Empowering people in low-resource communities to eat better and exercise more and thereby lessen their risk for heart disease, obesity, and diabetes continues to be a challenge for clinicians.
Motivational interviewing, however, can help and be part of an effective strategy to inspire patients at risk for cardiovascular and metabolic problems to change their behavior, Dr. Jeanie Tse said.
Photo Damian McNamara/Elsevier Global Medical News
From left to right are: Rosemarie Sultana-Cordero, LMHC; Jeanie Tse, M.D.; and Elisa Chow, Ph.D.
"As psychiatrists, we learn about physical health care in medical school and training, but we forget a lot when we start our practices," said Dr. Tse, director of integrated health at the Institute for Community Living, a nonprofit behavioral health agency in New York.
Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes, Dr. Tse said. "We feel strongly about collaboration. This is really about reaching out to primary care physicians, endocrinologists, and case managers."
Close collaboration also is important because "sometimes physical problems are misidentified as mental health symptoms." An example would be a person who goes to the emergency room with low blood glucose and ends up assigned to mental health care.
Motivational interviewing helps clinicians learn to phrase guidance in a way that encourages and supports patients. Advice about making healthy choices is provided in a nonjudgmental manner, for example. Empathic counseling delivered with warmth, respect, and understanding can foster self-efficacy and promote change, said Elisa Chow, Ph.D., director of outcomes evaluation at the Institute for Community Living. "It is really a simple tool that we as providers can use with our patients or clients.
Patients ready to make changes choose their own goals. "It is really about what patients want," Dr. Tse said, and it’s important to be realistic. "We may care about their diabetes, but in their world, they care more about housing, having a job, and finding a boyfriend or girlfriend."
Encourage patients to take small, "doable" steps, Dr. Chow recommended. "Your patient may walk away thinking ‘Oh my God, how am I going to lose 45 to 50 pounds?’ We help them step by step, maybe [with] losing a pound per week or just watching their portion sizes. Weight loss may be a goal over a year."
Dr. Jeffrey C. Fetter said in an interview that motivational interviewing is a well-established technique for improving behaviors such as smoking, but is rarely used to systematically improve diet and exercise in patients with severe mental illness. "One of the strengths of motivational interviewing is its respect for the client and his/her choices, a respect that especially resonates with mentally ill clients," said Dr. Fetter, a psychiatrist in private practice in Concord, N.H.
A recently published study showed that perceptions of motivational interviewing were more positive than standard care among patients with type 2 diabetes (Diabetes Res. Clin. Pract. 2011 [doi:10.1016/j.diabres.2011.08.011]). In that study, five themes tied to motivational interviewing emerged: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than critiquing.
"A patient might say, ‘I’m going to eat one apple a week. Great. Let’s go with that,’ " said Rosemarie Sultana-Cordero, a licensed mental health counselor and clinical coordinator at Community Living for its Diabetes Project and Healthy Living Project.
Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero shared their expertise during an interactive workshop session at the annual meeting of the American Psychiatric Association in Honolulu.
"We tell case managers that everyone has a goal, and they will be more motivated if the goal is self-imposed," Ms. Sultana-Cordero said. Instead of a lecture about the adverse health consequences of poor eating or physical inactivity, she suggested asking patients: What changes have you thought of making? What might you have to give up to make this change? What might you gain? Will your life be different if you make this change?
If you do not have time to learn all the aspects of motivational interviewing, "Developing Discrepancies" and "Rolling With Resistance" are two essential components, Dr. Chow said. Clinicians can, for example, increase a patient’s awareness about the discrepancy between where they are in terms of cardiometabolic or diabetes risk and where they want to be. A greater awareness of this dichotomy can motivate patients to reach their goals.
Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes.
"We have client we will call ‘Matt,’ who is slightly overweight, and sees Dr. Chow," Dr. Tse said. Matt told her he was going to diet and they agreed on a weight-loss plan. He plans to eat one vegetable every day and stay away from the corner bodega. They plan to follow up in 1 week. "Dr. Chow is then driving around and sees Matt eating fried rice and ribs in the window of a Chinese restaurant. Matt is saying one thing, but his actions say something else," Dr. Tse said. Dr. Chow will bring that up at next meeting and will use motivational interviewing to say something like: "I saw you at Chinese takeout place the other day. This seems to be in contrast with your goal."