11.3 Motivational Interviewing and Shared Decision-Making
Key Takeaways
- Motivational interviewing resolves ambivalence by evoking the patient's own reasons for change rather than supplying the pharmacist's reasons.
- The core skills are summarised as OARS: open questions, affirmations, reflective listening, and summaries.
- The righting reflex — the urge to correct and persuade — reliably increases resistance and reduces the likelihood of change.
- Shared decision-making applies when there is genuine equipoise, and requires that the patient understands the options, the benefits and harms, and the uncertainty.
- Non-adherence is usually a mix of intentional and unintentional causes, and the intervention must match the cause rather than defaulting to more information.
11.3 Motivational Interviewing and Shared Decision-Making
Exam Focus: The PEBC syllabus lists motivational interviewing and shared decision-making as distinct bullets. Examination items usually present a patient who is reluctant or undecided and ask which pharmacist response is most likely to help.
Motivational Interviewing
Motivational interviewing is a collaborative, goal-oriented conversational method for strengthening a person's own motivation and commitment to change. It was developed for substance use and now applies across adherence, smoking cessation, weight, and chronic disease self-management.
The spirit: partnership, acceptance, compassion, evocation
The approach rests on the premise that motivation cannot be installed from outside. The pharmacist's task is to evoke what is already there — the patient's own values and reasons — rather than to supply arguments.
The righting reflex
The righting reflex is the trained clinician's urge to correct what appears wrong: to explain the risks harder, to list the consequences, to persuade. It predictably produces the opposite of what is intended. When one person argues for change, the ambivalent person argues against it, hears themselves defend the status quo, and becomes more committed to it. Suppressing the righting reflex is the single most important behaviour change for the practitioner.
OARS: the core skills
| Skill | What it is | Example |
|---|---|---|
| O — Open questions | Invite elaboration | "What would need to be different for you to consider taking it daily?" |
| A — Affirmations | Recognise genuine strengths and effort | "You've kept the appointments even during a hard month — that takes real effort." |
| R — Reflective listening | Restate meaning, sometimes amplified | "You want the blood pressure down, and you don't want to feel dizzy at work." |
| S — Summaries | Collect and organise what was said | "So the cost is manageable, the timing is not, and the dizziness worries you most." |
Change talk and sustain talk
Change talk is any patient speech favouring change. Listen for and reinforce it using the acronym DARN-CAT: Desire ("I want to"), Ability ("I could"), Reason ("it would help my knees"), Need ("I have to"), then the mobilising forms — Commitment ("I will"), Activation ("I'm ready to"), and Taking steps ("I bought a pill organiser").
Sustain talk favours the status quo. It is not defiance; it is one half of ambivalence. Reflect it without arguing, then ask what sits on the other side.
Two practical tools:
- Scaling questions. "On a scale of 0 to 10, how important is it to you to stop smoking?" If the answer is 4, ask "Why a 4 and not a 2?" — which elicits the patient's own reasons for change. Asking "why not an 8?" evokes sustain talk and is the common error.
- Elicit-provide-elicit. Ask permission and find out what the patient already knows, provide the information neutrally, then ask what they make of it. This delivers advice without triggering resistance.
Shared Decision-Making
Shared decision-making is the process by which a clinician and patient reach a healthcare decision together, combining the best available evidence with the patient's values and preferences. It is indicated when there is genuine equipoise — more than one reasonable option, including doing nothing — which describes most preference-sensitive decisions in pharmacy: anticoagulation in atrial fibrillation, statin therapy in primary prevention, bisphosphonate duration, or deprescribing.
A workable three-step structure:
- Choice talk — make it explicit that a choice exists. "There is more than one reasonable option here, and what matters most to you should shape which one we pick."
- Option talk — describe each option with its benefits and harms in natural frequencies over a stated time horizon, including the option of no treatment, and name the uncertainty.
- Decision talk — explore what matters most to the patient, support deliberation, and reach a decision, allowing time where the decision is not urgent.
Shared decision-making is not the same as informed consent, though it supports it, and it is not the abandonment of professional recommendation. The pharmacist may still say what they would suggest and why; what changes is that the patient's values are treated as evidence about what a good outcome looks like for them.
Decision aids — printed or digital tools presenting options, outcome probabilities, and value clarification exercises — measurably improve knowledge, produce more accurate risk perception, and reduce decisional conflict.
Diagnosing Non-Adherence Before Intervening
Roughly half of patients with chronic conditions do not take long-term therapy as prescribed. Effective intervention depends on identifying the cause.
| Type | Cause | Matched intervention |
|---|---|---|
| Unintentional | Forgetting, complex regimen, dexterity or vision limits, cost, access | Simplify and align doses, blister packs or organisers, reminders, easier devices, coverage assistance, synchronised refills |
| Intentional | Belief the drug is unnecessary or harmful, adverse effects, conflicting values, previous bad experience | Explore beliefs, address the specific concern, negotiate a trial with agreed monitoring, adjust therapy |
Providing more information helps only unintentional non-adherence caused by a knowledge gap. Giving a patient who has stopped a statin because of muscle pain a leaflet about cholesterol addresses nothing. Asking non-judgementally is the first step: "Most people miss doses sometimes. In the last week, how many times did you miss the tablet, and what usually gets in the way?"
The necessity-concerns framework is a useful lens: adherence rises when the patient's perceived necessity for the medicine exceeds their concerns about it. An intervention can therefore work by strengthening perceived necessity, by reducing a specific concern, or both.
A patient says, 'I know I should quit smoking, but it's the only thing that helps my stress.' Which pharmacist response is most consistent with motivational interviewing?
A patient rates the importance of starting a statin as 3 out of 10. Which follow-up question best elicits change talk?
Shared decision-making is most clearly indicated in which situation?
A patient stopped her alendronate because she read that it causes jaw problems. Which intervention is best matched to this type of non-adherence?