Broaching the subject of changing behaviors can be daunting. Motivational interviewing may make these conversations easier.
Table 1 – Motivational interviewing of patients with psychotic symptoms
Table 2 – MI modifications for patients with psychotic symptoms
Premiere Date: May 20, 2016
Expiration Date: November 20, 2017
This activity offers CE credits for:
1. Physicians (CME)
The focus of this article is on motivational interviewing to promote health behavior changes in patients with psychotic symptoms.
At the end of this CE activity, participants should be able to:
• Understand the correlation between serious mental illness and physical health
• Screen for health behavior risk in patients with serious mental illness
• Adopt motivational interviewing to encourage health behavior changes in their patients with psychotic illness
This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
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Marie E. Rueve, MD, has no disclosures to report.
Laura E. Maphis, PhD, has no disclosures to report.
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Patients with serious mental illness (SMI) face many adversities in their daily lives, as well as a shortened life expectancy. Despite short appointment times, long waiting lists, and multiple needs competing for attention, psychiatrists would do well to devote time during an appointment to counselling patients on ways to change health behavior. But broaching the subject of changing behaviors with patients who have psychotic symptoms can be daunting. When working with these patients, motivational interviewing may offer key techniques and strategies to make these conversations easier (Table 1).
Serious mental illness and physical health
Individuals with SMI have a 5-fold increased risk of all-cause mortality compared with the general population, and the mortality gap is growing.1 Most salient among the causes of this excess mortality are physical diseases that are directly related to modifiable lifestyle risk factors. Patients with psychotic disorders are at greater risk for nutritional and metabolic diseases, cardiovascular diseases, respiratory conditions, and obesity-related cancers.2 The incidence of obesity, diabetes, hypertension, dyslipidemia, and metabolic syndrome is also higher among these patients.
To compound these lifestyle problems, patients with SMI often have decreased access to care because of problems of affordability, transportation, and stigma. Antipsychotics, which are the mainstay of treatment for psychosis as well as many other types of SMI, further add to health risk because of their associated adverse effects (eg, weight gain).
Walsh and colleagues3 demonstrated that mental health and psychosocial struggles predicted health-compromising lifestyle behaviors-but not the reverse. This finding suggests that health-compromising behaviors may function as coping strategies for stress among patients with SMI. It can also be argued that better treatment of the mental illness, including improved stress management and coping mechanisms, may lead to fewer health-compromising behaviors. Certainly, poor lifestyle choices and subsequent decline in physical health status make antipsychotic use more difficult in these patients, which further inhibits symptom control.
Screening for health behavior risks
Generally, recommendations for health screening of individuals with schizophrenia include:
• Patient and family history of obesity, diabetes, dyslipidemia, hypertension, and cardiovascular disease
• Smoking status
• Weight, BMI, and waist circumference
• Blood pressure
• Fasting lipid panel
• Neurologic examinations
• Eye examinations
These recommendations were developed with the primary care physician (PCP) in mind (for the complete tabular tool, see Viron and colleagues4). Hence, partnering with the patient’s PCP may be an effective and time- efficient way to accomplish screening.
Aside from smoking status, other lifestyle factors for assessment include fruit and vegetable intake, exercise behavior, and alcohol consumption, for which a 22-item screen that comprises adult measures for behavior change has been created.5 Although this screen was developed for the primary care setting, its brevity makes it well suited for the outpatient psychiatry setting.
Self-monitoring tools may be a more useful way of capturing data in real time if patients are organized enough to record targeted behavior changes (eg, recording intake at each meal, duration of exercise, number of cigarettes smoked). Recording for shorter periods (eg, 1 week) may increase compliance with such an assignment. Involving the patient’s PCP and family members can provide invaluable collateral information.
Treating health behavior risks in a psychotic population
A meta-analysis showed that lifestyle interventions can produce significant change in cardiometabolic risk for individuals with psychotic disorders.6 Behavioral and motivational interventions are effective in health risk reduction for this population, although there have been few trials of motivational interviewing alone.7 With schizophrenia and comorbid substance abuse, better outcomes are associated with multicomponent interventions.8
The results of these larger-scale, multicomponent studies are difficult to generalize to a psychotic patient’s everyday life, however. Small, incremental health behavior changes may be most feasible for both psychotic patients and the psychiatrists who treat them. And, motivational interviewing may be an effective and feasible method for engaging these patients.
Overview of motivational interviewing
Motivational interviewing is defined as “a person-centered counseling style for addressing the common problem of ambivalence about change.”9 Originating from the substance abuse treatment literature, motivational interviewing has become an effective communication style with far-reaching application (eg, substance abuse, risky behaviors, diet/exercise, treatment engagement, gambling, parenting practices); and it is user-friendly and brief.10,11
Motivational interviewing emphasizes the need to resist the urge to tell patients what is wrong and how to fix it. An approach that is too directive may cause pushback by the patient in an effort to reestablish autonomy-what seems like the most direct route ends up slowing progress and being detrimental to the partnership with the patient. Hence, motivational interviewing emphasizes the need to resist the urge to tell patients what is wrong and how to fix it.
Motivational interviewing should be implemented with a particular “spirit” that encompasses partnership, compassion, acceptance, and autonomy. The partnership and the process of collaboration are central to this style of interviewing. The psychiatrist asks permission before changing topics or providing psychoeducation; he or she acts as a guide while the patient does most of the talking. Compassion involves working in the best interest of a patient while seeking a deeper understanding of the patient’s life. It can be difficult to tolerate the patient’s choices if these choices are damaging to his or her welfare. Acceptance does not mean approval of behaviors but recognition of the patient’s autonomy and right to choose. Viewing the patient as the sole arbiter of change (honoring autonomy)-and recognizing that ambivalence is ubiquitous-can help lessen the burden the psychiatrist feels in guiding the patient toward change.
The provider’s role is to evoke “change talk” or a patient’s desire for change. Any time the patient mentions change, that change talk is highlighted using the core skills of motivational interviewing. Listening for change talk entails an attuned ear for the patient’s expression of desire for change, ability to change, reasons for change, the need to change, and commitment toward change. Exploring the patient’s values can reveal patient motivation. The provider ascertains what is important to the patient and highlights any discrepancy between ultimate goals and current status.
The core skills of motivational interviewing include asking open-ended questions and providing affirmations that give the opportunity both to better understand where the patient is in his change journey and to reinforce the patient’s strengths. Reflections help the patient to feel heard and allows him to repeatedly hear his own arguments for change. The psychiatrist’s approach to the conversation may be to offer 3 reflections for every question the patient asks and to intentionally reflect change talk when it is offered. Reflections also move the conversation along. Without frequent and directive reflections, the session may feel more fragmented because of the patient’s psychotic and/or cognitive symptoms.
Summarizing multiple reflections ensures that accurate information has been collected and elucidates relevant motivations for change. Use of the core skills of motivational interviewing helps the patient to feel more understood while moving the conversation toward change. Practicing core skills strengthens the psychiatrist’s ability to respond to change talk.
(This section provides an overview on motivational interviewing. For the newest edition of the seminal text, see Miller and Rollnick9; to read about the theory of motivational interviewing, see Miller and Rose12; and to read about what motivational interviewing is not, see Miller and Rollnick.13)
Psychotic symptoms and motivational interviewing applications
Positive symptoms of psychosis
Positive symptoms interfere with many elements of basic care, planning for lifestyle changes, establishing helpful relationships, and trusting new resources, including presenting for psychiatry visits. Paranoia, in particular, can heighten the inevitable resistance to behavior change. It can erase the extrinsic motivation that comes from being part of a social relationship, such as wanting to please the other person.
Paranoid delusions and hallucinations arguing against change will hinder the process of moving toward better health behaviors. Disabling psychotic symptoms lead to a patient’s demoralization and subsequent lack of motivation for sustaining change.14 Focusing on the patient’s values and change agenda can help increase the patient’s sense of autonomy and control.
Establishing trusting relationships
The limited ability to engage comfortably in relationships, coupled with positive symptoms of paranoia, represents a major barrier to treatment adherence and sustained behavior change. Trusting a provider enough to embark on a sometimes scary path toward behavior change can be difficult for a psychotic patient. Patients recollect past experiences of treatment, including counseling that is authoritarian or condescending rather than therapeutic and supportive, and these experiences add to reluctance to adhere to treatment and to change behavior. Involuntary commitments, forced medication orders, and stern cautions about risk may degrade the ability to establish a trustful working alliance. Poor social skills may compound the patient’s inability to negotiate a better treatment relationship.
Motivational interviewing can remedy these through engagement, collaborative stance, support of autonomy, and affirmations, which reduce anxiety about the therapeutic relationship. Honoring the patient’s preferences for goals, priorities, and plans may further aid the alliance. The celebration of any small success the patient achieves in changing behaviors not only creates momentum toward further change but also builds a trusting, positive regard for the psychiatrist.
Negative symptoms of psychosis
Negative symptoms of psychosis comprise amotivation, difficulty with activation, and alexithymia. Poor insight breeds difficulty with self-monitoring and compromised assessment of one’s health risk. Negative symptoms cause problems with self-expression, naming and recognizing emotions, and verbalizing thoughts, as well as many other elements of forming and sustaining relationships; and these may hinder the expression of change talk. Frequently returning to the patient’s values and goals and the discrepancy between these and current behavior can motivate the patient to begin changing his behavior.
Cognitive symptoms of psychosis
Cognitive impairments that psychotic patients exhibit include problems with attention and concentration, short-term and working memory, organizing and abstracting information, planning and prioritizing, and general mental flexibility. Adaptations to the usual techniques of motivational interviewing can work around these cognitive deficits.14
Flexibility in the duration and frequency of motivational interviewing sessions is important; psychotic patients may benefit from frequent breaks at intervals of their choosing to support autonomy and to refresh attention span. Simple questions rather than compound inquiries that require abstract thought and attention to grasp, as well as more explicit structure on the sessions in the form of agenda-setting, are recommended. Psychoeducation on disease, risk, and behaviors follows after explicitly asking for the patient’s permission to share such information.15 Similarly, asking permission to share what has helped other patients may give patients ideas on how they can implement changes.
Information may need to be packaged differently (Table 2). This may come in the form of simple, visual materials that the patient can take home as reinforcement for the motivation developed during a session. Encouraging small increments of change toward a specific goal, such as graduated increases in vegetable servings, and allowing more time for change to occur will make it easier for the patient.16 Moreover, strive to remain open to the widest variety of possible goals and change strategies that a patient may conceive.
Bringing it all together
Building and refining the therapeutic alliance with the patient is an ongoing priority, and much of a medication management appointment can be taken up with reviewing the efficacy and tolerability of medications. In the remaining minutes, however, exploration of a possible target of change for the patient could pay off exponentially. The motivational interviewing techniques, practiced over time, can turn the leftover moments of a patient’s appointment into a conversation prompting transformation of a health behavior that could be life-changing. (See the Patient Scripts box for sample dialogues.)
The basic tenets and principles of motivational interviewing make the technique well-suited for use with psychotic patients. The intrinsic empathy, engagement, and patient-centeredness serve to help overcome common psychotic symptoms, such as paranoia and suboptimal social skills. Adaptations to basic motivational interviewing techniques can allow for more effective use of such tools to highlight values, set goals, and develop plans for health behavior changes. Attention to developing motivational interviewing skills will enable psychiatrists to adapt to the special needs of patients with SMI.
PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR A YEAR AFTER.
Dr Rueve is Chief of Psychiatry Services and of Inpatient and Consultation Services, and is also Residency Program Director in the Division of Psychiatry at Geisinger Health System in Danville, PA. Dr Maphis is a Resident in the Department of Psychiatry, Adult Psychology/Behavioral Medicine at Geisinger Health System.
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