Expert: Pharmacists Can Use Motivational Interviewing to More Effectively Address Treatment Nonadherence
Motivational interviewing is an evidence-based method of communicating with patients who are ambivalent or resistant to change for the sake of their health.
In 2021, treatment nonadherence was a $500 billion problem, explained Bruce Berger, PhD, president of Berger Consulting, LLC, during a presentation at the National Community Pharmacists Association 2022 Annual Convention. In prior years, that number has ranged from $200 billion to $700 billion, so the scale of this problem is not a new one for the United States, Berger noted.
“The rate of nonadherence has not changed in 40 years. [Back then], we had 4 times a day meds and 3 times a day meds, so everybody said the reason that nonadherence was so high is because of 4 times a day and 3 times a day therapies. Now we have once a day, once a week, once a month, or even once every 6 months [therapies available]. They are amazing, but the rate of nonadherence is still 50% in year 2 [of a patient] having a chronic illness, on average,” Berger said. “I'd like to propose that the way we talk to patients also has not changed appreciably in 40 years. We have made some changes, but not enough.”
Berger explained that in his research assessing communication tactics used by health care providers when speaking to patients, he started by listening to hundreds of hours of recorded calls between health care professionals and patients. Notably, Berger heard an ongoing theme in these calls.
“We are still engaged in very paternalistic conversations, even though we are now in the age of patient-centered care, which means it shouldn't be paternalistic,” Berger said.
Instead, Berger teaches pharmacists in his work as a professional health coach a method called motivational interviewing (MI) to support the development of a more patient-centered culture. When MI was first developed, it was created for the purpose of supporting clinical psychologists who were working with patients with substance use disorders. However, because pharmacists are often not trained on effective communication strategies with patients to the same extent—if at all—that clinical psychologists are, Berger noted that pharmacists generally need some additional training to understand how exactly MI works in practice.
“In health care, we've had substance abuse issues for years. Yet MI almost never comes up, even though it is the most effective evidence-based method for keeping people off substances, with the lowest rate of relapse,” Berger said. “It allows patients to reason their own way to what they want to do to maintain [their] health. So we changed that acronym-based approach, because we found that people didn't understand it, and we developed what is called a ‘sensemaking approach.’”
The sensemaking approach is based on a simple yet profound idea, according to Berger. Specifically, this approach starts by assuming everyone is a sensemaker in their own lives, using all their prior knowledge and experiences when making sense of their current one.
“Patients are sensemakers, and they're deciding how to make sense of their illness, their treatment, and their relationship with us,” Berger said.
However, Berger noted that MI is not necessary during communication with all patients, such as those who are open and willing to make changes in their lives for the sake of their health. Instead, it’s valuable for communicating with ambivalent or resistant patients who are saying, ‘I don't know if I want to take the medicine; I don't know if I want to lose weight; I don't want to quit smoking.’
“That's who MI was developed for—not the people who are ready to do something,” Berger said. “These are the patients that most of us in health care have the most difficult time with—it’s those that are pushing back. What we've learned is that when people are ambivalent or resistant to change, [it’s because] their sensemaking is corrupted by either misinformation or missing information.”
To address this, Berger explained that what pharmacists should listen for when using MI with resistant or ambivalent patients is how they're making sense of their illness, treatment, and relationship with their health care team. Specifically, it is beneficial for the pharmacist to ask the patient what information they are using to make sense of these areas, which allows the pharmacist to then assess whether the issue is misinformation or missing information.
“That's what we're training people to listen for. So when that patient says, ‘I don't want to take the COVID-19 vaccine, I heard it has a computer chip in it,’ their resistance was because of misinformation,” Berger said. “Then our job is to get that information corrected in a way that doesn't put the patient off.”
Berger noted some additional questions the pharmacist can ask to learn more about the patient’s sensemaking strategies. For example, questions can include:
- What does having (condition) mean to you?
- How important is it for you to manage your (condition)?
- What would make taking the (medicine) more important to you, and what gets in the way?
- What's your understanding of the purpose of the (medicine), and what gets in the way?
- What would you have to change in order to decide to take the (medicine)?
Berger explained that one of the key aspects of the sensemaking approach to MI is that it creates a meeting of experts: the pharmacist is the expert on drugs, and the patient is an expert on themselves and how they're making sense of their illness and treatment.
“You can't know how to use your expertise if you don't know how they're making sense [of things],” Berger said. “What is critically important is that we really listen and honor what the patient says; [however] honoring what the patient says does not mean we're agreeing with them. It means we're creating a relationship in which the patient feels safe enough to tell us how they're thinking, and safe enough to push back if they don't like some of what we're saying.”
According to Berger, a patient-centered relationship depends on what exactly the pharmacist thinks their role is with a patient. If the pharmacist thinks their job is to play prosecuting attorney and prove the patient wrong because the pharmacist has the data and knows what needs to be fixed, a patient who is ambivalent or resistant to change will likely not open up to the pharmacist in a way that will bring about a change in their behavior. However, if the pharmacist believes their job is to try to educate the patient in a way that might make her think about taking the medicine as prescribed, an ambivalent or resistant patient will likely be more honest in this type of conversation.
“The most ineffective strategy to use with people who are ambivalent or resistant to change is persuasion,” Berger said. “Motivational interviewing is not about motivating patients; it's about exploring their motivation. If you think your job is to motivate your patients to quit smoking, lose weight, take a medicine—you have an impossible job. But if you think your job is to explore their mode of motivation, provide some information for them to consider, and then ask where this leaves them now, that's not an impossible job.”
Berger B. When Time Is Short: Winning Communication Strategies to Improve Patient Outcomes. Kansas City, MO: National Community Pharmacists Association 2022 Annual Convention; October 1, 2022.