Section 19.2: Motivational Interviewing and Coaching Skills

19.2.1 The “Why”: The Paradox of Change

As a pharmacist, you are a highly trained expert in the logical, evidence-based world of medicine. You understand the clear, causal relationship between taking a medication and achieving a desired health outcome. From this expert position, it can be profoundly frustrating when a patient does not follow a prescribed regimen that is clearly in their best interest. We see the path forward with perfect clarity: “If you take this blood pressure medication, your risk of stroke will decrease.” “If you monitor your blood sugar and use insulin as prescribed, you can prevent kidney failure.” We deliver this information with precision and good intent, yet often, nothing changes. This is the paradox of change, and it is the central problem that Motivational Interviewing (MI) was designed to solve.

The traditional model of patient counseling is the “Expert Model.” We, the experts, identify a problem, provide the solution, and instruct the patient on how to implement it. This model is built on a fundamental, and often flawed, assumption: that the patient’s lack of change is due to a knowledge deficit. If they just knew more, they would do more. But what if the problem isn’t a lack of knowledge? What if the patient is ambivalent? Ambivalence is the state of simultaneously wanting to change and wanting to stay the same. “I want to lower my A1c, but I hate needles.” “I want to quit smoking, but it’s the only way I can cope with stress.”

When a healthcare professional confronts an ambivalent patient with direct, unsolicited advice, we often trigger a predictable and counterproductive psychological phenomenon known as the “righting reflex.” Our deep-seated instinct is to “make it right”—to fix the problem. But in doing so, we force the ambivalent patient to defend the other side of their own argument. We argue for change, so they are compelled to argue against it. The more we push, the more they resist, and the less likely change becomes. Motivational Interviewing offers a radical and more effective alternative. It is a guiding, collaborative counseling style that intentionally sets aside the “righting reflex” and instead focuses on exploring the patient’s own motivations, values, and reasons for change. It is about helping patients resolve their own ambivalence and talk themselves into changing. This section is a deep dive into this transformative approach, providing you with the skills to move from being an expert instructor to a collaborative partner in your patients’ health journeys.

19.2.2 The Foundation: The “Spirit” of Motivational Interviewing (PACE)

Before learning the specific techniques of MI, one must first adopt its underlying “spirit” or mindset. MI is more than a set of tools; it is a fundamental way of being with a patient. Attempting to use MI techniques without embracing its spirit will feel manipulative and inauthentic, and patients will see right through it. The spirit of MI can be remembered with the acronym PACE.

Masterclass Table: Translating the “Spirit” into Pharmacist Behavior

MI Spirit Component	Traditional “Expert Model” Behavior	Motivational Interviewing Behavior
Partnership	“Here’s what you need to do.” (Confronting, directing)	“Where should we start?” “What are your thoughts on this?” (Collaborating, asking permission)
Acceptance	“You really shouldn’t be skipping your doses. That’s very dangerous.” (Judging, shaming)	“It sounds like it’s been really challenging to remember to take it every day. That’s understandable with your busy schedule.” (Empathy, validating)
Compassion	Focusing solely on the clinical numbers (A1c, BP). “We have to get this number down.”	Focusing on the patient’s experience. “How has this diabetes diagnosis been affecting your day-to-day life?”
Evocation	“Let me tell you why quitting smoking is so important…” (Giving reasons, lecturing)	“What are some of the reasons you’ve thought about for wanting to quit smoking?” (Eliciting the patient’s own reasons)

19.2.3 The Core Skills: Mastering OARS

The spirit of MI is put into practice through four core communication skills, remembered by the acronym OARS. These are the practical tools you will use in every MI conversation. Mastering them allows you to navigate conversations about change with skill and purpose.

1. Open-Ended Questions

Open-ended questions are the engine of an MI conversation. They are questions that cannot be answered with a simple “yes” or “no” or a single-word response. They invite the patient to tell their story, explore their thoughts and feelings, and do the talking. A well-crafted open question opens the door to a deeper conversation and prevents the pharmacist from falling into the “Question-Answer Trap,” where the pharmacist asks a series of closed questions and the patient gives a series of short answers, creating a passive and unengaging dynamic.

Masterclass Table: Transforming Closed Questions into Open-Ended Questions

Clinical Topic	Closed-Ended Question (Leads to a dead end)	Open-Ended Question (Invites conversation)
Adherence	“Are you taking your medication every day?”	“How has it been going with fitting this new medication into your daily routine?”
Dietary Changes	“Have you been avoiding salty foods?”	“What are some of the challenges you’ve run into when trying to make changes to your diet?”
Smoking Cessation	“Do you want to quit smoking?”	“What are your thoughts about quitting smoking at some point?” or “What are some of the good things and not-so-good things about smoking for you?”
Blood Sugar Monitoring	“Are you checking your sugars?”	“Tell me about your experience with checking your blood sugar. What’s that process like for you?”
Initial Engagement	“Do you have any questions about this new prescription?”	“To make sure I’m giving you the most important information, what do you already know about this new medication, lisinopril?”

2. Affirmations

Affirmations are statements that recognize a patient’s strengths, efforts, and positive attributes. They are not praise (“Good job!”); they are genuine acknowledgements of the patient’s character and struggles. Affirmations are crucial for building rapport and self-efficacy—the patient’s belief in their own ability to change. Many patients with chronic conditions feel demoralized or ashamed. A well-placed affirmation can be incredibly powerful, signaling that you see them as a capable person, not just a set of clinical problems.

An effective affirmation is genuine and specific. It often focuses on the process, not the outcome. You are affirming the effort, the courage, the persistence, even if the clinical results aren’t perfect yet.

3. Reflective Listening

Reflective listening is the most important skill in MI. It is the process of actively listening to what the patient says, forming a reasonable guess about their intended meaning, and then reflecting that meaning back to them in the form of a statement (not a question). Reflections are the primary way you demonstrate empathy, build rapport, and guide the conversation. When you reflect a patient’s statement, you are holding up a mirror, allowing them to see their own thoughts and feelings more clearly. This process is essential for exploring ambivalence and eliciting change talk.

There are two main levels of reflection:

• Simple Reflections: These stay very close to what the patient said, repeating or slightly rephrasing their words. They show you are listening but don’t add much direction.
• Complex Reflections: These are more powerful. You make a guess about the underlying meaning, feeling, or implication of what the patient said. This is where you can gently guide the conversation by reflecting and emphasizing certain parts of their statement.

Masterclass Table: The Art of Reflection

Patient’s Statement	Simple Reflection (Repeating)	Complex Reflection (Paraphrasing Meaning)	Complex Reflection (Reflecting Feeling)
“I know I’m supposed to take this cholesterol pill, but I feel fine. I hate taking pills for no reason.”	“You hate taking pills for no reason.”	“So, on one hand, you understand why the doctor prescribed it, but on the other, it’s hard to be motivated to take a medication for a problem you can’t feel.” (This is a double-sided reflection, which is excellent for exploring ambivalence).	“It sounds frustrating to have to take a pill for something that doesn’t even bother you.”
“I tried to quit smoking last year, and it was a disaster. I was so irritable, and I gained ten pounds. I’m not sure I can go through that again.”	“You’re not sure you can go through that again.”	“That past experience makes you hesitant to try again, even though a part of you wants to.”	“You sound really discouraged about what happened last time you tried to quit.”
“My doctor says I have to start insulin, but I’m terrified of needles. My grandmother took insulin, and she ended up losing her leg.”	“You’re terrified of needles.”	“You associate insulin with very frightening health outcomes because of what happened to your grandmother.”	“The idea of starting insulin is really scaring you right now.”

4. Summaries

Summaries are essentially extended reflections. They involve pulling together several things the patient has said and presenting them back in a concise, organized way. Summaries are incredibly useful for several reasons: they show the patient you have been listening carefully, they allow you to organize the conversation, they can highlight the patient’s ambivalence by presenting both sides of their argument, and they provide a natural way to transition to a new topic or toward a plan.

19.2.4 The Four Processes: A Roadmap for the MI Conversation

An MI conversation is not a random collection of OARS skills. It has a natural flow and direction, guided by four sequential processes. You must establish one before moving to the next. Think of it as building a house: you must lay the foundation (Engaging) before you can put up the frame (Focusing), and so on.

Process 1: Engaging

The first step is to establish a connection and a comfortable, trusting working relationship. Without engagement, nothing else can happen. The patient must feel that you are listening, that you understand them (or are trying to), and that you respect them. This is where the “spirit” of MI is most visible. Your goal is not just to be friendly, but to build a therapeutic alliance.

Key Tasks: Use OARS skills, especially open-ended questions and simple reflections, to understand the patient’s perspective and concerns. Ask permission before offering advice. Avoid the “assessment trap” (asking a barrage of questions) and the “expert trap” (presenting as the all-knowing authority).

Process 2: Focusing

Once a rapport is built, the conversation needs a direction. It is rare that you have unlimited time, and patients often have multiple health issues. The focusing process is a collaborative effort to decide on a specific topic or behavior to talk about. This prevents the conversation from becoming scattered and unproductive. The agenda should be set collaboratively, not imposed by the pharmacist.

Key Tasks: Offer an agenda map (“There are a few things we could talk about today—your new blood pressure pill, your diet, or your smoking. What seems most important to you to focus on right now?”). Use summaries to transition to a specific focus. The goal is to have a clear, shared understanding of what the conversation is about.

Process 3: Evoking

This is the heart of Motivational Interviewing. The goal of evoking is to elicit “change talk”—any speech from the patient that favors movement in the direction of change. At the same time, you want to minimize “sustain talk”—speech that favors the status quo. The more someone argues for change in their own words, the more committed to it they become. Your job is to be a skilled interviewer, strategically asking questions and offering reflections that draw out the patient’s own motivations, reasons, and abilities to change.

Masterclass Table: Recognizing and Eliciting Change Talk (DARN CAT)

Type of Change Talk	Definition	Patient Example	Pharmacist’s Evocative Question
Preparatory Change Talk (DARN)
Desire	Statements about wanting or wishing for change.	“I wish I had more energy to keep up with my kids.”	“In what ways would your life be different if you had more energy?”
Ability	Statements about capability to change.	“I think I could probably walk for 15 minutes a day.”	“That’s great. What makes you think you could do that?”
Reasons	Specific arguments for change.	“My doctor said if I don’t get my blood pressure down, I could have a heart attack.”	“What are some of your other reasons for wanting to make a change?”
Need	Statements about the importance or urgency of change.	“I have to do something about my weight. I can’t keep going on like this.”	“How urgent does this feel to you?”
Mobilizing Change Talk (CAT) – Signals Readiness for a Plan
Commitment	Direct statements of commitment to change.	“I am going to start checking my blood sugar every morning.”	(Shift to Planning) “That sounds like a solid first step. What do you need to make that happen?”
Activation	Statements that signal readiness or willingness, but fall short of full commitment.	“I’m ready to at least try.”	(Shift to Planning) “What would that first step look like for you?”
Taking Steps	Patient reports actions already taken.	“I actually went online and looked up some low-sodium recipes yesterday.”	(Affirm & Plan) “That’s fantastic. You’re already taking action. How can we build on that?”

Process 4: Planning

You should only move to the planning process after you have heard a good amount of change talk, particularly mobilizing change talk (CATs). The patient is now leaning toward change, and the ambivalence has started to resolve. The planning process is, like all of MI, collaborative. It is not about giving the patient a pre-made plan. It is about helping them create their own plan that fits their life, values, and confidence level.

Key Tasks: Use a transitional summary (“So, after talking about all this, what do you think you’ll do?”). Offer a menu of options, not a single prescription. Help the patient develop a SMART goal (Specific, Measurable, Achievable, Relevant, Time-bound). Troubleshoot potential barriers and affirm their ability to succeed.

19.2.5 Practical Application: A Discharge Counseling Session Using MI

Let’s walk through a realistic scenario of a hospital pharmacist counseling a 58-year-old patient, Mr. Garcia, who is being discharged after his first heart attack. He is being started on four new medications: aspirin, clopidogrel, atorvastatin, and metoprolol.