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The management of long-term conditions depends crucially on an individual’s adherence to treatment and recommendations but this is known to be poor, with only about 50% of patients taking their medicines as directed[1]
. Indeed, sub-optimal adherence is often identified as the single biggest reason why treatments fail[2]
, contributing significantly to morbidity and mortality and lowered quality of life, increased dosage which results in drug-resistance, over-treatment and side effects and discontinuation of medication perceived to be ineffective[3],[4],[5]
. Adherence problems are more prevalent when regimens are time consuming, complicated, make the disease visible or offer no ‘perceived’ immediate benefits[6]
.
The advent of motivational interviewing
Motivational interviewing (MI) was first used with people who were alcohol dependent. Traditional interventions were confrontational — the belief was that unless patients admitted they had a problem, they would never improve. However, patients who were challenged in this way often denied having a problem. Rather than see this as part of a pattern of poor self-control and denial, Bill Miller, a clinical psychologist at the University of New Mexico, suggested that these responses were more likely to be a reaction to the confrontational style of the counsellor. He proposed an alternative approach which would be more likely to increase motivation to change[7]
. This laid the foundations of MI, which has become one of the front line treatments for treating drug and alcohol problems around the world, its application extending to healthcare behaviours in the mid to late 1990s[8]
.
MI is “a directive, [patient]-centered counselling style for eliciting behavior change by helping [patients] to explore and resolve ambivalence”[8]
. The aim is to listen to and understand patients’ reasoning for their partial adherence, in order to develop discrepancies between their thoughts and behaviours so that they acknowledge change as an option. When people are ambivalent about change they struggle to balance thoughts about what they “should” do with what they are “actually” doing. Such conflict typically results in feelings of discomfort known as “cognitive dissonance”[9]
, which individuals try to avoid.
However, MI provides a framework for exploring dissonance and identifies it as a potentially crucial lever for change. Yet, for change to actually occur, confrontation must be avoided and a truly collaborative approach is established. This is referred to as ‘the spirit of MI’ which follows the principles of: (i) not imposing change on patients; (ii) facilitating discussion about their ambivalence to change; (iii) helping resolve that uncertainty by being patient enough to let people express their own will to change or not; and (iv) accepting that their readiness to change will not be fixed but variable.
Motivational interviewing in practice
MI is practical in its application. Strategies are more engaging than coercive, more supportive than argumentative and any health professional can learn to use the four-step framework. The first step involves beginning a conversation, so the factors bearing influence on adherence can be aired in a supportive environment, where the possibility of change is raised. Expressing empathy through reflective listening (reflecting back what someone has said and sometimes expressing your own thoughts on what it means) is an important part of this.
The second step is to steer conversation to discuss discrepancies between the patients’ goals, thoughts or values and their current behaviours, allowing the uncertainty of it all to be discussed in a non-judgmental way.
The third step is to avoid arguing, giving advice or any form of confrontation. If a patient seems resistant to change, the response should consist of basic reflective and empathic statements — the simpler the better. For example, if the patient conveys that they have struggled to continue with the smoking cessation plan that is being worked on, and that they have been irritable and fidgety —“I’ve been so angry this week and I’ve had so many arguments”— a simple reflective response would convey the essence of what the listener thinks the patient has said — “So you’ve been falling out with people”.
The final step is to support self-efficacy and maintain optimism when someone expresses that they are ready to change. This helps to optimise the individual’s confidence so that they actually attempt to make the change. Techniques that can be useful in these four phases are outlined in ‘Box 1: Skills to use during motivational interviewing’.
Box 1: Skills to use during motivational interviewing
- Open-ended questions: Open-ended questions cannot be answered with a single word or phrase. For example, rather than asking, “Do you take your medicines?” ask, “How do you get on with taking your medicines?” This helps to initiate conversation and develop its focus.
- Reflective listening: The conversation can be continued and deepened by reflective statements that demonstrate that you have heard and understood the patient. At the simplest level these may just be paraphrasing what the patient has just said, but they may contain attempts to understand the meaning.
- Summaries: It is useful to summarise periodically what the patient has said and provide some direction for the next part of the conversation.
- Affirmations: If a patient does decide to change their behaviour, they will need to feel confident to attempt it. You can help increase morale in a session by making reference to your patient’s strengths, motivations, intentions, progress and past successes.
- Elicit self-motivational statements: Telling your patient why they should change has limited impact. It is far better that the patient voices personal concerns and intentions as a result of the conversation they have had with you. People persuade themselves to change much more effectively than other people can.
Training required
Training in MI is widely-available, and includes web-based video and written resources[10]
. The first level of training offers an introduction to MI, describing the basics and giving examples of use in practice (2–4 hour sessions). The second involves technical learning to put MI skills and tools into practice over time and is usually offered in half-day or day-long sessions. The first two levels of training are perhaps the most accessible for pharmacists who may be unlikely to be released from duties for more than a day at a time.
The third phase is usually only undertaken by psychosocial professionals or those who are working in a particular field (for example, addictions) and moves from basic to advanced competence over six days, usually spread out over an academic year and clinical practice is recorded and evaluated. Yet what is most important in MI training is developing competence in using certain soft skills. These are listed in ‘Box 2: Tips for motivational interviewing’.
Box 2: Tips for motivational interviewing
A healthcare professional using motivational interviewing will:
- Express empathy for their patient and understanding of their situation through reflective listening;
- Communicate respect for and acceptance of patients and their feelings, and their decisions;
- Establish a non-judgmental, non-confrontational collaborative relationship with patients;
- Be supportive and knowledgeable;
- Listen rather than give advice, unless it is asked for;
- Help patients become aware of any discrepancies between their goals or values or both and their current behaviour in relation to adherence;
- Be open about a desire to help the patient change and work hard to keep change on the agenda, but also respect at all times that the responsibility to change rests solely with the patient;
- Avoid argument and confrontation, adjusting and responding to resistance but never opposing it;
- Support self-efficacy and optimism by making reference to their previous achievements and current strengths.
While training in MI, health professionals demonstrate changes in knowledge and clinical practice in the short-term, but establishing routine use of the techniques in the longer-term is more challenging in the face of demanding clinics, busy schedules and different priorities[11]
. Long-term changes often require whole-team and operational changes first. Time needs to be set aside to plan practical change, for example, in how the clinics are run or booking in double appointments for more complex patients. However, implementation is often easier than anticipated[12]
.
Evidence-based technique
The efficacy of MI for alcohol treatment was demonstrated in large trials[13],[14]
and it was established as a front-line intervention for drug and alcohol problems in a Cochrane review[15]
. The Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness study (MARMITE)[16]
included 72 trials with >14,250 participants treated with MI (for an average of 2.2 hours) — 45 studies were on addiction problems and 5 on medication adherence. Although there was variation in outcome between studies, MI produced robust and enduring effects. The most comprehensive meta-analysis to date included 119 studies targeting a variety of problem-behaviours (for example, smoking, gambling and adherence to medication) and concluded that MI produces “small though significant positive effects across a wide range of problem domains”. The review also cited MI as being durable even after brief interventions, and demonstrated that the professional background of the interviewer was unlikely to have an impact on efficacy[17]
.
Using MI as a technique to increase medication adherence has been subject to particular scrutiny in the past decade, with good evidence emerging in conditions such as diabetes[18],[19]
and HIV[20]
. A meta-analysis of 48 trials in physical health settings found significant, modest advantages for MI. As with previous reviews, the effectiveness of MI in different trials varied — for example, there was no effect for treating eating disorders, but particular promise in increasing adherence in HIV care[21]
. However, it is important to note that communication and patient-adherence are inter-related, with one meta-analysis showing the odds of patient adherence to be more than two times higher when health professionals communicate effectively[22]
. With this in mind, it was inevitable that MI for pharmacists started to attract attention.
In the US, MI has been recommended as routine training for US speciality pharmacists[23]
. In the UK, a cluster randomised trial in 76 community pharmacies explored the effectiveness of MI with methadone patients and found that, although MI did not significantly reduce heroin use, there was an increase in treatment satisfaction[24]
. The authors also noted that other studies have found MI effective for drug abuse and called for further work to understand the cause of the differences. This is important — MI is more potent in some situations than others and, in some cases, does not work. The variations in efficacy should perhaps not be surprising because the populations for which MI is designed include those who typically have not been able to achieve behaviour change on their own, and have often already experienced unsuccessful interventions aimed at helping them change. Working with entrenched problem-behaviours or high-resistance using MI is unlikely to have any great advantage over any other evidence-based interventions, although there is some suggestion that it produces some change more quickly[13]
. Broadly though, for patients who are at least willing and able to engage, the evidence suggests that MI has a significant advantage over treatment as usual in healthcare.
Using motivational interviewing with patients with cystic fibrosis
Case study 1
Patient One is a 21-year-old female with cystic fibrosis and a history of non-adherence. She was diagnosed aged two months following presentation with failure to thrive and recurrent chest infections. She is chronically infected with Pseudomonas aeruginosa, Mycobacterium abscessus and Mycobacterium avium.
Her medicines for M. avium were stopped because her poor adherence led to concerns about antibiotic resistance. The pharmacist used MI techniques to find out what barriers there were to medication adherence. The patient explained that she only wanted to take a total of seven oral medicines and that this should be no more frequent than twice a day. She added that the figures were arbitrary but she felt she could only take this amount of medicines.
Her medicines were therefore limited to this effect. Azithromycin, ethambutol, minocycline, moxifloxacin and rifampicin were all stopped and her calcichew D3 caplets were changed to weekly colecalciferol.
At her next admission, two months later, the medical team was keen to restart her treatment. However, the patient wished to continue with the medicines as currently prescribed. An important aspect of motivational interviewing is that change can only happen when a patient feels ready — therefore, no changes to her medicines were made at this time. The patient was offered support with her adherence and so received a weekly telephone call to ensure she was taking her medicines correctly.
Three months later, the patient wanted to restart her antibiotics for her M. avium. She added that she felt happy to take a maximum of nine tablets in the morning and eight in the evening. The consultant, dietician and pharmacist discussed which medicines were a clinical priority and which were a priority for the patient. This was challenging because the ideal quantity of oral medicines would have exceeded the limit given by the patient. In order to initiate treatment, one of the existing medicines would have to be stopped.
With this in mind she was prescribed azithromycin 500mg once a day, linezolid 600mg twice a day and moxifloxacin 400mg once a day. At the time her vitamin A level was 0.79umol/L so the medical team wished to increase the dose of vitamins A and D from two to three capsules daily. However, if she was finding it difficult to manage the number of medicines once she went home, the additional vitamin A and D capsule could be stopped. She was also given a compliance aid.
By the following year, the patient was able to take her medicines on most days and no longer felt that she needed to limit the number of oral medicines. The patient still requested that her medicines were no more frequent than twice a day so any changes made to her prescriptions reflected this.
Case study 2
Patient Two is a 19-year-old female with cystic fibrosis who had recently transitioned to adult care. The transition to adult care from paediatric care can be a difficult time for young people. The Care Quality Commission’s transitional care document found that only 50% of young people and parents felt they received adequate support during the period prior to transfer to adult service.
This patient had learning difficulties and a history of non-compliance with her medicines. In addition to nine oral medicines, the patient was using two inhalers and three nebulised medicines. At the time of transition, she struggled to remember to take her medicines despite her father filling a compliance aid for her.
On speaking with the patient, it became apparent that she did not know why she was taking her medicines and she lacked insight into her condition. She only remembered those medicines she found difficult to take, including oral medicines that were difficult to swallow or nebulised medicines that were time consuming to use.
The patient expressed that she had never fully understood what it meant to have cystic fibrosis, which she felt was the biggest barrier to her medication adherence. Because she did not understand the importance of taking her medicines, she felt no motivation to take them.
The clinical psychologist and pharmacist provided the patient with a diagram of the human body labelled with the organs affected by her disease and the medicines that helped. This gave the patient a visual aid to refer to when she could not remember the information. Because the patient was due to start a beauty course at college, the team tried to describe some treatments, such as vitamins, in relation to her hair and skin to help her recall this information.
After this discussion, the patient wanted to try to take her medicines more often. Using the principles of motivational interviewing, the team asked the patient why she wanted to make this change and how important it was for her to make it.
The team formulated a table to complete with the patient. It included information on what each medicine looked like, why she was taking it and how it worked. This was useful for the patient to complete because she was able to write it in a way she understood. It was also a good way to ensure she had understood the information. This process also enabled the team to identify medicines that were a particular problem for patient and made suggestions for changes to her treatment.
Over the following weeks the team maintained regular contact with the patient, who reported that she was now finding it easier to take her medicines. She added that she remembered to take these herself four days a week and her father reminded her on the days she forgot.
The patient was admitted back into hospital in June 2015. She still had her medicines chart with her and she also reported that she now filled her own compliance aid.
Acknowledgements
With thanks to Ashifa Trivedi (specialist pharmacist — cystic fibrosis at St Bartholomew’s Hospital, London) for providing the case studies.
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