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International Journal of Mental Health Promotion Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rijm20 Motivational interviewing with the older adult Mirsad Serdarevica & Sonne Lemkeb a Geriatrics Research, Education and Clinical Centers (GRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA b Center for Health Care Evaluation and Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA Published online: 11 Dec 2013.

To cite this article: Mirsad Serdarevic & Sonne Lemke , International Journal of Mental Health Promotion (2013): Motivational interviewing with the older adult, International Journal of Mental Health Promotion, DOI: 10.1080/14623730.2013.862362 To link to this article: http://dx.doi.org/10.1080/14623730.2013.862362

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Motivational interviewing with the older adult Mirsad Serdarevica and Sonne Lemkeb*

aGeriatrics Research, Education and Clinical Centers (GRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA; bCenter for Health Care Evaluation and Program Evaluation and Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA (Received 29 October 2013; final version received 6 November 2013)

Motivational interviewing (MI) is an evidence-based psychotherapeutic approach to health behavior change and has great potential to improve medical regimen adherence among the older population. This article provides a concise summary of MI as it can be applied to geriatric patient populations. The goal is to provide readers with an overview of MI, its clinical applications within psychological and medical settings and its adaptation for use with older individuals dealing with both mental health and general medical conditions. The article also discusses how varied systemic and therapeutic contexts (e.g., biomedical vs. psychological) may affect the meaning and implementation of MI. Although published randomized controlled studies on the effects of MI in the older population are limited, the majority of such studies indicates that MI is effective in influencing change in health behaviors. As a proven, cost-efficient treatment, MI should be considered for clinical use in geriatric and primary care clinics providing care to older adults. Keywords: Empathy, health behavior change, primary care, self-efficacy, therapeutic alliance, treatment adherence.

Why motivational interviewing for the elderly? Older patients are likely to present health-care settings with multiple, interacting problems or complaints, such as chronic pain, diabetes, hypertension, congestive heart failure, dementia and depression. They are consequently likely to be on complex treatment regimens requiring multiple medications or medical interventions that may increase the likelihood of negative side effects. Furthermore, older patients are often dealing with grief over losses, fear of physical illness and guilt over past events, all of which can have a negative impact on self-efficacy and can impede treatment adherence and needed behavior

Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 change. Undertaking and maintaining positive health behaviors, such as physical activity and exercise, medication adherence and other forms of medical and psychological treatment engagement, can be challenging but can significantly improve both quality of life and longevity for the elderly (e.g., Phillips, Schneider, & Mercer, 2004). Thus, to address the varied medical and mental health needs of their clients, geriatric medical and mental health services would benefit from non-psychopharmacological treatments that are person-centered, that address the need for behavior change and that are adapted to the needs of elderly clients (e.g., Bugelli & Crowther, 2008). Motivational interviewing (sometimes referred to as MI) is one such approach. It has been defined as: ‘A skillful clinical style for eliciting from patients their own for making changes in the interest of their health’ (Rollnick, Miller, & Butler, 2008, p. 246). As such,

*Corresponding author. Email: [email protected]

q 2013 The Clifford Beers Foundation 2 M. Serdarevic and S. Lemke

MI could be a powerful psychological intervention in working with older peoples’ ambivalence or resistance to change during psychotherapy and other health-related treatments. The word ‘style’ in the definition of MI implies a degree of therapeutic flexibility, which allows the clinician to continuously adjust to unique demands of each individual patient. As a therapeutic style, rather than restrictive, manualized psychotherapeutic treatment, MI lends itself to adaptation across different settings and different populations. MI’s greatest strength is its adaptability to different clinical problems and situations. MI is grounded in the Rogerian premise that all humans have the built-in motivation to develop their potential to the fullest extent possible, even when faced with barriers and challenges (Rogers, 1995). Making use of this internal motivation to encourage change of maladaptive health-related behavior is the primary focus of MI. Within Rogers’ framework, change occurs through the ‘paradox of acceptance,’ as only after the patient experiences empathy and acceptance and perceives the clinician as genuine can change begin. By exploring and resolving the patient’s ambivalence, MI enhances intrinsic motivation to change. It also elicits from the patient and reinforces ‘change talk,’ as the patient feels safe to explore and verbalize his/her goals to the clinician. Incorporating a Rogerian approach as a fundamental part of MI, the clinician is able to listen and reflect the client’s story in a therapeutic (or ‘holding’) environment where the whole experience (emotions, actions, thoughts, etc.) is unconditionally accepted by the clinician. It is thought that such an approach allows the patient to become gradually more comfortable with aspects of the self that may be anxiety-causing, shameful, scary, threatening and so on, which in turn facilitates the patient’s growth and eventual change. Rogers described this process as follows: ‘If I can provide a certain type of relationship, the other person will discover within himself the capacity to use that relationship for growth, and change and personal development will occur’ (Rogers, 1995, p. 33). The ‘if’ in Rogers’ statement implies that ‘a certain type of relationship’ is a primary goal for the clinician as it will lead to gradual self-acceptance and growth on the patient’s part. While acceptance can be conceptualized in many ways, an example may best illustrate it. Picture a toddler who is roaming around in a supermarket with her parents, picking up random items from shelves, which she then, with a smile on her face, offers to some total strangers. Other than being charmed by a young child, these recipients will most likely feel accepted by this toddler, who is not judging them, not telling them what or how to be, but simply rewarding them with a smile, acknowledging their presence and offering a ‘present’ in turn. At the most fundamental level, such an

Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 experience has a psychologically (and possibly physiologically) beneficial effect on these individuals. MI integrates both person-centered and directive psychotherapeutic approaches. As noted above, MI affects positive behavioral change by utilizing therapeutic empathy forged within a person-centered psychotherapeutic framework. It also entails a goal- oriented therapeutic collaboration focused on problem solving, which in turn can bolster a patient’s self-efficacy (Bandura, 1982). Self-efficacy within health-care settings refers to the patient’s belief that he/she can successfully perform the targeted behavioral change that would lead to improved health outcomes. When a patient’s self-efficacy increases, it is likely that he/she will actually attempt such change and succeed in implementing it. Human motivation, well-being and sense of personal accomplishment are all founded on self-efficacy beliefs, and these beliefs impact the effort the patient puts forth in a given task, the choices the patient makes and how he/she confronts life’s obstacles. International Journal of Mental Health Promotion 3

Principles of MI Expressing empathy MI is built on the therapeutic skill of reflective listening and on the assumption that qualities of the counselor who provides treatment are one of the strongest determinants of client outcomes, an assumption that is supported by research evidence. The therapeutic skill of accurate empathy, originally described by Rogers (1995), has been found to account for a meaningful proportion of variance in treatment outcomes and quality of the therapeutic alliance. High-empathy counselors appear to have higher success rates, regardless of their theoretical orientation (Moyers & Miller, 2013). Therapists who use reflective listening and are more empathic are significantly more likely to create positive therapeutic change than those who do not. Research has shown that up to two-thirds of the variance in psychotherapy outcomes is accounted for by empathy and the presence of reflective listening (Elliott, Bohart, Watson, & Greenberg, 2011; Miller & Baca, 1983). The importance of empathy in both medical training and practice has also been emphasized by leading medical scholars and educators (e.g., Hojat et al., 2002; Spiro, 2009). Empathy is described as the ability to feel what the client feels. But how does a therapist know if he/she is indeed being ‘empathic’? As described by Rogers, reflective listening is a therapeutic skill that demands that the therapist attempt to experience the world through the client’s eyes and to communicate, in a nonjudgmental way, what he/she is hearing from the client. This requires frequently checking in with the client to ensure that the client’s view is being understood (i.e., allowing the client to correct or further elaborate). Correctly implemented reflective listening during a psychotherapy session is likely to lead to the client’s experience of being heard and of the therapist as an individual who is actively attempting to understand the client’s sense of the world in an accepting and nonjudgmental way, that is, as someone who is empathic. Note that while empathy requires acceptance and nonjudgment, it does not mean that the therapist or clinician must agree with the client, but rather that he must communicate that the client is being understood and accepted. A patient’s experience of the clinician’s unconditional acceptance allows the patient to be more accepting of the flawed but real self. This acceptance decreases the polarization between the real and the ideal self. Through therapeutic acceptance, the patient becomes more comfortable with his/her real self, a comfort that leads to greater outward expression of the real self and a more modulated sense of self. Acceptance also allows the ideal self to be less perfect, further reducing the incongruence or tension between the real and the ideal self. Not only does Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 acceptance reduce this incongruence, but it also helps reduce the tension and psychic distress that result from such incongruence, thus allowing the patient to achieve better integration of these selves, become more aware of his/her intrinsic desires, reflect that awareness through actions that are congruent and have more energy available to carry out these actions. The ‘real self’ and ‘ideal self’ have specific salience in the context of primary geriatric care. For example, an elderly patient may be feeling sad, but because he believes that this feeling is not something that others (family, doctor, nurse, etc.) want to see, he may present an ideal self that is optimistic and resilient and may consequently underreport some symptoms of depression that should be addressed in treatment. In such cases, MI offers a ‘way of being’ in the therapist role that can establish an environment in which vulnerability is an accepted state and real issues can be more effectively addressed. 4 M. Serdarevic and S. Lemke

Rolling with resistance Health practitioners often encounter patients who are resistant to treatment or who resist behavioral change relevant to their health (e.g., medication adherence, changes in diet or activity levels, discontinuing misuse of substances). ‘Rolling with resistance’ asks health practitioners to understand patients’ ambivalence or resistance to treatment and to identify and reframe it to create therapeutic communication that will lead toward change. Playing the role of an expert, even just providing an individual with ‘empirical data’ about consequences of behavior, is likely to be ineffective and may in fact increase the patient’s resistance to suggested treatments or behavioral health changes. This is especially the case for ambivalent patients who are contemplating change. To effectively roll with the patient’s resistance requires the use of mostly open-ended questions aimed at better understanding the reasons for resistance, as well as validating the patient’s concerns or ambivalence about change. Such an approach is likely to make patients less defensive and more open to discussing the reasons behind their resistance. The clinician’s handling of resistance will influence whether resistance increases or diminishes and, ultimately, whether the client moves toward change. If the clinician pushes forcefully against resistance, the patient is likely to move in the opposite direction and defend the status quo. The following is a brief example (adapted from McCracken and Corrigan [2008]) of an exchange between a patient who wants to discontinue psychotropic medications because of undesirable side effects and a health practitioner who is rolling with resistance: Therapist: I understand that you have some concerns about your antidepressant medication and may be thinking about stopping it. Would you be willing to discuss your reasons for wanting to discontinue it? (Asking for permission, affirming patient’s autonomy) Patient: Yes, taking them makes me so sleepy and gives me a drugged feeling. I struggle to get anything done during the day, and I can’t really enjoy things I like to do. Therapist: That must be difficult for you given how important your gardening and crafts are to you and how hard you’ve worked to remain independent. (Validating) Would you tell me more about it? Patient: Sure, but you will not change my mind about this. I am not taking that medication. Therapist: That is your choice. (Emphasizing patient’s personal control and rolling with resistance) I’d like to understand your experience better. Could you tell me if there are additional things about this medication that interfere with your daily life? In addition to sedation, or these feelings of sleepiness and being drugged that you are reporting, does this medication have any additional effects that are bothersome to you?

Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 Patient: I can’t think of any additional problems with the medication. Therapist: Could you think of any reasons to continue taking the medications? (Open-ended questions aimed at further exploring and understanding patient’s resistance to taking medication) Patient: I suppose when I initially started taking the medication it was very helpful, and I noticed that my mood improved, but it certainly made me sleepier. Therapist: What do you think may happen if you stop taking the medication? Patient: Well, I hope I’ll be less out of it. I hope that I will not have really bad withdrawal. I guess I am a bit concerned if discontinuing medication would contribute to me going back to feeling so sad again. Therapist: It sounds like if you stopped this medication, you expect to get some relief from bothersome effects that interfere with your daily life such as sleepiness and feeling drugged, but you also have some concern about how it may affect your mood after discontinuation? International Journal of Mental Health Promotion 5

Patient: Yes, I really want to stop, but I do worry at times about getting worse. Therapist: You presented some very important concerns regarding your current medications, including some concern about withdrawal and increased sadness. (Validation) I was wondering if you would be willing to join me in consulting with your psychiatrist about the concerns you have regarding withdrawal and increased sadness, as well as possibly addressing the problems with sleepiness before you completely discontinue? (Collaboration, goal- oriented) Patient: Yes, I guess I would consider joining you in talking to the psychiatrist.

Developing discrepancy For MI to be effective, the clinician also needs to identify and reflect back to the patient an incongruence or discrepancy between the patient’s current or planned behavior, and his/ her stated goals. Incongruence is generated by the patient, and the objective of the clinician is to have the patient feel ownership of the incongruence versus experiencing an external authority instructing or directing him/her what to do. The aim of MI is to amplify this discrepancy for the client. Continuing with the above clinical example, here is a brief excerpt of how therapist/health practitioner may develop discrepancy: Therapist: Let’s talk about how discontinuing medication would either interfere or help with your goals of being able to garden and to maintain your ability to perform household activities independently. When you were feeling sad in the past, how did that affect these activities? (Exploring and developing discrepancy between the patient’s ultimate goal of being engaged in household activities independently and how stopping the medication may impact that goal)

Supporting self-efficacy Self-efficacy refers to the patient’s belief in his ability to initiate, maintain and succeed with a specific task (Bandura, 1982). Enhancing the patient’s confidence in his ability to overcome obstacles and to succeed in behavior change is a general goal of MI. The role of a clinician in MI is to bolster the patient’s self-efficacy through collaborative problem solving and by highlighting the patient’s prior successes in resolving similar problems in the past.

MI in relation to other treatment models Models of treatment adherence Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 Elderly patients can have multiple reasons for not adhering to medication or treatment recommendations. These include possibly elevated levels of negative side effects, financial concerns, cultural issues and the demands involved in managing multiple chronic conditions (e.g., Depp, Lebowitz, Patterson, Lacro, & Jeste, 2007; McCracken & Corrigan, 2008). Three main models or approaches have been developed to understand and promote treatment adherence in areas such as medications, physical exercise or diet. These models are the Mental Health Belief Model, models based on the provider/patient relationship and communication process and models that promote the individual’s self- efficacy regarding change through exploration of emotional and cognitive ambivalence (e.g., McCracken & Corrigan, 2008). MI has components of each of these models, highlighting its comprehensiveness and potential value. MI encourages the individual to weigh the risks and benefits of change (as in the Mental Health Belief Model). MI also strongly emphasizes the communication 6 M. Serdarevic and S. Lemke

process and the relationship between the provider and the patient. Finally, MI places emphasis on the patient’s beliefs and feelings; it both uses an empathic response to induce individuals’ exploration of emotional and cognitive ambivalence, and promotes the individual’s self-efficacy.

Models of therapeutic change The premises of MI are also consistent with influential models of therapeutic change. For example, because MI is attempting to ignite intrinsic motivation, it meshes well with the Stages of Change Model (Prochaska & DiClemente, 1982); that is, the clinician must understand the patient’s current readiness to change and choose the type and degree of intervention based on that. Hence, an individual who does not recognize any problem and who expresses an unwillingness to change would be validated and encouraged to further consider the current situation and whether there are areas where change is desired, but an individual who expresses ambivalence about change can be skillfully guided, first toward change talk and then toward change itself. For example, if the client is in the contemplative or ambivalent stage (often referred to as ‘sitting on the fence’) regarding readiness for changing their behavior, he/she is expected to be aware of the need for change, but may not be ready to engage in the needed behaviors. The clinician who accurately assesses such client’s stage of readiness for change would validate the client’s reluctance to commence with behavioral changes, clarify his/her autonomy by acknowledging that the choice is his/hers, encourage evaluation of the pros and cons of behavioral change and promote new, positive behavioral change outcome expectations (bolster client’s self-efficacy). Some studies have shown improved outcomes utilizing the Stages of Change Model (often termed the Transtheoretical Model) to focus on matching the therapeutic intervention to patients’ level of readiness to change their health-related behaviors (e.g., Yoo, Kim, & Cho, 2012).

Other considerations How clinical contexts shape the practice of MI The practice of MI is influenced by goals, patterns of practice and norms of the setting in which it takes place. Ledderer (2011) categorized qualitative data on how clinic personnel offer, define and perform MI for preventive treatment into two fundamentally different types of routines or approaches – biomedical and psychological. Ledderer argues the

Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 meaning of an intervention, such as MI, is constructed and defined based on existing shared meaning within the institution, such as a medical practice. For example, MI delivered through the relatively rigid structure within a primary care clinic significantly differs from MI’s spirit of loose structure and collaborative approach, which may be more fully practiced in a community mental health clinic. These differences in how MI is enacted can in turn produce different outcomes. Health practitioners’ awareness of how their organizational paradigm impacts MI can influence its appropriate delivery. Indeed, the tension between a biomedical and psychological approach to MI is created by distinctive organizational value systems, and this tension needs to be resolved if MI is to be delivered in its evidence-based form. Despite the possible tension between medical settings and MI principles, health policy researchers (Boyd et al., 2007) have suggested that MI can be a cost-effective element of models such as Guided Care for older adults presenting with multimorbidity. Within this model, Guided Care Nurses (GCNs) would utilize MI in conjunction with monitoring calls International Journal of Mental Health Promotion 7

to reinforce and facilitate patient’s participation in care (Bennett et al., 2005). Trained in MI principles, GCNs would utilize these principles to improve delivery of health services. Such applications must take into account the organizational value system and strategies for maintaining the flexibility and patient-centered nature of MI approaches.

Effectiveness and cost-effectiveness of MI MI has been shown to be effective in various spheres of mental health settings and health psychology within primary care settings. A meta-analysis of MI, which covered 119 studies on MI across different settings, showed that MI exerts a significant, positive influence across a wide range of problem domains, although it is more potent in some clinical contexts (e.g., outpatient substance use treatment clinics) compared to others (Lundahl & Burke, 2009). In this meta-analysis, overall, 25% of participants gained a moderate-to-substantial level of improvement from MI, and an additional 50% gained a small but significant effect. The two factors that research has found to be most closely linked to motivation to change, patients’ engagement in treatment and their intention to change, are significantly increased as a result of MI treatment. For example, MI-based interventions have been found to promote increased treatment retention (Carroll et al., 2006). More recently, a steady stream of studies has explored the effectiveness of MI in conjunction with other treatment modalities, such as cognitive behavioral therapy (CBT; e.g., Cooper, 2012), and its relevance to varied populations, including older adults. A recent meta-analytic study (Lundahl et al., 2013) found MI to have beneficial effects, with 63% of the main outcome comparisons in the studies included in the meta-analysis yielding statistically significant advantages favoring MI (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). In addition, a cost-effectiveness advantage for MI has been found in some studies. For example, one study compared a four-session MI-based treatment, Motivational Enhancement Therapy (often referred to as MET) and two 12-session treatment methods using CBT and 12-step approaches (Cisler, Holder, Longabaugh, Stout, & Zweben, 1998) and found similar outcomes for all treatments, both immediately after treatment and at the three-year follow-up (Babor & Del Boca, 2003; Holder et al., 2000; Project MATCH Research Group, 1997, 1998). Clearly, the MET approach, which required fewer sessions, had a substantial cost advantage, at least in terms of immediate outcomes. While these studies did not provide full cost-effectiveness evaluations (Gold, Siegel, Russell, & Weinstein, 1996), they suggest that MI has the potential to reduce costs associated with

Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 mental health treatment. On conceptual grounds, it is expected that MI can be successfully adopted and modified for use with a geriatric population, but limited research has directly addressed its effectiveness with the older population (Bugelli & Crowther, 2008). Researchers have concluded that adaptations and modifications to general psychotherapy approaches work well for use with older people (Cook, Gallagher-Thompson, & Hepple, 2005). For example, a meta-analysis of controlled intervention studies of psychotherapy with older adults tentatively concluded that effects of psychotherapy do not decrease for participants in the 60- to 80-year-old age range (Pinquart, Duberstein, & Lyness, 2007). Extrapolating from these finding, we anticipate that such adaptations of MI delivery to the geriatric population will have beneficial results. Pinquart et al. further argue for the benefits of continuous monitoring of patient’s motivational level throughout treatment, especially when treatment is prolonged or when attrition is high, an ideal application for MI. Because MI starts where the person is in terms of the person’s readiness for change, it alerts the 8 M. Serdarevic and S. Lemke

clinician to the patient’s unique needs. So, while clinicians may need to make some technical adjustments to address possible deficits (e.g., using repetition in patients who may have mild cognitive impairment and/or hearing loss), it appears that MI does not need substantive adjustments for the elderly population. Overall, the expectation that MI will be similarly effective with older adult clients is supported by the limited literature on MI. For example, in a randomized controlled study on the effects of MI on alcohol consumption, younger (21–64 years old) and older adult clients (65 and older) were compared, and no statistically significant outcome differences were found (Gordon et al., 2003). Similarly, additional statistical analysis of the above- mentioned meta-analyses suggests that MI is equally effective when used with younger adult clients (,60 years old) and older adult clients (.60) (B. Lundahl, personal communication, February 25, 2013). Along these same lines, MI has been shown to improve the motivation of elders to initiate and maintain exercise (Phillips et al., 2004). Even though physical activity promotes health, prolongs functional independence and slows disease progression in the geriatric population, initiating and maintaining physical activity among elders remains a challenge. Philips et al. outlined interventions specifically focused on increasing motivation among elderly for exercise and physical activity. MI in geriatric behavioral health may focus on any or a combination of the following: education, better adherence to physical and occupational therapy, increase in exercise programs, graduated activity progression as well as affordable activity options.

Conclusion To be effective, MI cannot be provided in a rigid or formulaic manner. Providers need to be sensitive to specific needs of the individuals and populations they are treating and to constantly adjust MI to fit these needs. Despite this requirement for flexibility in approach, MI principles can be taught to a range of providers, including physicians, nursing staff, dieticians, and social workers (e.g., Cunningham et al., 2010). Finally, providers need to be aware of systemic influences or how the organizational paradigm impacts conceptualization and implementation of MI. In summary, effective use of MI with older people requires collaboration and flexibility in planning and in venue. Further, treatment goals should be clearly articulated and continually highlighted with the aim of reinforcing the treatment purpose and direction. In addition to hospital visits and telephone calls, other modalities can be

Downloaded by [Dr Mirsad Serdarevic] at 16:44 11 December 2013 considered for delivery of therapy (e.g., telepsychology). Clinicians working with older adults may need to provide MI at a slower pace and use repetition as well as other strategies that aid in retention of information. However, because MI is inherently patient- centered, it should require minimal substantive adjustments for the elderly population. More work is needed to identify adaptations of MI that are most beneficial for older clients with distinctive needs (e.g., dysthymia or severe cognitive impairment) and in different settings (e.g., primary and specialty care, long-term care).

Acknowledgements This work was made possible by the Special Fellowship Program in Advanced Geriatrics at the Geriatrics Research, Education and Clinical Centers (GRECC), VA Palo Alto Health Care System, and by the Center for Health Care Evaluation, Health Services Research & Development Service, Department of Veterans Affairs. The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. International Journal of Mental Health Promotion 9

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