Dealing with the Unmotivated

and Non- Compliant Patient

David C. Robbins, MD

Professor of Medicine

Director, KU Diabetes Institute

A patient comes to your

office . . . She is a 64 year old obese smoker with

hypertension, hypertriglyceridemia and diabetes.

It has been over a year since her last visit.

She has debilitating, painful peripheral

neuropathy

she list her medications as including amitriptyline,

gabapentin and percocet

BP 164/90, HbgA1c 0.4%, BMI 33.4, TGs 255 HDL 29

Oncology Nursing Forum • Vol. 39, No. 1, January 2012

To ActionTo

Action

Motivational Interviewing

MI works by activating the patient’s own

motivation

The myth of the unmotivated patient

Guide rather than direct

Collaborative, evocative, honors the

patient’s autonomy – patient makes the

ultimate decision

Pascal

“People are generally better

persuaded by the reasons

which they themselves

discovered than by those which

have come into the mind of

others.”

Pensees, 17th century

WelcomeAmbivalencePeople get stuck in ambivalence. Arguments on either side cancel each other out. Ambivalence is often experienced as the first thinking of a reason to change . . .

Ambivalence . . . listen for talk

change

I need to lose weight but I hate exercising

I mean to take my blood pressure

medication but I forget.

I know I should log my blood sugars

but it’s just too much trouble

Six Kinds of Talk Change Desire

I want to, I wish I . .

Ability

I could, I might be able to

Reasons

I would probably feel better if I . .

Need

I ought to, I really should

Commitment

I am going to . . . I will . . .

Taking Action

I actually went out and . . This week I started . . .

Closed v open questions

How can I be most helpful to you today?

How do you remind yourself to take your

medication?

What concerns you most about the pain?

Tell me more about . . .

Have you thought much about giving up

smoking?

Using a Ruler

How strongly do you feel about wanting

more exercise? On a scale of 1 to 10,

where 1 is not at all and 10 is very much,

where would you place yourself?

On a scale of 1 to 10, how ready are you to

change?

How important would you say it is important

for you to lose weight?

More on Rulers

Tell me why your are a

5 and not a lower

number?

What would have to

happen to make you

go to a 6?

Ask the pros and cons

What are the benefits of exercise?

What is the downside for you?

What do you think you will do?

What might it take for you to make a decision to begin an exercise program?

If you did start, what would be the benefits for you?

Suppose you continue on like this for 5 years without making any changes?

Informing and Listening

Chunk-check-chunk

Provide information

Check with the patient, did you understand that?

Can be directive

Does that make sense to you?

Is there anything about that you’d like to ask me about?

And you’re OK with that idea?

Elicit-provide-elicit

Draw from the patient what they know, what they need to know and what new information means to them

What would you most like to know about taking care of your feet?

What do you already know about foot care?

Would you like me to tell you a bit more about foot care?

What does this mean for you?

CHUNK-CHECK-CHUNK

It’s important that you inspect your feet every

day. If you don’t you could lose your foot. Have

you been doing that?

Well, most of the time.

You know you need to do that every night?

Yes, but sometimes I’m too busy

You have to make time for it, it just takes a

minute.

Sure, I’ll try harder.

Putting it all together

Let the patient set the initial agenda . . . Listen

Grab on to ambivalence and change talk

Measure the desire to change

Ask thenm what they already know

Explore pros (benefits) and cons (obstacles)

Help the patient develop a detailed plan, visualize the what

if . . .

Express confidence, interest in seeing how they do

Make a “contract”

Reward good behavior