1. Module 2: Supporting Behavior Change
This module will review key counseling techniques and how to use them to conduct adherence counseling.

2. Learning Objectives Understand key counseling techniques
Learn and apply motivational interviewing tools to adherence counseling

3. Outline Key Counseling Techniques Therapeutic Alliance
Collaborative Health Education
Motivational Interviewing

4. Therapeutic Alliance Eye Contact Active Listening
Normalize and Be Nonjudgmental
Demonstrating Caring
Developing Trust
Individual Goals
Instill Hope
Know Your Limits
Therapeutic alliance refers to the relationship between the healthcare professional and patient. It is important to build a therapeutic alliance with your patient to encourage open communication and to work together to improve their adherence to ART. We will discuss what goes into developing a therapeutic alliance.

5. Therapeutic Alliance Eye Contact
Looking directly at someone is the first way to show them they are important and matter.
Do not look at the flipchart or document while the person is talking.
When counseling, attend to the what the person says and demonstrate attention with body language.
Nod when you understand someone.
Ask follow-up questions to clarify: “I want to understand better, can you tell me more?
Active Listening
EYE CONTACT: It is important to maintain eye contact with the patient to show you are paying attention to them. (See slide) __
ACTIVE LISTENING: Active listening shows that you are engaged in the conversation and listening to what the patient is saying. (See slide)

6. Therapeutic Alliance “Many people struggle taking ARVs every day.”
Normalize and Be Nonjudgmental
“Many people struggle taking ARVs every day.”
“Thank you for telling me so we can work together to make it easier.”
With body language
Leaning forward when someone is upset, offering a tissue if tearful
Facial expressions: nonjudgment and kind
With words
“I hear how hard that was, I’m sorry you had to go through that.”
“You are working so hard, I can tell you are handling so much.”
Demonstrating Caring
Normalizing statements, such as “many people struggle taking ARVs every day,” help the patient feel that they’re doing something that’s common for others. It is also important to be nonjudgmental, or non-critical, in your statements to help encourage the patient to be honest, even if they are sharing something difficult about their behaviors or personal life. We will talk more about the importance of normalizing and being nonjudgmental later on. __
There are multiple ways that you can demonstrate caring to patients during your discussions. For example: (See slide)

7. Therapeutic Alliance Demonstrate you want the best for them
Developing Trust
Demonstrate you want the best for them
“My goal today is to help you be in control of your health.”
I would like to think together how we can make things better for you.”
If they tell you something difficult, be kind.
Patient: “I haven’t been taking my medications.”
Provider: “Thank you for sharing that with me, it is hard to talk about but I appreciate you trusting me with this. Let’s talk about how we can work together for your health.”
Patient: “I’m just not sure I have HIV, I feel fine when I don’t take my medication.”
Provider: “I am so glad you brought this up. Let’s discuss your concerns.”
It is important to develop trust with your patient so that they feel comfortable being honest with you, especially about the challenges they may be facing when taking ARVs. For example, (see slide)

8. Therapeutic Alliance
Individual Goals
“What do you hope will be better for you in the future?”
“You’ve said your children are the most important thing to you, how might being healthy help your children?”
“What do you think would be better for you if you were taking medications?”
“I see that you have strength to handle so many challenges, I’m sure we can work together to help you take your medicine.”
“You are so motivated to be healthy for your children, taking your medications will help keep you strong and well.”
Instill Hope
In developing a therapeutic alliance it is important to discuss the patient’s individual goals, both to show that you understand them and to make plans that are specific to their lives. For example, (see slide). __
It is also critical to instill hope in patients and to encourage them to continue taking ARVs and take care of their overall health. For example, (see slide).

9. Therapeutic Alliance
If you feel someone needs more help than you can offer, find additional support and guidance.
Only offer realistic potential supports otherwise you could lose trust
Know Your Limits
Try to use additional resources such as other cadres of staff in your facility (like expert clients), or services in your community, to help provide the patient with the best care possible.

10. Normalize and Be Nonjudgmental
Adherence is a common problem because it is hard.
It is not the person in front of you being weak, it is the task that is hard.
There are many things that make good adherence a challenge:
- Managing appointments
-Taking medications every day
Dealing with stigma
Dealing with emotions related to being HIV+
Dealing with other life events
Taking a medication that doesn’t make the patient feel better now, might initially make them feel worse, and that they maybe are not sure is important.

11. Normalize and Be Nonjudgmental
Nearly everyone misses doses. We need to help people feel comfortable talking about this extremely normal event.
Nonadherence risks patients’ health. Providers are not harmed by nonadherence so we should not respond with anger or irritation.

12. Normalize and Be Nonjudgmental
Many people struggle taking ARVs every day.
Ask questions that make it clear you expect doses have been missed because this is normal:
“Tell me about your last missed dose?”
“When was your last missed dose?”
“What gets in the way when you miss a dose?”

13. Normalize and Be Nonjudgmental
Praise effort, not outcome. This will reduce over-reporting adherence so as not to disappoint you.
“That is wonderful that you are trying to take your medications every day.”
“Your viral load is low, you must be working hard to take your ARVs.”

14. Normalize and Be Nonjudgmental
Viral Load is high
What are some ways to give feedback?
Practice: Invite people to consider ways to non-judgmentally discuss high viral load with an adult/teen/parent? What language might they use?
Focus on nonjudgmental, normalizing, empathy
For example: Your viral load test result is high. The goal is to keep it below 1,000. I am glad you came to get your results so that we can help you work towards a lower viral load. Can you tell me why you think your viral load may be high?

15. Providing Health Education Collaboratively
You have a lot of information and you want to help people understand their health.
Providing information as a discussion rather than a lecture will:
Maintain the therapeutic relationship
Ensure the patient is receptive to the information
Assess what the patient knows
Target information that the patient needs
Improve motivation for the patient to learn the information
Help people become in charge of their own health
Questions promote discussion and will encourage the patient to also ask questions when they don’t understand.

16. Providing Health Education Collaboratively
Ask
Confirm
Inform
This is the model of providing collaborative health education. This model helps you to engage in a conversation with the patient by asking questions along the way to ensure that they understand the information you are giving them.

17. Providing Health Education Collaboratively
Ask
“A lot of people struggle taking ARVs. What do you find most difficult?”
Confirm
“I bet that is really frustrating. People keep telling you to do something you don’t like, is hard to remember, and doesn’t feel important.
Ask
“Would you like more information about why taking ARVs keeps you healthy?”
Inform
Focus on immediate benefits like keeping partners healthy, fewer medical visits, keeping the body and brain healthy, and fewer medications.
Ask
“What questions do you have about that information?”
“Did any of those benefits seem important to you?”
“With this information, how does it change how you think about ARVs?”

18. ACTIVITY
Facilitators will demonstrate how to provide collaborative health education to discuss viral load.
Ask
Confirm
Inform
We will conduct a quick demonstration of how to provide collaborative health education.

19. Introduction to Motivational Interviewing
Next, we will learn about motivational interviewing. Motivational interviewing is a therapeutic approach that attempts to move an individual away from a state of indecision or uncertainty and towards finding motivation to make positive decisions and established goals, in this case, taking ARVs every day as prescribed.

20. Motivational Interviewing: Meeting People Where They Are
We want to work with patients, not against them.
Life events, skills, and knowledge affect readiness to change.
If the provider is working to set goals with someone who has not committed to changing, this can lead to a struggle between you and your patient.
Signs you may be working against your patient:
You find yourself working hard to convince a patient
Arguing with a patient
When experiencing these signs, it is important to stop struggling with the patient and instead meet at his/her readiness to change.
It is important to “meet people where they are,” that is, understand our patient’s current readiness or ability to change, in order to effectively work with them. (See slide)

21. Motivational Interviewing: Increasing Motivation to Change
The following techniques can increase motivation to change and develop collaborative situations:

22. Motivational Interviewing: Increasing Motivation to Change
Open Ended Questions:
Avoid questions that are answered as Yes/No
“What makes it difficult for you to take ARVs every day?”
“What have you already done to try to take your ARVs every day?”
“What do you think is likely to happen if you keep taking your ARVs as you do now?”
Asking open-ended questions, rather than questions that can be answered as yes/no, facilitates better discussion and can guide what people have already tried so you can offer more helpful solutions. For example, (see slide)

23. Motivational Interviewing: Increasing Motivation to Change
Affirmations:
Praise Effort to Change
“I appreciate that you are able to be honest about the way you take ARVs.”
“You are clearly a resourceful person to manage so many challenges.”
“You’ve worked really hard to take your medications despite these challenges.”
By praising effort, we encourage more change-related behavior. For example: (see slide)

24. Motivational Interviewing: Increasing Motivation to Change
Reflective Listening:
Repeat back what they have told you
“You’re wondering if it matters if you take ARVs.”
“So you said you feel sad when you think about taking ARVs and that makes it really hard.”
“What I heard you saying is you are so overwhelmed, your medications are the least of your problems right now.”
Before offering solutions, demonstrate you have heard what they have told you by repeating back to them what they have said. For example, (see slide)

25. Motivational Interviewing: Increasing Motivation to Change
Summary Statements
“Let me see if I understand so far. You are struggling to take your ARVs because although you want to be well and healthy, you also have other problems in your life that make it difficult to focus on your health.”
“Here’s what I’ve heard you say, let me know if it is right. You feel fine when you miss a dose and you are feeling really uncertain about whether ARVs are necessary to keep yourself healthy.”
Summary statements are another way to demonstrate that you understand the situation. Working on solutions after this will be much easier now with your shared understanding.

26. ACTIVITY
Pair off with a partner and take turns role-playing patient and provider using the characters of Grace and John. Use OARS skills to discuss the character’s problems with adherence.
See facilitator’s guide for instructions on carrying out the activity. .

27. Grace
28 years old
Found out she was HIV+ 3 years ago while pregnant with her youngest daughter.
Has three children (8, 6, and 3 years old) who are all HIV-.
Took her medications every day while pregnant and breastfeeding, but now struggles to maintain adherence.

28. John 36 years old First diagnosed as HIV+ 10 years ago
Works hard to maintain income for his family (wife and two children, ages 10 and 7)
Has never taken his medications regularly for longer than a few months and has not noticed any problems with his health as a result

29. Discussion: Motivational Interviewing
What was difficult about using these skills?
What was different about your partner’s response to an open-ended question?
What did it feel like to have a statement affirmed?
What made affirmations or reflections feel genuine (or not genuine)?
How useful did summary statements feel?

30. Summary Accept: Approach behavior change nonjudgmentally.
Collaborate: Before providing psychoeducation, questions are key to involving someone in learning.
Motivate: Meeting someone where they are by demonstrating understanding can stimulate and support internal motivation.
Remember to use OARS techniques!

31. Questions?