Assisting With Patient Directed
Health Decisions
Lisa Becker, MAHS, DPh, NCPS
Claremore Comprehensive Indian Health Facility
To assist in behavior change, providers must
first assess patients’:
Health care knowledge
 Define motivational interviewing (MI)
 Discuss differences between provider and patient centered
 Define role of health care provider in patient guided
disease management
 Verbalize key concepts of patient centered decision
 Identify several MI processes to aid in assessing and
resolving patient resistance or ambivalence
 Identify several patient assessment tools useful in
practice and medical home models of care
The Problem
 Current models of care are paternalistic
 Communication is practitioner-centered, not
 Information giving vs. information exchange
 Save the patients vs. patients save themselves
 Labeling of patient: in denial, difficult, etc.
 Compliance vs. adherence
 Dictate rather than negotiate behavior change
MI Defined
The most recent definition of motivational
interviewing (2009) is:
“A collaborative, personcentered form of guiding to
elicit and strengthen
motivation for change”
The Spirit of MI
The “spirit” of MI is based on three key
 Collaboration between the therapist and
the client,
 Evoking or drawing out the client’s ideas
about change,
 Emphasizing the autonomy of the client.
Motivational Interviewing (MI)
 Useful in Chronic Disease, Chronic Care
 Useful in Health Promotion/Disease
Evidence based standards guide self managed
care with resulting improved outcomes.
The Tool Kit
Motivational Interviewing Skills
 READS principles
 Roll with resistance
 Express empathy
 Avoid argumentation
 Develop discrepancy
 Support self-efficacy
 Importance, confidence rulers
 The envelope
 The insurance card
 A look over the fence
R: Roll with Resistance
“You are not ready to quit smoking at
this time.”
When to use?
When patients are expressing issue
E: Express Empathy
“You are worried that you may not be able to quit
without your husband quitting.”
When to use ?
To demonstrate understanding and to
address a patient’s core concern
(Active Listening, Safe environment, Support,
Information, Rephrase with “feeling”)
Empathy Starters:
 “You seem_____”
 “In other words…”
 “You feel ___ because ___”
 “It seems to you…”
 “You seem to be saying…”
 “I gather that…”
 “You sound…”
Express Empathy, example ?
 Patient: Everyone makes it sound so easy…just
take the medicine, quit smoking, change your
diet, and exercise more!
 HCP: Well, studies show that these things do
improve quality of life. Just follow the plan I give
you and start taking care of yourself.
Express Empathy, example
 Patient: Everyone makes it sound so easy…just
take the medicine, quit smoking, change your
diet, and exercise more!
 HCP: You sound frustrated. You have been
asked to make a lot of changes to control your
diabetes and blood pressure and people don’t
seem to appreciate how overwhelming and
difficult all of it can be.
A: Avoid Argumentation
Example :
“You do not see yourself quitting smoking at
this time. What types of things are you willing
to do to get your cholesterol down?”
When to use?
To demonstrate understanding and to
prevent creating relational resistance
Avoid Argumentation, example
Patient: My doctor says I need to lose weight, take
the medicine, quit smoking, and reduce the salt
in my diet. I don’t think I need to quit smoking,
do you? How about cutting back?
HCP: It sounds like a lot to do. It’s great that you are
willing to take your medicine and watch your salt
intake. Cutting back on your smoking would be a
great first step. Ultimately, quitting smoking
would be the healthiest thing to do. What are your
D: Develop Discrepancy
“On the one hand, you have an important goal of
lowering your blood pressure to prevent stroke and
heart attack. On the other hand, your smoking raises
your blood pressure and your risks. What are your
When to use?
To create change talk and throw the
patient’s system out of kilter without
creating more resistance
(Identify core values of patient and if their behavior is
consistent with those values)
Develop Discrepancy, example
Patient: I want to lower my blood pressure
and reduce my risk of stroke or heart attack.
HCP: On the one hand, taking your medicine
as you do really supports your goal of lowering
your blood pressure. On the other hand,
smoking raises your blood pressure and
interferes with your goal.
S: Support Self-efficacy
“I am really glad to hear that you are thinking
more about quitting. What has you thinking
more about that?”
When to use?
To reinforce both thoughts and actions
regarding behavior change
Supporting Self-efficacy, examples
Patient: I don’t think I am ready to walk
4 days a week, but I am willing to try
twice a week.
HCP: That sounds like a great start and
will really help with your osteoporosis.
Patient: I’ve thought a little more about what you said
about quitting smoking.
HCP: Great. Tell me more about what
you have been thinking. What’s got you thinking about it?
F: Fence
 “If you were to wake up tomorrow and you were no
longer a smoker, what would you like about that?”
 “If you could snap your fingers and be at the
weight you wanted to be at, what would you like
about that? What would you see as the benefits?”
“Encourage change talk, create dissonance”
I: The Insurance Card
Patient: We’ve all got to die some time. Might
as well go out doing something I enjoy.
HCP: You really enjoy smoking and no one can
live forever any way.
Patient: Right.
HCP: May I tell you what concerns me?
Prevent “fixing” or “saving” the patient
R: The Ruler
Scale TWO concepts: Importance and
Example: from a 1 to 7 or a 1 to 10 scale
 How important is this change for you?
 How confident are you that you can
make this change if you want to?
 Why did you choose a ____, not a 1?
Elicits “Change Talk”
E: The Envelope
“If I were to hand you an envelope, what
would the message have to say inside for
you to consider quitting?”
(or whatever change you are discussing)
Explore readiness for change
Primary Skills in MI
“Change talk”: communication with the
patient in a way that elicits their own
reasons for change:
A. Disadvantages of status quo
B. Advantages of change
C. Optimism for change
D. Intention to change
Progression of MI
 Early emphasis on developing a solid relationship
with the patient
 Less relational work required later
 Later emphasis on engaging the
patient’s reasoning
 Allows you to speed up because patient is not
defensive and argumentative
 Saves time by precisely targeting the patient’s
thinking: rifle vs. shotgun
Patient Motivation
 Reflecting and empathizing with the patient’s
core motivational issues
 Helps to create early rapport with the patient
 Helps to initiate the process of engaging the
patient’s reasoning process
 If the patient feels that you haven’t heard and
haven’t respected their issues,
the patient will become defensive
and/or aggressive
 The patient is no longer listening to you
 Patient: I’ve tried to quit smoking for a while,
but I always come back to it again.
So, I don’t see the point in trying any more.
 HCP: It feels pointless to try to quit one more time if
you are just going to smoke again anyway.
 Patient: You got it!
 HCP: Now, you said that you’ve been successful in
quitting previously, but then you start back again.
When you quit initially, what worked for you?
 Follow (reflect)
Reflect back your understanding of core concerns and
line of reasoning
 Inform (ask permission) and identify
Ask permission to give information, make suggestions,
or clarify
Identify the core concerns
 Guide:
Present a menu of options and determine what the
patient wants to work on
Often called micro-counseling skills, OARS is a
brief way to remember the basic approach
used in MI.
These are core behaviors employed to move the
process forward by establishing an alliance
and eliciting discussion about change.
Open Ended Questions
Quick Quiz
 On a scale from 1 to 7, where 1 is not at all important
and 7 is very important, how important is it for you to
quit smoking?
 May I tell you what concerns me about your
continuing to smoke?
 You are certainly right about smoking being bad for
you. Tell me more about that.
 Earlier, you told me that you have a goal of reducing
your risk of stroke and heart attack. On the other
hand, smoking increases those risks. What are your
thoughts about that?
 It has been hard to quit smoking even though you are
concerned about its impact on your health.
Quiz, continued
 It sounds like you know smoking is bad for you,
yet it is difficult for you to quit. If you were to
wake up tomorrow and were no longer a smoker,
what would you see as the benefits? What would
you like about that?
 You see long-term negative effects to smoking.
What concerns you the most?
 What would have to change for you to
consider quitting?
 What makes it most difficult for you to quit?
 On the one hand, you see smoking as bad for your
health, but on the other hand, you are not ready to
Key Concepts and Principles
 Always maintain the spirit of motivational
interviewing (AGAPE)—acceptance and compassion
 Be patient (client)-centered—what does the patient
want to work on? What are his/her goals?
 Address the patient’s core concern(s) and line of
 Create a climate that is safe for the patient to learn
The patient needs to make the argument for change—
ask the patient what are the benefits of the change?
Key Concepts and Principles (cont)
Assess the patient’s understanding
of the risk/susceptibility involved in not treating the illness
or changing a behavior (eg, quitting smoking)
What does the patient understand about the illness and its
 Be honest and truthful with the patient—
don’t “soften” lab values (blood pressure is 155/110—“It’s a
little high”) to “protect the patient”—it backfires
 Be explicit in your empathy
 Explore the decisional balance
When faced with ambivalence or resistance, EXPLORE,
don’t explain
 Be aware of issue and relational resistance
 What does the patient know and
understand about the illness and its
 What is the patient’s understanding of
what can happen if the illness (behavior)
is not changed?
 What are the patient’s goals?
 What options are available to the patient?
 What does he/she want to work on first?
MI: Inspiration
“The mediocre teacher tells.
The good teacher explains.
The superior teacher demonstrates.
The great teacher inspires.
 *William A. Ward
Suggested Readings
 Berger, BA, APhA. Communication Skills for
Pharmacists. Washington, DC, 3rd edition.
 Definition of Motivational Interviewing.
 Rollnick, S, Miller, WR, Butler, CC. Motivational
Interviewing in Health Care.
The Guilford Press, New York. 2008.
 Rollnick, S, Mason, P, and Butler, C. Health
Behavior Change. Churchill Livingstone, London.

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