Motivational Interviewing Lowers Cardiometabolic Risk

Empowering people in low-resource communities to eat better and exercise more and thereby lessen their risk for heart disease, obesity, and diabetes continues to be a challenge for clinicians.

Motivational interviewing, however, can help and be part of an effective strategy to inspire patients at risk for cardiovascular and metabolic problems to change their behavior, Dr. Jeanie Tse said.

Photo Damian McNamara/Elsevier Global Medical News

"As psychiatrists, we learn about physical health care in medical school and training, but we forget a lot when we start our practices," said Dr. Tse, director of integrated health at the Institute for Community Living, a nonprofit behavioral health agency in New York.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes, Dr. Tse said. "We feel strongly about collaboration. This is really about reaching out to primary care physicians, endocrinologists, and case managers."

Close collaboration also is important because "sometimes physical problems are misidentified as mental health symptoms." An example would be a person who goes to the emergency room with low blood glucose and ends up assigned to mental health care.

Motivational interviewing helps clinicians learn to phrase guidance in a way that encourages and supports patients. Advice about making healthy choices is provided in a nonjudgmental manner, for example. Empathic counseling delivered with warmth, respect, and understanding can foster self-efficacy and promote change, said Elisa Chow, Ph.D., director of outcomes evaluation at the Institute for Community Living. "It is really a simple tool that we as providers can use with our patients or clients.

Patients ready to make changes choose their own goals. "It is really about what patients want," Dr. Tse said, and it’s important to be realistic. "We may care about their diabetes, but in their world, they care more about housing, having a job, and finding a boyfriend or girlfriend."

Encourage patients to take small, "doable" steps, Dr. Chow recommended. "Your patient may walk away thinking ‘Oh my God, how am I going to lose 45 to 50 pounds?’ We help them step by step, maybe [with] losing a pound per week or just watching their portion sizes. Weight loss may be a goal over a year."

Dr. Jeffrey C. Fetter said in an interview that motivational interviewing is a well-established technique for improving behaviors such as smoking, but is rarely used to systematically improve diet and exercise in patients with severe mental illness. "One of the strengths of motivational interviewing is its respect for the client and his/her choices, a respect that especially resonates with mentally ill clients," said Dr. Fetter, a psychiatrist in private practice in Concord, N.H.

A recently published study showed that perceptions of motivational interviewing were more positive than standard care among patients with type 2 diabetes (Diabetes Res. Clin. Pract. 2011 [doi:10.1016/j.diabres.2011.08.011]). In that study, five themes tied to motivational interviewing emerged: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than critiquing.

"A patient might say, ‘I’m going to eat one apple a week. Great. Let’s go with that,’ " said Rosemarie Sultana-Cordero, a licensed mental health counselor and clinical coordinator at Community Living for its Diabetes Project and Healthy Living Project.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero shared their expertise during an interactive workshop session at the annual meeting of the American Psychiatric Association in Honolulu.

"We tell case managers that everyone has a goal, and they will be more motivated if the goal is self-imposed," Ms. Sultana-Cordero said. Instead of a lecture about the adverse health consequences of poor eating or physical inactivity, she suggested asking patients: What changes have you thought of making? What might you have to give up to make this change? What might you gain? Will your life be different if you make this change?

If you do not have time to learn all the aspects of motivational interviewing, "Developing Discrepancies" and "Rolling With Resistance" are two essential components, Dr. Chow said. Clinicians can, for example, increase a patient’s awareness about the discrepancy between where they are in terms of cardiometabolic or diabetes risk and where they want to be. A greater awareness of this dichotomy can motivate patients to reach their goals.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes.

"We have client we will call ‘Matt,’ who is slightly overweight, and sees Dr. Chow," Dr. Tse said. Matt told her he was going to diet and they agreed on a weight-loss plan. He plans to eat one vegetable every day and stay away from the corner bodega. They plan to follow up in 1 week. "Dr. Chow is then driving around and sees Matt eating fried rice and ribs in the window of a Chinese restaurant. Matt is saying one thing, but his actions say something else," Dr. Tse said. Dr. Chow will bring that up at next meeting and will use motivational interviewing to say something like: "I saw you at Chinese takeout place the other day. This seems to be in contrast with your goal."

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.

Empowering people in low-resource communities to eat better and exercise more and thereby lessen their risk for heart disease, obesity, and diabetes continues to be a challenge for clinicians.

Motivational interviewing, however, can help and be part of an effective strategy to inspire patients at risk for cardiovascular and metabolic problems to change their behavior, Dr. Jeanie Tse said.

Photo Damian McNamara/Elsevier Global Medical News

"As psychiatrists, we learn about physical health care in medical school and training, but we forget a lot when we start our practices," said Dr. Tse, director of integrated health at the Institute for Community Living, a nonprofit behavioral health agency in New York.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes, Dr. Tse said. "We feel strongly about collaboration. This is really about reaching out to primary care physicians, endocrinologists, and case managers."

Close collaboration also is important because "sometimes physical problems are misidentified as mental health symptoms." An example would be a person who goes to the emergency room with low blood glucose and ends up assigned to mental health care.

Motivational interviewing helps clinicians learn to phrase guidance in a way that encourages and supports patients. Advice about making healthy choices is provided in a nonjudgmental manner, for example. Empathic counseling delivered with warmth, respect, and understanding can foster self-efficacy and promote change, said Elisa Chow, Ph.D., director of outcomes evaluation at the Institute for Community Living. "It is really a simple tool that we as providers can use with our patients or clients.

Patients ready to make changes choose their own goals. "It is really about what patients want," Dr. Tse said, and it’s important to be realistic. "We may care about their diabetes, but in their world, they care more about housing, having a job, and finding a boyfriend or girlfriend."

Encourage patients to take small, "doable" steps, Dr. Chow recommended. "Your patient may walk away thinking ‘Oh my God, how am I going to lose 45 to 50 pounds?’ We help them step by step, maybe [with] losing a pound per week or just watching their portion sizes. Weight loss may be a goal over a year."

Dr. Jeffrey C. Fetter said in an interview that motivational interviewing is a well-established technique for improving behaviors such as smoking, but is rarely used to systematically improve diet and exercise in patients with severe mental illness. "One of the strengths of motivational interviewing is its respect for the client and his/her choices, a respect that especially resonates with mentally ill clients," said Dr. Fetter, a psychiatrist in private practice in Concord, N.H.

A recently published study showed that perceptions of motivational interviewing were more positive than standard care among patients with type 2 diabetes (Diabetes Res. Clin. Pract. 2011 [doi:10.1016/j.diabres.2011.08.011]). In that study, five themes tied to motivational interviewing emerged: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than critiquing.

"A patient might say, ‘I’m going to eat one apple a week. Great. Let’s go with that,’ " said Rosemarie Sultana-Cordero, a licensed mental health counselor and clinical coordinator at Community Living for its Diabetes Project and Healthy Living Project.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero shared their expertise during an interactive workshop session at the annual meeting of the American Psychiatric Association in Honolulu.

"We tell case managers that everyone has a goal, and they will be more motivated if the goal is self-imposed," Ms. Sultana-Cordero said. Instead of a lecture about the adverse health consequences of poor eating or physical inactivity, she suggested asking patients: What changes have you thought of making? What might you have to give up to make this change? What might you gain? Will your life be different if you make this change?

If you do not have time to learn all the aspects of motivational interviewing, "Developing Discrepancies" and "Rolling With Resistance" are two essential components, Dr. Chow said. Clinicians can, for example, increase a patient’s awareness about the discrepancy between where they are in terms of cardiometabolic or diabetes risk and where they want to be. A greater awareness of this dichotomy can motivate patients to reach their goals.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes.

"We have client we will call ‘Matt,’ who is slightly overweight, and sees Dr. Chow," Dr. Tse said. Matt told her he was going to diet and they agreed on a weight-loss plan. He plans to eat one vegetable every day and stay away from the corner bodega. They plan to follow up in 1 week. "Dr. Chow is then driving around and sees Matt eating fried rice and ribs in the window of a Chinese restaurant. Matt is saying one thing, but his actions say something else," Dr. Tse said. Dr. Chow will bring that up at next meeting and will use motivational interviewing to say something like: "I saw you at Chinese takeout place the other day. This seems to be in contrast with your goal."

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.

Empowering people in low-resource communities to eat better and exercise more and thereby lessen their risk for heart disease, obesity, and diabetes continues to be a challenge for clinicians.

Motivational interviewing, however, can help and be part of an effective strategy to inspire patients at risk for cardiovascular and metabolic problems to change their behavior, Dr. Jeanie Tse said.

Photo Damian McNamara/Elsevier Global Medical News

"As psychiatrists, we learn about physical health care in medical school and training, but we forget a lot when we start our practices," said Dr. Tse, director of integrated health at the Institute for Community Living, a nonprofit behavioral health agency in New York.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes, Dr. Tse said. "We feel strongly about collaboration. This is really about reaching out to primary care physicians, endocrinologists, and case managers."

Close collaboration also is important because "sometimes physical problems are misidentified as mental health symptoms." An example would be a person who goes to the emergency room with low blood glucose and ends up assigned to mental health care.

Motivational interviewing helps clinicians learn to phrase guidance in a way that encourages and supports patients. Advice about making healthy choices is provided in a nonjudgmental manner, for example. Empathic counseling delivered with warmth, respect, and understanding can foster self-efficacy and promote change, said Elisa Chow, Ph.D., director of outcomes evaluation at the Institute for Community Living. "It is really a simple tool that we as providers can use with our patients or clients.

Patients ready to make changes choose their own goals. "It is really about what patients want," Dr. Tse said, and it’s important to be realistic. "We may care about their diabetes, but in their world, they care more about housing, having a job, and finding a boyfriend or girlfriend."

Encourage patients to take small, "doable" steps, Dr. Chow recommended. "Your patient may walk away thinking ‘Oh my God, how am I going to lose 45 to 50 pounds?’ We help them step by step, maybe [with] losing a pound per week or just watching their portion sizes. Weight loss may be a goal over a year."

Dr. Jeffrey C. Fetter said in an interview that motivational interviewing is a well-established technique for improving behaviors such as smoking, but is rarely used to systematically improve diet and exercise in patients with severe mental illness. "One of the strengths of motivational interviewing is its respect for the client and his/her choices, a respect that especially resonates with mentally ill clients," said Dr. Fetter, a psychiatrist in private practice in Concord, N.H.

A recently published study showed that perceptions of motivational interviewing were more positive than standard care among patients with type 2 diabetes (Diabetes Res. Clin. Pract. 2011 [doi:10.1016/j.diabres.2011.08.011]). In that study, five themes tied to motivational interviewing emerged: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than critiquing.

"A patient might say, ‘I’m going to eat one apple a week. Great. Let’s go with that,’ " said Rosemarie Sultana-Cordero, a licensed mental health counselor and clinical coordinator at Community Living for its Diabetes Project and Healthy Living Project.

Dr. Tse, Dr. Chow, and Ms. Sultana-Cordero shared their expertise during an interactive workshop session at the annual meeting of the American Psychiatric Association in Honolulu.

"We tell case managers that everyone has a goal, and they will be more motivated if the goal is self-imposed," Ms. Sultana-Cordero said. Instead of a lecture about the adverse health consequences of poor eating or physical inactivity, she suggested asking patients: What changes have you thought of making? What might you have to give up to make this change? What might you gain? Will your life be different if you make this change?

If you do not have time to learn all the aspects of motivational interviewing, "Developing Discrepancies" and "Rolling With Resistance" are two essential components, Dr. Chow said. Clinicians can, for example, increase a patient’s awareness about the discrepancy between where they are in terms of cardiometabolic or diabetes risk and where they want to be. A greater awareness of this dichotomy can motivate patients to reach their goals.

Psychiatrists and other health care providers can adopt motivational interviewing techniques to improve patient outcomes.

"We have client we will call ‘Matt,’ who is slightly overweight, and sees Dr. Chow," Dr. Tse said. Matt told her he was going to diet and they agreed on a weight-loss plan. He plans to eat one vegetable every day and stay away from the corner bodega. They plan to follow up in 1 week. "Dr. Chow is then driving around and sees Matt eating fried rice and ribs in the window of a Chinese restaurant. Matt is saying one thing, but his actions say something else," Dr. Tse said. Dr. Chow will bring that up at next meeting and will use motivational interviewing to say something like: "I saw you at Chinese takeout place the other day. This seems to be in contrast with your goal."

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.