Motivational Interviewe

MotivATIonAl InteRVIewinG
By JAn KAVOOkjIAn, MBA, PH.D.

Reviewed by Chrystian R. Pereira, Pharm.D., BCPS; and Shannon W. Finks, Pharm.D., FCCP, BCPS (AQ Cardiology)
LeARninG Objectives
to engage in healthy behaviors so that chronic disease
1. Classify helpful and harmful interactions between
outcomes are positively affected.
patient and provider to develop motivational inter-
Many theories have tried to explain and predict why
viewing (MI) skills. patients do or do not engage in behaviors that are good
2. Given patient-resistant scenarios, apply an appro- for them (e.g., taking prescribed drugs) or why they
priate MI-based response. do not stop engaging in behaviors that are considered
3. Analyze the strengths and weaknesses of a health- harmful (e.g., smoking). The transtheoretical model of
behavior change intervention according to MI change suggests there are sequential stages of motiva-
principles. tional and behavioral readiness for change. These stages
4. Design an MI-based communication strategy to help explain action and aid in decision-making about
increase patient adherence to a target health how to intervene with a patient who is in either the
behavior. action or pre-action stage. Spending time trying to cat-
5. Assess provider communication strategies that pro- egorize a patient into a transtheoretical model of
mote or hinder treatment adherence. change stage is not always practical in health care
6. Given different patient attitudes and responses, delivery. A more efficient intervention involves
rationalize the use of certain MI strategies. supporting self-efficacy (SE) for the patient to move
to a state of change or action by nonjudgmentally
exploring ambivalence and resistance with the pre-
IntRoDUCTIon action patient. This process is based on patient-
centered motivational interviewing (MI). Specific MI
Nonadherence to medication regimens has been
terms used in this chapter are defined in BoX 1-1.
studied extensively for about 5 decades yet still is as high
as 50% to 80% for some diseases/drugs. Ambivalence and Resistance to
Nonadherence to drugs and other health behaviors for Changing Health Behaviors
disease management continues to rise and contribute Ambivalence can be identified by characteristic
to the increased prevalence of chronic diseases and their behaviors such as procrastinating, being stuck, and
complications. The resulting outcomes are costly for inconsistency between stated attitudes and actual
patients and the health care delivery system. Significant behaviors (e.g., a patient says she will fill her prescrip-
effort and study has been given to reducing these costs tion on time but consistently does so a week after
and detriments to patients, including interventions to the due date). Underlying any target health behavior
help patients decide may be
BASeline Review ResoURCes

The goal of PSAP is to provide only the most recent (past 3–5 years) information or topics. Chapters do not pro-
vide an overall review. Suggested resources for background information on this topic include:
• Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care. New York: Guilford Press, 2008.
• Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London: Churchill
Livingstone, 2000.
• Miller WR, Rollnick S. Motivational Interviewing, 2nd ed. New York: Guilford Press, 2002.
PSAP-VII • ScIeNce AND PRAcTIce OF PhARMAcOTheRApy 1 MOTIVATIONAl INTeRVIewING

AbbReviATIons in THIS CHApteR G.H., a 58-year-old man with T2DM and hypertension
(HTN). G.H. is resistant to several health behaviors
HTN Hypertension that would have a significant and positive effect on both
MI Motivational interviewing his T2DM and his HTN. BoX 1-3 shows statements
SE Self-efficacy G.H. might make as a resistant patient.
T2DM Type 2 diabetes mellitus The literature is replete with theories and mod-
els proposed as frameworks for behavioral interven-
tions to address ambivalence and resistance; a founda-
thought processes in which the patient may not tional premise of these theories and models is that the
know what to do or why it should be done, may not patient must be motivated to change. Because moti-
believe it will help, or may doubt his or her ability to do vation is an important component of positive lifestyle
it. changes, all health disciplines should be equipped with
Consider patient J.C., a 39-year-old woman who is effective communication skills to address motivation.
obese and has type 2 diabetes mellitus (T2DM). J.C. is Currently, few health professional schools equip their
ambivalent about engaging in physical activity and about graduates with psychosocial counseling skills focused
changing the foods she eats to achieve weight loss. State- on health behavior change. Few health care providers
ments she might make include those listed in Bo X 1-2. have the necessary training to use these skills. In addi-
Patients resistant to change may be easier to tion, research suggests that the clinical interview train-
identify; they sometimes, but not always, engage in ing they have received is well intended but may do more
overt behaviors like arguing, raising their voice, harm than good. In fact, providers may contribute to
adopting a strident tone, blaming, excusing, the problem of nonadherence by leaving the patient
feeling disrespected, thereby exacerbating
discounting, becoming hos- tile, interrupting, or
ambivalence or resistance. Of importance, clinicians
ignoring what the provider says. Resistance can derive
should critically self-evaluate their communication
from two general sources: relational discomfort or
style to determine if and how well it aids in exploring
direct issues specific to the individual. Relational and addressing ambivalence or resistance with
resistance evolves from something about the patient- patients, even during brief patient interactions.
provider interaction that creates an uncomfortable
feeling, or dissonance, for the patient. Often, this stems Background and Rationale for MI
from feeling misunderstood or having self- esteem Motivational interviewing is a theory-based commu-
violated in the areas of competence, autonomy, or nication skills set with an established evidence base for
approval. Issue resistance derives from practical or its potential to affect patient outcomes in comprehen-
logistic barriers in the daily life of a patient. These may sive disease management, even during brief encounters.
include knowledge deficits, inadequate transportation Motivational interviewing began from applications in
or money to get prescriptions refilled, a cultural pref- the addiction and substance abuse fields; it is included
erence for unhealthy foods, or an aversion to adverse in the U.S. Substance Abuse and Mental Health
effects from a drug. Services Administration’s National Registry of
A resistant patient can often be identified by examin- Evidence-Based
ing the statements made by the patient. Consider
patient
Box 1-1. Definitions of Specific MI Terminology

Change talk: The patient discusses positive aspects of or plans for change for a target behavior (e.g., what the change will be like, wh
Face: This is the positive self-image that a person wants to be seen as and wants to claim for himself.
MI principles: These five communication principles include expressing empathy, supporting self-efficacy, avoiding argumentation
Righting reflex: This is the clinician’s instinctive desire to “fix” the nonadherent patient by taking an advising, expert stance on ho
Self-efficacy: Defined as one’s confidence to engage in a particular target behavior, higher self-efficacy predicts action for change
Spirit of MI: A way of being that is foundational to MI-adherent intervention, the spirit of MI is collaborative, caring, nonjudgmental,
MI = motivational interviewing.
MOTIVATIONAl INTeRVIewING 2 PSAP-VII • ScIeNce AND PRAcTIce OF

PhARMAcOTheRApy
Box 1-2. Typical Statements from an Ambivalent Patienthyperlipidemia,
with Obesity and congestive
Type 2heart failure,
Diabetes human immu-
Mellitus
“Yeah, I know I need to lose weight and I know it will help my numbers, but I just don’t feel like exercisingobstructive
nodeficiency virus (HIV), asthma/chronic and dieting.”
“I AM worried that my A1C is 10%, but it’s hard to fit exercisepulmonary disease,
into my busy and multiple sclerosis.
schedule.”
“I should start an exercise routine because I feel better when I do,Appropriate
but it hurtstraining in MI equips providers to help
once I start.”
patients decide to
“I know I need to cut back on those comfort foods that make me gain weight, but they’re make changes
what I’vein always
health eaten
behaviors.
and I wouldn’t kno
These targeted health behaviors may include
“It seems like every time I try to do anything, it’s not enough to make a difference; I don’t know what I could do medica-
that would make a
tionpeople
“I like my smaller-size clothes when I lose weight, but I don’t like adherence,
to seechanges in dietary
me exercising; intake (e.g., reduc-
it’s embarrassing.”
A1C = hemoglobin A1C. tion in salt intake for HTN management), increased
physical activity (e.g., for risk reduction of diabetic
complications), and smoking cessation. Nonadherence
to these important health behaviors often stems from
some form of resistance or ambivalence; MI strategies
are designed to explore and resolve the resistance and/
or ambivalence that interfere with decision-making for
actions that benefit health.
Motivational interviewing is a patient-centered pro-
cess used to gauge a patient’s readiness to act on a target
behavior and to apply specific skills and strategies that
respect the patient’s autonomy and facilitate confidence
and decision-making. The use of an MI-consistent coun-
seling process increases behavior change by stimulating
a patient’s internal motivation for change while address-
ing any ambivalence or resistance to change. Motiva-
tional interviewing includes five specific communica-
Box 1-3. Typical Statements from a Resistant tion skills and several tools or micro skills to assess read-
Patient with Type 2 Diabetes Mellitus and iness for change.
Hypertension A practitioner can use MI to establish the patient’s
“I know you’re going to try to make me feel bad about understanding of the illness and treatment plan, deter-
myself like the nurse and the doctor did, so you may mine how this treatment plan fits with the patient’s goals
as well quit now.” for health, address ambivalence and/or resistance, and
“I just don’t see why it’s a big deal—my numbers aren’t help the patient start talking positively about the
that far out of range and I feel fine.” change. In contrast, traditional patient education and
“I work hard and I am not giving up my after-work advice- giving efforts usually attempt to persuade or
drinks and cigarettes at the bar with my coworkers.” convince a patient to make a significant health
“No, I don’t see the value in cutting back on portion sizes behavior change by providing external motivation
or salt in the choices I make at the all-you-can-eat through advice and questioning. Unfortunately, such
buffet lunches I share with my buddies; getting the traditional methods can cause inadvertent shaming,
most value for what I pay is more important to me.” judgments, scare tactics, and even arguments. This
“I take my medicine most of the time anyway, so I kind of counseling approach can increase patient
should be able to eat what I want…OK, so I miss it resistance, making the patient less likely to be adherent
a few days a week, but don’t make a big deal out of to the target behavior.
it. I feel fine.”
Internal Motivation and Decisional Balance
Programs and Practices. Most early applications of Any person who thinks about making a health behav-
MI intervention were given in the context of lengthy, ior change goes through an internal weighing of the
repeated psychotherapy sessions and were successful in pros and cons for the change before deciding to follow
helping patients change difficult addictive behaviors. through. This person should think about the last
In recent years, with increased prevalence of health attempt to address a health behavior target. If trying to
detriments like medication nonadherence, sedentary engage in greater physical activity, the pros may
include factors such as better health, risk reduction,
lifestyle, high-fat and high-sodium diet, and smoking
more energy, and better fit of clothes. The cons may
and alcohol consumption, the focus of MI intervention include lack of time, lack of energy, other
studies has shifted to considerations of brief interven- responsibilities taking priority, and lack of adequate
tions in health care settings. These studies assess the attire/equipment/facility. If an individual is not taking
potential for better outcomes through the behavioral action (e.g., engaging in physical activity), the cons
management of chronic diseases like T2DM, HTN, for making the change are more salient than the pros.
This is the decisional balance, in which the person will
not decide to take action until the
pros for making the change outweigh the cons. Table when recognized and supported by the provider, and is
1-1 depicts a typical patient’s decisional balance for most likely to be sustained.
medication adherence.
The weighing of pros and cons is the actual develop- The Righting Reflex
ment of the internal motivation that enables a The desire to help others is foundational to the spirit
change and a decision to remain changed. In MI, the of MI; it must be present for MI to be genuine and
process of interviewing helps the patient express salient effective. Unfortunately, many clinicians have been
pros for the change, rather than the provider telling the trained in a problem-solving, fiX-it mode of
patient what the pros should be. This process, known communication that feels successful and rewarding.
as eliciting, uses decisional balance to help the This desire to “fiX the patient” can supersede the
patient make the argument for the change while patient’s role in decision- making. As a result, the
responding to MI- based questions (interview). The internal motivation development processes that must
patient is led to internal motivations that already exist take place for the patient to make a lasting change do
but that the patient is not actively exploring or thinking not occur. The originators of MI refer to this fiX-it mode
about. as the righting reflex.
The righting reflex is counterintuitive to human
External Push Encounters nature. We all want to make our own decisions rather
It is human nature to want to make our own than be told what to do. Autonomy is an important part
decisions. Although some segments of the population, of feeling powerful and productive as a human being.
including a few ethnic cultures, prefer to have their Being powerless and unproductive produces feelings
health care provider take directive charge over of being stuck and even of depression; this sense of
treatment decision-making, most individuals benefit pow- erlessness and being unproductive can interfere
from participating in decisions about their treatment. with making decisions about health behaviors. The
This is especially true regarding the health behaviors righting reflex assumes an expertise and authority over
needed to manage and prevent complications from what is best for a patient. This reflex is often an
disease. However, many patient- provider instinctive reac- tion born of some combination of
interventions are based on the assumption that caring and the need to feel successful in getting the
patients who obtain information about their health will patient to do what the provider desires. It is
be motivated to make big changes all at once. This important to become immersed in a concerted patient-
rationale assumes an outside authority or expertise centered communication style because a provider-
over a patient’s life; in reality, patients are truly the centered approach will leave the provider feeling a loss
experts about their life and what will and will not work of face, or esteem, when the patient does not, or will
for them. This external push can do more harm not, do what is advised.
than good. With patients who want to be autonomous, the pro-
Some patients will openly resist further progress, vider’s righting reflex gets in the way and violates the
whereas others will say what the pharmacist wants to patient’s face by sending a message that says, “I know
hear, then leave and do nothing differently. Helping what’s best for you [and you do not; therefore, you
the patient decide to make a change is the focus of the must be incompetent or incapable].” Most people
MI- consistent intervention. This type of individual respond negatively to that message, either consciously or
decision is rewarding and empowering to the patient, uncon- sciously, by digging in their heels further and
especially refusing even to talk about change. Some may
withdraw and respond dishonestly to smooth over the
resulting dissonance they feel.
Table 1-1. Example of Patient Decisional Balance for Medication Adherence
ProsCons
Prevent complicationsInconvenient or
complicated regimenControl my own health Dislike the expense
Avoid hospitalizationFood interaction with my

avorites Have more energySide effects are unpleasant
Make my family happyRepresents how ill I am, do

not want reminder
Because of their training, most providers feel success-
ful and comfortable in the clinician-interviewing mode.
PhARMAcOTheRApy
Have peace
I feel
of embarrassed
mind for people to know I have illness
An efficient way of getting information quickly, this talking. A proverbial test of successful MI use is when
mode usually involves a series of closed-ended or the clinician uses open-ended questions and other MI-
yes/no questions, followed by unsolicited advice consistent strategies while the patient does most of the
about how to fiX the problem. The interview feels talking about his or her experience.
autonomous and productive, but it is a provider- For most clinicians, provider-centered communica-
centered way of communicating with a patient that tion has been reinforced at all levels. These encounters
usually results in the provider doing most of the can include a highly scientific level of communication
with complexity, wording, or acronyms that are beyond A1C is a 10, and that’s a little higher than where we’d
the patient’s literacy or educational level. This type of like to see it.” Although this feels less confrontational
provider-centered communication is currently high- and like a softer way of delivering the message, it is
lighted as the antithesis of the growing body of evidence dishonest and could even send a harmful message. When
supporting patient-centered communication. Over- the patient hears the pharmacist discounting even a 7.2
coming the righting reflex is one of the greatest chal- hemoglo- bin A1C, the impression is given that it must
lenges clinicians face when being trained in MI. not be that
THe SpiRIT oF MI
As established by Miller and Rollnick, MI is defined
as “a collaborative, person-centered form of guiding to
elicit and strengthen motivation for change.” The phi-
losophy underlying the spirit of MI is based on three
main tenets: collaboration, evocation, and autonomy.
Each tenet is an important component in patient-
centered care and communication. The spirit of
MI is a foundational way of interacting with
patients and includes being patient-centered,
collaborative, caring, nonjudgmental, and honestly
assertive and directive.
Being patient-centered and collaborative may not
come naturally to all clinicians, and this approach may
require decision and effort to practice and develop.
Set- ting aside all preconceived notions and judgments
about a patient is challenging; however, such
notions and judgments can be destructive in a
pharmacist-patient relationship, and a conscious
decision to set them aside is required.
The spirit of MI involves attentive, active listening
and reflecting and includes trying to help the patient
feel understood and cared for. This is facilitated through
empathic, nonshaming responses, together with the
deliberate use of a nonjudgmental, conversational voice
tone. The most important thing to remember about MI
is that the first priority is building and preserving
the relationship, even if the patient leaves without a
commitment for change. Chances are that if the
spirit of MI is engaged and the patient’s autonomy is
respected, a seed of dissonance will be planted. The
patient will begin to think about the change and, when
ready to talk about it, is likely to seek you out.
Many perceive that because MI is patient-centered,
it is nondirective and should not include giving unso-
licited advice. This is untrue. Using MI appropriately
requires an assertive, honest approach that may be direc-
tive and gently confrontational. Being direct and hon-
est removes uncertainty, builds trust, and is an impor-
tant foundation for the spirit of MI. Clinicians often
use language that is not direct and assertive to cushion
the blow of bad news. For example, “Your hemoglobin
important. An MI-consistent statement is more direct provider wants. This means that when being truly
and assertive: “Your A1C is a 10, which is high. What patient-centered, there is no script or algorithm of the
are your thoughts about that?” or “Your A1C is high right way to respond to every patient every time. Of
—it is at 10.0. Tell me what you know about what this importance, many different tools can be selected that
number puts you at risk of.” are equally MI consistent in any encounter. There
Being direct and assertive requires practice for pro- will always be choices for how to use these skills for
viders who do not like to confront patients. engaging one patient versus another or for what
However, it is an honest way of communicating that helps with a certain patient today versus last time.
will earn mutual respect and trust, which are Often, MI is referred to as a technique that can be
important to the MI-consistent priority of building used to motivate the patient. This is not accurate. Stat-
and preserving the patient relationship. Foundational ing that one person will apply strategies to motivate
to this type of statement, and to the spirit of MI, is another person implies external push or pull, which
careful attention to nonthreatening, nonjudgmental, contradicts the premise that patients need their own
nonverbal behaviors (e.g., maintaining eye contact, internal motivation to decide whether to change a tar-
using a calm and conversational voice tone, using get behavior. Motivational interviewing is about help-
approachable and responsive body language such as ing patients decide to change by drawing on the inter-
facing the patient directly and nodding to affirm while nal motivation they already have; this is done by inter-
listening). viewing in such a way that the patient ends up making
an argument for the change. This concept illustrates the
spirit of MI evocation tenet.
ASSUMptionS, PRemiSeS, AnD ConceptS
Choosing Among MI Strategies Establishing Patient Understanding About Disease
Motivational interviewing includes five main Risks, Clinical Parameters, and Treatments
communication principles, several assumptions, and a An important early step in talking with a patient
series of micro skills that help facilitate the tenets about a health behavior change is establishing the
described above (i.e., collaboration, evocation, and patient’s understanding about why the change is
autonomy). The art of MI is about remaining patient- important to the management of a particular disease. This
centered and metaphorically flowing or dancing means assessing knowledge about the diagnosis, the risks
along as the patient leads the conversation, as of what happens
opposed to wrestling the discussion to go where the
from uncontrolled disease, the clinical parameters gies. First, it introduces the topic early in the conversation
(e.g., laboratory values), and the possible effects of the so that it can be tied directly to the target behavior
drug or target behavior on these. The patient must be changes. Second, it explores what the patient knows first
able to make the tie between changing the target before giving information, deferring to the patient’s
behavior and reaping the benefits (pros) of doing so competence; this is important for face-saving, and it is
with respect to disease and risk control. In the G.H. also efficient
example of a resistant patient, there were some
knowledge deficits. In the following example, a
pharmacist response establishes the understanding of risk:
Pharmacist: Mr. H., tell me what you know about how

your blood pressure numbers put you at risk.
G.H.: I feel fine most of the time; I don’t think it
means anything—maybe that I’ll have a heart attack
someday, but that’s not going to happen anytime soon.
Pharmacist: That’s right, high blood pressure can
contribute to causing a heart attack. May I share some
additional information with you? [G.H. agrees]
Pharmacist: High blood pressure doesn’t always have
obvious symptoms, and that may be why you’re feeling
fine most of the time. I am worried about the times
that you’re not feeling good. High blood pressure means
risk of stroke and heart attack, especially if the numbers
continue to rise. What are your thoughts about that?
This dialogue accomplishes several important strate-

PhARMAcOTheRApy
because the pharmacist then can give only the be used to support or maintain patient autonomy:
information the patient does not know. In addition, open-ended questions, agenda setting, and asking
the risk information that required consciousness- permission before giving advice or information.
raising came from the patient’s own words; this can Open-ended questions support autonomy and face,
be thought provoking and reinforcing by itself. Using but they also elicit more information than closed-ended
terms introduced by the patient can seem less like a questions. As described previously about the righting
scare tactic than if they came first from the pharmacist. reflex, clinicians trained to ask yes/no questions to
Another important strategy in this dialogue is gather health information often go through a checklist
preservation of the patient’s autonomy (i.e., the right of questions so that problem solving and advice can be
to choose whether to receive the information given). provided. Many patients, when asked questions having
By asking permission to give information, the dichoto- mous answers, feel that they are being
pharmacist respects the patient and circumvents the interrogated and that judgment is rendered on the basis
potentially dam- aging effects of the righting reflex. of their response. When only two possible responses
exist (yes or no), and the patient’s honest response is
Micro Skills That Maintain Patient Autonomy not what the provider wants to hear, patient
Maintaining patient autonomy is one of the perception can be that the provider is right and the
three tenets of the spirit of MI. Three micro skills can patient is wrong. This type of questioning
Table 1-2. Examples of Closed- and Open-Ended Questions

Closed-Ended QuestionsOpen-Ended Questions
Have you tried walking
What for
areactivity?
some things you can think of to get more activity into your routine? Wha
Can you tell me what this medicine is for? Tell me what this medicine is for.
Can you think of anything to help remember?What are some things you can think of to remember to tak
Did you ever miss taking any of your pills? About how many pills did you miss in the past week?
Did you get your refill on
I noticed
time? that the prescription has been ready for a few days. Tell me about an
Can you tell me what the doctor told you about what it means to have
Tell me
diabetes?
what you know about diabetes.
Have you been cutting out the salt in your diet toWhat is your understanding about the impact of salt in the foods help your high blo
Are you weighing yourself every day? (to monitor CHF) How has the monitoring/weighing been going this p
Your INR is up to 3.3 this time; did you eat any

Yourbroccoli
INR is up
orto
other
3.3 this
effective
week;foods
whatthis
are week?
some things you can think of in your lif
CHF = chronic heart failure; INR = international normalized ratio.
often puts the patient on the defensive, leaving a management), but the patient’s interest is in another
feeling of alienation and loss of control. Switching from a topic (e.g., medication taking). Patients are likely to
closed- ended to an open-ended approach is one of the remain anxious about getting their own topic discussed,
greatest challenges clinicians face in MI training. If the and may be unable to focus if the pharmacist asserts a
closed- and open-ended questions in Table 1-2 are provider-centered topic. Agenda setting involves telling
contrasted, more information is likely to be offered patients what topics can be discussed and asking which
by the patient with the open-ended format. In topic they would like to talk about first. Here is an
addition, the patient is likely to perceive that the example from the J.C. ambivalent patient example:
pharmacist is person-centered and interested in
hearing patient perspectives, not just in problem Pharmacist: Ms. C., there are three things we can dis-
solving and giving opinions from a provider- centered cuss today to help bring your blood sugar numbers down.
approach. These are medication taking, small changes in the foods
Another autonomy-preserving MI micro skill is known you eat, and getting more activity into your routine.
as agenda setting. This involves giving the patient choices Which of these would you like to talk about first? [Patient
about which of several topics to talk about first. Often, chooses medication taking, and a discussion takes place;
the pharmacist has in mind something particular to dis- this may include evocation through a question like “What
cuss (e.g., salt reduction in foods for HTN are some things you can think of to remember to take your

medication?” This involves getting patient input before If the pharmacist’s time is limited, a boundary and
asking permission to give suggestions, if needed.] structure to the conversation can be set in an MI-
Pharmacist: Now that we’ve discussed medication consistent manner. Although it sounds provider-
taking, which one of the other two topics would you centered, the patient should be told up front in an
like to talk about? honest, assertive manner that a time constraint exists.
This approach is much more comfortable for both
In addition to preserving patient autonomy, agenda pharmacist and patient than not setting the boundary
setting is efficient. It helps organize the conversation, up front but inserting it unexpectedly and awkwardly
even adding some structure, if needed, in a time- at the end. (“So sorry, Ms. C., I hate to cut you off—I
limited setting. Going back to the pharmacist statement realize we’re out of time, and I guess I should have told
you up front that we had only 15 minutes to talk.”)
to J.C., a derivative that asserts the time limit might look
When met with an unexpected cutoff, the patient may
like this:
feel unimportant and think the pharmacist just did not
want to continue listening. However, if discussed up
Pharmacist: Ms. C., there are three things we can talk
front, the patient will not have doubts when the
about to help bring your blood sugar numbers down. encounter has to end as expected.
Because we have only 5 minutes today, which one of If the pharmacist is practicing in a setting with open
these would you like to talk about this time? OR time or appointments, another strategy is to use an
Because we have only 5 minutes left in our time together open- ended question such as “What type of strategies
today, which topic would you like to talk about next? would you like to talk about today for bringing your
OR Now that we’ve talked about medication taking blood sugar down?” OR “What concerns you today?”
and have only 5 minutes left in our session, which one of The third micro skill for preserving patient
the other two topics would you like to talk about next? autonomy involves asking permission before giving
information or advice. In talking with a patient and
realizing a knowledge deficit exists, the righting reflex
prompts the pharmacist to respond with an argument
(“yes, but…”). This is often followed by evidence-
based information or inadvertent scare tactics. These
responses are not MI consistent and can do more harm
than good to a change intervention. When a
pharmacist feels the righting reflex emerging,
together with a strong desire to give information or
advice, the best approach is to step back and apply
the episodic steps in BoX 1-4. These steps can help fulfill
the evocation tenet of the spirit of MI.
This autonomy-preserving, systematic process is a
treatment for the provider’s righting reflex. An
example of this process can be seen in the dialogue
with the resistant patient, G.H., in the previous section
about establishing patient understanding regarding risks
and susceptibility. Permission-asking can be direct (e.g.,
“May I share some information with you?”) or indirect
(e.g., “I’d like to tell you about your blood pressure, if
you don’t mind” OR “If it’s OK with you, I’d like to
recommend a few things you can do to remember to
take your medication”). Asking permission to give
information or advice is another MI- consistent
strategy that clinicians find challenging when being
trained in MI.
Box 1-4. MI Steps to Address Knowledge Deficits

Ask what the patient knows about the topic or what he or she can do.
Affirm that information, if any.
Ask permission to fill in the blanks.
Give the information or advice.
MI = motivational interviewing.

PhARMAcOTheRApy
Change Talk Predicts Action 1 to 10, with 1 being not at all ready or confident or
A person internally decides to make a change when important and 10 being
the salience of the pros outweighs the cons. Humans
who are ambivalent or resistant may focus more on the
cons to rationalize why the target change is not being
made. When the cons are verbalized by the patient, the
reasons for not changing are reinforced. Even though
patients may know the pros or benefits of making the
change, they may not verbalize them because they have
been forced to defend the cons in response to
judgmental assertions by significant others or providers.
Asking the patient questions to elicit the benefits of
making a change can be powerful for many reasons. First,
the list of benefits comes from the patient, not from
others. Second, the process of thinking about and
verbalizing the benefits of a behavior change can be a
fruitful self- evaluation for the patient, conjuring
internal motivations. Recent MI intervention research
suggests that one of the significant predictors of
change comes when the patient engages in change talk.
Change talk is a form of intention to change, or intention
to think about changing. Change talk refers to patient
statements that express acceptance or movement
regarding a target behavior. These may include
expressions of a plan or goals for engaging, the
importance or benefits of the behavior, or even
thoughts about making some change in the behavior.
Verbalizing intentions is predictive of taking action.
The pharmacist can ask certain questions to engage
the patient in change talk. These include what the
patient knows about the benefits of making the
change (e.g., “What do you see as the benefits of
losing weight?” OR “If I were to ask you to write
down your pros for losing weight, what would be your
top three?”). Another strategy is to have the patient
talk about previous successes and what, specifically,
made them successful (e.g., “When you were able to
quit smoking for 6 months last time, what were
some of the things you did that worked for you?”
OR “When you brought your A1C down before, what
were you doing that helped you succeed?”). A third
strategy is to have patients talk about how they felt
during previous successes (e.g., “How did you feel
when your blood pressure came down after you
decided to start taking your medicine?”). A fourth
strategy is to visual- ize what life would be like if the
change occurred (e.g., “If you lost the 30 pounds
you’ve set as your goal, what would you then like about
your life?” OR “How would it feel to you if taking the
medicine regularly brought your high blood sugar down,
reducing your risk of the complications you
mentioned?”).
A fourth strategy for eliciting change talk is to use
what is referred to as a ruler. The ruler involves asking a
series of questions about the patient’s readiness,
importance, or confidence for engaging in the target
behavior. EXamples of the readiness ruler are provided
below. The ruler is typically anchored on a scale from

completely ready or confident or important. The Much of the language usually used in discussing health
patient responds with a rating and the follow-up behavior change implies big, intimidating change (e.g.,
questions elicit the change talk. diet, exercise, quitting). For some patients struggling
with change, just hearing words with change connota-
Pharmacist: On a scale of 1 to 10, with 1 being not at tion causes a motivational hesitation. Resistance sets in
all and 10 being completely, how ready are you to because of fear of failure, particularly for patients who
reduce the salt in your diet to control your blood have not been successful at these changes in the past.
pressure? Self-efficacy describes a person’s confidence in his or
her ability to engage in a specific behavior. For the patient
Patient: Well, probably about a 7.
with a previously unsuccessful attempt at a target
Pharmacist: A 7 is great! Why a 7 and not a 1? behavior, SE can be low and will affect access to any
internal motivation that may exist. Particularly for
The patient’s response expresses his or her motivators the patient with low SE, the use of big words and the
for the change; this is change talk. In addition, the setting of large goals (e.g., “cut out all the fat from your
pharmacist’s initial comparison of the 7 with the 1 is diet to bring your cholesterol down”) can do more
intended to encourage the patient’s confidence in harm than good and may result in the patient’s being
that it sends a subtle message that the pharmacist less likely to engage in the change. Self-efficacy is a
recognizes that the patient is higher than the strong predictor for taking action, and SE theory
minimum. The pharmacist’s second follow-up suggests that small successes in a given target behavior
question should be: lead to small increases in SE. The hope is that with
incremental and progressive successes, SE will
Pharmacist: What would have to happen for it to be an 8 increase, as will the likelihood for additional and
or 9? continued action for goal accomplishment.
Therefore, for the patient who drinks siX sugar-sweet-
This follow-up question also elicits motivators, or ened beverages a day, a question should be posed
change talk, while emphasizing incremental change about a reasonable goal such as reducing the daily
rather than complete change at a level the patient may number of sugar-sweetened beverages during the first
not feel ready for or confident about (i.e., 10). week. This reduction may be by only one beverage, but
it is hoped that success at cutting one beverage will
Setting Incremental, Specific Goals for SE Building help the patient subsequently decide to cut two. For the
smoker unwilling
to quit or unconfident of quitting, asking permission to and reinforces that there are available actions the patient
suggest a goal for cutting back the number of cigarettes can take to get control over health.
smoked per day is an MI-consistent strategy (e.g.,
“May I tell you what has worked for other patients I’ve
worked with? [yes] They found it more feasible to cut CoRe MI CommUnicATIon PRIncipleS
back on the number of cigarettes smoked per day than Motivational interviewing includes the use of five
to quit alto- gether. What do you think about that?”). main communication principles. These principles are
In all respects, pharmacists should carefully (1) expressing empathy, (2) developing discrepancy, (3)
consider the language used to convey these messages supporting SE, (4) rolling with resistance, and (5)
so that they do not inadvertently scare the patient away avoiding argumentation. Because the last two are very
from making some type of incremental change. The similar, they are often described together.
American Associ- ation of Diabetes Educators (AADE)
has long followed this philosophy in the language used Expressing Empathy
to express emphasis on the seven core behaviors needed EXpressing empathy is not only an MI communication
for diabetes self-management. For example, AADE principle, it is also a foundational component of the
refers to exercise behavior as “being active” and diet spirit of MI. The expression of empathy, especially right
changes as “healthy eating.” The pharmacist engaged in after a patient expresses strong emotion, helps the
comprehensive disease management could discuss patient feel the provider is listening and trying to
target health behaviors with phrases like “small understand. Many patients overtly express their feelings
changes in the foods you eat can help bring down out of a need for somebody to understand what they
blood sugar,” “there are ways to get more activity into are going through. These instances are particularly
your routine to help reduce your cholesterol,” and important to respond to (e.g., “I can’t believe I have
“think of the number of cigarettes to cut back on per diabetes [patient with newly diagnosed diabetes]”; “I
day for the first week to help lower your blood pressure.” just really don’t want to inject myself because I have a
Tying the behavior back to the health goal, as in fear of needles”; “My doctor made me so mad when he
these statements, also reinforces the patient’s said that to me”). Feeling understood can help alleviate
awareness about susceptibility, as previously described, anxiety, which can interfere with the patient’s ability to
PhARMAcOTheRApy
effectively listen to the information given by a provider. the underlying feeling experienced by the patient (e.g.,
True empathic responding goes beyond listening “The thought of enduring a bowel preparation for a
and reflecting; it involves carefully paying attention to colonoscopy seems uncomfortable, and that worries
you” OR “This must be discouraging to you”). Trying
to understand a patient, and expressing that through
empathy, helps build trust in the relationship.
Empathy is not sympathy (e.g., “I am sorry…”); instead,
empathy focuses on the patient and the underlying
effect: “It is unfair that your mother died of a heart
attack at such a young age.”
Because expressing empathy does not come
naturally to most people, it requires a conscious effort
to put aside judgments to understand a patient’s
feelings. Most providers will need to think about and
actively decide to put on an empathic mind-set and
may even need to practice openings to empathic
statements. Some openings may include statements like
“You seem [angry, or upset, or worried],” “You sound
[discouraged, or frustrated, or upset],” “It sounds like
[this has been hard for you, or you are angry about
this, or this has been unfair for you”]. One common
misconception is that “I understand…,” is an empathic
statement. This phrase may feel patronizing or
condescending to many patients; it is unlikely the pro-
vider fully understands, and even if so, using this state-
ment draws attention back to the provider and away
from the patient. For those who use this statement
regularly, awareness and patience are required to
remove it from their vocabulary.
Developing Discrepancy
Developing discrepancy is often somewhat confronta-
tional and involves creating a motivating dissonance in
a patient. This strategy, which is meant to be thought-
provoking, can help a resistant patient begin to think
about change. In the ambivalent patient, it may tip
the decisional balance scale toward action. The
strategies and examples in BoX 1-5 can help accomplish
this goal.
When implementing this strategy, it is important

Box 1-5. Strategies for Developing Discrepancy
to use compassion and a nonjudgmental tone of
voice. Because the strategy is confrontational (i.e., 1. Repeat the pros and cons the patient states.
highlighting what the patient is not doing regarding the “So, on the one hand, you want to check your blood
target behavior), the patient may feel judged and sugar because you’re looking for peace of mind, but on
become defensive unless the provider uses careful the other hand, you don’t want to because you don’t
attention to voice tone and nonverbal communication. like to stick yourself.”
2. Ask about behaviors that do not support the goals
Supporting SE the patient states.
Self-efficacy has been a significant predictor of “Mr. G, your medicine has been ready for pickup for
engage- ment in many different target health behaviors. a couple of weeks, and I’m concerned that you’re
Confi- dence in the ability to engage in the behavior is an not
important contributor to making a change and getting optimal benefit from it; what are your thoughts
sustaining it. The role of the pharmacist in helping about how this might affect the goal you told me last
support a patient’s confidence to engage in target time about reducing your risk of stroke or heart attack?”
behaviors can be important. Participation can simply 3. Ask thought-provoking questions.
involve noticing, encouraging, and supporting patient
“What would have to happen for you to think
about quitting smoking?”
attempts, or even thoughts, about change. Some makes me feel defective, like I can’t even control my
statements might include the following: own health.”
“Ms. C., you are well on your way to better health Pharmacist: “You sound discouraged, Mr. G. I hope
because you are thinking about lowering your you will come to see the medicine as something that will
cholesterol.” help you gain control over your health. What are
your thoughts about that?”
Be sure to praise the behavior, not the person:
Resistant Patients and Other MI Applications
“Mr. G., it’s great that you completed your Communicating with resistant patients can be
scheduled screening as you planned.” among the most stressful of patient encounters. Many
providers who talk with a resistant patient will avoid
“Taking your medicine regularly as you have been doing the resistant topic, change the subject, find themselves in
will really help you continue to bring your blood pressure an argument, or end the conversation. To keep the
down.” relationship the top priority, it is important first to
explore the resistance with open-ended questions
The pharmacist can play a significant role in (“Tell me more about that”), or use a ruler as
boosting a patient’s SE. It is important not to described previously. If the patient remains resistant or
overpraise; this can sound insincere and will dilute the reports that the number on the scale is the minimal
impact of statements meant to support SE. anchor, it is important to respect the patient’s right to
be resistant, even if the clinician does not agree with it.
Rolling with Resistance and Avoiding Argumentation This is challenging for the clinician who feels a duty to
Rolling with resistance and avoiding argumentation give information and help the patient commit to taking
are similar strategies. Many providers who hear action, and who feels successful only if the patient does
patients make resistant or irrational statements often so. For the patient unwilling to receive information
instinctively follow with a “yes, but” response, which or make a change, forcing it will only do more harm than
forces the patient to become defensive. The key to these good; it disrespects the patient, leads the patient to
two MI principles is to focus on the foundational defend, and reinforces the cons for change.
objective of relationship building and not to be drawn Two strategies are recommended to use with a
into an argument; these strategies focus on being on patient who remains resistant after exploring and
the same side as the patient developing discrepancy. The first strategy is simply to
and collaborating for problem solving and goal setting. ask the patient, “May I tell you what concerns me?” This
It is helpful to practice ignoring antagonistic state- strategy respects the patient’s resistance by asking
ments and personal attacks. Recognize that resistance permission to give information, expresses concern so
is information to be explored, and stay with the that the patient can hear the provider’s desire to give
underlying issues to stay focused on the topic. The information because of a caring motive, and opens the
patient expects the pharmacist to join the argument; door to express the patient’s risk if the target behavior is
when the pharmacist does not engage in an argument, not changed. After delivering the information, an open-
thought-provoking behavior occurs, which can plant a ended question should follow to bring the conversation
seed of trust. back to the patient in a nonthreatening manner
Note the following example: (“What are your thoughts about that?”).
The second potential strategy is to emphasize personal
Patient: “What do you know? You don’t have to take choice: “It really is your decision; all I can do is tell you
all of this medicine. Having to take medicine every day the advantages and disadvantages of taking the medicine.
But only you can decide to take it.” This strategy can be
powerful for a patient who feels beaten down by a
sequence of providers who have advised, judged, and
shamed. The patient is resistant and expecting an
argument that disrespects her feelings; when she
receives respect and the “ball is placed back in her
court,” this can cause thought- provoking behavior and
create healthy dissonance. Even if the patient does not
decide at that moment to change, it is likely to prompt
thoughts about change, and it will certainly support
the development of the type of trust needed for the
patient to begin talking about making the change.
When patients are unwilling to change, the only
appropriate patient-centered response is to respect the

PhARMAcOTheRApy
patient’s right to be resistant. An optimal response might
include, “It is clear you aren’t ready to quit or cut back on
AnnotATeD BiblioGRA pHY
smoking; if you decide at some point that you would like 1. Britt E, Hudson SM, Blampied MV. Motivational inter-
to talk about it or explore other options, I would like to viewing in health settings: a review. Patient Educ Couns
help you. I hope you will see me as a resource for 2004;53:147–55.
information when you are ready.” Leaving the door This literature review assesses MI as an interven-
open for the patient to return is a caring strategy and tion in a variety of health care settings. In addition
can lead to thought-provoking behavior if the patient is to a description of the origins of MI in the alcohol
struggling with ambivalence or resistance. and substance abuse literature, this article describes the
literature addressing lifestyle changes within a compre-
Providers who have embraced MI have generally hensive disease management context and interventions
been satisfied with using these techniques. Some have occurring in health care settings. The article includes an
expressed that these techniques make the interview overview of MI and has a descriptive section that com-
process more efficient, even in a brief encounter. Sim- pares MI with several other prevailing health behavior
ply engaging the spirit of MI can help the patient theories and models (e.g., locus of control, theory of
feel understood or supported; these communication reasoned action, social cognitive theory, health belief
intentions can be used in an encounter as brief as one model). The authors conclude with recommendations
or two exchanges. Many providers trained in MI have for adapting MI encounters to health care settings,
expressed that it changes the dynamics of their personal including the need to develop and use MI skills for brief
relation- ships as well. Learning to communicate in a encounters, even if the encounters involve just listening
and helping patients feel understood.
person-centered manner can affect interactions with
patients, family, significant others, colleagues, and 2. Golin C, Earp J, Hsiao-Chuan T, Stewart P, Porter
other health care providers. Pharmacists have used MI C, Howie L. A 2-arm, randomized, controlled trial
with physicians to influence their prescribing to be of a motivational interviewing-based intervention to
more evidence-based. EXploring resistance and improve adherence to antiretroviral therapy (ART)
responding with early empathy are effective ways of among patients failing or initiating ART. Acquir
maintaining the respect and autonomy physicians expect Immune Defic Syndr 2006;42:42–51.
when communicating with other providers. This study used a clinic-based two-arm random-
ized controlled trial design to compare the adherence
of patients receiving MI with that of patients receiv-
ConclUSIon ing a dose-matched HIV information control program.
For most, MI represents a change in communica- Participants in both groups received three components:
tion skills that may not come naturally. For pharmacists (1) a 20-minute audiotape and booklet before seeing
who may be interested in adopting this evidence-based, their primary care provider, (2) two face-to-face ses-
patient-centered strategy, here are three final thoughts. sions with a health educator at 4 and 8 weeks’ follow-up,
First, just as incremental goals may be set for patients and (3) a mailing 2 weeks after each individual session.
The MI intervention focused on patient concerns that
to help develop SE, so can incremental goals be set for were salient; confidence-boosting letters that reviewed
making a change in practice behavior. For example, the issues discussed in the previous MI session were
the first or second week could only involve making mailed 2 weeks after each session. Conducting the
efforts to listen, express empathy, and support SE, with MI sessions were three health educators with master’s
subsequent goals for progression in complexity of degrees who received 24 hours of MI training. The pri-
skills adoption. Second, seeking quality training is mary outcomes were mean adherence level (percentage
essen- tial. Learning theory research suggests that adult of prescribed doses taken in the previous month) at the
learn- ers must develop the cognitive aspects of a skill 12-week visit, change in mean adherence, percentage of
before applying it. Research has shown that good patients achieving greater than 95% adherence in the
training in MI will involve 16–30 hours of cognitive third 4-week block, and change in viral load. The results
revealed that the MI group’s mean adherence improved
development and skills development exercises that
4.5% compared with a decrease in the control group’s
include role-playing with feedback and follow-up adherence (3.83%; p=0.10). For the MI group, 29%
training when feasible. The feedback process is critical achieved greater than 95% adherence compared with
to learning a new skill and is particularly critical to only 17% in the control group (p=0.13). Controlling
successfully adopting MI skills in communicating with for ethnicity, the MI group had a 2.75 times higher
patients. Yet without cognitive development, trying to odds of achieving more than 95% adherence than did
apply the skills in role- playing is unlikely to be the control group (p=0.045). Several mediating vari-
successful, and the pharmacist may not have confidence ables (e.g., beliefs about antiretroviral therapy, coping
or desire to try again. Third, acquiring MI skills is a style, social support, goals set) showed statistically sig-
process, not an event. Allowing time and practice for nificant changes in the expected direction of the MI
maximal development may very well be career- and group compared with the control group; however, the
intent-to-treat analysis for mean adherence at the study
life-changing.
conclusion revealed 76% for the MI group and 71% for the control group. This study provides some evidence

that MI offers an effective approach for helping patients and a greater percentage of doses taken on schedule
decide to improve adherence. compared with the control group during the postinter-
vention data collection period.
3. Soria R, Legido A, Escolano C, Yeste AL, Mon-
toya J. A randomized controlled trial of motivational 5. Anshel MH, Kang M. Effectiveness of motivational
interviewing for smoking cessation. Br J Gen Pract interviewing on changes in fitness, blood lipids, and
2006;56:768–74. exercise adherence of police officers: an outcome-based
This trial established whether MI was more effec- action study. JCHC 2009;14:48–62.
tive for successful smoking cessation than antismoking This case-control study examined the effect of a
advice. The study randomly assigned 200 participants 10-week intervention on selected measures of fitness,
to either the antismoking advice group (n=86) or blood lipids, and exercise adherence among 67 police
the MI group (n=114). Patients in both groups were officers—54 men and 13 women—in the southeast-
assessed at baseline, 6 months, and 12 months. Patients’ ern United States. Each study participant engaged in
general practitioner physician recruited participants one of siX “high-performance training” seminars that
during a regular office visit. E XClusion criteria consisted were offered for 6-month periods, with a different
of the existence of a severe psychiatric disorder, a ter- group of officers in each seminar. At the end of each
minal illness or drug addiction, or age younger than seminar, officers were invited to enroll in a 10-week
15 years or older than 75 years. The MI group received program intended to improve their fitness, nutrition,
three 20-minute MI sessions during the study. There and lipid profiles. Baseline measures collected include
were no established time intervals for conducting the body composition measured by a Lange skinfold cali-
second and third MI sessions; subsequent sessions with per, blood pressure, cardiovascular fitness measured by
the physician were set up at the patient’s convenience.
Vo2max, and muscular strength assessed with a universal
Outcome measures consisted of assessing smoking weight machine. The intervention began with a 3-hour
habits at 6 and 12 months after the intervention by group seminar that used a workbook, a DVD, group
mea- suring the number of cigarettes smoked per member interaction, and a lecture. Each participant
day, the degree of nicotine dependency, the stage of created a self-regulation action plan, which consisted of
change, and the carbon monoXide in expired air. The determining the details of developing a habit of regular
final primary outcome measured was a success index, exercise during the week including the type of exercise,
which was the point prevalence of abstinence at 6 and exercise location(s), days of the week and times of day
12 months after intervention. The measure of the exercise would occur, availability of social support,
effectiveness of the treatment for quitting smoking and other related items. The performance coaches who
showed that the MI group action was 5.2 times supervised these action plans were graduate students
higher than the antismoking advice group after both 6 trained to supervise intervention content in exercise
and 12 months (18.4% compared with 3.4%; p=0.00 and nutrition. Weekly MI meetings were scheduled
and 0.001, respectively). The results show that MI is with each subject in the police fitness facility or the
more effective than brief antismoking advice for officer’s office. The results indicate that the officers
quitting smoking. statistically significantly improved on four measures
of their physical fitness and blood lipid profile scores
4. Diiorio C, McCarty F, Resnicow K, Holstad MM, Soet
(6.87% reduction in total cholesterol, 15.03% reduction
J, Yeager K, et al. Using motivational interviewing to
in low-density lipoprotein) from pre- to postinterven-
promote adherence to antiretroviral medications: a ran-
tion. Thus, MI appears to markedly encourage selected
domized controlled study. AIDS Care 2008;20:273–83.
changes in health behaviors among police officers.
This trial tested the efficacy of an intervention
designed to support antiretroviral drug adherence 6. Severson HH, Peterson AL, Andrews JA, Gordon JS,
among primarily low-income men and women with Cigrang JA, Danaher BG, et al. Smokeless tobacco ces-
HIV. Participants were recruited from an HIV/AIDS sation in military personnel: a randomized controlled
clinic in the Atlanta, Georgia, area; 247 participants trial. Nicotine Tob Res 2009;11:730–8.
completed the baseline assessment and were assigned
to the intervention (n=125) or control (n=122) In this trial, military personnel including 785 active
group. Participants were beginning antiretroviral duty participants from 24 military dental clinics across
therapy or changing to a new drug regimen. The the United States were assessed at baseline, 3 months,
intervention consisted of five MI sessions delivered by and 6 months. Usual care was compared with a
registered nurses who used individual counseling minimal contact intervention set that included a
sessions; patients were compensated ($25 cash, two smokeless tobacco cessation manual, a videotape
tokens for public transportation, and a snack) for cessation guide tailored for military personnel, and
each session attended. The primary outcome measure three 15-minute telephone counseling sessions using
was medication adherence, assessed with the MI. Participants in the intervention group were
MEMS (Medication Event Monitoring System) from significantly more likely (p<0.001) than those in the
baseline to 12 months after- ward. Patients in the MI usual care group to be absti- nent at 3 months (25% vs.
group showed a trend toward a higher mean 7.6%) and 6 months (16.8% vs. 6.4%). Results
percentage of prescribed doses taken suggest that an MI-based intervention, structured
with minimal contact (e.g., brief
telephone encounters), has an impact on a challenging health behavior target like smoking cessation.

PhARMAcOTheRApy
questionnaire. The study lasted 5 months and revealed
7. Miller WR, Rollnick S. Ten things motivational inter- significantly improved scores for motivation and three
viewingisnot. Behav Cogn Psychother 2009;37:129–40. dimensions of the quality-of-life scores in the MI group
This article is a commentary from the originators of compared with the scores in the usual care group
MI about the evolution of MI and the 10 most common (p<0.05).
misperceptions about it. This article further elucidates
MI as an internationally tested, evidence-based inter- 10. Miller WR, Rose GS. Toward a theory of motivational
vention strategy set for health behavior change. The interviewing. Am Psychol 2009;64:527–37.
authors point out 10 things as follows. (1) Motivational This article gives an overview of the history of MI
interviewing is not based on the transtheoretical model development and dissemination by one of the original
of change. (2) Motivational interviewing is not a way authors and a colleague. The perspectives on how the
of tricking people into doing what they do not want MI clinical style emerged contribute to understanding
to do. (3) Motivational interviewing is not a singular MI as a whole as well as its subsequent components and
technique. (4) Motivational interviewing is not a deci- concepts. The review and commentary address miXed
sional balance. (5) Motivational interviewing does not findings; multisite trials (including Project MATCH for
require assessment feedback. (6) Motivational inter- alcohol abuse); and a critical view of the rigor of meth-
viewing is not a form of cognitive behavior therapy. (7) ods used in MI trials, including intervention fidelity (or
Motivational interviewing is not just client-centered lack of it) in many trials, and variability in the length
counseling. (8) Motivational interviewing is not easy. and type of MI training for providers of study interven-
(9) Motivational interviewing is not what you were tions. The authors also discuss the role of change talk in
already doing. (10) Motivational interviewing is not a helping patients decide to change and the way in which
panacea. The updated definition of MI the authors offer the presence of change talk is a significant predictor
is “a collaborative, person-centered form of guiding to of actual behavior change. The discussion section also
elicit and strengthen motivation for change.” addresses the problem of disingenuous change talk.
8. Hettema J, Steele J, Miller WR. Motivational interview- 11. Possidente CJ, Bucci KK, McClain WJ. Motivational
ing. Annu Rev Clin Psychol 2005;1:91–111. interviewing: a tool to improve medication adherence?
This article is a meta-analysis of MI intervention Am J Health Syst Pharm 2005;62:1311–4.
studies across several health behaviors, including alco- This commentary reviews the potential of MI as an
hol abuse, smoking, drug use, treatment adherence, intervention tool for pharmacists to use in counsel-
gambling, water purification/safety, eating ing patients about medication adherence. The authors
disorders, and diet and exercise, as well as studies review some of the evidence base for MI among the
across diverse populations including ethnic target health behaviors needed for comprehensive
minorities. This article summarizes a significant disease management. The article (1) presents an
evidence base for MI as a health-behavior change overview of the lateral comparison with the stages of
intervention. The article incor- porates discussion change of the transtheoretical model of change, (2)
about the impact of analyses and methods in the gives an overview of MI’s basic assumptions, (3)
literature, including how the effect size factors into the compares and contrasts traditional counseling with MI,
analysis of existing MI studies and how a lack of (4) describes the key principles of MI, (5) describes a
homogeneity of methods and analyses chal- lenge general approach to using MI in a patient interview, and
comparison across studies. The discussion section of the (6) reviews and discusses the literature for MI
article points out the characteristics of providers, applications in adherence to drug therapy. The article
populations, target behaviors, and settings and how concludes that MI can be an effective communication
they contribute to the reported variable effectiveness tool for pharmacists when talking with patients about
of MI interventions. The authors discuss contributions adherence to their drug therapy.
to the conversation about a theory of MI and present
research into how clinicians develop proficiency in MI. 12. Knight KM, McGowan L, Dickens C, Bundy C. A
systematic review of motivational interviewing in
9. Brodie DA, Inoue A, Shaw DG. Motivational interview- physical health care settings. Br J Health Psychol
ing to change quality of life for people with chronic 2006;11:319–32.
heart failure: a randomized controlled trial. Int J Nurs
Stud 2008;45:489–500. This systematic review included studies that focused
only on MI as an intervention for comprehensive dis-
This randomized controlled trial enrolled 60 senior ease management administered in actual physical
adults with chronic heart failure; a physical activ- health care settings. Of the original 51 abstracts iden-
ity lifestyle intervention with an MI approach was tified in the initial search, 8 were retained for review
compared with conventional treatment. The target out- and included focuses on diabetes, asthma, HTN,
come variable was quality of life, as measured by the hyperlipidemia, and heart disease. The MI intervention
generic Medical Outcomes Short Form-36 and the positively affected psychological, physiological, and
disease-specific Minnesota Living with Heart Failure lifestyle change outcomes in most of the retained stud-
ies. As with other reviews, the conclusions of this review
were limited by the heterogeneity of target outcomes, call was made for additional research in health care
methods, and analyses, as well as small sample sizes. A settings using MI as an intervention.
13. Martins RK, McNeil DW. Review of motivational model of MI training, recommendations are made that
interviewing in promoting health behaviors. Clin Psy- suggest brief training without skills development exer-
chol Rev 2009;29:283–93. cises and feedback/coaching helps comprehension
This review examined the literature exploring the and some of the skills but does not result in full-scale use
impact of MI in emerging areas of focus including in practice. This is a landmark study regarding the state of,
diet and exercise, diabetes, and oral health. The review and recommendations for training in, MI.
included 37 heterogeneous studies; studies varied not
only across disease/behavior targets but also in design,
populations, outcomes variables, and measures. It was
not possible to make direct comparisons, but the
authors concluded from the general findings that MI is an
effective intervention for helping patients decide to
change health behaviors in the context of diabetes and
lifestyle change in general. In addition, results
specific to the diet and exercise targets suggest that
providers beyond nutritionists should use MI to
continue the conversation with patients about
engaging in behaviors that help treat current conditions
and prevent future conditions. The authors also support
the importance of change talk as an important mediator
to behavior change.
14. Rubak S, Sandbaek A, Lauritzen T, Christensen B.

Motivational interviewing: a systematic review and
meta-analysis. Br J Gen Pract 2005;55:305–12.
This meta-analysis of the evidence for MI interven-
tion in different areas of disease showed a significant
effect of MI on body mass index, total blood cholesterol,
systolic blood pressure, and blood alcohol concentra-
tion, but nonsignificant effects for changes in cigarettes
per day and hemoglobin A1C. Overall, psychologists
and physicians achieved an effect in around 80% of the
72 randomized controlled trials included; other health
care providers achieved a significant effect in 46% of
studies. In addition, brief MI encounters (e.g., 15 min-
utes) were effective in 64% of studies. The authors
concluded that several MI-based encounters have more
impact than a single encounter, and that MI outper-
forms traditional advice giving when treating various
diseases.
15. Madson MB, Loignon AC, Lane C. Training in motiva-

tional interviewing: a systematic review. J Subst Abuse
Treat 2009;36:101–9.
Several previous reviews and meta-analyses have con-
cluded that many MI studies are limited by either lack
of adequate training of MI interventionists or lack of
reporting the level or type of MI training for providers
who conducted the MI interventions. This systematic
review examined rigorous MI intervention studies for
how well they addressed the eight stages of learning MI
in the training used for providers conducting the inter-
ventions. Twenty-seven articles were included from
medicine, general health care (e.g., nutrition, exercise),
substance abuse, and general mental health. Using the
results of the review and Miller and Moyers’ eight-stage

PhARMAcOTheRApy
SelF-ASSeSSMent QUeSTIonS
Questions 1 and 2 pertain to the following case. Pharmacist:
S.D. is a 57-year-old woman who comes to your phar- A. “It’s a good thing you can afford to take
macy to pick up her prescription for metoprolol. You another medicine every day.”
begin a conversation with her because you see a pack B. “Do you understand why this is necessary?”
of cigarettes on top of her purse. C. “You don’t like having to depend on taking
medicine.”
1. In discussing smoking cessation with S.D., D. “It’s really your choice.”
which one of the following statements best
expresses the spirit of motivational interviewing 4. G.H.: “I never used to have to take so much medi-
(MI)? cine. I don’t like getting old.”
A. “I see that you are still smoking; you should let Pharmacist:
me work with you to help you quit.”
A. “Even young people have to take drugs.”
B. “Your blood pressure is still high; tell me what
B. “Growing older has been difficult for you to
you know about things you can do to help
accept.”
lower it.”
C. “You are healthy otherwise.”
C. “I understand that this has been hard for you;
D. “What concerns you the most about this
let me tell you some ways you can lower your
medicine?”
blood pressure.”
D. “Quitting smoking is hard, but it really is
5. G.H.: “I’ll take the medicine. I just don’t like that
important to preventing complications from
I have to take it to be OK.”
heart disease.”
Pharmacist:
2. S.D. responds that she is unwilling to quit smoking, A. “You do need to take it. What would have
and is unwilling to talk further about it. Which one to happen for you to be OK with taking
of the following responses is most consistent the medicine?”
with the spirit of MI? B. “I understand. It is for your own
A. “I am really worried that you may not good, though.”
understand what I have to say; it will benefit C. “You really do need to take the medicine each
you in the long run.” day.”
B. “Do you think you’re going to see D. “I believe that taking the medicine is the best
improvement in these lab values if nothing decision for controlling your blood pressure.”
changes?”
C. “It really is your decision; I can give you my 6. G.H.: “I know I need to exercise also, but 3 days a
opinion, but only you can decide for yourself week after work seems like a bit much…especially
if you’re going to take this medication as 30 minutes of walking each time. I am pooped
prescribed.” when I get home.”
D. “You really need to get this information before Pharmacist:
you leave; I’m worried about you.” A. “I think you will find that it really isn’t too
hard to incorporate into your daily routine.”
Questions 3–7 pertain to the following case. B. “Being tired is a barrier for you to exercise.”
G.H. is a 58-year-old man with type 2 diabetes mellitus C. “Maybe you won’t feel so tired if you try
(T2DM) and hypertension (HTN). He is resistant to exercise.”
many changes that will affect his T2DM and HTN out- D. “Could you try to exercise on 2 days a week?”
comes. A comprehensive disease management encoun-
ter between G.H. and his pharmacist included medica- 7. G.H.: “I am just not willing to do this after
tion therapy management and other lifestyle changes work for 4 days a week right now.”
to optimize disease outcomes. For each of the follow- Pharmacist:
ing statements by G.H., choose the one pharmacist A. “Is that your final decision?”
response most consistent with MI principles. B. “I really wish you would reconsider.”
C. “What are you willing to do right now?”
3. G.H.: “I know I need it, but I don’t like the idea of D. “This really could help both your DM and
having to take another drug every day.”
HTN.”
Questions 8–10 pertain to the following case. A. “Can you think of ways to get back on track?”
M.C. is a 68-year-old woman who is overweight and has B. “Can you think of things you could
HTN. She presents to your pharmacy, where the do to reduce your risks of
following dialogue takes place: uncontrolled hypertension?”
C. “On a scale from 1 to 10, what is your level of
Statement 1. M.C.: “Hi. I have a bad cold and fever; commitment for getting back on track?”
I’m here for the medicine my doctor called in.” D. “Tell me what you know about how
Statement 2. Pharmacist: “OK, before I give you the new the medicine affects risks of
medicine, I need to ask about your blood pressure uncontrolled hypertension.”
medicine. I see that you’re about 3 weeks late picking
up the refill. Why is that?” 10. As a response to the patient’s statement 3,
which one of the following statements would
Statement 3. M.C.: “Well, I should get that one, too,
be most consistent with the spirit of MI?
but I really can only afford one medicine today, so I’d
better just get the new one today so that I can get this A. “It sounds like it’s been a tough time with
cold taken care of; I feel awful, and I am miserable trying to deal with expenses and now with the
from it. I still have some left for the blood pressure terrible cold you’re suffering from.”
medicine, anyway. I am taking it regularly.” B. “What can I do to help you?”
C. “On the one hand, you want to fill the
Statement 4. Pharmacist: “I see. However, if you’re tak- prescription; on the other hand, you don’t
ing it regularly, you shouldn’t have some left. I see that have enough money to do so.”
it’s been about 3 weeks since you were last due to get
D. “What are some things you can think of to
it filled. Maybe if you could start back on track today, you
resolve your situation, besides taking half the
could reduce your risks of uncontrolled hypertension.”
recommended dose?”
Statement 5. M.C.: “I take it almost every day. It’s just
that I don’t have any extra money, and my rent went Questions 11–14 pertain to the following case.
up, so I have to cut somewhere; I have a pill splitter, M.K. is a 38-year-old woman who is obese and has
and I take half a pill most days. Hey, it’s better than T2DM. The pharmacist has been talking with her about
not taking it at all.” health behaviors to help manage her diabetes and now
Statement 6. Pharmacist: “You are putting yourself at shifts the conversation to talk about healthy eating
risk of being sicker than having a cold by not taking care strategies.
of your blood pressure. Are there other things you can
do instead of omitting your medicine to cut back?” Statement 1. Pharmacist: “What are your thoughts
about making some small changes in some of the foods
8. Regarding statement 2, which one of the follow- that you eat?”
ing describes the most significant violation of Statement 2. M.K.: “I know what you’re going to say
the spirit of MI? — the same thing my doctor said—that I have to quit
A. The pharmacist focuses on the patient’s failure eating that nightly bowl of ice cream. I am just not
(for being late picking up the medication) interested in giving up something that I enjoy as a
instead of on the patient’s behavior (the relaxing treat at the end of my hard day.”
prescription has been ready for 3 weeks). Statement 3. Pharmacist: “It sounds like you really like
B. The pharmacist does not give an early ice cream and that it is relaxing to reward yourself for
empathic statement in response to the patient’s finishing a hard day.”
statement about having a bad cold and fever.
C. The wording of this statement sounds like an Statement 4. M.K.: “EXactly.”
interrogation is about to take place. Statement 5. Pharmacist: “Tell me what you know about
D. It is provider-centered when the pharmacist how eating ice cream affects your diabetes.”
says, “Before I give you your new medicine,
I need to ask you about your blood Statement 6. M.K.: “I know it’s bad for me, and I
pressure medicine.” know it’s bad at that time of night. I still don’t want to
cut it out.”
9. The pharmacist shows the righting reflex at the Statement 7. Pharmacist: “You are clear that you aren’t
end of statement 4. Which one of the following ready to give up the ice cream at night.”
replace- ment statements would be most
consistent with the spirit of MI? Statement 8. M.K.: “That’s right.”
Statement 9. Pharmacist: “What are your thoughts about making small changes that could benefit your blood
strategies you could try for keeping it in your diet while sugar levels?”
Statement 10. M.K.: “I thought I would have to cut it out C. Supporting the patient’s autonomy to choose
entirely. What strategies?” is important.
Statement 11. Pharmacist: “That’s great that you’re will- D. Early empathy helps the patient feel
ing to hear options. Some patients have affected their understood and respected.
weight and diabetes by cutting back on portion sizes
or switching to less-fattening or lower-sugar ice cream 13. Which one of the following is the best MI-based
options. What are your thoughts about trying any of rationale for pharmacist statements 13 and 14?
these options?” A. Focus on concern for incremental goals
to support SE building.
Statement 12. M.K.: “I’ve never tried any of those things;
B. EXpress apprehension while asking permission
I don’t think I would like them as much.” to deliver information and tying the behavior
Statement 13. Pharmacist: “May I tell you what concerns to concerns.
me?” [yes] C. Use assertive communication to support
patient autonomy and set reasonable
Statement 14. Pharmacist: “It’s great that you’re doing goals.
a lot of hard work to change other things in your D. Engage the patient in change talk to
eating habits and physical activity; yet your weight elicit motivations for change.
and hemoglobin A1C have continued to rise despite all
of your efforts. The ice cream may really be 14. Which one of the following MI communication
contributing significantly to the increases in your principles best describes pharmacist statements
weight and A1C. What are your thoughts about making 11, 14, and 16?
one of the small changes regarding the amount or type
A. Supporting SE.
of ice cream?”
B. Rolling with resistance.
Statement 15. M.K.: “I know I should do something—if C. Asking open-ended questions.
I ate half the amount I usually eat, I could also save some D. Establishing patient understanding.
money.”
Statement 16. Pharmacist: “That’s great that you’re think- 15. A patient states: “I heard this medicine will make
me tired. Is that true? I am already tired, and I
ing about cutting back on portion size—that should be
just don’t need that.” Which one of the following
helpful. What portion size do you think is realistic for
pharmacist responses is most consistent with
you to work on reducing to for this coming week?”
MI principles?
11. Which one of the following is the best MI-based A. “Some patients feel tired at first. This doesn’t
rationale for the pharmacist’s statement 1? happen to all patients, and these symptoms
usually go away in a few days.”
A. Develop discrepancy to create dissonance and B. “It shouldn’t be a significant problem for very
support self-efficacy (SE) for small successes. long; I understand, and I would like to give
B. Nonthreatening, open-ended exploration to you more information if that’s OK with you.”
get patient input and focus on incremental C. “Yes, it can have some side effects and this can
goals. be of concern; I wouldn’t worry about it;
C. Attempt to engage a strategy to elicit change these will go away in time.”
talk from the patient. D. “It sounds like you’re worried about what this
D. EXploration of the patient’s ambivalence for drug might do to you if you start taking it. May
change. I share some information with you to address
your concerns about the medicine?”
12. Which one of the following is the best MI-based
rationale for the pharmacist’s statement 3? 16. A patient states: “I heard this medicine could make
A. Agreeing with the patient makes it more me jittery. Is that true? I work with my hands and
patient-centered. can’t afford to not have them be steady.” Which
B. Reflective listening helps the pharmacist think one of the following rationales would best guide
about what to say next. the pharmacist to a statement consistent with
MI principles?
A.EXplain to and reassure the patient.
B.Reassure the patient and express empathy.
C. Be honest and reassure the patient.
D. Show early empathy and ask permission.
Questions 17 and 18 pertain to the following case. M.M., a patient unwilling to quit smoking, has the fol-
lowing encounter with her pharmacist: C. “Why a 5 and not a 10?”
M.M.: “I don’t have any desire to quit smoking.” D. “Why a 5 and not a 1?”
Pharmacist: “But you need to think about how you can 20. The pharmacist asks S.T.: “What would have to
quit or cut back; your smoking is affecting your high happen for your readiness to go from a 5 to a 6
blood pressure.” or 7?” Which one of the following best describes
the strategy behind the pharmacist’s question?
17. Which one of the following statements would best A. Engages the patient in change talk and focuses
exemplify M.M.’s response to the righting reflex? on incremental change.
A. “Why do you care?” B. Empathic responding makes the patient feel
B. “Look, I’m not quitting, and I’m not even going connected to the pharmacist.
to cut back, so leave me alone about it.” C. EXplains the patient’s cons or reasons for not
C. “What are my options?” adhering to his drugs.
D. “Just give me a pill or a patch or something.” D. Asking open-ended questions supports patient
autonomy.
M.M. continues the encounter with her pharmacist:
Pharmacist: “Tell me what you know about how smok-
ing affects your blood pressure.”
M.M.: “I know that it’s bad for me.”
Pharmacist: “May I share with you some additional
information about that?”
18. Which one of the following best characterizes the

pharmacist’s MI goal?
A. Ask open-ended questions to be less
threatening and to support patient autonomy
and SE.
B. Roll with the resistance to avoid engaging
the patient in an argument; ask permission to
support patient autonomy.
C. Find out what the patient knows about risks
to raise consciousness; then set up to ask
permission to give the information.
D. Support SE by allowing the patient to feel
confident; develop internal motivation by
having the patient tell what she knows.
Questions 19 and 20 pertain to the following case.

S.T. is a 34-year-old man who is HIV-positive and ambiv-
alent about taking his drugs as prescribed. His pharma-
cist initiates a conversation on the topic of adherence.
The pharmacist decides to use a readiness ruler, and
asks: “On a scale of 1–10, with 1 being not at all and
10 being completely, how ready are you to start taking
your medicine every day as prescribed?” S.T. responds
that he is a 5.
19. Which one of the following is best for the pharma-

cist’s first follow-up question?
A. “Why a 5 and not an 8?”
B. “Why a 5 and not a 4?”

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MotivATIonAl InteRVIewinG

By JAn KAVOOkjIAn, MBA, PH.D.

BASeline Review ResoURCes

PSAP-VII • ScIeNce AND PRAcTIce OF PhARMAcOTheRApy 1 MOTIVATIONAl INTeRVIewING

Box 1-1. Definitions of Specific MI Terminology

MOTIVATIONAl INTeRVIewING 2 PSAP-VII • ScIeNce AND PRAcTIce OF

Avoid hospitalizationFood interaction with my

Make my family happyRepresents how ill I am, do

Pharmacist: Mr. H., tell me what you know about how

This dialogue accomplishes several important strate-

MOTIVATIONAl INTeRVIewING 6 PSAP-VII • ScIeNce AND PRAcTIce OF

Table 1-2. Examples of Closed- and Open-Ended Questions

Your INR is up to 3.3 this time; did you eat any

CHF = chronic heart failure; INR = international normalized ratio.

PSAP-VII • ScIeNce AND PRAcTIce OF PhARMAcOTheRApy 7 MOTIVATIONAl INTeRVIewING

Box 1-4. MI Steps to Address Knowledge Deficits

MOTIVATIONAl INTeRVIewING 8 PSAP-VII • ScIeNce AND PRAcTIce OF

PSAP-VII • ScIeNce AND PRAcTIce OF PhARMAcOTheRApy 9 MOTIVATIONAl INTeRVIewING

When implementing this strategy, it is important

MOTIVATIONAl INTeRVIewING 12 PSAP-VII • ScIeNce AND PRAcTIce OF

PSAP-VII • ScIeNce AND PRAcTIce OF PhARMAcOTheRApy 13 MOTIVATIONAl INTeRVIewING

MOTIVATIONAl INTeRVIewING 14 PSAP-VII • ScIeNce AND PRAcTIce OF

14. Rubak S, Sandbaek A, Lauritzen T, Christensen B.

15. Madson MB, Loignon AC, Lane C. Training in motiva-

MOTIVATIONAl INTeRVIewING 16 PSAP-VII • ScIeNce AND PRAcTIce OF

18. Which one of the following best characterizes the

Questions 19 and 20 pertain to the following case.

19. Which one of the following is best for the pharma-

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