William A. Villaume, PhD

This article is the second of a 2-part series. In 

, we (1) briefly described motivational interviewing (MI), (2) provided an example of how it works, (3) explained our conceptual approach to MI, and (4) explained why it is so effective in helping patients engage in healthy behaviors (taking their medications, losing weight, quitting smoking, etc). In this article, we describe the clinical and economic effectiveness of MI compared with traditional counseling methods used by health care professionals (HCPs).

Because MI training for HCPs varies considerably in terms of quantity and quality, any review of the efficacy of MI must factor in the type and the extent of training involved. The literature consistently shows that when MI training is of sufficient length and appropriate quality, MI is highly effective at promoting health behavior change and better clinical outcomes. The effectiveness of MI has been especially well established in the substance abuse literature.

 As an intervention, MI has the lowest sustained relapse rates for substance abuse. Given the overwhelming success of MI in treating substance abuse, it seemed reasonable that MI might also be useful for facilitating constructive behavior related to chronic disease management. Therefore, the studies reported here focus on health care and HCPs who received training of sufficient length and quality. Sufficient training requires a minimum of 8 hours focused on mastering MI strategies to engage patient sense-making in a nonthreatening way.

Clinical and Economic Evidence of the Efficacy of MI in Health Care

Numerous studies have supported the use of MI in health care to reduce cholesterol level, blood pressure, blood alcohol level, weight, etc.

 For example, Simpson et al demonstrated statistically significant decreases in weight and body mass index (BMI) in a randomized clinical trial in which the treatment group received MI interventions.

 Other studies have shown the effect of MI on various cognitive and emotional variables underlying patient sense-making and decision making. More specifically, Linden et al used MI-based health coaching for 160 chronically ill patients and compared the results with 230 chronically ill patients who did not receive this coaching over the same period of time. Patients coached with MI improved their scores for self-efficacy (

 = .03) versus patients not coached with MI. Fewer participants increased their stages-of-change risk (eg, moved from Preparation back to Contemplation or Precontemplation) over time, than nonparticipants (

 <.01). In addition, more participants decreased their stages-of-change risk over time (eg, moved from Precontemplation to Contemplation or Preparation) than nonparticipants (

Various reviews of research have confirmed the overall effectiveness of MI in increasing patient and provider satisfaction and in producing better health outcomes. For example, Rubak et al

		MI “…outperforms traditional advice-giving in approximately 80% of the studies. No studies have reported motivational interviewing to be harmful or to have any kind of adverse effect.”

		MI was clinically and statistically significantly effective in reducing BMI, total cholesterol level, systolic blood pressure, and blood alcohol content.

		Motivational interventions did not need to take longer than 15 minutes, and just 1 intervention with a patient can increase the likelihood of a positive outcome.

, pharmacist-conducted MI improved adherence 17% using 15- to 20-minute interventions during a 3-month follow-up and 6-month follow-ups. Continuity of care, between patient discharge from the hospital and patients visiting community pharmacies, was an important element of this study.

 A similar study reported an increase in adherence of 14%.

As a result, health care systems are increasingly looking to MI for the reduction of treatment nonadherence and the adoption of healthier behaviors by patients. This focus on MI will grow as performance-based compensation strategies increasingly focus on outcomes achieved (as measured by star ratings, readmission rates, etc) rather than on services performed. The potentially massive economic impact of MI is starkly delineated in one study, conducted in 2005 for Biogen Idec, concerning the specialty drug Avonex for multiple sclerosis.

 In a randomized controlled clinical trial, patients in the MI intervention group had a statistically and clinically significantly lower proportion of Avonex treatment discontinuation (1.2%) than the standard care group (8.7%). This reduction in treatment discontinuation represented a potential $93,600,000 cost recovery per year.

 Similar reductions in treatment nonadherence would require MI to be implemented across multiple disease states in a variety of health care settings.

Recently, qualitative feedback has established that the benefits of implementing MI extend beyond just economic savings to the institution. MI also helps transform how people relate to each other within health care institutions. For example, the University of Florida Medication Therapy Management Communication and Care Center (UF MTMCCC) completed 3 days of MI training for their MTM pharmacists, pharmacy technicians, and students. Here is what Anna Hall, PharmD, Director, at the UF MTMCCC, said about the impact of the training:

“There are several key things that motivational interviewing training has enhanced for our program:

		The ability to engage patients on our ‘cold’ calls has improved dramatically. Patients are far more willing to learn about our MTM services and discuss medication concerns. Patients are simply less defensive.

		Call center personnel feel far more confident and comfortable in making calls and engaging patients, as a result of training and feedback.

		Motivational interviewing skills have now extended to how we talk to each other internally, and how we engage clients. It has substantially changed the culture of our organization.”

Dr. Hall emphasized that even after completing a 3-day, high-quality trainer program that incorporated baseline training, multiple practice opportunities, and expert feedback, refreshers are still necessary to reinforce skills and the MI philosophy. The more this occurs, the more all staff members internalize the skills, and MI becomes a way of being with others. Overall, patient and employee satisfaction has markedly improved, as a result of continuous MI training.

When based on sufficient high-quality training, MI is highly effective at producing better outcomes in patients across a wide range of chronic illnesses and health behaviors. As star ratings become more important in determining the compensation level for HCPs, MI will continue to grow in importance. It is crucial not to shortchange the length or quality of training in order to see substantial improvements in health behaviors from MI. The vast majority of related studies used MI interventions that were brief, lasting only 5 to 20 minutes. This makes MI well suited to community pharmacy environments. When MI interventions are done well and up front, when patients first receive a prescription for a chronic illness, less time is invested and fewer problems occur downstream.

This article is published in collaboration with the 

Bruce A. Berger, PhD, is president of Berger Consulting, LLC, and emeritus professor at Auburn University Harrison School of Pharmacy in Auburn, Alabama.

William A. Villaume, PhD, is emeritus professor at Auburn University Harrison School of Pharmacy in Auburn, Alabama.

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Motivational Interviewing: Helping People Change.

		Channon SJ, Huws-Thomas MV, Rollnick S, et al. A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. 

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		Dilorio C, McCarty F, Resnicow K, et al. Using motivational interviewing to promote adherence to  antiretroviral medications: a randomized controlled study. 

2008;20(3):273-283. doi: 10.1080/09540120701593489.

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		Resnicow K, McMaster F, Bocian A, et al. Motivational interviewing and dietary counseling for obesity in primary care: an RCT. 

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2004;30(3):404-406, 408-410, 414-416 passim.

		Simpson SA, McNamara R, Shaw C, et al. A feasibility randomised controlled trial of a motivational interviewing-based intervention for weight loss maintenance in adults. 

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		Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. 

t. 2010;16(1):166-174. doi: 10.1111/j.1365-2753.2009.01300.x.

		Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. 

		Wick JY. Motivational interviewing can improve ACS medication adherence. 

 website. pharmacytimes.com/resource-centers/ACS/motivational-interviewing-can-improve-acs-medication-adherence. Accessed April 27, 2016.

		Berger BA, Hudmon KS, Liang H. Predicting treatment discontinuation among patients with multiple sclerosis: application of the transtheoretical model of change. 

Articles

Numerous studies have supported the use of motivational interviewing in health care to reduce cholesterol level, blood pressure, blood alcohol level, and weight.

Making Sense of Motivational Interviewing, Part 2: Clinical, Economic, and Other Evidence

This article is the first of a 2-part series. This part will (1) briefly describe motivational interviewing (MI), (2) provide an example of how it works, (3) explain our approach to MI, and (4) explain why it is so effective in helping patients engage in health behaviors (eg, taking their medications, losing weight, quitting smoking). Part 2 will describe the clinical and economic effectiveness of MI compared with traditional counseling and information giving methods used by health care professionals (HCPs). The reader is referred to our book, 

Motivational Interviewing for Health Care Professionals: A Sensible Approach

 and our 8-hour continuing education accredited MI e-learning program (nacds.learnercommunity.com/motivational-interviewing) for further elaboration on these concepts and their evolution in health care.

MI was originally developed by psychologist William Miller.

 Miller’s insightful reaction to the typical confrontational approach widely used in the field of addiction counseling in the 1980s was the start of MI.

Here is Miller’s principle in his own words:

	Counsel in a way that evokes defensiveness and counter-argument, and people are less likely to change. . . I set out, then, to discover how to counsel in a way that evokes people’s own motivation for change rather than putting them on the defensive. A simple principle that emerged from our earliest discussions was to have the client, not the counselor, voice the reasons for change.

Miller’s new counseling approach was eventually called MI because the term “interviewing” carries the sense of (1) respecting patients, and (2) inviting patients to talk about their own motivation to change.

MI was widely adopted in addiction counseling and proved to be very effective in helping patients to change their behavior. Many people thought that it could be effective for other health behavior issues. In fact, subsequent research has shown MI to be effective in helping patients to change a wide range of health behaviors.

MI was developed specifically for patients who are ambivalent about change (individuals who might say, “I’m not sure I want to quit smoking now”), or resistant to change (individuals who might say, “I am not going to quit smoking. Stop bugging me.”).

Only by valuing and supporting the patient, as a person, does the patient have the 

to examine his or her behaviors and their consequences on self and others.

MI does 3 important things: (1) it accurately and nonjudgmentally reflects the concerns and emotions of the patient, (2) it provides insight or new information to address these concerns in a nonjudgmental and nonthreatening manner, and (3) it places ultimate decision making where it belongs…with the patient. This combination of actions is powerful. It creates safety so that the patient can be open to learning new ideas, drawing new conclusions, and, consequently, engaging in new behaviors.

The following is an example of patient counseling using a traditional approach, and then using MI. A 50-year-old man with a new diagnosis of diabetes presents a new prescription to lower his blood sugar. After the pharmacist fills the prescription, he begins to talk to the patient.

Patient: (Interrupting) OK, look, I don’t need a lecture. I’ll take the medicine once a day. I don’t plan on appreciably changing what I eat or getting more exercise to control my diabetes, so save your breath. That’s what the medicine is for.

Pharmacist: Taking the medicine alone is not enough. It can’t work as well if you don’t take in less sugar or carbs and burn more calories. So, if you want to control your diabetes, you need to do all three.

Patient: Fine, why don’t you let me worry about it? It’s my life. Are you done?

Pharmacist: OK. Sure. Here you go (hands over the prescription). But, I think you’ll find the medicine is not enough.

This patient might be labeled as difficult by a lot of HCPs. He seems defensive and unwilling to do what is necessary to really control his diabetes. Unfortunately, being lectured to and told what to do are not going to reduce his defensiveness and cause him to listen. The pharmacist insults the patient by essentially telling him, “You’re wrong, and you need to listen to me.”

Pharmacist: (1) I’m glad to hear that you are willing to take your medication to control your diabetes. (2) Sounds like you are taking this seriously.

Patient: That’s right. I am. I’ll take the medicine.

Pharmacist: (3) Glad to hear that. Would you mind if I share some thoughts with you, and then you can tell me what you think? After all, this really is your decision, and I want you to do what you think is best for you.

Patient: OK, but don’t expect me to change anything.

Pharmacist: (3) I sure won’t push. I promise. (4 and 5) Here are my thoughts. The medication prescribed is really effective at lowering blood sugar. It does have a limit, though. To give you an idea of what it can do, let’s say that it can remove 100 particles of blood sugar. Any sugar or carbs that you take in (or don’t burn) beyond that 100 start to accumulate over time, and that’s how diabetes can do serious damage to your eyes, nerves, kidneys, heart, etc. Anything you would be willing to do to decrease the amount of blood sugar over that 100 level, either through healthy eating or increased physical activity, like simply walking more, will help keep your diabetes under control and prevent problems. Very simple things like drinking water versus a sugary drink, or eating baked chicken instead of fried chicken, can really help. (6) What do you think about this?

Patient: Hmmm. Never thought about that. So even walking would help? I think I can do that. And small changes in my diet can help that much?

Pharmacist: (3, 4, and 5) Both sure can. To me, it’s important to find things to do that won’t seem like a burden to you. You don’t have to sweat to get more activity, and you don’t have to cut out everything you like to eat. Moderation is the key so you will stick with it. (7) I’d be glad to talk to with you more about this whenever you’re ready.

Patient: Let me try some things on my own, and then I might talk some more on my first refill.

Pharmacist: (7) Terrific! Glad you’re willing to consider trying some things. That will go a long way!

Notice the difference in the responses from the pharmacist and the patient. The pharmacist acknowledges the patient’s willingness to take the medication and the patient’s desire to take a step in controlling his blood sugar, rather than correcting the patient. The pharmacist asks permission to “share some thoughts” with the patient. The pharmacist is careful to point out that he realizes this really is the patient’s decision. It is 

 diabetes. Because there is no humiliation from being corrected, the patient is willing to consider the new information and perspectives. The patient is invited to consider the new information rather than having it forced on him. As a result, change is far more likely.

Our approach is based on human sense making. We are all sense makers. As you read this article, you are deciding if it makes sense. Patients make sense of their illness and treatment. With our approach to MI, we train HCPs to do the following:

		Listen for how the patient is making sense.

		Reflect back that understanding (develop rapport).

		Identify the information that is missing or incorrect.

		Directly address the issue (with permission).

In the previous dialogue, the patient’s sense is that the medicine should be enough. When individuals are ambivalent or resistant to change, they are working with partial or inaccurate information. This patient was partially correct. Additional information was needed for him to understand why medication alone was not enough. The dialogue is numbered so you can see where each step takes place.

This article introduced you to our approach to MI. Because MI was developed for patients who are ambivalent or resistant to health behavior change; it is crucial to understand how they are making sense, to reflect that understanding to create rapport, and then to provide new information that addresses their issues and invites them to reconsider changing their behavior. Information-giving, alone, and telling these patients what to do, simply does not work. Part 2 will provide clinical and economic evidence of MI’s effectiveness.

Bruce A. Berger, PhD, is president of Berger Consulting, LLC, and emeritus professor, Auburn University Harrison School of Pharmacy, Auburn, Alabama. William A. Villaume, PhD, is emeritus professor, Auburn University Harrison School of Pharmacy, Auburn, Alabama.

Motivational Interviewing: Preparing People to Change Addictive Behavior

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Motivational interviewing was widely adopted in addiction counseling and proved to be very effective in helping patients to change their behavior.