Experts Discuss Best Use of Motivational Interviewing

This episode features Bruce Berger, PhD, president of Berger Consulting, LLC, who discusses how pharmacists should best use motivational interviewing with patients.

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Christina Madison, PharmD, BCACP, AAHIVP: Hello, everyone, and welcome to another episode of Public Health Matters. I am your host, Dr. Christina Madison, also known as the Public Health Pharmacist. This podcast is being brought to you from Pharmacy Times as part of their Pharmacy Focus podcast series. I'm extremely happy to bring today's guest, Dr. Bruce Berger, to talk about things [like] welcoming and opening up a dialogue about why we need to have more incorporation of motivational interviewing, and those skills and how they can be incorporated into many facets of pharmacy, health care, and beyond. With that being said, I am so excited to bring Bruce in today and he's someone that I've been a fan of for a while. And I was pleasantly surprised when I had this lovely message in my inbox on LinkedIn from him. And with that we had an extraordinary conversation which led to him being on the podcast today. With that, I'm going to go ahead and let Dr. Berger introduce himself, and then we're going to dive into some questions.

Bruce Berger, PhD: Thank you. Well, thanks. Thanks for doing this, Christina. It's my pleasure to be here. Well, let's see where to start. I'm a 3-time Ohio State University graduate; they make us say the Ohio State University. I got a bachelor's in pharmacy, then I went back to school to really focus on health communication and health psychology. And so that's pretty much what I've been doing most of my professional life. I taught at West Virginia University for a couple of years, moved to Auburn with the idea of being here 3 to 5 years, and this is my 40th year. I taught at the university for 28 years. And I really started teaching motivational interviewing probably 30 to 35 years ago. It was actually introduced to me by one of my graduate students, Karen Hudson, who has done a lot of work in tobacco cessation. And she said, “You need to look at this stuff.” And Miller and Rollnick, the 2 clinical psychologists, particularly William Miller, PhD, developed motivational interviewing for substance abuse. And what's when I started reading about what he had done. And again, you know, back 35 to 40 years ago, the way that most people were treating substance abuse, too many, was tough love. Yeah, it doesn't work. And so, Miller and Rollnick really developed an entirely new approach. And it is still to this day the most successful intervention for substance abuse. What I find curious, and I imagine you do, too, Christina is that here it is the most successful intervention in terms of the lowest rate of relapse for having an opioid crisis in this country. And you hardly ever hear of motivational interviewing in health care.

Christina Madison, PharmD, BCACP, AAHIVP: It's crazy, right? Like, I always think about, what is it, Occam’s razor? The simplest answer is usually the best, but we're so bad about it. We overcomplicate things in general. And you wouldn't think that something that is scientifically based and has been so tried and true, has been so ignored. And I love that you use those harm reduction strategy examples because, obviously, that's a big component of public health.

Bruce Berger, PhD: Yeah, well, and when I saw it and read what they had done, and how successful it was, what went through my mind was, my goodness, if they could do this with people who were involved in substance use, which is very complicated, couldn't we use it to help somebody with high blood pressure? You know, or diabetes? And then, of course, one of the reasons you and I were talking, I mean, I saw your TED Talk. If anybody's not seeing Christine's TED Talk, you need to go see it. It's really good. And that's obviously why I sent you a message on LinkedIn. But, you know, one of the points of your message was about, not just what we say about how we approach people, but how we basically have empathy for who they are and what they're struggling with. And, you know, that struck a chord with me. That's at the heart of MI (motivational interviewing). And one of the things that has been frustrating for me and going through this whole COVID-19 experience is how many times I hear people in the news or in the media say, you know, how are we going to convince these people to get vaccinated? And it's absolutely the worst strategy. You know, if we're going to get people vaccinated who have not been vaccinated, the best strategy would have been to really listen to them, listen to their stories, and validate their stories. You know, even if even if the information they're using is not accurate, we've got to first let them know, in a respectful way, that we've heard their story, because they're their stories.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, and really, I so love that you said that, because I think, honestly, the biggest issue that we had, and in particular, I say this a lot with the Black community, is that they were labeled as vaccine-hesitant before we even ever talked to them. Again, I think we need to understand things around historical trauma and systemic racism. But you can't label entire groups of people without actually listening to what they have to say, because a lot of it wasn't specific to the vaccine, it was more of the system.

Bruce Berger, PhD: Right? Well, and the other thing is, you know, as soon as you label a group of people—I was watching a discussion that went out on LinkedIn the other day, I don't know if you saw it, the discussion was, are women more emotional than men?

Christina Madison, PharmD, BCACP, AAHIVP: No, I didn't see it, I definitely would have commented.

Bruce Berger, PhD: Well, it was one of the surveys where you put yes, no. And then my comment was, what difference does it make? In other words, if I am going to effectively deal with you, or have a have any kind of relationship with you, as a professional, as a patient, as a friend, I've got to throw out all of those generalities so that I can see you. And so these labels of vaccine hesitant or noncompliant or difficult patient, they're always objectifying a human being, reducing them to an object. And to be honest, I think we do it so that we can feel justified in not providing care.

Christina Madison, PharmD, BCACP, AAHIVP: Exactly, people are not problems to be solved. They're human beings that need love and compassion. And I say that all the time. And you know, especially because of my work within the HIV space and because I have so much of a connection with the LGBTQIA+ community, a lot of times the lack of desire to be involved or engaged in the traditional health care system is because they feel othered, because they feel like they're being objectified, because their lived experience is not being taken into consideration. And I think that's where motivational interviewing is really the bridge for us to be able to take those things into consideration and really incorporate someone's lived experience so that they that they're able to, you know, to feel like they can truly speak to their health care professional, and that that individual can provide them with culturally competent care.

Bruce Berger, PhD: Absolutely. I had the opportunity several years ago, I was asked to go to [a hospital] in the Bronx, but they brought me in as somebody who knew MI to their HIV clinic staff, to talk to them about how to talk to HIV patients. And, and as you know, even though we're I don't know how many years into HIV, the stigma is still there. You know, one of the nurses told the story to me, and she said, now she was a social worker. So, a young man who was about 26 years old was diagnosed by the doctor as HIV positive, right? And he looked just shocked. Anyway, the doctor said to him at one point in the conversation, “Well, that's what happens when you don't have safe sex.” Well, he comes down from the doctor's office and, first of all, he's dealing with the fact that he's now HIV positive. Right? What all that means. And he tells the social worker that the doctor said to him, “Well, that's what happens when you don't have safe sex,” in a very condescending tone. The social worker looked at him and said, “Oh, my.” And he, the patient, literally just grabbed his backpack and walked out of the clinic. And she said, “I don't understand what happened. I said, ‘Oh, my.’” And I said, “You said, ‘Oh, my,’ and waited for a response.” He is coming from a place where he was just shamed by a physician. And so he doesn't know whether your ‘Oh my’ is empathy or acknowledgement.

He didn't know whether it's “Oh, my, you didn't have safe sex? You're HIV positive?” Or “Oh, my, what a horrible thing to say.” Yeah. And she was actually wanting to communicate, “Oh, my, what a horrible thing to hear from a physician when you found out.” And one of the things that we teach people when we teach MI is don't short circuit the “Oh my” and the “I understand” and the “Uh-huh.” Tell people what it is that you understand. Because if she had just said, “Oh, my, what a deflating and shaming thing that your physician just said,” it would have been a whole different situation. And meanwhile, a patient just lost care.

Christina Madison, PharmD, BCACP, AAHIVP: Yep. Or just saying I'm sorry. Like, “oh, I am so sorry that that happened to you.” I can't tell you how many times I start the conversation with that. I can say, “You know what? I cannot excuse or make any kind of justifications about how you were treated before, but I can tell you, I will be here, and I will provide you with this level of care.” Right? Like, I can only control my actions. I can't do anything about how you've been treated in the past other than telling you I'm sorry, and I hope that we can take better care of you in the future. And I think that's really what it's about, is acknowledgement that we're human. We're flawed. You know, I can't tell you how many times just a simple apology has made all the difference.

Bruce Berger, PhD: Yeah. And similarly, we tell pharmacists to just to say, “I'm so sorry to hear that you were treated that way.” We had a pharmacist that was at a call center, and somebody at the store level of the same organization mistreated that same patient. And so, all the pharmacist at the call center needed to say was, “I'm so sorry to hear that happened to you. Would you be willing to start over with me?”

Christina Madison, PharmD, BCACP, AAHIVP: I love that. That's so good.

Bruce Berger, PhD: One of the things we talked about the other day is they call patients who they know are not taking their medicine the way they're supposed to. This is this is a really powerful MI idea. The patients are not taking the medicine the way they're supposed to, they know it's in their record, they're 30 days late for a blood pressure medicine, and the patient gets very defensive. “I take my medicine every single day.” How? Okay, why is this happening? Probably because they got scolded by their physician, right? So, what are you supposed to say? And I said what you say depends on whether you see your job as being the prosecuting attorney and proving the patient wrong or caring about the patient. And they say, okay, so let's say we agree we should care about the patient, what do we do? And I said, here's what I would do. If that patient said to me, “How dare you? I take my medicine every day,” even though I know she doesn't. Here's what I would say: “I am so glad to hear that you're taking your medicine every day. Believe it or not, I have other patients that are taking lisinopril for their blood pressure. They feel okay. They skip days, and they don't realize their blood pressure is elevated. And they're putting themselves at risk for stroke or heart attack. So, the fact that you're taking it every day makes me feel really good. Would you mind telling me what do you to help you remember to take it every day so I can tell them?

Christina Madison, PharmD, BCACP, AAHIVP: Oh, my gosh, that's so good.

Bruce Berger, PhD: So, what have I done? I've just used another patient as the bad example, in order to do what I wanted to do with her or him, which is to educate them about the risks, right?

Christina Madison, PharmD, BCACP, AAHIVP: Well, not just educating about the risk, but then now you've empowered them, right? Which that's the key, right? Empowered them to take control of their own health care by saying, what techniques are you using in order to make sure that you're taking your medication as prescribed? Which is genius!

Bruce Berger, PhD: Yeah, we call this asking for helping behavior. And, you know, we're really asking [them to] help us help other patients. Yeah, you know, tell us what you're doing. We really want to help other patients. You know, it's very interesting. One of the one of the people on the webinar said, I just realized by doing what you just said, rather than what's typical, is a pharmacist will say, “Well, according to our records you're not taking it,” and then we're off and running, right? You might as well just call them a liar. So, the pharmacist said, doing what you just said allows the patient to relax, have to think about defending themselves, so that they can actually maybe draw the conclusion, “I wasn't taking it right.” And I said, that's wonderful. That's just wonderful insight.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, it's incredible. Because now you put them on, like, solid ground. Like, they're not on this defensive footing where they feel like they have to tell you why something is the way it is. It's funny, you know, I think we always come from this place of, like, “help me help you,” when really, that's not what we should be doing. We should be thinking the opposite. Like, you know, what can I do that makes it so that you feel comfortable taking charge of your health care? What is it in your environment that's making it challenging, right? And so, the other thing, too, is a lot of times, it may be just as simple as “I don't have transportation.” Because that is such a big issue. Or, like, it’s cold outside with the weather and I have to take public transport.

Bruce Berger, PhD: Yep. One of the people in the HIV clinic at very end said, “We get them in here. Why don't we get them back? Because sometimes they don't come back.” And I said, “Have you ever asked your patients before they check out, what do we need to be doing to make sure you come back?” Yeah, that's a patient-centered question. And, you know, again, a lot of times patients said, “I need transportation.”

One other example of a really weak part of the problem also, is we tend to train people in health care to look at what patients are not doing rather than what they are doing. So, one of the things that comes up is a lot of times, [medication therapy management] companies have to call a patient because they're not taking their medicine the way they're supposed to. And right from the start it's a negative call, right? Yeah. So, somebody said to me the other day, okay, so, Mr. Jones, again, is supposed to be taking his lisinopril every day for his blood pressure, right? Taking it 4 out of 7 days a week. He gets a call, and the pharmacist says, ‘Hey, Mr. Jones, I noticed you're taking your lisinopril about 4 days a week and you really need to take it every day to get your blood pressure down. Mr. Jones says, ‘Yeah, I know, I know, I need to do better.’ Next time they talk to Mr. Jones, guess what he's doing? He's taking it better. Nope. He's taking it 4 days a week again. Okay. So, the pharmacist said to me, “Well, what are you supposed to do? I just told him what to do.” Right? Yeah. And I said 2 things. I said if educating people was all we needed to do, no pharmacist or health care professional would ever be overwhelmed, maybe needed. Second of all, I said, what do you learn when you tell him you need to take it every day? And he kind of paused and he said, “What do you mean?” I said, we have a problem here. He's taking it 4 days a week, instead of 7. What do you learn about the problem when you tell him he needs to take it 7 days a week? And he looked at me and he said, “Nothing?” I said, “That's right.” I said, here's what I'd like you to think about doing. Call the patient and say, “Hey, Mr. Jones, I noticed you're taking your medicine 4 days a week for your blood pressure. That's a really good start in getting your blood pressure under control. What's made it important for you to take it on those 4 days?” Will we learn something? I mean, if there's even a patient taking their blood pressure medicine or diabetes medicine twice a day, twice a week, I want to know what's motivating them on those 2 days, because I may be able to use that to help with the other days.

Christina Madison, PharmD, BCACP, AAHIVP: Fantastic. I love that so much. And again, that is really the heart of motivational interviewing, right? And how it can be honestly used in every facet of the health care system.

Bruce Berger, PhD: It's really too bad that in so many cases during COVID-19, as you know, in any vaccination situation, we have patients dealing with so much misinformation or missing information. We had a patient who said they weren't getting a flu shot this year because they got the flu from it last year. And that's out of the pharmacist’s mouth where you can't get the flu from a flu shot. And I always tell people, if you can add the word stupid to the end of a sentence that you just said and it doesn't change the meaning, you're going down. Right? I mean, that's basically what you're saying to the patient. The patient says, “I'm not going to take it, I got the flu last year from it,” and you say, “You can't get the flu from a flu shot.” You might as well just say “Stupid”

Christina Madison, PharmD, BCACP, AAHIVP: Because you've basically discounted them. You've basically told them, you know, I'm sorry, but your rationale is not valid. And that's really what we can't do. And it's so interesting that you said this, because I've had people ask questions about specifically mRNA vaccines, and it's like, instead of asking the question, “I'm really sorry to hear that.” You know what, “Why do you think that the flu vaccine gave you the flu?” Right? Like, why? What is it that happened to you that you feel like that's what occurred? Then you can understand. So, is it that they got the flu vaccine, and then 2 days later, they have flu-like symptoms? Is it because maybe the vaccine didn't have time to work, and they unfortunately still got it? Or maybe they were exposed to a virus that wasn't covered by the vaccine. There are so many different things. Granted, the statement that you made may be accurate, but it's very discouraging and very demeaning to the person that you're saying it to.

Bruce Berger, PhD: Well, it causes what's called face loss. We have done research and found that when people lose face, when a patient loses face either through the pharmacist saying you're wrong, or we've been through this before, whatever it is that when people lose face, they stop listening and they discount whatever information they've been given. So, exactly what you were saying. We train people to say to that patient, “Wow. Okay. So, last year after you got the flu shot, you felt really bad. And as a result of that, you decided you don't want to get it this year.” [The patient] says yes. And one of the reasons we reflect back like that is so the patient really knows we've listened without judgment, and it gives him an opportunity to correct any of it if it's not quite right, because we might as well start on the same road. And so, the patient says yes, then we're going to say, “Tell me about the kind of symptoms you had.” And when did they take place in this particular patient's case? They had the typical reaction to the vaccine for about 24 hours, but nobody told them they would have that kind of reaction. So, they thought they got the flu. Right? Now, could it be 3 days, it could be like you said that they already had the flu, and they got vaccinated and it just was asymptomatic? Sure. But we don't know that until we explore with the patient what was the timing of all this.

Christina Madison, PharmD, BCACP, AAHIVP: I feel like the biggest thing here and sort of my takeaway message from what you're saying is that communication—and very clear, concise, and compassionate communication—is paramount to all interactions within our health care system. And honestly, one of the biggest things that I think we struggle with still to this day is being able to properly communicate public health messaging to the public, because it's very difficult to tell people to take or to do something for something that they do not have, right? Because we live in this society where there's a pill for every ill. But we haven't discussed the importance of taking something for prevention at the same level of importance that we have for medicating chronic illness.

Bruce Berger, PhD: In your TED Talk and the story that you told, what you did most powerfully is that you developed rapport with a patient who was who was frightened. I tell people, in motivational interviewing, rapport is what gives us the leverage to use our expertise. But you've got to do that first, you’ve got to demonstrate to the patient that I really get the problem you're having. And until that, our expertise means nothing.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, I mean, I couldn't agree with you more. If you don't establish trust, and you don't establish that, like you said, that rapport, nothing that comes out of your mouth is going to be communicated. Nothing, because you basically put up a wall, because you haven't opened the door to possibility, right? The possibility of them not just hearing the information, but internalizing it, and then that planting a seed that will therefore go on to create action, and then that action will go on and create meaningful and lasting change. And I think that's really paramount.

Bruce Berger, PhD: Yeah, even the patient who said, “I don't want to get a COVID-19 vaccine, I heard they're putting chips in there,” the very first words out of our mouth ought to be “Okay, so you have heard that there may be chips in these vaccines, and somebody's going to be invading your privacy and you thought there is no way I'm going to get a vaccine if something like that is happening.” And that is a valid very first thing. Absolutely. If you believe that's true, why in the world would you get the vaccine? And the only way I'm going to be able to get my foot in the door is by first acknowledging how frightening that would seem to the patient, or how angry they would be about that.

Christina Madison, PharmD, BCACP, AAHIVP: Or as a parent, if I'm concerned about getting my child vaccinated because I'm worried that it's going to impact their future fertility, that's a really valid concern. Because, you know, I might want to be a grandpa or grandma. So that's a valid concern that I think that a lot of people didn't take the time to acknowledge. I remember having somebody specifically ask me about the being magnetic, like the vaccine causing you to be magnetic. And so, I asked them, I said, you know, first and foremost, I want to take the time to acknowledge that this is a valid concern. And then the next thing I asked was, do you mind telling me, you know, where you saw that information? And, you know, what was it that really captured you, that made you feel like this was something that could happen to you?

Bruce Berger, PhD: You’ve got to acknowledge that this is very real and very frightening for the patient. And then the transition for me, I usually ask permission, I usually from there, say, after I've established with the patient, that I've really listened to him, and understood their concerns, I then will say something to the effect of, you know, “This brought some thoughts to mind, would you mind if I just shared some thoughts with you? And I'd really like to hear what you think.” And now I can use some of my expertise. I never decide for them because it's there, but I try to give them better information to make a decision. And I never say, “You're wrong.” I simply say, “Here's what I know and hear, and I feel safe. Here's what I even might know about where some of that information came from,” you know, if possible. But yeah, the process is always the same. We've got to honor and respect the concern of the patient.

Christina Madison, PharmD, BCACP, AAHIVP: Because the thing is, when they heard it, it was valid and real for them. And again, it's making sure that you acknowledge someone else's lived experience, regardless of whether or not you've had those thoughts or those feelings yourself, that is valid to them. And we need to do a better job of making sure people feel affirmed and safe to have those kinds of decisions. And then based on that, we can provide them with the facts as we know them, and then give them the tools in order to make the best decisions for themselves and their families. And I think the other part of that, too, is the community aspect. So, you know, one of the things that I talked about in my TED Talk, not to bring it up again, but one of the major ways that people found information and made a decision about being vaccinated was from family and friends. And then the last part was from their provider. So, family and friends was like up here and then, like, health care professional, of course, was there, but the family and friends was the biggest thing, right? Because all of these people are on social media, and they're looking to see what their peer groups are doing. And so, if their peer group was more likely to be vaccinated, then that was a predictor that they would be more vaccinated because their peer circle had already affirmed that decision.

Bruce Berger, PhD: Well, that woman you talked to got vaccinated and look at how many people she would interact with about her vaccination experience. But you know what? If you did it wrong, look at all the people she would talk to about not doing it. And that's the real problem.

Christina Madison, PharmD, BCACP, AAHIVP: Yeah, I mean, I think about those people who waited in line for hours at the very beginning of the pandemic, and I just remember, like, you know, just thanking them, thanking them for their time, thanking them for making this decision for themselves, and thanking them for, you know, for their patience. I just really feel that that kind of humility, and being humble, it goes such a long way. And then also just understanding our purpose. Like, our purpose is not to judge and our purpose is not to dictate and to lecture, it's to be a safe place for people to feel like they can ask and be honored. You know, that's a big thing for me is understanding that.

Bruce Berger, PhD: I like to tell people that I think we should be a loving resource.

Christina Madison, PharmD, BCACP, AAHIVP: Oh, that's so nice.

Bruce Berger, PhD: Again, it is called health care, right? But we should be a resource who demonstrates to the patient some form of love, you know, the verb. And part of that love, the verb, is respecting and acknowledging the cares and concerns of the patient. Even if it's not based on real information, it’s real to them. And then being a resource, so that they can make a better decision. And we kind of have it backwards in health care, in the sense that we think we're driving the bus and the patient's a passenger. The fact is, the patient's driving the bus, we're trying to influence the route.

Christina Madison, PharmD, BCACP, AAHIVP: Ohman, I couldn't have said it any better. This has been such a fantastic conversation. I could talk to you for at least another hour. But at this point, I just am so grateful for your time, for your expertise, and all that you've done in this space. And really just want to give you credit and really wanted to acknowledge the many, many, many health care professionals and in particular pharmacists that you've impacted. One of the things that I neglected to disclose to you when we spoke is that one of the first faculty development meetings that I attended as a new faculty member, when I started at my college of pharmacy, was a lecture taught by you/

Bruce Berger, PhD: Really? About what?

Christina Madison, PharmD, BCACP, AAHIVP: It's some of those skills and some of those teaching methods that you talked about. This is like 2000, I want to say 2008. It’s a while back, but I use it still to this day.

Bruce Berger, PhD: Like I said, it was obvious that was one of the reasons I contacted you, because your TED Talk really made a difference and really connected with me, and I wanted to just connect. So here we are.

Christina Madison, PharmD, BCACP, AAHIVP: Here we are. Well, with that, I would love for my audience to be able to see what you're up to, maybe connect with you if they want more information about motivational interviewing or how they can get resources. What would be the best place for people to reach out?

Bruce Berger, PhD: People can go to LinkedIn, look up my profile. In my profile, it has my email address it has my cell number if they want to text me. My email addresses is just like my name, it's BBergerconsulting@gmail.com. I have a website, it's very easy to remember, because it's mihcp.com. And that's where they can find a lot of resources, books, e-learning program videos. So yeah, I hope that'll interest them, and they'll go visit. Again, thanks. Thanks for doing this, Christina, and keep doing what you're doing.

Christina Madison, PharmD, BCACP, AAHIVP: Oh, thankyou so much. This has just been such a delight and I really hope that we stay in touch. And at some point, I hope that we will see each other in the future in person. And I really hope that you are enjoying your time in sunny Florida. And please give my regards to your lovely spouse because I know you said that she watched my TED Talk, too, which was so lovely that you said that. So, thank you so much for the kind words and for your continued support and just uplifting of the profession and just, you know, being a beacon of hope and light. And so, I just really, really, really appreciate that comment that you said about, like, we should be providing love, and really thinking about the fact that care is in our name. So, I just couldn't be more thrilled with how this conversation went. And I know that my audience is going to get a lot out of it. So, with that again, I am your host Dr. Christina Madison, and this has been another episode of Public Health Matters, part of the Pharmacy Times Pharmacy Focus podcast series. And with that, remember, Public Health Matters.