1. Dr. Christina Tarantola Licensed Pharmacist & Certified Health Coach
Motivational Interviewing: Adding value to your existing Community Pharmacy business
Dr. Christina Tarantola
Licensed Pharmacist & Certified Health Coach

2. Objectives
Define terms and value of Motivational Interviewing (MI) for the Community Pharmacist
Provide techniques and tools for effectively incorporating MI into practice
Describe the Stages of Behavior Change for the MI patient
Illustrate step-by-step process to implementing a successful MI Consultation Service for the Community Pharmacist

3. What is MI?
A method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior.
A goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.
A toolkit of principles utilized to move the patient forward in their goals.
Idea is that Knowledge X Motivation=Change
How many of us know what is right/wrong yet do it anyway!?
Getting to the WHY or motivation of the underlying need to change is how change occurs

4. Spirit of MI
Underlying spirit of MI as a crucial component of its efficacy. This spirit:
(1) is collaborative rather than authoritarian,
(2) evokes the client’s own motivation rather than trying to install it, and
(3) honors the client’s autonomy.
Rollnick S, Miller WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995;23:325–334.

5. The Origin of MI
Originally described by psychologist Bill Miller which involved helping patients with alcoholism change behaviors.
Miller’s research demonstrated that the style of the practitioners interaction is a critical component in facilitating change and improves patient outcomes.
Confrontation produced high levels of resistance, whereas a patient-centered approach reduced opposition.
In one study, the outcome, in terms of drinking 1 year later, was poorer in the group of patients who were given confrontational feedback vs utilizing MI techniques (Miller et al, 1993).
Miller and his group at the Center on Alcoholism, Substance Abuse, and Addictions (CASAA) in Albuquerque demonstrated that the style of the therapist’s interaction is a critical component in facilitating change (for a review of this literature, see Miller, 1995).
Reference: Miller W. R. (1995) Motivational Enhancement Therapy with Drug Abusers. Albuquerque, NM: University of Albuquerque Department of Psychology and CASAA.

6. What conditions have been studied?
More than 200 clinical trials of MI have been published, and efficacy reviews and meta- analyses have begun (Burke, Arkowitz, & Menchola, 2003)yielding positive trials for an array of target problems including:
Cardiovascular rehabilitation
Diabetes management
Dietary change
Hypertension
Infection risk reduction
Management of chronic mental disorders
Addictions: problem drinking, problem gambling, eating disorders
Smoking

7. How are Medication Therapy Management and MI linked?
MI techniques is a large portion of MTM and can be utilized along with counseling to empower patients
Patient Counseling, Medication Therapy Review, Motivational Interviewing, Disease Management, Assessment,
Patient Education, Documentation, Follow-up

8. Value of MI in Pharmacy Practice
Additional revenue stream (MTM, Smoking Cessation Program)
Increased professional-patient connection and relationship
Target Outcomes:
Humanistic: patient satisfaction, quality of life
Clinical: decrease in blood pressure, A1C, avoiding complications etc
Intermediate: behavior change

9. Available MI Programs Stress Management Weight Management
Medication Adherence
Smoking Cessation

10. What does conducting an MI session require?
Empathy and non-judgment: Changing behavior is not an easy task. Empathizing with the patient helps them know they are supported.
Dedication: Maintaining a non-confrontational, supportive session will lead to trust and rapport for future patients.
Checklist: Staying on track during the session helps the pharmacist AND patient focus on the goal of the meeting.

11. How motivational therapy works.
Treasure J APT 2004;10:
©2004 by The Royal College of Psychiatrists

12. Stages of Change
Rollnick and colleagues created a 12-question "readiness to change" questionnaire for use in matching intervention techniques with a given patient's stage of readiness to change.
Assessing which stage the patient is in will help you guide them to move forward on the “readiness” scale.
Your guidance and support helps the patient begin to be empowered and see that it is possible to change the behavior.

13. The Stages of Change
Rollnick and colleagues (39) created a 12-question "readiness to change" questionnaire for use in matching intervention techniques with a given patient's stage of readiness to change.
Precontemplation: Being uninformed or under informed about the consequences of one’s behavior may cause a person to be in the Precontemplation stage. Multiple unsuccessful attempts at change can lead to demoralization about the ability to change. Both the uninformed and under informed tend to avoid reading, talking, or thinking about their high-risk behaviors. They are often characterized in other theories as resistant, unmotivated, or unready for help.
Contemplation: more aware of the pros of changing, but are also acutely aware of the cons ambivalence. This phenomenon is often characterized as chronic contemplation or behavioral procrastination
Preparation: These individuals have a plan of action, such as joining a health education class, consulting a counselor, talking to their physician, buying a self-help book, or relying on a self-change approach.
Action: In most applications, people have to attain a criterion that scientists and professionals agree is sufficient to reduce risk of disease. For example, reduction in the number of cigarettes or switching to low-tar and low-nicotine cigarettes were formerly considered acceptable actions. Now the consensus is clear—only total abstinence counts.
Maintenance: While this estimate may seem somewhat pessimistic, longitudinal data in the 1990 Surgeon General’s report support this temporal estimate. After 12 months of continuous abstinence, 43% of individuals returned to regular smoking. It was not until 5 years of continuous abstinence that the risk for relapse dropped to 7%
Image Source: "Voice Continuity Plan for Hurrican Arthur." VOIXIS. N.p., 02 July Web. 12 Jan

14. Tools to advance client through stages
Consciousness (awareness): Sedentary people, for example, may not be aware that their inactivity can have the same risk as smoking a pack of cigarettes a day.
Dramatic relief: draw on emotions: inspiration from others who have done it (support group.)
Reflect on how behavior impacts others
Self-liberation: Telling others to keep accountability and have external support
Counter-conditioning: walking as a healthier alternative than “comfort foods” as a way to cope with stress.
Pre-contemplation Stage
Preparation Stage
Action Stage
Consciousness raising: use at precontemplation to apply knowledge
Dramatic relief: precontemplation
Self-liberation: preparation stage
Counter-conditioning: Action
Decisional balance sheet designed by Janis and Mann (1977)

15. Tools to advance client through Stages
Contemplation stage: pros = cons tendambivalence. If pros< cons, many individuals move to the Preparation or even Action stage.
Self-efficacy or confidence to avoid temptation/change behavior helps move from Preparation to Action.

16. MI Toolkit and Principles
Having compassion for the patient’s struggle and opening up an authentic conversation to create trust and rapport.
Discussing what the patient’s goals are and revealing how their behavior is does not reflect those values.
Having an openness about concerns, questions and working to resolve disagreement to maintain a peaceful environment.
Understanding that fears or “push-back” may come up and to “roll” with that resistance.
Establishing and supporting patient autonomy, decision-making and respecting boundaries
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self­efficacy
Express empathy – Acknowledging a person’s struggles and challenges without judgement, giving them the freedom to change. This principle is predicated on reflective listening.  
Develop discrepancy – Ambivalence is not an obstacle to change, it can actually be the catalyst to change. When a behaviour comes into conflict with a deeply held value, it is usually the behaviour that changes. In that way ambivalence can fuel the change being sought.
Roll with resistance – Reluctance to change is natural. It is important to not argue with the individual if they appear to be resisting the change. Invite new perspectives but do not impose them.
Support self-efficacy – A person’s belief in the possibility of change is an important motivator. Therefore when the Motivational Interviewer has and expresses a belief in the person’s ability to change, it can become a self-fulfilling prophecy. Motivation to change is elicited from the person being engaged in motivational interviewing, and not imposed from without.

17. Assumptions to Avoid This person OUGHT to change
This person WANTS to change
This person’s health is the prime motivating factor for him/her
If he or she does not decide to change, the consultation has failed
Individuals are either motivated to change, or they’re not
Now is the right time to consider change
A tough approach is always best
I’m the expert ­­ He or she must follow my advice
A negotiation approach is always best

18. Format of a Session
Being clear on time of appointment and investment price before the session begins.
Creating a comfortable, quiet and private space for the session if face-to-face intervention.
Having a checklist: goal sheet, list of pro’s and con’s, PMH/Intake form
Working to set 2 goals WITH the patient
Setting up a follow up call or appointment
Not for him/her

19. Format of a Session Health History/Patient Intake
Exploring patient readiness (stage) and goals
Assessing barriers to change
Utilizing MI toolkit to move patient forward
Creating a plan WITH the patient
Setting two SMART goals
Follow up

20. SMART goals
Specific (and strategic): Linked to position summary, departmental goals/mission, and/or overall goals and strategic plans. Answers the question—Who? and What?
Measurable: The success toward meeting the goal can be measured. Answers the question—How?
Attainable: Goals are realistic and can be achieved in a specific amount of time and are reasonable.
Relevant (results oriented): The goals are aligned with current tasks and projects and focus in one defined area; include the expected result.
Time framed: Goals have a clearly defined time-frame including a target or deadline date.

21. Documentation
Use a SOAP (Subjective Objective Assessment Plan) format to document interventions
Keep a copy of patient goal sheet
Provide relevant handouts to session (Smoking Cessation pro/con sheet, Healthy Plate Method)
Appropriate follow up (within 1 week)

22. Example Patient Case Collect all relevant data: Family Hx Occupation
PMH
Main concerns/health goals
Medication/Supplement List
Nutrition Hx
Present patient case of diabetes patient

23. T2DM Patient
“I know I need to lose weight and it will help my numbers. My A1C is 9% and I should start exercising. I know I will feel better once I start but it is hard to fit exercise into my routine and I don’t want people to see me exercise. Anytime I try, it never seems to make a difference anyway.”
What resistance behaviors is this patient displaying?
Change talk “I should start exercising”

24. Resistance behaviors Blaming Excusing Minimizing
Other behaviors patient may exhibit:
Ignoring provider
Hostility
Disagreeing

25. How can you help?
Help facilitate patient’s own decision-making process.
Use honest, assertive communication
“Meet them where they are at” in their stage of change
Use the MI toolkit (empathy, roll with resistance etc)

26. Back to our T2DM Patient…
“You seem to feel discouraged to work out because of others seeing you. However you also mentioned it helps you feel better after you do exercise and it can help lower your A1C. What are your thoughts about how you could carve out a small amount of time to increase your activity level?”
Which MI tools did the pharmacist use here?
-Empathy, roll with resistance, developing discrepancy, supporting self-efficacy
Also edifying confidence to change

27. Creating and sustaining an effective MI practice
Attend live or online Continuing Education MI courses and trainings.
Hire an MI pharmacist to provide the coaching sessions for your clients.
Create the space for private sessions to be held.
Establish time slots, cost of sessions and marketing strategy for new practice.
Measure patient outcomes, revenue and MI effectiveness.

28. Measuring effectiveness
Outcomes:
Direct indicators (health outcome; for example, blood glucose, blood cholesterol; utilization of healthcare services; for example, hospitalizations or doctor visits)
Indirect indicators (subjective report, self-assessment, questionnaires)

29. Training Requirements
The characteristics of effective training include:
–  A focus on the underlying philosophy and principles of motivational interviewing
–  Adequate duration to allow embedding of skills
–  Opportunities to practice skills through simulation and role play
–  Opportunities for ongoing feedback and supervision.
Research suggests that empathy, communication skills and an affinity with the philosophy of motivational interviewing are important

30. Training Requirements
Workshops may involve:
Role playing
Written assignments
Case-based interactive instruction
Watching videos of interviewer/interviewee
Progressive individual feedback on performance, and
Personal follow-up coaching
More than 1 training session may be needed with feedback and coaching

31. Questions?

32. Resources
Heckman, C. J., B. L. Egleston, and M. T. Hofmann. "Efficacy of Motivational Interviewing for Smoking Cessation: A Systematic Review and Meta-analysis." Tobacco Control 19.5 (2010): Web.
Michael, Taitel. "The Impact of Pharmacist Face-to-face Counseling to Improve Medication Adherence among Patients Initiating Statin Therapy." Patient Preference and Adherence (2012): Apr Web.
Miller W. R. (1995) Motivational Enhancement Therapy with Drug Abusers. Albuquerque, NM: University of Albuquerque Department of Psychology and CASAA.
Prochaska JO, DiClemente CC Transtheoretical therapy: toward a more integrative model of change. Psychotherapy. 1982; 19:276-88
Song, Dan et al. "Effect of Motivational Interviewing on Self- Management in Patients with Type 2 Diabetes Mellitus: A Meta-analysis." Science Direct, Web.
"Training Professionals in Motivational Interviewing." The Health Foundation (2011): 1-37.
"Transtheoretical Model (or Stages of Change) - Health Behavior Change." Prochange.com. N.p., n.d. Web. 18 Jan
Treasure, J. L. & Schmidt, U. H. (1997) A Clinician’s Guide to Management of Bulimia Nervosa (Motivational Enhancement Therapy for Bulimia Nervosa). Hove: Psychology Press.