ENERGÍA SOLAR TÉRMICA

This chapter explores how motivational interviewing (MI) enriches the care we pro-vide for patients with particular health concerns in a variety of settings: screening interviews for unhealthy/risky behaviors, sexual health, chronic pain, eating disorders, substance use during pregnancy, palliative care, psychiatric disorders, and substance use disorders. Evidence demonstrating the value of MI in these groups varies, but research is ongoing.

What is known is that MI helps patients bring about behavior changes that have the potential to mitigate, even avert, catastrophic medical consequences. The first step is to assist each patient to identify unhealthy behaviors so that the appropriate, MI-related interventions may be planned and implemented. Unfortunately, we often contribute to a systemic failure to help patients recognize and acknowledge problematic behaviors.

Sometimes we lack familiarity with appropriate screening tools and strategies, while in other instances, we lack sufficient confidence or expertise to address the unhealthy behaviors we do identify. MI provides a sound foundation for screening, identifying, and exploring a wide range of harmful behaviors, we must acquire these skills in order to serve our patients to the best of our abilities.

You’ll notice that many of the dialogues presented in this chapter are longer than those in previous chapters. This is a deliberate choice; our goal in doing so is to high-light, in an extended fashion, the pacing of the encounters with patients regarding particularly sensitive issues.

SCREENING

As obvious as it may seem, it’s worth remembering that one cannot tell whether a patient is struggling with certain behaviors simply by observing him or her. Earlier chapters have reviewed a plethora of nonverbal cues that we should attend to in our patient interactions; let these signals guide how the interviews unfold. Even within a relatively short screening interview, establishing a therapeutic alliance with the patient is essential; a safe and secure atmosphere encourages patients to share their perspec-tives regarding specific health concerns, and it increases their readiness to request, listen to, and learn from the information we share in return. Screening interviews call for a unique combination of medical knowledge concerning specific illnesses blended with an ability to use empathic, reflective listening in the pursuit of an open, trusting relationship with each patient.

Medical screening refers to the process of integrating data gathered through obser-vation, written self-reports, patient interviews, laboratory tests, and physical examina-tions to determine whether patients are (1) engaging in behaviors that increase their risk of contracting an illness or worsening an existing condition, or (2) experienc-ing clinical manifestations of a secondary problem. The patients we interview in the clinical exchanges often experience feelings of shame or guilt about themselves or their

Motivational Interviewing170 behaviors, and they may be reluctant to share intimate information. Fear of disap-proval or an acute sense of the social stigma that accompanies various signs and symp-toms is another deterrent. In some situations, patients will acknowledge sympsymp-toms and/or behaviors but minimize their frequency, significance, and possible sequelae.

By improving the likelihood of honest, open reporting and emphasizing a spirit of collaboration and support for a patient’s autonomy, MI helps us engage with patients who might otherwise fall between the cracks in our healthcare system. Important skills include expressing empathy, using reflective listening with an egalitarian approach, maintaining a nonjudgmental tone, and providing objective feedback regarding high-risk behaviors, diagnoses, treatment options, and prognoses.

The Screening Process

Screening for a particular condition should be prefaced by a short discussion outlining what will be explored in the encounter. Do not overlook this element; it plays a key role in reducing the potential for discord that may arise when patients feel ambushed, surprised, or offended at the content of your questions. In the following interview, MI skills are incorporated from the outset:

Trainee: Hi, I’m Doctor Jones, you’re here for a routine physical exam, is that right?

(Closed-ended question) Patient: Yes, that’s why I’m here.

Trainee: It’s nice to meet you. Part of our interview will include talking about your lifestyle, which includes topics like drug use and sexual activity. Are you OK with us having a discussion about this? (Providing information followed by asking permission)

Patient: I’m a little bit uncomfortable talking about some of this stuff, but I under-stand that’s important. Overall, I’m pretty happy with my life and my choices right now.

Trainee: It’s up to you to decide what, if any, changes you’d like to make, and it’s impor-tant that you know this won’t affect our working relationship. I may make recom-mendations, but these are not meant to be judgmental. (Autonomy statement) Patient: Phew! I’m relieved that you’re not going to tell me what to do.

Trainee: You’ve had some experiences in the past in which doctors haven’t seemed to listen or understand you. You don’t have any specific health concerns right now, and at the same time, by coming here today, you demonstrate that you value your health. (Complex reflection)

From the moment of introduction, this trainee demonstrates a transparent approach to the interview that emphasizes collaboration. On a more subtle level, the trainee reinforces respect for patient autonomy and self-determination and a genuine interest in promoting patient health.

Screening for Unhealthy Alcohol Use

The US Preventive Services Task Force (USPSTF) ranks screening and counseling for unhealthy alcohol use as third among the top five health-related prevention priori-ties for American adults. Given the strong contribution overconsumption of alcohol

171Special Populations and Settings

has on morbidity and mortality rates, this type of screening is widely recognized as a highly cost-effective measure, and virtually any patient interview that includes refer-ence to alcohol use will be enriched by integrating the MI approach. Attitudes and approaches to alcohol range from abstinence, infrequent or low-risk use, to higher risk behaviors, including problem drinking, alcohol abuse, and the less common, but more severe, alcohol dependence.

Brief interventions for unhealthy alcohol use typically last from several minutes to an entire visit and may occur within a single session or multiple sessions. These patient-centered, motivational conversations focus on increasing insight and aware-ness regarding alcohol use and supporting patients’ motivation for behavioral change;

they are suitable as stand-alone interventions for at-risk individuals, as well as for those who need more extensive care.

The acronym FRAMES summarizes the six key points of brief interventions:

• Feedback regarding personal risk or impairment is offered to patients following assessment of alcohol use patterns and consequences.

• Responsibility for the decision to change, and to bring about change, belongs solely to our patients.

• Advice concerning how to modify substance use is shared in a nonthreatening, nonjudgmental manner.

• Menu of options regarding strategies to modify behavior and/or possible treat-ments support autonomy and encourage patients to participate in their own care.

• Empathic approach assumes that we demonstrate warmth, respect, and under-standing at all times.

• Self-efficacy and a patient’s belief that he or she is capable of behavior change are supported when we elicit and reinforce change statements.

Following is a sample of statements during a brief intervention using the FRAMES model (Fig. 13.1):

Feedback (Summarize current assessment): What I understand you saying is that, on average, you have five or six drinks in a single day, two or three times each week.

Earlier today, we discussed why monitoring your blood pressure and taking your antihypertensive medication as prescribed is so important to your health. These two

FIGURE 13.1 Brief interventions using FRAMES.

Motivational Interviewing172 behaviors are connected in that the amount of alcohol you consume is in the range of what is called “high risk,” partly because of how it might affect your blood pressure.

What are your thoughts about this relationship? (Elicit patient’s reaction and listen) Responsibility: It’s up to you to decide when, or if, you’re ready to reduce your alcohol

consumption or to stop drinking altogether. Whatever you decide will not affect our working relationship or your treatment with us. (Emphasize patient responsibility) Advice: Would it be okay if I shared with you which actions you might take to improve your health and, in particular, your blood pressure? (Wait for permission: proceed if permis-sion is granted) My suggestion would be to limit your drinking to seven drinks or fewer per week, and no more than three drinks on a single occasion; sometimes don’t drink at all when you’re out. What are your thoughts about this advice? How do you feel about reducing your drinking? (Recommend changes with patient’s permission)

Menu of Alternatives: I realize that reducing or giving up drinking might be really chal-lenging, and I’m wondering if we could brainstorm strategies that could help lessen your exposure to situations that prompt you to drink. I could also make some sug-gestions about programs and community support. (Present alternative options) Empathy: Sorting out what you need and want to do about your drinking is not an easy

decision. (Respectful, nonjudgmental approach)

Self-Efficacy: Could we spend a few minutes reviewing what you’ve done in the past to manage your drinking? These experiences, regardless of how successful they were, provide important clues as to what works or doesn’t work for you. (Wait for permis-sion, and then proceed) I believe that, together, we can come up with a strategy that will work for you when you decide you want to change your drinking. (Eliciting and reinforcing hope and optimism)

Sexual Behaviors

In the area of HIV/AIDS prevention, MI helps to target patients’ ambivalence about acknowledging and reducing high-risk sexual behaviors. For example, the randomized clinical trial of the EXPLORE study investigating behavioral interventions in a large sample of men who had sex with men demonstrated a significant reduction in the rate of HIV infection among those who received MI, compared with those who were given standard counseling sessions regarding risk reduction. One reason for this finding may be that MI’s effectiveness is closely related to the strength of the therapeutic alliance practitioners establish with their patients over an extended period of time. Another possibility is that MI allows practitioners to address substance use and risky sexual behaviors simultaneously.

Although little research has been conducted on MI’s effectiveness in screening for sexually transmitted diseases (STDs), MI is more effective when compared to standard care, among patients being rescreened for these diseases.

Primary care settings and sexual health clinics provide a wealth of opportunities to engage patients in therapeutic conversations about risk-taking behaviors, and the skillful use of MI techniques, even in brief interventions, has tremendous potential to affect behav-ior change. Prefacing your conversations with an emphasis on confidentiality, supporting autonomy with empathic statements, and providing personalized feedback regarding the health risks associated with particular sexual activities will help patients feel more comfort-able discussing their behaviors. Remember that the content of your discussions will include highly personal and private details; a sensitive, tactful approach is a must.

173Special Populations and Settings The OARS skills, informed by the spirit of MI, are well suited to the process of screening for, and discussing, high-risk sexual behaviors: