Motivational Interviewing Can Improve Adherence to Oral Cancer Agents
By Kate O’Rourke
Dallas, TX | Posted May 3, 2016
Do you have patients who are nonadherent to their oral cancer therapy? Have you tried motivational interviewing, which has been most widely used for patients with substance abuse?
“There is a lot of information out there showing that motivational interviewing can be applied to everything, including medication adherence,” said Jenny Van Amburgh, PharmD, a clinical professor and the residency program director at Northeastern University School of Pharmacy, in Boston. She presented a primer on the topic during a talk at the 2015 annual conference of the Hematology/Oncology Pharmacy Association.
A variety of intrinsic and extrinsic factors can affect adherence to medication, including lack of symptoms, bothersome side effects and high medical costs (Table). First described in 1983, the concept of motivational interviewing sprang from the recognition that problem drinkers who eventually went sober experienced the same six cycles of change (Am Psychol 2009;64:527-537). The first is precontemplation, of which a person does not intend to change anytime soon, followed by contemplation, when a person can be strongly inclined to change a behavior but doesn’t know how to begin. In the preparation stage, a person intends to act in the near future. In the action stage, a person takes steps toward making a change. In the maintenance stage, the new behavior has been sustained over a period of time, and then there is the possibility of a sixth stage, relapse.
Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. A variety of skills can be used to help move individuals through the stages of change. “When you are using motivational interviewing skills, you need to have open-ended questions, affirmations that are sincere and true, and active listening and reflection. It is a learned process. It takes time,” Dr. Van Amburgh said. “You are letting the patient do all of the talking, and you are listening to what the patient is saying and trying to figure out how to move them into action.”
You might say, “It must be difficult to take your medication every day if it makes you feel worse. About how many times per week would you say you miss your medication?” Dr. Van Amburgh typically tells patients that she has difficulty remembering her daily vitamin, as a way of relating to patients.
Clinicians can reflect on words and body language. “You can say, ‘I noticed when we were discussing these new medications, you appeared upset and frustrated. What are you thinking about?’” Dr. Van Amburgh said.
Sometimes just getting patients into the clinic can get them to buy in, if clinicians can follow up with something such as, “I’m glad you came into the clinic today for another appointment, and I appreciate your honesty about how you take your medications.” You are affirming that your patients shared their problems with you, but you are not passing judgment and are engaging them to tell you more, she noted.
Providing quick summaries at the end of a conversation can be very helpful, such as, “We discussed a couple ways to help you take your medication; which would you be most interested in trying?” Dr. Van Amburgh said. “The difference is I am not telling the patient; the patient is leading the conversation. Motivational interviewing is about having patients be their own advocate and making them more in control of what they are doing. The more they are in control, the more they are likely to do it.”
Dr. Van Amburgh discussed a few of the motivational interviewing principles of change: rolling with resistance, expressing empathy, developing discrepancy and supporting self-efficacy. To roll with resistance and express empathy, you might say, “Taking medications can be difficult, especially when they make you feel worse. Let me suggest an idea that you could consider to see if it would help. If it works, then great, but if not, feel free to let me know so we can think about something else.”
To develop discrepancy, clinicians can evoke the patient’s own reason for and against change, such as, “What difficulties have you encountered when trying to take your medications every day?”
Pharmacists can support self-efficacy using importance/confidence scales. “How important is it to you to take all your medications every day on a scale of 1 to 10, with 0 being not important and 10 being very important? How confident are you that you can take your medications every day using the same scale? What would it take to move you from 7 to 8 on the scale, and what do you think you would need to do it?” Dr. Van Amburgh said.
Dr. Van Amburgh pointed out that she had only covered the very tip of the iceberg of motivational interviewing. “You can take courses for weeks on motivational interviewing,” she said, noting that it takes time to implement in practice.
The use of motivational interviewing for cancer patients is growing. The Oncology Nursing Society includes motivational interviewing techniques in their Oral Adherence Toolkit (www.ons.org/practice-resources/clinical-practice/ons-toolkit-helps-patients-adhere-oral-therapies-cancer). According to Stephanie Wheeler, PhD, an assistant professor of health policy and management at University of North Carolina Gillings School of Global Public Health, in Chapel Hill, who studies medication adherence, motivational interviewing is a promising technique for addressing many types of behavior change in cancer patients or survivors, including diet, exercise, smoking cessation and cancer-related stress.