healthy changes? [complex reflection; open-​ended question] PATIENT: Well, I suppose I could write a list of the changes that I want to make and keep it in my bedroom. TRAINEE: That is one way to keep track of your changes over time and monitor your progress. [complex reflection; self-​monitoring] MOTHER: Maybe I should do that too—​my doctor would be impressed if I did! TRAINEE: If you both made lists, you could keep each other accountable and encourage each other to stick with some healthy changes. [complex reflection]

Cognitive Strategies As mentioned earlier, MI has been applied as an adjunct for treatments such as CBT (Wilfley, Kolko, & Kass, 2012) in order to increase motivation for and commitment to the intervention, especially when components of the treatment may be challenging such as problem-​solving, cognitive restructuring, and relapse prevention. Integrating the clinical style of MI and OARS is feasible and has the potential to improve treatment engagement. Problem-​Solving During MI interventions, patients are encouraged to identify specific problem areas that present challenges to achieving their intended goals. Together with the practitioner, patients can identify a problem area, generate solutions, and evaluate the consequences of each solution. Problem areas may include planning ahead for activity, eating out, managing negative emotions in specific situations, or negotiating desired social support with a partner or family member. Regardless of the type of problem, patients can work collaboratively with the practitioner to develop an individualized plan to meet their needs.

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The addition of problem-​solving strategies to a weight-​loss intervention is believed to contribute directly to weight loss as well as treatment adherence. Cognitive Restructuring A critical component of CBT, cognitive restructuring, includes identifying and challenging maladaptive cognitions related to a person’s weight management goals. Specifically, patients may have certain thoughts or beliefs related to weight management that are unhelpful in meeting their goals. These potentially sabotaging cognitions are “permission-​giving” ideas that may serve as justification for overeating or inactivity. Relapse Prevention Part of weight management includes patients being encouraged to anticipate “slips” in their behavior. Expected lapses in a patient’s intended behavior change are presented as a realistic possibility and encourage patients to think about how to prevent lapses from becoming a relapse to the previously undesired behavior.

INTEGRATING MI-​CBT INTERVENTION DELIVERED USING THE EMPATHIC AND COLLABORATIVE STYLE OF MI AND OARS SKILLS The setting is the adult diabetes clinic. The patient is a 36-​year-​old man, diagnosed at age 34 years with type 2 diabetes mellitus, who presents to his primary care practitioner (PCP). Despite treatment with multiple oral medications, his hemoglobin A1c has slowly continued to rise. He has been obese since he was a teenager, and despite advice from his PCP, he has continued to gain weight since his diagnosis. This has contributed to his worsening blood sugar control. His PCP has referred him to the endocrinologist to discuss insulin treatment to target his elevated blood sugars. The following encounter is with the endocrinology fellow. FELLOW: Diabetes management is complex and requires a lot of moving parts: healthy diet, exercise, taking your medications, and monitoring other aspects of your health, like your weight and your blood pressure. What is the most difficult part of managing diabetes for you? [providing context; open-​ended question] PATIENT: Sometimes all of it feels too difficult. I am pretty good at remembering to take my medications, and I always come to my doctor’s appointments like I am supposed to. I have tried to buy and eat healthy food, but I also just got promoted at work, so I am working longer hours and it’s hard to find time.

194  Motivational Interviewing, 2E FELLOW: Congratulations on your promotion. Exercise is a particularly hard thing to incorporate into your life right now. [complex reflection] PATIENT: Right. Maybe it would be easier if I had equipment at home, like a Peloton, or belonged to a gym, but I can’t afford equipment or a gym membership right now. FELLOW: It is difficult when you don’t have easy access to exercise equipment. For many people, physical activity can come in multiple forms. What are some ways you could engage in physical activity that doesn’t require a gym or equipment? [complex reflections; open-​ended question] PATIENT: I used to love taking long walks and hikes with my parents when I lived closer to them back in college, but I only see them every few months now since I moved away. FELLOW: Long walks and hikes have worked for you in the past and they are a great way to get your body moving. Who are your social supports here in town? [complex reflection; closed-​ended question] PATIENT: Well, I have grown close with a few of my coworkers, and we’ve started hanging out outside of work. Some of them go on walks at lunch. FELLOW: How do you usually spend your lunch hour at work? [open-​ended question] PATIENT: At lot of times, I just eat lunch at my desk. Maybe I should try to join some of my coworkers when they go out for a walk; there’s actually a nice walking path right behind our building. FELLOW: That is a great way of incorporating some extra movement into your day. What about on days where the weather doesn’t permit outdoor walking, what would you be able to do indoors? [complex reflection; open-​ended question; problem-​solving] PATIENT: I’m not sure. I don’t really get into yoga and that kind of thing. FELLOW: Structured activities like yoga certainly aren’t for everyone. There are other ways to keep your body active and break a sweat. What could you do around your house? [complex reflection; open-​ended question] PATIENT: Well, I have a new bookshelf I’ve been meaning to put together but keep putting off. I could do that on the next rainy day at home. FELLOW: That could afford you the opportunity to also feel productive. What are some other barriers that you see with incorporating some kind of daily physical activity into your life? [complex reflection; open-​ended question] PATIENT: I just feel like such a failure that I even got to this point. FELLOW: How do you feel that you have failed? [open-​ended question] PATIENT: I couldn’t lose weight even with healthy eating, and then I couldn’t even use medications to control my blood sugars. Now I’m here having to take insulin when I could have controlled this all by just running every day. FELLOW: You have actually been successful in other domains of your life outside of diabetes: getting a promotion and gaining some new friends. [affirmation; cognitive restructuring]

Motivational Interviewing and Obesity  195 PATIENT: Yeah, I guess that’s true. But still, on the days that I don’t find time to go on a walk or do something at home, it will be a total setback. The whole day will be ruined. FELLOW: Expecting that you’ll be able to fit structured exercise into every single day, especially with your busy job, seems almost unrealistic. [complex reflection] PATIENT: Trying to fit it in on really busy days will just stress me out even more. FELLOW: And stress can in turn worsen your blood sugars. You know better than anyone that diabetes and weight management is a balance, and multiple factors are at play. Not getting a workout in on one day does not undo a long walk from the day before or prevent you from taking a walk the next day. [complex reflections] PATIENT: Yeah, I suppose a day off here and there doesn’t matter a whole lot in the long run as long as I’m trying to be more active most days of the week. FELLOW: There will definitely be days where you are simply too busy, or don’t feel well, or have other plans besides physical activity. Knowing these days will happen is something to expect, and you can still plan to fit physical activity in the following day and continue with other healthy choices in the meantime, like eating healthy meals. [summary; relapse prevention]

Psychotherapeutic approaches that have been successfully used for weight loss include CBT and MI. MI has been shown to be effective as an adjunct to a behavioral weight control program. It can be helpful in maintaining behavior change as well as initiating change and supporting engagement in the behavioral treatment program. Behavioral interventions that can be well integrated with MI that have been specifically endorsed in high-​quality randomized controlled trials and shown to offer significant benefit for weight-​loss maintenance include goal-​setting, problem-​solving, relapse prevention, self-​ monitoring, and daily self-​weighing, and social support.

PERSONAL REFLECTION (Lindsay Leikam) As a primary care pediatrician in training, time spent with my patients and their families is typically limited in the outpatient setting, and it is not unusual to feel rushed during well-​child appointments to address every aspect of a child’s health. If there is acute illness, safety concerns, or need for procedures such as blood work and vaccination administration, any additional time to address weight management is precious and can feel like too much of a burden to incorporate into the visit. As noted above, jumping straight to weight concerns, and addressing strategies for change in such a short time-​frame can be overwhelming for the patient or parent; if not addressed in a sensitive manner, it can ultimately lead to a severed relationship with the practitioner.

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One advantage for pediatricians is that we have the opportunity of seeing a patient’s growth chart in the electronic medical record before entering the room. When noting obesity or significant weight gain, I immediately make a mental note before entering a room, so that I can be on alert for cues that may allow for a smoother segue into this sensitive topic. With adolescents in particular, I have often found that identifying their strengths, interests, values, and future goals can serve as a starting point. I recall a session with a 15-​year-​old girl who expressed interest in pursuing a career as a firefighter; however, she was currently leading a sedentary lifestyle that had predisposed her to significant weight gain since onset of puberty. Maintaining equanimity through the MI spirit and nonconfrontational and respectful style allowed me to establish rapport and engage her in discussing her struggles with weight gain. In fact, I followed this roadmap, which started with making a statement normalizing ambivalence about changing health behaviors in general, followed by emphasizing her autonomy for decision-​making. Next, I asked an open-​ended evocative question about her weight concerns (“What are your concerns about your weight?”), establishing the focus of the clinical encounter. She responded in a way that displayed a high level of ambivalence about managing her weight, at the same time she was open to exploring it further when I asked her permission to do so. I used reflective listening and a variety of MI techniques, such as exploring readiness to change, evoking change talk, and exploring target behaviors (physical activity and lifestyle), and I pointed out how a firefighting career would be physically demanding and would require her to be as physically fit as possible in order to perform her best. She started expressing change talk about her desire and need to increase her level of physical activity and how important it is for her to also initiate making some changes in her diet and lifestyle. We have brainstormed around her ideas for change and helped her identify barriers and challenges to making changes such as her disinterest in organized sports and cold weather that would not permit her to go on long walks or runs outside. We have explored alternative physical activities that would be more fulfilling for her. She shared that much of her free time was spent listening to hip-​hop music and watching choreography videos. She set a goal to explore online resources that might allow for her to engage in dance at home on her own time. When she returned several months later for a visit, she was excited to share that (with mother’s supervision, of course!) she had found a free YouTube exercise channel with dance moves to a wide variety of songs, and she had been working to incorporate this into her daily routine. Within a year, she had brought her weight into a healthy BMI percentile and is now preparing for high school graduation.

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Reducing her ambivalence about making changes and identifying something she valued (desired career as a firefighter) that was aligned with increased physical activity and weight management moved the process toward identifying behavioral goals. Maintaining a MI-​adherent approach and using goal-​setting (behavioral strategy) and problem-​solving (cognitive strategy) helped to plan for this positive change and address potential challenges associated with the implementation of increased physical activity. A small change, spurred by her future goals and elicited by discovering resources based on her values, ultimately strengthened her self-​efficacy to manage her weight.

SELF-​ASSESSMENT QUIZ True or False 1. Most patients with obesity have no interest in discussing their weight or strategies for weight loss with their practitioners. 2. MI can be well integrated with behavioral strategies addressing obesity. 3. It’s easiest for the patients if you, the trainee, make change plans regarding weight management and set goals without patients’ involvement. 4. MI is a therapeutic approach used to support preparation for behavior change and maintenance of progress within weight-​loss settings by enhancing motivation, strengthening self-​efficacy, and improving adherence to other weight-​related interventions.

Answers 1. False. Many patients with obesity do care about their weight and may even have multiple concerns regarding their weight. They may not bring it up out of fear of being punished or lectured, which is why the topic must be approached carefully and sensitively by trainees. Using the MI approach provides a safe and empathic atmosphere for the patient to share, and it facilitates conversation about weight management struggles. 2. True. Integrating the MI clinical style and its OARS skills with behavioral strategies could yield positive outcomes. 3. False. This is the opposite approach of MI. Using the person-​centered MI approach, the trainee encourages exploration of patients’ values and goals and helps them see the discrepancy between the stated values and

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their selected weight management behavior(s). When patients are ready to make a change and have resolved their ambivalence, you would work collaboratively with them to discuss their change plan and generate their ideas for change. 4. True. Within the obesity care setting, there is increased evidence of the effectiveness of MI interventions for behavioral outcomes such as eating behaviors and physical activity, and at the same time, there are less-​ conclusive findings as to the appropriate quantity and delivery of MI in that setting.

REFERENCES Amiri, P., Mansouri-​ Tehrani, M. M., Khalili-​ Chelik, A., Karimi, M., Jalali-​ Farahani, S., Amouzegar, A., & Kazemian, E. (2022). Does Motivational Interviewing improve the weight management process in adolescents? A systematic review and meta-​analysis. International Journal of Behavioral Medicine, 29(1), 78–​103. Armstrong, M. J., Mottershead, T. A., Ronksley, P. E., Sigal, R. J., Campbell, T. S., & Hemmelgarn, B. R. (2011). Motivational Interviewing to improve weight loss in overweight patients: A systematic review and meta-​analysis of randomized controlled trials. Obesity, 18(9), S86–​S87. Barnes, R. D., & Ivezaj, V. (2015). A systematic review of Motivational Interviewing for weight loss among adults in primary care. Obesity Review, 16(4), 304–​318. Barrett, S., Begg, S., O’Halloran, P., & Kingsley, M. (2018). Integrated Motivational Interviewing and cognitive behaviour therapy for lifestyle mediators of overweight and obesity in community-​dwelling adults: A systematic review and meta-​analyses. BMC Public Health, 18(1), 1160. Cushing, C. C., Jensen, C. D., Miller, M. B., & Leffingwell, T. R. (2014). Meta-​analysis of Motivational Interviewing for adolescent health behavior: Efficacy beyond substance use. Journal of Consulting and Clinical Psychology, 82(6), 1212–​1218. Falko Sniehotta, P., Bunten, A., Coulton, V., Blackshaw, J., & Tedstone, A. (2017). Changing behaviour: Techniques for tier 2 adult weight management services. doi: 10.13140/​ RG.2.2.13089.71520. Accessed June 23, 2020. Gayes, L. A, & Steele, R. G. (2014). A meta-​analysis of Motivational Interviewing interventions for pediatric health behavior change. Journal of Consulting and Clinical Psychology, 82(3), 521–​535. Hales, C. M., Carroll, M. D., Fryar, C. D., & Ogden, C. L. (2020). Prevalence of obesity and severe obesity among adults: United States, 2017–​2018. NCHS Data Brief, 360, 1–​8. Hales, C. M., Carroll, M. D, Fryar, C. D., & Ogden, C. L. (2017) Prevalence of obesity among adults and youth: United States, 2015–​2016. NCHS Data Brief, 288, 1–​8. Hardcastle, S. J., Fortier, M., Blake, N., & Hagger, M. S. (2017). Identifying content-​based and relational techniques to change behaviour in Motivational Interviewing. Health Psychology Review, 11(1), 1–​16. Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele R. G. (2011). Effectiveness of Motivational Interviewing interventions for adolescent substance use behavior change: A meta-​analytic review. Journal of Consulting and Clinical Psychology, 79(4), 433–​440.

Motivational Interviewing and Obesity  199 Makin, H., Chisholm, A., Fallon, V., & Goodwin, L. (2021). Use of Motivational Interviewing in behavioural interventions among adults with obesity: A systematic review and meta-​ analysis. Clinical Obesity, 11(4), e12457. Moss, E. L., Tobin, L. N., Campbell, T. S., & von Ranson, K. M. (2017). Behavioral weight-​loss treatment plus motivational interviewing versus attention control: Lessons learned from a randomized controlled trial. Trials, 18(1), 351. Ogden, C. L., Carroll, M. D., Lawman, H. G., Fryar, C. D., Kruszon-​Moran, D., Kit, B. K., & Flegal, K. M. (2016). Trends in obesity prevalence among children and adolescents in the United States, 1988–​1994 through 2013–​2017. Journal of the American Medical Association, 315(21), 2292–​2299. Patel, M. L., Wakayama, L. N., Bass, M. B., & Breland, J. Y. (2019). Motivational Interviewing in eHealth and telehealth interventions for weight loss: A systematic review. Preventive Medicine, 126, 105738. Reims, K. G., & Ernst, D. (2016). Using Motivational Interviewing to promote healthy weight. Family Practice Management, 23(5), 32–​38. Vallabhan, M. K., Jimenez, E. Y., Nash, J. L., Gonzales-​Pacheco, D., Coakley, K. E., Noe, S. R., DeBlieck, C. J., Summers, L. C., Feldstein-​Ewing, S. W., & Kong, A. S. (2018). Motivational Interviewing to treat adolescents with obesity: A meta-​ analysis. Pediatrics, 142(5), e20180733. Ward, Z. J., Bleich, S. N., Long, M. W., & Gortmaker, S. L. (2021). Association of body mass index with health care expenditures in the United States by age and sex. PLoS One, 16(3), e0247307. Wilfley, D. E., Kolko, R. P., & Kass, A. E. (2012) Cognitive behavioral therapy for weight management and eating disorders in children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 20(2), 271–​285.

12 Healing Justice Frameworks and Motivational Interviewing Supporting Survivors of Intimate Partner Violence Lauren Auster, Judy Chang, and Elizabeth Miller

Intimate partner violence (IPV) is defined as physical and sexual violence, emotional abuse, and stalking by an intimate partner. The US Centers for Disease Control and Prevention’s National Intimate Partner and Sexual Violence Survey (NISVS) indicates that one in four women and one in ten men have experienced contact sexual violence, physical violence, and/​or stalking by an intimate partner severe enough to have significant impact such as injury, need for medical care, or posttraumatic stress symptoms (Breiding, Smith, Basile, Walters, Chen, & Merrick, 2014). Globally, the leading cause of homicide death for women is IPV (Devries, et al., 2013). The health impacts of IPV are myriad and well documented, and include substance use, depression, anxiety, suicidality, poorly controlled chronic health conditions, undesired pregnancies, and HIV and other sexually transmitted infections (Miller & McCaw, 2019). The prevalence of IPV is highest among individuals aged 18 to 24 years, and for many, their first experiences of IPV occur during adolescence. Abusive experiences in adolescent romantic relationships are associated with IPV exposure later in adulthood (Exner-​Cortens, Eckenrode, & Rothman, 2013). The 2015 national Youth Risk Behavior Survey of high school students in the United States found that 21.4% of female and 9.6% of male students reported physical or sexual violence victimization by a partner in the past year (Rasberry, et al., 2017). Abuse through online technology and social media, including both sexual and nonsexual harassment and monitoring, is common among adolescents (Zweig, Dank, Yahner, & Lachman, 2013). For adolescents such experiences of abuse contribute to poor mental health, including substance use, chronic absenteeism, and inattention in school.

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Exposure to IPV occurs across all social strata, locations, and cultural backgrounds; prevalence estimates also vary by demographic characteristics. Specifically, exposure to IPV is higher among individuals who identify as sexual and gender minorities (Messinger, 2011); some racial or ethnic minorities, including Native American, multiracial, and non-​Hispanic Black women (Smith, et al., 2017); and people with mental and physical disabilities (Breiding & Armour, 2015), when compared to cisgender, heterosexual, White, and able-​bodied individuals. IPV is nested within other forms of violence and trauma, including systemic oppression, highlighting interactions with other forms of societal marginalization (Montesanti & Thurston, 2015). IPV also overlaps with sexual and labor exploitation; perpetrators of human trafficking may act initially like caring, romantic partners, but use coercive and controlling tactics that are like those seen with IPV (Moore, Houck, Hirway, Barron, & Goldberg, 2020). Abusive partners may also use threats, degrading comments, humiliation, and behaviors to monitor or control their victim, with significant health consequences, including poor adherence to treatment regimens. In the NISVS, for example, over a third of women reported experiencing psychological aggression in their lifetime (Smith, et al., 2017). Individuals who use violence and coercion in their relationships may also use alcohol, medications, or illicit drugs to subdue and control partners (i.e., substance use coercion) or use victims’ mental health diagnosis against them (e.g., calling them “crazy” and unstable and isolating them) (Warshaw, Lyon, Bland, Phillips, & Hooper, 2014). As portrayed in Scenario 1 below, partner interference with seeking care, keeping medical appointments, and filling prescriptions may make the individual who is experiencing such controlling behaviors appear medically nonadherent (McCloskey, Williams, Lichter, Gerber, Ganz, & Sege, 2007). Experiencing IPV is clearly disempowering, leading individuals to distrust their own ability to make appropriate decisions. During the COVID-​ 19 pandemic, survivors and advocates have also shared ways in which abusive partners are using the pandemic to force isolation, preventing their partner from seeking care, interfering with transportation, and stopping visits with family members and social supports. Thus, practitioners should always consider IPV and whether abusive behaviors may be contributing to poor health and difficulty with managing chronic health conditions.

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HEALING-​CENTERED APPROACHES AND MOTIVATIONAL INTERVIEWING IN CLINICAL SETTINGS For the past several decades, the primary paradigm for addressing IPV in the clinical setting has been a “screening” approach. Studies have found that simply screening for IPV (questions like “Are you being abused?” or “Are you in a relationship where you are afraid or feeling unsafe?”) does not actually improve quality of life or health outcomes for survivors (Klevens, et al., 2012; Taft, O’Doherty, Hegarty, Ramsay, Davidson, & Feder, 2013; Wathen & MacMillan, 2012). Interventions that are supportive and culturally relevant do make a difference in reducing isolation and increasing options for safety. The primary challenge with the screening paradigm is that provision of referrals and resources are tied to disclosure. Qualitative studies indicate that women experiencing IPV do want health trainees to talk to them about the violence in a safe and private setting, to be prepared to ask multiple times without pushing for disclosure, and to offer tangible medical and social resources for support (Chang, et al., 2005; Feder, Hutson, Ramsay, & Taket, 2006). Patients may not connect their somatic symptoms such as frequent headaches, musculoskeletal pain, palpitations, and insomnia to the chronic stressors associated with living with IPV. Printed information about linkages between stressful relationships and personal health can be useful in providing patients with information about available supports, while building trust with the practitioner and the practice. Over time, this may lead to a discussion with a practitioner who can provide a brief and caring intervention, and work with victim service advocates to implement safety and recovery strategies. When survivors of IPV (including adolescents and young adults) are asked about what they want from professionals who are in a helping role, they identify four key characteristics: 1. Be open to listening. 2. Avoid judgmental responses. 3. Offer support and information about existing resources (regardless of disclosure). 4. Do not push for disclosure (Chang, et al., 2005; Feder, Hutson, Ramsay, & Taket, 2006; Kulkarni, Bell, & Rhodes, 2012; Munro-​Kramer, Dulin, & Gaither, 2017; Reeves & Humphreys, 2018).

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It is vital to recognize that patients have a myriad of reasons not to disclose abuse to a healthcare practitioner, including shame and fear of consequences. Among populations that are marginalized and minoritized, the heavily carceral response of law enforcement, child welfare, and ongoing surveillance (that may come as an unintended consequence of disclosure) remains a serious deterrent to discussing violence with practitioners. Healing-​centered engagement (HCE), also called radical healing, is a health equity-​aligned approach that seeks to address prevention and aftermath of exposure to IPV, especially with those living in oppressed communities (French, et al., 2020). Ginwright describes HCE as an approach that “views trauma not simply as an individual isolated experience, but rather highlights the ways in which trauma and healing are experienced collectively” (2018). Specifically, health professionals working with survivors of IPV have opportunities to promote an understanding of history, collective experiences of trauma, and the ability of our patients and clients to be part of the solution. Specifically, within clinical encounters, a healing-​centered approach shifts away from disclosure-​driven practice to one that centers on the autonomy and strengths of our patients, which is at the core of Motivational Interviewing (MI). MI creates an atmosphere of safety, uses a collaborative approach, and focuses on empowering individuals by enhancing their self-​efficacy about changes that they can control themselves through, for example, coping, self-​ care, safety planning, health, social support, and substance use. Resisting the “righting reflex”—​the desire to make better, fix, or prevent harm (Miller & Rollnick, 2002; Chapter 2)—​is of fundamental importance in the context of working with individuals experiencing IPV. Practitioners can inadvertently replicate controlling behaviors that survivors have experienced in the past by pressuring them and attempting to persuade them to leave their abusive partners (Wahab, 2006). Such activation of the righting reflex can backfire and lead to discord in the relationship and a natural tendency to argue for the status quo and eventually cause the survivor to disengage from services (Grauwiler, 2008). Few studies have examined MI specifically for IPV. MI can enhance treatment engagement when used as a prelude to IPV treatment to strengthen motivation for change, treatment involvement, and session attendance (Soleymani, Britt, & Wallace-​B ell, 2018). Findings from other studies with general health-​seeking IPV survivors demonstrate MI’s effectiveness in reducing depressive and trauma symptoms and improving quality of life and

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self-​efficacy (Hegarty, et al., 2013; Saftlas, Harland, Wallis, Cavanaugh, Dickey, & Peek-​ Asa, 2014; Trabold, Swogger, McMahon, Cerulli, & Poleshuck, 2020). A recent randomized clinical trial evaluating RISE (recovering from IPV through strengths and empowerment), a brief, survivor-​ centered counseling intervention rooted in the principles of empowerment, trauma-​informed care, and MI, showed effectiveness in enhancing psychosocial well-​being, particularly empowerment, and self-​efficacy, among women experiencing IPV (Iverson, et al., 2022). Therefore, the integration of an MI framework into a healing-​centered approach yields positive outcomes and facilitates changes that are congruent with survivors’ values and goals. Universal prevention education and harm-​reduction counseling related to IPV during all clinical encounters mitigates against the assumption that a “no” response to a screening question about abuse means the patient has not experienced violent or controlling behaviors. One such universal approach, CUES is described in Table 12.1, with the MI theoretical framework and strategies. This approach has been evaluated in reproductive and adolescent health settings. It has been shown to increase patients’ knowledge of resources and strategies for harm reduction, and to reduce reproductive coercion and abuse victimization among adolescent and young adult women (Miller, et al., 2011; Miller, et al., 2015; Miller, et al., 2016). Interventions include ensuring that our patients from diverse backgrounds can access affirmative spaces where their identity, culture, and history are celebrated, thereby fostering trusted relationships. Clinical settings that embrace HCE can help ensure confidential access to information about relevant resources and services that are inclusive and culturally responsive, connecting patients to vital supports including victim service advocates. Among young people in particular, practitioners may also have the opportunity to connect youth to affirming activist spaces that nurture youth leaders to challenge patriarchy and related oppression. For patients with coexisting conditions, additional scripts to engage open discussion about IPV are described in Table 12.2. These scripts use the MI strategy of Ask-​Tell-​Ask (asking, listening, and informing) or Elicit-​Provide-​ Elicit (E-​P-​E) to create a collaborative space where patients feel more comfortable sharing their experiences. The CUES approach uses the MI spirit (collaboration, evocation, acceptance, and compassion), OARS (open-​ ended questions, affirmations, reflections, and summaries), and strategies such as E-​P-​E that can be easily integrated into all visit types.

Healing Justice Frameworks and MI  205 TABLE 12.1  CUES Approach Using CUES to Promote Healthy Relationships and Connect Patients to Resources Confidentiality Speak with the person alone for a part of every visit. Know and share limits of confidentiality: “Before I get started, I want you to know that everything here is confidential, meaning that I won’t talk to anyone else about what is happening unless you tell me that you are being hurt physically or sexually by someone, or planning to hurt yourself.” Universal Education Signal to patients you are a safe and trustworthy person to talk to: “I offer this information to all my patients because so many people struggle with complicated relationships that can affect their health. This card talks about situations where someone may be made to do things they do not want to do, and tips so they don’t feel alone. The back of the card has 24/​7 text and help lines that have folks who really understand complicated relationships. You can also talk to me about any health issues or questions you have, any time.” Acknowledge mistrust: “There are so many reasons that our patients may not trust the health care or social service system. I get that and never want you to feel like you have to share your story. A lot of patients aren’t ready or may feel afraid to share certain things about their health or relationships. I want you to know that you can use these resources for yourself or for a friend, regardless of what you choose to share with me today.” Empowerment Offer the person two resource cards: “I’m offering two of these cards to all my patients, in case it’s ever something you need and also for you to have information to help someone you know.” Offer option not to take the card for safety: “Please take this information if it’s safe for you to do so. Some of my patients prefer to put this information into their phone with a fake name, so they have easy access to essential resources, whenever. What works best for you?”

MI Framework and Strategies

Emphasis on patient autonomy. Underscore importance of privacy and confidentiality in this healing relationship.

Resist the “righting reflex”: resist telling, directing, or convincing patients what to share or do. Point out that individuals are experts on themselves, and their lives. Offer information in a MI-​ consistent way regardless of disclosures status. Allow patients to guide their narrative and how they choose to share their story. Build our trustworthiness as practitioners who are willing to respect and listen to ensure accurate understanding.

Emphasize collaboration and empowerment. Give patients options and identify strategies to overcome barriers. Provide an opportunity for patient to reflect on their own situations, experiences, and perceptions and avoid labeling. Support patients in considering their ability to help others. Emphasize altruism: a key strategy for enhancing resiliency, especially connectedness to others. (continued)

206  Motivational Interviewing, 2E TABLE 12.1 Continued Using CUES to Promote Healthy Relationships and Connect Patients to Resources Support Disclosure is not the goal of this healing-​centered approach, but disclosures will happen. Offer to provide a warm hand-​off to resources and create a care plan that takes IPV into consideration: “Thank you for trusting me with this part of your story. Relationships can be complicated, and it can be hard to know how to handle things with a partner. Is it OK if I connect you to [name], who can let you know about some of the resources other patients I care for have found helpful and ways that we can help?”

MI Framework and Strategies

Provide and emphasize autonomy support and increasing perception of choice. Ask for permission to connect to resources; transfer the trust nurtured between the practitioner and patient to another advocate or source of support.

Scenario 1 A 28-​year-​old woman, who does not use tobacco has had multiple emergency department visits over the past 2 years for asthma exacerbations. She has a daily preventive inhaler and verbalizes understanding of the importance of management of asthma and how to use inhalers. TRAINEE: First, I would like to share with you that the visit is confidential. I have seen many patients struggle with managing their health conditions. You have been

TABLE 12.2  Scripts for Patients with Coexisting Conditions Using the Ask-​Tell-​Ask/​Elicit-​ Provide-​Elicit Approach Mood disorder

Substance use disorder

Eating disorder

“Is it OK if I share some information with you? [Pause for response, if patient accepts the offer, then say] Some patients experience worsening of their depression because their partner makes them feel guilty about their symptoms or limits their ability to get support. How does your partner interact with you about your health?” “Can I share some information with you? [Pause for response, if patient accepts the offer, then say] Some of my patients who struggle with using substances have shared with me that their partner makes them use when they don’t really want to or discourages them from getting treatment to stop using. What has your experience been like?” “Is it alright if I share something with you? [Pause for response, if patient accepts the offer, then say] Sometimes patients who struggle with an eating disorder notice that their partner makes comments about their body or tries to influence what they eat. How is your partner a part of your story?”

Healing Justice Frameworks and MI  207 going through a tough time coping with your asthma. What has it been like taking your medications daily? [creating a safe atmosphere; complex reflection; open-​ ended question] PATIENT: Well, yes, it’s been hard for many years dealing with asthma attacks, and I do miss my medications sometimes. TRAINEE: Help me understand what you mean by “sometimes”? [open-​ended question] PATIENT: Oh, I just forget! TRAINEE: It is not unusual for a lot of people to forget taking medications daily. Before I just assume the reasons you forget to take the medication sometimes, and if it is OK, I want to share this information about relationships that I’m offering to all of my patients. From my experiences working with patients, they share that sometimes other situations in their lives, like their relationships or partners, get in the way of taking care of themselves. How do you see that being relevant or not to you? [affirmation; asking permission; open-​ended question]

With Disclosure PATIENT: [Looks down.] It’s not a big deal. He just keeps saying I shouldn’t have to use the inhaler all the time, that I’m not sick. He refuses to smoke outside the house. TRAINEE: I appreciate your trusting me enough to share your story and concerns. Clearly these situations can make caring for yourself challenging. [complex reflections] PATIENT: Yes, we argue a lot about this issue, and I have been trying to focus more on what I need to do instead of trying to change his behavior. TRAINEE: You are prioritizing your health and making sure you manage your condition the best you can. [affirmation] PATIENT: I must. TRAINEE: I was wondering whether you would be interested in some information about supports and counseling services listed on this informational card, and we can together work on facilitating any referrals you need. [asking permission] PATIENT: Sure. What do you suggest? TRAINEE: First, we can work on finding a pharmacy closer to your workplace where you can pick up your medications and work with the pharmacist on adjusting your asthma care plan, this way you will be able to take your medications at work and at your neighbor’s house on weekends. What do you think? [providing followed by eliciting] PATIENT: That sounds like a good plan. How about setting me up with some counseling to help me cope with problems at home? TRAINEE: Of course. Let us review some options and you can decide from there. How does that sound? [open-​ended question]

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Without Disclosure PATIENT: Not relevant. TRAINEE: You are not experiencing any situations with relationships that interfere with your taking the medications daily. If it’s safe for you to take this information about relationships and health, please do. Perhaps you have a friend or loved one who could use this information. [complex reflection followed by sharing information with permission] PATIENT: Thanks, yes, I know someone who can use this. TRAINEE: How do you feel about briefly discussing your forgetting to take the medications daily? [open-​ended question] PATIENT: Sure. What do you want to know? TRAINEE: I was wondering about what makes it challenging for you to take your medications at home. And whether it’s easier to take them while at work? [open-​ ended questions] PATIENT: I think I can handle it. I’m not much concerned about it. TRAINEE You feel confident about managing any challenges related to taking your medications. You are the expert on yourself. Whenever you think it would be helpful to discuss more, I will be available to listen and work with you on any concerns you may experience. [affirmation; autonomy support; open invitation for more conversations]

Scenario 2 A 31-​year-​old woman with major depressive disorder who is prescribed maintenance medication is experiencing recurrence of her depressive symptoms. She previously noted robust response to her antidepressant medication and has not experienced any depressive episodes for several months. After providing reassurance that the visit is confidential and that barriers to medication adherence are common, the trainee starts the conversation about medication adherence. TRAINEE: How have you been doing with taking your antidepressant? [open-​ended question] PATIENT: I have been taking my medication like usual. I even have a reminder on my phone. I think I’m just experiencing more stress than usual. TRAINEE: You have been more stressed out and overwhelmed recently. [complex reflection] PATIENT: Yes, it has not been easy at all. TRAINEE: What do you think has been contributing to your being more stressed out? [open-​ended question] PATIENT: It’s my girlfriend.

Healing Justice Frameworks and MI  209 TRAINEE: [A few moments of silence] Is it OK to share some information with you? [an informational card about relationships and health is offered; asking permission] PATIENT: Sure. TRAINEE: From my experience, some patients experience worsening of their depression because their partner makes them feel guilty about their symptoms or limits their ability to get support. How does your girlfriend talk with you about your depression or about getting support and treatment? [providing; open-​ended question]

With Disclosure PATIENT: [Becomes tearful] My girlfriend says that I am a waste of space when I have these episodes. I hate being such a burden. She’s right, there’s no reason for me to see my friends when I’m like this. TRAINEE: You have demonstrated so much courage about opening up regarding your struggles. I appreciate your trusting me with the process. Your girlfriend has difficulty understanding what you are going through when you have a depressive episode and tends to blame you and put you down. [affirmation; complex reflection] PATIENT: I understand that this is also hard for her, but I need her support when I am struggling with coping with depression. TRAINEE: It is crucial for you to have her support when you are depressed. [complex reflection] PATIENT: I was wondering maybe she does not clearly know how to be supportive of me. I should talk with her about it. TRAINEE: You made a valid point and having a conversation about your expectations from her could be helpful. [affirmation; complex reflection] PATIENT: Yes, I am going to do this. TRAINEE: How do you feel about discussing some options for additional support and services that can be available for you? [open-​ended question] PATIENT: Sure. I would need as much support as I can get.

The trainee then points to information about supports and services available on the informational card and offers to make referrals. Together the patient and trainee identify other social supports the patient can seek out when experiencing a depressive episode.

Without Disclosure PATIENT: I would rather not talk about it right now. TRAINEE: That’s OK, you are the best judge of if and when you want to discuss any concerns. I offer all my patients this information card about relationships and

210  Motivational Interviewing, 2E health. If you feel safe taking it home with you, please do. [support autonomy; offer information] PATIENT: Not sure TRAINEE: Sometimes people prefer to put this information under a fake contact in their phone, if that works better, it’s your choice. What do you think? [support autonomy; open-​ended question] PATIENT: Actually yeah, let me take a minute to type this into my phone. TRAINEE: How do you feel about discussing some options for additional support and services that can be available for you? [open-​ended question] PATIENT: Maybe some other time. TRAINEE: I respect your decision. And if you would like to discuss more about your relationship with your girlfriend, please let me know and I will be here to listen and work together. [supporting autonomy and personal control]

Scenario 3 A 26-​year-​old woman with opioid use disorder (OUD) is unsure about starting medication to treat it (MOUD). PATIENT: I tried to stop using opioids many times, but I have a hard time doing it. TRAINEE: You have not been able to quit using and at the same time you are determined to keep working on it. [complex reflection] PATIENT: I have to do it. I want to be a better mother and using opioids makes it hard for me to be able to function. TRAINEE: You want to reclaim your identity and that means not using opioids. What makes it challenging for you to quit using? [complex reflection; open-​ended question] PATIENT: My cravings are so overwhelming, and I cannot control them. And my boyfriend always wants me to use with him. TRAINEE: You are sharing two major issues interfering with your ability to quit using. [simple reflection] PATIENT: Yes, I’m really stuck. TRAINEE: We can work together on figuring out how to cope with these two concerns. [collaboration] PATIENT: Yes. I need your help. TRAINEE: Is it OK to share my experiences working with patients and provide some information? [asking permission] PATIENT: Alright. TRAINEE: Some of my patients who struggle with using substances have shared with me that their partner makes them use when they do not want to or discourages

Healing Justice Frameworks and MI  211 them from getting treatment. How is that relevant to you? [providing; open-​ended question]

With Disclosure PATIENT: [Nods her head and looks down.] Yea, he is always pushing me to use. Sometimes he gets angry, and it’s just easier to use than to deal with him. TRAINEE: Thanks so much for sharing with me. You are dealing with very challenging circumstances, which makes it hard for you to stop using even though you are highly motivated to stop. [complex reflection] PATIENT: Yeah, I am so frustrated and angry. I need to do something about it. TRAINEE: You want to take charge of your life. How do you feel about discussing some options for additional support and services that can be available for you? [complex reflection; open-​ended question] PATIENT: Like what? TRAINEE: Maybe having a private conversation with an advocate who is especially trained in helping people who are in complicated and challenging relationships. What do you think? [advice; open-​ended question] PATIENT: No, thanks. I don’t feel comfortable doing that. TRAINEE: I totally respect your decision. [autonomy support] TRAINEE: How do you feel about us discussing some suggestions about how to address your opioid use and review some options regarding medications that might help regulate your brain and control your cravings? [open-​ended question] PATIENT: Sure. That would be helpful.

The patient and the trainee work together to develop a safety plan. They also review harm-​reduction practices and revisit the patient’s thoughts on starting MOUD, including ways to safely store the medication and take it in private.

Without Disclosure PATIENT: No, it’s not like that. TRAINEE: Thanks for sharing your perspective. If you feel safe taking this home, here is a card about relationships and health that could be helpful to you or to your friends or family. [providing] PATIENT: Thanks doc, but I don’t think I need that. TRAINEE: Totally your decision. You are the best judge of what you need and want. I ask all of my patients if they’d be willing to put the information into their phone so

212  Motivational Interviewing, 2E that they always have the information available to be able to help a friend. How do you feel about doing that? [autonomy support; open-​ended question] PATIENT: No, I don’t need it. TRAINEE: It’s clearly not relevant at this time. What are your thoughts on discussing some options such as medication to help address your craving? [complex reflection; open-​ended question] PATIENT: We can do that. TRAINEE: If you think of other issues related to your recovery that you would like to explore, I will be available. [collaboration]

The trainee revisits the patient’s thoughts on starting MOUD, ways to privately take the medication, and goes over harm-​reduction practices. The three vignettes discussed above demonstrate how integrating MI within the healing-​centered approach creates a collaborative, safe, and empathic climate in which patients’ autonomy and decision-​making regarding change are communicated, respected, and supported. The compassion component of the MI spirit displayed in the clinical scenarios emphasizes the commitment to patients’ well-​being as a top priority.

Personal Reflection (Lauren Auster) Reflecting on my training in MI, the overwhelming feeling I want to share is gratitude. Specifically, as it applies to my role working with patients who have experienced trauma and IPV. I am grateful to practice a clinical framework that prioritizes partnership, compassion, and equipoise over forcing disclosure or routine treatment. MI continues to guide my reflective listening practice, enabling me to build rapport with patients and explore therapeutic options aligned with their needs and readiness moment to moment. I have also learned to develop discrepancy in my clinical encounters, which has improved my ability to elicit patients’ experiences and perspectives without offering judgment. Just as MI values the continuous and evolving relationship between patient and practitioners, I look forward to building upon my skills as a trainee and beyond.

CONCLUSION HCE helps to shift away from case-​identification and disclosure-​driven practice to an approach that focuses on harm reduction and patient strengths and autonomy. This approach recognizes that survivors of IPV share collective

Healing Justice Frameworks and MI  213

experiences of trauma, influenced by systems of oppression and marginalization, and that practitioners can partner with their patients to brainstorm and find solutions. Navigating the clinical encounter using the person-​centered MI framework and skills, always remembering to support the patient’s autonomy without imposing the practitioner’s aspirations for the patient, provides an ethical framework and can be a helpful antidote to the “righting reflex” and phenomenon of the “privileging leaving” bias (Wahab, 2006) when working with survivors of IPV. CUES can be used as a universal prevention education and harm-​reduction method for IPV and be adopted for those with coexisting conditions. Clearly more research is needed to investigate the effectiveness and mechanisms of advocacy, healthcare based, and MI interventions following disclosure and to better understand how they can serve as a bridge for services for other health needs. Practitioners must be well trained in the delivery of these interventions to practice them with fidelity.

SELF-​ASSESSMENT QUIZ True or False 1. MI is useful for survivors of IPV to convince them to leave an unhealthy relationship. 2. Eliciting a disclosure from a survivor about being in an abusive relationship should be the goal for a clinical encounter. 3. HCE is a research-​informed approach that centers the autonomy and strengths of survivors of IPV and situates the clinical encounter within a health equity lens and it is a natural fit with MI. 4. MI skills and strategies should not be used with patients who have experienced significant trauma.

Answers 1. False. MI is a collaborative conversation between patients and practitioners, rooted in principles of empathy and patient directed. The goals for addressing IPV in the clinical setting is to reduce a survivor’s sense of isolation and to increase the options for safety. Building trust with patients and connecting them to additional supports and services (if desired) is our goal, not pressuring, coercing, or convincing patients to leave an unhealthy or abusive relationship.

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2. False. Patients have many reasons for not wanting to disclose an abusive relationship to their practitioner, including concerns about shame, judgment, fear of retaliation; mistrust of the practitioner and health care system; and concern about carceral responses (including involvement of child welfare or law enforcement). Ensuring that patients feel safe and supported and receive relevant information about supports and safety should be the goal of clinical encounters, not forcing disclosures. 3. True. HCE situates IPV in the context of other forms of oppression and trauma, recognizes individual and collective resilience, and brings a health equity lens to clinical encounters. Offering universal education, unconditional support (regardless of disclosure), and connection to additional supports and services are all elements of a healing-​centered approach. Randomized clinical trials have shown that this approach increases recognition of abusive behaviors and increases awareness and uptake of safety strategies. MI can be easily integrated into this framework. 4. False. MI is a trauma-​sensitive practice. By meeting patients where they are at, listening to their stories, and reflecting their goals and values, MI creates space for patients who have experienced trauma to remain in control of their own narrative. Thus, MI is an ideal approach for building trust with patients, especially those who have experienced significant trauma and often do not see the health care system as trustworthy.

References Breiding, M. J., & Armour, B. S. (2015). The association between disability and intimate partner violence in the United States. Annals of Epidemiology, 25(6), 455–​457. Breiding, M. J., Smith, S. G., Basile, K. C., Walters, M. L., Chen, J., & Merrick, M. T. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—​national intimate partner and sexual violence survey, United States, 2011. MMWR Surveillance Summaries, 63(8), 1–​18. Chang, J. C., Cluss, P. A., Ranieri, L., Hawker, L., Buranosky, R., Dado, D., McNeil, M., & Scholle, S. H. (2005). Health care interventions for intimate partner violence: What women want. Womens Health Issues, 15(1), 21–​30. Devries, K. M., Mak, J. Y. T., García-​Moreno, C., Petzold, M., Child, J. C., Falder, G., Lim, S., Bacchus, L. J., Engell, R. E., Rosenfeld, L., Pallito, C., Vos, T., Abrahams, N., Watts, C. W. (2013). Global health: The global prevalence of intimate partner violence against women. Science, 340(6140), 1527–​1528. Exner-​Cortens, D., Eckenrode, J., & Rothman, E. (2013). Longitudinal associations between teen dating violence victimization and adverse health outcomes. Pediatrics, 131(1), 71–​78. Feder, G. S., Hutson, M., Ramsay, J., & Taket, A. R. (2006). Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: A meta-​analysis of qualitative studies. Archives of Internal Medicine, 166(1), 22–​37.

Healing Justice Frameworks and MI  215 French, B. H., Lewis, J. A., Mosley, D. V., Adames, H. Y., Chavez-​Duenas, N. Y., Chen, G. A., & Neville, H. A. (2020). Toward a psychological framework of radical healing in communities of color. Counseling Psychologist, 48(1), 14–​46. Ginwright, S. (2018). The future of healing: Shifting from trauma informed care to healing centered engagement. Medium. https://​ginwri​​​the-​fut​ure-​of-​heal​ing-​shift​ing-​ from-​tra​uma-​infor​med-​care-​to-​heal​ing-​cente​red-​eng​agem​ent-​634f5​57ce​69c. Accessed April 26, 2021. Grauwiler, P. (2008). Voices of women: Perspectives on decision-​making and the management of partner violence. Children and Youth Services Review, 30(3), 311–​322. Hegarty, K., O’Doherty, L., Taft, A., Chondros, P., Brown, S., Valpied, J., Astbury, J., et al. (2013). Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): A cluster randomized controlled trial. Lancet, 382(9888), 249–​258. Iverson, K. M., Danitz, S. B., Shayani, D. R., Vogt, D., Wiltsey Sterman, S., Hamilton, A. B., Mahoney, C. T., et al. (2022). Recovering from intimate partner violence through strengths and empowerment: Findings from a randomized clinical trial. Journal of Clinical Psychiatry, 83(1), 21m14041. Klevens, J., Kee, R., Trick, W., Garcia, D., Angulo, F. R., Jones, R., & Sadowski, L. S. (2012). Effect of screening for partner violence on women’s quality of life: A randomized controlled trial. JAMA, 308(7), 681–​689. Kulkarni, S. J., Bell, H., & Rhodes, D. M. (2012). Back to basics: Essential qualities of services for survivors of intimate partner violence. Violence Against Women, 18(1), 85–​101. McCloskey, L. A., Williams, C. M., Lichter, E., Gerber, M., Ganz, M. L., & Sege, R. (2007). Abused women disclose partner interference with health care: An unrecognized form of battering. Journal of General Internal Medicine, 22(8), 1067–​1072. Messinger, A. M. (2011). Invisible victims: same-​sex IPV in the National Violence Against Women survey. Journal of Interpersonal Violence, 26(11), 2228–​2243. Miller, E., Decker, M. R., McCauley, H. L., Tancredi, D. J., Levenson, R. R., Waldman, J., Schoenwald, P., & Silverman, J. G. (2011). A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion. Contraception, 83(3), 274–​280. Miller, E., Goldstein, S., McCauley, H. L., Jones, K. A., Dick, R. N., Jetton, J., Silverman, J. G., et al. (2015). A school health center intervention for abusive adolescent relationships: A cluster RCT. Pediatrics, 135(1), 76–​85. Miller, E., & McCaw, B. (2019). Intimate partner violence. New England Journal of Medicine, 380(9), 850–​857. Miller, E., Tancredi, D. J., Decker, M. R., McCauley, H. L., Jones, K. A., Anderson, H., James, L., & Silverman, J. G. (2016). A family planning clinic-​based intervention to address reproductive coercion: a cluster randomized controlled trial. Contraception, 94(1), 58–​67. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). Guilford Press. Montesanti, S. R., & Thurston, W. E. (2015). Mapping the role of structural and interpersonal violence in the lives of women: Implications for public health interventions and policy. BMC Women’s Health, 15(1), 100. Moore, J. L., Houck, C., Hirway, P., Barron, C. E., & Goldberg, A. P. (2020). Trafficking experiences and psychosocial features of domestic minor sex trafficking victims. Journal of Interpersonal Violence, 35(15–​16), 3148–​3163. Munro-​Kramer, M. L., Dulin, A. C., & Gaither, C. (2017). What survivors want: Understanding the needs of sexual assault survivors. Journal of American College Health, 65(5), 297–​305. Rasberry, C., Tiu, G., Kann L., McManus, T., Michael, S. L., Merlo, C. L., Lee, S. M., et al. (2017). Health-​related behaviors and academic achievement among high school students—​United States, 2015. Morbidity and Mortality Weekly Report, 66(35), 921–​927. Reeves, E. A., & Humphreys, J. C. (2018). Describing the healthcare experiences and strategies of women survivors of violence. Journal of Clinical Nursing, 27(5–​6), 1170–​1182.

216  Motivational Interviewing, 2E Saftlas, A. F., Harland, K. K., Wallis, A. B., Cavanaugh, J., Dickey, P., & Peek-​Asa, C. (2014). Motivational interviewing and intimate partner violence: A randomized trial. Annals of Epidemiology, 24(2), 144–​150. Smith, S. G., Chen, J., Basile, K. C., Gilbert, L., Merrick, M. T., Patel, N., Walling, M., & Jain, A. (2017). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010–​2012 State report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. https://​​vio​lenc​epre​vent​ion/​pdf/​NISVS-​Stat​ eRep​ortB​oOK.pdf. Accessed June 2022. Soleymani, S., Britt, E., & Wallace-​Bell, M. (2018). Motivational interviewing for enhancing engagement in intimate partner violence (IPV) treatment: A review of the literature. Aggression and Violent Behavior, 40, 119–​127. Taft, A., O’Doherty, L., Hegarty, K., Ramsay, J., Davidson, L., & Feder, G. (2013). Screening women for intimate partner violence in healthcare settings. Cochrane Database of Systematic Reviews, (4), CD007007. Trabold, N., Swogger, M., McMahon, J., Cerulli, C., & Poleshuck, E. (2020). A brief motivational intervention to address intimate partner violence victimization: A pilot study. Research on Social Work Practice, 30(6), 633–​642. Wahab, S. (2006). Motivational interviewing: A client centered and directive counseling style for work with victims of domestic violence. Arete, 29(2), 11–​22. Warshaw, C., Lyon, E., Bland, P. J., Phillips, H., & Hooper, M. (2014). Mental health and substance use coercion surveys. Report from National Center on Domestic Violence, Trauma & Mental Health (NCDVTMH) National Domestic Violence Hotline, 1–​25. Wathen, C. N., & MacMillan. H. L. (2012). Health care’s response to women exposed to partner violence: Moving beyond universal screening. JAMA, 308(7), 712–​713. Zweig, J. M., Dank, M., Yahner, J., & Lachman, P. (2013). The rate of cyber dating abuse among teens and how it relates to other forms of teen dating violence. Journal of Youth and Adolescence, 42(7), 1063–​1077.

13 Motivational Interviewing for Substance Use Antoine Douaihy, Jody Glance, and Estelle Hirsh

Substance use disorders (SUDs) are heterogeneous conditions characterized by recurrent compulsive use of a psychoactive substance associated with significant morbidity and mortality. According to the US Centers for Disease Control and Prevention, the number of Americans dying from overdose quadrupled between 1999 and 2019. Numbers continued to rise during the COVID-​19 pandemic, with over 100,000 overdose deaths in the 1-​year period between April 2020 and April 2021, the first time in any 12-​month period that this number exceeded 100,000. Additionally, 95,000 Americans die each year from the effects of alcohol use disorder. In comparison, diabetes-​related deaths totaled 87,647 in 2019. Given the gravity of these data, SUD should be treated on par with any other life-​threatening medical illness. In the spirit of Motivational Interviewing (MI), the practitioner views the patient through an empathic, nonjudgmental lens to create a collaborative and empowering relationship. However, stigma remains one of the greatest barriers to treatment for substance use. The stigma surrounding SUD does not necessarily accompany other diseases (i.e., diabetes, hypertension), creating a unique treatment challenge. In the preceding decades, there has been little improvement in addressing stigma; in fact, from 1996 to 2006, attitudes of the general public (adults aged older than 18 years) toward people with alcohol use disorder did not improve. Of those surveyed, a majority did not want to work closely with, socialize with, or be neighbors with someone with alcohol use disorder (AUD), nor have a person with AUD marry into their family (Pescosolido, Martin, Long, Medina, Phelan, & Link, 2010). Another study found that most (69.2%) primary care physicians believe that patients could, with treatment, “get well and return to productive lives.” However, negative attitudes still existed among these physicians; a majority were unwilling to work closely with persons with addiction to prescription pain medications,

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and a majority were unwilling to have them marry into their family (Kennedy-​ Hendricks, et al., 2016).

STATE OF RESEARCH ON MOTIVATIONAL INTERVIEWING AND SUBSTANCE USE Clinical trials with a wide range of populations, conditions, cultures, and professions have demonstrated the efficacy of MI, which was originally conceptualized to facilitate change and reduce drinking in people with AUD (“problem drinkers”) (Miller, 1983; Miller & Moyers, 2017). Miller’s 1983 seminal work Motivational Interviewing for Problem Drinkers outlines the early conceptualization of the approach and spirit of MI: The model deemphasizes labeling and places heavy emphasis on individual responsibility and internal attribution of change. Cognitive dissonance is created by contrasting the ongoing problem behavior with salient awareness of the behavior’s negative consequences. . . . This motivational process is understood within a larger developmental model of change in which contemplation and determination are important early steps which can be influenced by therapist interventions.

Since that pivotal paper, MI has been established as an efficacious collaborative and evocative counseling approach that enhances motivation for change (Miller & Rollnick, 2013). Much of the MI outcomes research has focused on treatment of SUD, particularly AUD. Studies of MI for SUD have shown the largest treatment effects, indicating a fundamental role of MI in the treatment of SUD (Schumacher & Madson, 2014). It has been well established through research that, regardless of the type of treatment for SUD, therapist empathy is a predictor of positive outcome (Miller & Moyers, 2015; Moyers, Rowell, Manuel, Ernst, & Houck, 2016). Practitioners’ MI skillfulness and techniques predict increased change talk regarding addictive behaviors (Barnett, et al., 2014; Gaume, 2010; Moyers, Martin, Houck, Christopher, & Tonigan, 2009). Even a single session at the outset of treatment doubled the rate of abstinence at follow-​up (Brown & Miller, 1993). MI seems to be more effective in individuals with more severe levels of substance use, such as heavier drinkers; among pregnant women; and in individuals with heavy cannabis use (Handmaker, Miller, & Manicke, 1999; Mason, Sabo, & Zaharakis, 2017). A systematic review and meta-​analysis demonstrated that a single-​session brief alcohol intervention incorporating MI skills and strategies may be particularly effective

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in reducing alcohol consumption among college students engaged in heavy drinking (Samson & Tanner-​Smith, 2015). There has been some debate about the degree to which MI that is more intensive, in the form of more frequent and/​or longer sessions, could be associated with better outcomes. A current study of Intensive Motivational Interviewing (IMI), a 9-​session dose of MI designed for women with alcohol use disorders compared to a single MI session (SMI), showed a significant reduction in drinking among heavy drinkers at 2-​and 6-​month follow-​up compared to the SMI condition (Polcin, et al., 2019). MI has been also used as an adjunct to existing therapies, most typically as a pretreatment to prepare patients to engage in inpatient or outpatient substance use treatment programs (Lundhal & Burke, 2009). In a large clinical trial (Project MATCH Research Group, 1993), MI was adapted to a four-​session format by adding assessment feedback of the patient’s results (Miller, Zweben, DiClemnte, & Rychtarik, 1992) and called Motivational Enhancement Therapy (MET). Earlier studies of a similar “drinker’s check-​up” demonstrated effectiveness in reducing the use of alcohol and other drugs (Miller & Sovereign, 1989; Walker, Stephens, Towe, Banes, & Roffman, 2015). In the MATCH trial, cognitive-​behavioral therapy (CBT) skill training was compared head-​to-​head with two other evidence-​ based therapies: 12-​ step facilitation therapy (TSF) and MET (Project MATCH Research Group, 1997a). The MET intervention yielded similar improvement to that from CBT or TSF. Once treatment has ended, however, all three interventions showed similar and substantial benefit through 3 years of follow-​up on the study’s main outcome measures (Babor & Del Boca, 2003). The personalized feedback in the MET intervention is given using a nonconfrontational, empathic style reviewing the multiple dimensions of drug use, including level of use, severity of consequences, physical health and risk factors, and asking the patient to respond to the assessment information compared to treatment as usual for SUD. MI has also been shown to reduce youth substance use across a variety of settings (Jensen, Cushing, Aylward, Craig, Sorell, & Steele, 2011; Naar-​King & Suarez, 2010). In a recent study (Clair-​Michaud, Martin, Stein, Bassett, Lebeau, & Golembeske, 2016), MI worked best at reducing alcohol and cannabis use and other risky behaviors in adolescents with low levels of depression in a juvenile correction facility. Co-​occurring psychiatric disorders could play a role as moderators of MI outcomes. An emerging area of research of MI efficacy in criminal justice settings has shown that MI is efficacious with “offenders” in community corrections to facilitate engagement and retention in treatment (McMurran, 2009; Spohr, Taxman, Rodriguez, & Walters, 2016).

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Another area that requires more research is the degree to which MI is uniquely effective with individuals from racial and ethnic minority backgrounds. Hettema et al. (2005) and Lundahl et al. (2010) found mixed results in relation to MI outcomes with individuals from Native American, African American, and Hispanic backgrounds. Some results suggested greater efficacy of MI within ethnic minority populations (Hettema, Steele, & Miller, 2005), while other results showed no differences (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). MI’s emphasis on individual patient values and aspirations and on patients being the experts on themselves, combined with its person-​centered collaborative nature, makes it a potentially effective cross-​cultural approach (Landry, Madson, Thomson, Zoellener, Connell, & Yadrick, 2015; Lundahl and Burke, 2009; Miller, Hendrickson, Venner, Bisone, Daugherty, & Yahne, 2008; Oh & Lee, 2016). However, more research exploring MI with homogeneous samples of diverse and underrepresented groups is needed to help better understand and design culturally congruent adaptations of MI that might improve its treatment effects (Dickerson, Brown, Johnson, Schweigman, & D’Amico, 2015).

COMBINING MI WITH OTHER THERAPEUTIC MODALITIES MI used in clinical trials as a stand-​alone treatment is often effective even without add-​on treatments, but combining the clinical style of MI with other treatment modalities is a common practice (Miller, 2004; Naar & Safren, 2017). In this sense, Miller pointed out that MI is a way of doing whatever else you do (MINT Forum, 2019). The successful mélange of MI and other interventions for substance use is much more common than the use of “pure” MI (Hettema, Steele, & Miller, 2005). The question of whether to use MI alone or with other treatment modalities continues to be debated, with many studies showing an even greater effect for MI when it is paired with more intensive interventions such as inpatient treatment (Bien, Miller, & Tonigan, 1993; Brown & Miller, 1993). A large-​scale study found that a combined MI, CBT, and family therapy approach can be effective in reducing substance use for at least 1 year among patients with schizophrenia (Barrowclough, et al., 2010). Bellack and Gearon (1998) developed a combined MI/​Contingency Management approach (Behavioral Treatment for Substance Abuse in Severe and Persistent Mental Illness [BTSAS]) that includes relapse prevention strategies and short-​term goal setting. Another illustration of a combination of MI with other treatment modalities is the COMBINE research project. This was

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a clinical trial funded by the National Institute of Alcoholism and Alcohol Abuse to investigate the effectiveness of two medications (naltrexone and acamprosate) for heavy drinking, both alone and in combination with each other (COMBINE Study Research Group, 2003a and b). The result of this trial was the Combined Behavioral Intervention (CBI). CBI was based on the principles and skills described in the early editions of MI (Miller & Rollnick, 1991; Miller & Rollnick, 2002) and CBT (Litt, Kadden, Cooney, & Kabela, 2003). It included components from CBT, MET, and TSF, all originally developed for and evaluated positively in Project MATCH (Project MATCH Research Group, 1997). Although CBI merged elements from each of these treatments, the therapeutic style of MI was used based on strong empirical support for MI as an intervention with patients with SUDs (Miller, Wilbourne, & Hetema, 2002). MI can be successfully blended with other treatment modalities, for instance, using the example of CBI, employed in the COMBINE research project (Moyers & Houk, 2011).

WHICH PATIENTS ARE RESPONSIVE TO MI IN SUD TREATMENT? A comprehensive review of the efficacy and effectiveness of MI interventions did not find any consistent individual characteristics that moderate MI’s effects on outcomes for alcohol, tobacco, or other drug use (DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017). This raises the issue of which patients would be a good “fit” for MI. The primary tenet of the MI approach is that ambivalence is common and normal, particularly with SUDs. Using a collaborative and empathic style, the MI practitioner engages the patient in conversations about change and seeks to evoke and strengthen change talk while reframing and deflecting sustain talk as the conversation continues. The technical hypothesis of MI supports the link between patient speech during a session and actual positive behavioral outcomes (Amrhein, Miller, Yahne, Knupsky, & Hochstein, 2003; Miller & Rose, 2009). A meta-​analysis added that the dynamic resolution of ambivalence, not just the technical aspect of evoking change talk, is likely necessary for behavior change to occur (Magill, et al., 2014). The recent evidence suggests that MI may be most effective with people expressing a high degree of ambivalence early in the session (Forman, Moyers, & Houck, 2021). An increase in the percentage of change talk occurred when early session language had equal ratios of change talk to sustain talk, suggesting high levels of ambivalence. These individuals were responsive to the evoking strategies of MI. For patients who are moving in the

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direction of change and showing readiness to change, MI may be unhelpful or even counterproductive (Forman, Moyers, & Houck, 2021). In fact, individuals already expressing a high degree of readiness to change at the start of a session showed a decrease in the percentage of change talk during the evoking phase of MI. Identifying the importance of ambivalence as a clinical indicator for the use of MI also helps determine in which clinical encounters MI might not be indicated. It also is reasonable to further expand this rationale: for patients who have made significant change in their substance use or are in remission from SUD, relapse prevention and behavioral coping skills interventions using MI style are more appropriate and potentially more effective. The following clinical encounter with a young adult who presented to the emergency department intoxicated with alcohol illustrates the use of MI skills and strategies to address his alcohol use and his strong ambivalence about engaging in treatment. Accompanied by the police, he was admitted to the dual diagnosis unit on an involuntary commitment order. After initially refusing to meet, he later agreed to join the team for the initial session. TRAINEE: Thank you for coming to meet with us. What’s your understanding of how you ended up in the hospital? [open-​ended question] PATIENT: I’m here because I got to a breaking point, I called 911, and they brought me here. TRAINEE: You got to a breaking point when you felt you needed help. What was going on for you? [complex reflection followed by an open-​ended question] PATIENT: I was angry, man! Really angry. TRAINEE: You were angry, and you felt so angry it got to a breaking point. What was that like for you? [simple reflection; complex reflection; open-​ended question] PATIENT: Yeah . . . I thought I was going to do something violent. TRAINEE: You felt so angry that you were out of control. You thought you might do something you would regret if you didn’t get help. What were you angry about? [complex reflections; open-​ended question] PATIENT: My situation. I’m homeless. TRAINEE: You were feeling angry about being homeless. How did you lose your housing? [complex reflection; open-​ended question] PATIENT: I lost my job in February and could not pay my rent. By April, they kicked me out, and I’ve been on the streets ever since. TRAINEE: You have been dealing with being homeless for a while, and it makes you angry. You were afraid you would become violent and do something you would regret. [summary] PATIENT: Well, not really afraid. Probably nothing would’ve happened, and I could have just gone to a friend’s place.

Motivational Interviewing for Substance Use  223 TRAINEE: You are not sure you would have gotten violent, and at the same time, you were feeling so angry that it was overwhelming, and you felt out of control. So, you decided to call 911. [complex reflections] PATIENT: Yup. TRAINEE: Then what happened? [open-​ended question] PATIENT: I came here . . . with a bit of help. TRAINEE: You are looking for some help. How do you feel about being here now? [complex reflection; open-​ended question] PATIENT: I think I made a mistake. I have to go to court Thursday and Friday for my hearings, and if I don’t make it, I’ll have to go back to jail. I don’t want to go to jail, and that’s what will happen if I miss the hearings. TRAINEE: You feel like it was a mistake to end up here because you are concerned that you will miss your hearings. [complex reflection] PATIENT: Yeah, and I cannot go back to jail. TRAINEE: And it is important for you to go to court because you do not want to end up in jail again. [complex reflection] PATIENT: Well, would you want to? TRAINEE: That is a big consequence for you, or anyone, and it is important that you avoid it. [complex reflection] PATIENT: Right. TRAINEE: And you are wondering if you made the right decision coming here and at the same time, last night you felt so angry that it became overwhelming and out of control, and you felt you needed to call for help. [summary] PATIENT: Yeah, well, I never would have called if I were not drinking. I would have gone to a friend’s house and probably nothing would have happened. TRAINEE: You were drinking, and you think that made you lose control and prompted your call. How long had you been drinking? [complex reflection; close-​ended question] PATIENT: A few hours. TRAINEE: What else was going on yesterday? [open-​ended question] PATIENT: Nothing, I spent some time with some friends. TRAINEE: You have been homeless since April . . . what happened that made your anger reach a breaking point last night? [complex reflection; open-​ended question] PATIENT: I was just getting angry about my situation. TRAINEE: Your situation. [simple reflection] PATIENT: I just keep getting turned out of places and don’t have so many options. TRAINEE: And you have been angry . . . at your situation, at the people who have been unwilling to help you. [complex reflection] PATIENT: Yeah, and that I got into this situation.

224  Motivational Interviewing, 2E TRAINEE: And a little angry at yourself, for getting into this situation. [complex reflection] PATIENT: Yeah. TRAINEE: What happened that made you homeless most recently? [open-​ended question] PATIENT: Some so-​called friends said I could stay with them, and then they changed their minds and kicked me out. TRAINEE: You had some friends who offered to help you out, and they betrayed your trust. [complex reflection] PATIENT: Yeah, betrayed . . . they just kicked me out. TRAINEE: How did you initially lose your housing? [open-​ended question] PATIENT: I was renting a place, and I asked a friend to give my rent money to my landlord for me one time, and she just pocketed it instead. TRAINEE: So, you trusted your friend to help you, and instead she betrayed you. How did that make you feel? [complex reflection; open-​ended question] PATIENT: Angry! And hurt. TRAINEE: You felt angry at your friend, at your situation, at yourself for trusting her because she hurt you. [complex reflection] PATIENT: Wouldn’t you be? TRAINEE: Well, it does hurt that she violated your trust . . . I think anyone would be hurt and angry about that. [complex reflection] PATIENT: Yeah, for sure. That’s why I can’t trust anyone. TRAINEE: You feel you cannot trust anyone because you have had that trust violated so many times before. [complex reflection] PATIENT: Yeah. TRAINEE: You were also feeling angry about what happened . . . how do you usually handle things when you are feeling that angry? [complex reflection; open-​ended question] PATIENT: It just rolls off. TRAINEE: Sometimes it just rolls off. And at the same time, it builds up until it gets overwhelming, like last night. What’s the difference between anger that rolls off and anger that gets overwhelming for you? [complex reflections; open-​ended question] PATIENT: Well, a lot of times it’s something little and it’ll just roll off. But the big things that don’t go away kind of build up. TRAINEE: So more recently, the big things—​being homeless, and feeling like you can’t trust anyone—​didn’t go away, and your anger kept building up. I know you said you wouldn’t have called for help last night if you hadn’t been drinking. [summary] PATIENT: Yeah.

Motivational Interviewing for Substance Use  225 TRAINEE: And at the same time all this anger was building up. How do you think your drinking played a role in your calling for help? [complex reflection; open-​ended question] PATIENT: Drinking makes me think about my situation, and my anger more . . . it makes me focus on it. TRAINEE: When you are drinking, you focus more on how you are feeling. [complex reflection] PATIENT: After I’m done drinking, I do. TRAINEE: After you stop drinking you start to focus on your feelings, and that makes them more intense and overwhelming. [complex reflection] PATIENT: Yeah. TRAINEE: What is it like when you are drinking? [open-​ended question] PATIENT: While I’m drinking, I feel happy, feel good. Then when I lay down for the night and I’m still drunk, I start thinking about my situation. TRAINEE: And then you feel worse. So, when you’re drinking, it’s like an escape from how you feel about being homeless, and then after you’re done you feel even worse than when you started. [complex reflections] PATIENT: Yeah. TRAINEE: You have been struggling with being homeless, feeling like you cannot trust anyone who offers help, feeling hurt by others, and feeling angry about your situation and at yourself for being stuck. And that makes you want to drink to escape from it. And when you drink, you end up feeling even more angry and sad afterward. [summaries] PATIENT: Yeah, when I focus on it, I feel worse. TRAINEE: I understand that you wish you had not come here—​what do you think would happen if you left now? [complex reflection; open-​ended question] PATIENT: I’ll be fine if I don’t drink. TRAINEE: If you do not drink, you feel you could manage. How does drinking get in the way? [complex reflection; open-​ended question] PATIENT: Well, it makes me end up here, and then I miss my hearings . . . and go back to jail. TRAINEE: Drinking makes your emotions feel out of control, and then you need to get help, which gets in the way of the rest of your life. How else? [complex reflection; open-​ended question] PATIENT: I run out of money, and then it’s hard to get an apartment and get to AA meetings and everything. TRAINEE: Drinking keeps you from getting to AA meetings and making steps that would help you get housing, which is a major goal for you. How confident do you feel that you can stop drinking, let us say on a scale of 1 to 10, where 1 is not confident and 10 is very confident? [complex reflection; open-​ended question; confidence ruler]

226  Motivational Interviewing, 2E PATIENT: I’m confident, maybe 6 or 7. TRAINEE: What makes you confident at 6 or 7? [open-​ended question] PATIENT: I know myself, and when I set my mind to something, I do it. TRAINEE: You are the kind of person that follows through when you set your mind to something. [affirmation] What puts you at 6 or 7 instead of 2? [open-​ended question] PATIENT: Yeah, I have a strong willpower and especially when there’s something important motivating me, like I need to get to those hearings. I can’t go back to jail. TRAINEE: When you have important things to follow through and you are aware your drinking interferes with that, you feel more able to control it. Like making it to your court date, attending AA meetings, getting money, and making your appointments for housing. [complex reflections] PATIENT: Right. TRAINEE: What can we work on together while you are here to help you follow through with your goals? [open-​ended question reflecting collaboration] PATIENT: I just need to do it. TRAINEE: How do you feel about working together for a short period of time so we can determine what resources in the community we can assist you with? [open-​ended question] PATIENT: Sure, as long as I don’t have to stay for more than few days. TRAINEE: Of course, we can negotiate that. Thanks for sharing your struggles and your willingness to work together. [collaboration]

This therapeutic encounter emphasizes the importance of meeting the patient where he is, as well as showing he is a good “fit” for MI, since his language at the start of the session demonstrates a high degree of ambivalence about engaging in treatment and addressing his alcohol use and its connection to negative consequences. The trainee maintained the spirit of MI consistently throughout the session and used OARS skills to reduce discord in the working alliance, facilitate engagement, and explore ambivalence.

PERSONAL REFLECTION (Estelle Hirsh) On my first rotation as a psychiatry resident, I was assigned to rotate on the dual diagnosis unit. The focus of this rotation was to work with patients with SUDS and co-​occurring substance use and psychiatric disorders. Learning and using MI in addressing patients’ substance use problems and receiving real-​time in vivo coaching were core aspects of this rotation. This is easier said than done, especially for a novice. It is not uncommon to

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feel underprepared and inadequate during medical training, so I was accustomed to this discomfort and low self-​efficacy, at the same time it was a unique feeling during this experience. In fact, I felt like a fish out of water. I have not had previous training with working with patients with SUDs. In my encounters with patients, I found myself fumbling over my words, often using antiquated terms, and at times stigmatizing language that had negative connotations in relation to patients’ behaviors. I felt like an impostor. I bombarded my patients with closed-​ended questions and often found my sessions stopped before they could even start. Slowly and gradually, something clicked. I began to embrace the spirit of MI and engage in deliberate practice of its skills and strategies (while receiving consistent in vivo coaching and feedback and adopting a growth mindset) and I learned to pay close attention to certain aspects of my patient language and responded to it skillfully and mindfully. I discovered what the true nature of MI is about and how it allows a better understanding of patients’ struggles and focuses on enhancing their motivation for change instead of blaming, persuading, stigmatizing, and labeling them! Understanding the role of ambivalence as the most common motivational obstacle to change in patients with SUDs, described by Miller as “like having an internal control committee” (Miller, 2022), and learning how to tackle it using the MI approach through evoking change talk has been one of the highlights of my training experience during the rotation. In MI, you address the ambivalence and help people find their way out of the forest (Miller & Rollnick, 2004). Integrating the cornerstones of the relationship in MI (defined by the partnership, acceptance, compassion, and evocation) with the technical skills clearly produces positive behavioral outcomes.

SELF-​ASSESSMENT QUIZ True or False 1. MET is an adaptation of MI that has been shown to be successful in treating patients with SUDs. 2. Patient motivation for change in addictive behaviors is highly responsive to counseling style. 3. MI is an appropriate approach with patients who showed low degree of ambivalence about changing their substance use. 4. Combining MI with other treatment methods can have a synergistic effect.

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Answers 1. True. MET, a very successful adaptation of MI, is a four-​session therapeutic intervention that includes addressing patients’ substance use and strengthening motivation for change. 2. True. The practitioner adherence to and skillfulness in the collaborative and empathic style of MI predicts greater patient change in addictive behaviors. 3. False. For patients who are showing readiness to change and exhibiting a low level of ambivalence, MI may not be helpful or even could be counterproductive. MI is mostly effective with patients who express a high degree of ambivalence about changing their substance use behavior. 4. True. Combining MI with other treatment modalities is a common practice and can yield positive outcomes.

REFERENCES Amrhein, P. C., Miller, W. R., Yahne, C., Knupsky, A., & Hochstein, D. (2004). Strength of client commitment language improves with therapist training in Motivational Interviewing. Alcoholism-​Clinical and Experimental Research, 28(5), 74A. Babor, T. F., & Del Boca, F. K. (Eds.). (2003). Treatment matching in alcoholism. Cambridge University Press. Barnett, E., Spruijt-​Metz, D., Moyers, T. B., Smith, C., Rohrbach, L. A., Sun, P., & Sussman, S. (2014). Bidirectional relationships between client and counselor speech: The importance of reframing. Psychology of Addictive Behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 28(4), 1212–​1219. Barrowclough, C., Haddock, G., Wykes, T., Beardmore, R., Conrod, P. J., Craig, T., Davies, L. M., Dunn, G., Eisner, E., Lewis, S., Moring, J. C., Steel, C., & Tarrier, N. (2010). Integrated Motivational Interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial. BMJ, 341, c6325. Bellack, A. S., & Gearon, J. S. (1998). Substance abuse treatment for people with schizophrenia. Addictive Behaviors, 23749, 766. Berman, J. S., & Norton, N. (1985). Does professional training make a therapist more effective? Psychological Bulletin, 98(2), 401–​407. Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88(3), 315–​335. Brown, J. M., & Miller, W. R. (1993). Impact of Motivational Interviewing on participation and outcome in residential alcoholism treatment. Psychology of Addictive Behaviors, 7(4), 211–​218. Clair-​Michaud, M., Martin, R. A., Stein, L. A. R., Bassett, S., Lebeau, R., & Golembeske, C. (2016). The impact of Motivational Interviewing on delinquent behaviors in incarcerated adolescents. Journal of Substance Abuse Treatment, 65, 13–​19. COMBINE Study Research Group. (2003a). Testing combined pharmacotherapies and behavioral interventions in alcohol dependence: Rationale and methods. Alcoholism: Clinical and Experimental Research, 27, 1107–​1122.

Motivational Interviewing for Substance Use  229 COMBINE Study Research Group. (2003b). Testing combined pharmacotherapies and behavioral interventions for alcohol dependence (The COMBINE Study): A pilot feasibility study. Alcoholism: Clinical and Experimental Research, 27, 1123–​1131. Dickerson, D. L., Brown, R. A., Johnson, C. L., Schweigman, K., & D’Amico, E. J. (2015). Integrating Motivational Interviewing and traditional practices to address alcohol and drug use among urban American Indian/​Alaska Native youth. Journal of Substance Abuse Treatment, 65, 26–​35. DiClemente, C. C., Corno, C. M., Graydon, M. M., Wiprovnick, A. E., & Knoblach, D. J. (2017). Motivational Interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychology of Addictive Behaviors, 31(8), 862–​887. Forman, D. P., Moyers, T. B., & Houck, J. M. (2021). What can clients tell us about whether to use Motivational Interviewing? An analysis of early session ambivalent language. Journal of Substance Abuse Treatment, 132, 108642. Gaume, J., Bertholet, N., Faouzi, M., Gmel, G., & Daeppen, J. B. (2010). Counselor Motivational Interviewing skills and young adult change talk articulation during brief motivational interventions. Journal of Substance Abuse Treatment, 39(3), 272–​281. Handmaker, N. S., Miller, W. R., & Manicke, M. (1999). Findings of a pilot study of Motivational Interviewing with pregnant drinkers. Journal of Studies on Alcohol, 60(2), 285–​287. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1, 91–​111. Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of Motivational Interviewing interventions for adolescent substance use behavior change: A meta-​analytic review. Journal of Clinical and Consulting Psychology, 79(4), 433–​440. Kaner, E. F., Dickinson, H. O., Beyer, F., Pienaar, E., Schlesinger, C., Campbell, F., Saunders, J. B., Burnand, B., & Heather, N. (2009). The effectiveness of brief alcohol interventions in primary care settings: A systematic review. Drug and Alcohol Review, 28(3), 301–​323. Kelly, J. F., & Westerhoff, C. M. (2010). Does it matter how we refer to individuals with substance-​ related conditions? A randomized study of two commonly used terms. International Journal on Drug Policy, 21(3), 202–​207. Kennedy-​Hendricks, A., Busch, S. H., McGinty, E. E., Bachhuber, M. A., Niederdeppe, J., Gollust, S. E., Webster, D. W., Fiellin, D. A., & Barry, C. L. (2016). Primary care physicians’ perspectives on the prescription opioid epidemic. Drug and Alcohol Dependence, 165, 61–​70. Landry, A., Madson, M., Thomson, J., Zoellner, J., Connell, C., & Yadrick, K. (2015). A randomized trial using Motivational Interviewing for maintenance of blood pressure improvements in a community-​engaged lifestyle intervention: HUB city steps. Health Education Research, 30(6), 910–​922. Litt, M. D., Kadden, R. M., Cooney, N. L., & Kabela, E. (2003). Coping skills and treatment outcomes in cognitive-​behavioral and interactional group therapy for alcoholism. Journal of Consulting and Clinical Psychology, 71(1), 118–​128. Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of Motivational Interviewing: A practice-​ friendly review of four meta-​ analyses. Journal of Clinical Psychology, 65, 1232–​1245. Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-​analysis of Motivational Interviewing: Twenty-​five years of empirical studies. Research on Social Work Practice, 20(2), 137–​160. Magill, M., Gaume, J., Apodaca, T. R., Walthers, J., Mastroleo, N. R., Borsari, B., & Longabaugh, R. (2014). The technical hypothesis of Motivational Interviewing: A meta-​analysis of MI’s key causal model. Journal of Consulting and Clinical Psychology, 82(6), 973–​983.

230  Motivational Interviewing, 2E Mason, M. J., Sabo, R., & Zaharakis, N. M. (2017). Peer network counseling as brief treatment for urban adolescent heavy cannabis users. Journal of Studies on Alcohol and Drugs, 78(1), 152–​157. McMurran, M. (2009). Motivational Interviewing with offenders: A systematic review. Legal & Criminological Psychology, 14, 83–​100. Miller, W. R. (1983). Motivational Interviewing with problem drinkers. Behavioural Psychotherapy, 11(2), 147–​172. Miller, W. R. (2000). Rediscovering fire: Small interventions, large effects. Psychology of Addictive Behaviors, 14(1), 6–​18. Miller, W. R. (2022). On second thought: How ambivalence shapes your life. Guilford Press. Miller, W. R. (Ed.). (2004). Combined Behavioral Intervention: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. (Vol. 1, COMBINE Monograph Series). National Institute on Alcohol Abuse and Alcoholism, Public Health Service, U.S. Dept of Health and Human Services. Miller, W. R., Hendrickson, S. M. L, Venner, K., Bisonó, A., Daugherty, M., & Yahne, C. E. (2008). Cross-​cultural training in Motivational Interviewing. Journal of Teaching in the Addictions, 7, 4–​15. Miller, W. R., & Moyers, T. B. (2015). The forest and the trees: Relational and specific factors in addition treatment. Addiction, 110(3), 401–​413. Miller, W. R., & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change addictive behavior. Guilford Press. Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. (2nd ed.). Guilford Press. Miller, W. R., & Rollnick, S. (2004). Talking oneself into change: Motivational Interviewing, stages of change, and therapeutic process. Journal of Cognitive Psychotherapy, 18, 299–​308. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). Guilford Press. Miller, W. R., & Rose, G. S. (2009). Toward a theory of Motivational Interviewing. American Psychologist, 64(6), 527–​537. Miller, W. R., & Sovereign, R. G. (1989). The check-​up: A model for early intervention in addictive behaviors. In T. Løberg, W. R. Miller, P. E. Nathan, & G. A. Marlatt (Eds.), Addictive behaviors: Prevention and early intervention (pp. 219–​231). Swets & Zeitlinger Publishers. Miller, W. R., Wilbourne, P. L., & Hettema, J. E. (2002). What works? A summary of alcohol treatment outcome research. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (pp. 13–​63). Allyn & Bacon. Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. (Vol. 2, Project MATCH Monograph Series). National Institute on Alcohol Abuse and Alcoholism. MINT Forum 2019. Annual MINT Forum, September 26–28, 2019, Tallinn, Estonia. Moyers, T. B., & Houck, J. (2011). Combining Motivational Interviewing with cognitive-​ behavioral treatments for substance abuse: Lessons from the COMBINE research project. Cognitive and Behavioral Practice, 18(1), 38–​45. Moyers, T. B., Martin, T., Houck, J. M., Christopher, P. J., & Tonigan, J. S. (2009). From in-​ session behaviors to drinking outcomes: A causal chain for Motivational Interviewing. Journal of Consulting and Clinical Psychology, 77(6), 1113–​1124. Moyers, T. B., Rowell, L. N., Manuel, J. K., Ernst, D., & Houck, J. M. (2016). The Motivational Interviewing Treatment Integrity Code (MITI 4): Rationale, preliminary reliability and validity. Journal of Substance Abuse Treatment, 65, 36–​42. Naar, S., & Safren, S. A. (2017). Motivational Interviewing and CBT: Combining strategies for maximum effectiveness. Guilford Press.

Motivational Interviewing for Substance Use  231 Naar-​King, S., & Suarez, M. (2011). Motivational Interviewing with adolescents and young adults. Guilford Press. Oh, H., & Lee, C. (2016). Culture and Motivational Interviewing. Patient Education and Counseling, 99(11), 1914–​1919. Pescosolido, B. A., Martin, J. K., Long, J. S., Medina, T. R., Phelan, J. C., & Link, B. G. (2010). “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry, 167(11), 1321–​1330. Polcin, D. L., Nayak, M. B., Korcha, R., Pugh, S., Witbrodt, J., Salinardi, M., Galloway, G., & Nelson, E. (2019). Heavy drinking among women receiving intensive Motivational Interviewing: 6-​month outcomes. Journal of Psychoactive Drugs, 51(5), 421–​430. Project MATCH Research Group. (1993). Project MATCH (matching alcoholism treatment to client heterogeneity): Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical & Experimental Research, 17(6), 1130–​1145. Project MATCH Research Group (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol and Drugs, 58, 7–​29. Rollnick, S., Butler, C. C., Kinnersley, P., Gregory, J., & Mash, B. (2010). Motivational Interviewing. BMJ, 340, c1900. Roy-​Byrne, P., Bumgardner, K., Krupski, A., Dunn, C., Ries, R., Donovan, D., West, I. I., Maynard, C., Atkins, D. C., Graves, M. C., Joesch, J. M., & Zarkin, G. A. (2014). Brief intervention for problem drug use in safety-​net primary care settings: A randomized clinical trial. JAMA, 312(5), 492–​501. Samson, J. E., & Tanner-​Smith, E. E. (2015). Single-​session alcohol interventions for heavy drinking college students: A systematic review and meta-​analysis. Journal of Studies on Alcohol and Drugs, 76(4), 530–​543. Schumacher, J. A., & Madson, M. B. (2014). Fundamentals of Motivational Interviewing: Tips and strategies to address common clinical challenges. Oxford University Press. Spohr, S. A., Taxman, F. S., Rodriguez, M., & Walters, S. T. (2016). Motivational Interviewing fidelity in a community corrections setting: Treatment initiation and subsequent drug use. Journal of Substance Abuse Treatment, 65, 20–​25. Vasilaki, E. I., Hosier, S. G., & Cox, W. M. (2006). The efficacy of Motivational Interviewing as a brief intervention for excessive drinking: A meta-​analytic review. Alcohol and Alcoholism (Oxford, Oxfordshire), 41(3), 328–​335. Walker, D. D., Stephens, R. S., Towe, S., Banes, K., & Roffman, R. (2015). Maintenance check-​ ups following treatment for cannabis dependence. Journal of Substance Abuse Treatment, 56, 11–​15.

14 Motivational Interviewing and Psychiatric Disorders Elliot Collins and Tina Goldstein

The spirit of Motivational Interviewing (MI) invokes a collaborative effort between trainees and their patients to achieve meaningful behavioral change. While well known for its broad applications in the field of addiction, MI has also been implemented with a wide variety of populations for whom meaningful behavior change may be impactful. This includes application with individuals with a range of psychiatric disorders (e.g., affective, psychotic, personality, and developmental disorders), as well as across the developmental spectrum (i.e., children, adolescents, adults, and older adults). Herein we discuss the applications and effectiveness of MI and clinical considerations when implementing MI in psychiatric care. We conclude with recommendations for incorporating core MI spirit, processes, skills, and strategies to further enhance other effective therapeutic modalities employed with these populations.

APPLICATIONS AND ADAPTATIONS OF MI IN ADULTS WITH PSYCHIATRIC DISORDERS MI is increasingly being used across behavioral health. Broadly, practitioners commonly use MI to increase engagement in, and adherence with, treatment, as well as to further enhance the effects of other evidence-​based treatment modalities (Arkowitz, Miller, & Rollnick, 2015; Naar & Safren, 2017; Swanson, Pantalon, & Cohen, 1999). The most obvious difference between the application of MI in the treatment of broad-​ranging psychiatric disorders, as compared with the treatment of addiction, is identification of a behavioral target. In the treatment of addiction, the behavioral target most commonly includes decreasing substance use and/​or minimizing harmful consequences. Beyond addiction, application of MI for a range of psychiatric disorders necessitates the clear identification of target(s) for behavior change. Initially, these targets

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may be challenging to identify in the face of active psychiatric symptoms, particularly when the patients identify their distress as arising from their subjective experiences with symptoms rather than a clear set of behaviors. Trainees can develop a greater understanding of these symptoms by approaching them with curiosity using the spirit of MI, and can then more readily connect the symptoms directly to behaviors that can then be targeted with MI. To highlight, for a patient with major depression, the application of MI to health behaviors that could meaningfully improve depressive symptoms, such as sleep and/​or eating behaviors, medication-​taking, or daily physical activity, may be central to the patient’s treatment outcomes. As such, MI skills and strategies may be used to target change related to clearly identified behavioral goals broadly, and/​or in the context of other evidence-​based approaches like Behavioral Activation Therapy (BAT) for major depression. Integrating MI with a brief adaptation to BAT has significant potential to improve overall outcomes for patients with depression by strengthening and maintaining motivation to change in BAT (Balán, Lejuez, Hoffer, & Blanco, 2016). There is growing evidence-​based support for the use of MI as an adjunctive treatment to enhance treatment outcomes for patients with anxiety disorders (Aviram & Westra, 2011; Marker & Norton, 2018; Westra, Arkowitz, & Dozois, 2009), eating disorders (Cassin, von Ranson, Heng, Brar, & Wojtowicz, 2008; Ziser, et al., 2021), comorbid psychiatric and substance use disorders (Martino, Carroll, Nich, & Rounsaville, 2006; Steinberg, Ziedonis, Krejci, & Brandon, 2004), as well as suicidal ideation and suicide-​related behavior (Britton, Conner, Chapman, & Maisto, 2020; Britton, Patrick, Wenzel, & Williams, 2011). Using MI can facilitate patient motivation and engagement in other treatments such as cognitive-​behavioral therapy (CBT), resulting in more positive treatment outcomes (Marker & Norton, 2018; Westra, Aviram, & Doell, 2011). Patient engagement with treatment appears to be a potential mechanism of change for people diagnosed with psychiatric disorders (Romano & Peters, 2015). A 2017 systematic review and meta-​analysis demonstrated that MI is most beneficial for individuals who are not seeking mental health treatment (Lawrence, Fulbrook, Somerset, & Schulz, 2017). Even very brief interventions, such as two MI sessions for 15 minutes, enhanced treatment attendance (Lawrence, et al., 2017). More research is needed to better evaluate the additive benefits of MI and how integrating it into existing treatments improves outcomes in these populations. Another benefit of applying MI to the treatment of psychiatric disorders more broadly is the collaborative relationship created through patient affirmation. Patients are more likely to continue in, and derive benefit from, therapy

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when they feel safe with and supported by the practitioner (Boardman, Catley, Grobe, Little, & Ahluwalia, 2006). In working with patients who have a range of psychiatric disorders, the use of core MI skills and strategies (e.g., affirmations, reflections) may enhance therapeutic alliance, which in turn can lead to superior outcomes across disorders (Simpson & Zuckoff, 2011; Westra, Arkowitz, & Dozois, 2009). As in the treatment of addiction, MI can be applied during brief interventions for other psychiatric disorders. For example, in treating a patient presenting to the emergency department during a suicidal crisis, a trainee may explore the patient’s reasons for wanting to die by suicide while simultaneously exploring their reasons to continue living. This exchange may serve to reflect, affirm, and evoke change talk as the patient verbalizes ambivalence toward living (Britton, Patrick, Wenzel, & Williams, 2011). The following is a clinical scenario using the MI approach during an emergency department evaluation between a trainee and a patient reporting suicidal thoughts. TRAINEE: What made you decide to seek treatment now? [open-​ended question] PATIENT: I can’t keep going anymore . . . I am just sick of being miserable. TRAINEE: You are feeling demoralized and struggling to stay hopeful. [complex reflection] PATIENT: Yes, what’s the point of being around. TRAINEE: Help me understand your experience of depression. [open-​ended question] PATIENT: I’ve just about had it; everything is too much for me. Even getting here took way more energy than I’ve got. I’m exhausted. TRAINEE: You feel overwhelmed, and very, very tired, even with things that you used to be able to manage. [complex reflection] PATIENT: Totally overwhelmed. First, I lost my job, then my wife left me. Now she won’t let me see the kids unless I get some help. TRAINEE: You have suffered a lot of losses because of your depression. I’m wondering if you’ve been having thoughts of suicide. [complex reflection, followed by an invitation to share] PATIENT: Sure, I think about ending it all the time . . . but I know it would really hurt my kids . . . maybe even ruin them. TRAINEE: You care very much about your children. You realize that if you die by suicide, it might destroy them. [complex reflections] PATIENT: Yeah, but my life feels so out of control. I’m hurting so much . . . I miss my kids a lot . . . I need to be there for them, but I can’t.

MI and Psychiatric Disorders  235 TRAINEE: You feel so horrible that sometimes you want to end your life. At the same time, you think about your kids, and you want to be part of their lives, to support them as they grow up. They’re important to you, as you are to them. [double-​sided reflection; complex reflection] PATIENT: I feel like killing myself is a cop-​out. I know I need to get back into treatment, back on my medications. I stopped taking them a year ago after I started feeling better. TRAINEE: You’re willing to take responsibility for your life. You’re willing to start the process by resuming treatment for your depression. [complex reflections] PATIENT: I do not really want to take medicine or go to therapy, but I know that if I do, I’ll probably feel more in control . . . and maybe start rebuilding my life. I’ve done it before. TRAINEE: You have lived through similar experiences in the past, and you have learned about what helps you and what does not help you. How important is it for you to start treatment as soon as possible? [complex reflection; open-​ended question evoking change talk] PATIENT: I think if I do not do it soon, I will feel much worse and treatment might not work. TRAINEE: It is a top priority for you to initiate treatment as soon as possible. [complex reflection] PATIENT: I cannot be the father I want to be if I don’t get my life back together. TRAINEE: You are more determined than ever to do whatever it takes to control your depression and reclaim your identity as the father you want to be. [amplified complex reflection emphasizing his value system] PATIENT: There is nothing more important to me than being there for my kids. TRAINEE: What would you be willing to do at this time? [open-​ended question evoking change talk] PATIENT: I want to start with therapy first and see how it goes then decide whether I need an antidepressant. TRAINEE: Your approach is valid and reasonable. Would it be OK if we talk about some of the therapy resources that are available to you? [complex reflection; support for autonomy; asking permission] PATIENT: Sure, go ahead. I guess the least I can do is listen. Maybe you can also help me set up an appointment as soon as possible.

For new trainees, particularly those working in acute settings, there is a tendency to focus on MI strictly as an approach to help patients resolve ambivalence around near-​term behaviors such as initiating therapy or medication treatment. While these are certainly critical behavioral

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change targets for MI among individuals with heterogeneous psychiatric disorders, additional behaviors that support maintaining wellness and build positive emotions (e.g., fulfillment, happiness) are also important considerations. Therefore, operationalizing such behavioral targets can be challenging. One approach to mitigating this challenge is to break down poorly defined behavioral targets like “happiness” into specific actions that may, over time, invoke or elicit these emotions. For example, a patient with generalized anxiety disorder may identify that they derive happiness from helping others. A trainee might then collaborate with the patient to not only increase adherence to evidence-​based treatment (e.g., CBT), but also to engage in meaningful activities that involve contributing, like caring for family members, or volunteering in the community. As such, the intervention focus that employs an MI framework includes targeting behavioral changes that both help treat the symptoms of the psychiatric disorder directly, while simultaneously building toward optimal mental wellness. It is important to consider that patients themselves are at varying stages of readiness to change different individual behaviors. For example, the patient with anxiety described above may reach the planning stage with respect to his anxiety disorder symptoms prior to reaching the same stage with respect to resuming volunteer work, or vice versa. Understandably, patients have different priorities during their recoveries, and practitioners should work collaboratively to identify those behaviors that are most important to the individual in the present moment. At the same time, practitioners can take advantage of the connections between different behavioral targets to enhance motivation for broader change. In the clinical scenario above, the patient seems open to re-​engaging in treatment for his depression. To further extend the clinical example presented above, consider if the patient also presents with a co-​occurring substance use disorder and reports that his substance use is not currently problematic, and he is not interested in discussing change related to substance use. The practitioner might explore thoughts or ambivalence around substance use while simultaneously focusing on behavior change related to re-​engaging in treatment for depression. Further, the practitioner might work with the patient to draw connections between substance use and depression, reaffirming the patient’s preference to improve his depression. While connections between problem behaviors (e.g., substance use and depression in this example) may not immediately be evident to patients, practitioners can use MI strategies (e.g., elicit-​provide-​elicit (E-​P-​E), reflections, strategies for evoking change talk) to initiate conversations aimed

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at helping patients better understand the relationship between depression and substance use and the potential usefulness of behavioral changes that facilitate patients’ goals and/​or values. While MI can be useful across a variety of psychiatric diagnoses, important factors should be considered. Fundamentally, MI requires that patients can engage in meaningful conversation and have sufficient insight to reflect on their behaviors. Unfortunately, some psychiatric presentations are associated with substantial impairments in judgment, insight, and cognition, thereby limiting the potential for patients to meaningfully engage in, and benefit from, MI. For example, patients experiencing acute psychosis may display extremely disorganized thought processes that render such conversations challenging and potentially unproductive. At the same time, MI, as a treatment approach, requires modifications to meet the special needs of patients with substance use co-​occurring with psychotic disorders, such as adopting an integrated care approach and accommodating cognitive impairments and thought disorder (Martino, Carroll, Kostas, Perkins, & Rounsaville, 2002). If a patient is experiencing catatonia, strongly fixed paranoid delusions, or has a profound developmental disorder, they may be unable to engage meaningfully in a therapeutic conversation. Different stylistic approaches may enhance practitioners’ ability to effectively use MI with patients with more limited insight. Patients with developmental disorders, for example, may find focusing on emotions or complex coping skills such as redirecting thoughts to be challenging. In this situation, a practitioner may consider taking a more concrete approach to meet the patient where they are cognitively. At the same time, practitioners can recognize that just because a patient is unable to engage meaningfully with some specific MI skill or strategy, that does not mean the patient cannot benefit from conversations using the therapeutic style and spirit of MI. For example, all patients can benefit from affirmations, reflections, and summaries, as they serve to enhance therapeutic alliance. Patients will feel more supported and more likely to trust a practitioner who demonstrates accurate empathy. As patients begin to engage to a greater degree in a therapeutic conversation, the practitioner can then leverage their existing relationship during continued conversations. Simply put, there are very few instances where working with patients with psychiatric disorders should not include accurate affirmations and reflections for enhancing the therapeutic experience.

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APPLICATIONS AND ADAPTATIONS OF MI IN ADOLESCENTS AND YOUNG ADULTS WITH PSYCHIATRIC DISORDERS Just as adult patients benefit from MI, youth stand to gain from the enhanced therapeutic relationship, collaborative approach, and validating environment created when using MI (Dean, Britt, Bell. Stanley, & Collings, 2016). MI used as a pretreatment intervention facilitated treatment engagement in adolescent mental health settings (Dean, Britt, Bell, Stanley, & Collings, 2016). The practitioner’s approach should be flexible, enabling them to match each adolescent’s developmental capabilities and maturity level, family situation, and presenting problem. Further, practitioners should adapt their MI skills and strategies to collaborate not only with patients and caregivers individually, but also to support collaboration between caregivers and adolescents. Through MI, practitioners can support collaboration between caregivers and adolescents to achieve mutually desired behavior change (Chapter 17 reviews comprehensively the research literature and the general applications of MI in pediatric settings). The relational and technical components of MI are highly adaptable and relevant to adolescent and young adult developmental processes. MI can be incorporated in diverse clinical settings and integrated with other treatment approaches that have focused on behavioral treatments, pharmacotherapies, and CBT for a wide range of psychiatric and substance use disorders (Cornelius, et al., 2010; Cornelius, et al., 2011; Cornelius, Douaihy, Kirisci, & Daley, 2013; Gowers, et al., 2007; Merlo, et al., 2010; Sepulveda, Lopez, Macdonald, & Treasure, 2008; Suarez & Mullins, 2008). Additionally, MI adaptations in psychiatric settings have been feasible and beneficial in brief settings and delivered as a brief intervention, as well as a platform for which other treatment are conceptualized (Goldstein, et al., 2020; Kennard, et al., 2018). A manualized brief motivational intervention delivered as an adjunctive treatment yielded positive outcomes by improving medication adherence among adolescents with bipolar disorder (Goldstein, et al., 2020). Further, MI is a potential process and useful approach to improve mental health services uptake in therapeutic encounters with youth affected by chronic medical conditions (Reinauer, et al., 2021). This is an example of a clinical encounter with a 16-​year-​old girl who has bipolar disorder and is questioning the need to continue taking her medication regimen. This example demonstrates the relational and technical components of MI with a mixture of OARS and E-​P-​E.

MI and Psychiatric Disorders  239 TRAINEE: Thanks for coming to the session today. Your therapist told me that you expressed some concerns about your medications. [focusing the session] PATIENT: Yes, I have few concerns and I was wondering whether I need to continue taking them. I have been on the medications for more than a year and I have been doing fine. TRAINEE: You have been thinking whether you need to continue taking the medications since you have been stable and have not had any episodes of depression or mania. [complex reflection] You have worked very hard to take your medications as prescribed despite your mixed feelings about taking them every day. [affirmation] PATIENT: I am doing very well, and I am concerned about potential side effects of the medications. I already have some side effects. I just noticed that I have gained some weight recently and I believe its related to some of the medications. TRAINEE: You have two major concerns: First, the effects that taking multiple medications may have on you. [complex reflection]. And second, the need to continue taking the medications regularly since your bipolar illness is stable. [complex reflections; agenda mapping] PATIENT: Exactly. Can we discuss these issues? TRAINEE: Of course. Both your concerns are intertwined. How do you feel about starting to tackle the issue related to staying on your current medications? [complex reflection; open-​ended question] PATIENT: Sure! TRAINEE: What is your understanding of the role of medications in treating your bipolar disorder? [open-​ended question; eliciting] PATIENT: A major role in addition to therapy. I can tell you that being in therapy has considerably helped me cope with the ups and downs of my illness, so I am wondering whether it’s still necessary to continue taking all the medications or maybe taking less or even reducing the doses, not sure. TRAINEE: Your points are valid. You see the importance of both taking the medications and doing therapy to help best manage your illness. And, yes, the most effective treatment approach is to integrate both medications and therapy. [complex reflections; providing] Is it OK to review your medications and see if we can make some changes that would potentially reduce the occurrence of side effects and recurrences of depression or mania? [asking permission; eliciting] PATIENT: That would be helpful. At least I would like to try to take as little medications as possible without taking the risk of going into another episode of depression. TRAINEE: That sounds reasonable to negotiate. How do you feel about reviewing our options and their pros and cons and some strategies to mitigate some of the side effects from the medications? [open-​ended question]

240  Motivational Interviewing, 2E PATIENT: Sounds good to me. One more thing. My parents are pressuring me about stopping some of these medications. Not sure how to deal with this issue. I don’t want to stop them cold turkey. They said therapy should be enough since I am doing well. TRAINEE: Your parents are approaching your treatment from a different perspective, and you want to be careful about not making any rushed decision that could affect the stability of your illness. How do you feel about inviting your parents to a joint session so we can discuss and get everybody on the same page? [complex reflections; open-​ended question] PATIENT: That’s a great idea.

PERSONAL REFLECTION (Elliot Collins) Since first learning the spirit and core skills of MI as a medical student, I have made continued use of them in my psychiatric practice. There are many examples in my own experience, in this textbook and others, that demonstrate how MI can improve patient outcomes and satisfaction with their care. At the same time, one of the many underappreciated aspects of MI is how enriching the experience can be for the trainee. MI allows me to feel more connected to my patients, more aligned with them in working toward their goals, and more empathic regarding their life circumstances. These factors continually reinforce my desire to provide my patients with the best possible care. Further, the use of MI in my psychiatric practice has dramatically reduced feelings of burnout. Patients with severe and complex psychiatric disorders can present with some of the most challenging problems in medicine. It is understandable how trainees can grow weary in this work, particularly when treating patients whose symptoms and social circumstances never seem to improve. At the same time, the use of MI allows me to focus on what I can control as a practitioner—​and what I cannot (controlling the righting reflex!). For example, a patient diagnosed with bipolar disorder presented to the hospital in an acute affective episode for the fourth time in as many months; each hospitalization included acute mood stabilization, yet the patient did not follow-​up with the postdischarge outpatient treatment plan. In this case, I can recognize that the patient may simply not be ready to engage in follow-​up treatment. Using MI with this patient changes my perspective from an external locus of control (“I am never going to be able to help this patient.”) to an internal locus of control (“I will be able to better help this patient move toward change by using MI skills (OARS) in a strategically focused manner and maintaining the spirit of MI, by reinforcing that it’s always up to them to

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decide about following up with treatment (supporting autonomy).”). In this way, MI can bring more meaning and focus to each interaction I have with patients, contributing to my continued ability to meaningfully engage with patients and feel fulfilled in doing so.

CONCLUSION The application of MI with individuals with psychiatric disorders and across development holds great promise to improve treatment outcomes. Herein we consider unique clinical considerations for incorporating the MI spirit, core skills, and strategies with these populations to further enhance behavior change in them, both as stand-​alone interventions and to complement other evidence-​based treatment approaches.

SELF-​ASSESSMENT QUIZ True or False 1. MI is well suited to be integrated in the treatment of anxiety, eating disorders, and concurrent psychosis and substance use disorder. 2. When combined with CBT, MI is particularly helpful in treating depression. 3. The relational and technical components of MI cannot be easily adapted to adolescent and young adult development processes. 4. It is well established that MI enhances treatment adherence among individuals with psychiatric disorders. 5. The research into the mechanisms through which MI enhances treatment outcome in psychiatric disorders has not been clearly determined.

Answers 1. True. Existing research supports adding MI to existing treatment approaches for most psychiatric disorders in adult and adolescent populations, particularly as a pretreatment or when integrated into care. 2. True. Among patients with depression and anxiety disorders, the combination of MI and CBT facilitates patients’ engagement with therapy,

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adherence to treatment plans, and ability to follow through with homework assignments. Research also suggests that MI, followed by traditional CBT, is effective when applied as brief interventions among patients with suicidal ideation. 3. False. MI is well suited for adolescents, given their emerging developmental need for autonomy. The relational and technical components of MI can be adapted to adolescent developmental processes (cognitive, emotional, and social). 4. True. MI is effective as a pretreatment intervention to motivate and engage individuals to attend post-​ MI treatment and psychiatric counseling. 5. True. Patient engagement with treatment may be a potential mechanism for change in individuals with anxiety, mood, and psychotic disorders. More research is needed to elucidate the role of practitioner behaviors and patient change talk in this area.

REFERENCES Arkowitz, H., Miller, W. R., & Rollnick, S. (Eds.). (2015). Motivational interviewing in the treatment of psychological problems. Guilford Press. Aviram, A., & Westra, H. A. (2011). The impact of motivational interviewing on resistance in cognitive behavioural therapy for generalized anxiety disorder. Psychotherapy Research, 21(6), 698–​708. Balán, I. C., Lejuez, C. W., Hoffer, M., & Blanco, C. (2016). Integrating motivational interviewing and brief behavioral activation therapy: Theoretical and practical considerations. Cognitive and Behavioral Practice, 23(2), 205–​220. Boardman, T., Catley, D., Grobe, J. E., Little, T. D., & Ahluwalia, J. S. (2006). Using motivational interviewing with smokers: Do therapist behaviors relate to engagement and therapeutic alliance? Journal of Substance Abuse Treatment, 31(4), 329–​339. Britton, P. C., Conner, K. R., Chapman, B. P., & Maisto, S. A. (2020). Motivational interviewing to address suicidal ideation: A randomized controlled trial in veterans. Suicide and Life-​ Threatening Behaviors, 50, 233–​248. Britton, P. C., Patrick, H., Wenzel, A., & Williams, G. C. (2011). Integrating motivational interviewing and self-​determination theory with cognitive behavioral therapy to prevent suicide. Cognitive and Behavioral Practice, 18(1), 16–​27. Cassin, S. E., von Ranson, K. M., Heng, K., Brar, J., & Wojtowicz, A. E. (2008). Adapted motivational interviewing for women with binge eating disorder: A randomized controlled trial. Psychology of Addictive Behaviors, 22(30), 417–​425. Cornelius, J. R., Bukstein, O. G., Douaihy, A. B., Clark, D. B., Chung, T. A., Daley, D. C., Wood, D. S., & Brown, S. J. (2010). Double-​blind fluoxetine trial in comorbid MDDCUD youth and young adults. Drug and Alcohol Dependence, 112, 39–​45. Cornelius, J. R., Douaihy, A., Bukstein, O. G., Daley, D. C., Wood, S. D., Kelly, T. M., & Salloum, I. M. (2011). Evaluation of cognitive behavioral therapy/​motivational enhancement therapy (CBT/​MET) in a treatment trial of comorbid MDD/​AUD adolescents. Addictive Behaviors, 36(8), 843–​848.

MI and Psychiatric Disorders  243 Cornelius, J. R., Douaihy, A. B., Kirisci, L., & Daley, D. C. (2013). Longer-​term effectiveness of CBT in the treatment of comorbid AUD/​MDD adolescents. International Journal of Medical and Biological Frontiers, 19(2), 1–​12. https://​www.nov​apub​lish​​cata​log/​produ​ct_​i​ nfo.php?prod​ucts​_​id=​44874 Dean, S., Britt, E., Bell, E., Stanley, J., & Collings, S. (2016). Motivational interviewing to enhance adolescent mental health treatment engagement: A randomized clinical trial. Psychological Medicine, 46(9), 1961–​1969. Goldstein, T. R., Krantz, M. L., Fersch-​Podrat, R. K., Hotkowski, N. J., Merranko, J., Sobel, L., Axelson, D., Birmaher, B., & Douaihy, A. (2020). A brief motivational intervention for enhancing medication adherence for adolescents with bipolar disorder: A pilot randomized trial. Journal of Affective Disorders, 265, 1–​9. Gowers, S., Clark, A., Roberts, C., Edwards, V., Bryan, C., Smethurst, N., Byford, S., & Barett, B. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents: Randomised controlled trial. British Journal of Psychiatry, 19(15), 427–​435. Kennard, B. D., Goldstein, T., Foxwell, A. A., McMakin, D. L., Wolfe, K., Biernesser, C., Moorehead, A., Douaihy, A., Zullo, L., Wentroble, E., Owen, V., Zelazny, J., Iyengar, S., Porta, G., & Brent, D. (2018). As Safe as Possible (ASAP): A brief app-​supported inpatient intervention to prevent postdischarge suicidal behavior in hospitalized, suicidal adolescents. American Journal of Psychiatry, 175(9), 864–​872. Lawrence, P., Fulbrook, P., Somerset, S., & Schulz, P. (2017). Motivational interviewing to enhance treatment attendance in mental health settings: A systematic review and meta-​ analysis. Journal of Psychiatric and Mental Health Nursing, 24(9–​10), 699–​718. Marker, I., & Norton, P. J. (2018). The efficacy of incorporating motivational interviewing to cognitive behavior therapy for anxiety disorders: A review and meta-​analysis. Clinical Psychology Review, 62, 1–​10. Martino, S., Carroll, K., Kostas, D., Perkins, J., & Rounsaville, B. (2002). Dual diagnosis motivational interviewing: A modification of motivational interviewing for substance-​abusing patients with psychotic disorders. Journal of Substance Abuse Treatment, 23(4), 297–​308. Martino, S., Carroll, K. M., Nich, C., & Rounsaville, B. J. (2006). A randomized controlled pilot study of motivational interviewing for patients with psychotic and drug use disorders. Addiction, 101(10), 1479–​1492. Merlo, L. J., Storch, E. A., Lehmkuhl, H. D., Jacob, M. L., Murphy, T. K., Goodman, W. K., & Geffken, G. R. (2010). Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-​ compulsive disorder: A preliminary study. Cognitive Behaviour Therapy, 39(1), 24–​27. Naar, S., & Safren, S. A. (2017). Motivational interviewing and CBT: Combining strategies for maximum effectiveness. Guilford Press. Reinauer, C., Platzbecker, A. L., Viermann, R., Domhardt, M., Baumeister, H., Foertsch, K., Linderskamp, H., Krassuski, L., Staab, D., Minden, K., Kilian, R., Holl, R. W., Warschburger, P., & Meißner, T. (2021). Efficacy of motivational interviewing to improve utilization of mental health services among youths with chronic medical conditions: A cluster randomized clinical trial. JAMA Network Open, 4(10), e2127622. Romano, M., & Peters, L. (2015). Evaluating the mechanisms of change in motivational interviewing in the treatment of mental health problems: A review and meta-​analysis. Clinical Psychology Review, 38, 1–​12. Sepulveda, A. R., Lopez, C., Macdonald, P., & Treasure, J. (2008). Feasibility and acceptability of DVD and telephone coaching-​based skills training for carers of people with an eating disorder. International Journal of Eating Disorders, 41, 318–​325. Simpson, H. B., & Zuckoff, A. (2011). Using motivational interviewing to enhance treatment outcome in people with obsessive-​compulsive disorder. Cognitive and Behavioral Practice, 18(1), 28–​37.

244  Motivational Interviewing, 2E Steinberg, M. L., Ziedonis, D. M., Krejci, J. A., & Brandon, T. H. (2004). Motivational interviewing with personalized feedback: A brief intervention for motivating smokers with schizophrenia to seek treatment for tobacco dependence. Journal of Consulting and Clinical Psychology, 72(4), 723–​728. Suarez, M., & Mullins, S. (2008). Motivational interviewing and pediatric health behavior interventions. Journal of Developmental & Behavioral Pediatrics, 29(5), 417–​428. Swanson, A. J., Pantalon, M. V., & Cohen, K. R. (1999). Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients. Journal of Nervous and Mental Disease, 187(10), 630–​635. Westra, H. A., Arkowitz, H., & Dozois, D. J. (2009). Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial. Journal of Anxiety Disorders, 23(8), 1106–​1117. Westra, H. A., Aviram, A., & Doell, F. K. (2011). Extending motivational interviewing to the treatment of major mental health problems: Current directions and evidence. Canadian Journal of Psychiatry /​La Revue canadienne de psychiatrie, 56(11), 643–​650. Ziser, K., Rheindorf, N., Keifenheim, K., Becker, S., Resmark, G., Giel, K. E., Skoda, E. M., Teufel, M., Zipfel, S., & Junne, F. (2021) Motivation-​enhancing psychotherapy for inpatients with anorexia nervosa (MANNA): A randomized controlled pilot study. Frontiers in Psychiatry, 12, 632660.

15 Integrating Community Psychiatry and Motivational Interviewing Joshua T. Morra, Daniel Cohen, Melinda Armstead, and Antoine Douaihy

Concerns around medication adherence, substance use, and other behavioral determinants of patient health are commonplace in community psychiatry. Patients seen in outpatient community treatment programs often experience multiple behavioral comorbidities, and effective care often requires an engaged and collaborative treatment relationship. Motivational Interviewing (MI) can be an ideal fit; it assists a largely disempowered patient population to identify their strengths and aspirations and it promotes autonomy around decision-​making. The need for MI as a core skillset in community psychiatry seems clear. There is just one problem: community systems of care are not structured with this approach in mind. Today’s community practitioners face tightening time pressures and an ever-​ expanding burden of electronic documentation and administrative work. A growing emphasis on medication therapy has encouraged a vernacular that narrows the expectations of stakeholders. The practitioner has become the prescriber. Appointment? You mean med check. The context of modern psychiatry has become a threat to conversation as a meaningful tool in real-​world practice. Still, hope remains. We have found that integrating MI and community psychiatry is less about carving out time for conversation, and more about MI becoming a way of practice. This is a concept we are calling motivational psychiatry, and we believe it to be one road to patient care that is more empirically based and humanistic. In this chapter, we introduce a novel framework for understanding the natural synergies and dissonances of motivational psychiatry. We offer an account of what well-​integrated community practice can look like. We also review the higher order skillsets needed to mitigate the logistical and philosophical tensions that emerge when MI becomes a way of practice.

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MOTIVATIONAL PSYCHIATRY MI is not a psychotherapy technique; it is a way of being with people (Miller & Rollnick, 2013). The spirit of MI entails an attitude of collaboration, deep acceptance of a person’s intrinsic worth, and a willingness to trust others to be resourceful, resilient, and capable. Psychotherapy is an example of a therapeutic modality that can incorporate MI. Medication management is another. Motivational psychiatry is less about carving out time to do psychotherapy and more about how the spirit, processes, and skills of MI shape your way of partnering with patients. Motivational psychiatry is an integrated practice in which MI serves as a way of conducting medication-​focused psychiatry visits. We examine this below through several key steps of a “modern” patient encounter: 1. The Patient Shows Up MI has been shown to improve community behavioral health attendance (Lawrence, Fulbrook, Somerset, & Schulz, 2017). This effect remains significant even when MI is delivered in one to two brief encounters that are consistent with commonplace community psychiatry time limitations. MI improves patient attendance. 2. Agenda Setting Traditional medical choreography can create overly structured discourse. A prime example is the “chief complaint.” This approach can reduce a golden opportunity for patient engagement to little more than manualized data collection. On the other hand, the practitioner who uses MI can instead offer an open-​ended invitation for the patient to share their intent and expectations of the visit. “What did you have in mind for today’s session?” Such a question is as evocative as it is efficient. One open-​ended question can quickly elicit multiple concerns, allowing the practitioner rapid access to valuable information needed to budget time and triage agenda items. 3. Data Collection Open-​ended questions may grant rapid access to multiple pieces of important diagnostic information. When assessing for depression, what might take 5 or 6 volleys using serial, closed-​ended questions can sometimes be accomplished with a simple “tell me about your depression.” Psychosocial context is often offered unprompted, aiding in rapid case formulation. This efficiency can mitigate the assessment trap, whereby little is learned because time is spent asking and answering close-​ended questions. Moreover, time saved up front using open-​ended prompts

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can be invested in follow-​up reflections, further deepening empathic engagement, and building rapport. 4. Information Exchange The MI skill elicit-​provide-​elicit (E-​P-​E) is an extremely helpful tool (Miller & Rollnick, 2013). Beginner-​proficiency trainees can effectively make use of this scripted framework as an evidence-​based scaffold for sharing medical information and advice. Example: TRAINEE: What do you know about the antidepressant fluoxetine? [elicit] PATIENT: It helps with depression, right? TRAINEE: It can, yes. Would you like to hear some more about it? [ask permission] PATIENT: Sure. TRAINEE: It’s a once-​a-​day medication. When successful, it can improve your mood, reduce feelings of hopelessness, and even restore normal sleep and appetite. [provide] What are your thoughts about it so far? [elicit]

5. Treatment Planning The available strategies for improving one’s mental health are myriad. Medication, psychotherapy, and peer support combined with meditation are only a few strategies that may be helpful. With so many potential avenues to wellness, and often very limited time to explore these options, MI can be an efficient pathway to a wellness plan. A willingness to surrender the expert role and embrace a spirit of evocation is often enough to rapidly identify realistic targets for treatment planning. Example: “In addition to taking the medication I’ve prescribed, what else do you think will be most important for reducing your anxiety between now and our next appointment?”

Trusting the patient to have their own ideas can often identify individualized change goals that are both sensible and specific. 6. Treatment Adherence Much of a patient’s wellness is determined after an appointment ends. Most often the patient is the one who needs to enact a treatment or “change” plan. MI provided across a variety of contact points can improve treatment adherence (Palacio, Garay, Langer, Taylor, Wood, & Tamariz, 2016). It is our experience that the psychiatric appointment is

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no exception. Consistent use of MI by all members of a psychiatric treatment team improves treatment adherence.

CHALLENGES IN INTEGRATED PRACTICE Even when motivational psychiatry is going well, there are lingering tensions between MI and modern community practice.

Logistical Challenges Here we review the logistical and philosophical challenges that an integrated practitioner may face, along with some partial solutions. Time Management Time is at a premium in today’s care delivery systems. Often a practitioner has only 15–​20 minutes to complete a patient encounter. The pressure to focus a conversation quickly and rush to develop a plan is not imagined. There simply isn’t always enough time to engage a patient and develop a plan of care. This is where the practitioner must make some tough choices. Every volley is an opportunity to be intentional in balancing engagement and planning. Here are some self-​reflections we have found helpful in guiding our own choices in these situations: • Which parts of my usual evaluation and chart review process will change my medical decision-​making today? Which parts can be safely delayed? • Is developing a plan today likely to impact clinical outcome if the patient is disengaged? If so, is the impact likely to be positive or negative? Documentation We find that the more we refrain from taking notes, the more effective our conversations feel. Ideally, we strive to commit our full attention to the patient for the first quarter of an appointment. Gains in engagement do come at a cost; time left for documentation compresses. This is a cost that can be managed, and most of this happens outside of a patient encounter. We have learned to invest in developing routines that minimize keystrokes and mouse clicks. You will know better than us how your workflow can look! Perhaps there is a questionnaire that patients can complete prior to their appointment. Could a note template be a helpful reference

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for streamlining your documentation? Solutions might involve making peace with the idea that “good enough” documentation really is good enough. Finally, when we do take notes in the patient’s presence, we have found it helpful to ask permission before doing so. Productivity Our current systems reimburse based on visit duration and complexity of medical decision-​making. While our current billing systems may not recognize empathy, a patient’s recovery may depend on it. Holding a therapeutic space (i.e., being physically, mentally, and emotionally present with the patient) is a choice of integrity, and often you won’t get credit for doing it. For this to be a sustainable choice, you (the practitioner) need to be emotionally healthy. We suggest findings ways to invest in a healthy work-​ life balance and making a real commitment to your own wellbeing. Like-​ minded peer support is invaluable for resiliency. Remember, part of MI relies on your ability to feel something positive and authentic for and with your patients.

Philosophical Challenges Trainee as an Expert Patients may enter a medical encounter expecting to meet an authority figure. Treatment teams sometimes expect or even hope for the same. Questions of medical disability and liability are organized around assumptions of a practitioner’s expertise and authority. Our systems of care create hierarchy and place practitioners near the top. You can expect an attitude of trust and collaboration to catch others off guard. This is often a welcome surprise in patient encounters and may be precisely what encourages a patient to invest in recovery. The lowering of oneself, and the surrendering of power to the patient is a putative mechanism of action for MI (de Almeida Neto, 2017). There are challenges when introducing shared power to a system that expects hierarchy. Implicit requests for the practitioner to be the ultimate steward of medical decision-​making and responsibility are frequent. Practitioners may feel pressure to refuse treatment to patients who decline key medical recommendations. Yet, when relevant, the principle of supporting patient autonomy dictates that the practitioners explain that the practitioner’s role is similar to that of a “consultant” or “coach,” and emphasize patients’ ultimate responsibility for deciding what is in their own best interests. Of course,

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ethical limits exist such that the practitioner will not provide treatment that may harm the patient (see vignette below). This cultural mismatch can be partially mitigated when MI is married with harm reduction. Harm reduction is a philosophy of care that validates empirically supported, albeit imperfect, treatment options as ethically viable (Hawk, et al., 2017). Another mechanism for reducing the perception that a hierarchy vests one practitioner with decision-​making is to indicate that all members of the community psychiatry team have different roles to play (e.g., psychiatrists and nurses most often specialize in medication treatment; therapists (psychologists, social workers, and nurses) specialize in therapies. Team members share their knowledge through routine clinical meetings to discuss treatment strategies and recommendations. This treatment management style reflects egalitarianism among practitioners similar to what takes place in the patient-​practitioner dyad. It reinforces autonomy and the spirit of MI. Finally, in this regard, providing formal MI training for other nonpsychiatric personnel who interact with our patients may be beyond the purview of most community practitioners. However, explaining the MI approach during interagency meetings and outreach efforts with teachers and probation officers, for example, can be invaluable for introducing MI into community psychiatry. That emerging, disparate pockets of treatment culture are arriving at similar conclusions speaks to psychiatry’s readiness for change. Trainee as a Diagnostician Part of MI is understanding diagnoses as potentially damaging labels. “Schizophrenic” is a label that can be invalidating and disengaging. Labels can make a person feel misunderstood and undervalued. Entering conversations about diagnosis with humility and openness can help. Describing an illness using the patient’s words can be key to building therapeutic alliance and encouraging treatment adherence. Sometimes “mood swings” is a more helpful phrase than “bipolar disorder.” Philosophical tension can arise when the relativism of absolute acceptance is introduced to the medicalized systems of psychiatry. An emphasis on diagnosis and psychoeducation is stressed by many of our medical institutions. Implicit pressure can mount when standard pathology language is set aside in favor of patient-​specific language. Here we again find cultural bridging to be a helpful exercise. Recovery-​ oriented care is a person-​centered, strengths-​based philosophy of care that emphasizes reducing stigma and honoring the individual’s unique perspective (Sowers, Primm, Cohen, Pettis, & Thompson, 2016). Recovery has become a

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core organizing principle in mainstream community psychiatry and a natural fit for the spirit of MI. On Responsibility and Discord It is important to acknowledge practitioner power and the responsibility that comes with it. Society has collectively chosen practitioners as safe keepers of medical risk and liability. The practitioner may be called upon to deny certain treatments, even when the treatment is requested, and in some circumstances, to compel treatment even when it is refused. To give a helper this degree of power pushes the boundaries of context for MI. In these situations, we often find it necessary to constrain the scope of partnership. Part of partnership is a genuine attitude of openness. It is about a willingness to enter a conversation without knowing how it will end. If you have already decided how a conversation is going to end, we do not suggest feigned openness as a strategy for avoiding discord. Telegraphing disingenuous openness is not respectful; it’s condescending. Often a choice like this is more about avoiding our own discomfort than it is about helping the patient. Consider this vignette: A 38-​year-​old patient with a history of compulsive, nonmedical use of high dose alprazolam (Xanax®), alcohol, and intravenous heroin presents to their psychiatric practitioner, requesting a prescription for alprazolam. A recent urine toxicology suggests ongoing polysubstance use. The patient appears malnourished. PATIENT: I’ve tried every medication under the sun for my anxiety. Nothing has ever helped me except for Xanax®. TRAINEE: You’re really tired of trying other medications when you know what to expect from Xanax®. [complex reflection] PATIENT: Exactly, and I know all of the risks. I get it, Xanax® is addictive, I can get tolerant to it, and I know it’s really dangerous to mix it with other substances. But I can’t keep living like this, I’m anxious all the time.

A practitioner using standard MI may elect a double-​sided reflection for their next volley. Follow the decision rules of MI long enough and you may spend most of the session hoping the patient decides to rescind her request. But what if she doesn’t? Are you willing to prescribe alprazolam for this patient? What would it feel like as a patient to spend 15 minutes with a helper who is seemingly open to your ideas, only to be denied at the end of the session? Imagine you are a Parisian tour guide, and a client makes it clear at the beginning of the excursion that her top priority is visiting the Louvre. Now

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imagine that you know the Louvre is closed today. What would be more helpful to your client: spending half of the morning driving her to the Louvre and acting surprised when she discovers the truth, or setting clear expectations so that she can help you decide on next best options? Now consider this volley as an alternative to a double-​sided reflection: TRAINEE: I really do want to understand your experience, and at the same time I don’t want you to feel like I’m misleading you. Out of fairness to you, I think it’s important to let you know that I won’t be prescribing a benzodiazepine like Xanax® today. I can talk more about that if you’d like, and, you’re already well educated on the risks that I’m concerned about, so maybe it would be less helpful for me to review that information again. What do you think would be the most helpful direction for our conversation? [complex reflection; summaries; open-​ended question]

There are some elements to this volley that really don’t reflect high fidelity MI. The practitioner is sharing their concerns without permission, and flatly declining a patient’s request. “I” is the subject of every statement in this volley. And at the same time, a more constrained partnership is still offered. The patient is still invited to participate in shaping next steps in the conversation, even after a limit has been set. How might this limit shape the rest of the appointment? How much do you feel compassionate limit-​setting has created space for more productive collaboration to occur?

MOTIVATIONAL INTERVIEWING IN PSYCHIATRY TRAINING Learning motivational psychiatry is a developmental process. MI is simple enough that practitioners can gain proficiency with limited practice and supervision (Hall, Staiger, Simpson, Best, & Lubman, 2016) yet complicated enough that one can spend a lifetime “perfecting” it. Integration with psychiatry is more complicated still. The more our medical institutions can anticipate ongoing supervision and coaching as a norm of integrated practice, the more motivational psychiatry can become accessible and normative. Consider the following perspectives on integrated practice from two vantage points: one a psychiatry resident, and the other a senior attending psychiatrist who has spent a career developing and training in motivational psychiatry.

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Trainee Perspective (Melinda Armstead) As a third-​year psychiatry resident I learned MI in a counseling setting. I was excited to carry this skillset forward. However, I found it challenging to maintain fidelity while at the same time meeting the expectations of various supervisors. The demands of training resulted in a regression of my MI skills as I worked to balance expanding priorities. Eventually, it became clear that I was feeling burned out. I needed a change. I started small, focusing on MI for the first 5 minutes of my sessions. This allowed me to build therapeutic alliance and access a highway of information without resorting to an onslaught of close-​ended questions. Patients seemed more likely to attend appointments and adhere to treatment plans. I began to reconnect with a sense of personal meaning at work, and my feelings of burnout dissipated. I wanted to integrate even further. I advocated for additional assessment time, allowing for two sessions to complete a psychiatric assessment. Reduced time pressure allowed me to obtain pertinent medical information while at same time practicing high-​quality MI. The more confident I became, the easier it got to balance both priorities. I became efficient at integrating MI into shorter, medication-​ focused appointments. One of my most valuable training resources was a collection of supportive supervisors. While not all my supervisors were trained in MI, most of them were open to my training goals. It is my hope that more trainees be able to access MI training as part of their core curriculum.

Senior Attending Perspective (Antoine Douaihy) I first encountered MI in residency training when I read Miller and Rollnick’s book Motivational Interviewing: Preparing People to Change Addictive Behavior (1991). In the preface, I noticed a statement, “A word of informed consent: This approach is likely to change you.” MI is more a way of being than an intervention and it’s based on building empathy, congruence, and positive regard. Miller articulated that “it is love and profound respect that are the music in MI, without which the words are empty.” Isn’t that what the “music” of psychiatry is about? Identifying and understanding your underlying motives and checking them against the spirit of MI are essential to an integrated practice. The most rewarding aspect of my career has been working with medical trainees and mentoring them with the motivational spirit of evocation: calling out their own humanism and passion (Douaihy & Driscoll, 2018). Trainees

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have clearly expressed that learning MI not only changed their clinical practice but their personal ways of being with others. This is the difference between doing MI and being MI.

CONCLUSION Community psychiatry is changing. Financial pressure, time constraints, and cultural inertia have become a threat to therapeutic alliance. Motivational psychiatry offers a pragmatic, evidence-​based approach to person centeredness amid these challenges. We hope this skill set provides a tangible starting point for integrating rigorous patient engagement into the realities of the modern workflow. At the same time, skillfulness may not be enough to safeguard psychiatry’s core humanity. Putting the patient at the center of our work will also require a collective will. Motivational psychiatry, recovery-​oriented care, and harm reduction represent independent cultural movements converging on a unified philosophy of care. We view enriched, cross-​cultural dialogue as a next step in actualizing a more humanistic way of practice.

SELF-​ASSESSMENT QUIZ True or False 1. MI can be delivered in as little as 15 minutes. 2. MI is a psychotherapy modality that requires intensive training. 3. Harm reduction is a core skill of MI.

Answers 1. True. Studies have shown that MI, delivered in brief 15-​minute sessions, can produce measurable and durable reductions in harmful patterns of behavior. 2. False. MI is a way of talking with people about change. This may very well happen in the course of psychotherapy but can just as easily happen in the course of delivering medical care, education, coaching, or any variety of help-​oriented settings. While it can take a lifetime to “perfect” MI, beginner proficiency can be reached in just a handful of training sessions.

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3. False. The core skills of MI include open-​ended questions, affirmations, reflections, and summarizations. Harm reduction is an independent, cultural movement in medicine that shares common philosophical features with MI.

REFERENCES Douaihy, A., & Driscoll, H. P. (2018). Humanizing addiction practice: Blending science and personal transformation. Springer International Publishing AG. de Almeida Neto, A. C. (2017). Understanding Motivational Interviewing: An evolutionary perspective. Evolutionary Psychological Science, 3, 379–​389. Hall, K., Staiger, P. K., Simpson, A., Best, D., & Lubman, D. I. (2016). After 30 years of dissemination, have we achieved sustained practice change in Motivational Interviewing? Addiction, 111(7), 1144–​1150. Hawk, M., Coulter, R. W. S., Egan, J. E., Fisk, S., Reuel Friedman, M., Tula, M., et al. (2017). Harm reduction principles for healthcare settings. Harm Reduction Journal, 14(1), 70. Lawrence, P., Fulbrook, P., Somerset, S., & Schulz, P. (2017). Motivational Interviewing to enhance treatment attendance in mental health settings: A systematic review and meta-​ analysis. Journal of Psychiatry and Mental Health Nursing, 24(9–​10), 699–​718. Miller, W. R., & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change addictive behavior. Guilford Press. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). Guilford Press. Palacio, A., Garay, D., Langer, B., Taylor, J., Wood, B. A., & Tamariz, L. (2016). Motivational Interviewing improves medication adherence: A systematic review and meta-​analysis. Journal of General Internal Medicine, 31(8), 929–​940. Sowers, W., Primm, A., Cohen, D., Pettis, J., & Thompson, K. (2016). Transforming psychiatry: A curriculum on recovery-​oriented care. Academic Psychiatry, 40(3), 461–​467.

16 Addressing Healthcare Access and Disparities Using Motivational Interviewing Vivianne Oyefusi and Jeanette South-​Paul

It has been well documented that stress on the individual, household, and societal levels is a significant contributor to healthcare disparities and may contribute to the exacerbation of existing disease burden. Unfortunately, many of the contributors to these stressors lay outside of individuals’ immediate control. Those experiencing health disparities often manifest an unequal burden of diseases and other adverse health conditions that are associated with identifiable cultural characteristics. Those factors most associated with chronic and debilitating diseases include race and ethnicity, gender, sexual orientation, nationality, religion, education, income, geographic location, language spoken, and disability. An assessment of these factors at first contact drives the clinical encounter in a positive or negative direction. Motivational Interviewing (MI) cannot be effectively implemented without this cultural context (Bahafzallah, Hayden, Raffen Bouchal, Singh, & King-​Shier, 2019). For those circumstances that fall within an individual’s locus of control, the collaborative and empathic approach of MI empowers individuals to make sustainable life changes. Though life circumstances may vary, MI has been shown to be effective in various populations and has many applications across healthcare settings. It is no coincidence that the key tenets of the spirit of MI—​ partnership, acceptance, compassion, and evocation—​are the same attributes that are necessary to create a safe, comfortable, nonjudgmental environment for collaboration to take place, especially with populations that are more likely to have been denied access to care. By practicing MI, we embrace partnership, respect the autonomy of every person, and convey equal regard for all. MI focuses on the belief that every person has the wisdom, strength, and motivation to change, and we seek to empower people by evoking and reflecting these attributes. MI focuses on understanding people’s unique challenges and

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perspectives. In this chapter, we will explore the ways that MI is a humanistic approach, with the assumption that patients have an inherent drive toward wholeness and health. Further, this drive may be used to improve the ability of underserved communities to access high-​quality healthcare services and engage in treatment. MI can serve as a catalyst to reduce the burden of healthcare disparities, problem-​solve treatment barriers, promote fairness, and foster social justice (Miller, 2013).

SOCIOECONOMIC STATUS (SES) Case Excerpt #1 Grandma Evelyn has been the anchor of her family for years. When her daughter, Mary, got pregnant, she vowed she would deliver her baby because she knew that was what God would want. Grandma Evelyn was with her daughter during labor and joyously welcomed little Marcus into the world. Marcus’ father tragically died in a car accident early on in the pregnancy, and Grandma Evelyn was a widow herself. Then Mary spiraled into a postpartum depression. Grandma Evelyn recognized her daughter’s symptoms since she had battled depression herself since early adolescence and never had reliable access to mental health services. Socioeconomic status is a major predictor of factors from multimorbidity to educational outcomes. In fact, neighborhood disadvantage at birth has been linked to achievement gaps starting before kindergarten (Vinopal & Morrissey, 2020). As such, it is no surprise that socioeconomics are also implicated in the unfolding of healthcare access and outcomes. Constraints posed by socioeconomic status have an overpowering influence on health care decision-​making in disadvantaged communities. Frequently, practitioners direct patients to make appointments, travel distances to access services, or obtain medications or other therapeutic products that they cannot afford. This is often exacerbated by the variable lived experiences resulting from the discrepancies between the socioeconomic strata occupied by many patients compared to their practitioners. Behavioral health services are usually funded and managed separately from medical services—​except in practices where services are bundled such as federally qualified health centers and school-​based health centers. In certain states, the clinical contracts in medically underserved communities are held by different insurers with different rules, locations, and workforces. They usually operate parallel to the medical system without exchange of information

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or collaboration—​a particularly difficult situation when patients are affected by multiple social determinants of health. Often, when practitioners who are unaware of patients’ socioeconomic constraints (their social determinants of health) learn that a patient has not followed recommendations, the patient is labeled “noncompliant” or even “disruptive” and may be forced to move to the end of the line to reschedule a missed appointment or may actually be refused future appointments. These institutional policies and/​or types of misunderstandings frequently result in substandard care, poorer health outcomes, and decreased trust and/​or rapport between patients and practitioners. The collaborative approach facilitated by MI is particularly helpful since it offers an empowering, patient-​centered, and culturally congruent approach which often reveals patients’ challenges and barriers to care about which practitioners were previously unaware.

Consider Again the Case of Grandma Evelyn Grandma Evelyn has worked since her husband passed away over 20 years ago. She is careful with the management of her financial resources and can get by on her savings and the payments from her modest pension and social security. When she assumed care of her grandchildren, Grandma Evelyn began to worry more than she did before about her ability to cover her expenses. Gradually, as her savings dwindled, she began to worry more about her financial stability. She feared she would be unable to afford her medications, even after insurance and other discounts were applied. For the past 3 months, she has been unable to afford her blood pressure medications because of some unexpected expenses that depleted her carefully monitored budget. This was not the first time that Grandma Evelyn has had to skip medications. Last year, her practitioner added a second blood pressure medicine because of poor control, and Grandma Evelyn wondered how she would afford two medications. Grandma Evelyn has been unable to consistently afford her medications and has been trying to stretch her prescriptions out by alternating days or cutting pills in half. When she returns to the practitioner for a follow-​up appointment, she sees a new practitioner who has reviewed the changes made to Grandma Evelyn’s medications over the past year. Grandma Evelyn appreciates being able to see the same practitioner when she goes for care for herself or Marcus at the neighborhood health center. Then she does not need to provide distant history every time she visits. Further, her practitioner understands the stressors she is under from worrying about her daughter and her grandchildren. So, she

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was surprised when she went to her recent appointment and a different practitioner, who is a medical trainee, entered the examination room. This is how the trainee in this clinical encounter used the MI spirit, OARS skills (open-​ended questions, affirmations, reflections, and summaries), and strategies to engage Grandma Evelyn: TRAINEE: Hi Ms. Evelyn. I know I am not your regular doctor. She and I work closely together, and she shared with me about your medical issues. I want to reassure you she will look over my notes and my recommendations to be certain you receive the best care! [collaboration; establishing therapeutic alliance] GRANDMA EVELYN: I appreciate your telling me that you have communicated with my doctor about my conditions. I want to make sure you understand my struggles. TRAINEE: You are making a valid point. Working together will help me better understand your struggles and figure out how we can address them. You have expressed a major concern regarding your medications. How do you feel about having a conversation about it? [complex reflections; collaboration; open-​ended question] GRANDMA EVELYN: Yes, this is a major problem, and I am not sure what to do about it. TRAINEE: OK, let us discuss it. How have you been doing since your last appointment? [open-​ended question] GRANDMA EVELYN: I am managing but I am concerned about not being able to afford taking the medications as prescribed, which can affect my health. And as you know, I have to take care of two energetic grandsons, and finding the time to care for myself has not been easy. TRAINEE: You have been unable to take your medications consistently because you cannot afford them, at the same time you know how important it is to take them as prescribed. You are so resilient and doing your best to take care of your grandsons and manage your own life, in spite all these challenges. [double-​sided reflection; affirmation emphasizing her value system] GRANDMA EVELYN: Yes, but I am still not sure what to do. I do not have the means financially, and they keep going up, and I cannot even afford the copay. TRAINEE: You are feeling stuck and helpless. And you need to know about resources that can help you get back on the right track with taking your medications as they are prescribed. [complex reflections] GRANDMA EVELYN: Yes. I do not know what to do. What do you suggest? TRAINEE: Let us brainstorm together options and resources to help you access these medications. Is it OK to review your medication regimen to re-​evaluate what is needed and how you are responding to them and to look for lower cost substitutes? [collaboration; asking permission]

260  Motivational Interviewing, 2E GRANDMA EVELYN: Sure. TRAINEE: From reviewing your regimen, I can see there are less expensive alternatives that would reduce your out-​of-​pocket costs. So, I could switch you to those medications. Some of the medications you are on are not needed at this time so you could stop taking them. How do you feel about these suggested changes? [complex reflections; open-​ended question] GRANDMA EVELYN: I feel relieved, and yes, let us make these changes. Thanks for listening to my concerns and coming up with some solutions. TRAINEE: My pleasure! How do you feel about meeting with our social worker who can be very helpful with connecting you with more resources in the community? [open-​ended question] GRANDMA EVELYN: Sure, that would be great. TRAINEE: How do you feel about meeting with me again in a couple of weeks to revisit your medications and discuss how you have been managing your life and medical issues? [open-​ended question] GRANDMA EVELYN: That would work.

Being transparent about the process, focusing on establishing a trusting relationship, and acknowledging Grandma Evelyn’s commitment to her family and cultural values are key to her willingness to partner with her practitioners so they have no blind spots regarding her ability to engage with the proposed treatment plan. Oftentimes, practitioners without personal experience with patients’ experienced barriers from time constraints, financial limitations, and employment instability do not consider or include these factors into their approach. In addition, the demanding nature of medical care may make it difficult to fit such screening for social determinants of health into increasingly limited appointments. Nevertheless, it is important to screen for such barriers and assume that factors, outside of willful nonadherence, are contributing to a lack of adherence to recommended treatment regimens. Identifying the extra clinical resources that are available in nontraditional practices such as federally qualified health centers and school-​based health centers (e.g., psychologists, social workers, nutritionists, clinical pharmacists, dentists, and others) allows practitioners to extend the therapeutic encounter and better meet the needs of vulnerable patients. The trainee used MI to enhance the relational components of equal partnership, accurate empathy, reflective listening skills, and the value of asking evocative questions in a nonjudgmental way. This approach helped the patient openly disclose her struggles, supported her autonomy, and facilitated the process of addressing barriers to her medication adherence.

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GENDER It is important to consider gender dynamics when approaching conversations about behavior changes. It is no secret that women often have different social considerations. When layered with transgender identity or sexual orientation, which will not be explored in this chapter, the picture may become particularly complex.

Case Excerpt #2 (Gender Roles) Marcus’ father died before Marcus was born. Mary’s father had never maintained a relationship with his daughter, so there were no men in the household. Because of Mary’s depression and inability to focus on her newborn son, Grandma Evelyn fed, bathed, and nurtured Marcus from birth. According to the World Health Organization (2021), some of the sociocultural factors that impede health equity for women globally include power dynamics between men and women, disparities in education and employment opportunities, an emphasis on reproductive roles, and experiences of various types of violence. Though being a caregiver is not a universal experience for women, it is one that a large majority of women come to share over their lifetimes. In addition, a larger percentage of the burden of childcare responsibilities often falls upon the shoulders of female caregivers, compared to their male counterparts. This responsibility is often compounded by caring for elder relatives or extended into later adulthood when considering multigenerational households. As such, it is important to consider the unique challenges experienced by the thousands of women with caregiver responsibilities that practitioners will encounter over their careers. Further, women experience many chronic diseases differently as they age and may not receive care appropriate to their individuality—​gender, socioeconomic status, race, ethnicity, and age—​especially when sublimated to their family responsibilities (Legato, Johnson, & Manson, 2016). Consider Grandma Evelyn. She has been the primary caregiver for Marcus for much of his life. She often places her own needs on the backburner and attends to his instead. As mentioned before, this often reduces the financial resources that she has left to attend to her own needs. Further, other members of the extended family infrequently respond to her requests for assistance. She worries about what will happen to her grandchildren if anything happens

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to her and has struggled to secure additional resources to help her care for her boys. Such scenarios are more common than many realize, and it is important to consider the unique burdens and responsibilities that many women share, regardless of socioeconomic, religious, or cultural circumstances. The dialogue in the next section provides an example of how this may play out.

RACE AND ETHNICITY Race and ethnicity have been shown to be important determinants of health. Many disparities exist between racial minority and majority populations. Practitioner bias has been shown to creep into the care of minority patients and leads to differential care, much to the dismay of patients who may hold unconscious biases. A study at the University of Pennsylvania showed that black patients are more likely than their white counterparts to be labeled nonadherent (Beltran, Lett, & Cronholm, 2019). Therefore, it is also important that clinical approaches be culturally tailored to maximize the chances that the proposed solution falls within a particular patient’s realm of possibility. These could be linguistic, environmental, or conversational approaches that consider variations in experiences among patient populations. To do this, practitioners must be willing to approach their patients with an open mind and learn about and challenge their own assumptions, without placing the burden of that education on their patients. It is important then to create an environment that centers on patients and protects them from the additional burden of bias. A way to do that is by approaching every patient with curiosity, openness, and humility. Indeed, these are characteristics that we should aim to embody if we are truly embracing the spirit of MI. When considering race, racial trauma, combined with the trauma imposed by denial of the lived experiences of marginalized communities, it is even more important to adopt a MI approach to avoid inadvertently creating barriers in clinical relationships. The focus on compassion as an element of the MI spirit is intended to convey the notion that the practitioner must be working in the patient’s best interest, rather than for the benefit of another party. Of course, racial minorities are distinct in ways that have nothing to do with trauma and oppression. Though it is important to acknowledge the possibility of an increased trauma burden, it is also important not to assume that such experiences are defining characteristics of patients’ lived experiences and to make space for cultural differences that may arise from other barriers to participating in proposed treatment plans. These include differences such

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as community celebrations, culinary preferences, and haircare practices. The humility necessary for a MI approach is helpful because it allows cultural differences to be revealed and more effective solutions to be proposed through a strengthened therapeutic alliance.

Case Excerpt #3 (Race and Ethnicity) In addition to Marcus, Grandma Evelyn also watches his cousin, Johnny, 5 days a week, so his parents can work. As hourly workers in the nearby warehouse with limited sick time, Johnny’s parents have been unable to afford to enroll Johnny in the nearby daycare center. Johnny is only 1 year older than Marcus, and they spend much time together at their grandmother’s home. So, the boys are like brothers. One day when Marcus was 5 years old, while Marcus and Johnny were playing boxing, Marcus lost his balance and fell and hit the side of his head against the dresser in the bedroom. While being interviewed in the Emergency Department (ED), Grandma Evelyn was asked multiple questions regarding how Marcus got injured. The nurse, who took Marcus’ vital signs, asked him what happened, and then a trainee came in and asked Grandma Evelyn what happened. In front of her, the trainee asked Marcus the same question as if his grandmother had not just answered the same question. When he was finished meeting with them and examining Marcus, they waited almost an hour, and another practitioner came in and asked the same questions again and added new questions. Who else was in the house at the time? When Grandma Evelyn mentioned Johnny, they wanted to know how old he was? Were there other adults there? Has Marcus been injured before? Have they gone to urgent care or the ED for previous injuries? Grandma Evelyn was offended that the trainee did not seem to be doing anything to decrease the swelling on Marcus’ ear but rather persisted in interrogating them to identify another guilty person. The staff evaluating Marcus assumed an adult had injured him. The practitioner wanted Grandma Evelyn to admit she practiced corporal punishment that resulted in Marcus’ injury or suggested there was some other person in the home who had hit him. Grandma Evelyn is an attentive older caregiver and carefully confines her two grandsons to her home. She is uncomfortable with their vulnerability if she lets them run around the community unsupervised. She knows they are at increased risk for experiencing violence or being exposed to bad habits, so she encourages vigorous activities indoors. At the trainee’s office, she mentions the repeated assertions that she was abusing her grandchildren. Many

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practitioners may hesitate to directly engage with this comment, especially if they are from a different background than their patient. However, doing so would be a missed opportunity to connect with important aspects of this patient’s lived experience, which is influenced by her racial and ethnic background. Instead, practitioners should see this as an opportunity to affirm their patient’s realities. Let us consider how this might play out. GRANDMA EVELYN: I have just been so upset since our visit to the ED. Children roughhouse and have bruises all the time. It is like they think that black people are more likely to neglect or abuse their children. TRAINEE: Maybe they just thought that the bruises were unusual or too frequent. GRANDMA EVELYN: I only took him to the ED for that one event. And we both told them what happened. I even had pictures. They just wanted me to say I was lying. TRAINEE: [Brief pause.] So how have your diet changes been going? GRANDMA EVELYN: Fine.

Let us take a moment to assess how that interaction could have gone differently. The trainee totally dismissed Grandma Evelyn’s feelings of frustration and pain and chose to set the agenda of the conversation. Minimizing her feelings can clearly communicate the practitioner’s discomfort with emotional intensity and lead the patient to disconnect. This MI-​nonadherent approach jeopardizes the therapeutic alliance and is counterproductive. Now consider how this scenario would have unfolded if the trainee had adopted the empathic “way of being” of MI, using specific reflective listening skills and maintaining the spirit of MI throughout the encounter: GRANDMA EVELYN: I have just been so upset since our visit to the ED. Children roughhouse and have bruises all the time. It is like they think that black people are more likely to neglect or abuse their children than whites or other people. TRAINEE: You work very hard to ensure the health and safety of your grandchildren, and it is very distressing to be accused of intentionally harming them. [affirmation; complex reflection acknowledging the emotional intensity] GRANDMA EVELYN: Right! When this happened, I was just in the kitchen making dinner—​I make a lot of things from scratch because it is cheaper that way—​but they were within earshot. What am I supposed to do? I am afraid to let them go to their friends’ homes because I do not know their families. I do my best—​then these doctors just accuse me of abuse! TRAINEE: This was an accident that could have happened to anyone. At the same time, you feel like you are stretched thin, and you feel you need more help with the boys. [complex reflections]

Healthcare Access and Disparities Using MI  265 GRANDMA EVELYN: I really am. And I feel so guilty. Maybe I cannot take care of these boys. Maybe I am just too old. TRAINEE: Children get hurt all the time, no matter how attentive their caregivers are. You are working hard and successfully providing for the needs of your grandchildren. You have a lot of needs for yourself as well, including making some dietary changes and managing your blood pressure. What do you think would be helpful to make these tasks less overwhelming? [complex reflections; evocative question] GRANDMA EVELYN: I know that my church has a program for children, but I do not have a way to drop them off, take care of things at home, then pick them back up. I have known the people who run the children’s programs for a long time, so I trust them. Plus, they would get a healthy meal there too. TRAINEE: There are some programs that could help you with transportation and other resources. How do you feel about talking with our social worker who can review some options for you to consider? [giving information; open-​ended question] GRANDMA EVELYN: That would be great.

You can see how the trainee’s willingness to acknowledge Grandma Evelyn’s experience using reflective listening statements could help to create a more collaborative environment by building rapport, encouraging her to fully disclose her thoughts and feelings, evoking her strengths, and allowing her experiences and values to shape the therapeutic environment. The importance of the church, an institution that has played a vital role in many African American communities, may not have been revealed without the nonjudgmental, empathic, compassionate presence with the patient. With time and trust, this practitioner may learn about additional resources that may be available to provide Grandma Evelyn, and her grandchildren, with better health outcomes, by addressing less obvious barriers to their well-​being. This is an approach that should be taken with all racial groups to help maximize health outcomes in a society that produces disparate realities based on racial backgrounds.

RELIGION There are approximately 350,000 social entities that identify themselves as congregations—​some of whom do not identify themselves as formal religions. However, these faith-​based assets form what has been called “a connective tissue of social infrastructure that supports, connects, and protects neighborhoods” (National Academies of Sciences, Engineering and Medicine, 2021). These congregations not only can formally partner with health care organizations, but personal faith has been shown to anchor individuals and provide them strength and energy to withstand and overcome many medical and

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behavioral comorbidities. Many practitioners miss the opportunity to explore patients’ personal faith when they first meet them—​even when that evaluation occurs in an acute crisis.

Case Excerpt #4 (Religion) Grandma Evelyn struggled when her daughter, Mary, started using drugs. Although she made it clear to Mary that God does not support drug addiction, she stayed in touch with Mary—​she prays regularly that Mary will be healed. Grandma Evelyn’s faith and lifelong membership in her local church have anchored her life from childhood. She recognizes that all people sin but believes that God can forgive anyone. This belief prompts her to sustain her relationship with Mary, while cherishing her responsibility to raising her grandsons when their parents are absent or unavailable. She prayed fervently that Marcus’ ear would heal spontaneously but soon became anxious. In spite of acetaminophen, ice packs, and prayer for 2 days, the swelling remained prominent and was very tender to touch. She decided that God must have a plan and it was important for her to seek human guidance from her family practitioner. When assessing individuals who are seeking medical care, it is vital to understand their spiritual convictions as these closely held beliefs color the lens through which they see and interpret life events and have health effects that are both proximal and distal. The optimal alignment of one’s spiritual convictions and the challenges of one’s home situation and daily journey shapes one’s decision-​making, as well as how one responds to family, peers, and authority figures such as those in the healthcare system. Organized intersections of faith and health have occurred many places in the world throughout history. People who faced their human condition realized that they needed to look beyond humanity for the strength to move forward (National Academies of Sciences, Engineering, and Medicine, 2021). Religion and spirituality have long anchored certain marginalized communities—​especially African American and Latino communities in the United States. Research focusing on the impact of religion during the past 3 decades has supported the significant influence on the health of both minority and majority populations (Koenig, 2015). Methodologically rigorous studies of religion/​spirituality (R/S) were evaluated with respect to the impact of Religion/Spirituality on mental health, well-​being, hope, optimism, depression, anxiety, substance use, and response to chronic diseases including cancer.

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Religious persons report greater well-​being, more purpose and meaning in life, greater hope, and greater self-​esteem and are more likely to be optimistic. Diagnoses of mental health conditions such as anxiety and depression are also less common among religious people (Koenig, 2015). The sincerely held beliefs of patients should be identified at the beginning of clinical evaluations in order to support them and to understand this powerful influencer on patients’ decision-​making and ultimate well-​being. MI fits very well as a useful approach for practitioners working with patient issues related to religion and spirituality (Giordano & Cashwell, 2014). However, some data indicate that practitioners may be ambivalent about addressing spirituality or religion in clinical encounters (Cashwell, et al., 2013). Training practitioners in MI could have an impact on their willingness to explore patients’ religious and spirituals beliefs. Within the MI spirit and framework, practitioners could facilitate the exploration of spiritual and religious beliefs and their impact on behavior change without imposing their own values.

PERSONAL REFLECTION (Vivianne Oyefusi) Every healthcare system is flawed. That is a well-​accepted perspective that is held by many people in a variety of cultural, religious, and social contexts. Yet that knowledge does little to prepare the passionate, wide-​eyed trainee for the myriad of ways that the healthcare system fails their patients, no matter how hard they try to solve the problems presented. When faced with patients and their healthcare needs, it is easy for a trainee to reach into their ever-​expanding well of knowledge and develop a set of optimal treatment plans. Though less gratifying, trainees also adjust when, because of common barriers like insurance coverage, they must offer alternative solutions. Yet it is much more difficult when the solutions to their patients’ healthcare needs are intertwined with an assortment of systemic barriers that impair healthcare access and provide fertile ground for the development of healthcare disparities. Of course, there are limitations to the ability of any one healthcare practitioner to address the behemoth that is healthcare disparities and issues with healthcare access. Nevertheless, MI helps practitioners to uncover the very real challenges that our patients face, provide the best possible solutions in the face of those challenges, and turn to advocacy to affect systemic change that can be felt by individual patients. By removing the paternalism inherent in the traditional approach to Medicine, MI opens the door to understanding. Grandma Evelyn

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is not just a made-​up patient. I have seen her in many of the patients that I have encountered in my city safety net hospital. Many patients have come in after not adhering to care because the treatment plans were inaccessible to them. One such patient came in with an elevated HgbA1c, significantly higher than the last recorded reading 9 months prior. He had been lost to follow-​up and came back to treatment with a poorly healing foot wound that required surgical debridement. In initial conversations, the patient simply voiced understanding of the importance of adhering to his medication regimen. However, in an effort to ensure that he would engage and adhere to care, I employed the E-​P-​E approach combined with the OARS skillsets within the spirit of MI to explore the barriers to medication adherence. He revealed multiple interpersonal struggles, including job loss, insurance loss, homelessness, and his medications being stolen in a shelter. These factors made it more difficult to follow the treatment plan as prescribed. As a result, the treatment team was able to involve social work, provide him with housing resources, and simplify his medication regimen to fit his lifestyle. Had our team written him off as “noncompliant,” we would have missed an important opportunity to address this patient’s concerns and improve his long-​term outcomes!

CONCLUSION Disparities in healthcare access and outcomes have long been a focus of practitioners and laypeople alike. Though a multifaceted issue that requires a multipronged approach, MI is an egalitarian approach and a “way of being” that uses specific skills and techniques that can help strengthen the therapeutic alliance and improve the delivery of patient-​centered care by coming up with strategies that are more aligned with the individual patients’ social contexts, life goals, and core values. MI guides the patients to make fully informed and deeply contemplated life choices, even if the decision is not to change.

SELF-​ASSESSMENT QUIZ True or False 1. The cultural adaptation of MI, as well as acknowledging and understanding the sociocultural differences/​diversity of patients, enhances the effectiveness of MI.

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2. MI fits very well as a useful therapeutic approach for practitioners working with patient issues related to religion and spirituality. 3. Psychoeducation and prescriptive information-​giving by the “expert” practitioner without consideration of disparities that are attributable to race/​ethnicity could yield to positive outcomes for patients.

Answers 1. True. MI is a therapeutic approach whereby patients’ beliefs about their illness and how it fits into the sociocultural context of their lives are evoked and explored. MI as a therapeutic intervention allows trainees to understand patients’ current understanding, beliefs, and perspectives about their illness, as well as their ability and willingness to change certain behavior. 2. True. MI provides a framework within which a practitioner can both assess spirituality/​religious beliefs and facilitate patient exploration of spiritual issues throughout maintaining neutrality and without fear of imposing values. 3. False. This MI-​nonadherent approach risks eliciting sustain talk and produces discord in the therapeutic alliance. The MI-​consistent approach using the E-​P-​E strategy enables the trainee to engage patients in genuine discussions about their value system and foster change talk.

REFERENCES Bahafzallah, L., Hayden, K. A., Raffin Bouchal, S., Singh, P., & King-​Shier, K. M. (2019). Motivational Interviewing in ethnic populations. Journal of Immigrant and Minority Health, 22(4), 816–​851. Beltrán, S., Lett, E., & Cronholm, P. F. (2019). Nonadherence labeling in primary care: Bias by race and insurance type for adults with type 2 diabetes. American Journal of Preventive Medicine, 57(5), 652–​658. Cashwell, C. S., Young, J. S., Fulton, C., Willis, B. T., Giordano, A. L., Wyatt Daniel, L., Crockett, J., Tate, B. N., & Welch, M. L. (2013). Clinical behaviors for addressing religious/​spiritual issues: Do we “practice what we preach”? Counseling and Values, 58, 45–​58. Giordano, A. L., & Cashwell, C. S. (2014). Entering the sacred: Using Motivational Interviewing to address spirituality in counseling. Counseling and Values, 59, 65–​79. Koenig, H. G. (2015). Religion, spirituality, and health: a review and update. Advances in Mind-​ Body Medicine, 29(3), 19–​26. Legato, M. J., Johnson, P. A., & Manson, J. E. (2016). Consideration of sex differences in medicine to improve health care and patient outcomes. JAMA, 316(18), 1865–​1866.

270  Motivational Interviewing, 2E Miller, W. R. (2013). Motivational Interviewing and social justice. Motivational Interviewing: Training, Research, Implementation, Practice, 1(2), n. pag. Owen, W. F. Jr, Carmona, R., & Pomeroy, C. (2020). Failing another national stress test on health disparities. JAMA, 323(19), 1905–​1906. National Academies of Sciences, Engineering and Medicine. (2021). Faith health collaborations to improve community and population health: Proceedings of a workshop. The National Academies Press. https://​​10.17226/​25375 Resnicow, K., Jackson, A., Wang, T., De, A. K., McCarty, F., Dudley, W. N., & Baranowski, T. (2001). A Motivational Interviewing intervention to increase fruit and vegetable intake through black churches: Results of the EAT for life trial. American Journal of Public Health, 91(10), 1686–​1693. Vinopal, K., & Morrissey, T. W. (2020). Neighborhood disadvantage and children’s cognitive skill trajectories. Children and Youth Services Review, 116, 105231. World Health Organization. Women’s health. Accessed October 2, 2021. https://​​ hea​lth-​top​ics/​women-​s-​hea​lth/​

17 Motivational Interviewing in Pediatric Settings Katelin Blackburn and Pamela Burke

Pediatric settings generally provide health care to children from birth to age 21 years, typically in cooperation with their parent(s).1 Motivational Interviewing (MI) has been widely used with adults and adolescents; however, its use with school age children has been less well studied. In order to provide a context for when MI may be appropriate for use with children at various developmental stages, we present a summary of relevant cognitive, verbal, and social-​emotional milestones in Figure 17.1. Threaded throughout this chapter are examples of the “spirit” of MI in action, which is characterized by compassion, acceptance, partnership, and evocation or empowerment, and applications of OARS (open-​ended questions, affirmations, reflections, and summaries), the core MI skills in the context of the MI processes (i.e., engaging, focusing, evoking, and planning).

GENERAL CONSIDERATIONS MI can be used with parents of children of any age; however, children need to have adequate causal reasoning capacity, expressive language abilities, self-​understanding, and the ability to consider other people’s perspectives and feelings, if they are to benefit from MI (Erickson, Gerstle, & Feldstein, 2005; Lohse, Kalitschke, Ruthmann, & Rakoczy, 2015; Strait, Mcquillin, Smith, & Strait, 2012). Children have an enormous range of ability to engage in conversations about behavior change during middle childhood. Some may have achieved emotional and linguistic developmental milestones at

1. The term parent refers to the caregiver who is legally responsible for the child’s health and welfare. In some cases, that caregiver could be a relative (e.g., a grandparent), a foster parent, or some other adult who is raising the child.

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precocious levels, while others may exhibit delays or regressions in these areas of development for a variety of reasons. Given this wide range of abilities, there is no exact age “cut-​off ” for when it is appropriate to start using MI with children. Rather, the decision is based on an “in the moment” assessment of the child’s developmental maturity and the family dynamic. We will discuss the developmental considerations that can inform your decisions to utilize MI with children and their parents in more detail later in this chapter. The behaviors that effect children’s health vary greatly from infancy to adolescence, as do the uses of MI with this population. Research on the use of MI in pediatrics has focused on issues specific to childhood, such as engaging in safe sleep, managing child behavior problems, and preventing dental caries. Other research on the use of MI with adolescents has focused on improving diet and physical activity, medication adherence and follow-​up care, and harm reduction related to interpersonal violence, sexual behavior, and substance use (Chiappata, Stark, Mahmoud, Bahnsen, & Mitchell, 2018; Kells, Burke, Parker, Jonestrask, & Shrier, 2019; Stormshak, DeGarmo, Garbacz, McIntyre, & Caruthers, 2021; Tomlin, Bambulas, Sutton, Pazdernik, & Coonrod, 2017; Wu, Gao, Lo, Ho, McGrath, & Wong, 2017). MI is a goal-​oriented style of communication that has traditionally been used for exploring opportunities for healthy behavior change. However, MI—​in particular its “spirit”—​is a way of being with and engaging pediatric patients and their parents. It has significant value for eliciting and prioritizing families’ main concerns and for crafting therapeutic relationships throughout clinical encounters. Applying the MI spirit and core skills creates space for young patients to share their views, build autonomy, and experience the resilience-​promoting benefits of feeling respected and understood. Assessing their capacity for conversations using MI can be accomplished by first asking young patients (who have the expressive and receptive language skills necessary to respond) a simple question, such as, “Who do you have here with you?” The best response is for them to engage directly with you by introducing their caretakers. A subsequent open-​ended, information-​gathering question such as, “What is the reason for your visit today?” is helpful. If the child has difficulty expressing why they have presented for medical care, then closed-​ended questions are often helpful to provide a sense of structure and security to the young person. Observe for nonverbal cues, such as glances toward the parents, and other signs of discomfort that can clue you in to the child’s developmental readiness to engage with you in conversation. After directing questions toward the child, you can round out the story via further open-​ended questions directed toward the parents.

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While MI works especially well when parents or patients are unsure or ambivalent about making a health-​promoting behavior change, opportunities to incorporate MI can also naturally occur when discussing “advice, education, prescriptions, care coordination, referrals, therapies . . . self-​monitoring techniques, and follow-​up” (Barnes & Gold, 2012). Providing advice using an MI-​consistent approach entails the Elicit-​Provide-​Elicit (E-​P-​E) framework, which we provide examples of below. It is paramount to take time to establish an alliance with both the child and the parent through the use of core MI skills including reflective listening and affirmations, as the family unit is truly “the patient” in pediatric settings. It can be challenging when patients and parents want practitioners to support their disparate points of view. The MI spirit underscores the importance of collaboration and partnership as we navigate such encounters. Even with the most challenging of conversations surrounding a behavior-​change goal, the four MI processes can serve as a roadmap: these include engaging both parent and child patient in conversations about the behavior in question, evoking their individual perspectives and concerns, focusing on common ground related to specific behavior change, and finally, working together to come up with a reasonable plan going forward. Decision-​making in pediatric settings is founded on the belief that most, if not all, parents want what is best for their children. By extension, the paradigm of the “family as patient” must be kept in mind as we engage both patient and parents to promote healthy behaviors. Practitioners including medical trainees help parents understand their child’s capacity for change from a developmental standpoint and recognize potential differences between their child’s and their own interests and motivations for behavior change. For both younger and older children, MI can be used to guide parents as they adapt their parenting style or practice to promote their child’s health and wellness. Using MI may even enhance parent-​child relationships by allowing for open discussion of motivations and interests in behavior change, leading to an improved understanding of and respect for each other.

A DEVELOPMENTAL APPROACH TO USING MI IN PEDIATRIC SETTINGS Every part of pediatric medical care is informed by development, from the way the waiting areas are set up, to how the practitioner approaches the physical exam, to the words used to discuss treatment plans and interventions. In order to understand how to use MI with a pediatric patient, we must first

274  Motivational Interviewing, 2E Emotional Processing of Peer and Adult Perspectives Reasoning Capacity to Link Past, Present and Future Events

Morality, Altruism, and Conscience

Attention and Perception Skills

Sense of What Others May Be Thinking (Theory of Mind)

Adequate Expressive Language Abilities

Self Awareness


5 years

10 years

15 years

20 years


Figure 17.1  Development of children’s cognitive, language, and social-​emotional skills.

review certain aspects of child development that guide our “in the moment” assessments of a child’s ability to engage with us in discussions about behavior change. Developmental milestones, or functions that most children can do by a certain age, are often categorized into four domains: social and emotional, language/​communication, cognitive (learning, thinking, problem-​solving), and motor skills. Figure 17.1. depicts the developmental trajectory for when most young people achieve specific cognitive, language, and social-​emotional milestones, which in turn informs whether and how practitioners can use MI with them (Erickson, Gerstle, & Feldstein, 2005; Hagan, Shawn, & Duncan, 2017; Lohse, Kalitschke, Ruthmann, & Rakoczy, 2015).

Infancy (Birth Through 11 Months) and Early Childhood (1–​4 Years) Given that very young children do not yet have the causal reasoning capacities, expressive language abilities, and self-​understanding necessary for engaging in conversations around their health behaviors, MI is only used with their parents during these developmental stages (Erickson, Gerstle, & Feldstein, 2005). One such opportunity might be discussing vaccinations with a parent.

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Exchange 1: Engaging With a Parent Who Is Hesitant About Accepting Vaccines In childhood, there are a series of vaccinations recommended by the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices. Despite the known benefits of vaccines for decreasing mortality and morbidity from infectious diseases, in recent years, a growing number of parents have chosen not to vaccinate their children. Reasons for vaccine refusal and hesitancy have included a preference for “natural” or “organic” living, distrust in health systems rooted in lived or historical experiences of institutional racism, advice from other parents, and a myriad of other reasons (Orenstein & Ahmed, 2017). Marie is a 2-​month-​old healthy infant girl who presents for her routine check-​up accompanied by her mother. TRAINEE: Now that we’ve had a chance to check in on Marie’s growth, eating, sleeping, and development, I’m hoping we can discuss the routine vaccines that we offer for all children her age. What questions about vaccines do you have that you would like to talk about? [open-​ended question] MARIE’S MOTHER: I knew this would be coming up, and I know that vaccines prevent a lot of important diseases, but I’m honestly not sure I’m ready for Marie to get vaccines today. I’ve just read so much on the Internet about potential side effects. When I asked my mother-​in-​law what I should do about the vaccines at today’s appointment, she told me not to let her get any because they cause autism. TRAINEE: I can tell you’ve been really thoughtful about Marie’s well-​being and safety by the way you sought out information on vaccines and advice from family members before today’s visit. [affirmation] You want to make sure you are keeping her safe from harm. You, and only you, get to make this choice for Marie, and I want to make sure you have all of the information you feel you need to make your decision. I follow vaccine safety very closely and can offer some more information about vaccines and autism. Would it be OK if I shared with you some additional information about this? [complex reflection, followed by asking permission] MARIE’S MOTHER: Sure, I’d like to understand what’s going on a little better. TRAINEE: OK, great. There was a study done years ago with 12 children that suggested there could be a connection between the measles vaccine and autism. The doctor who published that study was found to have used fake data, and actually lost his license to practice Medicine. Since then, hundreds of additional studies have been done with tens of thousands of children that show no connection at all between vaccines and autism. What are your thoughts about this information? [providing information, followed by open-​ended question]

276  Motivational Interviewing, 2E MARIE’S MOTHER: I didn’t know that so many extra studies were done and did not show what that first one did. That’s helpful to know. I bet other parents have the same concerns. TRAINEE: Certainly. You are not alone and are doing what any great parent would do by gathering information to help you make informed choices to best care for your child. In addition to the concerns about autism raised by your mother-​in-​law, what additional concerns about side effects of vaccines do you have that we can talk through to help you make this decision? [affirmation; open-​ended question] MARIE’S MOTHER: Yeah, she cried so much when she got the Hepatitis B vaccine in the nursery—​I don’t want her to suffer. TRAINEE: You love her and don’t want her to experience discomfort unnecessarily. [complex reflection] MARIE’S MOTHER: That’s right. If I do choose to give her vaccines, is there anything we can do to make her more comfortable?

In this encounter, a key strategy was affirming the mother’s autonomy in making this decision about her child. Rather than telling her that she should vaccinate her daughter, information was provided in a nonconfrontational manner that helped her arrive closer to the decision to vaccinate her child (Gagneur, 2020). Continued use of open-​ended questions also allowed for evocation of any additional perceived barriers to further explore. This encounter also provides an example of how information can be shared in an MI-​consistent manner. Notice how the trainee transitioned to information sharing by first asking an open-​ended question about what questions the mother had about vaccinations, then asking permission to provide information, and then, after providing key information, following up with another open-​ended question to elicit the mother’s thoughts. This is called the Elicit-​ Provide-​Elicit (E-​P-​E) framework for sharing information. This method allows the trainee to continue to honor parents’ autonomy while providing information that informs their decision-​making. If Marie’s mother had said that she did not want to hear more information about vaccines, then it would have been important for the trainee to honor her request.

Middle Childhood (Age 5–​10 Years) As children grow from preschoolers to school-​aged children, they mature in their capacity for causal reasoning, which is the ability to link past events with current health behaviors or problems (Kalish, 2010). Once in late-​middle childhood, many now have adequate expressive and receptive language skills

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to engage with practitioners independently; however, their social, emotional, and intellectual skills are still developing and thus they are dependent on their parents to varying degrees. They are building their skills in empathy, self-​ control, self-​esteem, and a developing sense of morality. Their identity formation has begun, and by age 8–​9 years, they can passionately defend their ethical stances. Ten-​year-​olds have the capacity to value and respect rules and authority and manage their emotional states (Hagan, Shaw, & Duncan, 2017). Given the wide range of abilities in this age group, in order to maximize the benefits of MI for each school-​aged child we encounter, we need to remember to use clear, simple language that matches their level of an ever-​growing understanding of themselves and the world around them. Be concrete in the words you use to engage them in change talk and in any recommendations you provide. Do not assume that children will have the ability to generalize your recommendations at these developmental stages. Instead, it is important to do the work with them to help them know the different settings and circumstances in which specific behaviors are expected (Erickson, Gerstle, & Feldstein, 2005). This age group responds particularly well to genuine affirmations, as well as clearly stated expectations. Exchange 2: Using a Readiness Ruler With a Child With Sickle Cell Disease Sickle cell disease results from a mutation in the adult hemoglobin gene that causes red blood cells to get misshapen, or sickled, leading them to get stuck in various blood vessels in the body and ultimately burst. This can result in anemia, pain crises, lung problems, spleen problems, strokes, and several other dangerous sequelae. Management for some individuals who have sickle cell disease includes taking a medication called hydroxyurea each day to help increase the body’s supply of fetal hemoglobin, which unlike adult hemoglobin, does not have the mutation that leads to sickling of the red blood cells. Tiana is a 10-​year-​old girl with sickle cell disease admitted to the hospital with her third vaso-​occlusive episode, or pain crisis, over the past 2 months. She is prescribed hydroxyurea to take daily at home. TRAINEE: Is it okay if we talk about your understanding of why you are in the hospital? [asking permission] TIANA: Sure. I’m here because I have sickle cell disease, and sometimes my blood cells change shape and then I get pain. The pain was super bad, so we came to the hospital. My doctor said I’m supposed to take my medicine every single day because that will help prevent pain crises. But I don’t take it sometimes, so that’s probably why I’m having more pain.

278  Motivational Interviewing, 2E TRAINEE: First off, you should feel super proud of yourself for knowing what is going on in your body so well, and for recognizing that taking the medicine, hydroxyurea, every day can really help your body stay healthy and out of the hospital. Thank you too for telling me about how sometimes it’s challenging to take it. What are some of the reasons you think you haven’t been able to take it every day? [affirmation; complex reflection; affirmation; open-​ended question] TIANA: Huh? TIANA’S MOTHER: They want to know why you don’t always take your medicines. TRAINEE: Let me ask you in a different way. So, some people have trouble taking their medicines every day because they forget to take them; some people live at two houses and forget the medicine at one house; some people don’t like the taste of their medicines; and some people’s families have trouble paying for the medicines. Are any of those, or something different, the challenges that make it hard for you? [closed-​ended question for fact finding] TIANA: Well, I’m in charge now of remembering to take my medicine myself. My mom used to give it to me with breakfast, but it made my tummy hurt when I’m on the bus to school. We used to fight about me taking the medicine before school. Now I get to be in charge of taking the medicines when I get home from school. But sometimes I do soccer practice after school, and I forget to take them because it’s late when I get home. Oh, and I forgot to take them when I slept over my friend’s house for the weekend a few times. TRAINEE: So, it was tough taking them in the morning because your stomach hurt, and it’s also challenging remembering to take them at different times of the day because you’ve got a busy life outside of the hospital. [complex reflection] TIANA: Yeah. I wish I were playing soccer now instead of being here again. TRAINEE: It can be hard to spend time in the hospital when you’d rather feel healthy and do things outside that bring you joy. What are some ways that you might be able to take your medicines every day so that you can spend less time in the hospital and more time playing soccer? [complex reflection; open-​ended question) TIANA: I was thinking it might be a good idea if I take my medicine at night right before bed when I brush my teeth instead or after school so that it’s easier to remember. TRAINEE: Awesome idea! On a scale of 0 to 10, with 10 being super confident, and 0 being not confident at all, how confident are you that you’ll be able to take your medications every night with this new plan? [confidence ruler] TIANA: Probably a 7. TRAINEE: 7? That’s high, you’ve thought a lot about this! Why a 7 and not something lower like a 4? [affirmation; open-​ended question] TIANA: Because I think that if I put the medicine right next to my tooth brush it’ll be a lot easier to remember. I already do a good job brushing my teeth every night. And I really don’t want to come back to the hospital, so I really want to do a better job.

MI in Pediatric Settings  279 TRAINEE: You are really determined to figure this out! What do you think it would take to get that confidence number to an 8 or a 9? [affirmation; open-​ended question] TIANA: I’m not sure. TRAINEE: That’s OK. You did a lot of troubleshooting, and I think you came up with a great plan that sounds like it will work for you to remember to take your medicines every night when you brush your teeth. This will work whether you’re at home or sleeping over a friend’s house because you always brush your teeth every night no matter where you are sleeping. [affirmation; reflection] TRAINEE: [To Tiana’s mother] What if any barriers do you anticipate to Tiana’s new plan of taking her medication at night when she brushes her teeth? [affirmation; open-​ended question] TIANA’S MOTHER: I think it’s a good plan, and I still want to double check to make sure she has taken the medicine, so I can remind her if she forgets. . . . TRAINEE: Teamwork! [collaboration]

You’ll notice that when the child seemed confused about an open-​ended question, the trainee pivoted away from a purely open-​ended question. Instead, the trainee provided an affirmation followed by a question with a menu of answers for her to choose from when discussing barriers to medication adherence. Finally, the menu of options is followed by another open-​ ended question to ensure that the child knows it is OK to provide an answer that is not part of the offered menu. This is one effective strategy if open-​ended questions cause confusion for children, as genuine affirmations will continue to help build rapport, while the menu of answers will allow an eager-​to-​please child a chance to continue engaging with you. Another key strategy used in this encounter was to ask the patient to describe why she did not rate a lower number on the confidence scale. This encourages articulation of change talk (i.e., her motivations for engaging in behavior change) and verbalizing her goals for avoiding future hospitalization. Then, the trainee asked what would help get her get to a higher number on the scale. This is one strategy that can be utilized to help encourage troubleshooting perceived barriers to implementing change. When the child struggled with thinking of barriers to change, the trainee appropriately gave the child an affirmation about the hard work already put into crafting a plan and worked to include the parent’s perspectives in the plan for change. Parental buy-​in is critical to promoting the health and well-​being of children in middle childhood in particular, as parents still largely control the environment. You’ll notice too that the trainee used concrete examples in the summary of the plan to include recommendations that the patient take her medications while she is both at home and at sleepovers, as again it is often

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challenging for children in this age group to make generalizations about behavior change on their own.

Adolescents Early adolescence is notable for puberty, with its hormonal surges, growth spurts, and development of secondary sex characteristics. However, brain development, in particular, the prefrontal cortex, which regulates impulse control, continues to develop until around age 25 years. Although adolescents may appear physically mature, they are not adults and thus cannot be expected to think or act like adults (McNeely & Blanchard, 2009). While chronological age does not necessarily predict an adolescent’s maturity level, adolescent development has been described using the following age-​based stages: early (ages 11 through 14 years), middle (ages 15 through 17 years), and late (ages 18 through 21 years) (Hagan, Shaw, & Duncan, 2017). In early adolescence, children still tend to have relatively concrete, dichotomous thinking with strong opinions about “right and wrong,” or “good and bad.” Early adolescents continue to work on understanding the perspectives of other people because they often misinterpret the perspectives of others. Because these skills are still developing, they are sometimes quite self-​ conscious (Allen, 2019). Their self-​esteem can be bolstered or undermined during interactions with practitioners at this time. Applying the spirit of MI, expressing genuine interest in the young person’s well-​being, and offering affirmations can help bolster an early adolescent’s sense of self-​efficacy. Asking open-​ended questions to evoke personal motivations and explore health risks associated with their newfound opportunities for independence and autonomy is key. Adolescents may be inclined to take risks, especially when they are with their friends, because they are more likely to focus on the rewards of a risky choice than on the potential costs. This propensity for pleasure seeking has been attributed in part to the increase in dopamine that begins in early adolescence (Steinberg, 2011). Middle adolescents continue to gain skills of abstract thinking. They are dealing with increased academic demands and more intense peer pressure juxtaposed with decreased parental supervision and ongoing assertions of independence. As a result, some adolescents are driven to action during emotionally heightened experiences, sometimes engaging in high-​risk, high-​reward behaviors (Alderman & Breuner, 2019). Late adolescents typically have a strong sense of their own individuality and values, are future focused, and frequently make decisions based on their

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hopes and ideals (Allen, 2019). Legally, young adults are no longer minors, but, functionally, many still rely on their parents for housing, health care insurance, and financial support. While most parents remain invested in their children’s health and safety across the lifespan, emerging young adults are ultimately responsible for their own lifestyle choices and health behaviors. MI is an ideal behavior-​change intervention to utilize with adolescents at all developmental stages, as it aligns well with the key developmental tasks of adolescence: building autonomy, achieving independence, and forming identity. MI honors patients’ autonomous decision-​making, explores opportunities for them to build their independence, and encourages them to recognize discrepancies between their current behaviors and their core goals, values, and beliefs (Erickson, Gerstle, & Feldstein, 2005). As children mature from early to late adolescence, one of their main developmental tasks is to gradually take on more and more responsibility for their health and well-​being. Practitioners typically use MI with their adolescent patients more so than with the parents; however, MI is ideally used with both parents and adolescents for family interventions (Chapter 18). Most encounters with adolescents appropriately include an important time where the practitioner speaks with the adolescent alone, which is critical to building rapport. During this time, confidentiality and its limits (i.e., in cases of suicidality, homicidality, or child abuse) are discussed. Time alone with the practitioner for both the adolescent patient and the parent allow for opportunities for each to express concerns and ask questions, secure in the knowledge that confidentially will be maintained. During each visit with an adolescent, a strengths-​based psychosocial review of systems is performed. A common way of organizing this assessment is by the SSHADESS acronym, focusing on the adolescent’s strengths, school, home, activities, drugs/​substance use, emotions/​depression, sexuality, and safety (Ginsburg, 2020). Discussing these elements of your patients’ lives, in addition to building rapport, clarifies their strengths, goals, motivations, and values, allowing practitioners ample opportunities to offer genuine affirmations for the work patients are doing toward becoming thriving, healthy adults. The spirit of MI encourages us to be curious and learn about the strengths and resources that each young person has. Summarizing their personal strengths for them can powerfully promote resilience (Ginsburg, 2020). MI can be utilized throughout the encounter to help young people explore discrepancies between engaging in any risky or unhealthy behaviors and their stated goals and values. After drawing attention to discrepancies between patients’ behaviors and their goals, ask permission to discuss the issue further. If they are ready, partner with them, asking them what ideas they have thought of to help make a change. If you are able to get to a place where they

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feel ready to craft a plan for change, guide them through the process and ask them how you, as their practitioner, can support them in making their plan a reality. Exchange 3: Using the SSHADESS Assessment to Inform MI in a Primary Care Setting Isaiah is a 16-​year-​old boy presenting to his pediatrician’s office for a routine check-​up. During the confidential SSHADESS assessment, he shares that he plans to become a lawyer to help kids in the foster care system. He also shares that he was suspended from school for fighting twice, once with another student who had been texting his girlfriend, and another time with a different student who was making fun of Isaiah’s basketball team. TRAINEE: It’s really admirable that you are thinking ahead about your career goals, and that you want to spend your life advocating for young people. I can tell you’ve really put a lot of thought into this plan, and it matters a lot to you that you go to college and law school so you can become a lawyer one day. [affirmation; summary] ISAIAH: Thank you, I’m looking forward to making it a reality. TRAINEE: If it’s OK with you, could we talk about what you shared with me about being suspended after getting into a few fights this year? [asking permission] ISAIAH: Yeah, we can do that. TRAINEE: OK thanks. You know, I worry that if you were to get into additional fights and get suspended again that it may make it harder for you to get into college and achieve your goals. What are your thoughts about this? [providing information; open-​ended question] ISAIAH: I honestly hadn’t even thought about how it might be tough to get into colleges because of my suspensions, but yeah, you’re right, getting into college and law school is important to me. It probably wasn’t the right call to get into those fights. I just got so mad so fast and acted without thinking. TRAINEE: Your emotions came on really fast and it was hard to think of ways to manage them other than fighting. Now that you’ve had a chance to think about those incidents, looking ahead, what might you do differently in the future to manage your emotions? [simple reflection; open-​ended question] ISAIAH: Yeah, my mom and I have been talking about getting me a therapist so I can learn some coping skills. I haven’t done it yet though because I have basketball practice or work every weeknight. I’d rather not get into fights though; I just don’t really know what else to do when I get heated. TRAINEE: On the one hand, you have a really busy schedule keeping up with work and basketball practice, and at the same time, you don’t want to get into any more fights and be suspended. You are considering seeing a therapist to learn other

MI in Pediatric Settings  283 coping skills so that you can manage your emotions. [double-​sided reflection followed by a complex reflection] ISAIAH: That’s right. I think it’s probably a good idea to try and learn some new coping skills. The fights were stupid and aren’t worth not getting into college. TRAINEE: You care a lot about achieving your future goals and learning some emotional management skills. The biggest challenge though right now seems to be time. What might be some ways that you could find time to engage in therapy to learn those skills? [affirmation; simple reflection; open-​ended question] ISAIAH: You know the basketball season is about to end, and I’ll have more time then. I think I’ll talk to my mom and see if she could get me in to see a therapist then. I think that it’s important I figure this stuff out now so I don’t mess up anything in the future. TRAINEE: You are ready to work on this and take control of the situation for your future. What ideas do you have about ways that I could support you in making that happen? [affirmation; open-​ended question] ISAIAH: I’m actually a little worried that therapy might be kind of expensive, and we’re not going to be able to pay for it. Are there any referrals or things you could do to help?

You’ll notice that Isaiah had an idea about how he could learn to manage his anger. Although he and his mother had discussed his seeing a therapist, no action had been taken yet because of the perceived barrier of time. Engaging Isaiah in a conversation about his behavior in relation to his educational goals, focusing on the consequences of his anger (fighting and school suspensions), and evoking his reasons for wanting to change, created momentum for his formulating a plan of action. The trainee used open-​ended questions, reflective listening, and genuine affirmations while guiding Isaiah to troubleshoot potential barriers to change and providing him the space to share both his concerns and goals for change. The way we ask adolescents open-​ended questions can be autonomy promoting as well. For example, we could start or end a complex reflection with a statement emphasizing personal choice, for example: “Whether or not you decide to make a change is completely your choice.” Such a statement conveys to adolescents that you are truly there to collaborate with them and that you respect their right and capacity for self-​determination. Evoking their perspective and motivation for change demonstrates your recognition that they have assets that can be tapped for behavior change to promote their health and well-​being. Rather than confrontational, adversarial, or “scare tactic” approaches, which often result in anxiety, increased defensiveness, and discord, the spirit

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of MI promotes patients’ welfare and gives priority to their needs. Meeting adolescents where they are, even if that means they are not ready to engage in conversations about change, is a foundation for a trusting relationship. When we ask them if we can talk about a particular behavior today, such as weight management or condom use, and they say “No,” then we should honor their autonomy. Simply share a statement about how we will continue to be available to talk about the topic in the future, if and when they are ready to do so. Another opportunity to utilize MI with adolescents includes “teachable moments,” or unplanned opportunities when adolescents might be more willing to explore growth-​fostering decisions based on an event that just occurred. Examples could include: • Discussing helmet use after a skateboarding related injury. • Engaging in a discussion about birth control options after an initially false positive pregnancy test. • Brief intervention around alcohol use after treatment for a laceration from a fall while intoxicated. • Talking about pre-​exposure prophylaxis for HIV prevention after a positive test for gonorrhea. Addressing such teachable moments in the context of an ongoing visit allows the trainee to explore the young persons’ immediate issues and concerns when they may have an increased desire to learn (Stein, 2008). When utilizing MI during these teachable moments or “windows of opportunity,” it is critical that the practitioner focuses on engaging and building rapport. Avoid reviewing a long list of items about why a behavior should have been avoided, as this often leads to patients feeling criticized or shamed and promotes discord in the therapeutic relationship. Exchange 4: The “Window of Motivational Opportunity” for a Patient Who Vapes With an Asthma Exacerbation Emerging research is showing that adolescents who have asthma may be uniquely susceptible to adverse effects of vaping (or electronic cigarette/​e-​ cigarette use), including worsening asthma exacerbations (Bradford, Rebuli, Ring, Jaspers, Clement, & Loughlin, 2020; Clapp, Peden, & Jaspers, 2020). Alex is an 18-​year-​old boy with a distant past history of asthma. He is currently admitted to the hospital for an asthma exacerbation, thought to be secondary to his new use of e-​cigarettes. He is on day 4 of hospitalization during which he required oxygen, intravenous steroids, and albuterol, and is now preparing for discharge home.

MI in Pediatric Settings  285 ALEX: I can’t wait to get out of this place . . . I’m so glad to finally be feeling better! TRAINEE: I’m so glad your breathing has finally improved! If it’s all right with you, before you leave, I was hoping we could talk about your understanding about why you were admitted to the hospital? [open-​ended question] ALEX: Sure. I had a lot of trouble breathing and was wheezing and coughing. I couldn’t stop coughing so I had to come to the emergency room, and get treated for my asthma attack, but now I’m all better. Oh, and you folks all think that vaping caused the attack, but I’m not so sure about that because it’s not like it’s a real cigarette. Whatever caused this though, I hope it never happens again because I’ve got to get back to work! TRAINEE: You’re feeling motivated to decrease your risk of having future asthma attacks so you can stay out of the hospital and won’t miss work again and you’re not exactly sure about the best way to do that. [summary] ALEX: Yes, exactly. TRAINEE: If it’s OK with you, I can share some information I have about what the research has shown us so far about the effects of e-​cigarettes on young peoples’ lungs. [asking permission] ALEX: Yeah, that’s fine. TRAINEE: So, you’re right that we are still learning about the dangers and potential side effects of e-​cigarettes for teenagers because they are relatively new devices on the market. There have been multiple studies showing that adults who have asthma seem to be at higher risk of having damage to their lungs when they use e-​cigarettes. There have also been reports of teenagers who needed life support after having asthma attacks that were thought to be triggered by vaping. Overall, the early evidence suggests that vaping can make asthma symptoms worse for teenagers. What are your thoughts about this? [providing information; open-​ ended question] ALEX: I’m kind of shocked, I had no idea people with asthma have gotten so sick from vaping. I haven’t even vaped for that long, and I really hated being in the hospital. Maybe I should just stop.

The trainee recognized that this hospitalization event was a teachable moment or a window of motivational opportunity to share information about vaping and connect vaping to potential lung damage and asthma exacerbation. Using the E-​P-​E framework, after asking for and receiving permission, the trainee provided early—​though not definitive—​scientific evidence and approached the conversation not from a place of blame or shame, but rather in the spirit of collaboration and partnership. The use of MI for this brief intervention helped Alex realize the potential side effects of vaping and its potential to trigger asthma exacerbations. Given his history of asthma and his

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desire to avoid future hospitalizations, he is contemplating stopping vaping because the risk to him is not worth it.

ENVIRONMENTAL CONSIDERATIONS In order to be as effective as possible in guiding children and their parents toward engaging in changes that promote health, it is critical to assess each child’s developmental stage, as well as the environment in which the behavior is occurring, especially given that children have very little control over their environments (Erickson, Gerstle, & Feldstein, 2005). More specifically, practitioners need to take into consideration the social determinants of health (SDOH), which are conditions in the environment where people are born, live, learn, work, play, worship, and grow-​up that affect a wide range of health, functioning, and quality-​of-​life outcomes and risks (US Department of Health and Human Services Office of Disease Prevention and Health Promotion, 2020). You might learn, for example, that the reason a pediatric patient has had such poor asthma control is because they have not been receiving their daily controller medication. In one case, the child and his family may have been traveling on vacation recently and lost the medication. In another case, a family may have been fleeing domestic violence and in the rush to leave forgot to bring the medication, and now cannot afford to purchase another inhaler. The spirit of MI champions a compassionate, empathic, and nonjudgmental approach that fosters open and honest discussions so that practitioners and families can achieve a shared understanding of the SDOH in order to troubleshoot barriers to change together.

CHALLENGING ENCOUNTERS IN PEDIATRIC SETTINGS There are several unique encounters in pediatrics for which the use of MI might not be appropriate, the most critical of which is mandatory reporting in instances where practitioners have concerns about the perpetration of nonaccidental trauma, sexual abuse, or neglect of a child. Additionally, if young people tell us they are planning to kill themselves or others, we are obligated to break confidentiality in order to protect the safety and well-​being of our patients and others. As discussed previously, it is critical that we start adolescent encounters by outlining confidentiality and its limits. Individuals have a right to know both when and why confidentiality would need to be broken.

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Having these honest discussions with our patients at the first visit actually enhances their trust in our judgment rather than diminishing rapport in the relationship. Throughout these challenging encounters, we continue to use the spirit and processes of MI, including practicing empathic listening by offering simple and complex reflections, giving genuine affirmations, providing a safe space for everyone present to share their perspectives, and sensitively providing constructive feedback. In emergency situations, we typically assume a more directive style (as compared with the guiding style of MI) until a patient is safe and has been stabilized. However, MI can be used after the critical illness period has ended, especially if the clinical encounter with the young person illuminates a “teachable moment” or “window of motivational opportunity” for engaging in information sharing and eliciting change talk. There can also be situations in which the practitioner is using MI with a patient or parent who is exploring a difficult decision. Examples include pregnancy options, decisions about hormonal or surgical interventions for individuals who have diverse genders, or participation in experimental treatments for various medical conditions. Even if we hold opinions about which of those we would choose for ourselves based on available evidence and our own value system, a practitioner generally should remain neutral while helping patients explore their thoughts, feelings, goals, and values. Adopting this neutral stance is known as equipoise. Dealing with ambivalence can feel uncomfortable, and, thus, it is common for some patients or parents to want the practitioner to tell them what they should do, such as by asking “What would you do if you were in my shoes?” However, practitioners can avoid falling into the “expert trap” by recognizing when being directive is appropriate versus when what is indicated is guiding the patient or parent through the decision-​making process.

PERSONAL REFLECTION (Katelin Blackburn) I quickly realized in medical school that learning about how to prevent illness and manage disease was not enough to become an effective practitioner or the best advocate I could be for my patients. In order for the knowledge I had gained about practicing Medicine to be useful, I had to learn how to communicate effectively to help guide patients toward engaging in steps to prevent or treat their health problems. After sharing these concerns with several friends and mentors, I learned about MI, and immediately recognized that it could equip me to better partner with my patients to help them achieve their health goals. I was able to find a mentor who trained me as part of a

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research study on using MI with adolescents who were committing acts of physical and sexual violence against their dating partners. The study intervention helped guide the adolescents toward using healthy and nonviolent means to meet their relationship needs. I received feedback and coaching on my MI skills, as I worked to become proficient in using this skillset. I quickly found myself incorporating the spirit and core skills of MI into nearly all my patient encounters. Further, I took on any opportunity I could to share my passion for MI by teaching the skillset to my fellow medical students and co-​residents, and to advocate for the integration of more intensive MI training into our medical training curricula. At the bedside, beyond engaging my patients in change talk, MI helped me elicit patients’ agendas, which made me more efficient and effective in my visits, as I sought to understand the patients’/​parents’ goals and what they truly valued. My patients told me that they felt heard and supported, and MI allowed me to listen and connect with them in such powerful, healing ways. I found myself replenished each time I got to use MI with a patient, and I truly believe that incorporating it into my daily practice helped shield me from burnout. Now as an Adolescent Medicine Fellow, I continue to use MI and am so grateful that I am able to incorporate the MI spirit and skills into my work with patients each and every day.

SELF-​ASSESSMENT QUIZ True or False 1. MI is an excellent approach to use with adolescents, as it honors their newfound autonomy. 2. A 3-​ year-​ old child is brought in by his father to the Emergency Department after sticking a small Lego piece in his ear. This represents a teachable moment during which the trainee can utilize MI with the child to troubleshoot how to prevent this from happening again. 3. An 18-​year-​old college freshman is admitted for acute alcohol intoxication after being found asleep in the park near her dormitory. To take advantage of this teachable moment, the trainee should list for her the dangers of drinking alcohol in excess. 4. After learning that his partner tested positive for gonorrhea, a patient presents for testing and medical treatment. The trainee asks him if it’s OK to talk about condom use today, and the patient declines. The trainee

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responds: “If in the future you would like to talk about condoms and STD prevention, then I am available.” The trainee adhered to the spirit of MI.

Answers 1. True. MI enables the practitioner to support the adolescent’s autonomy, facilitate development of important life skills, and promote healthy choices. 2. False. This child is too young and does not yet have the language/​ verbal or cognitive abilities to engage in MI. It would be appropriate, however, to use MI with the patient’s father to explore how he might make changes to improve the safety of the child’s home and play environment. 3. False. Listing the dangers of drinking alcohol to excess is unlikely to change future behavior and falsely assumes that the patient lacks knowledge. An MI-​consistent approach would be to evoke the young person’s thoughts and feelings about the incident and then elicit and listen for change talk (i.e., her own motivations for change). 4. True. The trainee asked permission to discuss condom use, and the patient refused. The trainees respected the patient’s decision and autonomy and adhered to the spirit of MI.

REFERENCES Alderman, E. M., & Breuner, C. C. (2019). Unique needs of the adolescent. Pediatrics, 144(6), e20193150. Allen, B. (2019). Stages of adolescence. Barnes, A. J., & Gold, M. A. (2012). Promoting healthy behaviors in pediatrics. Pediatric Review, 33(9), e57–​e68. Bradford, L. E., Rebuli, M. E., Ring, B. J., Jaspers, I., Clement, K. C., & Loughlin, C. E. (2020). Danger in the vapor? ECMO for adolescents with status asthmaticus after vaping. Journal of Asthma, 57(11), 1168–​1172. Chiappatta, L., Stark, S., Mahmoud, K. F., Bahnsen, K. R., & Mitchell, A. M. (2018). Motivational interviewing to increase outpatient attendance for adolescent psychiatric patients. Journal of Psychosocial Nursing and Mental Health Services, 56(6), 31–​35. Clapp, P. W., Peden, D. B., & Jaspers, I. (2020). E-​cigarettes, vaping-​related pulmonary illnesses and asthma: A perspective from inhalation toxicologists. Journal of Allergy and Clinical Immunology, 145(1), 97–​99. Erickson, S. J., Gerstle, M., & Feldstein, S. W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: A review. Archives of Pediatric and Adolescent Medicine, 159(12), 1173–​1180.

290  Motivational Interviewing, 2E Gagneur, A. (2020). Motivational interviewing: A powerful tool to address vaccine hesitancy. Canada Communicable Disease Report, 46(4), 93–​97. Ginsburg, K. (2020). Reaching teens: Strength-​based, trauma-​sensitive, resilience-​building communication strategies rooted in positive youth development (2nd ed.). Edited by K. Ginsburg & Z. McClain. American Academy of Pediatrics. Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2017). Bright futures guidelines for health supervision of infants, children, and adolescents (4th ed). American Academy of Pediatrics. Kalish, C. W. (2010). What young children’s understanding of contamination and contagion tells us about their concepts of illness. In M. Siegal & C. C. Peterson (Eds.), Children’s understanding of Biology and Health (pp. 99–​130). Cambridge University Press. Kells, M., Burke, P. J., Parker, S., Jonestrask, C., & Shrier, L. A. (2019). Engaging youth (adolescents and young adults) to change frequent marijuana use: Motivational Enhancement Therapy (MET) in primary care. Journal of Pediatric Nursing, 49, 24–​30. Lohse, K., Kalitschke, T., Ruthmann, K., & Rakoczy, H. (2015). The development of reasoning about the temporal and causal relations among past, present, and future events. Journal of Experimental Child Psychology, 138, 54–​70. McNeely, C., & Blanchard, J. (2009). The teen years explained: A guide to healthy adolescent development (1st ed). Center for Adolescent Health at Johns Hopkins Bloomberg School of Public Health. https://​​resea​rch/​cent​ers-​and-​ins​titu​tes/​cen​ter-​for-​ado​lesc​ ent-​hea​lth/​_​docs/​TTYE-​Guide.pdf Orenstein, W. A., & Ahmed, R. (2017). Simply put: Vaccination saves lives. Proceedings of the National Academy of Sciences, 114(16), 4031–​4033. Stein, M. T. (2008). Strategies to enhance developmental and behavioral services in primary care. In Wolraich, M. L., Drotar, D. D., Dworkin, P. H., Perrin, E. C. (Eds.), Developmental and behavioral pediatrics, evidence and practice (pp. 887–​903). Mosby. Steinberg, L. (2011). Demystifying the adolescent brain. Education Leadership, 68(7), 42–​46. Stormshak, E. A., DeGarmo, D., Garbacz, S. A., McIntyre, L. L., & Caruthers, A. (2021). Using Motivational interviewing to improve parenting skills and prevent problem behavior during the transition to kindergarten. Prevention Science: The Official Journal of the Society for Prevention Research, 22(6), 747–​757. Strait, G., Mcquillin, S., Smith, B., & Strait, J. (2012). Using Motivational Interviewing with children and adolescents: A cognitive and neurodevelopmental perspective. Advances in School Mental Health Promotions, 5, 290–​304. Tomlin, K., Bambulas, T., Sutton, M., Pazdernik, V., & Coonrod, D. V. (2017). Motivational interviewing to promote long-​acting reversible contraception in postpartum teenagers. Journal of Pediatric and Adolescent Gynecology, 30(3), 383–​388. US Department of Health and Human Services Office of Disease Prevention and Health Promotion. (2020). Social determinants of health. Healthy People 2030. Wu, L., Gao, X., Lo, E. C. M., Ho, S. M. Y., McGrath, C., & Wong, M. C. M. (2017). Motivational interviewing to promote oral health in adolescents. Journal of Adolescent Health, 61(3), 378–​384.

18 Motivational Interviewing in Family Settings Thomas M. Kelly and Meghan Keil

Motivational Interviewing (MI) is an approach of interpersonal joining. It enriches therapeutic encounters with our patients, and is a highly effective, one-​on-​one behavioral intervention. However, MI with family members is an underutilized way of enhancing outcome effects. Medical training focuses on the conventional doctor-​patient relationship. In this traditional model, the patient is “host” to “a defect or disease”; in effect, the patient is a closed system, and a condition inside the patient has been identified and must be removed. Treatment consists of diagnosing this medical illness or injury and a doctor recommending options for eradicating it. This approach prioritizes practitioner’s knowledge and skill over patient perspective and life experience. It derives from the assumption that physically based conditions can be treated solely by physical interventions such as medication and surgery. This model of healthcare may be effective for physical illness and injury. However, it is ineffective against behaviors and lifestyle choices that lead to the high levels of morbidity and premature death we experience today (e.g., smoking, drug use, and overeating). Furthermore, problems in interpersonal life often precede or co-​occur with some physical and most psychiatric disorders. Recall, for instance, that effective treatment for eating disorders demands that family and psychosocial factors be taken into account (Couturier et al., 2020). Because few of our patients live completely solitary lives, it is critical to explore the quality of ties to family, friends, and community. Psychosocial factors must be understood according to how they affect decision-​making leading to suboptimal health. These aspects play an especially important role in disorders of childhood and adolescence where the unique bonds between parent and child shape how illness is perceived and understood. Similarly, the nature of marital ties affects how illness impacts both partners.

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The ability to enhance emotional support provided by a patient’s loved ones facilitates a powerful force for promoting change. Research finds that family functioning and social relationships play key roles in improving mental health and in coping with disabilities (Tough, Siegrist, & Fekete, 2017). Practitioners are well placed to encourage patients to make use of the full spectrum of emotional assistance available to them. Furthermore, problems facing patients with psychiatric diagnoses have profound effects on those close to them. Family and friends of the patient often experience high levels of anxiety in relation to the patient’s illness (Rady, Mouloukheya, & Gamal, 2021; Zhang, 2018). Conversely, including the family and friends of a patient in treatment reduces their anxiety and, thereby, increases the quality of support they can offer the patient (Law, Fisher, Eccleston, Palermo, & Cochrane Pain, Palliative, and Supportive Care Group, 2019).

BRIEF FAMILY INTERVENTIONS (BFI) While formal family therapy is neither realistic nor appropriate during most family encounters in healthcare settings, practitioners may still employ core MI skills to facilitate familial communication. Although BFI are often informal, they are important for: (1) increasing patients’ family members’ understanding of illness or injury, (2) clarifying treatment recommendations, (3) resolving treatment-​related disagreements that may occur between patient and family members, and, importantly, (4) enhancing motivation to follow through with more formal behavioral therapies. As a result of time constraints, BFI should be targeted toward very circumscribed goals (e.g., helping patients and their families understand the importance of taking medication as prescribed or resolving arguments between patients recovering from surgery and their family over the patients’ participation in an exercise program). Trainees as healthcare practitioners may encounter family members at a patient’s bedside while making rounds during an inpatient admission, in the emergency department when their loved one is being evaluated for an acute complaint, or at the outpatient appointment of a child, parent, spouse/​partner, or sibling. Consider the following scenario regarding advance care planning with an elderly patient and her adult daughter. TRAINEE: [To patient] We have previously discussed your end-​of-​life wishes in an advanced directive. Is it alright if I review this with you now? [asking permission]

Motivational Interviewing in Family Settings  293 PATIENT: Yes. TRAINEE: [To patient] You have said that you would not want to be resuscitated if your heart was to stop . . . . DAUGHTER: [Interrupting] Mom, you don’t mean that! Don’t you want the doctors to keep you alive? TRAINEE: [To daughter] Your mother’s wishes are a surprise. You care about her deeply. It’s difficult to think about her end of life. I appreciate your being here so we can discuss this all together. [complex reflections] TRAINEE: [To patient] How do you feel about sharing your wishes for end-​of-​life care? [open-​ended question]

With this brief intervention, the trainee reflects on the daughter’s emotion. While affirming her love for her mother, and then uses an open-​ended question to begin a discussion so the daughter can see the reasoning behind her mother’s decision and ultimately, enhance support for the mother’s end-​of-​ life decision. Brief encounters dictate that rapport be established quickly. Active listening behaviors (e.g., maintaining eye contact, avoiding distractions, leaning toward speakers, and not interrupting) are critical. Furthermore, BFI often take place in open areas. If the setting does not ensure privacy, find a setting nearby that does so. Ensuring privacy is part of establishing rapport as patients appreciate sensitivity to their healthcare information being safe guarded. While open-​ ended questions, affirmations, reflections and summaries (OARS) facilitate communication, the nature of BFI necessitates that some features of MI be emphasized over others. Too many open-​ended questions invite extended discussions that time limitations will not allow. As a way to mitigate this constraint, take enough time to review the available history of illness and talk briefly with other practitioners who have treated the patient. Upon meeting the patient, start by summarizing what you already know and invite clarification. Provide affirmations to each person present to validate that you recognize their concern. Following the summary, Elicit-​Provide-​ Elicit (E-​P-​E) is relevant but may be limited to asking one or two open-​ended questions. This can be followed by reflections and reframing about the problem, including a request for suggestions on resolving the problem. Commonly referred to as “brainstorming,” you can invite participation in problem resolution by asking everyone in the family to contribute ideas. Brainstorming is particularly effective when directed to the patient while asking family members to recall times when the patient was making better healthcare decisions. Use of this intervention increases the chance of patient

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engagement because the affirmations provided remind patients of their true capacity for change. This, in turn, helps the patient develop discrepancy between current behavior and future goals. The session can wrap-​up by summarizing suggestions for resolving the problem. Many BFI do not involve behavioral problems, but exceptions occur. Consider the following example of a teenager admitted to an emergency department following an accidental drug overdose. She is uncertain about beginning formal treatment for substance use. TRAINEE: [To patient] I appreciate your openness with me about your substance use. I know you don’t believe using drugs is a big problem for you and you also said this overdose has really been a wake-​up call. And you are not sure you want to start formal treatment. [double-​sided reflection; summary) What are your thoughts about sharing some of our discussion with your parents? [open-​ended question] PATIENT: I don’t know. I may decide to see someone, just to talk about some things . . . and it would be a lot easier if my parents know, but they won’t understand. They always overreact. TRAINEE: [To patient] It is difficult to share your life struggles with your parents, particularly when you do not get the response you would like. At the same time, it would be really helpful to have their support if you start treatment. [double-​sided reflection] What if we talk to them together about your concerns? [open-​ended question] PATIENT: OK, I’ll try.

Note, the trainee supports patient autonomy and respect by recognizing that the choice of starting treatment is hers alone. While validating the patient’s feelings, the trainee uses reflective listening and summaries to help the patient work through ambivalence about talking to her parents. TRAINEE: [To parents] I have some information about your concerns. My understanding is that you knew something about Tina’s drug use and have disagreed with her. Yet, you are good parents in a close family and will do whatever you can to work through this with her. [summary] With your permission, I would like to have a conversation about what happened and steps moving forward. Everyone will have a chance to share their perspective. It is important for people be able to express themselves fully, so I appreciate if you listen to her perspective without interrupting. Does that sound reasonable? [asking permission] PATIENT AND FAMILY: OK. TRAINEE: [To patient] Would you share what we discussed privately? [closed-​ended question]

Motivational Interviewing in Family Settings  295 PATIENT: [To all] We have argued about my smoking marijuana, and I still don’t think it’s a big problem, but I realize using meth was wrong. . . . So, I think I may need some help. MOTHER: [Interrupting] It is that boy, we have told you to stay away from him. He is 3 years older than you and he got you started on drugs. PATIENT: [To trainee] You see, I told you they do not understand. I admit that I started using marijuana with Gary, but he didn’t make me do it. I make my own choices. TRAINEE: [To mother] I can see how deeply you care for your daughter. [affirmation] Your concern is so great you had difficulty not interrupting, as I had asked, while she talked. Providing guidance is how you want to help her but there may be other things you can do. [complex reflection] TRAINEE: [To patient] You want to make your own judgments in life, and you are willing to take what comes of your decisions. [summary] PATIENT: [To mother] Yes. Mom, I want to be able to talk to you, but you jump at me before I have a chance to say anything. PATIENT: [To father] Dad, I never hear anything from you. I think sometimes you disagree with Mom. I wish you talked to me more. FATHER: [To patient] I know I stay out of it, probably more than I should. But most of the time I agree with your mother and, the way you two yell at each other, I don’t want to make it worse. MOTHER: [To patient] Well, you need to remember that, at your age, your decisions still affect your father and me, and your little brother. But I can see that you are asking for more freedom, and I can understand that at your age. Your father agrees we should be more trusting of you. He and I have had discussions about that and so maybe we can all talk about it. TRAINEE: [To everyone] You understand things better when you respect each other’s perspective. [complex reflection] What is a good next step to keep the conversation going? [open-​ended question] PATIENT: Well, this helped. TRAINEE: [To patient] I can recommend someone who will talk with you alone and include your parents if you want. What do you think? [open-​ended question] PATIENT: OK. I’ll try it.

The trainee’s transitions from one-​on-​one with the patient to include the family by affirmations of everyone’s efforts, reflective listening, and reframing situations to reveal the family’s positive motivations. For a more nuanced discussion of the use of MI in pediatric settings, review Chapter 17.

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MI-​BASED FAMILY THERAPY (MIFT) Formal family therapy is usually conducted in psychiatric and behavioral health settings. It may include marital couples, older nuclear families (adult children and parents), and minor children brought to treatment for problematic behavior. Family evaluations usually take 1.5 to 2 hours. If possible, it is best that all family members (who are living together) come into the meeting. Of course, if family members who live outside the home come to the session, invite them in and assess their role regarding problems. The objectives of MIFT involve longer-​term goals than BFI, whereby patients decrease unhealthy behaviors and increase healthy ones (e.g., abstinence). To save healthcare resources, current managed care models often specify that family therapy treatment plans allow for four to six sessions, followed by an evaluation for continuing or terminating treatment. Short-​ term contracts can sometimes cause anxiety because of concern that there may not be enough time to complete therapy. However, one benefit of this reality is that everyone understands the importance of not wasting time in the therapy. The most important element of family intervention is to engage a patient’s support system such that it becomes part of the change process. Focusing on complex and sensitive family dynamics can be challenging; it may seem that there are too many elements to consider. However, you can use MI skills to begin to comprehend and utilize the intricate web of relationships and interactions. The core MI skills, OARS, are essential components of family encounters. In practice, the two primary objectives of family interventions, (1) improving communication and (2) restructuring relationships, cannot be achieved if you are unable to accurately hear, reflect, and reframe family expectations. Honest family communication occurs when each person feels understood. Therefore, you must be able to maintain a therapeutic alliance with the group as a whole. Sometimes you need to offer support for one family member’s position, at other times, you must be able to tactfully suggest that a particular family member consider the perspectives of others. By remaining empathic and using MI skills consistently, you can provide support at one time and withdraw it at another, without damaging therapeutic relationships. We now turn to a description of the content and behaviors that must be present to ensure the effectiveness of MIFT.

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Content of the First Family Session MI is based on the belief that practitioners do not “fix” patients, which means avoiding the righting reflex (Miller & Rollnick, 2013). Instead, MI proposes that each person has the answers to how they can change. Equanimity exists in MIFT because practitioners know about Medicine and human behavior, while family members are the experts on their own lives and must decide for themselves what will help them change. A central tenet of MI is to reduce the distance caused by the classic “doctor-​ patient” relationship. Use of first names helps decrease relational distance. In keeping with this principle, if you are comfortable with relinquishing your title, introduce yourself using your first name and expect to be addressed in this manner by the family. If a family member is more comfortable using your title that is fine. Do not make an “issue” of it. At this juncture, you might note that it is common practice for people to use first names with each other. However, ask family members if it is alright to address them by their first name, or to specify how they would like to be addressed. In most cases, children play little or no role in the reason for treatment (unless they are the “identified patient”) and can be excluded from ongoing treatment based on clinical judgment. Conversely, if it becomes apparent that they may provide important information, parents can be asked to bring them. When this occurs, care must be taken to account for their developmental level (Chapter 17). Confidentiality should be discussed next, emphasizing that you will not reveal anything any family member asks you to keep private, with the noted exception of sexual or physical abuse or neglect and homicidal or suicidal behavior. Practitioners are sometimes asked to keep secrets by one person (e.g., an adolescent engaging in risky behavior) and to not reveal it to other family members. You must judge whether such information is relevant to treatment. If you deem that it is, recognize that keeping family information secret can cause distrust and slow or destroy progress in treatment. Although it is not your place to reveal information, emphasize to anyone engaging in keeping secrets that you must raise the issue in your sessions, and, in your professional judgment, that the information should be disclosed. Here, you should suggest to the secret-​keepers that they consider their options (e.g., revealing the information outside or inside the sessions). Often family members with secrets are very ambivalent about revealing emotionally charged information outside of treatment. Offering your support and exploring with people how they would most like to reveal information can be critical to their resolving an issue. If

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necessary, take time to discuss how withholding information is destructive to treatment, and express your willingness to support them. Of course, interviewing, and engaging individuals outside of the family setting may bring up concerns by others that you are taking sides. It is important to tell the family that you sometimes see individual family members when communication problems slow progress. In any event, the clinical rationale for meeting with individuals or subsets of family members outside of the entire family should be made clear. For example, other than for marital therapy, it is important to spend some time interviewing the identified patients alone because they will have things to say that they will not discuss with their family. It is common for the identified patient to experience anger because of feeling unjustifiably maligned. These feelings must be explored openly in an individual session to articulate and understand them.

Behavior and Tone of Family Sessions From the outset, it is helpful to establish ground rules for the session. Remind patients and families to focus on positive change and to accept each other’s perspectives in a nonjudgmental way. Blaming, name calling, and accusations will thwart the process of change. Miller and Rollnick (2013) briefly discuss family consultations and warn against allowing family sessions to degenerate into defensiveness, which leads to sustain talk. Similarly, family therapists state that hostility and problematic communication make progress impossible (Patterson, Williams, Grauf-​Grounds, & Chamow, 1998). The manner portrayed in communicating during treatment is important. Your behaviors should portray warmth and openness with emphasis on what the family can expect from you and what you expect from them. Notice that the issues discussed above are relevant to autonomy and responsibility. They include choosing how people want to be addressed, the practitioners’ responsibility as a mandated reporter, and the expectation that all people will bear the onus of speaking for themselves in the family, not through you. Miller and Rollnick (2013) contend that attention to autonomy is so important that MI cannot be practiced without it. During individual treatment, MI helps patients display their ambivalence and feel the discrepancy between their present behavior and their values that will eventually help them improve. Similarly, each person in the family must be induced to develop discrepancy between how they are now relating to the patient and how they need to change to help the family.

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STAY BALANCED BETWEEN PERSPECTIVES We can easily find ourselves allied with family members who seem to be asking for reasonable change in the patient’s behavior. For instance, a young man living in his parents’ home and using drugs not only jeopardizes his own welfare but that of other family members as well. Accordingly, we might view his parents’ demand that he stops using drugs as quite reasonable. While this response may appear both rational and objective, such a position opens a significant counterproductive issue. If we are unwilling to accept and explore the young person’s point of view, we will also be unable to establish a therapeutic alliance with him and little will be accomplished. Remember, we do not need to agree with a patient’s position to accept it. The critical issue is to listen attentively to all perspectives, find common ground between opposing views, and recognize the potential value and worth of every family member’s opinion in resolving differences. Just as we can find ourselves siding with a family, so too we may be biased toward our patient in the mistaken belief that a family is either too demanding or they unfairly blame the patient for his maladaptive behaviors. Family therapists have long identified various roles that people play in dysfunctional families, one of the most well-​known is that of the scapegoat (i.e., the person other people view as “the problem”). When we recognize that we are having difficulty maintaining our objectivity, we can give ourselves a philosophical reminder that we must not side with the patient, rather we must ally with them against their struggle. This realization helps guide our interventions and keeps us focused on what really matters. Equipoise is the term for remaining open to what everyone says (Chapter 4). Even when a family has steadfastly taken sides about a problematic behavior, it is crucial that we remain neutral during treatment sessions. Recall the basics of MI strategies and techniques used in an individual encounter. Rather than allowing yourself to be drawn to one side or other of the ambivalence, remember to take your time and use open-​ended questions and reflections to explore and understand the issues that contribute to emotional conflicts. Just as internal ambivalence is resolved by an ongoing exploration of pros and cons, a continuing review of family members’ differing perspectives is the only way to help them resolve their conflicts with each other. Practitioners must help everyone consider their thoughts and feelings and resolve their own ambivalence in order for them to adopt behavior changes. By maintaining equipoise, you maintain the ability to make and break alliances with all family members as they help the family to recognize ambivalence and develop discrepancy. Individual patients must develop discrepancy

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during MI. So too, each family member must develop discrepancy between how they have been relating to the patient and how they must change for the patient to change his/​her/​their behavior. By validating each person’s perspective in the spirit of MI, you avoid the risk of eliciting discord from those who may provide meaningful support to the patient.

Stay Problem Focused Setting ground rules at the beginning of treatment helps with family members treating everyone’s perspective nonjudgmentally. It is crucial to intervene and refocus attention back on the problem, if the discussion turns personal. One method to transition away from hurtful comments is to discuss how challenging it may be for the patient to implement the changes that are being considered. MOTHER: [To young adult son] I know you are depressed, but using drugs can’t be helping you. I know the doctor has told you this many times. We’ve been dealing with this for 5 years now. You were doing better just last year when you had that job. I know you weren’t using drugs when you were working. Why did you start again and why did you stop working? Sometimes it seems like you do these things on purpose. You say you’re depressed but sometimes I think you’re just lazy. I want to keep helping you, but I am coming to the end of my rope here. SON: Yeah, yeah, I’ve heard it all before. You don’t know what I am going through. TRAINEE: [To son] See? I told you, all she does is criticize me. I want to stop using and I’ve made some progress. She’s right, I was better last year, but I get stressed and I get cravings. And when she hammers me about being lazy, I just feel like going out and using! TRAINEE: [To mother] You have stayed supportive of your son, and at the same time you are frustrated with your son’s drug use and the long course of his illness. [affirmation; complex reflection] We see this with other families, and it is common for parents to feel the way you are feeling. [normalizing] When you say your son seems lazy, it is a reference to how he behaves when he is using drugs and not the person you know when he is not using. [complex reflection] MOTHER: [Crying] Yes, that’s it exactly. I know he is a good person and can do better. TRAINEE: [To son] You have talked about how you feel when your mother says she is concerned about you being lazy. But she just clarified that laziness for you seems to be a characteristic of drug use. [complex reflection] Neither of you like to consider laziness as part of your true character, and she remains very supportive of

Motivational Interviewing in Family Settings  301 your staying abstinent. [complex reflection] What can she do to help you with that? [open-​ended question] SON: Well, last year, before I started working, I had a bus pass to get to job interviews. I know Mom won’t want to give me money now because I have been buying drugs, but I need to show up, if I get a job. MOTHER: If you will set up the interviews, I will buy the bus pass for you. TRAINEE: How does that sound? What do you make of that idea? [open-​ended question]

Note how the trainee “normalizes” the emotion they both feel and focuses on the behavior that must be changed, not on the accompanying frustration. Further, by refocusing attention on common ground, sustain talk (reasons for using drugs) gives way to change talk.

Stay Present-​Oriented Family therapy models often link current problems to past traumas. A major difference with MIFT is a focus on what occurs during treatment. Further, use of OARS involves response to the conduct of the “identified patient”, as well as reflections on family member behavior. As an example, consider the case of Jim, a 14-​year-​old boy brought to treatment because he had been caught stealing at school several times in the past month. The school authorities insist he receive treatment as a condition of his returning to school. He appears depressed and anxious, and has been withdrawn, with poor sleep, and stomach distress. His grades have dropped precipitously in the past few weeks. TRAINEE: Please tell me what brings you in and how you think we can work together to make things better. [silence] Anyone can start. [open-​ended question] MOTHER: I don’t know what we are going to do. We’ve tried talking to him and we had him see the school counselor. He doesn’t need the things he is taking. If he misses anymore school, he won’t pass. FATHER: [Looking at the trainee pensively but silent]. JIM: [Quiet; eyes downcast]. TRAINEE: [To mother, but looking at everyone] So, like good parents, you have talked to your son and have done as much as you can on your own. [affirmation; complex reflection) You are confused about why your son steals and worried about how the stealing will affect his future in school. Is that right? [complex reflection; closed-​ ended question] FATHER: Yeah, we just don’t get it. We don’t understand why he is stealing. JIM: [Still silent but shifts in his chair and looks at father].

302  Motivational Interviewing, 2E TRAINEE: [To son] What your father just said seems to have gotten your attention. What would you like to add? [complex reflection; open-​ended question] JIM: I’m not talking. I didn’t even want to come here. Besides, they just gang up on me when I do. They don’t do anything to help. All they care about is me going to school. TRAINEE: It seems like your parents are trying to help but maybe they do not know how. They want you to go to school but that does not seem very important to you right now. [complex reflections] Tell me more about what is important to you. [open-​ended question] JIM: I just want people to get off my back and to leave me alone. TRAINEE: [To parents] I would like to talk with Jim alone for a while. Is that OK with you? [asking permission] PARENTS: Whatever you think will help. TRAINEE: [To Jim] I need some more information and I think seeing you alone would be the best way to get it. It is up to you; you do not have to do it if you don’t want to. [complex reflection] JIM: No, I’ll do it. TRAINEE: [Alone with Jim] You have said your parents are pushing you to go to school and you want them to leave you alone. How are those connected? [complex reflection; open-​ended question] JIM: Well, you said no one else will know about what I say in here, right? I don’t want people at school to know anything. That’s why I wouldn’t talk to the school counselor. TRAINEE: You are making a valid point. [complex reflection] JIM: These guys at school. They pick on me a lot. Most of the time they do it when no one else is around. When I cross the quadrangle to get to my 10:00 o’clock class, I have to go between the buildings, and that’s where they get me. I can’t fight back, or it will be worse. And they say if I tell a teacher, they’ll really get me. TRAINEE: And so, you have been stealing to get kicked out of school? [closed-​ended question] JIM: [Crying] I just can’t go back there. TRAINEE: As I told you, I will not tell your parents about this if you don’t want me to. But there is help for this if you want it. Is it OK for us to talk about it? [asking permission] JIM: Yes. TRAINEE: Well, there is a policy at your school that says students cannot bully each other. If your teachers know this is happening, they will look out for you. They can make sure these boys understand that they can’t go around hurting others without being disciplined. These boys may need counseling themselves. [providing information] JIM: Well, it sounds OK, but what do I have to do?

Motivational Interviewing in Family Settings  303 TRAINEE: Thanks for asking me. Well, usually the first step is to tell your parents. [giving advice] JIM: I want to, but they are busy. They don’t have time for me. I just get the idea that they don’t want to be bothered. I didn’t know what else to do so I took those things figuring they would send me somewhere else, even reform school would be better than what is happening to me now. TRAINEE: Your parents certainly have time now to listen to you, and I will be here. If you are willing to talk to them, I’ll call them back in. [asking permission] JIM: OK. TRAINEE: Well, I have had some time to talk with Jim and I think he has some things to talk to you about. [engaging the parents] JIM: The reason I stole those things is because I am being picked on at school and I just wanted to get kicked out, so I didn’t have to go back there. MOTHER: Why didn’t you say something? FATHER: Yes! JIM: I thought you really didn’t care. You just kept saying I had to stop stealing and that I had to stay in school. MOTHER: Now that I think back, there was a day last week when you seemed so upset. I remember I had to go to work but I also felt like I should ask you about it. TRAINEE: So, you were torn between going to work and staying with your son. The choice was between being a good employee and being a good mother. [complex reflection] MOTHER: Yeah, now that I think about it, that’s no choice at all. I want to be a good mother above anything else. Now I wish I had trusted my “mother’s intuition.” I have to remember this situation if something like this ever happens again.

In the above vignette, the trainee starts with an open-​ended question to everyone. It is not uncommon for this question to be met with silence as family members are anxious. The trainee doesn’t press but uses affirmations to emphasize that the patient has responsible parents and uses a summary to elicit additional information. When the son’s nonverbal behavior indicates some interest, the trainee calls attention to it. This reflection leads to the patient opening up enough for the trainee to understand he is withholding sensitive information. The trainee’s manner in relating to the patient and the assurance of confidentiality leads to a revelation and a possible problem resolution.

Change Plans As treatment progresses, strategies for implementing behavioral changes must be considered. Taking time to review the quality of family communication

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and interaction is important before considering change plans. If family functioning has not improved, it is unlikely that formal change plans will be effective. Conversely, if treatment is working, changes will likely occur spontaneously. Consistent with the primary tenet of MI (i.e., patients are their own source of solutions to unhealthy behavior), Miller and Rollnick (2013) indicate that ideas the patient has for change should be given the highest priority. Ideas for change can be interjected in other ways. The practitioner can ask family members, including the patient, to suggest things, some of which may have worked in the past. Of course, practitioners can recommend change plans. However, such recommendations should only be made when other methods are not producing ideas, or when the patient and family asks for them. You must assess whether the entire family agrees with any plan, or if anyone disagrees and will not cooperate. Of course, any suggestions brought up by family members should be explored in relation to the patient’s own thoughts. You should emphasize that patients should reject any plan they do not believe will work, discuss their feelings about it, and suggest any changes they believe they need to make for the plan to be more viable. No matter how a change plan comes about, if one is agreed upon, you should not express significant optimism or pessimism about it. It is best to affirm the family for the work that went into the plan and the opportunity for change, while taking note that the plan is an idea that has yet to be tested. Miller and Rollnick (2013) indicate that change plans should be reviewed with an eye toward what could go wrong and suggest that screening for problems may produce change talk, which increases the potential for success. You might use a brainstorming technique to have the family look for potential pitfalls. Following this discussion and how problems might be avoided, remind the family that the plan can be modified or discarded as needed. If possible, family members should be permitted to contact you outside of sessions to discuss the plan and to schedule a session, if changes in the plan are needed.

PERSONAL REFLECTION (Meghan Keil) As both a medical student and as a psychiatry resident, I have found that approaching family conversations with the spirit of MI has been particularly impactful. As this chapter indicates, informal family interventions using core MI skills can not only enhance familial communication, but also familial understanding of an illness and its treatment, along with motivation for follow through. I recall a family meeting between a young adult

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patient with schizoaffective disorder and his mother, where this was particularly true. The patient had poor “insight” into his illness, and often stopped taking his medications. His mother was incredibly frustrated at his frequent hospitalizations because of his nonadherence to treatment and medications. With the use of OARS, we were able to explore both the patient’s and his mother’s perspectives of his illness, the treatment, and motivation for following through with treatment. Ultimately, the patient was able to articulate that his main goal was to return home with his mother and prevent rehospitalization. He realized that to do that, he would need to take his medications. His mother was willing to support him in this endeavor. While the patient still did not fully accept his diagnosis, the family meeting served to enhance his natural supports. Further, it helped him identify a goal (going home) and formulate a change plan with which to achieve that goal (adhering to medications).

SELF-​ASSESSMENT QUIZ True or False 1. The traditional understanding of patients as “host to defect or disease,” as a basis for treatment, is not effective against unhealthy behaviors (e.g., smoking cigarettes). 2. The two primary objectives of family therapy sessions are to allow family members to express their concerns and to provide an environment in which patients see how their illness or behaviors affect their family. 3. Focusing on the patient’s perspective is an essential element in using MIFT during family encounters. 4. Remaining focused on behaviors and what needs to be changed during MIFT is critical to achieving treatment goals. 5. Attention to the autonomy of each person is the central element of engaging the family in treatment. 6. Validating patients’ experiences over those of family members is key to successfully using MI in family encounters.

Answers 1. True. No patient should ever be viewed as a mere “host.” Trainees must remember that patients live and work within a social context. Few patients lead isolated lives. Most have a network of relationships with

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family, concerned significant others, friends, and community, all of whom are important sources of information regarding patient struggles, and potential sources of support. Treatment effects are maximized when the psychosocial components of suboptimal health are acknowledged. 2. False. The objectives of family interventions include improving communication patterns between patients and family members and restructuring family relationships. Trainees must maintain a therapeutic alliance with the group. To facilitate this process, practitioners must listen empathically, reframe, and reflect each individual’s experiences and expectations vis-​à-​vis the family. 3. False. When using MI in family encounters, trainees must assume a balanced position between a patient’s perspectives and those of family members. Aligning with one perspective over another can occur because it reverberates with the trainees’ own values. However, failing to maintain equanimity will negatively affect the therapeutic alliance and damage potential for progress. 4. True. Remaining focused on addressing unhealthy behaviors in the patient and family is a critical element of the family therapy process. Trainees cannot allow family members to personalize a problem or engage in personal attacks and accusations; these will result in patient defensiveness and discord. Family sessions cannot be allowed to degenerate into arguments. 5. True. Emphasis on autonomy is the primary way that the trainee communicates an expectation of responsible behavior to the family during MIFT. It is the basis for honesty and serious attempts by everyone to change in an effort to help the patient through improved family functioning. 6. False. It is important to validate both patients and family members during clinical encounters: doing so motivates everyone to work in therapy, and it helps trainees maintain a therapeutic alliance with everyone involved. The therapeutic alliance of the trainee with the family and family members with each other is the catalyst by which positive change occurs despite differences of opinion.

REFERENCES Couturier, J., Isserlin, L., Norris, M., Spettigue W., Brouwers, M., Kimber, M., McVey, G., et al. (2020). Canadian practice guidelines for treatment of children and adolescents with eating disorders. Journal of Eating Disorders, 8, 4.

Motivational Interviewing in Family Settings  307 Law, E., Fisher, E., Eccleston, C., Palermo, T. M., & Cochrane Pain, Palliative and Supportive Care Group. (2019). Psychological interventions for parents of children and adolescents with chronic illness. Cochrane Database of Systematic Reviews, 3(3), CD009660. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). Guilford Press. Patterson, J. E., Williams, L., Grauf-​Grounds, C., & Chamow, L. (1998). Essential skills in family therapy. Guilford Press. Rady, A., Mouloukheya, T., & Gamal, E. (2021). Posttraumatic stress symptoms, quality of life, and stress burden in caregivers of patients with severe mental illness: an underestimated health concern. Frontiers in Psychiatry, 12, Article 623499. Tough, H., Siegrist, J., & Fekete, C. (2017). Social relationships, mental health and wellbeing in physical disability: A systematic review. BMC Public Health, 17, 414. Zhang, Y. (2018). Family functioning in the context of an adult family member with illness: A concept analysis. Journal of Clinical Nursing, 27(15–​16), 3205–​3224.

19 Integration of Motivational Interviewing with Mindfulness and Other Integrative Health Modalities Jessica J. Stephens and Melanie A. Gold

In this chapter, we will explore how Motivational Interviewing (MI) can enrich the care we provide to our patients through exploration of some less conventional approaches to treatment. We will focus on mindfulness and other integrative health modalities as a means to further enhance motivation for change, provide patients with a plethora of treatment options for symptom management and improvement of chronic diseases, and offer beneficial resources aimed at engaging patients in self-​care practices. Additionally, we will describe how synergism between MI and these modalities can strengthen the practitioner and patient relationship to enhance motivation for change. An entire textbook could be dedicated to this topic; however, this chapter will function as a guide and a starting point for medical trainees. It will serve to facilitate the use of MI with patients across various settings, allowing the opportunity to affirm and explore complementary resources that empower change toward positive self-​care practices.

WHAT ARE MINDFULNESS AND INTEGRATIVE HEALTH THERAPIES? When describing nonconventional approaches to Medicine, often the words complementary and alternative are used. These terms are thought to be interchangeable; however, this is not necessarily the case. Per the National Center for Complementary and Integrative Health (NCCIH), complementary refers to the use of a nonmainstream practice in addition to traditional Medicine, whereas alternative refers to the use of a nonmainstream practice instead of traditional Medicine (NCCIH, 2018). Data collected from the CDC between

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2002 and 2012 suggest that over one-​third of US adults aged 18 and older have reported use of any complementary health approaches (Clarke, et al., 2015). This amount is likely even higher today, given the shift toward the less traditional approaches to care within the last 10 years. Complementary approaches to health care are appealing to patients for many reasons. An important consideration is that many challenges exist within the framework of the Western medical model of treatment, including efficacy of certain pharmacological and surgical treatment options, cost of treatment, and degree of invasiveness (Rakel, 2018). For instance, when considering management for mental health illness, chronic pain, and gastrointestinal disease, which are often interrelated, patients may have had little success with conventional treatment approaches (Drewes, et al., 2020; Mao, 2009; Sato & Yeh, 2013;) or do not seek treatment for fear of associated stigma (Holder, et al., 2018; Ruddere & Craig, 2016). Some patients may have a particular lifestyle preference for more natural treatments and want to avoid medication options that may result in unwanted consequences, adverse effects, or financial costs. Other patients may want to augment conventional approaches to further improve their healing. Patients may even obtain a sense of support through involvement in complementary approaches that often emphasize community-​based resources (SAMHSA, 2015). The use mindfulness and integrative health therapies, described separately below, can provide our patients with a wide array of options that emphasize a more holistic approach (NCCIH, 2018). Much like the spirit of MI, integrative health and mindfulness-​based practices focus on patient-​centered care. These modalities have also been shown to lower health care costs, improve self-​ efficacy, and increase patient satisfaction with their practitioner (Delgado, et al., 2014). The list of available mindfulness and integrative health modalities is large, as shown in Figure 19.1, which provides our patients with many options for a more individualized approach to improvement in symptoms as well as promoting and sustaining healthy behaviors.

Mindfulness In this chapter, mindfulness is included as its own entity, separate from Integrative Medicine. However, many consider this practice to be categorized as a subset of integrative health under the wide umbrella of complementary integrative health therapies. Over the past 30 years, mindfulness-​based practices have become increasingly popular in the clinical setting. Mindfulness can be traced back to ancient Buddhist thought (Ludwig & Kabat-​Zinn, 2008);

Herbal Remedies


Bach Flower




Shamanic Healing



Acupressure/ Acupuncture




Emotional Freedom Technique (EFT) Tapping


Qi gong

Tai Chi


Movement Therapies

Physical Therapy


Creative Writing/ Journaling

Chiropractic Manipulation

Osteopathic Manipulative Therapy (OMT)

Manipulative Therapies

Art Therapy

Music Therapy


Sensory Art

Figure 19.1  Modalities for mindfulness & integrative health. The figure outlines some of the various therapeutic modalities that patients may find beneficial. This list represents a fraction of the numerous modalities that exist for symptom management and treatment of health conditions. It is important to note that there is much overlap among these therapies. For instance, some may consider acupuncture to be a manipulative therapy, whereas others may characterize it as more of an energetic practice. Qi gong, although listed as movement therapy, can also be considered an energetic practice. Additionally, keep in mind that whole system practices, such as Ayurveda, can incorporate the use of multiple other modalities, such as yoga, dietary considerations, meditation, and abhyanga (self-​massage).

Dietary Supplements


Traditional Chinese Medicine

Whole Practices/ Lifestyle

Mindfulness & Integrative Health Modalities

MI, Mindfulness, Integrative Health Modalities  311

however, the use of mindfulness was recently introduced to Western culture by Jon Kabat-​Zinn in 1979 as a method for addressing chronic pain (Kabat-​ Zinn, 2009). By Kabat-​Zinn’s definition, mindfulness is “the awareness that arises from paying attention on purpose, in the present moment and non-​ judgmentally” (1994). Research on this topic (Black & Slavich, 2016; Cherpak, 2019; Galhardo, Cunha, & Pinto-​ Gouveia, 2013; Howarth, et al, 2019; Larouche, et al., 2015) has shown a variety of clinical benefits (Table 19.1). Traditional mindfulness-​ based exercises include breathing techniques, body scan, mindful eating, walking meditation, and mindful stretching (Kabat-​ Zinn, 2009). These exercises can be accomplished through self-​ practice, facilitated by a practitioner one-​on-​one, or even performed in a group setting. Aspects of mindfulness have been incorporated into treatment for psychiatric illness, such as the psychotherapeutic modalities, cognitive behavioral therapy, and dialectical behavioral therapy (Mace, 2018). Outside of treatment for psychiatric illness, hospital systems and programs are increasingly adapting mindfulness-​based practices in the training curriculum for medical care workers. The focus of these programs is to combat and prevent stress and burnout (Luchterhand, et al., 2015), which has become increasingly more prevalent.

Integrative Health While in the past scientific research and the medical community mainly referred to nonmainstream medical models as CAM, the title has since shifted toward integrative health (NCCIH, 2018; Rakel, 2017). Integrative health, which has become a rising interest since the early 1990s, emphasizes the importance of evidence-​based practices and how they can best be integrated into the health care model to promote health and healing. There are many clinical benefits (Rakel, 2017) to the use of integrative health modalities (Table 19.1).

TABLE 19.1  Clinical Benefits of Mindfulness and Integrative Health Modalities Pain reduction Decrease depression Decrease anxiety Improvement in sleep Reduction in nicotine cravings Prevention of burnout

Cardiovascular benefits Improvement in wellness/​well-​being Improvement in oral/​digestive health Immune support Fertility enhancement Improvement in memory/​cognition

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Integrative health brings together both traditional and complementary approaches, incorporating influences from the mind, body, spirit, and community to approach healing and prevention of disease (Maizes, Rakel, & Niemiec, 2009). This includes special focus on lifestyle, diet, exercise, stress-​ management, and emotional well-​being. It often utilizes natural, less invasive options whenever possible. For medical trainees interested in additional training opportunities related to these therapies, please refer to Table 19.2.

INTEGRATION OF MI AND MINDFULNESS/​ INTEGRATIVE HEALTH MODALITIES There are many similarities between MI, mindfulness, and integrative health modalities, and when they are used together, they can serve to enhance one

TABLE 19.2  Additional Training Opportunities Modality


Mindfulness-​based stress Brown University’s Mindfulness Center reduction (MBSR) https://​​executive/​mindfulness?utm_​ source=​google&utm_​medium=​cpc&utm_​campaign=​ webvisit&utm_​content=​homepage&creative=​ 654948490926&keyword=​mindfulness%20 class&matchtype=​b&network=​g&device=​c&gclid=​ CjwKCAjwo7iiBhAEEiwAsIxQEa6RfONhoH5sLwcD11erU_​ QKq49OpXj6-​kNybiYu_​x081MfrQmvmcxoC5dIQAvD_​BwE Acupuncture Helms Medical Institute: https://​​ admission-​procedure/​ Integrative health University of Arizona’s Integrative Medicine elective rotation and fellowship program: https://​​ education/​ Aromatherapy American College of Healthcare Science: https://​​academics/​departments/​ accredited-​online-​aromatherapy-​degrees/​ Integrative nutrition UC San Diego: https://​​courses-​and-​programs/​ nutrition Hypnosis American Society of Clinical Hypnosis: https://​ EFT Tapping https://​​certification/​clinical-​eft-​ certification?orid=​1335&opid=​57 Transcendental https://​ mediation * Please note that this is not an exhaustive list, and there are many additional training opportunities for practitioners interested in learning more about mindfulness and integrative health therapies.

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another to facilitate and motivate patients toward health behavior change. For instance, both mindfulness and MI emphasize acceptance without judgment. This naturally lends itself to a guiding approach to patient care rather than one that is overly directive or confrontational. The specific principles that define Integrative Medicine, according to the American Board of Physician Specialties (ABPS, 2021), support a partnership between the patient and physician, similar to the collaborative approach of MI that results in patient empowerment (Maizes, Rakel, & Niemiec, 2009). These principles support patient-​centered care, which is integral to eliciting change talk, and make it more likely that a patient will take steps toward positive behavior change. As medical trainees, we receive “traditional” training in history taking, data gathering, and conducting interviews that help to determine the most likely diagnosis and plan for treatment. However, we sometimes struggle to focus on the individual person in front of us as we mentally check off the boxes of associated symptoms that help to narrow down a diagnosis. This style naturally forces trainees into future thought about further work up and treatment, rather than solely focusing on what the patient is actually saying. As a result, trainees unaccustomed to the spirit and process of MI may find it initially challenging to truly listen to what their patients are saying and identify their needs. Conversely, when practitioners focus on the present, this increases patient-​centered communication and overall patient-​reported satisfaction with care (Beach, et al., 2013). By embodying mindfulness practices and truly staying in the moment, such as paying attention to our patients’ words, tone, and body language, we can become more effective at establishing a partnership with our patients and provide a compassionate and accepting environment. Although it takes intention and effort, by staying in tune with ourselves, we can learn to focus on the conversation at hand and stay present with our patients, in turn, making us more effective at implementing crucial MI skills. When MI and integrative health modalities are used together, they can serve to enhance one another and increase engagement toward change. For instance, when MI was incorporated with auricular acupressure, one study revealed significantly increased rates of smoking cessation compared to placebo or counseling alone (Lee, 2019). It is plausible that many of these integrative health modalities can be used synergistically with MI to enhance motivation for change toward additional self-​care behaviors. In the next section, we will share specific examples of how to incorporate integrative health modalities with MI skills and strategies with our patients.

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INCORPORATING MI SKILLS AND STYLES TO FACILITATE BEHAVIORAL CHANGE FOR INTEGRATIVE THERAPIES AND SELF-​CARE Often time, our patients come to us and discuss their current interests in or use of integrative therapies. This presents a great opportunity to utilize MI. Unlike other topics of focus with MI, such as alcohol cessation or medication adherence, having a conversation about mindfulness or integrative health therapies might be uncomfortable or particularly challenging for the medical trainee, as these approaches to care are not commonly widespread across the medical training curriculum. The patient may even have greater expertise in or understanding of these integrative health modalities. This gives us, as medical trainees, the benefit of engaging our patients in a willing and collaborative conversation, while avoiding the “expert trap” of feeling the need to have all the answers for our patients (Miller & Rollnick, 2013). As such, we are better able to understand our patients’ perspectives on diagnosis, treatment options, and additionally provide ample opportunity to affirm their efforts toward change (Box 19.1). Another important consideration that is unique to the use of MI with integrative health therapies is that there is often a strong focus on self-​care, and these therapies can be learned in a variety of settings. For instance, a patient may express interest in guided meditation, which can be conducted one-​on-​ one or via an audio recording of a guided meditation script. Patients may also express interest in engaging in group-​based integrative activities such as yoga, tai chi, qigong, or music therapy, which can also be learned by oneself or one-​ to-​one with an instructor. Depending on your audience (individual patient, family, or larger group), you may need to adjust how you integrate MI with your patients. For a more in-​depth dive into how MI can be adjusted for various settings, please refer to Chapter 18 on MI in family settings. As integrative health modalities are often used together with conventional approaches, it is common for patients to utilize more than one modality at

Box 19.1  Integrative health modalities for self-​care. Key point: Our patients may have more knowledge of various integrative health modalities for self-​ care practices, which provides the opportunity to engage our patients in a collaborative conversation, promote patient autonomy, and affirm their efforts toward change.

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Box 19.2  Learning integrative therapies. Key point: Often integrative therapies focus on self-​care and can be learned with the traditional patient-​practitioner dyad, but also by oneself or in a small group.

a time. Often these can be layered to obtain various benefits. For example, in pain management, in addition to pharmacotherapy, patients may combine the use of physical therapy, yoga, transcendental meditation, and emotional freedom technique (EFT) tapping, a technique in which an individual focuses on negative emotions or experiences while tapping on a series of acupoints on the hands, face, chest, trunk, and head to restore balance and release discomfort (The Tapping Solution, 2021). It is important to note that there is much overlap among integrative health modalities, and often whole practices/​ lifestyles may incorporate multiple modalities. An example would be a patient who has adopted an Ayurvedic lifestyle, which also incorporates specific sleep and activity routines, dietary considerations, abhyanga (self-​massage), movement practices (e.g., walking and yoga), and meditation (Box 19.2). This means that as trainees, we may have to adapt our approach to obtain a true understanding of our patients, their experiences, and even their readiness for change. This can be accomplished through the use of the micro skills OARS (open-​ended questions, affirmations, reflections, and summaries), Elicit-​Provide-​Elicit (E-​P-​E) techniques, and agenda mapping.

Using OARS Skills Around Integrative Therapies As you move through the processes of MI from engaging to focusing to motivating to planning, you can incorporate the OARS practitioner skills to assess your patients’ current behaviors and guide them toward “change talk” or as it applies, “sustain talk.” Below are some suggestions for incorporating OARS skills to facilitate the use of mindfulness and other integrative health modalities (Box 19.3). For a more in-​depth look at OARS, please refer to Chapter 3.

Elicit-​Provide-​Elicit Technique Another MI technique that can be used to guide patients toward integrative self-​care practices is the Elicit-​Provide-​Elicit method of exchanging

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Box 19.3  OARS skills for mindfulness and integrative health. Open-​ended questions/​statements:

• “What about [insert integrative modality] interests you or makes you think it will suit you?”

• “What do you know about [insert integrative modality]?”

• “What are some issues you’d like to address and things you’ve thought of or al-

• “What are the ways that your current symptoms could be treated by members of

• “Which treatments have you heard about/​want to explore or learn more about?”

• “Tell me more about your experiences using different types of integrative health

ready done to address them? What has worked and what has not worked so far?” your family or community?”

therapies such as [insert several modalities as examples] to manage your [insert symptom or condition].” Affirmations:

• “You really care about your health and want to take action to be as healthy as

• You’ve really taken an active role in managing your health with all the different

• “You’ve pointed out an important perspective.”

• “You have a lot of great ideas about how to improve your health.”

• “Thank you for being so honest about the various treatments and remedies that

you can.” integrative modalities that you have explored.”

you have tried.” Reflections:

• “You’re concerned about the effects that taking multiple medications may have

• “You are struggling with figuring out what else you could do to improve your

• “You care very much about improving your health and you want to figure out

on you and want to explore a more natural approach.” health.” what more you could work on incorporating to help you better control it and live a healthier life.”

• “It’s important to you to choose a therapy that suits your beliefs and at the same time empowers you to manage your symptoms/​condition.” Summaries:

• “Before we talk about the next step you might like to take in your treatment, is it OK if I share with you my understanding of your current struggles with self-​care?” [transitional summary; asking permission]

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• “You have described yourself as someone who has tried a lot of methods for self-​care, none of which have stuck. At the same time, you remain open to new suggestions and are optimistic. What other strengths do you see yourself having?” [collecting summary, followed by open-​ended question]

• “The way you feel now about your mindfulness practice is similar to the reaction you shared previously with another experience. You really value your life and find pleasure from taking in all its moments.” [linking summary]

information and advice, which is discussed in more detail in Chapter 3. This approach can be helpful when working through ambivalence toward change or when planning treatment options, especially if the patient has expressed interest in a specific topic. As it is possible that your patient may not know a lot about integrative treatment options, it is important to not provide too much information in any given encounter in order to avoid the “information-​ dump trap” (Miller & Rollnick, 2013). This occurs when patients are provided with an overload of information and do not retain what has been said, regardless of interest level. The information-​dump trap can be avoided through appropriate pacing and frequently checking in with your patients (Miller & Rollnick, 2013). Below is a sample vignette of an encounter that might occur between you and your patient utilizing E-​P-​E. TRAINEE: How would you describe your interest level in discussing integrative health approaches, such as biofeedback, to address self-​care? [eliciting] PATIENT: Well, I’ve heard of that before, but I’m not entirely sure what it’s all about or how it can be helpful for me. TRAINEE: You have heard of biofeedback before but are not sure exactly what it is or the specific potential benefits it can provide for your situation. [complex reflection] Would it be OK if I share with you what we know about biofeedback and self-​ care? [asking permission] PATIENT: Yeah. TRAINEE: Biofeedback is a method of using equipment such as heart rate monitors that allow you to become aware of your body’s physiological responses to stress. With training, you can reduce stress levels through control and awareness of your emotions and reactions that correlate to factors such as change in heart rate. [providing information] How might this method apply to you? [eliciting] PATIENT: Well, I like to see results, so this seems like something I could try.

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Agenda Mapping As mentioned previously, often patients who express interest in integrative health or mindfulness modalities may layer these treatments or even be considering multiple directions toward achieving self-​care goals. For these patients, it can be helpful to utilize agenda mapping to help them manage these many directions and options without feeling overwhelmed. By listing many options, as shown in Figure 19.2, you can also avoid the “premature-​ focus trap” of pushing your own agenda on a patient who is not ready to make the steps toward change (Miller & Rollnick, 2013). Specifically, you can guide your patients by assisting in structuring thoughts, considering various options, and having the patient decide on the focus that may include involvement with one (or more) therapies based on their comfort level and commitment. Through incorporation of OARS skills, you can promote engagement, while at the same time, obtain a better understanding of your patient’s story, experiences and interests, goals, and values; generate topics for discussion; and anticipate guidance that might be necessary to assist patients in resolving ambivalence and moving toward change. Listed below are some tools for agenda mapping with an ultimate focus on motivating self-​care practices (Box 19.4). For more information on agenda mapping please refer to Chapter 3.

IMPORTANT RESOURCES Once you begin to build upon change talk with your patients, it can be helpful to further guide them toward resources that may serve to strengthen their desire for change or even be used as a tool to sustain healthy behaviors. As mentioned earlier in this guide (Chapter 3), building a toolbox is an integral component to developing interpersonal and clinical skills. It can also be beneficial to incorporate within your toolbox resources for self-​care. By having a list of resources to provide to your patients, this can additionally become an effective way to engage them and determine what local resources they may find of interest to support their desires for behavior change. Discussion of resources can be done by first eliciting what resources your patients already know of and then asking permission to offer resources as shown in the E-​P-​E technique. A comprehensive toolbox that includes some of your own popular self-​care resources can also be effective. A study performed by Frank, Breyan, and Elon (2000) revealed that when patients considered their practitioner to

MI, Mindfulness, Integrative Health Modalities  319

Yoga Meditation

Herbs Managing Self-Care



Music Therapy


Figure 19.2  Agenda mapping to facilitate self-​care using integrative therapies. Agenda mapping can provide patients showing ambivalence toward change with multiple strategies or considerations to try. Providing a list of suggestions and including some open circles where patients have the opportunity to continue exploring interests and self-​care practices can facilitate more patient autonomy and motivation toward change. Agenda mapping can be helpful to begin to organize the conversation, develop additional behavioral modification ideas to focus on, and further discussion on potential pros and cons of each item listed on the agenda. Resources will likely vary based on availability, location, and access to modalities, but the list of potential resources is vast and can be better visualized through the use of agenda mapping. Once a focus or multiple focuses have been established, the map can further be used as a timeline for temporal organization and ultimately prioritization of interests.

be invested in healthier practices, they were more believable, and they provided patients with more motivation toward change (Box 19.5). Although it can be great to share resources that you personally have found helpful, it is also important to keep in mind that our patients can often be more knowledgeable on some of these topics. They are likely to be able to

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Box 19.4  Agenda mapping for self-​care practices. Promoting Structured Thought:

• “Based on what I know about you so far, may I suggest we talk about things in your life related to your self-​care?”

• “Would it be OK if we talked about your approach to self-​care?” Considering Options:

• “You have shared a number of goals, values, and beliefs that are important to you when it comes to self-​care and wellness. What else is important to you?”

• “Tell me more about what self-​care approaches you’ve used in the past as well as any you have considered exploring in the future or are curious about.” Choosing a Focus:

• “Of all the things that you mentioned that contribute to your current self-​care patterns, what do you think has the biggest influence and in what ways?” • “Of the topics that you have come up with thus far, which one is the biggest challenge for you to face?” • “On this sheet are some integrative health modalities we can discuss that relate to self-​care. Which of these do you think we might want to talk about further?”

provide a more thorough list of resources to add to your toolbox. Being open and willing to discuss resources that your patients suggest can serve to increase engagement and assist you in affirming your patient’s resourcefulness and facilitate their motivation toward healthier self-​care practices. Table 19.3 provides a nonexhaustive list of resources to consider implementing in your practice.

Box 19.5  Tools in the toolbox. Key point: Utilizing MI skills (OARS, E-​P-​E, and agenda mapping) and additional resources from your comprehensive toolbox can further engage patients, guide them toward a focus while promoting autonomy, and introduce modalities to further sustain positive self-​ care practices.

MI, Mindfulness, Integrative Health Modalities  321 TABLE 19.3  Resource Tools for Trainees Type


Web-​based hypnosis audio recordings guided meditations TED Self-​Care Playlist Online Containing Education Series: (https://​​training/​videolectures) Headspace Calm The Tapping Solution—​EFT tapping About Herbs Breathr Insight Timer Fitbit Apple Watch HR Monitors Handouts (agenda mapping) Dietary supplement fact sheets: (https://​ Exercise description Local classes (yoga, tai chi, Qigong)


Biofeedback Instructional

PERSONAL REFLECTION (Jessica J. Stephens) I am often reminded of the benefits of MI when I think back to an experience as a medical student teaching a mindfulness-​based curriculum to a group of adolescent athletes. Although I did not know it at the time, I found more success engaging these teens when I utilized a guiding approach, with a combination of open-​ended questions and discussions. Following the first session, I remember feeling frustrated that the group was not connecting with the material. I reread through the lesson plan and noticed that most of the curriculum had predominantly focused on directing or telling the athletes specific definitions, expectations, or instructions with very little room for exploration. I had assumed these athletes were interested in learning about mindfulness techniques for self-​care, but I did not appreciate that there were many reasons they were joining the class—​not all of them truly expressing any desire to change habits or learn a new skill. In many ways this mirrors traditional encounters we trainees have with patients. And similar to my athletes, patients react the same—​disengaged. I found that by adjusting the sessions to include more of a focus on what the athletes already know, have tried, or were curious about in relation to mindfulness practice brought with it a welcoming and interactive environment. Soon discussions ensued, and the transition to practice of the mindfulness exercises seemed effortless and natural. The best

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part was that the athletes found benefit from the mindfulness exercises and began to use them more frequently between sessions. To this day, I doubt that I would have seen the same results if I continued with the earlier strategy. Once I began to learn MI as a trainee, I finally understood why the adjusted approach to teaching the athletes was so successful. The answer was MI! I have found that the spirit of MI and the MI approach are integral to my one-​on-​one patient encounters, to family meetings, and even to larger group settings, such as coaching athletes.

SELF-​ASSESSMENT QUIZ True or False 1. Much like the approach of MI, integrative health and mindfulness-​based practices focus on patient-​centered care. 2. Although integrative health therapies often focus on self-​care, they can only be provided within the traditional patient-​physician dyad. 3. Examples of integrative health modalities that our patients might have interest include acupressure, EFT tapping, aromatherapy, and biofeedback techniques. 4. Being open to discussing resources that patients suggest can serve to increase engagement and assist you in affirming and motivating your patients toward healthier self-​care practices. 5. Choose the best answer. What component of OARS would the following statement exemplify? “You care very much about improving your health and you want to figure out what more you could work on to help you live a healthier life.” A. open-​ended question B. affirmation C. reflection D. summarization

Answers 1. True. All these modalities focus on a patient-​centered approach. 2. False. Integrative health therapies can incorporate the traditional patient-​physician dyad and can also be practiced by oneself or in a small group, and the way we perform MI must adjust to this unique quality.

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3. True. Acupressure, EFT tapping, aromatherapy, and biofeedback techniques are all examples of integrative health modalities. 4. True. Approaching patients with acceptance can increase engagement, allow opportunities for affirmation, and increase motivation toward change. 5. C. Reflection.

REFERENCES American Board of Physician Specialties. (Updated 2021). Integrative medicine defined. Tampa, FL: American Board of Physician Specialties. Accessed February 2021. https://​www.abp​sus. org/​inte​grat​ive-​medic​ine-​defi​ned/​ Beach, M. C., Roter, D., Korthuis, P. T., Epstein, R. M., Sharp, V., Ratanawongsa, N., Cohn, J., Eggly, S., Sankar, A., Moore, R. D., & Saha, S. (2013). A multicenter study of physician mindfulness and health care quality. Annals of Family Medicine, 11(5), 421–​428. Black, D. S., & Slavich, G. M. (2016). Mindfulness meditation and the immune system: A systematic review of randomized controlled trials. Annals of the New York Academy of Sciences, 1373(1), 13–​24. Cherpak, C. E. (2019). Mindful eating: A review of how the stress-​digestion-​mindfulness triad may modulate and improve gastrointestinal and digestive function. Integrative Medicine (Encinitas), 18(4): 48–​53. Clarke, T. C., Black, L. I., & Nahin, R. (2015). Trends in the use of complementary health approaches among adults: Unites States, 2002–​2012. National Health Statistics Report, 79, 1–​16. Delgado, R., York., A., Lee, C., Crawford, C., Buckenmaier, C., Schoomaker, E., Crawford, P., Freilich, D., Hickey, A., Jonas, W. B., May, T., Petri, R. P., Schoomaker, E. B., Spevak, C., & Swann, S. (2014). Assessing the quality, efficacy, and effectiveness of the current evidence base of active self-​care complementary and integrative medicine therapies for the management of chronic pain: A rapid evidence assessment of the literature. Pain Medicine, 15(1), 9–​20. Drewes, A. M., Olesen, A. E., Farmer, A. D., Szigethy, E., Rebours, V., & Olesen, S. S. (2020). Gastrointestinal pain. National Reviews Disease Primers, 6(1). Franke, E., Breyan, J., Elon, L. (2000). Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Archives of Family Medicine, 9(3), 287–​290. Galhardo, A., Cunha, M., & Pinto-​Gouveia, J. (2013). Mindfulness-​based program for infertility: Efficacy study. Fertility and Sterility, 100(4), 1059–​1067. Holder, S. M., Peterson, E. R., Stephens, R., & Crandall, L. A. (2019). Stigma in mental health at the macro and micro levels: Implications for mental health consumers and professionals. Community Mental Health Journal, 55, 369–​374. Howarth, A., Smith, J. G., Perkins-​Porras, L., & Ussher, M. (2019). Effects of brief mindfulness-​ based interventions on health-​related outcomes: A systematic review. Mindfulness, 10, 1957–​1968. Kabat-​Zinn, J. (1994). Wherever you go there you are: Mindfulness meditation in everyday life. Hyperion. Kabat-​Zinn, J., & Nhat Hanh, T. (2009). Full catastrophe living: Using wisdom of your body and mind to face stress, pain, and illness. Bantam Dell. Larouche, E., Hudon, C., & Goulet, S. (2015). Potential benefits of mindfulness-​ based interventions in mild cognitive impairment and Alzheimer’s disease: An interdisciplinary perspective. Behavioural Brain Research, 27, 199–​212.

324  Motivational Interviewing, 2E Lee, E. J. (2019). Auricular acupressure and positive group psychotherapy with Motivational Interviewing for smoking cessation. Holistic Nursing Practice, 33(4), 214–​221. Luchterhand, C., Rakel, D., Haq, C., Grant, L., Byars-​Winston, A., Tyska, S., & Engles, K. (2015). Creating a culture of mindfulness in Medicine. WMJ, 114(3), 105–​109. Ludwig, D. S., & Kabat-​Zinn, J. (2008). Mindfulness in Medicine. JAMA, 300(11), 1350–​1352. Mao, J. (2009). Translational pain research: Achievements and challenges. Journal of Pain, 10(10), 1001–​1011. Mace, C. (2007). Mindfulness in psychotherapy: An introduction. Advances in Psychiatric Treatment, 13, 147–​154. Maizes, V., Rakel, D., & Niemiec, J. D. (2009). Integrative medicine and patient centered care. Explore (NY), 5(5), 277–​289. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Preparing people for change. Guildford Press. National Center for Complementary and Integrative Health. (2018). Complementary, alternative, or integrative health: What’s in a name? Accessed February 2021. https://​www.nccih.​hea​lth/​comple​ment​ary-​alte​rnat​ive-​or-​inte​grat​ive-​hea​lth-​whats-​in-​a-​name Rakel, D. (2017). Integrative Medicine (4th ed.). Elsevier. Ruddere, L. D., & Craig, K. D. (2016). Understanding stigma and chronic pain: A state-​of-​the-​ art review. PAIN, 157(8), 1607–​1610. SAMHSA (2015). Complementary health approaches: Advising clients about evidence and risks. SAMHSA Advisory, 14(2), 1–​11. Sato, S., & Yeh, T. L. (2013). Challenges in treating patients with major depressive disorder: The impact of biological and social factors. CNS Drugs, 27(1), S5–​S10. The Tapping Solution. (Updated 2021). What is tapping and how can I start using it? Accessed March 2021. https://​www.the​tapp​ings​olut​​what-​is-​eft-​tapp​ing/​

20 Integration of Motivational Interviewing into the Electronic Health Record and Electronic Communication Jordon Post and Jessica Gannon

Use of the electronic health record (EHR) has become standard in medical practice over the past 2 decades, with over 80% of physicians in the United States using them in outpatient practice and 96% of nonfederal acute care hospitals deploying a certified EHR (Office of the National Coordinator for Health Information Technology, 2019). EHR use has skyrocketed in recent years, compelled by government regulations and financial incentives, and accompanied by the promise of improved population health data collection and care quality. Traditionally, EHRs were championed as tools to reduce medical error, increase information sharing between health care organizations and practitioners, and improve billing workflows. Despite great potential, many physicians, nurse practitioners, physician assistants, psychologists, pharmacists, nurses, social workers, and allied health care practitioners have noted that EHRs have decreased efficiency, led to new medical errors, and have made it increasingly challenging to find clinically relevant information when it is needed. In fact, EHR use has been compellingly associated with practitioner stress and even burnout (Kroth, et al., 2019). In more recent years, the EHR has been increasingly recognized as a tool to enhance communication, not only between practitioners but between practitioners and their patients. Patient educational materials, including tools built to enhance shared decision-​making between patients and their health care team members, have been built within EHRs for ready access during patient visits. Likewise, patient education can be provided through patient facing electronic portals, collated by patients’ care teams. Through these portals, patients can also view portions of their medical records, including medication lists, vitals, and laboratory and test results. Compellingly, many of these portals allow for direct written communication between patients and clinical

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staff. By 2022, as part of provisions of the federal 21st Century Cures Act (21st Century Cures Act PUBL255.PS (, patients will, where technologically feasible, have unfettered, free access to their entire medical record through electronic portals. Access will include documentation like progress notes as well as hospital admissions and discharges. This builds upon the foundation of Open Notes, an international movement centered on enhanced information sharing between patients and their chosen treating practitioners.

ELECTRONIC HEALTH RECORDS, PATIENT PORTALS, AND MOTIVATIONAL INTERVIEWING (MI) Routine use of EHR systems has led to a better understanding of the pros and cons of its use. EHR adoption does have potential pitfalls in relation to the practice of MI. Research suggests computer use during patient appointments can lead to decreased eye contact, missed nonverbal cues, speech interruption, and reduced use of open-​ended questions and reflections (Alkureishi, et al., 2016). This can cause healthcare practitioners to appear to be disengaged and cause them to miss important therapeutic moments or less overt clinical signs. EHR use may lead trainees to spend more time on data collection and data entry than on active communication with patients. This led them to miss important clinical moments necessary to providing patient-​centered care and foster therapeutic relationships. For example, a practitioner preoccupied with clicking boxes in an EHR may fail to notice patient body language indicating ambivalence about a proposed treatment plan, thereby missing the opportunity to engage with the patient on shared decision-​making. Despite these pitfalls, there are several well-​ founded and emerging advantages of EHR’s use in the practice of MI: 1. In medical systems with a common EHR interoperable with other systems, shared patient data can enrich patient-​practitioner encounters such that the focus can shift from data collection to MI and behavior change. 2. EHR facilitates and enhances interdisciplinary collaboration and information sharing between all current and future practitioners, as well as with the patient through advanced patient health portals. For example, through a common EHR, a primary care practitioner may share electronic messages with an endocrinologist, diabetes nurse educator, and dietician to coordinate care for a patient with diabetes. These specialty

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practitioners may, in turn, reach out to the patient through a patient health portal, linked to the EHR, with pertinent education and health coaching. 3. Having the computer with the EHR in the exam or consultation room with the patient provides the accessibility to offer personalized feedback by reviewing and explaining test results or show trends, such as body mass index (BMI), hemoglobin A1c (HbA1C), blood pressure, and weight. 4. Patients and trainees can search together for patient educational materials (including from the internet), which can be printed and given to the patient or shared electronically. Patient information is often available in a variety of different languages, so the patient can learn about their condition or treatment in the language in which they have the greatest fluency. Printing out educational materials for patients is especially important for those with limited internet access and/​or health literacy challenges. 5. When used collaboratively with patients, an EHR can facilitate shared decision-​making around treatment and self-​care. 6. EHR use can promote an increase in patient self-​ownership of treatment when patients see that their own suggestions or goals written in the treatment plan, especially when patients review documentation between appointments through an advanced patient health portal. 7. Access to an advanced patient health portal (i.e., mobile app, messaging, prescription renewal, and laboratory results) also allows patients to ask nonurgent questions, facilitates check-​ in/​ follow-​ up between appointments, and promotes the use of pre-​and postappointment scales and assessments. 8. EHR use often enables telemedicine and mobile access to healthcare records. 9. Cultural and diversity considerations, including sexual orientation and gender identity and preferred language; communication barriers, such as visual and hearing barriers; and social determinants of health can be documented in the EHR, fostering improved patient healthcare experiences and identification of needed specialty services.

Advances in technology continue to expand the scope of EHR application and its utilization in the practice of medicine. With careful deployments, the EHR can be incorporated into and even enhance the practice of MI.

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STRATEGIES FOR USING EHR IN A MI-​ADHERENT APPROACH DURING APPOINTMENTS The practitioner should consider several factors when deciding how the EHR will be used during the appointment. Documentation in the EHR during the visit may not always be appropriate. Factors to consider include clinical setting, patient preference, if the patient is known to the trainee, patient demographics (especially considering age and cultural norms), and the patient’s physical or emotional state. The trainee should remain flexible and be prepared to change plans around documentation strategies as necessary to preserve a patient-​centered atmosphere. Prior to the appointment, the trainee should review the patient’s EHR, including documentation by others and test results. The patients’ report of their medical history, acute health concerns, Review of Systems (ROS), or any preappointment surveys and questionnaires should also be reviewed, if the system allows. The trainee can now focus more time on discussing and exploring the information using MI rather than falling into the question-​ answer or premature focus trap. An example of this technique would be to first ask open-​ended questions around a positive finding on the ROS, such as, “You noted here that you are having shortness of breath. Tell me more about that?”; then explore, in a nonjudgmental way, contributing factors such as medication adherence for treating asthma. Another important way practitioners can integrate the use of MI with EHRs and medical care is through the facilitation of Elicit-​Provide-​Elicit (EPE) or Ask-​Tell-​Ask (Chapter 3; Douaihy, Kelly, & Gold, 2014). The use of EPE fosters a nonjudgmental stance and enhances the collaborative environment and patient engagement in healthcare. In eliciting a patient’s knowledge about a particular topic relevant to their treatment, the trainee can then ask permission and, if granted, offer to provide information or advice tailored to most benefit the patient. Permission to give information should be asked by saying, “Would it be OK if I told you more about that or about some options I know about, and you can tell me what you think of that?” Once permission is granted, the EHR can be used to access web-​based information or other electronic tools that can be viewed together with the patient. This approach may be especially helpful for patients with new diagnoses, for visual learners, the hearing impaired, and those with technological barriers to healthcare. The trainee should offer to print out any materials reviewed and/​or send them electronically to the patient via a patient portal or through secure messaging. Additionally, past visits, labs or imaging, treatment plans, appointments, and other relevant information can be viewed and discussed. This gives the patient

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a platform to express any concerns and share their perspectives and goals. Validating patient values, goals, and beliefs fosters trust and strengthens the therapeutic alliance with the practitioner. Toward the end of the appointment, after-​visit summaries generated by EHRs can be printed and reviewed with the patient, as they contain medication order summaries, diagnoses, vitals, and next appointment information. Referrals and any patient education materials discussed with the patient can be provided, as suggested above. This is also a good time to remind patients that they can use the patient portal to review their visit and to communicate any nonurgent information or ask questions between appointments.

DOCUMENTATION DURING AN APPOINTMENT With increasing documentation demands of EHRs and availability of computers and tablets in most clinical settings, balancing documentation while simultaneously conducting good clinical care becomes an important issue. Several strategies can be used to incorporate EHR use with MI. First, the trainee should notify the patient when and why they plan to use the EHR; for patients unfamiliar with EHRs, the trainee should explain its benefits, capabilities, and common uses. It is important that patients understand that the computer serves as more than a note-​taking device, but as a “tool” to enhance collaboration and optimization of their health. The room should be set up so that the patient can easily see both the medical trainee and the monitor; one such way is for the trainee and patient to sit side by side. This facilitates a more collaborative atmosphere and still allows for nonverbal communication, both key components of MI. Computer documentation during encounters will inevitably detract from patient interaction in some capacity. To remain consistent with MI, the trainee must strike a balance between typing and person-​to-​person interaction. Nonverbal communication has been shown to influence a patient’s sharing of socioemotional concerns (Rathert, Mittler, Banerjee, & McDaniel, 2017). As nonverbal behavior has the potential to either greatly enhance or detract from establishing rapport, it is important to be cognizant of moments where it may be more appropriate to focus solely on the patient and actively listen rather than look at a computer screen. This may be especially so when discussing sensitive topics, patient concerns, psychosocial factors, and cultural considerations important to treatment. Toward the end of an appointment, we would recommend, using the EHR alongside the patient to formulate and document treatment goals, using

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the patient’s own words and insights, as well as treatment suggestions. This could seamlessly lead to ordering medication through the EHR, and in doing so, allow for natural review of medication pricing and preferred pharmacy location, while reviewing patient-​centered instructions written on the prescriptions. The trainee can then wrap up the visit and ask what other questions the patient has. It is a good time to check in with the patient and ask, “How do you feel about the changes we made?” While the above approach makes use of periodic documentation during the appointment, a second approach, the collaborative documentation (CD) model, allows for documentation of the entire encounter during the appointment time and requires active patient collaboration. This includes documentation of the history of present illness (HPI), examination findings, evaluations, and treatment plans. CD incorporates the goal of a strong therapeutic alliance with the concept of shared decision-​ making. Research suggests that CD facilitates a stronger therapeutic alliance, increases patient involvement in shared decision-​making, and improves outcomes. Further, CD promotes more efficient and accurate documentation; is more efficient for the practitioner and, therefore, cost-​effective; and enhances work-​life balance for practitioners (Grantham, 2010; Schmelter, 2012). Partnership and supporting autonomy, major components of MI, allow the CD model to fit well within its framework. As CD may be new to many patients, its benefits and its application should be discussed, and patient permission to use this method should be obtained. A review with the patient can include emphasizing: (1) the patient’s involvement in the documentation process, (2) the explanation of how the trainee and patient will collaborate on the documentation, (3) the review of parts of the note where it is OK to disagree (or agree to disagree) or seek clarification, (4) and the clarification that all documentation occurs during the appointment (Flora & Fruth, 2019). True to MI, CD recognizes that patients themselves are the real experts in their lives and their insights and perspective are crucial to their medical care. Documentation is typically allocated to the end of the appointment, which allows most of the interview to be a traditional MI interview. For follow-​ ups, the beginning of the appointment should be spent reviewing progress or updates since the last visit. Here, MI can be used to facilitate dialogue of strengths or challenges, of health concerns or treatments. Throughout the appointment, the EPE framework should be used to understand the patients’ values, motivations, personal goals, beliefs, and barriers, and how these may directly or indirectly affect their health. If necessary, take notes on a pad,

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reminding the patient, “I’m writing down a few words to help us remember when we write our note at the end of the appointment” (Schmelter, 2012). Toward the end of the session say, “Let’s review what we’ve discussed and together we’ll write the important parts of our visit today” (Schmelter, 2012). While working through the note, asking clarifying open-​ended questions and offering reflections and summaries helps to engage the patient in the process. The trainee should record values, concerns, and/​or personal goals that the patient feels are important. This allows the opportunity to gauge motivation and provide health education using EPE. The patient should be given ample opportunity to ask questions. Collaboratively, a personalized treatment plan consistent with the patient’s values, preferences, beliefs, and personal goals is developed and documented (Schmelter, 2012). For example, a patient with mild-​to-​moderate depression who is concerned about possible medication side effects (e.g., weight gain and sexual dysfunction) may choose to engage in a course of cognitive behavioral therapy before taking a prescribed antidepressant medication to treat the depressive episode. The patient’s symptoms, diagnosis, treatment options, and potential risks and benefits of each treatment option, as well as the patient’s attitudes and values around illness and treatment and treatment choice would all be documented. Such documentation may also include a plan to address how the patients’ needs will be measured and how they will be treated (Leone, 2019). Any strengths and challenges that the patient identifies in relation to the diagnosis and the treatment plan should be documented, as well as the patient’s ideas regarding how to resolve or address and barriers or challenges. Additionally, the patient’s response to the intervention should be recorded in a “response to intervention” section. Lastly, the note should be written using a balance of patient-​friendly language and the patient’s own words. In the EHR, record that the note “was written in collaboration with the patient.”

Documentation Example Next, we present an example of the documentation discussed in this section, which includes an evaluation and a plan. Evaluation and Plan The patient presents with symptoms consistent with a moderate episode of major depressive disorder (MDD). She has had no prior episodes of depression. Currently, the patient continues to work and meaningfully engage with

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family, though she feels like she is isolating somewhat from friends, is having trouble focusing at work, and is not participating in household chores to the degree that she would like. Her primary treatment goals are to improve in these domains and “get back to normal.” The practitioner is providing the integrated treatment with medications and psychotherapy. We have discussed two convergent treatment strategies for this depressive episode: (1) psychotherapy (behavioral activation and cognitive-​behavioral therapy (CBT)) and (2) antidepressant medication. The patient notes that she would prefer not to take medication for depression unless her episode worsens, as she is concerned about side effects that her friends have experienced on selective serotonin reuptake inhibitors (SSRIs), namely weight gain and sexual side effects. She also notes a preference not to take medications in general. Given these concerns and preferences, she is interested in a trial of CBT alone. We have reviewed the potential benefits of this treatment option, including behavioral activation and a reduction of automatic negative thoughts and cognitive distortions. We have discussed how this may treat the depressive episode. We have also reviewed the main risk of this approach: that therapy alone will not be sufficient to treat the episode, and the symptoms could worsen. Progress in treatment will be measured with Patient Health Questionnaire-​9 (PHQ-​9) (Kroeneke, Spitzer, & Williams, 2001) and review of goals (which may be broken down into measurable components, for example: I will vacuum the house and do four loads of laundry this week). The patient notes several strengths, including strong motivation to feel better and good family support. She is able to engage in safety planning around steps to take should her symptoms worsen, particularly if she were to experience suicidal ideation, thoughts, and/​or plan (safety plan documented elsewhere in the EHR). She is concerned that she may sometimes struggle with transportation to appointments; we have discussed scheduling telemedicine appointments through video visits as an option to overcome this barrier. She agrees that this should greatly mitigate the risk of missing appointments. The trainee should understand that collaborative documentation is not negotiating what is documented in the record. Documentation must still be objective. To be considered collaborative, the patient should: (1) know what is being documented (ideally can see the note as it is being written), (2) have the opportunity to ask questions, (3) have the opportunity to disagree and have their perspective documented, and (4) have the ability to correct objective (factual) errors. Though CD can be used for most note types including evaluations and progress notes, clinical judgement should be used as when to utilize it, as this approach may not work with every patient in every situation. Some patients

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may express apprehension towards the CD model for a variety of reasons. Additionally, different clinical scenarios may require variations in the application of CD, including situations that may only allow for the partial collaboration of the note or on only certain sections. Detailed summaries of past histories and extensive notes on physical examination or test result interpretations may best be documented outside of a patient visit for efficiency and so as to not detract from patient rapport building. On the other hand, the plan portion of the note can quite often be written with the patient, as illustrated above. Additionally, as many patients are accompanied by family or caregivers, it may not be appropriate to document the visit (or certain aspects of the visit) with the other parties present.

Documentation Language As technology continues to push medicine into a more “virtual” platform, the language of documentation becomes exceedingly important. Congress and the Executive Branch of the federal government continue to define clinical documentation as belonging to the patient. However, it is important to remember that the language we choose not only affects our relationship with the patient, but it also impacts the quality of patient interactions with other healthcare professionals. Careful consideration must be made to not let personal beliefs or judgements be reflected in the EHR. Negative, condescending, and dismissive language should be avoided, including in documentation of physical and mental exams (Table 20.1). At the same time, objective medical information must always be documented, even if the patient does not agree with the assessment, as avoiding doing so can compromise quality patient care. Examples may include track marks from intravenous (IV) drug use or scars secondary to self-​injurious cutting. Language on how to properly address a patient should always be included in the EHR. If the patient gives permission for the trainee to do so, information on the patient’s preferred name and pronouns are especially important to record, as well as the patient’s self-​defined gender identity. This can help ensure that the patient is addressed in a manner consistent with their identity during all healthcare encounters. Judgmental statements, such as the “patient is noncompliant” or “abuses XYZ,” are examples of language that should be avoided in documentation. Using this language may not only cause a disruption in the therapeutic relationship with the patient, but it may also create a false assumption of the patient that initiates a cycle of negative healthcare experiences. Patients may

334  Motivational Interviewing, 2E TABLE 20.1  Documentation Language to Avoid and to Use Avoid



Person with a substance use disorder [describe which one] or “reports use of [insert substance]” Asking for specific medication throughout visit; requests were declined because of risk to patient and lack of medical indication Does not consistently take medication as prescribed [describe how often misses meds]. He has missed x/​x number of scheduled appointments. He notes he misses medications as he forgets and doesn’t really think they help. Transportation barriers and motivation to attend interfere with appointment attendance [Specify given reasons and/​or concerns as to why] patient elected not to receive treatment today Person with schizophrenia, diabetes, hypertension, or asthma Clothes and hair appear to not have been recently washed [State age] BMI is 35, placing the patient in the obese category [Use patient preferred gender pronouns]

Drug seeking Noncompliant with treatment

Refuses treatment Schizophrenic, diabetic, hypertensive, asthmatic Poor hygiene Elderly Obese Using pronouns associated with legal or birth assigned sex of a transgender patient Documenting race or ethnic identifiers in the first line of a History and Present Illness (HPI)

[Document race and ethnic identifiers in HPI when relevant to diagnosis/​treatment; otherwise, consider documenting in social history]

become distrustful of their healthcare team and less motivated to engage with healthcare professionals. This can, in turn, negatively influence health outcomes. In lieu of using words like noncompliant, it is more productive to describe why the patient found it difficult to maintain the agreed upon treatment. The word abuse should generally be avoided in medical documentation. Diagnosing the patient with “XYZ disorder” and/​or describing how they “use XYZ” is both less pejorative and more clinically relevant. When using the EHR database to select diagnoses, be sure the most accurate diagnosis is chosen (i.e., choosing “alcohol use disorder, severe” versus “alcohol use disorder, mild” as clinically appropriate). Similarly, it is critical not to preemptively label patients, especially marginalized individuals, by adding another potentially disenfranchising “reason” to be scrutinized by healthcare professionals. For example, choosing “cannabis use disorder” for a patient of color who smokes two joints on the weekend is both diagnostically inaccurate and deeply stigmatizing, especially given ongoing racial inequities in medicine.

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The importance of diagnostic precision cannot be understated. In addition to explaining diagnoses and relevant pathophysiology and/​or diagnostic criteria to patients, it is also important to familiarize patients with common medical terminology. It should never be assumed that any patient, including those with high levels of formal education, have high levels of medical literacy. For example, explaining the connection between “having high blood sugar” and type 2 diabetes mellitus is very important, as are terms like HbA1C, glucose, and insulin. It is also important to explain the roles of relevant specialists, such as endocrinologists and nephrologists. As we move toward increasing sharing of clinical documentation with patients through patient portals, an option is to define these terms in a portal “glossary” or in the note, such as for example “. . . blood sugar (glucose)” may be particularly helpful for patient education and empowerment. There are situations when it may not be possible to give an immediate or precise diagnosis during treatment. Lab results, imaging, or appointments with specialists may be pending. In these cases, following up with the patient is important. After speaking with the patient (in person or by video or phone), the EHR should be updated, and any necessary information sent via the patient health portal. It is critical that a qualified member of the healthcare team review any updates in diagnosis with the patient before it can be seen in the patient portal. For example, labs on a patient with longstanding diabetes return following an appointment and show a decrease in kidney function. The trainee then verbally communicates with the patient, stating “there is evidence of a mild loss of ability for your kidneys to filter waste” but then updates the EHR as “stage II kidney disease.” If the patient is unfamiliar with the terminology, this may cause them significant undo distress. Documentation of sensitive information should also be reviewed with patients. Some patients may have provided family members with access to their health portals with a health care proxy but do not want these individuals to see all their health-​related information. In such instances, it is important for the trainee to consider not documenting this information, or, if important to document for medical reasons, blocking it from release to the portal when possible, noting this is by patient request. Patients may also be concerned about other healthcare professionals knowing details about their trauma histories and/​or information that they may be concerned is potentially stigmatizing and not directly relevant to their current health condition: for example, remote history of sex work or homelessness. Again, it may be important for the trainee to consider excluding such facts from documentation and/​or utilizing mechanisms built into the EHR that prevent information sharing with other healthcare team members.

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Despite its many shorting comings, the EHR holds promise as a tool to better communicate with patients, enhance shared decision-​making, and facilitate MI. Not only can the EHR be used for patient education, the EHR can also be used to track objective progress on mutually agreed upon treatment goals. Supported by federal legislation, patient-​facing electronic portals are now widely available through which clinical documentation can be shared; this technology amplifies between visit patient engagement. Given that patients are increasingly interacting with their electronic health information, it is critical that medical trainees become comfortable with documenting in ways that support and enhance the use of MI. Doing such will further empower patients as “owners” of an EHR that serves less as a static record of treatment and more as a dynamic tool that helps facilitate patients’ progress in treatment. Sample Case At the beginning of the appointment: The trainee should introduce the collaborative documentation approach and obtain verbal consent. TRAINEE: At the end of today’s visit, I am going to take a few minutes to write in your chart with you. We can summarize what we talked about today and discuss any questions or concerns you may have. I may write down a few notes during the appointment, all of which we can review at the end. [summary]

At the end of the session: TRAINEE: We’re getting close to the end of the appointment so let’s stop here. Let’s summarize what we talked about today and work together to write your note. TRAINEE: Let’s write down the important parts of our visit today. PATIENT: Well, I’m having a real hard time quitting smoking. I quit 2 months ago and didn’t smoke for a month but have been really stressed lately and started smoking again. I just don’t think I can quit on my own anymore. TRAINEE: You feel very discouraged about having a hard time quitting smoking after you were able to successfully stop before. What does tobacco do for you? [complex reflection followed by an open-​ended question] PATIENT: It calms my nerves when I am feeling wound up and stressed. TRAINEE: What makes it most difficult for you to quit? [open-​ended question] PATIENT: [Discusses the role stress plays in nicotine cravings; reaffirms motivation to quit].

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Documentation example: Patient has been struggling with nicotine cravings in response to a recent increase in life stressors. He recently quit for 1 month and restarted about 2 weeks ago to manage increased stress. At the same time, he is motivated to quit. TRAINEE: What is the ideal outcome for you as we move forward and what changes would that make for your life? [open-​ended evocative questions]

Document a specific collaborative goal with patient, for example, patient responds: “I am able to manage my cravings without giving into the temptation of smoking.” TRAINEE: What are your beliefs about smoking cessation? [open-​ended question] TRAINEE: What methods are you familiar with? [open-​ended evocative question]

Document the patient’s beliefs about smoking cessation and anything that would shape treatment plan. Example: “Light” cigarettes are less harmful than regular cigarettes, or cold turkey is the only way to quit. TRAINEE: So, you are motivated to quit. What do you think about working together to come up with some other options to deal with the cravings? [complex reflection followed by open-​ended question] PATIENT: That sounds great doc! I really want to quit; I just need a little help. TRAINEE: Would you mind if I shared with you a few other options that may help you reach your goal? [asking permission] PATIENT: Please do! TRAINEE: [First explains what the nicotine patch does] What do you think of this option? [evocative question] PATIENT: I’d like to give it a try.

Document that the patient has recently been struggling with nicotine cravings, so he decided to add a nicotine patch. He plans to avoid areas or scenarios (work break) where he typically smokes. He set a new quit date for this Friday and will follow-​up via a telemedicine visit in 3 weeks. TRAINEE: I’m going to write down some important information for you about the nicotine patch along with directions for how and when to apply. You can also always securely message me through the patient portal with any questions you may have. [trainee writes easy to understand instructions using patient-​centered language]

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PERSONAL REFLECTION (Jordon Post) As many trainees know, residency is a time of transition, quick-​pace learning, finding professional direction in your field, and growing into yourself as a physician and an individual. This time is as rewarding as it is busy, with many days often shadowed by the latter. Often, I have found it challenging to effectively use MI and EHR in a quick-​pace environment. However, utilizing the EHR to obtain a patient’s preferred name, pronouns, ethnicity (culture), preferred language, social history, and relevant medical history has allowed me to set the stage to efficiently use MI, and appropriately build rapport with my patients. Additionally, it has also been useful to connect with other members of a patient’s interdisciplinary team and further strengthen therapeutic alliance. MI is about approaching patients as the expert on their own lives, and understanding that my role is as a collaborator, for which the EHR has been a valuable asset.

SELF-​ASSESSMENT QUIZ True or False 1. The advantages of the EHR include the following: simplified billing, reduction in medical errors, and improved documentation. 2. The EHR provides easy access to clinical data that facilitates the use of the E-​P-​E framework and personalized feedback. 3. When EHRs are used in an MI-​consistent manner, they have the potential to strengthen the alliance with the patient and facilitate health behavior change. 4. The EHR does not have a role in discussing with the patient the trainee’s clinical findings from the history and physical examination (H&P). 5. The EHR does not have the capacity to facilitate the process of self-​ management of chronic medical conditions and shared decision-​ making using an MI framework. 6. The EHR can increase the efficiency and delivery of healthcare for both patient and trainee.

Answers 1. True. The EHR has many advantages including simplified billing, improved communication, reduction in medical errors, and facilitating

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the implementation of practice guidelines and sharing medical information between practitioners. 2. True. When using an EHR, there are ample opportunities to integrate E-​P-​E framework. For example, E-​P-​E is a natural fit when working collaboratively with a patient on a treatment plan. 3. True. When data in EHRs are utilized to facilitate a dialogue with the patient about clinical findings, it has the potential to improve the patient-​ trainee relationship and initiate a conversation about change. 4. False. EHRs can play a significant role in conveying in an MI-​consistent manner the trainee’s findings from the H&P. 5. False. The EHR can positively influence the process of behavior change and patient empowerment to self-​ manage medical conditions and strengthen the process of decision-​making using the MI approach. 6. True. The EHR (patient-​portal access) allows pre visit surveys or questionnaires, ROS, as well as postvisit follow-​up and the ability for patients to access their health information at any time. This allows communication, medication questions, or health education to continue after the visit, allowing the patient to be more invested in their care plan.

REFERENCES Alkureishi, M. A., Lee, W. W., Lyons, M., Press, V. G., Imam, S., Nkansah-​Amankra, A., Werner, D., & Arora, V. M. (2016). Impact of electronic medical record use on the patient-​doctor relationship and communication: A systematic review. Journal of General Internal Medicine, 31(5), 548–​560. Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational Interviewing: A guide for medical trainees. Oxford University Press. Flora, M., & Fruth, J. (2019). Collaborative documentation: There’s nothing basic about it [PowerPoint]. https://​stat​ic1.squa​resp​​sta​tic/​59c00​5cd8​a02c​7dae​8cd5​e80/​t/​5c9eb​ 982e​b393​1364​258c​4a4/​155390​6063​959/​Nat​con2​019+​Collab​orat​ive+​Docume​ntat​ion+​-​+​ There%27s+​Noth​ing+​Basic+​About+​It+​-​+​M.+​Flora+​and+​J.+​Fruth+​%28Fi​nal%29+​DB.pdf Grantham, D. (2010). Concurrent documentation wins trifecta: How one documentation project made clinicians, clients, and even accountants happy. Behavioral Healthcare, 30(8), 32–​37. Kroeneke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-​9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–​613. Kroth, P. J., Morioka-​Douglas, N., Veres, S., Babbott, S., Poplau, S., Qaedan, F., Parshall, C., Corrigan, K., & Linzer, M. (2019). Association of electronic health record design and use factors with clinician stress and burnout. JAMA Network Open, 2(8), e199609. Leone, L. (2019). Patient-​centered documentation: Collaborative documentation. [Power Point slides]. National Council for Behavioral Health. https://​​wp-​cont​ent/​uplo​ ads/​2017/​03/​Nat​Con-​Webi​nar-​Pati​ent-​Cente​red-​Docu​ment​atio​n_​2.4.19.pdf

340  Motivational Interviewing, 2E Office of the National Coordinator for Health Information Technology. (2019). Health IT dashboard—​Quick stats. Accessed 2019. https://​dashbo​ard.healt​​qui​ckst​ats/​qui​ckst​ ats.php Rathert, C., Mittler, J. N., Banerjee, S., & McDaniel, J. (2017). Patient-​centered communication in the era of electronic health records: What does the evidence say? Patient Education and Counseling, 100(1), 50–​64. Schmelter, B. (2012). Implementing collaborative documentation: Making it happen! [Power Point slides]. http://​www.inte​grat​ion.sam​​pbhci-​learn​ing-​commun​ity/​jun_​2​012-​_​ co​llab​orat​ive _​documentation.pdf 21st Century Cures Act PUBL255.PS ( 2022 FDA.

21 Motivational Interviewing in e-​Health and Telehealth Elizabeth Hovis and James Latronica

In the preface to Miller and Rollnick’s first edition of Motivational Interviewing (1991), the authors offer readers a kindly warning: “A word of informed consent: This approach is likely to change you.” They are, of course, referring to the approach of Motivational Interviewing (MI) itself, but this same injunction serves as an apt preamble to the discussion of technology’s role in the process of MI as well. We are aware that any book chapter written about the subject of emerging technology will, by definition, eventually require updating or revision, but considering the mass expansion of telehealth services rolled out during the COVID-​19 pandemic, we would be remiss without touching on the history, benefits, challenges, and implementation of MI in clinical encounters, viewed through the framework of remote engagement. Research during the COVID-​19 pandemic suggests that many patients will avoid seeking medical care, even for urgent or emergent issues, for fear of contracting the disease (Czeisler, et al., 2020; Lu, Kong, & Shelley, 2021). This is a rational and expected response to contagious endemic disease, which naturally leads to discussion of delivery of health care while mitigating the risk of viral spread. Even prior to the pandemic, access to mental health services was a widespread challenge. A 2009 survey of Primary Care Physicians (PCPs) suggested that two-​thirds of PCPs were unable to refer their patients to outpatient psychiatric services (Cunningham, 2009), and a nation-​wide survey of 1,031 rural hospital CEOs in 2013 demonstrated that nearly 50% of rural hospitals lack trained psychiatrists (MacDowell, Glasser, Fitts, Nielsen, & Hunsaker, 2010). With fewer than one million total practicing physicians (Young, Chaudhry, Pei, Arnhart, Dugan, & Steingard, 2019), and fewer than 150,000 mental health counselors (US Bureau of Labor Statistics, 2020) available for the more than 325 million people living in the United States (US Census Bureau, 2021), COVID-​19 simply underscored an already critical lack of access to behavioral health services.

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Fortunately, remote delivery of mental health services has been an ongoing project, with literature attesting to its efficacy. A 2016 systematic review of telepsychiatry practice that included 452 publications suggested that “telepsychiatry is comparable to face-​to-​face services in terms of reliability of clinical assessments and treatment outcomes” (Hubley, Lynch, Scheneck, Thomas, & Shore, 2016). Similarly, a 2020 systematic review of randomized controlled trials suggested that medication adherence for patients with depression, bipolar disorder, or schizophrenia improves with application of telemedicine (Basit, Mathews, & Kunik, 2020). The precise execution of these services is not as clear. A recent systematic review from 2021 revealed that “best practices” generally came from reviews or expert opinion (Bitar & Alismail, 2021), suggesting a gap in the literature regarding evidence-​based implementation and strategic uniformity. As an additional complication, billing for telehealth services, has also lacked standardization. Medicare plans traditionally disallowed reimbursement for most nonrural telehealth services, as the patient’s home was not considered an “originating site” like a traditional doctor’s office (Center for Medicare and Medicaid, 2021). During the pandemic, this restriction was dropped, and many state-​run Medicaid programs followed suit; unfortunately, these measures were time-​limited and reliant on continuing public health emergency orders. Thus, as the COVID-​19 pandemic continues, and the pre-​existing lack of access to behavioral health services is compounded by concerns for the mitigation of viral spread, investigating best practices and standards of care remains a critical paradigm to study.

PERSONAL REFLECTION (Elizabeth Hovis, PART I) A. A 30-​year-​old single mother with three children in treatment, regularly sees me for opioid use disorder (OUD) treatment with buprenorphine-​ naloxone. Prior to COVID-​19, she had been driving roughly 2 hours round trip to see me once per month for follow-​up and medication refill. Since the COVID-​19 pandemic began, we have been meeting via telehealth. She explained to me that the time and gas money saved have allowed her more financial flexibility, and she has been able to begin saving for a down payment on a house. She asks if telehealth visits can be continued indefinitely. What should I say to her? B. A 60-​six-​year-​old man with severe chronic obstructive pulmonary disease and on oxygen at home has been engaging exclusively in telehealth visits for OUD and buprenorphine-​naloxone treatment since March

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of 2020. He has remained adherent to treatment and has asked that we continue his appointments in this way indefinitely. He also asks if exemptions to in-​office appointments might be considered during flu season, as the travel has contributed to his becoming seriously ill and hospitalized with influenza pneumonia before. What can I tell him? C. A 56-​year-​old man in long-​term, stable OUD treatment has enjoyed the convenience of conducting his visits remotely since the start of the pandemic. However, he has difficulty with technology, and we have reverted to using telephone-​only communication for his appointments. He has not used any nonmedically obtained substances in over 13 years, and never misses appointments. He is very fond of the telephone-​only appointments, and he has concerns that even if video telehealth visits are permitted to continue, he will be “left out,” given his limited proficiency with smartphones and computers. How can I best provide care for this gentleman?

TELEHEALTH HISTORY AND ORIGINS Telehealth is the use of information and communication technologies to deliver healthcare services, including clinical, educational and research services, despite geographical separation between patients and healthcare professionals (Center for Medicare and Medicaid Services, 2021; WHO Global Observatory for eHealth, 2010). The ability to remotely diagnose patients dates to the mid-​seventeenth century in the form of medical consultation through written correspondence. Since then, increasingly advanced communication technologies have led to greater ability to diagnose and treat patients despite geographic distance. An 1879 report published in Lancet described a physician using the telephone to evaluate and diagnose a baby’s cough (Nesbitt & Katz-​Bell, 2017). By the 1920s the advent of two-​way radio communication paved the way for the theorized “radio doctor,” depicted on a 1925 cover of Science and Invention Magazine (Board on Health Care Services, 2012). In the mid-​twentieth century, the University of Nebraska claimed the first use of interactive video technology for health care in the United States (Osborn, Squires, Doty, Sarnak, & Schneider, 2016). Between the 1960s and the 1990s, telehealth continued to grow with the support of federal, military and space sectors, aimed at providing health care to underserved or difficult-​to-​reach areas. With exponential advances in technology, the first quarter of the twenty-​first century yielded rapid growth in and improved access to telehealth services.

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Incorporating telehealth into the larger medical infrastructure depends not only on availability and training in telehealth technology but also on the ability to reimburse for such services. In 1999 the Center for Medicare and Medicaid Services (CMS) began reimbursing for telemedicine services in rural areas struggling with a shortage of healthcare professionals (Gilman & Stensland, 2013). The COVID-​19 pandemic resulted in the rapid growth and improved reimbursement for telehealth services as remote medicine occupied a critical position in providing care without exposing patients and healthcare providers to unnecessary risk (Shachar, Engel, & Elwyn, 2020).

BENEFITS OF TELEHEALTH The most apparent benefit of telehealth is improved access to care. By providing care across geographic barriers, telehealth improves access to quality healthcare in otherwise underserviced areas as well as helping those who suffer from rare diseases or limited access to therapies available in other urban areas. Telehealth has the potential to mitigate financial barriers to accessing care as remote care removes the need for transportation and parking considerations. Telehealth can readily be incorporated into one’s work and home responsibilities and minimizes the need for added childcare or lost income from work leave. Further, standard outpatient office hours hinder access for those that require after-​hours or weekend appointments. A 2016 commonwealth study found that half of Americans struggle to access healthcare on nights or weekends without utilizing emergency care services (Osborn, Squires, Doty, Sarnak, & Schneider, 2016). Telehealth has mitigated this barrier by providing a venue for readily accessible evening and weekend care. Because of a shortage of primary care practitioners and specialists, wait times for outpatient treatment have increased. Telehealth interventions have proven instrumental in reducing these wait times in a variety of outpatient as well as urgent care settings (Caffery, Farjian, & Smith, 2016; Patel, Stewart, & Horstman, 2020). In addition to improved access to high-​quality care, telehealth has paved the way for safely providing care to those who incur a degree of risk from ambulatory visits. The elderly, immunocompromised, as well as those with physical or intellectual disabilities, are at a disproportionate risk when accessing care in standard outpatient settings. The COVID-​19 pandemic accentuated the potential risk from in-​person visits, while forcing the population at large to recognize the risks related to outpatient care. The risk remained greater to vulnerable populations, thereby perpetuating health disparities. As such,

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telehealth was rapidly incorporated into healthcare delivery as a means of providing care and respecting social-​distancing guidelines. Although literature demonstrating the cost-​effectiveness of telehealth is limited, there is evidence that telehealth interventions can reduce hospital readmission and improve chronic disease management, thereby mitigating costs (Baker, Johnson, Macaulay, & Birnbaum, 2011; Chess, Whitman, Croll, & Stefanacci, 2018). For instance, incorporating virtual, after-​hours physician presence in a skilled nursing facility resulted in significantly reduced Medicare costs, a total of $1.55 million saved over the course of 1 year (Basit, Mathews, & Kunik, 2020).

CHALLENGES OF TELEHEALTH Barriers to implementation of a widespread telehealth infrastructure include reaching populations that lack reliable access to and fluency in internet and video technology, privacy and security concerns, and inability to sufficiently manage a subset of medical or psychiatric conditions remotely. The availability of broadband devices with video capability are necessary for telehealth. While virtual medicine can theoretically improve access to care for many underserviced populations, this is negated if that same population does not have the means of engaging with virtual platforms. For instance, less than 70% of rural areas have access to high-​speed broadband internet, and only 71% of rural residents have access to a smartphone (RHIhub, 2019). In addition, some populations may lack fluency in utilizing the technology required for telehealth. In a recent systematic review, lack of technological literacy hailed as the primary barrier to utilizing telehealth services among older adults (Kruse, Fohn, Wilson, Nunez Patlan, Zipp, & Mileski, 2020). According to the Pew Research Center, 27% of US adults aged older than 65 years did not use the internet in 2019 (Weigel, Ramswamy, Sobel, Slaganicoff, Cubanski, & Freed, 2020). While most health systems utilize telehealth platforms that are encrypted and in compliance with the Health Insurance Portability and Accountability Act, virtual visits pose greater privacy and security risks than in-​person care. For instance, certain remote medical monitoring systems (such as insulin pumps) have been recognized as vulnerable to hacking (Hall & McGraw, 2014). Smartphone apps required for certain remote interventions may collect and distribute personal information to third parties (Nesbitt & Katz-​Bell, 2017). Additional privacy concerns can arise from the environment in which the patient participates in remote care. An example of this is a patient engaging in a telehealth visit from home with family members present

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throughout the visit. Although the ideal is to conduct virtual visits in a private setting, this is not always feasible for patients. Despite the rapid expanse of information and communication technology, certain medical and/​or psychiatric illnesses are not conducive to remote evaluation and management. Specifically, portions of the physical exam are not possible with current technology. Further, virtual care makes it difficult to coordinate procedures, labs, and imaging with office visits.

MI AS A TOOL TO PROMOTE TELEHEALTH ACCEPTANCE AND UTILIZATION An additional barrier to telehealth services is patient preference for in-​person visits. Studies have shown that “resistance” to considering telehealth services stems from a variety of factors, including lack of knowledge, unfamiliarity with telehealth platforms and technology, and resistance to change; further, individuals’ experiences with healthcare, as well as their comfort with the practitioner, may influence their willingness to access care virtually (Almathami, Win, & Vlahu-​Gjorgievska, 2020). Many of the core tenets of MI can be used to address ambivalence about engaging in telehealth services. For example, open-​ended questions and reflective listening can help explore uncertainty in a nonjudgmental and collaborative way, while affirmations can recognize and highlight attributes conducive to both traditional in-​person models of health care and telemedicine. MI is a therapeutic style and approach that can be used to engage patients in a discussion about the rapidly changing climate of healthcare delivery, which may, like any change, be met with ambivalence.

Open-​Ended Questions • “Help me better understand how your diagnosis and medical appointments have impacted your life?” • “What is your understanding of how telemedicine works?” • “How do you see telemedicine fitting into your care?” • “What do you see as challenges related to your engaging in virtual sessions?” • “Tell me about your relationship with your treatment team?”

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Open-​ended questions can be also used to elicit change talk and soften sustain talk: • “What reasons might there be for you to use telehealth services?” • “If you decide to use telehealth services, how could you do it?” • “What are the steps you need to take to make it easier for you to engage in virtual sessions?”

Reflections • “You don’t like the idea of meeting with practitioners over the phone or by video.” • “On the one hand, the idea of telehealth services makes you feel like this will be an impersonal relationship, hard to connect; on the other hand, not having to drive 35 minutes each way is somewhat appealing to you.” • “You are leaning toward considering virtual sessions and you feel it is worth checking it out.” • “You are questioning whether virtual sessions might be as helpful as being physically present in the office.”

Affirmations • “You have made it a priority to attend your medical appointments despite needing to drive nearly an hour each way.” • “You downloaded the app for video visits despite a lot of discomfort with smartphones and technology.” • “You have really great relationships with your outpatient providers.” • “You are willing to work through some of the challenges related to telehealth sessions.”

Supporting Patient Autonomy • “You know best what type of visits will help keep your blood pressures within your goal range.”

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The Elicit-​Provide-​Elicit (E-​P-​E) approach gives trainees the opportunity to discuss some aspects of telehealth sessions, elicit patients’ thoughts and points of view, and provide information in a neutral, nonjudgmental fashion.

EVIDENCE FOR TELEHEALTH AND MI MI demonstrates evidence-​based efficacy in essentially every patient population or disease process in which it has been studied. A 2005 systematic review found clinically relevant effects using MI in 72% and 75% of physiological and psychological diseases processes, respectively. A meta-​analysis demonstrated quantitative changes in certain biological risk factors, such as body mass index, serum cholesterol, and systolic blood pressure (Rubak, Sandbæk, Lauritzen, & Christensen, 2005). Subsequently, a 25-​year retrospective meta-​analysis on MI examined 119 studies and suggested that “virtually anytime MI has been tested empirically in new areas (e.g., health-​ promoting behaviors); it has shown positive and significant effects” (Lundahl, Kunz, Brownwell, Tollefson, & Burke, 2010). Other studies have shown positive effects in patients with asthma, hypertension, and heart disease (Knight, McGowan, Dickens, & Bundy, 2006), patients with co-​occurring psychiatric and substance use disorder diagnoses (Swanson, Pantalon, & Cohen, 1999), eating disorders (MacDonald, Hibbs, Corfield, & Treasure, 2012), and adolescent substance use (Jensen, Cushing, Aylward, Craig, Sorell, & Steele, 2011), among others. In a broad systematic review published in 2017, the authors suggested that “MI is more effective than no treatment and as effective (but not necessarily more effective) than other active treatments” (DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017). Plainly put, there is a remarkable amount of evidence supporting the use of MI in essentially every facet of health care. The literature surrounding MI in telehealth is less well established, but comparators do exist. A randomized controlled trial (RCT) funded by the Department of Veterans Affairs published in the Journal of Clinical Psychology demonstrated the efficacy of remote MI on the success of smoking cessation (Battaglia, et al., 2016), and a RCT published in the American Journal of Physical Medicine and Rehabilitation demonstrated that a telehealth program for weight loss in patients with physical disabilities incorporating MI showed clinically and statistically significant weight reduction (Rimmer, Wang, Pellegrini, Lullo, & Gerber, 2013). Smoking cessation and weight loss constitute two of the most frequent comorbidities addressed across all patient populations. Therefore, RCTs supporting the efficacy of remote MI in

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addressing these conditions speaks to the broad appeal that remote MI has as a primary care treatment. Additionally, in terms of preventive care, a RCT in the Journal of Clinical Oncology showed that the group randomized to receive telehealth services was nearly three times as likely to participate in appropriate colon cancer screening compared to those who were simply mailed an informational brochure (Kinney, et al., 2014), and an AIDS and Behavior pilot RCT suggested that frequent telephone-​administered MI lowers the rate of risky sexual behavior in middle-​aged and older adults compared to similar adults who engaged in less frequent MI, or no MI at all (Lovejoy, Heckman, Suhr, Anderson, Heckman, & France, 2011). If patients can be engaged in primary preventive measures from the comfort of their own homes, the implications for public health may be truly significant. Remote MI also demonstrates effect outside of individual studies. A systematic review of 15 randomized control trials published in Preventive Medicine suggested that MI not only aids in weight loss but can be practiced in-​person or remotely with equivalent efficacy (Patel, Wakayama, Bass, & Breland, 2019). A 2021 systematic review of RCTs targeting MI-​based telehealth management of diabetes found 21 articles that showed demonstrable improvements in Hemoglobin A1c (McDaniel, Kavookjian, & Whitley, 2021). More broadly, a systematic review investigating technological adaptations of MI concluded that “studies indicated high acceptability and positive behavior change in interventions that tested efficacy” and that “[t]‌hese approaches offer considerable potential to reduce costs, minimize therapist and training burden, and expand the range of clients that may benefit from adaptations of MI” (Shingleton & Palfai, 2016). Even though the evidence available for remote MI is not as robust as the evidence for the practice of in-​person MI, the research available is promising and warrants further investigation.

“BEST PRACTICE” IN REMOTE MI There is a paucity of literature on how a telehealth appointment should be conducted. However, some recent studies from various fields offer suggestions. We will describe these studies, expound on them, and suggest actionable changes in telehealth to improve delivery. We will divide them into four categories: general, technological, environmental/​aesthetic, and reimbursement. A summary of the four categories and their respective recommendations can be found in Table 21.1.

350  Motivational Interviewing, 2E TABLE 21.1  Summary of Recommendations for Best Practice for Remote Motivational Interviewing General Considerations Full EHR integration Standardized transition process Cost-​effectiveness-​consider “block time” for telehealth visits Simplicity

Technological Considerations Telehealth onboarding visit Regularly updated software Practice device uniformity Clear designation of patient and trainee name on screen

Privacy Environmental/​Aesthetic Considerations Professional attire and appropriate background Appropriate proximity to camera-​consider a second monitor or separate camera Tidy foreground and background

Reimbursement Considerations Medical society advocacy for full reimbursement Standardized telehealth prepopulated phrases in EHR Standardized telephone-​only waiver forms/​ EHR phrases

Soft, diffuse lighting EHR =​electronic health record

General Considerations The systematic review by Bitar and Alismail (2021) regarding telehealth and best practice offers a useful framework from the standpoint of universal recommendations, and “big picture” considerations. They searched the literature for recommendations, then divided them into three categories: pre visit, during visit, and post visit. This can be seen in Figure 21.1. System integration is the sole component of the previsit category. The electronic health record (EHR) is a consistent source of physician frustration and burnout (Kroth, et al., 2019; Science Direct, 2021). Full integration of remote therapies into existing technology infrastructure represents a crucial initial step in maximizing patient interaction and minimizing barriers. Bitar and Alismail (2021) propose a standardized transition process from in-​person to virtual visits and recognize the importance of simplicity in the interface, to make the “bridge” between in-​person and remote visits as seamless as feasible, ideally creating a sense of normalcy and familiarity. As previously mentioned, population cohorts based on socioeconomic differences vary in access to and familiarity with telehealth services and devices used for telehealth, so additional care must be taken to avoid alienating certain patient groups. In terms of cost-​effectiveness, integrating telehealth visits into the usual workflow of a busy practice can be a

Billing reimbursement Allow for the billing of telemedicine, telehealth, and/or eHeatlth visits


Continuity of care Provide high-quality care for patients over time by using telemedicine, telehealth, and/or eHealth, including patients’ monitoring

Remote outpatient care Optimize the use of telemedicine, telehealth, and/or eHealth services for continuity of outpatient care


Figure 21.1  eHealth, telemedicine, and/​or telehealth solutions (Bitar & Alismail, 2021).

Privacy & Data sharing Ensure patient privacy and data sharing to improve heatlthcare systems and quality

Simplicity Simplify the steps for patients by offering a user manual and/or instructional video

Cost-effectiveness Assess the efficacy and cost-effectiveness of telehealth, telemedicine, and/or eHealth processes for a long-term utilization

Standardized transition process Develop a standardized process for transitioning from in-person visits to remote visits that can be used by medical facilities

System integration Consider a full integration of telemedicine, telehealth, and/or eHealth services into one ICT system


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challenge, especially as practitioner comfort with technology can also vary. In addition to universal training for all practitioners, sequestering telehealth visits into groups may be an efficient mechanism that allows practitioners to “get into the flow” of working with telehealth services as opposed to alternating between in-​person and telehealth visits throughout the day.

Technological Considerations A “lessons learned” post hoc descriptive analysis of a telehealth counseling study published in Telemedicine and e-​ Health identified nine recurring themes that created barriers to effective use of telehealth services (Wootton, McCuistian, Legnitto-​Packard, Gruber, & Saberi, 2020): (1) selection of platform, (2) practitioner device-​connection issues, (3) managing patient expectations, (4) incompatible/​poorly connected patient devices, (5) inadequate cell phone reception, (6) inadequate internet signal, (7) audio/​video interruptions, (8) poor video quality, and (9) patient difficulty with logging in. While all of these issues may have separate root causes, they may all share a similar, pre-​ emptive remedy: by holding a preliminary, in-​person appointment that utilizes the telehealth software while the patient is physically in the office, with the patient using the device(s) they plan to use for their appointments. Having both the practitioner and patient in the same physical location, with knowledgeable staff on hand to assist with setup, connectivity, and execution of the visit should be considered for all patients’ first telehealth encounter. This, essentially, is the technological version of an ounce of prevention is worth a pound of cure adage, and we refer to this as the “telehealth onboarding visit.” During this time, patients and practitioners can ensure that their devices are functional and compatible, and techniques for updating and maintaining relevant software can be discussed. Information Technology Departments may also consider standardizing all electronic devices within a practice so that troubleshooting and maintenance can likewise be standardized and streamlined.

Environmental and Aesthetic Considerations Environmental concerns regarding MI in clinical practice have already been investigated, including a 2019 mixed-​methods study that combined a scoping review with a survey of health professionals and investigated the sustainability of MI embedded in clinical practices (Lim, School, Lawn, & Litt, 2019). The authors suggested that “sustainability of MI at micro-​clinical levels can be fostered

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through use of enabling technology, focus on patient-​centered care, personnel development and process improvement,” indicating that even prior to the pandemic, foundational and institutional changes would likely be needed to foster effective, long-​term MI in clinical practice. The applications of such insightful though broad suggestions may have MI practitioners searching for practical solutions for altering both their practice and their physical spaces. In this vein, a 2020 narrative review (Duane, et al., 2022) scouted the literature and pulled from the fields of Social Psychology, Environmental Psychology, and Human-​ Computer Interaction to determine what factors can influence electronic visits. These findings were distilled into four schemas, which are detailed in the paper. Given that telehealth visits may be completely novel to many patients, maximizing patients’ comfort and “simulating” the traditional office visit experience is a rational consideration, especially when acknowledging that this new environment may constitute another barrier to MI that patient and trainee would be forced to navigate. Some of these changes may seem so insignificant as to not require attention, but the ultimate impact cannot be discerned until the visit has concluded, thereby warranting modest preparation. Trainees dressing as they normally would in the office—​whether the practitioner is at home or in their actual office—​signals to patients that they are engaging in “business as usual.” Camera placement can be an additional challenge, as laptops with built-​in cameras do not always offer the ideal clarity or focal distance. A separate camera on a desktop tripod may allow for better image quality and focal distance. Further, a second monitor attached to the practitioner device may allow for a smoother workflow when it comes to charting and navigation of various electronic resources during patient encounters. Finally, depending on how fully televisual technology can be integrated into the EHR, special considerations need to be made for the use of third-​ party applications, specifically regarding patient and trainee identification. Some third-​party applications default to the device name (as opposed to the patient’s name) both in virtual waiting rooms and during the appointment itself. If this is the case, instructions can be given for changing the name presented on screen to minimize confusion during the appointment.

Reimbursement Considerations As evidence continues to mount that telehealth appointments across specialties are effective, the previously mentioned “origination site” regulations imposed by CMS constitute a rational and attainable policy target. With specific regard to therapy appointments, telephone-​only visits have been an important

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tool for mental health professionals during the pandemic, especially for those whose patients lack reliable broadband internet or other material that aids in televisual engagement. Exemptions can currently be made for telephone-​only visits when required by patient need but, of course, this requires additional paperwork. For patients who will require telephone-​only services for an extended time period, standardized and prefilled exemption forms can be created, adjusting the date of service and rationale as appropriate. Further, integrating prepopulated phrases into the EHR can allow practitioners to easily signify how and why telephone-​only services are being provided. Finally, televisual appointments will still require explanation that consent has been obtained and privacy laws are being followed, and this is another aspect that can be streamlined by the use of prepopulated phrases within the EHR.

PERSONAL REFLECTION (Elizabeth Hovis, PART II) In reference to the patients mentioned at the beginning this chapter in the personal reflection (Part I), when considering the evidence for telehealth and what best practices might look like, the solution to their challenges and obstacles becomes clearer. We start with the a priori position that trainee expertise should guide the role and scope of telehealth in a given practice. With appropriate preparation, technology rollout, environmental setup, and billing reimbursement, all that remains to be considered is patient engagement and trainees’ approach to using MI spirit as “a way of being with people,” not just “doing MI, it’s “being MI.” Thus, whether we encounter a 30-​year-​old woman whose fiscal situation has improved because of telehealth appointments, a 66-​ year-​old man who is at high risk for communicable illness, or a 56-​year-​old man who prefers his telephone-​only appointments, we suggest that the onus for appropriate level of care determination should rest solely with trainees in shared decision-​making with their patients.

SELF-​ASSESSMENT QUIZ True or False 1. There is no evidence supporting the use of telehealth over traditional health care delivery models. 2. Benefits of telehealth include improved access to care as well as safe access to care.

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3. MI is not an approach that can be integrated within telehealth services. 4. Patient ambivalence about using telehealth services can be addressed using the collaborative and evocative elements of MI. 5. Best practices for telehealth visits include the practitioner dressed in casual attire and positioned in a room with low-​light or dark backgrounds. 6. A telehealth onboarding visit can be a useful tool for promoting telehealth adaptation.

Answers 1. False. A 2016 systematic review of telepsychiatry practice suggested that “telepsychiatry is comparable to face-​to-​face services in terms of reliability of clinical assessments and treatment outcomes.” Similarly, a 2020 systematic review of randomized controlled trials suggested that medication adherence for patients with depression, bipolar disorder, or schizophrenia improves with application of telemedicine. 2. True. Telehealth improves access to care by mitigating geographic, transportation, and financial barriers as well as offering after-​hours and weekend care. 3. False. MI’s foundation is based in person-​centered relational skills. As a therapeutic style, MI provides a guiding style of engaging patients so that their self-​expertise can be reinforced in order to facilitate change. In this sense, MI is a natural fit within telehealth sessions. 4. True. Patients may express strong ambivalence about using telehealth services and MI uses strategies to address and diminish ambivalence. 5. False. Best practices for telehealth visits include practitioners dressing in professional attire, a practitioner-​focused view (arms, torso, shoulders, and head), a plain background with limited, professional cues, as well as soft, warm, natural lighting, and being clinically present with the patient (MI spirit). 6. True. During this time, patients and practitioners can ensure that their devices are functional and compatible, and techniques for updating and maintaining relevant software can be discussed.

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356  Motivational Interviewing, 2E Baker, L. C., Johnson, S. J., Macaulay, D., & Birnbaum, H. (2011). Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings. Health Affairs (Millwood), 30(9), 1689–​1697. Basit, S. A., Mathews, N., & Kunik, M. E. (2020). Telemedicine interventions for medication adherence in mental illness: A systematic review. General Hospital Psychiatry, 62, 28–​36. Battaglia, C., Peterson, J., Whitfield, E., Min, S. J., Benson, S. L., Maddox, T. M., & Prochazka, A. V. (2016). Integrating motivational interviewing into a home telehealth program for veterans with posttraumatic stress disorder who smoke: A randomized controlled trial. Journal of Clinical Psychology, 72(3), 194–​206. Bitar, H., & Alismail, S. (2021). The role of eHealth, telehealth, and telemedicine for chronic disease patients during COVID-​19 pandemic: A rapid systematic review. Digital Health, 7, 20552076211009396. Board on Health Care Services, Institute of Medicine (2012). The role of telehealth in an evolving health care environment: Workshop summary. National Academies Press (US). Accessed September 6, 2021. http://​​books/​NBK207​145/​ Caffery, L. J., Farjian, M., & Smith, A. C. (2016). Telehealth interventions for reducing waiting lists and waiting times for specialist outpatient services: A scoping review. Journal of Telemedicine and Telecare, 22(8), 504–​512. Center for Medicare and Medicaid Services (2021a). Telehealth for providers: What you need to know (p. 17). Accessed 2021. Center for Medicare and Medicaid Services (2021b). Telehealth services (p. 6). Accessed 2021. Chess, D., Whitman, J. J., Croll, D., & Stefanacci, R. (2018). Impact of after-​hours telemedicine on hospitalizations in a skilled nursing facility. American Journal of Managed Care, 24(8), 385–​388. Cunningham, P. J. (2009). Beyond parity: Primary care physicians’ perspectives on access to mental health care. Health Affairs (Millwood), 28(3), w490–​501. Czeisler, M. É., Marynak, K., Clarke, K. E. N., Salah, Z., Shakya, I., Thierry, J. M., Ali, N., McMillan, H., Wiley, J. F., Weaver, M. D., Czeisler, C. A., Rajaratnam, S. M. W., & Howard, M. E. (2020). Delay or avoidance of medical care because of COVID-​19-​related concerns: United States. Morbidity and Mortality Weekly Report, 69(36), 1250–​1257. DiClemente, C. C., Corno, C. M., Graydon, M. M., Wiprovnick, A. E., & Knoblach, D. J. (2017). Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychology of Addictive Behaviors, 31(8), 862–​887. Duane, J. N., Blanch-​Hartigan, D., Sanders, J. J., Caponigro, E., Robicheaux, E., Bernard, B. Podolski, M., & Ericson, J. (2022). Environmental considerations for effective telehealth encounters: A narrative review and implications for best practice. Telemedicine and e-​Health, 28(3), 309–​316. Gilman, M., & Stensland, J. (2013). Telehealth and Medicare: Payment policy, current use, and prospects for growth. Medicare Medicaid Research Review, 3(4), mmrr.003.04.a04. Hall, J. L., & McGraw, D. (2014). For telehealth to succeed, privacy and security risks must be identified and addressed. Health Affairs (Millwood), 33(2), 216–​221. Hubley, S., Lynch, S. B., Schneck, C., Thomas, M., & Shore, J. (2016). Review of key telepsychiatry outcomes. World Journal of Psychiatry, 6(2), 269–​282. Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-​analytic review. Journal of Consulting and Clinical Psychology, 79(4), 433–​440. Kinney, A. Y., Boonyasiriwat, W., Walters, S. T., Pappas, L. M., Stroup, A. M., Schwartz, M. D., Edwards, S. L., et al. (2014). Telehealth personalized cancer risk communication to motivate colonoscopy in relatives of patients with colorectal cancer: The Family CARE randomized controlled trial. Journal of Clinical Oncology, 32(7), 654–​662.

MI in e-Health and Telehealth  357 Knight, K. M., McGowan, L., Dickens, C., & Bundy, C. (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11(2), 319–​332. Kroth, P. J., Morioka-​Douglas, N., Veres, S., Babbott, S., Poplau, S., Qeadan, F., Parshall, C., Corrigan, K., & Linzer, M. (2019). Association of electronic health record design and use factors with clinician stress and burnout. JAMA Network Open, 2(8), e199609. Kruse, C., Fohn, J., Wilson, N., Nunez Patlan, E., Zipp, S., & Mileski, M. (2020). Utilization barriers and medical outcomes commensurate with the use of telehealth among older adults: Systematic review. JMIR Medical Informatics, 8(8), e20359. Lim, D., School, A., Lawn, S., & Litt, J. (2019). Embedding and sustaining motivational interviewing in clinical environments: A concurrent iterative mixed methods study. BMC Medical Education, 19(1), 164. Lovejoy, T. I., Heckman, T. G., Suhr, J. A., Anderson, T., Heckman, B. D., & France, C. R. (2011). Telephone-​administered motivational interviewing reduces risky sexual behavior in HIV-​positive late middle-​age and older adults: A pilot randomized controlled trial. AIDS Behavior, 15(8), 1623. Lu, P., Kong, D., Shelley, M. (2021). Risk perception, preventive behavior, and medical care avoidance among American older adults during the COVID-​19 pandemic. Journal of Aging and Health, 33(7–​8), 577–​584. Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-​analysis of motivational interviewing: Twenty-​five years of empirical studies. Research on Social Work Practice, 20(2), 137–​160. Macdonald, P., Hibbs, R., Corfield, F., & Treasure, J. (2012). The use of motivational interviewing in eating disorders: A systematic review. Psychiatry Research, 200(1), 1–​11. MacDowell, M., Glasser, M., Fitts, M., Nielsen, K., & Hunsaker, M. (2010). A national view of rural health workforce issues in the USA. Rural Remote Health, 10(3), 1531. McDaniel, C. C., Kavookjian, J., & Whitley, H. P. (2021). Telehealth delivery of motivational interviewing for diabetes management: A systematic review of randomized controlled trials. Patient Education and Counseling, 105(4), 805–​820. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior (1st ed.). Guilford Press. Nesbitt, T. S., & Katz-​Bell, J. (2017). History of telehealth. In K. S. Rheuban & E. A. Krupinski (Eds.), Understanding telehealth. McGraw-​Hill Education. Osborn, R., Squires, D., Doty, M. M., Sarnak, D. O., & Schneider, E. C. (2016). In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Affairs, 35(12), 2327–​2336. Patel, M. L., Wakayama, L. N., Bass, M. B., & Breland, J. Y. (2019). Motivational interviewing in eHealth and telehealth interventions for weight loss: A systematic review. Preventive Medicine, 126, 105738. Patel, V., Stewart, D., & Horstman, M. J. (2020). E-​consults: an effective way to decrease clinic wait times in rheumatology. BMC Rheumatology, 4, 1–​6. Accessed September 6, 2021. https://​bmcrh​euma​tol.biomed​cent​​artic​les/​10.1186/​s41​927-​020-​00152-​5 RHIhub. (2019). Barriers to telehealth in rural areas: RHIhub toolkit. Accessed September 6, 2021. https://​www.rura​lhea​lthi​​toolk​its/​tel​ehea​lth/​1/​barri​ers Rimmer, J. H., Wang, E., Pellegrini, C. A., Lullo, C., & Gerber, B. S. (2013). Telehealth weight management intervention for adults with physical disabilities: A randomized controlled trial. American Journal of Physical Medicine & Rehabilitation, 92(12), 1084–​1094. Rubak, S., Sandbæk, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-​analysis. British Journal of General Practice, 55(513), 305–​312. Science Direct. (2021). The association between perceived electronic health record usability and professional burnout among US physicians. ScienceDirect. Accessed September 6, 2021. https://​www.scienc​edir​​scie​nce/​arti​cle/​pii/​S00256​1961​9308​365

358  Motivational Interviewing, 2E Shachar, C., Engel, J., & Elwyn, G. (2020). Implications for telehealth in a postpandemic future: Regulatory and privacy issues. JAMA, 323(23), 2375–​2376. Shingleton, R. M., & Palfai, T. P. (2016). Technology-​delivered adaptations of motivational interviewing for health-​related behaviors: A systematic review of the current research. Patient Education and Counseling, 99(1), 17–​35. Swanson, A. J., Pantalon, M. V., & Cohen, K. R. (1999). Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients. Journal of Nervous and Mental Disease, 187(10), 630–​635. US Bureau of Labor Statistics (2020). Occupational employment and wage statistics. Accessed September 6, 2021. https://​​oes/​2016/​may/​oes211​014.htm US Census Bureau (2021). US Census Bureau QuickFacts: United States. Accessed September 6, 2021. https://​www.cen​​qui​ckfa​cts/​fact/​table/​US/​PST045​219 Weigel, G., Ramswamy, A., Sobel, L., Slaganicoff, S., Cubanski, J, & Freed, M. (2020). Opportunities and barriers for telemedicine in the U.S. during the COVID-​19 emergency and beyond. KFF. Accessed September 6, 2021. https://​​wom​ens-​hea​lth-​pol​icy/​ issue-​brief/​opport​unit​ies-​and-​barri​ers-​for-​telem​edic​ine-​in-​the-​u-​s-​dur​ing-​the-​covid-​19-​ emerge​ncy-​and-​bey​ond/​ Wootton, A. R., McCuistian, C., Legnitto-​Packard, D. A., Gruber, V. A., & Saberi, P. (2020). Overcoming technological challenges: Lessons learned from a telehealth counseling study. Telemedicine and e-​Health, 26(10), 1278–​1283. WHO Global Observatory for eHealth. (2010). Telemedicine: Opportunities and developments in Member States: report on the second global survey on eHealth (p. 93). Young, A., Chaudhry, H. J., Pei, X., Arnhart, K., Dugan, M., & Steingard, S. A. (2019). FSMB census of licensed physicians in the United States, 2018. Journal of Medical Regulation, 105(2), 7–​23.

22 Learning and Experiencing Motivational Interviewing Cassandra Boness and Antoine Douaihy

Learning Motivational Interviewing (MI) is much more than learning and strengthening new clinical strategies for facilitating behavior change or avoiding behaviors that might present communication roadblocks. Focusing too much on skill acquisition, in fact, can interfere with the learning process and deflect from the natural opportunities MI presents to self-​reflect on our own abilities to communicate effectively. Thus, we argue that learning MI is more about how we approach the task of learning than the task itself. In this regard, it is imperative that we approach MI with a growth mindset, a construct initially described by Carol Dweck (2012). In comparison to a fixed mindset, which is characterized by avoiding challenges, giving up easily, and ignoring negative feedback, the growth mindset assumes that intelligence can be developed. Thus, the growth mindset reflects a desire to learn that often leads to embracing challenges, persisting in the face of roadblocks, viewing effort as a path to mastery, learning from feedback, and finding lessons and inspiration in the success of others. We therefore hold that cultivating a growth mindset is imperative to learning MI.

PERSONAL REFLECTION: MY LEARNING JOURNEY (Cassandra Boness) Like many helping professionals, I entered the field with a desire to help people. As I advanced in my training, however, I found that this was sometimes a problematic perspective; a perspective that would sometimes lead to frustration when I didn’t feel I was adequately helping patients or they weren’t interested in change. The most important thing that MI has taught me is that I cannot help people, and, in fact, that is not my primary role. The power to help is not solely within me as a professional, and, indeed, such an assumption

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creates distance between the practitioner and the patient. Instead, MI has taught me that my primary role is to help people find the power to change within themselves through empathy and acceptance. MI regularly reminds me, through its patient-​centeredness, that a patient’s desire to change is more important than my own expert desire to help. There’s no one “right way” to change, and MI has made that salient to me. I now realize that my job is to guide, not to fix. MI is a humanizing approach in this way. Such a perspective allows me to view ambivalence and resistance as opportunities and natural processes rather than something that gets in the way of the “goal” of the interaction. I feel more confident as a practitioner because I am not the primary person responsible for evoking motivation and facilitating change. I no longer feel defeated or burned out when patients do not share my goals for the interaction and, instead, I am able to embrace and respect their autonomy as the ultimate guide, practicing lovingkindness and compassion toward myself and my patients. MI has become a critical part of my personal and professional life, and I am better because of it.

EIGHT STAGES IN LEARNING MI According to Miller and Moyers (2007), the acquisition of the MI style and skills is thought to proceed through eight, roughly additive developmental stages (Figure 22.1). Each stage is intended to build the foundation for the next. This eight-​stage framework can be useful for understanding the training sequence and for identifying stages where trainees may get stuck when learning MI. Being able to identify “stuck points” and seek out guidance is a key part of the growth mindset and requires careful introspection and openness. By working through each stage, trainees can continue their advancement as MI practitioners. It is important to note, however, that just because a trainee passes through one stage doesn’t mean they might never return to an earlier stage again. Learning is a dynamic, and rarely linear, process.

Stage One: Understanding the Spirit of Motivational Interviewing Perhaps the most fundamental stage is understanding and embracing the spirit of MI. The spirit of MI is characterized by supporting patient autonomy, conveying acceptance of the patient’s position, collaboration with the patient, having compassion for the patient’s position, and evocation, a process

Learning and Experiencing MI  361 1. The spirit of MI Key skills: PACE

2. Reflective listening Key skills: OARS

3. Reinforcing change talk Key skills: DARN CAT

4. Strengthening change talk Key skills: tactical aiming of OARS, DARN CAT

5. Rolling with Resistance key skills: Reflections, Reframing, Reinforcing

6. Developing a change plan Key skills: transition summary

7. Consolidating Commitment Language Key skills: identifying commitment language

8. Incorporating other modalities

Figure 22.1  The eight stages of learning MI.

referred to as Patient autonomy, Acceptance, Collaboration, Compassion, and Evocation (PACCE). The willingness to take a patient-​centered approach and elicit the patient’s motivation for change is essential. In turn, this approach fosters greater consistency in MI-​adherent behaviors and the language we employ, resulting in improved patient receptiveness. Trainees often get stuck when they are not open to the spirit of MI and have assumptions about patients or about their role in the encounter. This can lead the trainee to become confrontational, overly directive, or overly advising. The early stage trainee must understand the importance of being open to the spirit and how the spirit guides the MI approach. Accepting the spirit of MI is especially emphasized when teaching trainees, particularly as it allays anxiety related

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to the experience of learning. The spirit of MI provides a context and fits well with one’s role as a medical trainee. It makes MI digestible and provides a foundation for the cumulative process of learning MI.

Stage Two: Patient-​Centered Counseling Through Reflective Listening The second stage of learning MI is focused on skill acquisition and, specifically, patient-​centered counseling skills. The major skill of importance here is reflective listening. Reflective listening conveys accurate empathy to the patient. It also has the ability to signal and reinforce empathy, patient confidence, collaboration, and compassion while providing opportunities to develop discrepancies and increase motivations for change (Miller & Moyers, 2007). That is, it sends the message, “I’m here with you, I understand your experience,” while moving the conversation forward toward change. Reflective listening is sometimes mischaracterized as simply repeating what the patient said. Although reflective listening often includes an accurate reflection of what the patient has said, more often, it reflects the complexity of the patient’s experience, often beyond what they have verbalized. Indeed, reflective listening is a complex clinical skill that requires continuous practice. The OARS (open-​ended questions, affirmations, reflections, and summaries) skills can aid the trainee in developing their reflective listening skills. Learning and being able to successfully use these specific skills serves as a key “building block” for increasing the likelihood of success in later stages of learning MI. Open-​Ended Questions PATIENT: In the past I have participated in 12 step recovery programs to try and reduce my drinking. TRAINEE: What has your experience in 12 step programs been like?

Affirmations PATIENT: I’ve tried many times in the past and find it hard to stay engaged with the 12 step meetings. TRAINEE: You’ve put a lot of time and effort into 12 step meetings.

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Reflections PATIENT: When I do go to meetings, it feels like no one there can really relate to my experiences. TRAINEE: Feeling connected to others in recovery is important to you.

Summaries PATIENT: I know it’s important for me to attend meetings, it’s just that sometimes I leave them and feel worse. Traveling to and from meetings takes time out of my day that I could be using for other things. Even though they sometimes help me stay on track with my recovery, I can’t help but feel like there must be a better way. TRAINEE: Although you’ve found 12 step meetings to be a big commitment, you have found them to be helpful for you. At the same time, you’re wondering if another program might be a better fit for you at this point in your recovery.

Stage Three: Recognizing and Reinforcing Change Talk During MI encounters, it’s key for trainees to consciously focus and guide the session with a specific goal in mind. This goal is often related to behavior change, such as decreasing alcohol use or increasing diabetes management behaviors. The trainee is tasked with the goal of helping the patient resolve ambivalence around and elicit motivation for change. To reinforce change talk, however, trainees first need to be able to recognize it. Change talk is usually expressed as desire, ability, reasons, and need (DARN) and commitment, activation, and taking steps (CAT) statements, which we refer to as DARN CAT. When the trainee observes the patient engaging in change talk, it’s important to reinforce this. Don’t stop with one reflection, though; keep probing for further change talk by using your OARS! This approach continues the process of eliciting additional change. Desire: “I would really like to make healthier choices when it comes to my diet.” Ability: “I’ve been successful in reducing my drinking in the past.” Reasons: “I want to be more active so I can play with my grandchildren more.” Need: “I need to start taking my medication consistently.” Commitment: “I am going to start exercising.” Activation: “I have been thinking a lot about finding a therapist.” Taking steps: “I started tracking how much I’m smoking yesterday.”

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Reinforcing change and minimizing sustain talk is important because increased change talk leads to increased commitment language and increased commitment language paired with reduced sustain talk directly predicts behavior change (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2013). Thus, trainees must be able to accurately recognize and reinforce change talk.

Stage Four: Strengthening Change Talk Once the trainee can actively elicit and reinforce change talk, this change talk must be strengthened in the direction of commitment language. Frequent change talk on the part of the patient signals to the trainee that they’re on the right track, but it does not guarantee commitment language. Using OARS is one effective way to facilitate the shift toward eliciting more commitment language (e.g., “How might this change positively impact your well-​being?”). Again, change talk leads to commitment language, and commitment language increases the likelihood of behavior change. Stage Five: Responding to Sustain Talk—​“Rolling with Resistance” In the next stage, trainees must learn how to roll with, rather than oppose, resistance or counter-​change arguments. To roll with resistance is to strike the balance between not eliciting sustain talk but also not dismissing it. Instead, the trainee learns to allow and accept sustain talk. By attempting to oppose the patient’s sustain talk, we tend to reinforce it, and it can come back stronger in the form of resistance, thus decreasing the likelihood of behavior change. Instead, trainees can shift their approach away from opposition and instead roll with resistance by using strategies such as selective reflections, reinforcing autonomy, reframing, and coming alongside the patient.

Stage Six: Developing a Change Plan As MI progresses, most patients will increase their change talk, which, in turn, increases the chances for commitment language to emerge. Once change talk is adequately strengthened, it’s time to start eliciting a change plan. However, this transition is far from straightforward. The major challenge of stage six is determining the patient’s readiness to move from change talk to planning. The trainee must be careful here because premature attempts to start planning can evoke resistance, setting the changes process back a step, and prolonged exploration of motivations for change can be counterproductive. Thus, the

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trainee must carefully time this transition and be prepared to roll with resistance if it should it arise. Remember, it is the patient who decides on the “right” timing, not the trainee. Reflections are useful for determining whether a patient is ready to engage in planning. For example, “You have been talking a lot about wanting to make these changes in your life and, at the same time, it’s unclear whether you want to discuss what might work for you and how you might plan to get started. Help me understand where you’re at with this.” Transitional summaries of change talk followed by an open-​ended question that prompts the patient to discuss change plans can also be effective. “You’ve mentioned how changing your smoking habits would help you feel healthy enough to start running and playing with your grandchildren more. It would also improve your quality of life, which you’ve shared is an important goal of yours at this time. What do you think about using this time to brainstorm a few things that you could introduce into your lifestyle to help you get there?” Such strategies can be used to evaluate a patient’s position and carefully time the transition to planning.

Stage Seven: Consolidating Commitment Language It’s imperative that trainees do not stop at coming up with a change plan. The major task of stage seven is therefore to bolster the patient’s commitment to the plan, maintaining the momentum toward change. Here, the trainee will evoke and reinforce commitment language, often using reflections and summaries related to the patient’s own change talk and plan. This is important because once a plan is discussed, it can be detrimental to revert back to eliciting motivation for change because it allows opportunities for sustain talk to emerge. Thus, the trainee must remain focused on moving toward the behavior change through the consolidation of commitment language rather than moving away from it. It can be helpful to remember that this is the patient’s change plan and the patient “owns” it, as an additional way to consolidate commitment language.

Stage Eight: Incorporating Other Therapeutic Modalities MI was never intended to exist in isolation or serve as a long-​term therapeutic approach. As patients move toward their own action plans and ambivalence is reduced, behavior-​change treatment works optimally when MI is integrated

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with other therapeutic modalities, such as cognitive behavioral therapy or acceptance and commitment therapy. Thus, in this stage, the trainee learns how to flexibly shift away from MI to other treatment approaches. We emphasize flexibility here because there may be times where the patient expresses ambivalence or resistance while engaged in other treatment approaches. This can serve as a signal to the trainee to switch back to the MI style.

STRUCTURAL FRAMEWORK OF MI TRAINING The structural framework of MI training provides a guide for trainers and trainees who wish to engage in or facilitate the learning process. The eight stages of learning MI serve as the “what,” and the structural framework of MI is the “how.” The framework includes various methods of training, and it highlights the importance of deliberate practice, using evidence-​based tools for providing feedback, coaching and modeling, and evaluating training outcomes.

Deliberate Practice Deliberate practice describes a set of practices that are associated with improved performance. It is premised on the idea that improvements in performance tend to be realized when people are (a) given a task with a well-​ defined goal, (b) motivated to improve, (c) provided with feedback, and (d) offered ample opportunities for practice and refinements of their performance (Ericsson, 2008). Deliberate practice therefore requires full concentration and attention and is easily facilitated when one already assumes the growth mindset. We argue that deliberate practice is key to MI training and that without it, results will rarely be maintained over time.

Methods of Training There are many ways in which MI can be learned ranging from independent readings to lectures to experiential exercises to workshops. Each of these approaches, which can be roughly organized from low-​to high-​immersion experiences, have their own strengths and weaknesses. Thus, we view these training methods as complementary and also insufficient in isolation. To be most effective, each method, regardless of immersion level, must have clear-​ defined learning goals.

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Low Immersion: Independent Readings and Lectures At the low end of the immersion continuum are independent readings and lectures. In our experience, it is best to focus readings on shorter, succinct, and relevant research and practice articles. Learning is bolstered when readings are accompanied by discussions that include personal reflections and end with “action steps” that articulate how the information can be applied to one’s own practice of MI. Similarly, lectures tend to be most useful when they are specific to the audience and permit ample opportunities for trainees to comment or ask questions. Lectures are especially beneficial when they include case examples, especially in the form of video recordings of patient interactions. Moderate Immersion: Skill-​Building Workshops Workshops provide an accessible, moderate-​immersion option for learning MI, which makes them quite common. This method typically consists of a variety of components including lectures, discussions, and interactive skills practice sessions. Indeed, the workshop format can be effective in helping trainees foster awareness, knowledge, and skills in MI. We recommend a “learning to learn” approach whereby the workshop focuses on how to better understand the spirit and assumptions of MI and become a lifelong learner of MI through one’s patient, rather than on how to acquire MI-​specific skills. This, again, is consistent with fostering a growth mindset among trainees. High Immersion: Role Play and the Use of Standardized Patients There is a strong precedent for the use of role plays and standardized patients (“real plays”) in training medical trainees to improve communication skills. Role plays are interactions between colleagues where one acts as the patient and the other as the trainee. Real plays typically use real actors to play the patient and are typically unknown to the trainee. Both have different advantages and disadvantages. For example, role plays give trainees more control over the practice scenarios, whereas real plays more accurately simulate potential patient interactions. In either case, we find these types of high-​immersion training methods are beneficial both for honing MI skills but also for understanding the patient’s experience after the interaction. Feedback As highlighted by the idea of deliberate practice, feedback is key to improving performance and maintaining improvements over time. Thus, it is important for trainees to maintain a position of openness to feedback and to have ample opportunities to receive feedback as part of the learning process. Trainees can sometimes find feedback to be aversive, so it’s important to view it through

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the lens of helping to improve performance through increased awareness of our communication and behavior in each interaction. We also suggest that trainees’ audio-​record or videotape themselves. It can be a humbling experience to view or hear yourself because we often overestimate our skills and can exhibit MI nonadherent behaviors without realizing it. It is critical to be continuously reflecting on and self-​assessing your own skills and to ensure that you receive objective feedback. We recommend the use of both, given research demonstrating that trainees tend to overestimate their skills and there is a limited correlation between self-​reported skills and patient outcomes (Miller & Rose, 2009). Evidence-​Based Tools for Providing Feedback Given the importance of ongoing feedback in MI, we recommend the regular use of evidence-​based tools in the evaluation of trainees. The following is a brief overview of the most practical tools. Motivational Interviewing Treatment Integrity Coding Manual 4.1 (MITI 4.1) The MITI 4.1 (Moyers, Manuel, & Ernest, 2014) is one of the most used tools for assessing MI adherence and for providing feedback to the trainee. It includes (a) specific MI-​relevant behavior frequency counts and (b) four global scores meant to assess the entire interaction. Behaviors counted include affirmation and giving information, whereas global scores include cultivating change talk, softening sustain talk, partnership, and empathy. This information can be combined into summary scores that reflect difference aspects of competence such as technical and relational competence. Motivational Interviewing Supervision and Training Scale (MISTS) The MISTS (Madson, Campbell, Barrett, Brandino, & Melchert, 2005) is a two-​component measure that was designed to (a) provide a behavioral frequency count of skills consistent with MI and (b) assess the quality with which the intervention is delivered. Behaviors counted include, for example, open-​ ended question, simple reflection, and affirmation. Intervention quality is assessed with 16 global ratings of the specific active listening skills, specific skills demonstrating the spirit of MI, and overall therapist ratings. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) Unlike the other tools described thus far, MIA: STEP is a package of tools (Martino, et al., 2006). This toolkit provides several useful assessment resources, including some self-​assessment skill summaries. Most important

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to our discussion, however, is the interview rating guide, which provides supervisors and trainees with a systematic way of monitoring individual MI adherence and competence. Adherence is assessed through evaluating frequency and extensiveness (i.e., depth or detail) of specific MI interventions or skills (e.g., open-​ ended questions, collaboration, and reflections). Competence is assessed through global ratings of the trainee’s skill level on each MI intervention or skill. Helpful Response Questionnaire (HRQ) The HRQ (Miller, Hendrick, & Orlofsky, 1991) is a brief, open-​response questionnaire that presents six standardized case scenarios. To evaluate MI skills, trainees are instructed to provide MI-​consistent responses. Responses, which can be provided verbally or in writing, are then rated for the occurrence or absence of MI-​consistent responses. The HRQ can be administered and scored in 10 to 15 minutes. Behavior Change Counseling Index (BECCI) Behavior Change Counseling (BCC) is an adaptation of MI primarily employed in healthcare settings. It is designed to help patients explore the “how and why of change” and help them understand how their perceptions affect behaviors and choices related to behavior change. The primarily difference between BCC and MI is that MI is focused on eliciting change talk and developing discrepancy, whereas BCC is focused more on listening and understanding the patient’s perspective in order to determine how to best guide the patient to behavior change. The BECCI was designed to evaluate BCC practice. It is a 12-​item scale that intends to measure specific MI behaviors such as eliciting, summarizing, and autonomy support (Rollnick, Mason, & Butler, 1999). The BECCI is the first instrument specifically developed to assess health behavior change within the framework of MI and BCC. Thus, it was designed with the healthcare setting in mind and is therefore relatively brief to complete. Taken together, we view each of these tools as possessing advantages and disadvantages, and the choice of which to use will likely vary widely depending on factors such as the training activity, the setting, and time constraints. We have found the MITI to be a great tool for reviewing key areas in MI with supervisors and trainees; however, it provides detail and time constraints that limit its practicality. As such, the BECCI may be a better assessment tool for everyday use in a healthcare environment, with the MITI being available for observed clinical interactions in a more structured setting for coaching and feedback purposes. The BECCI has been our choice for our MI curriculum as it is brief and easily scored, with good interrater reliability and relevance to

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the healthcare setting. We have also added a qualitative piece to the BECCI to give our supervisors more flexibility in providing feedback.

Coaching and Modeling Taking advantage of opportunities to receive coaching and observe the more advanced mentors practicing MI is an invaluable and fundamental learning opportunity. Although the MI skills can be learned and practiced in relative isolation, coaching and modeling allow one to observe the more nuanced aspects of MI including body language, facial expressions, and tone of voice, which are especially important for advancing through the stages of learning MI. Such opportunities also allow the trainee to adopt and “try on” different ways of doing and being MI, which can further enrich the learning experience. We also view the choice of coach or mentor as especially important. Working with mentors who are open about their process and transparently share their own difficulties in learning and practicing MI can be especially helpful as trainees.

Training Outcomes The goals of training in MI are twofold. The first goal is to demonstrate competency in the optimal use of skills in practice and facilitate the long-​term retention of such skills. The second goal is to demonstrate effectiveness in clinical encounters with patient outcomes or behaviors as the primary variable of interest. Toward the first goal, we recommend that trainees and their supervisors regularly engage in a combination of self-​assessments and the use of evidence-​ based tools for evaluating MI fidelity. For the second goal, there is evidence that, after 1 year of MI training, patients of MI-​trained trainees were more motivated to change and had a better understanding of factors that help prevent complications of disease, compared to controls (non-​MI-​trained trainees; Rubak, et al., 2009). As such, although we might expect good outcomes for goal one to have effects on goal two, we also recommend that trainees use structured ways of evaluating patient outcomes to ensure behavior-​change effectiveness, especially when the fidelity is not regularly monitored. As mentioned previously, trainees tend to overestimate their own skills. Therefore, the self-​reported belief that one has learned a technique that has not been learned can be a detriment to both pursuing further training and improving MI-​consistent skills. Down the line, this may be detrimental to the

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patient and affect patient outcomes. Thus, regular outcome evaluation, especially during training, is highly recommended.

CHALLENGES OF LEARNING MI There are numerous challenges that trainees might face when trying to learn MI. The first challenge can be finding a mentor and receiving regular supervision and coaching. As we have detailed elsewhere, we see this as a key learning process, yet it is potentially one of the most difficult to acquire because of the availability of mentors or other factors. The second challenge is time. Medical trainees have very little time which can make learning MI feel like a lower priority or not worth the investment. Confronting and addressing this belief can be difficult, but, in our experience, it pays off for both the trainee and their patients. We highly recommend that training programs and mentors incorporate MI training experiences into the standard curriculum. Third, deliberate practice of MI requires introspection and a willingness to accept feedback and change one’s own behaviors. This personal change process is rarely linear and can make it difficult to fully engage as a trainee, especially if the trainee doesn’t adopt a position of openness and a willingness to make mistakes during the process. On a positive note, we view these challenges as relatively amenable. There are many resources available to trainees that can help them address these challenges as they arise, including, for example, a large network of mentors spread out nationally and internationally who might be able to help with supervision virtually or otherwise.

MOTIVATIONAL INTERVIEWING NETWORK OF TRAINEES (MINT) In an effort to centralize MI training and resources, the Motivational Interviewing Network of Trainees (MINT) was established in the 1990s. The overall goal of the organization is to improve the quality and effectiveness of therapeutic approaches for behavior change. MINT held its first meeting in 1997 and has since grown to represent trainees from 35 countries and more than 20 different languages (per the MINT website). The MINT is composed of a group of individuals with specialized training and competency in the practice and dissemination of MI. It has developed rapidly into an international organization with a diverse group of trainers who apply MI in a variety of settings. The MINT promotes the use of MI and advocates for the practice of

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MI through sponsored research, education, and training. Resources, communications, publications, and other shared practice opportunities are disseminated through their website, www.motiv​atio​nali​nter​view​ The MINT has an annual meeting alternating with both a national (US) site and an international site with Train the Trainer workshops. Admittance to workshops is competitive, as it is based on merit and availability. The annual meeting also holds several didactic plenary sessions and small group workshops presenting new data on the practice of and training in MI.

PERSONAL REFLECTION: MY EXPERIENCE WORKING WITH MEDICAL TRAINEES (Cassandra Boness) I am a clinical psychologist by training. During my clinical internship, which is akin to a medical residency, I had the opportunity to work with medical trainees, including fellows, residents, and senior medical students. In my encounters with medical trainees, I observed several different behaviors and assumptions that made trainees more or less successful at learning MI. The most successful medical trainees, meaning those that were most able to practice the MI spirit and skills, were those that entered the training experience with openness and a willingness to learn. These trainees believed they might have something to gain from MI, and, as a result, they often flourished. I saw many trainees shift from viewing patients as individuals with deficits in need of fixing to viewing patients as bringing important experiences to the table and, therefore, taking the time to slow down and understand their perspectives. Those trainees that were less effective in their MI training tended to come in less open. They were inclined to engage in the righting reflex, assuming the position of an expert who knows best for their patient. This typically resulted in a cold and ineffective clinical encounter and often meant the trainee was less willing to receive feedback from the team. Indeed, it was a willing and collaborative position that allowed medical trainees to excel in their MI training and become more confident in their own clinical encounters. Such a position is consistent with the “learning to learn” and growth mindsets, which we’ve put forth as key to learning MI in this chapter.

CONCLUSION This chapter has covered a significant amount of information regarding learning and experiencing MI. As such, we want to take an opportunity to remind trainees that they do not have to do everything flawlessly during a patient encounter. Because MI places the responsibility of change on the patient,

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the trainee is merely there as a guide in the process. This should free trainees from the pressure of having to always have the right answers or MI skills at their fingertips. By keeping our expectations for patient encounters realistic and liberating ourselves from having to have all the answers or “fix” the patient, we become more willing and open and, as a result, are freer to “dance” with the patient. This brings us back, once more, to the discussion of the growth mindset. By approaching MI with a desire to learn, we are better able to embrace challenges and learn from feedback.

SELF-​ASSESSMENT QUIZ True or False 1. MI is best learned and practiced with the supervision and coaching of a mentor who is experienced in MI. 2. The spirit of MI comes last, after a trainee has mastered other skills and techniques. 3. Reflections are only used to demonstrate to the patient that the trainee has been listening. 4. “I need to quit using heroin because I want to be around for my kids and even my grandkids” is an example of “desire” change talk. 5. When a trainee hears change talk, it is important to move quickly to commitment language, to not lose momentum. 6. Once a patient has begun to share commitment language, it can be detrimental to continue exploring motivation for change. 7. There is a strong, positive correlation between a trainee’s self-​reported skill and patient outcomes. 8. The MINT is a source for education and training in MI.

Answers 1. True. A key process of learning MI is to find a mentor who can guide the learning process and can offer feedback on a trainee’s sessions. A proper mentorship also offers a pause to the hurried accumulation of techniques that can derail trainees, as well as offering honest perspective on the progress of a trainee’s skills. 2. False. Understanding the spirit of MI is a fundamental step as trainees begin their MI training. A solid grasp of the spirit makes MI digestible and provides a foundation for the cumulative process of learning

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it. Additionally, the spirit of MI offers a context and fits well with an individual’s role as a medical trainee. 3. False. While reflections can demonstrate to a patient that a trainee has been actively listening, they also express empathy, enhance patient confidence, reinforce collaboration, convey compassion, develop discrepancy, and increase expressed emotions for change. 4. False. This statement is an example of “need” change talk. Recall the helpful acronym DARN CAT (i.e., desire, ability, reason, need, commitment, activation, and taking steps) to categorize types of preparatory and mobilizing change talk. 5. False. While change talk provides a great feeling of confidence and cues trainees that they are on the right track, it is important to remember that change talk does not equal commitment language. It can be hazardous to jump too quickly from early change talk to commitment language. 6. True. When a trainee hears commitment language, it is important to allow for a smooth transition and support the momentum. By revisiting motivation for change after a patient has clearly demonstrated commitment language, a trainee runs the risk of making the patient regress to expressing sustain talk. 7. False. In studies of patient behaviors, observed, audio-​recorded or videotaped assessments of skill are more reliable than self-​assessments. Another study demonstrated that trainees’ self-​reports overestimated their skills and that there is a limited correlation between self-​reported skill and outcomes. 8. True. The MINT is an international organization of diverse trainers who specialize in the practice and training in MI. The focus of the organization is to improve the quality and effectiveness of counseling as it relates to behavior change. The MINT promotes the use of MI and advocates for MI practice through research, education, and training.

REFERENCES Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client commitment language during Motivational Interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 71, 862–​878. Dweck, C. (2012). Mindset: How you can fulfill your potential. Constable and Robinson. Ericsson, K. A. (2008). Deliberate practice and acquisition of expert performance: A general overview. Academic Emergency Medicine, 15(11), 988–​994.

Learning and Experiencing MI  375 Madson, M. B., Campbell, T. C., Barrett, D. E., Brondino, M. J., & Melchert, T. P. (2005). Development of the Motivational Interviewing supervision and training scale. Psychology of Addictive Behaviors, 19(3), 303–​310. Martino, S., Ball, S. A., Gallon, S. L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C., Hamilton, J., & Hausotter, W. (2006) Motivational Interviewing assessment: Supervisory tools for enhancing proficiency. Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University. Miller, W. R., Hedrick, K. E., & Orlofsky, D. (1991). The helpful responses questionnaire: A procedure for measuring therapeutic empathy. Journal of Clinical Psychology, 47, 444–​448. Miller, W. R., & Moyers, T. B. (2007). Eight stages in learning Motivational Interviewing. Journal of Teaching in the Addictions, 5(1), 3–​17. Miller, W. R., & Rose, G. S. (2009). Toward a theory of Motivational Interviewing. The American psychologist, 64(6), 527–​537. Moyers, T. B., Manuel, J. K., & Ernst, D. (2014). Motivational Interviewing treatment integrity coding manual 4.1. Unpublished manual. Accessed 2015. http://​​downl​oad/​ MITI​4_​2.pdf Rollnick, S., Mason, P., & Butler, C. (1999). Health behaviour change: A guide for practitioners. Churchill Livingstone. Rubak, S., Sandbaek, A., Lauritzen, T., Borch-​Johnsen, K., & Christensen, B. (2009). General practitioners trained in motivational interviewing can positively affect the attitude to behaviour change in people with type 2 diabetes: One year follow-​up of an RCT, ADDITION Denmark. Scandinavian Journal of Primary Health Care, 27(3), 172–​179.

23 Integration of Motivational Interviewing in Medical Training Laura Marengo and Neeta Shenai

With approximately 60% of Americans afflicted with a chronic health condition (Buttorf, Ruder, & Bauman, 2017), trainees must learn how to work with patients engaging in maladaptive health behaviors and facilitate change regardless of their intended specialty. Many maladaptive and modifiable health behaviors, such as unhealthy diet, sedentary lifestyle and being inactive, and excessive alcohol use, with their resultant health risk factors such as elevated blood pressure, high cholesterol levels, and weight gain, can significantly affect disease burden. Motivational Interviewing (MI) is a patient-​ centered, collaborative approach designed to help patients address their maladaptive health behaviors and facilitate change. MI has a solid evidence base that supports its application across a variety of health behaviors and medical conditions (Lundhal, et al., 2013). Since MI can be effectively taught in medical schools (Kaltman & Tankersley, 2020), it is optimal to integrate MI training into medical school curriculums and in other healthcare professions training in general.

SHOULD TRAINING IN MI BE INTEGRATED IN MEDICAL TRAINING? Effective communication is a universal skill that is important for practitioners across all specialties. Though there is substantial research that communication or counseling about lifestyle modifications can improve chronic conditions such as cardiovascular disease and diabetes, practitioners report a self-​ perceived lack of skill in influencing behavioral change (Keyworth, Epton, Goldthorpe, Calam, & Armitage, 2020). A 2002 survey of medical students identified a belief that, with respect to behavior modification counseling, the patient would not be adherent to physician recommendations (Foster, et al.,

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2002). A lack of confidence in addressing behavior change, combined with the commonly preconceived belief that patients are unlikely to adhere to physician advice, can lead to avoidance of topics pertaining to behavioral modification during patient encounters or, worse yet, to an approach that is perceived as confrontational by the patient (Frates, Xiao, Simeon, McCargo, Guo, & Stern, 2016). MI can bridge this gap and improve patient outcomes, practitioners job satisfaction, and decrease burnout (Pollak, et al., 2016). Below, two practitioners at different levels of training and in different specialties reflect on the ways in which MI has played a role in their career thus far. The first is a postdoctoral research fellow in his first-​year postgraduation, and the second is an attending physician in the Division of General Internal Medicine. I find reflective statements very helpful. In surgical specialties, things can easily feel very black and white, at least when you’re first learning. We are trained to focus on “What is the problem? What is the solution?” This can lead to ineffective history taking and a communication style in which you ask too many leading questions. The spirit of MI helps you understand more than just what pathology ails someone, but where the patient is coming from, which can help dictate treatment. On more than one occasion, patients have thanked me for “spending so much time” with them when I did not spend more than 10 minutes in the room. I think that it is just because they feel heard (Kevin Byrne, MD). MI offers a general approach to addressing nearly any behavior that is focused on the individual experiences, thoughts, feelings, wants, and wishes of our patients. It provides a versatile skill set that I rely on regularly in discussions with my patients about everything from smoking to blood sugar control to, more recently, receiving a novel vaccine to help address a global pandemic. In this way, MI is a philosophy and a skill set that helps me to be a better and more effective physician for my patients (Andrew Klein, MD).

Both practitioners learned MI in their medical student curriculum and clinical training and pursued careers outside of psychiatry. As MI is a complex skill, continued education through residency has been shown to increase knowledge and confidence (Miller-​Matero, Tobin, Fleagle, Coleman, & Nair, 2019). Thus, training in MI for medical students, residents, and fellows can be and should be integrated into the curriculum.

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MI EDUCATION IN MEDICAL SCHOOL AND TRAINING PROGRAMS Over the last 20 years, training in MI has been present in medical education curriculums (Brown & Oriel, 1998), with numerous studies providing evidence that medical students can achieve preliminary proficiency. In addition to developing proficiency in MI, studies have shown the impact of training on the perception of patients (Pollack, et al., 2011). In fact, a recent study demonstrated that simple interventions to teach MI to practitioners and staff via a coaching model in outpatient clinics improve practitioner/​staff satisfaction, team cohesions, perceived MI skills, and patient satisfaction (Pollak, et al., 2016). Even short trainings such as 4-​hour MI workshop showed a significant positive effect on medical students’ knowledge, skills, and confidence (Gecht-​ Silver, Lee, Ehrlich-​Jones, & Bistow, 2016), Similarly, researchers showed equivalent changes in student confidence and knowledge outcomes in a 2-​ hour training (Martino, Haeseler, Belitsky, Pantalon, & Fortin, 2007). This can be a promising approach toward preparing future practitioners to grow in the ever-​changing healthcare environment. Overall, longitudinal experiences with increased repetition and exposure to practice sessions are suggested to have the most impact on skill acquisition (Kaltman & Tankersley, 2020). However, the year in which MI training is scheduled within the curriculum, the length of intervention, the frequency of sessions, and the modality of teaching vary greatly across institutions. In a recent systematic review of MI training within medical schools, 16 studies were identified with heterogeneous curriculums (Kaltman & Tankersley, 2020). The timing of MI training within medical education differed across studies, with some implementing training in the preclinical years and others during clinical clerkships. Further, there was variability within the specific clerkship in which the training was given. Some curriculums focused content into one session, while others incorporated skill building through multiple sessions. Additionally, teaching modalities were varied and included the use of lectures, small groups, interactive exercises, videos, and skill practice. A blended learning training approach using classroom-​based lessons, video materials including role plays, and a consultation with a simulated patient, can be delivered to help trainees develop skills in counseling patients about behavior change (Keifenheim, et al., 2019). Similarly, curriculums in MI in residencies have variability in approach across specialties. While the majority of the literature focuses on efficacy of lengthier trainings (e.g., 2.5 to 12 hours), briefer trainings have also been found to increase knowledge and confidence (Miller-​Matero, Tobin, Fleagle,

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Coleman, & Nair, 2019). Regardless of length of training, experiential learning through in vivo coaching and ongoing feedback have been found to be the most effective in trainees gaining proficiency in MI (Kaltman & Tankersley, 2020; Miller-​Matero, Tobin, Fleagle, Coleman, & Nair, 2019).

PERSONAL REFLECTION (Laura Marengo) While I struggle to remember most lectures I attended as a medical student in my pre-​clerkship years, I distinctly remember my introductory lecture on MI. This is because this particular lecture differed in structure from most other medical school lectures I had attended, in which professors would simply lecture at the students for a couple of hours with the use of a PowerPoint presentation. During the presentation, after a brief explanation on what MI entails and a description of its skills OARS (open-​ended questions, affirmations, reflections, and summaries), a familiar song began to play from the lecture hall speakers: I hurt myself today To see if I still feel I focus on the pain The only thing that’s real

As we sat listening to the lyrics of “Hurt” (originally sung by Trent Reznor), we were informed that Johnny Cash would serve as our make-​believe patient for the remainder of the lecture. Early in the song, Cash’s struggle with addiction and his resulting feelings of hopelessness are palpable. While we were imagining that Mr. Cash was there with us, sitting in the lecture hall, the song was paused, and we were asked to take turns practicing MI. Open-​Ended Question: “What would life look like if you were free from the clutches of your addiction?” Affirmation: “You are very courageous to share these emotions so openly with us.” Reflection: “You’re in a tremendous amount of pain and you don’t recognize the person you’ve become.” Summary: “You believe that your suffering and your addiction have left you unable to maintain meaningful relationships with those you love.”

After providing us the opportunity to practice our new skills, the music resumed. Now, explained the professor, we could hear the impact that

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our MI skills had on Mr. Cash, as his words morphed from sustain talk to change talk: If I could start again A million miles away I would keep myself I would find a way

Obviously, our MI skills did not actually account for the progression of the song. Still, it was a memorable and engaging introduction to the valuable, evidenced-​based way of interacting with patients through MI, an approach and “a way of being” that I was fortunate to have the opportunity to practice daily during my third-​year clerkship on an inpatient dual-​diagnosis unit. However, as was previously mentioned, students across different medical schools—​and even those within the same program but at different clerkship sites—​will be exposed to highly variable educational resources and opportunities with respect to MI during their training. MI is a complex approach with a particular communication style, language, and skills, and understanding how to best teach this content is an area which requires further standardization and research. While anecdotal evidence may provide some clues regarding successful strategies for incorporating MI training within medical education, further research is needed to examine ideal approaches of retention and maintenance of the MI skills.

COMMON STRUGGLES FOR THE LEARNER The “Unconfident” Learner Each Liaison Committee on Medical Education (LCME)-​accredited medical school in the United States uses objective structured clinical examination (OSCE) in order to evaluate its students’ clinical skills. In the earlier years of their medical education, students are commonly told to prepare for these OSCE by learning to ask a defined set of questions necessary for a complete history. As such, students are often graded using an itemized rubric of standard medical interviewing questions and a limited number of concretely defined skills, such as the one seen in the table below (A =​performs correctly; B =​performs but incorrectly; C =​does not perform). Unfortunately, while these questions and skills may indeed be necessary, they may not

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always be sufficient to obtain an effective history that is tailored to a given patient’s unique needs and is consistent with the spirit of MI (Table 23.1). In their first and second year of medical school, students grapple with learning a torrential number of facts relating to anatomy, physiology, and pharmacology. At the same time, they are also tasked with keeping a mental representation of such checklists in their minds as they begin interacting with patients. The memorization-​heavy demands of these early didactic years do not lend themselves easily to the nuances of MI, which, in addition to being rooted in science, is also an art. For a group of students who struggle disproportionately with self-​doubt, who tend to be particularly harsh in their self-​assessment (Henning, Ey, & Shaw, 1998), and who are relatively new to patient interviewing, the thought of going beyond the check-​list in order to integrate MI into their practice may seem daunting. One first-​year medical student expressed such a sentiment perfectly, when they said, “It’s really hard for me to tackle a patient’s problem using MI because I feel like I’m not even qualified to make recommendations in the first place.” This student is missing the point of MI which is not to “tackle” patients’ problems and “make recommendations” but to understand where patients are coming from, their goals, values, and beliefs, and how their current behaviors will facilitate or be a barrier to reaching their goals or living out their values and beliefs. While facilitating small group sessions aimed at providing students with the opportunity to practice their MI spirit and skills with standardized patients, I have found it helpful to broach this lack of confidence with students directly. This can be done by reassuring students that it is OK—​in fact, that it is normal—​to feel awkward while working to develop one’s skills. I let them know that, even as a medical student 3 years their senior, who had been fortunate enough to have had a psychiatry clerkship focused primarily on MI, I still feel awkward when I practice it. I also let them know that I have spoken with faculty who are leaders in the realm of MI, who continue to “deny being MI experts,” as there is always more to learn. This has seemed to alleviate some tension and hesitation from students, building their confidence and allowing them to take more risks in their interactions with the standardized patients. In my experience, reminding students that it is not about “doing MI,” but instead about “being MI” and about approaching the patient with a mindset of acceptance and compassion (focusing more on the spirit of MI) goes a long way in supporting them in having the confidence necessary to take chances as they practice their skills.

382  Motivational Interviewing, 2E Table 23.1  Evaluating Clinical Skills from the Objective Structures Clinical Examination (OSCE) Assessment Form Chief Complaint A



Item number 6

Obtains chief complaint in the patient’s own words

History of Present Illness: Obtains Information About the Principal Symptom(S) A B C 7 Location A B C 8 Quality A B C 9 Quantity or severity (using numerical scale) A B C 10 Circumstance of onset (initially if continuous or at beginning of episodes) A B C 11 Total duration of illness A B C 12 Episode duration A B C 13 Episode frequency A B C 14 Symptom progression A B C 15 Aggravating factors A B C 16 Relieving factors A B C 17 Associated symptoms A B C 18 Patient’s response to this illness (e.g., functional impairment) A B C 19 Asks what the patient thinks is going on Medical History A B C A B C A B C A B C

20 21 22

Any current and prior medical illness Prior hospitalizations Any prior surgeries Acknowledges health maintenance (looks at sheet provided)

Current Medication A B C A B C

24 25



26 27 28

Asks about current prescription medications with doses Asks about nonprescription medications (e.g., vitamins, herbals, and Over The Counter) Asks about allergies to medications Asks what the symptoms of the allergic reaction are Asks about nonmedication allergies (ex+​food, seasonal allergies)


29 30 31 32 32 34


Social History A B A B A B A B A B A B

Asks about home situation Asks about educational status Asks about employment (at least current) Assesses tobacco use (past and/​or present Asks if consumes alcohol past or present Clarifies amount of alcohol: How many per day? How many per week?

Integration of MI in Medical Training  383 Table 23.1 Continued A A A A A



35 36 37 38 39








41 42 43

Family History A B C A B C

44 45

Asks about illicit drug use Asks about gender identity Asks if patient is married or in relationship Asks if patient is sexually active in relationship Asks if patient is sexually active outside of relationship (or sexually active if not in a relationship) Asks if patient is sexually active with men, women or both outside relationship Asks if has any problems with sex Ask about contraception if relevant Screens for intimate partner violence if in relationship Asks about ages and health of first-​degree family members Asks about illness that tend to have familial occurrence (e.g., diabetes, heart disease, cancers)

Review of Systems (See “Chart”) A B C 47 Uses open-​ended questions as primary way to obtain data A B C 48 Allows patient to talk without interrupting A B C 49 Is nonverbally attentive (e.g., leaning forward, nodding, and making eye-​contact) A B C 50 Uses active listening skills (e.g., summarizing, reflected the story back) A B C 51 Uses appropriate nonmedical language (avoids jargon) A B C 52 Remains nonjudgmental, respectful, and supportive A B C 53 Names patient’s emotional state/​concerns (e.g., “That must be scary.”) A B C 54 Uses silence appropriately (gives the patient time to answer/​think) A B C 55 Makes transition statements between sections of the interview Encounter Closure A B C A B C

56 57

Asks what final questions the patient has Summarizes problems

A = Performs correctly, B = Performs but incorrectly, C = Does not perform.

The “Perfectionist” Learner In addition to concerns surrounding skill level, the “righting reflex” is another major challenge for trainees to overcome as they learn to implement MI: the righting reflex is the impulse to immediately provide a patient with suggestions to “fix the problem.” Here, we discuss an example in which

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students were read the following scenario prior to interacting with a standardized patient: You are on your third-​year rotation at an outpatient clinic. Your preceptor asks you to see Mr. Dixon, a 35-​year-​old man with a history of hypertension and depression. One week ago, the patient was seen in the Emergency Department after a car accident. His injuries were minor, but his blood alcohol level was 0.15 (legal limit 0.08). The patient has no Primary Care Provider (PCP) and was referred to your preceptor to establish care. Vital signs are notable for a blood pressure of 150/​100. Your preceptor suggests you check to see if alcohol is really “a problem” for the patient, and if so, to assess readiness to quit.

When the medical student began to ask the patient about his drinking behavior, the patient became defensive, minimizing his alcohol use and the consequences he has experienced as a result. He rated the importance of change as a 3/​10. Both the medical student practicing his skills and the other students in the group who had been observing the interaction had several questions relating to this scenario, given the severity of the described consequences of Mr. Dixon’s drinking. STUDENT A: How direct should we be with patients? If the patient does not have “insight” into the fact that their behavior is problematic, I am worried the conversation will become circular. How do we get to the problem? STUDENT B: How do you balance the urgency of the needed change with building rapport? In this case, his drinking may have contributed to a motor vehicle accident. How do we balance helping Mr. Dixon see the need for change with meeting him where he is at?

Both questions stem from a common and well-​intended phenomenon among both trainees and healthcare professions, which was referenced earlier in this textbook: the righting reflex. The righting reflex is mutually exclusive from the spirit of MI. It can be so tempting to believe that by simply listing and explaining the consequences of the patient’s drinking behavior (and trying to win an argument of the need to change) or even using scare tactics, the patient will just realize “yes, that is why I need to change.” Of course, it is important to discuss the facts about the patient’s situation, at the same time, the directive approach (expert/​recipient) can lead to discord in the relationship, jeopardize the therapeutic alliance, and become a “losing argument.” As an alternative, in MI (partnership) the facts are discussed using the Elicit-​Provide-​Elicit

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(E-​P-​E) framework. This way, the trainee using the MI guiding style avoids persuading the patient with predigested and simple health behavior messages and focuses on a personalized approach, respecting and supporting his autonomy, his right to make decisions about his own behavior. Another example of the righting reflex can be seen in the following encounter: You are on your family medicine rotation at an outpatient clinic. Your preceptor asks you to see Ms. Jones, a 48-​year-​old woman who has high cholesterol and a family history of heart disease and diabetes. A few months ago, routine blood work revealed a fasting glucose of 115, which indicates significant diabetes risk. At that visit, the PCP advised the patient to lose weight without exploring level of readiness for change. Since that visit, the patient gained 10 pounds. Your preceptor suggests you use a different approach to help her to lose weight.

Ms. Jones remembers that her PCP had told her she should count calories and stop eating fried foods and desserts entirely. She has childcare responsibilities; her family is financially stressed; and she doesn’t have many supports. She is visibly frustrated with practitioners who don’t understand how hard it is to lose weight. The primary challenge that Ms. Jones expressed is that she does not believe she is capable of losing weight. TRAINEE: How do you balance being encouraging without being overly optimistic? If we arrive at a realistic yet small change, how do we make sure the patient understands that while this is a positive step, it isn’t enough to lead to significant weight loss?

Again, we see the righting reflex in action. The practitioner was well-​ intended and focused on securing the best possible outcome for the patient. At the same time, she was consequently unable to appreciate that the relationship between the magnitude of her recommendations and the degree to which a patient agrees to commit to change is usually not positively proportional. MI is based on the understanding that the patient’s motivation for change is dynamic. The strategies of MI can be tailored to the particular level of motivation for change addressing both dimensions of motivation: importance and confidence. If the trainee were to communicate acceptance and autonomy support through the spirit of MI and negotiate with the patient to consider a smaller, more achievable behavior change to work on before the next visit (e.g., walking during her lunch hour or cutting down on the number of times she eats fast food or drinking more water), the patient’s confidence in her

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ability to lose weight likely would have increased. This increased confidence would have been in contrast to what occurred following the patient’s previous encounter with her PCP, whose directive and persuasive MI-​inconsistent approach would certainly lead to more weight loss in theory, but in practice resulted in a 10-​pound weight gain.

The “Skeptical” Learner When trainees are first introduced to the concept and skills of MI, they have usually been trained in the more generic interviewing style, which involves asking a set of standardized close-​ended questions to collect a complete history, as demonstrated by the table earlier in this chapter. Trainees are also aware that they will often have a limited amount of time with patients in which to not only gather the relevant history but examine the patient and document the findings. Because MI is often a new and unfamiliar communication style, which most students and some residents have not heard of at this point in their training, and one which may initially seem to require more time and effort, students can sometimes be skeptical of MI—​or even “resistant” to it. In one workshop during which a small group of students were practicing their MI skills, one said, “In the most respectful way of asking this question, does this actually work or are we just saying things to say them?” While it is obviously important to teach the what and the how of MI, it is equally important to underscore the “why”—​to let them know that this is not only a way of meeting patients where they are and allowing them to truly feel heard, but also an evidence-​based method of effecting real change in patient behavior. Much of this evidence (Hettema, Steele, & Miller, 2005; Miller, 2000; Rubak, Sandbaek, Lauritzen, & Christensen, 2005) has been discussed in earlier chapters. Still, it is important to stress the importance of not glossing over the evidence when teaching trainees about MI, and reinforcing the concept that, yes, this really does work.

CONCLUSION As effective patient-​centered communication is a core component in the practitioner-​patient interaction, MI is an essential approach for medical trainees and should be integrated in the curriculum. There is a lack of consensus on the optimal timing and specifically effective pedagogies of training, though most studies favor skill-​based interactive practice sessions with feedback and in vivo coaching. While MI is complex, and it presents multiple

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challenges to the trainee, primary proficiency can indeed be achieved. With sufficient training opportunities, trainees report increased confidence in their ability to affect behavioral change.

SELF-​ASSESSMENT QUIZ True or False 1. MI has been shown to only benefit trainees in psychiatry. 2. Longitudinal experiential learning with feedback has been found to be the most effective approach for trainees to gain proficiency in MI. 3. Trainees often struggle with confidence in MI, which can lead to avoidance of discussion of topics related to behavioral change. 4. Trainees who are perfectionists tend to find learning MI easier.

Answers 1. False. MI is an evidence-​based approach to target behavior change, especially in patients with chronic medical conditions, and, thus, it benefits trainees across specialties. 2. True. Experiential training with feedback that occurs over time has been found to be the most effective MI training approach. 3. True. A lack of self-​perceived confidence can lead to avoidance of discussion or in some cases an approach that is perceived by the patient to be confrontational. 4. False. The “perfectionist” learner has unique challenges in learning MI because of activation of the righting reflex.

REFERENCES Brown, R. L., & Oriel, K. (1998). Teaching motivational interviewing to first-​year students. Academic Medicine, 73, 589–​590. Buttorf, C., Ruder, T., & Bauman, M. (2017). Multiple chronic conditions in the United States. RAND Corporation. https://​​pubs/​tools/​TL221.html Foster, K. Y., Diehl, N. S., Shaw, D., Rogers, R. L., Egan, B., Carek, P., & Tomsic, J. (2002). Medical students’ readiness to provide lifestyle counseling for overweight patients. Eating Behaviors, 3(1), 1–​13.

388  Motivational Interviewing, 2E Frates, E. P., Xiao, R. C., Simeon, K., McCargo, T., Guo, M., & Stern, T. A. (2016). Increasing knowledge and confidence in behavioral change: A pilot study. Primary Care Companion CNS Disorders, 18(6). Gecht-​Silver, M., Lee, D., Ehrlich-​Jones, L., & Bistow, L. (2016). Evaluation of a motivational interviewing training for third year medical students. Family Medicine, 48(2), 132–​135. Henning, K., Ey, S., & Shaw, D. (1998). Perfectionism, the impostor phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Medical Education, 32(5), 456–​464. Hettema, J, Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91–​111. Kaltman, S., & Tankersley, A. (2020). Teaching motivational interviewing to medical students: A systematic review. Academic Medicine, 95(3), 458–​469. Keifenheim, K. E., Velten-​Schurian, K., Fahse, B., Erschens, R., Loda, T., Wiesner, L., Zipfel, S., & Herrmann-​Werner, A. (2019). “A change would do you good”: Training medical students in motivational interviewing using a blended-​ learning approach—​ A pilot evaluation. Patient Education and Counseling, 102(4), 663–​669. Keyworth, C., Epton, T., Goldthorpe, J., Calam, R., & Armitage, C. J. (2020). Delivering opportunistic behavior change interventions: A systematic review of systematic reviews. Prevention Science, 21(3), 319–​331. Lundhal, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: A systematic review and meta-​analysis of randomized controlled trials. Patient Education and Counseling, 93(2), 157–​168. Martino, S., Haeseler, F., Belitsky, R., Pantalon, M., & Fortin, A. H. (2007). Teaching brief motivational interviewing to year three medical students. Medical Education, 41(2), 160–​167. Miller, W. R. (2000). Rediscovering fire: Small interventions, large effects. Psychology of Addictive Behaviors, 14(1), 6–​18. Miller-​Matero, L. R., Tobin, E. T., Fleagle, E., Coleman, J. P., & Nair, A. (2019). Motivating residents to change communication: The role of a brief motivational interviewing didactic. Primary Health Care Research and Development, 20, e124. Pollak, K. I., Nagy, P., Bigger, J., Bilheimer, A., Lyna, P., Gao, X., Lancaster, M., Watkins, R. C., Johnson, F., Batish, S., Skelton, J. A., & Armstrong, S. (2016). Effect of teaching motivational interviewing via communication coaching on clinician and patient satisfaction in primary care and pediatric obesity-​focused offices. Patient Education and Counseling, 99(2), 300–​303. Pollack, K. I., Alexander, S. C., Tulsky, J. A., Lyna, P., Coffman, C. J., Dollor, R. J., Gulbrandsen, J., & Ostbye, T. (2011). Physician empathy and listening: Associations with patient satisfaction and autonomy. Journal of American Board of Family Medicine, 24(6), 665–​672. Rubak, S., Sandbaek, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-​analysis. British Journal of General Practice, 55(513), 305–​312.

24 The Ethical Practice of Motivational Interviewing in Healthcare Settings Lisa Forsberg, Isra Black, and Mariel Piechowicz

In this chapter, we examine the ethical case for using Motivational Interviewing (MI) or MI skills in healthcare settings. First, we discuss ethical reasons that favor using MI in healthcare settings. Second, we consider two ethical challenges with respect to using MI in medical practice: the appropriate use challenge and the proficiency challenge. These challenges do not represent a decisive ethical objection to MI use in Medicine, but ought to shape and inform the decision to use MI (and its ongoing practice) in healthcare settings. Our chapter also includes a medical trainee’s insights both on the value of learning MI and the ethical practice of MI. We assume readers have sufficient working knowledge of MI (as described elsewhere in the book), including MI’s core elements and how it is thought to work. We note also that our aim is not to provide a complete, all-​things-​ considered evaluation of the ethics of using MI; rather, our focus is on some of the general ethical considerations that arise in its application and ongoing use in medical practice. We provide suggestions for further reading on the ethics of MI at the end of the chapter.

THE ETHICAL CASE FOR USING MI IN HEALTHCARE SETTINGS MI is a style of communicating with the aim of promoting behavior change. To the extent that the skillful use of MI is successful in bringing about positive behavior change in patients—​for example, improved medication adherence, adoption of healthier lifestyles, the choice of beneficial treatments (Lundhal, et al., 2013; Lundhal, Kunz, Brownwell, Tollefson, & Burke, 2010; Miller & Rollnick, 2013; Project Match Research Group, 1997, 1998)—​there are ethical reasons that favor its use in clinical encounters.

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What do we mean by ethical reasons? For our purposes, an ethical reason is fact or consideration that explains what a person ought to do with respect to some moral (or professional) matter. When we say that there are ethical reasons that favor, or that count against, some practice, we mean that a person ought to (or ought not, as the case may be) do that thing, morally (or professionally) speaking. What are the ethical reasons in favor of using MI in healthcare settings? In the context of healthcare provision, healthcare practitioners have a duty to offer treatments or interventions that are thought to be in their patients’ best interests—​practitioners should offer treatments on the grounds that they are good for patients. The sense of “good” that we have in mind includes the good of health and that of well-​being, for good health is often correlated with well-​ being. So, practitioners have reasons to promote certain kinds of good. And we tend to think of the reasons practitioners have to promote these kinds of good in moral (or professional) terms—​in terms of ethical reasons. Therefore, if the behavior change brought about by MI helps to achieve clinical objectives, we can say there are ethical reasons that favor using MI with patients. We should highlight that the ethical advantages of MI use may go beyond merely helping patients to change their behavior. The person-​centered skills MI requires may be used to elicit and actively listen to important information and concerns that patients may not otherwise volunteer (De Almeida Neto, 2017; Miller & Moyers, 2017). This may facilitate the provision of better treatment: for example, the choice of options that are tailored to a patient’s clinical needs and preferences. Here we might say that the use of MI again promotes patient well-​being—​supportive, empathic care is good for patients (Moyers & Miller, 2013). But we might also observe that another valuable ethical good is in play: that of supporting patient autonomy. MI aims explicitly at respecting, supporting, and reinforcing patient autonomy (Miller & Rollnick, 2013). Thus, using MI in clinical encounters may help to promote patient autonomy. Why should this matter? We have an ethical reason to use MI to the extent that it fosters the instrumental value of autonomy—​involving patients in decision-​making and attending to patient preferences may promote patient well-​being, may help patients feel respected, and may improve patient-​practitioner relations through trust (Pugh, 2020; Sumner, 1996; Tannsjo, 1989; Varelius, 2006). But we may also have reason to promote patient autonomy in healthcare if autonomy has noninstrumental value—​if it is ethically valuable, independent of its realization of other goods such as health or well-​being (Glover, 1990; Hurka, 1987). In many jurisdictions, an important principle of healthcare ethics (and law) is that the final decision with respect to medical treatment rests with patients’ decision-​ making capacity, even if the consequences of patient choice are unfavorable in clinical terms (ECtHR, 2002).

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To summarize, the positive case for using MI in healthcare settings is that it may promote patient health and well-​being, as well as promote patient autonomy. This positive case can be strengthened by thinking about the alternatives to MI by using some other communication style. We know from MI process research—​research that examines practitioner and patient behaviors during interactions and how these relate to patient outcomes—​ that communication styles that are MI nonadherent can make a significant (negative) difference to patients’ subsequent behaviors and health outcomes (Magill, et al., 2018). Patients may end up better or worse off in terms of their well-​being simply by how the practitioner communicates with them; poor communication may be harmful. Such MI-​nonadherent behaviors include, for example, condescending, blaming, or excessive, overly directive, authoritarian advice-​and information-​giving and warning or confronting the patient (Apocada & Longabaugh, 2009). These communication styles may make patients less likely to follow clinical recommendations, less likely to engage in health-​promoting behaviors, or more likely to engage in behaviors that are detrimental to health (Lindavist, et al., 2017). MI-​nonadherent communication may also lead practitioners to fail to elicit or to miss important information that would facilitate the provision of better treatment (Miller & Rose, 2009). And care that is inconsistent with MI may violate patient autonomy. So relative to a MI-​nonadherent alternative, an MI-​based communication style seems ethically preferable—​that is, we have more ethical reason to use it.

ETHICAL CHALLENGES WITH RESPECT TO USING MI IN MEDICAL PRACTICE In the previous section, we set out the ethical case in favor of using MI in healthcare settings. We now consider two ethical challenges that relate to its use: appropriate use and proficiency. It is important to note that we do not see these challenges as presenting a decisive ethical objection to using MI in Medicine. Rather, we argue that they ought to shape and inform the decision to use MI (and its ongoing practice) in particular healthcare settings and with particular patients.

Appropriate Use MI is a communication style and approach whose aim is to promote behavior change. MI is used with a target behavior in mind: for example, smoking less tobacco, drinking less alcohol, taking fewer drugs, increasing physical

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activity, and taking prescribed medication correctly. It may be open to the MI practitioner to choose the target behavior, but when practicing MI with proficiency it is the patient who should choose the target behavior. In principle, nothing would prevent MI use whose aim were to encourage people to smoke more tobacco, drink more alcohol, or take more drugs! We can see that the openness of possible MI target behaviors raises an important ethical issue: Whether some target behaviors are ethically impermissible (or at least questionable) and how we are to determine whether this is the case? There seems to be some agreement in the literature that some applications of MI are ruled out, ethically speaking. One potential example is the use of MI in sales (Miller & Rollnick, 2009; Miller & Rollnick, 2013). It is perhaps intuitive that it would be ethically impermissible to use MI in order to sell someone a car; the difficulty is in identifying the precise reasons why this practice is morally wrong. On the one hand, we might think that a car purchase (or the purchase of this car) is incompatible with a person’s best interests. On the other hand, we might think that even if a car purchase is not contrary to a person’s best interests, this is the kind of decision for which one ought not to be steered in a particular direction by another—​the choice should be the person’s own to make. Let us consider these claims in the healthcare context. In healthcare settings, there may appear to be applications of MI that raise either the ethical issue of the compatibility of a target behavior and a patient’s best interests or the ethical issue of the appropriateness of steering a patient one way or another. In respect of the first issue, we might think it is inappropriate, for example, to use MI to direct patients toward nonbeneficial or futile treatment. Consider a scenario in cancer care in which MI were employed always with the patient undergoing curative treatment as the target behavior. While this practice would be beneficial for many patients, for at least some, undergoing treatment would be futile or excessively burdensome—​it would be better for them to receive palliative care. In respect to the second issue, there may seem to be some medical decisions that ought to be a patient’s own. For example, it may seem unethical to use MI to steer patients toward or away from abortion or to direct toward assisted death (where it is lawful) over palliative care or vice versa, or to encourage people to become living kidney or liver donors. However, we need an explanation for why some decisions should be left to patients, undirected. Perhaps we can say the following: for some medical decisions patients differ widely and reasonably in their views about what they ought to do. This fact of reasonable pluralism about what to do means that it is difficult to determine for all patients what an appropriate target behavior would be in some healthcare settings. In

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such circumstances, it may not be ethical to use MI—​patients ought not to be directed toward a particular target behavior.1 However, this analysis leaves open the possibility that once each patient’s values and preferences have been ascertained, MI that aligns with the patient’s views is, other things equal, ethically permissible.2 Perhaps we might draw the following ethical insights from the foregoing discussion.3 First, policies that designate target behaviors to be pursued may require exceptions and tailoring to a patient’s circumstances (whether medical or personal) if their best interests are to be promoted. Second, the fact of reasonable pluralism may mean that it is not ethically appropriate to designate a target behavior for some medical decisions—​at least not until a patient’s values and preferences have been ascertained. Both claims highlight the importance of employing the person-​centered skills that undergird MI to gain a deep understanding of the patient, regardless of whether a target behavior is ultimately pursued. Our analysis also highlights the insufficiency of “compassion”-​oriented approaches to MI in healthcare. Compassion is in fact challenging to operationalize in the spirit of MI. In recent editions of Motivational Interviewing, Miller and Rollnick have emphasized that compassion is a guiding principle for ethical MI practice, including it within their account of the “spirit” of MI (2013). Compassion, they hold, precludes the use of MI “in pursuit of self-​ interest” (Miller & Rollnick, 2013). However, the exclusion of self-​interest does not rule out the use of MI with problematic target behaviors in healthcare settings. The conception of compassion within MI spirit is practitioner-​focused: it centers on the practitioner’s motivation or self-​interest (Miller & Rollnick, 2013). For some applications of MI, compassion can do the moral work. Compassion provides an ethical reason to criticize the car salesperson for using MI to drive up sales of expensive cars on consumer credit agreements. But compassion alone cannot provide adequate ethical action guidance with respect to target behaviors in healthcare. An overwhelming majority of healthcare practitioners are well-​intentioned or acting out of a concern for what they perceive to be in the patient’s best interests. MI provided in 1. We note that the fact of reasonable pluralism may also shape whether a target behavior aligns with a patient’s best interests. In this respect, the first and second issues connect. 2. To be clear, our claim does not entail a “consumerist” stance, according to which practitioners must provide MI interventions that align with patient preferences. The point is more subtle: if a range of options are available and consistent with a practitioner’s professional obligations, it may be ethically permissible to use MI with a target behavior that aligns with a patient’s preferences. 3. To the extent that the provision of MI interventions in healthcare settings is not merely a matter for individual practitioners, these lessons apply also to teams and institutions who use MI.

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accordance with this perspective will meet the criteria for compassionate use. But such care may not be ethical, especially when there is a mismatch between patient preferences or values and professional judgment. Paternalism is by definition well-​meaning. We can observe this in the discussion above regarding treatments that may not benefit the patient all things considered and in cases of reasonable pluralism. It might be argued that compassion can be fruitfully combined with other ethical principles. We are friendly to this suggestion. Our view is that the determination of an ethical target behavior will be structured by the exercise of professional judgment together with individualized consideration of a patient’s circumstances, values, and preferences and recognition of reasonable pluralism in society. This view is not incompatible with the use of compassion as an ethical principle for MI practice. However, we are less attracted to the suggestion that compassion may be combined with Beauchamp and Childress’s four principles of biomedical ethics (Miller & Rollnick, 2013): that is, the principles of nonmaleficence, beneficence, autonomy, and justice (Beauchamp & Childress, 1979, 1983, 1989, 1994, 2001, 2009, 2013, 2019). Beauchamp and Childress’s account has been very influential and remains extremely popular as an ethical framework for medical education, practice, and ethics in medical research. The problem we have with using compassion and the four principles to determine whether a target behavior is appropriate for MI use is that the four principles themselves—​as has been discussed extensively in the academic literature—​are difficult to operationalize and use (DeGrazia, 2003). The criticisms that have been made of the theory include the argument that there is a lack of clarity about how the four principles relate to each other, and in particular, how the principles are to be ranked vis-​à-​ vis one another in cases of conflict (Holm, 1995). This translates to a worry that either the four principles permit whatever ethical outcome the agent desires or that the four principles fail to deliver action guidance in concrete circumstances. So, combining the four principles with compassion may not help us to identify appropriate of MI use, since in so doing, we may either add more indeterminacy or license ad hoc ethical decision-​making. Before we close out this section, we should consider a suggestion for avoiding the ethical issues we have raised in respect of identifying an appropriate target behavior for using MI: the use of the alternative approach of decisional ​balance (or MI in equipoise or nondirectional MI, see Chapter 4): that is, being neutral as to the direction of behavior change (Forman & Moyers, 2021; Miller, 2012; Miller & Rollnick, 2002; Miller & Rollnick, 2013; Zuckoff & Dew, 2012) (see Chapter 4). Unfortunately, the use of decisional balance does not enable us to sidestep the problems discussed

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above. On the one hand, it might be thought that we can avoid the challenges associated with selecting appropriate target behaviors by always using decisional balance to explore, in a neutral fashion, the pros and cons associated with different behavioral choices. However, in at least some cases, for example, the exploration of the advantages and disadvantages of drinking alcohol excessively, it would be a dereliction of professional duty to fail to select a target behavior—​to be neutral as between reducing, maintaining, or increasing alcohol consumption. On the other hand, it might be suggested that we should use decisional balance in those cases in which the direction of behavior change is ethically contentious, or directionality is unclear such as decisional about abortion, organ donation, or end-​of-​life decisions. We agree to the extent that decisional balance may be a valuable resource to employ when working with patients to understand their values and preferences and identify their best interests (after which directional MI might be used). However, decisional balance cannot in and of itself tell us which cases are ethically contentious—​it is a strategy that may be ethical to employ once we have made the latter judgment on the basis of our discussion above. Finally, decisional balance, to the extent that it requires practitioners to “intentionally maintain neutrality with regard to change goal” may be particularly challenging in practice (Miller, 2012; Miller & Rollnick, 2013). This leads us to the discussion of our second ethical challenge related to using MI in healthcare practice.

Proficiency Empirical research has shown that it is difficult for practitioners to acquire a degree of skillfulness in MI that enables them to influence patient behavior (Eno Person, et al., 2016; Forsberg, Ernst, & Farbring, 2011; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Schwalbe, Oh, & Zweben, 2014). For example, one systematic review of MI dissemination in the substance use disorder field found that “for many practitioners, achieving proficiency in MI may take years” (Hall, Staiger, Simpson, Best, & Lubman, 2016). It is also the case that proficiency develops at highly variable rates across practitioners (Dunn, et al., 2016). Further, proficiency can wane over time (e.g., start off high and then drift over time) without ongoing feedback. With respect to decisional balance, Miller and Rollnick have conceded that nondirective counseling may require “a still higher level of clinical skillfulness than the directive variety of counseling, because one must avoid inadvertently tipping the scales in one direction or another” (2002).

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Why is the difficulty associated with learning MI an ethical issue? For at least three reasons. First, the evidence base for MI (predominantly from clinical studies) shows that MI can help bring about positive behavior change (Project Match Research Group, 1998). However, if MI is not practiced at the requisite level of competence, practitioners may fail to benefit patients. Worse, as we note above, MI-​nonadherent practitioner behaviors can harm patients. Thus, it is a matter of ethical challenge whether the communication style a practitioner uses with their patients is MI as intended. Second, for some practitioners, MI may be the communication style they adopt in everyday encounters with patients—​MI is their “bedside manner.” But in other circumstances, MI will be a specific intervention or treatment (e.g., a substance use or medication adherence intervention) to which the patient consents. Here, the failure to deliver MI for proficiency reasons may be ethically problematic for harm-​based reasons, but also for autonomy-​based reasons. It is axiomatic that patients ought not to receive interventions or treatments to which they have not consented. Third, the context of MI dissemination makes the ethical challenge regarding proficiency particularly pressing. MI has been widely disseminated and is employed by practitioners in contexts that we might expect (e.g., the health professions; Eno Persson, et al., 2016), to those that are less obvious (e.g., immigration officers and environmental inspectors; Forsberg, Wickstrom, & Kallmen, 2014). Sometimes ongoing training and support will accompany the implementation of MI in a particular setting (Beckman, et al., 2017). However, this does not seem to be routine practice. Indeed, it does not seem plausible that extensive or ongoing MI training and supervision would be routine, given the extent and pace of MI dissemination. To summarize the issue, many practitioners worldwide may be delivering “MI” interventions, who in fact are not proficient in MI. What can be done to address the proficiency challenge? In principle, it is easy to address what MI practitioners require is an adequate and ongoing level of training and support, ideally provided by skilled coaches and accompanied by reliable treatment integrity assessment (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). In practice, it may be very difficult to alleviate ethical challenge of practitioner proficiency. Adequate training and support are resource intensive, both in terms of financial outlay for individuals and institutions, but also in terms of the opportunity cost for practitioners for developing MI expertise over other professional activities. Perhaps particularly for medical trainees, institutional realities may make it such that specialization in MI is not an option, but even where it is, developing proficiency in MI may come at the cost of specialization in another field.

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PERSONAL REFLECTION (Mariel Piechowicz) During the course of medical training, we have all had experiences where we observe a patient encounter with an attending physician that we wish we could absorb and emulate. After some reflection, I realized that what made these encounters so successful was the impression that the patient felt heard, and the team knew how to partner better with the patient moving forward. The commonalities in these cases were collaboration, acceptance, and compassion, which are the core tenets of the spirit of MI. As a psychiatry resident, I am grateful that I have had the opportunity to receive dedicated training and supervision in MI. While it is not always formally taught in other fields in Medicine, it is a useful tool to navigate discussions that are relevant in all clinical practice, regardless of specialty. Most of my patient encounters include some element of MI. As described in the above chapter, MI has become a part of my “bedside manner.” However, the times I find myself reaching for mindful, deliberate practice of MI are often during the more advanced or difficult conversations with patients. This includes situations one would classically identify with MI, situations necessitating behavior change to improve a clinical outcome such as medication adherence, substance use cessation, and lifestyle modifications. Directional MI is perfect for this. In other situations, nondirectional MI is particularly effective in centering a patient’s values, thoughts, and beliefs in goals of care discussions, evaluations of capacity, and family meetings. There is evidence that MI is efficacious and beneficial to patients relative to other communication styles. Thus, we as medical trainees and practitioners alike have a responsibility to utilize MI to provide the best possible patient care. With proper guidance and supervision in MI, we can gain an understanding of the interpersonal skills required to motivate patients to move toward optimal health.

CONCLUSION We have proposed three arguments in this chapter. First, that there is a positive ethical case for using MI in healthcare settings, in that it may promote patient health and well-​being, as well as patient autonomy. Second, that identifying an appropriate (i.e., ethical) target behavior for MI practice raises complex ethical questions whose resolution cannot be avoided by the routine use of decisional-​balance MI. Third, that the proficiency of practitioners in MI is a pressing ethical issue. The second and third arguments influence the degree to

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which using MI in particular healthcare settings and with particular patients is ethically permissible, all things considered. In Chapter 1 of the first edition of Motivational Interviewing: A Guide for Medical Trainees—​ “Why Include Motivational Interviewing in Medical Training”—​the editors write: As trainees, we all aspire to become as skilled in the art of medicine as we are in the science of it. In order to achieve this balance, we must be able to have productive conversations with our patients, first by eliciting and actively listening to their concerns, and secondly, by effectively communicating information and making recommendations. Unfortunately, few medical programs offer a formal curriculum devoted to communication skills. Presumably, we will absorb these skills along the way, learning through a patchwork approach of observation, trial, and inevitable error. Without proper guidance and supervision, most of us will adopt an approach characterized by authoritarian, confrontational, or guilt-​inducing qualities. Clear evidence demonstrates that such an approach will compromise relationships with our patients and ultimately will contribute to negative behavioral and clinical outcomes. Our role as effective healthcare practitioners must include an understanding of the interpersonal skills required to motivate patients to move toward optimal health. In this regard, we find Motivational Interviewing (MI) incredibly valuable. (Douaihy, Kelly, & Gold, 2014)

We respectfully and wholeheartedly endorse these observations, save only for the qualification that MI offers an incredibly valuable approach to patient communication, but we may fall short of realizing MI’s promise if we fail to attend to important ethical considerations for its practice, including those of appropriate use and proficiency.


1. There is an ethical case for using MI in healthcare settings. 2. It is never ethically problematic to use MI in healthcare settings. 3. It is always ethically preferable to use decisional balance. 4. It is ethically problematic to practice MI without an adequate degree of proficiency.

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Answers 1. True. The appropriate and skillful use of MI in healthcare settings may promote patient health and well-​being, as well as promote patient autonomy. 2. False. We may have ethical challenges about whether using MI is appropriate in particular healthcare settings, for particular treatments or interventions, or with particular patients, as well as about healthcare practitioners using MI without adequate training and ongoing support. 3. False. There may be an ethical and professional duty to use directional MI; using decisional balance does not answer the question whether it is ethical to use directional MI for a particular intervention or treatment, or with a particular patient, and decisional balance may be more difficult than directional MI to practice. 4. True. Nonproficient MI practice may fail to benefit (or even harm) patients and may violate patient autonomy.

SUGGESTING READING ON THE ETHICS OF MI Black, I., & Forsberg, L. (2014). Would it be ethical to use Motivational Interviewing to increase family consent to deceased solid organ donation? Journal of Medical Ethics, 40(1), 63–​68. Black, I., & Helgason, Á. R. (2018). Using Motivational Interviewing to facilitate death talk in end-​of-​life care: An ethical analysis. BMC Palliative Care, 17(1), 51. Black, I., & Forsberg, L. (2020). Ethical challenges in the applications of Motivational Interviewing in HIV care. In A. B. Douaihy & K. R. Amico (Eds.), Motivational Interviewing in HIV care (pp. 157–​165). Oxford University Press. Miller, W. R. (1994). Motivational Interviewing: III. on the ethics of motivational intervention. Behavioral and Cognitive Psychotherapy, 22(02), 111–​123. Miller, W. R. (1995). The ethics of Motivational Interviewing revisited. Behavioural and Cognitive Psychotherapy, 23(4), 345–​348. Withers, J. M. J. (1995). Motivational Interviewing: A special ethical dilemma? Behavioural and Cognitive Psychotherapy, 23(4), 335–​339. Zuckoff, A., & Dew, M. A. (2012). Research on MI in equipoise: The case of living organ donation. MITRIP, 1(1), 39.

REFERENCES Apodaca, T. R., & Longabaugh, R. (2009). Mechanisms of change in Motivational Interviewing: A review and preliminary evaluation of the evidence. Addiction, 104(5), 705–​715.

400  Motivational Interviewing, 2E Beauchamp, T. L., & Childress, J. F. (1979). Principles of biomedical ethics. Oxford University Press (xvi; p. 314). Beauchamp, T. L., & Childress, J. F. (1983). Principles of biomedical ethics (2nd ed.). Oxford University Press (xviii; p. 364). Beauchamp, T. L., & Childress, J. F. (1989). Principles of biomedical ethics (3rd ed.). Oxford University Press (x; p. 470). Beauchamp, T. L., & Childress, J. F. (1994). Principles of biomedical ethics (4th ed.). Oxford University Press (x; p. 546). Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics (5th ed.). Oxford University Press (xi; p. 454). Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). Oxford University Press (xiii; p. 417). Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics (7th ed.). Oxford University Press (xvi; p. 459). Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press. Beckman, M., Forsberg, L., Lindqvist, H., Diez, M., Eno Persson, J., & Ghaderi, A. (2017). The dissemination of Motivational Interviewing in Swedish county councils: Results of a randomized controlled trial. PLoS One, 12(7), e0181715. Black, I. (2018). Refusing life-​prolonging medical treatment and the ECHR. Oxford Journal of Legal Studies, 38(2), 299–​327. de Almeida Neto, A. C. (2017). Understanding Motivational Interviewing: An evolutionary perspective. Evolutionary Psychological Science, 3(4), 379–​389. DeGrazia, D. (2003). Common morality, coherence, and the principles of biomedical ethics. Kennedy Institute of Ethics Journal, 13(3), 219–​230. Holm, S. (1995). Not just autonomy: The principles of American biomedical ethics. Journal of Medical Ethics, 21(6), 332–​338. Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational Interviewing: A guide for medical trainees. Oxford University Press. Dunn, C., Darnell, D., Atkins, D. C, et al. (2016). Within-​provider variability in Motivational Interviewing integrity for three years after MI training: Does time heal? Journal of Substance Abuse Treatment, 65, 74–​82. Eno Persson, J., Bohman, B., Forsberg, L., Beckman, M., Tynelius, P., Rasmussen, F., & Ghaderi, A. (2016). Proficiency in Motivational Interviewing among nurses in child health services following workshop and supervision with systematic feedback. PLoS One, 11(9), e0163624. ECtHR (2002). Pretty v United Kingdom. Forman, D. P., & Moyers, T. B. (2021). Should substance use counselors choose a direction for their clients? Motivational Interviewing trainers may be ambivalent. Alcoholism Treatment Quarterly, 39(4), 446–​454. Forsberg, L., Ernst, D., & Farbring, C. Å. (2011). Learning Motivational Interviewing in a real-​ life setting: A randomised controlled trial in the Swedish Prison Service. Criminal Behaviour and Mental Health: CBMH, 21(3), 177–​188. Forsberg, L., Wickstrom, H., & Kallmen, H. (2014). Motivational Interviewing may facilitate professional interactions with inspectees during environmental inspections and enforcement conversations. PeerJ, 2, e508. Hall, K., Staiger, P. K., Simpson, A., Best, D., & Lubman, D. I. (2016). After 30 years of dissemination, have we achieved sustained practice change in Motivational Interviewing? Addiction, 111(7), 1144–​1150. Hurka, T. (1987). Why value autonomy? Social Theory and Practice, 13(3), 361.

Ethical Practice of MI in Healthcare Settings  401 Glover, J. (1990). Causing death and saving lives: The moral problems of abortion, infanticide, suicide, euthanasia, capital punishment, war and other life-​or-​death choices (New ed.) Penguin. Lindqvist, H., Forsberg, L., Enebrink, P., Andersson, G., & Rosendahl, I. (2017). The relationship between counselors’ technical skills, clients’ in-​session verbal responses, and outcome in smoking cessation treatment. Journal of Substance Abuse Treatment, 77, 141–​149. Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational Interviewing in medical care settings: A systematic review and meta-​analysis of randomized controlled trials. Patient Education and Counseling, 93(2), 157–​168. Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-​analysis of Motivational Interviewing: Twenty-​five years of empirical studies. Research on Social Work Practice, 20(2), 137–​160. Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., Tonigan, J. S., & Moyers, T. (2018). A meta-​analysis of Motivational Interviewing process: Technical, relational, and conditional process models of change. Journal of Consulting and Clinical Psychology, 86(2), 140–​157. Miller, W. R. (2012). Equipoise and equanimity in Motivational Interviewing. MITRIP, 1(1), 31–​32. Miller, W. R., & Moyers, T. B. (2017). Motivational Interviewing and the clinical science of Carl Rogers. Journal of Consulting and Clinical Psychology, 85(8), 757–​766. Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change (2nd ed.). Guilford Press. Miller, W. R, & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioral and Cognitive Psychotherapy, 37(2), 129–​140. Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). Guilford Press. Miller, W. R., & Rose, G. S. (2015). Motivational Interviewing and decisional balance: Contrasting responses to client ambivalence. Behavioral and Cognitive Psychotherapy, 43(2), 129–​141. Miller, W. R., & Rose, G. S. (2009). Toward a theory of Motivational Interviewing. American Psychologist, 64(6), 527–​537. Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn Motivational Interviewing. Journal of Consulting and Clinical Psychology, 72(6), 1050–​1062. Moyers, T. B., & Miller, W. R. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27(3), 878–​884. Project MATCH Research Group (1997a) Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58(1), 7–​29. Project MATCH Research Group (1997b). Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58(1), 7–​29. Project MATCH Research Group (1998a). Matching alcoholism treatments to client heterogeneity: Project MATCH three-​year drinking outcomes. Alcoholism: Clinical and Experimental Research, 22(6), 1300–​1311. Project MATCH Research Group (1998b). Matching alcoholism treatments to client heterogeneity: Project MATCH three-​year drinking outcomes. Alcoholism: Clinical and Experimental Research, 22(6), 1300–​1311. Pugh, J. (2020). Autonomy, rationality, and contemporary bioethics (1st ed.). Oxford University Press. Schwalbe, C. S., Oh, H. Y., & Zweben, A. (2014). Sustaining Motivational Interviewing: A meta-​ analysis of training studies. Addiction, 109(8), 1287–​1294.

402  Motivational Interviewing, 2E Sumner, L. (1996). Welfare, happiness, and ethics. Clarendon Press. Tannsjo, T. (1989). Against personal autonomy. International Journal of Applied Philosophy, 4(3), 45–​56. Varelius, J. (2006). The value of autonomy in medical ethics. Medicine, Health Care and Philosophy, 9(3), 377–​388. Zuckoff, A., & Dew, M. A. (2012). Research on MI in equipoise: The case of living organ donation. MITRIP, 1(1), 39.

Epilogue Patrick H. Driscoll

How much in the field of Medicine depends not primarily on the efficacy of medications or procedures but on peoples’ choices and the ensuing behaviors that impact the very health about which they present in all manner of medical settings in the first place? A lot. When it comes to better health, one of the most important interventions is not a medication or concrete procedure at all, but it is a way of engaging people to help them connect the impact of their own behaviors with the very health problems that they seek to improve when they present to practitioners for consultation. The wisest practitioners, those who have most effectively helped these people improve and live more healthy lives, are the ones who learned how to be most effective in perhaps the most important of all interventions in medical settings: how to have conversations about the very behaviors that are so important to change in the first place. In some sense, behavior change and the means we as practitioners possess to effect that change is everything. And the most effective means to facilitating behavior change is the style of conversation we as practitioners can have with patients who present to us with problem behaviors. And that style of conversation is motivational. It is what we know through research, and it is a deep conviction we have from the feeling and experience of sharing the motivational spirit in the conversations that we have had with those people for whom the motivational interview has made a difference in the way they made choices about their health—​and sometimes even their lives. There are specific therapies to which people can be referred for problems of thinking, feeling, and acting, but experience (and research) has vindicated a certain style of conversation about behavior change as being the most effective at helping people change and improving outcomes (and lives) in medical settings and beyond. Motivational Interviewing is the most important way of engaging patients in any setting, and it is perhaps the most important intervention for early trainees (or at any stage of clinical development) in any field or specialty to learn, beginning in the earliest parts of their education. The development of a motivational style of engagement is a subtle tremor with the power to drive tectonic shifts in healthcare as this power is harnessed and used wherever patients present to practitioners with problems related to behavioral choices (which is pretty much everywhere).

404 Epilogue

Personally, the motivational style of engagement is the style that has made me a more effective practitioner (as a psychiatrist and psychoanalyst), and the learning culture of Motivational Interviewing (MI) has helped me as a teacher and educator. One of the most powerful insights that I learned from MI is how the motivational style of engagement is not a theory at all but rather a way of being—​with patients and in the rest of life. The motivational way of being was discovered through research into what Miller and Rollnick unforgettably called “those unspecified elements of change” (independent of any professed theoretical orientation or school of psychotherapy). Those elements of change are essentially a therapeutic way of being with a patient that is common to any practitioner who is observed to be achieving the effects of behavior change with patients they are helping regardless of psychotherapy background. That research-​based observation is one of the most powerful findings I have ever taken in, and it has stayed with me indelibly. It was the kind of understanding that, once I had it, changed my choice of clinical development forever. As a practicing psychoanalyst with a full slate of long-​term patients in in-​depth treatment, I find a true north clinically, not by trying to be “more psychoanalytic,” but by striving to be with a patient in a motivational spirit. I learned an important lesson from those early research studies on the psychotherapeutic treatments of addiction and behavior problems: it is not how closely I adhere to any theory or manual, psychoanalytic or otherwise, that helps patients to change; it is my way of being with people and how closely I adhere to their words and selves in attuned, empathic listening that makes the difference. As I learned MI and then went on to train in psychoanalysis, I insisted to myself a kind of mantra to stay on a true course of clinical and personal development: a psychoanalytic way of being with a person is primarily a motivational way of being. I have quietly believed it all along, especially in some of the most difficult and sometim