Mentioned in this episode:
Dr. Bruce Berger
Motivational Interviewing for Health Professionals: A Sensible Approach 2nd Edition
by Bruce A. Berger (Author), William A. Villaume (Author) 2020
- https://www.amazon.com/dp/1582123217/ref=cm_sw_em_r_mt_dp_U_BSNJEbXKMTCYR or
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. He taught at West Virginia University in 1980-1981. 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. He has written or presented over 800 papers (85 peer reviewed) or seminars (94 peer reviewed) on these topics.
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. The study focused on the impact of motivational interviewing.
Bruce is the 2009 recipient of the American Association of Colleges of Pharmacy’s Robert Chalmers Distinguished Pharmacy Educator Award, one of the Association’s three highest honors.
Bruce is the author of the book, Motivational Interviewing for Health Care Professionals: 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. A former grad student, Karen Hudman, told Dr. Berger about Dr. William Miller’s work. Dr. Miller developed an intervention in clinical psychology in the 1970’s, to help individuals with substance use disorders (addiction disorders). It revolutionized the way clinicians spoke to individuals with SUD. Before that, there was “tough love,” and it didn’t work. Tough love is shame-based.
Dr. Miller found that reflecting back to patients what they were going through and asking open-ended questions helped. Examples: “Tell me how serious you think this is. What kind of impact do you see it having? Do you think people are overblowing what’s going on with you? Dr. Miller’s methods were non-threatening and got people to talk about what was really going on.
Dr. Miller wasn’t trying to motivate people to stop abusing substances as much as he was trying to explore their motivation to quit. What would have to change? First, they had to recognize that there was a problem. He had to explore their motivation to use and quit. It was an interview because what they had to say was just as important as what he had to say. It was a meeting of experts! 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. They had some great conversations. MI is to this day the most successful intervention for substance abuse disorder and has the lowest rate of relapse. Dr. Berger drew a parallel from using MI for SUD to using MI for high blood pressure. So, he brought it to the healthcare space.
What is motivational interviewing for healthcare professionals?
MI is a set of skills that are evidence-based and work to help a healthcare provider be able to talk to patients who are either ambivalent or resistant to behavior change relative to health behaviors: taking medicine, losing weight, changing eating habits, and more. MI is non-confrontational and respects that ultimately this is the patient’s decision. It combines reflection and addressing patient’s issues to increase the probability that after the “interview,” the patient will be more likely to engage in healthy behaviors.
How long has Dr. Berger been teaching folks about MI?
About 30 years. It’s been a learning process for Dr. Berger too! He went by the book at first. Then, he realized he needed to adapt MI from clinical psychology to healthcare. 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. In practice, pharmacists can’t remember the acronyms or when to use them. Dr. Berger changed the acronyms to a “sense-making approach.” It got rid of all the acronyms. Bruce’s approach uses a theory developed by a communication expert named Brenda Durbin. She says humans are “sense-makers.” It’s just who we are. Patients, on the other hand, are making sense of 3 things:
- The illness: “What does high blood pressure mean to me?”
- The treatment: “Given what I know about blood pressure, does this treatment make sense to me?”
- Relationship with the healthcare professional. 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.
Who are Dr. Berger’s comMIt learners?
In the past, Dr. Berger taught at live events in Atlanta, GA. 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: 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.
The comMIt e-learning program
The e-learning program is 8 hours in length and has six modules. 8 hours of accredited continuing education is available for pharmacists, pharmacy technicians, doctors, nurses, and social workers. Once learners start, they have 3 months of access to the program, which has bookmarks so you can do it at your own pace. Group rates are available starting at 5 people with huge discounts. Groups have 3-years to use their group code.
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! Universities put the modules on their LMS, and students can use them until the year is up. Idaho State University, for example, has done this. Dr. Mike Biddle and Dr. Rebecca Hoover are using the six-module e-learning course as part of their curriculum. After students consume each module, they participate in immersion exercises to apply what they just learned. 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.
The comMIt program is great for healthcare professionals and students who need to learn MI.
Examples of using motivational interviewing
Dr. Berger gave some great examples of the sense-making approach to motivational interviewing. MI was developed for patients who are ambivalent or resistant to change. Their sense-making is problematic. It’s based on inaccurate or incomplete information. A patient’s sense leads to a conclusion, which leads to a decision about behavior.
Situation: A high blood pressure patient says, “I don’t know why I need this medication. “I feel fine.” Their conclusion is, “I feel fine, therefore, I am fine.” Humans use schema to make sense of things. They conclude that they aren’t going to take their medicine.
When people are ambivalent or resistant about behavior change, their sense-making is problematic because they are operating with inaccurate or incomplete information.
Incomplete: they don’t know how they can feel ok and not be at risk. Listening for that helps pharmacists know what to do.
Typical pharmacist response is, “Well, you can’t feel when your blood pressure is up.” We make the patient feel stupid. We cause them to lose face. They discount the information that is given to them or they disregard it altogether. There are studies to support this. Don’t try to persuade, convince, or cause them to lose face.
Dr. Berger’s version of MI helps the patient understand how they can feel ok and still be at risk without causing them to lose face.
- Patient: “I don’t know why I need this medication. I feel fine.”
- Pharmacist: “Because you’re feeling ok, you’re wondering why I need this medicine?”
- Patient: “Right!” (They feel understood because the pharmacist listened to them, and they do not feel judged.) The pharmacist gave the patient a chance to confirm their statement or correct the pharmacist/clarify.
- Pharmacist: “You raise a good question.” (Pharmacist encourages patient push-back.) “Would you mind if I shared some thoughts with you, and you tell me what you think?” (Be conversational!)
- Patient: “Sure.” If they say they will listen, but still won’t take the medicine, just remind them that this really is their decision. People aren’t going to do what we tell them just because we tell them to do it.
- Pharmacist: “HBP is one of those health conditions that does not have any symptoms. The first symptom is often a stroke or a heart attack. In other words, a person’s blood pressure can be elevated, and they don’t even feel it. Therefore, people stop taking their medicine or never start taking their medicine. I’d hate to see that happen to you because you can lower your blood pressure by taking this medicine. It would be really tragic if you didn’t take your medicine and had a stroke or a heart attack because you felt ok. Where does this leave you now in terms of taking the medicine?”
- Patient “Wow, I never realized that!” Or, “Come on. You’re saying I can feel this good and still have a stroke or a heart attack?”
- Pharmacist can say, “Yes, and that’s the dangerous thing about high blood pressure. What are your thoughts?”
Example #2 from a pharmacist who had a one-on-one private coaching webinar with Dr. Berger
- Pharmacist calls patient and points out that compliance is low: 4 out of 7 days per week.
- Patient says, “Yeah yeah.”
- The Pharmacist didn’t learn from that interaction. Instead, the pharmacist should focus on what the patient is doing right. In this example, he’s taking his medicine 4 days/week.
- Pharmacist can ask, “What’s made it important for you to take it on those four days?”
- Patient says he felt fine after taking it 4 days/week. Or, he can’t afford it 7 days/week. Or, he can’t handle the side effects.
- Assume the patient felt fine taking it 4/7 days/week. The pharmacist says, “Because you felt ok after 4 days, you’re thinking, ‘Why do I need to take it more,’ right? Great question. Mind if I share some thoughts with you? You tell me what you think.” You can learn about their internal motivation. That could be reasonable thought from the patient’s point of view.
Dr. Berger’s comMIt e-learning course has example cases
Cases of pharmacists doing it wrong – no MI. Then, doing it using MI. Words appear on the screen. Dr. Berger talks about where in the conversation things went south, and words light up on the screen for emphasis. It’s easy to see WHY it went south. Using MI, the RIGHT words are highlighted to show a resolution that improves health. A single, one-on-one coaching webinar is provided with each individual or each group purchase. Participants can buy extra coaching as needed. It’s a webcast with video and audio.
Barriers to enrolling
Most people don’t think they need 8 hours.
Barriers to using MI once it is learned
MI is patient-centered. The patient’s needs are more important than mine. 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. When you’re not in that part of your brain, you make mistakes.
Dr. Berger had a pharmacy student who helped a patient who was buying aspirin with his warfarin. The student asked the patient some questions, and he responded in a threatening way. Her limbic system kicked in. She could ONLY fight, flee, or freeze. You can’t do MI in the limbic system. You’re too busy worrying about yourself…trying to survive. So, you can’t be patient-centered.
Sense-making in this example:
- Patient: “Aspirin is the only thing that helps with my back pain. I don’t trust the reason my healthcare professional wants to do bloodwork.”
- Pharmacists need to listen for – and address – the sense-making. “You’ve been getting a lot of relief from your back pain, and you don’t want anyone to take that away from you. And, I want you to know that I don’t want to take your pain relief away from you. It also sounds like you have some serious doubts about what your doctor’s motives are for having bloodwork done.”
- Patient said, “Damn right.” 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.
- Note: MI asks permission. There is an exception. When the pharmacist fears that the patient is at risk for harm by withholding information, permission is not needed. This is one of those examples. Without asking permission, you say, “Here’s what my concern is. I really want you to get relief from your back pain, and I want to talk to you about that. I don’t want to take your pain relief away from you. But, here’s what worries me. Aspirin can make your warfarin work better than it should. Instead of preventing blood clots, it could lead to hemorrhaging. You could die from that. Your doctor wants to monitor you so he can adjust your dose, if needed. It’s possible to take warfarin with aspirin, but only if you’re monitored. Even then, it’s somewhat dangerous. I’d like to act as your advocate and call your doctor, but before I do that, I’d like to talk to you about some alternatives to aspirin that you can use. I’d like to know what you’ve done with physical therapy too, so you can more safely get pain relief and still use your warfarin.”
- He said, “you think this is serious?” That’s the power of MI. It changes the dynamic!
In the book and the e-learning, there is an entire chapter and module about “The brain and social threat.”
Self-Deception and Objectification: another barrier to MI
APhA’s talk was going to be about self-deception and objectification. When we objectify a human being, we reduce them to an object. People are always people, even when they are behaving badly.
People sometimes become blind to the fact that someone is a person, which reduces them to an object.
What causes someone to become blind? That’s what the APhA workshop was about. 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.
When a healthcare professional says that someone is being difficult and won’t listen to what is being said, they are treating their patient like an object. They feel justified in not treating someone with the dignity and respect they deserve. That is dangerous in healthcare.
Example: Driving near a shopping center.
Someone pulls out in front of you. You have to honk and slam on your breaks. You gesture. You have reduced that person to an idiot in the moment. Then, you see it’s your priest or best friend, and you feel embarrassed and want to hide. 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.
Honk and slam on your breaks. Don’t give dirty looks or gesture. After all, it’s just another human being. When we objectify, we can not be patient-centered and use MI.
In conclusion, learn MI thoroughly. It is powerful. Invest the time in MI. 2 hours is not enough. It can be frustrating to use when you haven’t learned it thoroughly. A minimum of 8-16 hours of training and application is needed to become really good at using it. Use it daily. Hone the craft. Patient health outcomes can improve, and money can be saved.