BROADCASTS.com

Published: April 10, 2020, 4:30 a.m.

b'

Mentioned in this episode:

Dr. Bruce Berger

Motivational Interviewing for Health Professionals: A Sensible Approach 2nd Edition (2020)\\xa0by Bruce A. Berger (Author), William A. Villaume (Author)\\xa0

Idaho State University College of Pharmacy students use the comMIt program.\\xa0 https://www.isu.edu/pharmacy/\\xa0 Contact:\\xa0 biddmich@isu.edu\\xa0

Dr. Bruce Berger uses his voice to educate health care professionals on how to help patients more actively engage in health behaviors and explore reasons they may not engage.

Bruce is President of Berger Consulting, LLC and Emeritus Professor at Auburn University. He has developed comMIt (Comprehensive Motivational Interviewing Training for health care providers). He has taught motivational interviewing in health care and methods for improving treatment adherence for over 30 years.

Bruce received his BS in Pharmacy, his Masters and Ph.D. in social and behavioral pharmacy from The Ohio State University.\\xa0 He taught at West Virginia University in 1980-1981.\\xa0 After two years at WVU, Bruce moved to Auburn University and taught there until his retirement from the university in September of 2009.

His research interests included health behavior change and improving treatment adherence.\\xa0 He has written or presented over 800 papers (85 peer reviewed) or seminars (94 peer reviewed) on these topics. \\xa0

He has been a consultant and trainer for numerous pharmaceutical companies and health plans.

He is the recipient of numerous awards, including the 2007 APhA Wierderholt Prize for the best research publication in the social, behavioral, and administrative sciences in pharmacy in the Journal of the APhA.\\xa0 The study focused on the impact of motivational interviewing.

Bruce is the 2009 recipient of the American Association of Colleges of Pharmacy\\u2019s Robert Chalmers Distinguished Pharmacy Educator Award, one of the Association\\u2019s three highest honors. \\xa0

Bruce is the author of the book, Motivational Interviewing for Health Care Professionals:\\xa0 A Sensible Approach, 2nd Edition APhA, Washington, DC 2020, and an 8 hour accredited Motivational Interviewing E-Learning Program for Health Care Professionals (2015), along with William A. Villaume.

Getting started with Motivational Interviewing (MI)

Dr. Berger became interested in MI when he was researching the topic of improving adherence to medication.\\xa0 A former grad student, Karen Hudman, told Dr. Berger about Dr. William Miller\\u2019s work.\\xa0 Dr. Miller developed an intervention in clinical psychology in the 1970\\u2019s, to help individuals with substance use disorders (addiction disorders).\\xa0 It revolutionized the way clinicians spoke to individuals with SUD.\\xa0 Before that, there was \\u201ctough love,\\u201d and it didn\\u2019t work.\\xa0 Tough love is shame-based.

Dr. Miller found that reflecting back to patients what they were going through and asking open-ended questions helped.\\xa0 Examples:\\xa0 \\u201cTell me how serious you think this is.\\xa0 What kind of impact do you see it having?\\xa0 Do you think people are overblowing what\\u2019s going on with you?\\xa0 Dr. Miller\\u2019s methods were non-threatening and got people to talk about what was really going on. \\xa0

Dr. Miller wasn\\u2019t trying to motivate people to stop abusing substances as much as he was trying to explore their motivation to quit.\\xa0 What would have to change?\\xa0 First, they had to recognize that there was a problem.\\xa0 He had to explore their motivation to use and quit.\\xa0 It was an interview because what they had to say was just as important as what he had to say.\\xa0 It was a meeting of experts!\\xa0 They were experts on their own substance abuse; Dr. Miller was an expert at psychology and helping individuals.

Dr. Berger read about MI and contacted Dr. Miller.\\xa0 They had some great conversations.\\xa0 MI is to this day the most successful intervention for substance abuse disorder and has the lowest rate of relapse.\\xa0 Dr. Berger drew a parallel from using MI for SUD to using MI for high blood pressure.\\xa0 So, he brought it to the healthcare space. \\xa0

What is motivational interviewing for healthcare professionals? \\xa0

MI is a set of skills that are evidence-based and work to help a healthcare provider talk to patients who are either ambivalent or resistant to behavior change relative to health behaviors:\\xa0 taking medicine, losing weight, changing eating habits, and more.\\xa0 MI is non-confrontational and respects that ultimately this is the patient\\u2019s decision.\\xa0 It combines reflection and addressing patient\\u2019s issues to increase the probability that after the \\u201cinterview,\\u201d the patient will be more likely to engage in healthy behaviors. \\xa0

How long has Dr. Berger been teaching folks about MI? \\xa0

\\xa0About 30 years.\\xa0 It\\u2019s been a learning process for Dr. Berger too!\\xa0 He went by the book at first.\\xa0 Then, he realized he needed to adapt MI from clinical psychology to healthcare.\\xa0 One big reason is that pharmacists, for example, work in a time-limited environment and sometimes have one-time encounters with patients.

Acronyms vs. sense-making approach

Dr. Miller taught with acronyms.\\xa0 In practice, pharmacists can\\u2019t remember the acronyms or when to use them.\\xa0 Dr. Berger changed the acronyms to a \\u201csense-making approach.\\u201d\\xa0 It got rid of all the acronyms.\\xa0 Bruce\\u2019s approach uses a theory developed by a communication expert named Brenda Durbin.\\xa0 She says humans are \\u201csense-makers.\\u201d\\xa0 It\\u2019s just who we are.\\xa0 Patients, on the other hand, are making sense of 3 things: \\xa0

1. The illness:\\xa0 \\u201cWhat does high blood pressure mean to me?\\u201d
2. The treatment:\\xa0 \\u201cGiven what I know about blood pressure, does this treatment make sense to me?\\u201d \\xa0
3. Relationship with the healthcare professional.\\xa0 That relationship is critical to whether the patient wants to move forward with treatment and whether they believe what the healthcare professional is telling them. \\xa0

Who are Dr. Berger\\u2019s comMIt learners?

In the past, Dr. Berger taught at live events in Atlanta, GA.\\xa0 Now, learners are at conferences (APhA, for example), e-learning program participants, one-on-one coaching via webinars, and readers of his book.

Learners are healthcare professionals managing chronic illnesses:\\xa0 diabetes, high blood pressure, high cholesterol, and more; clinical psychologists from the VA, for example; medical doctors, pharmacists, pharmacy technicians, nurses, social workers, sociologists, veterinarians, physical therapists, and chiropractors.

At APhA, pharmacists, pharmacy technicians, and students are in attendance, but there are often faculty and sometimes physicians there too. \\xa0

The comMIt e-learning program

The e-learning program is 8 hours in length and has six modules.\\xa0 8 hours of accredited continuing education is available for pharmacists, pharmacy technicians, doctors, nurses, and social workers.\\xa0 Once learners start, they have 3 months of access to the program, which has bookmarks so you can do it at your own pace.\\xa0 Group rates are available starting at 5 people with huge discounts.\\xa0 Groups have 3-years to use their group code. \\xa0 \\xa0

Entire universities (colleges of pharmacy, nursing, medicine, and more) can subscribe to the e-learning program for $1,000/one year for unlimited student use!\\xa0 Universities put the modules on their LMS, and students can use them until the year is up.\\xa0 Idaho State University, for example, has done this.\\xa0 Dr. Mike Biddle and Dr. Rebecca Hoover are using the six-module e-learning course as part of their curriculum.\\xa0 After students consume each module, they participate in immersion exercises to apply what they just learned.\\xa0 Drs. Biddle and Hoover are publishing a paper on this soon, and they won an award for demonstrating an improvement in student skills and knowledge after using the ComMIt e-learning program. \\xa0

The comMIt program is great for healthcare professionals and students who need to learn MI.\\xa0

Examples of using motivational interviewing

Dr. Berger gave some great examples of the sense-making approach to motivational interviewing.\\xa0 MI was developed for patients who are ambivalent or resistant to change.\\xa0 Their sense-making is problematic.\\xa0 It\\u2019s based on inaccurate or incomplete information.\\xa0 A patient\\u2019s sense leads to a conclusion, which leads to a decision about behavior. \\xa0

Situation:\\xa0 A high blood pressure patient says, \\u201cI don\\u2019t know why I need this medication.\\xa0 \\u201cI feel fine.\\u201d\\xa0 Their conclusion is, \\u201cI feel fine, therefore, I am fine.\\u201d\\xa0 Humans use schema to make sense of things.\\xa0 They conclude that they aren\\u2019t going to take their medicine. \\xa0

When people are ambivalent or resistant about behavior change, their sense-making is problematic because they are operating with inaccurate or incomplete information. \\xa0

Incomplete:\\xa0 they don\\u2019t know how they can feel ok and not be at risk.\\xa0 Listening for that helps pharmacists know what to do.

Typical pharmacist response is, \\u201cWell, you can\\u2019t feel when your blood pressure is up.\\u201d\\xa0 We make the patient feel stupid.\\xa0 We cause them to lose face.\\xa0 They discount the information that is given to them or they disregard it altogether.\\xa0 There are studies to support this.\\xa0 Don\\u2019t try to persuade, convince, or cause them to lose face.

Dr. Berger\\u2019s version of MI helps the patient understand how they can feel ok and still be at risk without causing them to lose face. \\xa0

Example #1

• Patient:\\xa0 \\u201cI don\\u2019t know why I need this medication.\\xa0 I feel fine.\\u201d\\xa0
• Pharmacist:\\xa0 \\u201cBecause you\\u2019re feeling ok, you\\u2019re wondering why I need this medicine?\\u201d
• Patient:\\xa0 \\u201cRight!\\u201d\\xa0 (They feel understood because the pharmacist listened to them, and they do not feel judged.)\\xa0 The pharmacist gave the patient a chance to confirm their statement or correct the pharmacist/clarify. \\xa0
• Pharmacist:\\xa0 \\u201cYou raise a good question.\\u201d\\xa0 (Pharmacist encourages patient push-back.) \\u201cWould you mind if I shared some thoughts with you, and you tell me what you think?\\u201d\\xa0 (Be conversational!)
• Patient:\\xa0 \\u201cSure.\\u201d\\xa0 If they say they will listen, but still won\\u2019t take the medicine, just remind them that this really is their decision.\\xa0 People aren\\u2019t going to do what we tell them just because we tell them to do it. \\xa0
• Pharmacist:\\xa0 \\u201cHBP is one of those health conditions that does not have any symptoms.\\xa0 The first symptom is often a stroke or a heart attack.\\xa0 In other words, a person\\u2019s blood pressure can be elevated, and they don\\u2019t even feel it.\\xa0 Therefore, people stop taking their medicine or never start taking their medicine.\\xa0 I\\u2019d hate to see that happen to you because you can lower your blood pressure by taking this medicine.\\xa0 It would be really tragic if you didn\\u2019t take your medicine and had a stroke or a heart attack because you felt ok.\\xa0 Where does this leave you now in terms of taking the medicine?\\u201d \\xa0
• Patient \\u201cWow, I never realized that!\\u201d\\xa0 Or, \\u201cCome on.\\xa0 You\\u2019re saying I can feel this good and still have a stroke or a heart attack?\\u201d \\xa0
• Pharmacist can say, \\u201cYes, and that\\u2019s the dangerous thing about high blood pressure.\\xa0 What are your thoughts?\\u201d

Example #2 from a pharmacist who had a one-on-one private coaching webinar with Dr. Berger \\xa0

• Pharmacist calls patient and points out that compliance is low:\\xa0 4 out of 7 days per week.
• Patient says, \\u201cYeah yeah.\\u201d \\xa0
• The Pharmacist didn\\u2019t learn from that interaction.\\xa0 Instead, the pharmacist should focus on what the patient is doing right.\\xa0 In this example, he\\u2019s taking his medicine 4 days/week. \\xa0
• Pharmacist can ask, \\u201cWhat\\u2019s made it important for you to take it on those four days?\\u201d\\xa0
• Patient says he felt fine after taking it 4 days/week.\\xa0 Or, he can\\u2019t afford it 7 days/week.\\xa0 Or, he can\\u2019t handle the side effects.\\xa0
• Assume the patient felt fine taking it 4/7 days/week.\\xa0 The pharmacist says, \\u201cBecause you felt ok after 4 days, you\\u2019re thinking, \\u2018Why do I need to take it more,\\u2019 right?\\xa0 Great question.\\xa0 Mind if I share some thoughts with you?\\xa0 You tell me what you think.\\u201d\\xa0 You can learn about their internal motivation.\\xa0 That could be reasonable thought from the patient\\u2019s point of view. \\xa0

Dr. Berger\\u2019s comMIt e-learning course has example cases

Cases of pharmacists doing it wrong - no MI.\\xa0 Then, doing it using MI.\\xa0 Words appear on the screen.\\xa0 Dr. Berger talks about where in the conversation things went south, and words light up on the screen for emphasis.\\xa0 It\\u2019s easy to see WHY it went south.\\xa0 Using MI, the RIGHT words are highlighted to show a resolution that improves health.\\xa0 A single, one-on-one coaching webinar is provided with each individual or each group purchase.\\xa0 Participants can buy extra coaching as needed.\\xa0 It\\u2019s a webcast with video and audio. \\xa0

Barriers to enrolling

Most people don\\u2019t think they need 8 hours.\\xa0

Barriers to using MI once it is learned

MI is patient-centered.\\xa0 The patient\\u2019s needs are more important than mine.\\xa0 To be patient-centered means that I need to exist in the pre-frontal cortex of my brains where complex decision making and high-level empathy take place.\\xa0 When you\\u2019re not in that part of your brain, you make mistakes.

Brief example: \\xa0

Dr. Berger had a pharmacy student who helped a patient who was buying aspirin with his warfarin.\\xa0 The student asked the patient some questions, and he responded in a threatening way.\\xa0 Her limbic system kicked in.\\xa0 She could ONLY fight, flee, or freeze.\\xa0 You can\\u2019t do MI in the limbic system.\\xa0 You\\u2019re too busy worrying about yourself\\u2026trying to survive.\\xa0 So, you can\\u2019t be patient-centered. \\xa0 \\xa0

Sense-making in this example: \\xa0

• Patient:\\xa0 \\u201cAspirin is the only thing that helps with my back pain.\\xa0 I don\\u2019t trust the reason my healthcare professional wants to do bloodwork.\\u201d \\xa0
• Pharmacists need to listen for - and address - the sense-making.\\xa0 \\u201cYou\\u2019ve been getting a lot of relief from your back pain, and you don\\u2019t want anyone to take that away from you.\\xa0 And, I want you to know that I don\\u2019t want to take your pain relief away from you.\\xa0 It also sounds like you have some serious doubts about what your doctor\\u2019s motives are for having bloodwork done.\\u201d\\xa0
• Patient said, \\u201cDamn right.\\u201d \\xa0 The pharmacist is now in the position to make a positive change because he showed the patient he understood how the patient understood the world. \\xa0
• Note:\\xa0 MI asks permission.\\xa0 There is an exception.\\xa0 When the pharmacist fears that the patient is at risk for harm by withholding information, permission is not needed.\\xa0 This is one of those examples.\\xa0 Without asking permission, you say, \\u201cHere\\u2019s what my concern is.\\xa0 I really want you to get relief from your back pain, and I want to talk to you about that.\\xa0 I don\\u2019t want to take your pain relief away from you.\\xa0 But, here\\u2019s what worries me.\\xa0 Aspirin can make your warfarin work better than it should.\\xa0 Instead of preventing blood clots, it could lead to hemorrhaging.\\xa0 You could die from that.\\xa0 Your doctor wants to monitor you so he can adjust your dose, if needed.\\xa0 It\\u2019s possible to take warfarin with aspirin, but only if you\\u2019re monitored.\\xa0 Even then, it\\u2019s somewhat dangerous.\\xa0 I\\u2019d like to act as your advocate and call your doctor, but before I do that, I\\u2019d like to talk to you about some alternatives to aspirin that you can use.\\xa0 I\\u2019d like to know what you\\u2019ve done with physical therapy too, so you can more safely get pain relief and still use your warfarin.\\u201d
• He said, \\u201cyou think this is serious?\\u201d\\xa0 That\\u2019s the power of MI.\\xa0 It changes the dynamic!\\xa0

In the book and the e-learning, there is an entire chapter and module about \\u201cThe brain and social threat.\\u201d\\xa0

Self-Deception and Objectification:\\xa0 another barrier to MI

APhA\\u2019s talk was going to be about self-deception and objectification.\\xa0 When we objectify a human being, we reduce them to an object.\\xa0 People are always people, even when they are behaving badly. \\xa0

People sometimes become blind to the fact that someone is a person, which reduces them to an object. \\xa0

What causes someone to become blind?\\xa0 That\\u2019s what the APhA workshop was about.\\xa0 \\xa0 To be patient-centered and use MI, you can not reduce a person to an object because when you reduce a person to an object, you will feel justified in providing less care or mistreating that person.\\xa0 \\xa0

When a healthcare professional says that someone is being difficult and won\\u2019t listen to what is being said, they are treating their patient like an object.\\xa0 They feel justified in not treating someone with the dignity and respect they deserve.\\xa0 That is dangerous in healthcare. \\xa0

Example:\\xa0 Driving near a shopping center. \\xa0

Someone pulls out in front of you.\\xa0 You have to honk and slam on your breaks.\\xa0 You gesture.\\xa0 You have reduced that person to an idiot in the moment.\\xa0 Then, you see it\\u2019s your priest or best friend, and you feel embarrassed and want to hide.\\xa0 They are now a person.

When we betray the right thing to another person and we do not acknowledge the betrayal, we will justify ourselves, objectify, and become self-deceived. \\xa0

Honk and slam on your breaks.\\xa0 Don\\u2019t give dirty looks or gesture.\\xa0 After all, it\\u2019s just another human being.\\xa0 When we objectify, we can not be patient-centered and use MI. \\xa0

In conclusion, learn MI thoroughly. It is powerful.\\xa0 Invest the time in MI.\\xa0 2 hours is not enough.\\xa0 It can be frustrating to use when you haven\\u2019t learned it thoroughly.\\xa0 A minimum of 8-16 hours of training and application is needed to become really good at using it.\\xa0 Use it daily.\\xa0 Hone the craft.\\xa0 Patient health outcomes can improve, and money can be saved. \\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

\\xa0

'