mental health AIDS

Summer 2006 Newsletter / Volume 7, Issue 4

Emerging Methods for Motivating Effective Medication Practice

“[A] consistent theme to emerge in ... [the HIV-related adherence intervention]
literature ... was the critical role of the patient-provider relationship in
maximizing patient adherence. ... The HIV patient may have an
especially critical need for the physician as a source of technical and
informational expertise, as well as social and emotional support.”
                                                                –– Fogarty et al., 2002, pp. 102-103

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As clinicians who serve people living with HIV are well aware, optimal antiretroviral adherence "means taking all of every prescribed dose, within a designated timeframe, while at times also following dietary restrictions. … [R]esearch seeking to determine the level of adherence needed for optimal virologic outcome … [has] resulted in wide acceptance of a 95% standard ..." (Tugenberg, Ware, & Wyatt, 2006, p. 269). Consequently, providers may experience a sense of urgency concerning the manner in which patients take these medications and may convey this urgency by exhorting patients to maintain perfect adherence.

To assess the impact of clinician urgency on the medication-taking practices of highly active antiretroviral therapy (HAART) recipients, Tugenberg, Ware, and Wyatt (2006) conducted 214 qualitative interviews concerning adherence over a 2-year period with 52 adults living with HIV who also used illegal substances. The investigators found that, "[i]nstead of feeling encouraged to share particular difficulties or beliefs about medication and their effects[, study participants] ... felt 'lectured' on the importance of adherence" (Tugenberg, Ware, & Wyatt, 2006, p. 271). Fearing disapproval or damage to a relationship upon which they had come to rely for their very survival, participants "chose instead to conceal adherence information. Apprehensions about failing at perfect adherence [even] led some to cease taking antiretrovirals over the course of the study. [In this way, w]ell-intentioned efforts by clinicians to emphasize the importance of adherence can paradoxically undermine the very behavior they are intended to promote" (Tugenberg, Ware, & Wyatt, 2006, p. 269).

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"Adherence relies on the construction of the patient-provider relationship as
one with a dominant, directive professional, and a dependent, passive patient
where the function of the physician is to diagnose and treat, and the role
of the patient is to follow expert advice or directives. The patient's 'sick role'
 is assumed to [be] the most important role in the individual's life, and the
most significant determinant for his or her health-related choices and actions ... ."
                                                                        –––– Broyles, Colbert, & Erlen, 2005, p. 369

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The Problem With Adherence

A collaborative approach to addressing adherence barriers represents a significant improvement over lecturing on the importance of adherence, but for an approach to be truly collaborative, perhaps thinking needs to encompass greater consideration of the inherent power inequities underlying the patient-provider partnership. Broyles, Colbert, and Erlen (2005) observe that "[c]onceptualizations of adherence still rely on traditional paternalistic models of patient-provider relationships. Despite the calls for improved patient-provider communication and partnership, patients are still ultimately afforded limited autonomy over their regimen management" (p. 365). In the view of these investigators, "limit[ing] patient involvement in self-regulation and disease management ... [represents] a failure to understand what medication taking is and means for individuals managing chronic infectious diseases like HIV/AIDS" (p. 365).

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"[P]roviders may measure a behavior and label it as 'nonadherence,'
whereas from the ... patient’s perspective they are behaving in accordance
with decisions they have made for themselves, with their own best intention in mind."
                                                                                                  –– Remien et al., 2003, p. 70

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Realizing the Medication Day

Bresalier and colleagues2 expanded and elucidated medication practice in their ethnographic investigation of the work and experiences of taking antiretroviral therapy for HIV/AIDS. ... 'Realizing the medication day', becomes the process of creating and establishing the necessary conditions for medication-taking, and then translating regimen instructions into executed behaviour, where the themes are self-knowledge, self-regulation, and initiative, not acquiescence to clinical authority. ... The work of the individual is that of 'active self-manager'. The person first matches the ideal regimen plan prescribed by the provider with the real-time activity at hand, i.e., remembering to take the medication through the use of cues, reminders, routines, and other signals. The patient then 'completes the medication sequence' through actual ingestion after following (often idiosyncratic) steps for preparing doses or actually swallowing the pills. Complicating these tasks is the mental and emotional work of 'overcoming resistance' … associated with actual medication ingestion, i.e., 'coaching the reluctant self', for example, through the laboriousness of medication preparation, medication as a symbolic reminder of illness, or the anticipation of side effects. ...

In these conceptions of medication practice, individuals perceive various degrees of inherent flexibility in their regimens, see clinicians as 'the animator(s) of statements about ideal dosages', ... and often consider these parameters as guidelines that are provisional and evolutionary (particularly with respect to HIV/AIDS). Additionally, patients balance the biomedical and experiential sources of information about these parameters through their use of collaborative information-sharing networks comprised of other persons with HIV/AIDS. ... (Broyles, Colbert, & Erlen, 2005, pp. 372-373)

Broyles and colleagues take this line of thinking one step further by "integrat[ing] medication practice with feminist thought, further validating individuals' situated knowledge, choices, and multiple roles; more fully recognizing the individual as a multidimensional, autonomous human being; and reducing notions of obedience and deference to authority. Blame is thus extricated from the healthcare relationship, reshaping the traditionally adversarial components of the interaction, and eliminating the view of adherence as a patient problem in need of patient-centred interventions" (pp. 362-363). Broyles and colleagues suggest that "[a]voiding attributions of blame facilitates the patient-provider discussion imperative for increasing the degree of engagement with each another. In turn, professionals are more inclined and prepared to identify and rectify impediments preventing individuals from '[doing better] what they already want to do' ... i.e., improve their health and well-being" (p. 375).

With regard to interventions emerging from this critique, Broyles and colleagues have this to say:

Provider involvement in enhancing medication practice can ... avoid re-embracing traditional power assumptions by: 1) giving credence to the individual's voice in shaping one's own view of the health enhancement goal by incorporating personal needs, priorities, and beliefs; 2) challenging nuances of the traditional patient-provider relationship and offering alternatives rooted in reciprocity; and 3) refusing to dismiss discussion of structural influences [on health behavior, i.e., factors that are often outside the immediate control of patients and providers]. Providers ought to understand the self-regulatory, daily or even dose-by-dose nature of the choices made by individuals. ... Then providers can assist patients to develop plans that integrate desired medication practices into the complexities of their lives. More often than not, patients know what to do in self-care regimens, but not necessarily how to do it. Patients do not always require additional information about their medication, but rather, individualised guidance in order to assimilate medications into their routines based on their needs and values. ... People must be asked what they wish to conserve, as opposed to being told what they must change. ... Active participation in constructing enhancement interventions allows care to be informed, determined, and directed by individuals, in turn affording them greater ownership and choice. ... Finally, while the full extent of providers' social responsibility remains unsettled, clinicians are obligated to fully assess the many individual, social, and structural barriers which may negatively impact people's medication-taking, and then to help link individuals to supportive services which can reduce or eliminate these hurdles ... . (Broyles, Colbert, & Erlen, 2005, pp. 376-377)

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"Health care providers who recognize and reinforce autonomy rather than
viewing it as a threat can foster a supportive and collaborative environment, improving the odds of effective disease management.”
                                                                                –– Kennedy, Goggin, & Nollen, 2004, p. 624

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Power to the People

What techniques are available to clinicians who desire to engage clients in a collaborative process of identifying and addressing barriers to enhancing their medication practice? One option is motivational interviewing (MI), a nonconfrontational approach developed by Miller and Rollnick (see sidebar on "No Arguments Here"), who set out four general principles that "underpin its specific techniques and strategies: the expression of empathy, the development of discrepancy, rolling with resistance, and support for self-efficacy" (Markland, Ryan, Tobin, & Rollnick, 2005, pp. 813-814). As Cooperman and Arnsten (2005) describe it,

[t]he spirit and philosophy of MI … [encompass] collaboration, evocation, and autonomy, where the patient's goals and readiness to change dictate the direction of the intervention. Techniques – such as open-ended questions, reflective listening, and affirmation – help to establish and maintain therapeutic rapport, create a judgment-free environment and allow the patient to freely express his or her thoughts and feelings about a behavior change so goals and ambivalence can be explored. The goals and focus of the treatment are developed collaboratively with the patient, allowing for a variety of options. (p. 160)

Cooperman and Arnsten further observe that,

[a]lthough MI is patient-centered, it also incorporates the use of directive techniques to help move a patient forward through the stages of change3 and strategies to negotiate resistance. A goal of MI is to amplify the patient's ambivalence about a target behavior and elicit an argument for change from the patient. This is accomplished by providing information and advice that … [are] appropriate for the patient's stage of change, after obtaining the patient's permission. Through a guided exploration of the current versus desired condition and a supported evaluation of the pros and cons of behavior change as opposed to the status quo, the patient can begin to voice and solidify an argument for behavior change that is personally meaningful. Reflection is used selectively to reinforce "change talk" and to help weigh the patient's ambivalence towards moving to the next stage of change. In MI, resistance is not seen as a patient problem but is normalized and considered the result of the interaction between the therapist and the patient. Through reflection, reframing, siding with the negative, shifting focus, emphasizing personal choice, and reassessing goals and the patient's stage of change, MI provides the opportunity to deal with resistance and still accomplish positive treatment outcomes. (p. 160)

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"Clearly, the patient as a whole (all … beliefs, attitudes, feelings,
and social influences) must be considered when trying
to understand and address adherence in HIV care."                                                                                                           –– Remien et al., 2003, p. 70

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MI, Oh My!

Cooperman and Arnsten summarize emerging research on the use of MI as an intervention to enhance antiretroviral medication practice. They report that, to date, "few published studies have investigated its impact, and the studies that have been published are pilot or feasibility studies ... . However, two randomized, controlled pilot studies [DiIorio et al., 2003; Safren et al., 2001] have shown that MI-inclusive interventions have a positive influence on antiretroviral …. [medication-taking] behavior and attitudes ..." (p. 161). Two uncontrolled studies that used MI in combination with cognitive-behavioral therapy with active substance users produced divergent results; one set of authors (Parsons, Rosof, Punzalan, & Di Maria, 2005) did not find significant improvement in HAART medication practice, whereas the other set of authors (Cooperman, Parsons, Kaswan, & Arnsten, 2005) demonstrated significant positive outcomes.

Adamian, Golin, Shain, and DeVellis (2004) demonstrated the feasibility, acceptability, and usefulness of a brief MI session focused on medication practice. Subsequently, Golin et al. (2006) conducted a randomized, controlled trial involving 140 adults who were having medication-taking difficulties or were just beginning HAART "to compare ... [the medication practice] (at 12-week follow-up) of patients receiving an MI intervention with those receiving a dose-matched HIV information control program" (p. 42). Although Golin and colleagues found, on average, that the antiretroviral medication practice of the intervention group improved, while that of the control group declined, the investigators "did not definitively demonstrate the efficacy of the MI-based intervention at 12 weeks" (p. 49), as both groups demonstrated poor medication-taking practices overall.

The more recent findings of Golin and colleagues notwithstanding, Cooperman and Arnsten conclude that "[e]xisting research, although limited, suggests that MI combined with other interventions is feasible and efficacious for improving … antiretroviral medication … [practice], even among drug users" (p. 164). They are quick to caution, however, that "further investigation is necessary to understand how MI can best be adapted for this purpose. It is currently difficult to compare studies or determine the true impact of MI because the content of each intervention has been different. Furthermore, training of counselors and evaluation of fidelity to MI philosophy and techniques vary among the interventions reported. This is important because research has shown that the quality of the MI provided is significantly related to outcomes ..." (pp. 161, 163).

References

Adamian, M.S., Golin, C.E., Shain, L.S., & DeVellis, B. (2004). Brief motivational interviewing to improve adherence to antiretroviral therapy: Development and qualitative pilot assessment of an intervention. AIDS Patient Care & STDs, 18(4), 229-238.

Broyles, L.M., Colbert, A.M., & Erlen, J.A. (2005). Medication practice and feminist thought: A theoretical and ethical response to adherence in HIV/AIDS. Bioethics, 19(4), 362-378.

Cooperman, N.A., & Arnsten, J.H. (2005). Motivational interviewing for improving adherence to antiretroviral medications. Current HIV/AIDS Reports, 2(4), 159-164.

Cooperman, N.A., Parsons, J.T., Kaswan, D., & Arnsten, J.H. (2005, April 13-15). Intervening to improve utilization of and adherence to antiretroviral therapy among HIV-infected drug users receiving primary care in methadone maintenance treatment programs. Rapid communications poster presented at the Society of Behavioral Medicine's 26th Annual Meeting, Boston, MA.

DiIorio, C., Resnicow, K., McDonnell, M., Soet, J., McCarty, F., & Yeager, K. (2003). Using motivational interviewing to promote adherence to antiretroviral medications: A pilot study. Journal of the Association of Nurses in AIDS Care, 14(2), 52-62.

Fogarty, L., Roter, D., Larson, S., Burke, J., Gillespie, J., & Levy, R. (2002). Patient adherence to HIV medication regimens: A review of published and abstract reports. Patient Education & Counseling, 46(2), 93-108.

Golin, C.E., Earp, J., Tien, H.-C., Stewart, P., Porter, C., & Howie, L. (2006). A 2-arm, randomized, controlled trial of a motivational interviewing-based intervention to improve adherence to antiretroviral therapy (ART) among patients failing or initiating ART. Journal of Acquired Immune Deficiency Syndromes, 42(1), 42-51.

Kennedy, S., Goggin, K., & Nollen, N. (2004). Adherence to HIV medications: Utility of the theory of self-determination. Cognitive Therapy & Research, 28(5), 611-628.

Markland, D., Ryan, R.M., Tobin, V.J., & Rollnick, S. (2005). Motivational interviewing and self-determination theory. Journal of Social & Clinical Psychology, 24(6), 811-831.

Parsons, J.T., Rosof, E., Punzalan, J.C., & Di Maria, L. (2005). Integration of motivational interviewing and cognitive behavioral therapy to improve HIV medication adherence and reduce substance use among HIV-positive men and women: Results of a pilot project. AIDS Patient Care & STDs, 19(1), 31-39.

Remien, R.H., Hirky, A.E., Johnson, M.O., Weinhardt, L.S., Whittier, D., & Minh Le, G. (2003). Adherence to medication treatment: A qualitative study of facilitators and barriers among a diverse sample of HIV+ men and women in four U.S. cities. AIDS & Behavior, 7(1), 61-72.

Safren, S.A., Otto, M.W., Worth, J.L., Salomon, E., Johnson, W., Mayer, K., & Boswell, S. (2001). Two strategies to increase adherence to HIV antiretroviral medication: Life-Steps and medication monitoring. Behaviour Research & Therapy, 39(10), 1151-1162.

Tugenberg, T., Ware, N.C., & Wyatt, M.A. (2006). Paradoxical effects of clinician emphasis on adherence to combination antiretroviral therapy for HIV/AIDS. AIDS Patient Care & STDs, 20(4), 269-274.

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 1 Conrad, P. (1985). The meaning of medications: Another look at compliance. Social Science & Medicine, 20(1), 29-37.

 2 Bresalier, M., Gillis, L., McClure, L., McCoy, E., Mykhaloviskiy, E., Taylor, D., & Webber, M. (2002). Making care visible: Antiretroviral therapy and the health work of people living with HIV/AIDS [Research report]. Toronto, Ontario, Canada: Making Care Visible Working Group. Retrieved April 23, 2006, from http://cbr.cbrc.net/files/1052421030/makingcarevisible.pdf

 3 "Prochaska and DiClemente ... developed the Transtheoretical Model of Change to explain the process by which individuals make behavior changes. This model proposes that a change in behavior is dependent on an individual's stage of readiness to make the change. The stages are precontemplation, contemplation, preparation, action, and maintenance ... . Individuals in the precontemplation stage are unaware of or unwilling to acknowledge the need for a behavior change. Those in the contemplation stage can acknowledge that there is a problem and something needs to be changed, but they have not taken action to make any modifications. In the preparation stage, individuals have begun to make preliminary preparations and plan to make changes in the near future. Those in the action stage are actively working on the new behavior. Finally, the maintenance stage is reached once a new behavior has been sustained for a period of time. According to this model, individuals may relapse and often cycle through these stages several times before making a long lasting or permanent behavior change" (Cooperman & Arnsten, 2005, p. 160).

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No Arguments Here

First described by William R. Miller in 1983, and later elaborated upon by Miller and Stephen Rollnick in 1991, "motivational interviewing is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship" (Rollnick & Miller, 1995, p. 325).

Rollnick and Miller characterize that spirit in seven key points:

1. Motivation to change is elicited from the client, and not imposed from without. ...
2. It is the client's task, not the counsellor's, to articulate and resolve his or her
      ambivalence. ...
3. Direct persuasion is not an effective method for resolving ambivalence. ...
4. The counselling style is generally a quiet and eliciting one. ...
5. The counsellor is directive in helping the client to examine and resolve ambivalence.
       ...
6. Readiness to change is not a client trait, but a fluctuating product of interpersonal
       interaction. ...
7. The therapeutic relationship is more like a partnership or companionship than
      expert/recipient roles. ... (pp. 326-327)

Regarding the "specific and trainable therapist behaviours that are characteristic of a motivational interviewing style" (p. 327), Rollnick and Miller point to the following:

  o Seeking to understand the person's frame of reference, particularly via reflective
     listening
  o Expressing acceptance and affirmation
  o Eliciting and selectively reinforcing the client's own self motivational statements [or
     "change talk"] – expressions of problem recognition, concern, desire and intention to
     change, and ability to change
  o Monitoring the client's degree of readiness to change, and ensuring that resistance
     is not generated by jumping ahead of the client.
  o Affirming the client's freedom of choice and self-direction (pp. 327-328)

References

Miller, W.R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.

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