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2 OBJECTIVES Review the tool-box skills Identify reasons why we need to counsel and at times go beyond traditional counseling methods Assess the role of the pharmacist in changing patient behavior (medication adherence) Understand how to apply basic tool-box skills to motivational interviewing (MI) Apply assertiveness and persuasion skills to improve the care of our patients.

3 THE TOOL BOX Developing rapport (learning names, respect) Respecting privacy Listening (summarizing, paraphrasing, active listening) Empathic responding Attending to body language PAR (prepare, assess, respond) Open ended questions Use of silence Awareness of perceptions Stereotypes Recognizing barriers Respect CLOSER Verification Interactive counseling, “filling in the gaps” Assertiveness and persuasion (soon to be added) Philosophy: Integrate these skills into your own personal style of communicating with patients.

4 THE TOOL BOX: MI Developing rapport * (learning names, respect) Respecting privacy* Listening (summarizing, paraphrasing, active listening) Empathic responding Attending to body language PAR (prepare, assess, respond) Open ended questions Use of silence Awareness of perceptions Stereotypes Recognizing barriers Respect* CLOSER* Verification Interactive counseling, “filling in the gaps” Assertiveness and persuasion MI Uses these skills you already know – * is affirmation

5 PASSIVE, AGGRESSIVE AND ASSERTIVE Passive people tend to not respect themselves. Aggressive people tend to not respect others. Assertive people respect themselves and others. People who are assertive tend to be more persuasive. Do you agree? Why?

6 ASSERTIVENESS SKILLS Deal with confrontation, don’t avoid it. Inform the person by stating how you feel about their behavior. State the likely result of their behavior. Learn to say “No.” (Set personal limits in all areas, legal, ethical, moral etc.) Remember, yes to something you don’t want is no to something you do want. Do not fear asking for what you want, even when it comes to the behavior of others. Do not fear expressing your opinion. Let others know where you stand, this creates credibility. Initiate conversations, seeking opportunities to engage others. Use an optimal level of self disclosure. Not TMI.

7 PERSUASION Assertive people tend to be more persuasive Related to perceptions of credibility Trustworthy Qualified Personal dynamism How could being more “persuasive” assist a pharmacist in patient care, or you in dealing with others? This is the essence of MI, but we want to be persuasive not pushy.

8 PERSUASION MI is a technique designed to persuade patients to engage lasting behavior change. Some skills are specific to MI, but, in general, to be more persuasive: Find common ground Be honest about your intentions Be credible, admitting mistakes or knowledge deficit Reinforce your messages over time (be patient) Soften your appeals Save most important points for last

9 THE MI TOOLBOX Everything you already know – applied differently Specific skills taught for MI Open ended questions Affirmation (respect, reinforcement, praise, etc.) Reflecting responses Summarizing Acronym: OARS MI is extended counseling to change behavior Medication adherence, smoking cessation, weight loss, lifestyle change, diabetes, hypertension and many other disease states.


11 INTEGRATION OF METHODS WE KNOW PPCP/Prime Questions/Interactive Counseling Verification PAR Technique RIM(next week) Motivational Interviewing

12 MEDICATION ADHERENCE / MTM / PHARMACOTHERAPY REVIEW Logical next step in patient counseling We can think about counseling for adherence differently than the introductory counseling we do with a new prescription. New Rx: Make sure the patient knows how to take the medication, what its for and what to expect, how to deal with bad effects. Refill: What is the experience? Is the patient taking the medication correctly? Why? What you identify here could lead you to decide MI is an appropriate step for a patient. Patient with complex regimen, polypharmacy, etc.

13 A DIFFERENT PERSPECTIVE ON ADHERENCE Compliance Biomedical Model Practitioner centered Information giving Dictate behavior Authority Persuade / Manipulate Argue We are here to “save” the patient Adherence Psychosocial Model Patient centered Information for change Negotiate behavior Negotiation Understand, accept Address issues The patient saves self

14 ADHERENCE SOME KEY POINTS Low adherence can result in treatment change when its not needed! Patients may or may NOT be ready to change behavior It is the patients job to manage disease Patients want more involvement We will look at 2 methods to improve adherence Motivational Interviewing and the RIM Technique


16 MI EXAMPLES Most are MD and behavioral therapists Relatively newer for pharmacy professionals Examples: Appropriate (MD example/CD) Inappropriate (MD example/CD) Heart Foundation Video and related videos Heart Foundation Video Bill Matulich: Introduction to MIIntroduction to MI

17 MI GROUNDED IN THE SCIENCE OF BEHAVIOR CHANGE Trans Theoretical Model of Behavior Change (TTM)


19 TTM Stages of change Pre-contemplation Contemplation Preparation Action Maintenance Self efficacy The extent or strength in ones belief to reach a goal. Decisional balance The balance of the pros and cons related to a behavior change.

20 PATIENT READINESS TO CHANGE Pre-contemplationContemplationPreparationActionMaintenance Change Process Patient may be completely unaware. Consciousness raising Re-evaluationSelf liberationStimulus control High belief continued change is good / continue desired behavior Self-Efficacy (This will be good for me.) Low confidence I can do it or that change will help Increasing confidence in the positive aspect of change Increasing confidence High confidence Decisional Balance Cons > ProsCons ~ ProsCons < = ProsCons < Pros Pharmacist Role in the Process of Change Increase awareness Motivate, tip the balance Develop an action plan Assist and support the patient Provide reminders Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol 1992;47:1102–4, and Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991:191–202

21 MOTIVATIONAL INTERVIEWING MI is an effective (evidence based) way to talking with people about change. We are focusing on the skills (toolbox approach) you need. The process will come later with practice!

22 MOTIVATIONAL INTERVIEWING Begin by eliciting information from the patient Tell me about….? What are your thoughts on…? How much do you….? Do you think you…? So, where does not ______ leave you? Do you think it will be hard to….? What are the good aspects of….? What are the less good aspects of..? KEY: The information from questions like these help us understand where the patient is in terms of readiness for change.

23 MI TOOLS Rolling with resistance Expressing empathy Avoiding argumentation Developing discrepancy (dissonance = motivation) Supporting (self efficacy, i.e., this change will be good) READS (Roll, Express, Avoid, Develop, Support)

24 MOTIVATIONAL INTERVIEWING A partnership where we respect the patient, keeping their best interest in mind and eliciting ideas for change from the patient. Seeks to enhance the patient’s motivation to change Focus on exploring awareness, problems, ambivalence / resistance Aim: to create dissonance between goals and the non-adherent behavior. Patients will reduce the dissonance by adopting the adherent behavior The process makes change a “good” thing But remember, dissonance creates motivation for change and as dissonance decreases so can motivation which is one reason why we see relapse. The hope is the new behavior is rewarding and creates its own motivation to maintain.

25 EXAMPLE: ROLL WITH RESISTANCE Ignore any antagonistic elements. AntagonisticRoll with it… Look, I haven’t had any problems with not taking this, so don’t worry about it. I hope things stay that way, but maybe you should see your doctor since the damage to your kidneys caused by high blood pressure doesn’t really show up till much later when its too late for the medication to help. I don’t have a cough. Smoking is fine for me. I hope that continues to stay that way since many of the diseases smoking causes don’t have any early symptoms

26 EXAMPLE: EXPRESS EMPATHY StatementResponse Smoking is relaxingBut it’s bad for you. Smoking is relaxingIt will be hard to give up something that is so relaxing. Smoking is relaxingSo take up knitting or something.

27 EXAMPLE: AVOID ARGUMENTATION We want the patient to feel we are on their side. ArgumentativeAvoid Argument Your are late on your refill.Mrs. Smith, I see you are getting your medicine every 40 days or so when its only a 30 day supply You are supposed to take this twice a day. Taking this medicine twice a day will help more to lower your blood sugar. Smoking is bad for you.You may feel better if you smoke less.

28 EXAMPLE: DEVELOP DISCREPANCY Dissonance = motivation What’s good/not goodWhat are the good things and less good things about change? Pros and ConsYou may feel better if you take your medication more regularly. Your cough may decrease if you smoke less. GoalsTell, what is your goal related to your blood pressure medication? Re-enforce discrepancyThat’s right. Your blood pressure isn’t under control. Not taking your medicine for your diabetes is leading to high sugar readings and eventually, serious complications.

29 EXAMPLE: SUPPORT SELF EFFICACY A persons belief in the possibility of change And, the belief the change will be good for them Mrs. Smith, its terrific that you are taking the medication every day as we’ve discussed. Your blood pressure today was excellent, your goal to take this medication daily has really seemed to help.

30 MI EXAMPLES Diabetes counseling without MI Diabetes counseling with MI Cholesterol counseling with MI Ineffective smoking counseling Effective smoking counseling If you get bored, or are just a music fan, watch Tim Lafolette’s video of motivational interviewing set to the tune of Adele’s “Rolling in the Deep”“Rolling in the Deep”

31 READINESS RULER Readiness ruler questions are informative How important is the change? Do you think you can do it? Example: On a scale of 1-7, where 1 is the lowest and 7 the highest, how important is it for you to take you blood pressure medication every day? If the patient answers “3” ask: why not a “1” What would it take for you to say “4” or “5”?

32 THE ENVELOPE Smoking: I just don’t want to quit smoking. If I were to hand you an envelope, what would the message inside have to say in order for you to want to quit smoking? Using too much pain medicine: I take more than the prescribed amount because I have pain. If I were to hand you an envelope…..

33 MI: SUMMARY We use dissonance to create motivation Encourages patient involvement where they can state their own concerns and goals Provides us with information we can use to effect change Fills in gaps for patients Identifies barriers to good medication and habits Focus on how meeting your goals and changing behavior will be good for you Emphasizes empathy in responding to patients.


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