Motivational Interviewing and Medication Adherence
By Sarah A. Suzuki, LCSW, CADC
“How are you going to help me?” is one of the first questions a social worker on the front lines is often asked. When the agenda of the social worker clashes with the desires of the client, a power struggle ensues. Although clinical experience helps social workers build rapport, the path to completing treatment objectives is not always clear. Social workers may witness this clash of interests as they advocate for their clients in the public health system—particularly for clients who are HIV-positive. Motivational interviewing (MI) offers a directive, collaborative, client-centered approach that leads to client success (Miller & Rollnick, 2013).
Medication Adherence: A Public Health Crisis
With new health care laws, social workers are in a position—now, more than ever—to remove barriers to client medication adherence. The Centers for Disease Control and Prevention estimates that medication nonadherence accounts for the death of nearly 125,000 people per year as well as at least 10% of hospital admissions. In the United States, typical rates of adherence to HIV medication are extraordinarily low among patients who assessed as being at “high risk of nonadherence.” Nonadherence to HIV medications is correlated with severely negative health outcomes—including an increase in virus transmission, opportunistic infections, chronic pain, and death. Common barriers to HIV medication adherence include symptoms and adverse drug effects, psychological distress, lack of social or family support, complexity of the medication regimen, and low patient self-efficacy. These barriers are further exacerbated by factors such as low health literacy, cognitive impairment, poverty, and social stigma related to HIV status.
MI: The Bridge to Medication Adherence
Since its advent in 1983, MI has been applied to the treatment of multiple health-related behaviors, including drug and alcohol abuse, smoking cessation, diet, and exercise. At least 200 randomized clinical trials—the gold standard of research—have demonstrated the success of MI in these areas. MI has been translated into 47 languages and has been disseminated internationally with cross-cultural success.
Why is MI so effective? In short, MI facilitates change by using the client’s own motivation. William Miller, cofounder of MI, describes it as an “organic” process. “It’s something about nature—an idea of how to help people resolve ambivalence,” Miller says. “Change is broader than behavior” (Miller & Petersen, 2014). In MI, the intervention involves being intentional and using the client’s values to reduce the discrepancy between current behavior and the idealized self.
Significant research has been conducted on the effects of MI and the improvement of health behaviors, including the initiation and ongoing management of diabetes, substance use disorders, mental illness, hypertension, and heart failure. Across these areas of concern, MI has demonstrated consistent efficacy in facilitating behavior change—particularly among vulnerable populations.
Because HIV/AIDS is now viewed by the Health Resources and Services Administration (HRSA) as a “manageable health condition,” social workers are in a key position to bridge gaps in service and increase health outcomes. MI offers social workers a set of evidence-based interventions to increase medication adherence among HIV-positive clients.
The Spirit of MI
The “spirit” of MI, emphasizes establishing and maintaining a high-quality relationship between client and counselor. Learning the spirit of MI provides the foundation for the development of MI skills. It is, as social worker and MI trainer Scott Petersen notes, “The fundamental desire that the other be free of suffering.” The overlap of the NASW Social Work Code of Ethics and the spirit of MI is profound. The spirit of MI is rooted in respect for client self-determination. “It is a way of how we do what we do,” Petersen notes. “I sometimes think of clients as cotherapists.” MI is set apart from other approaches because of its emphasis on partnership, acceptance, compassion, and evocation. In short, the social worker evokes from clients their own, real strengths to help them change.
Multiple studies have examined the importance of clients feeling “known as a person” by the practitioner and how this relates to medication adherence outcomes—all indicating that it is essential for clients to have a strong sense of being understood in order for them to change. In the spirit of MI, the social worker provides accurate empathy, autonomy support, affirmation, and absolute worth to the client while offering guidance, education, and information. MI offers a structured set of guidelines, called the four processes, to ensure that social workers are attuned not only to each client’s individual needs, but also to the quality of the relationship—a clear determining factor in medication adherence.
The Four Processes of MI
In the third edition of Motivational Interviewing: Helping People Change, MI is structured into four processes: engaging, focusing, evoking, and planning (Miller & Rollnick). This radical shift in MI away from the stages of change model marks a serious departure from previous constructs of motivation. Rather than viewing clients as being in a fixed stage of motivation, the four processes emphasize how motivation can ebb and flow, providing a fluid roadmap whereby the social worker can maintain a flexible, person-first approach. “Some clients come through the door ready to change,” Miller notes. “But then something may shift and you go back. MI is about dancing up and down the stairs, or the four processes—supporting the client as they move towards change” (Miller & Petersen).
Key MI engaging process strategies can significantly reduce high-risk behaviors related to the transmission of HIV as well as increase retention in medical care. With helpful information available, the bridge to information delivery is the client-provider relationship. New HRSA-funded outreach programs have demonstrated that provider engagement with the client is positively associated with retention of underserved populations living with HIV in primary medical care. Essentially, engagement prevents the client from discontinuing services or emotionally shutting down.
Although it is tempting to provide education and advice once rapport has been built, the social worker uses the focusing process to guide a client-driven plan. Focusing allows for the social worker to use the MI strategy of agenda mapping to work collaboratively with the client, directing the client towards a particular change. “Think of it like a camera lens, moving in and out,” Miller says. “Focusing starts with eliciting the client’s agenda, offering a menu of choices, and asking permission to discuss your own agenda.” In such a way, the social worker has the ability to pair goals from the client’s agenda with a desired behavior change. “The change goal should always involve equanimity, collaboration, and autonomy,” Miller says.
In the evoking process, the social worker uses OARS—the “bread and butter” of MI—which consists of open-ended questions, affirmations, reflections, and summaries (Miller & Rollnick). Social workers use OARS during the evoking process to recognize “change talk,” or talk associated with change behavior. Being able to skillfully use OARS can help the social worker row through the choppy waters of client ambivalence. Unlike closed-ended questions, which are negatively associated with medication adherence, the social worker’s use of OARS opens up the conversation, allowing the client to express their own motivation to change. In the evoking process, the social worker elicits change talk to strengthen the client’s own commitment to change.
Once a client has made a commitment to change, the planning process begins. The social worker continues to offer support while the client completes objectives to achieve the change goal. In this case, the client will achieve adherence to HIV medications. MI offers a set of questions, responses, and techniques to aid the social worker during the planning process.
One common concern among health care providers is whether or not an intervention will consume too much time. Research demonstrates that an effective MI intervention can be delivered in 15 minutes or less. Whereas most social work interventions struggle to provide convincing evidence in the area of correlating interventions to outcomes, or measuring the impact of the intervention, MI is measurable and can be scored for fidelity throughout the four processes. Tools to score fidelity—such as the MISC (Motivational Interviewing Skills Code) and the MITI (Motivational Interviewing Treatment Integrity)—are free and available to download from the Internet.
The Essential Role of Social Work
Thoughtful, well-executed implementation and supervision of MI in health care settings is required to make an appreciable impact on client behavior change. Social workers who are familiar with the work of Carl Rogers will find the shift to an MI approach both natural and logical: “80% of motivational interviewing draws from the work of Carl Rogers,” Petersen says. “What sets MI apart is that it is an evocative, directing approach” (Miller & Petersen). Social workers can develop the skills necessary through self-study, workshops, training sessions, and group supervision.
Social workers are in a key position to provide evidence-based interventions to vulnerable populations, including HIV-positive clients. MI provides social workers with a direct, learnable, measurable set of skills to increase HIV medication adherence. A social worker skilled in MI can train an entire staff in how to implement MI in the workplace. Health care workers across educational backgrounds and professional training can use MI to provide the client with consistency, respect, and direction as they work toward achieving collaborative goals. Respect for the client’s objectives leads to increased retention and compliance with medical recommendations as well as a more positive client experience. In the spirit of MI, clients and social workers can move together toward change—dancing, rather than wrestling.
— Sarah A. Suzuki, LCSW, CADC, owns a private practice in Chicago. She is also a member of the Motivational Interviewing Network of Trainers.
Miller, W., & Petersen, S. (2014). Motivational interviewing: an advanced workshop. Professional Development Program. Lecture conducted from the University of Chicago.
Miller, W., & Rollnick, S. (2013). Motivational interviewing: helping people change. 3rd ed. New York: The Guildford Press.