Pointing out his discrepancies is "really about making him aware and taking ownership of his lifestyle," Dr. Chow said.
Rolling With Resistance prevents a communication breakdown between parties. The clinician does not argue or directly oppose resistance from the patient. A clinician can offer new perspectives but does not impose them.
Dr. Tse teaches basic reflective listening to case managers as part of this technique. "We line them up. One will say: ‘I don’t want to quit smoking.’ The other says it back: ‘You don’t want to quit smoking. "In our training, the psychiatrists and nurses have the most difficulty with this training. They feel the need to engage the person more and counsel about smoking cessation."
"We find that training very helpful for psychiatrists, medical doctors, social workers, and others," Dr. Chow said.
Regular progress checks are an important component of motivational interviewing and the overall chronic care model of medical care. At Community Living, participants provide feedback via self-management workbooks. These books contain "Action Step" pages. If, for example, a patient decides their goal is to drink a bottle of water instead of a soda once a week, they specify when and where they will make this substitution. They indicate whether they need someone to remind them. Later, they write why they succeeded or did not succeed, as well as how they plan to reward themselves if they followed through.
"There is also an action step review page, which is an opportunity for case manager and client to review how they did," Ms. Sultana-Cordero said.
"Our ‘Caring for Your Mental Health’ workbook is one of our most popular," Dr. Tse said. "It’s a huge realization for many that their mental health can adversely affect their overall health."
The Institute for Community Living offers about 100 programs focused primarily on housing, case management, clinics, and shelters, Dr. Tse said. More than 70% of the clients have schizophrenia or are schizoaffective, she added.
"People with serious mental illness are more than twice as likely to have diabetes. Why? Antipsychotics and other meds increase risk of dyslipidemia, diabetes, and stroke," Dr. Tse said. Also, "changes in appetite, medication side effects, and income make it harder to maintain a healthy diet." In addition, many people with mental illness also feature avolition and low energy, symptoms that can lead to reduced physical activity and contribute to worse outcomes.
"There is a lot of stigma associated with our patients with serious mental illness and intellectual disabilities. This stigma is huge, and it puts our patients at risk," Dr. Tse said. "They are at a disadvantage for getting their diabetes or heart disease looked at." Case managers complete psychiatric forms that include prompts for an annual physical exam report, weight, waist circumference, and blood pressure measurements. "It’s right in the notes. They have to fill it out each time they see a patient."
"We have two full-time psychiatrists for 10,000 people," Dr. Tse said. The workforce primarily comprises 1,400 bachelor- or associate-degree level case managers who receive 4 hours of training in motivational interviewing. "We’ve had to be very creative with very low resources to train these folks in the kind of integrative care work we want them to do."
Patients receive self-management material to reinforce their goals. These include a "Healthy Living Info Card"; a similar mini-card for their wallet or purse; letters to give their psychiatrist and primary care physician; and if they have or are at risk for diabetes, a Diabetes Info Card.
For his part, Dr. Fetter said preliminary data show that motivational interviewing focused on healthy lifestyle choices can move people with high metabolic risk with mental illness forward through stages of change toward making healthy diet, exercise, and tobacco choices. "This area bears further research, and the Community Living model is a great example of how motivational interviewing interventions to address cardiometabolic risk can be successful," he said.
Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero are employees of Community Living Inc. They had no other relevant disclosures.