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Brief motivational interviewing as a clinical strategy to promote asthma medication adherence

2007; Elsevier BV; Volume: 120; Issue: 5 Linguagem: Inglês

10.1016/j.jaci.2007.08.017

1097-6825

Belinda Borrelli, Kristin A. Riekert, Andrew G. Weinstein, Lucille Rathier,

Behavioral Health and Interventions

Patient-centered approaches are associated with better patient retention and treatment outcomes, without increased time and cost. Motivational interviewing (MI) is a patient-centered counseling approach that can be briefly integrated into patient encounters and is specifically designed to enhance motivation to change among patients not ready to change. Existing asthma management approaches (eg, education and self-management) increase resistance among patients not ready or willing to follow medical recommendations. MI helps patients resolve their ambivalence about behavior change and builds their intrinsic motivation before providing education. Although MI overlaps with patient-centered communication, it additionally includes some concrete motivational strategies that can be briefly and easily implemented in medical settings (eg, setting an agenda, assessing motivation and confidence for change, helping the patient weigh the costs and benefits of change, and providing medical advice and health feedback). Reflective listening is used to help patients clarify their ambivalence and diffuse resistance. MI has been shown to be efficacious across a wide variety of health behavior change areas. This article will describe the method and spirit of MI as applied to asthma management by reviewing the principles of MI, brief MI strategies to motivate medication adherence, the evidence base for MI, and the costs and benefits of building MI into clinical practice. Patient-centered approaches are associated with better patient retention and treatment outcomes, without increased time and cost. Motivational interviewing (MI) is a patient-centered counseling approach that can be briefly integrated into patient encounters and is specifically designed to enhance motivation to change among patients not ready to change. Existing asthma management approaches (eg, education and self-management) increase resistance among patients not ready or willing to follow medical recommendations. MI helps patients resolve their ambivalence about behavior change and builds their intrinsic motivation before providing education. Although MI overlaps with patient-centered communication, it additionally includes some concrete motivational strategies that can be briefly and easily implemented in medical settings (eg, setting an agenda, assessing motivation and confidence for change, helping the patient weigh the costs and benefits of change, and providing medical advice and health feedback). Reflective listening is used to help patients clarify their ambivalence and diffuse resistance. MI has been shown to be efficacious across a wide variety of health behavior change areas. This article will describe the method and spirit of MI as applied to asthma management by reviewing the principles of MI, brief MI strategies to motivate medication adherence, the evidence base for MI, and the costs and benefits of building MI into clinical practice. Successful asthma management requires an array of patient behaviors. National asthma guidelines (National Asthma Education and Prevention Program)1National Heart, Lung, and Blood Institute National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. National Institutes of Health, Bethesda (MD)1997Google Scholar suggest that individuals with persistent asthma take 1 or more daily controller medications, use rescue medication as needed for symptoms, monitor lung function with peak flow monitors, and avoid asthma triggers. Adherence rates for inhaled corticosteroids (ICSs) range from 44% to 72%.2Sherman J. Patel P. Hutson A. Chesrown S. Hendeles L. Adherence to oral montelukast and inhaled fluticasone in children with persistent asthma.Pharmacotherapy. 2001; 21: 1464-1467Crossref PubMed Scopus (67) Google Scholar, 3Krishnan J.A. Riekert K.A. McCoy J.V. Stewart D.Y. Schmidt S. Chanmugam A. et al.Corticosteroid use after hospital discharge among high-risk adults with asthma.Am J Respir Crit Care Med. 2004; 170: 1281-1285Crossref PubMed Scopus (153) Google Scholar, 4McQuaid E.L. Kopel S.J. Klein R.B. Fritz G.K. Medication adherence in pediatric asthma: reasoning, responsibility, and behavior.J Pediatr Psychol. 2003; 28: 323-333Crossref PubMed Scopus (318) Google Scholar, 5Bender B. Wamboldt F.S. O'Connor S.L. Rand C. Szefler S. 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Adherence and persistence with fluticasone propionate/salmeterol combination therapy.J Allergy Clin Immunol. 2006; 118: 899-904Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 9Marceau C. Lemiere C. Berbiche D. Perreault S. Blais L. Persistence, adherence, and effectiveness of combination therapy among adult patients with asthma.J Allergy Clin Immunol. 2006; 118: 574-581Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar Nonadherence is associated with increased asthma symptoms,3Krishnan J.A. Riekert K.A. McCoy J.V. Stewart D.Y. Schmidt S. Chanmugam A. et al.Corticosteroid use after hospital discharge among high-risk adults with asthma.Am J Respir Crit Care Med. 2004; 170: 1281-1285Crossref PubMed Scopus (153) Google Scholar, 10Bauman L.J. Wright E. Leickly F.E. Crain E. Kruszon-Moran D. Wade S.L. et al.Relationship of adherence to pediatric asthma morbidity among inner-city children.Pediatrics. 2002; 110: e6Crossref PubMed Scopus (178) Google Scholar frequent emergency department visits,11Williams L.K. Pladevall M. Xi H. Peterson E.L. Joseph C. Lafata J.E. et al.Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma.J Allergy Clin Immunol. 2004; 114: 1288-1293Abstract Full Text Full Text PDF PubMed Scopus (408) Google Scholar hospitalizations,10Bauman L.J. Wright E. Leickly F.E. Crain E. Kruszon-Moran D. Wade S.L. et al.Relationship of adherence to pediatric asthma morbidity among inner-city children.Pediatrics. 2002; 110: e6Crossref PubMed Scopus (178) Google Scholar and need for oral steroids.11Williams L.K. Pladevall M. Xi H. Peterson E.L. Joseph C. Lafata J.E. et al.Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma.J Allergy Clin Immunol. 2004; 114: 1288-1293Abstract Full Text Full Text PDF PubMed Scopus (408) Google Scholar Given the number of patients seen for asthma each year (13.6 million visits in 2004),12Hing E. Cherry D.K. Woodwell D.A. National ambulatory medical care survey: 2004 summary.Adv Data. 2006; 374: 1-33PubMed Google Scholar the medical visit is a prime opportunity to promote adherence. Increasing asthma knowledge through education yields little improvement in patient adherence or asthma outcomes.13Ho J. Bender B.G. Gavin L.A. O'Connor S.L. Wamboldt M.Z. Wamboldt F.S. Relations among asthma knowledge, treatment adherence, and outcome.J Allergy Clin Immunol. 2003; 111: 498-502Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Interventions that encourage patients to monitor symptoms or peak flow have shown significant but small effects on asthma morbidity.14Guevara J.P. Wolf F.M. Grum C.M. Clark N.M. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis.BMJ. 2003; 326: 1308-1309Crossref PubMed Google Scholar Self-management approaches, including identifying barriers to adherence, self-monitoring medication use, goal setting, and problem solving, result in fewer urgent care visits,15Walders N. Kercsmar C. Schluchter M. Redline S. Kirchner H.L. Drotar D. An interdisciplinary intervention for undertreated pediatric asthma.Chest. 2006; 129: 292-299Crossref PubMed Scopus (56) Google Scholar short-term improvements in adherence,16Smith J.R. Mildenhall S. Noble M.J. Shepstone L. Koutantji M. Mugford M. et al.The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes.Thorax. 2005; 60: 1003-1011Crossref PubMed Scopus (33) Google Scholar, 17Put C. van den Bergh O. Lemaigre V. Demedts M. Verleden G. Evaluation of an individualised asthma programme directed at behavioural change.Eur Respir J. 2003; 21: 109-115Crossref PubMed Scopus (84) Google Scholar higher asthma management self-efficacy,17Put C. van den Bergh O. Lemaigre V. Demedts M. Verleden G. Evaluation of an individualised asthma programme directed at behavioural change.Eur Respir J. 2003; 21: 109-115Crossref PubMed Scopus (84) Google Scholar, 18Cicutto L. Murphy S. Coutts D. O'Rourke J. Lang G. Chapman C. et al.Breaking the access barrier: evaluating an asthma centers' efforts to provide education to children with asthma in schools.Chest. 2005; 128: 1928-1935Crossref PubMed Scopus (71) Google Scholar improved quality of life,17Put C. van den Bergh O. Lemaigre V. Demedts M. Verleden G. Evaluation of an individualised asthma programme directed at behavioural change.Eur Respir J. 2003; 21: 109-115Crossref PubMed Scopus (84) Google Scholar, 18Cicutto L. Murphy S. Coutts D. O'Rourke J. Lang G. Chapman C. et al.Breaking the access barrier: evaluating an asthma centers' efforts to provide education to children with asthma in schools.Chest. 2005; 128: 1928-1935Crossref PubMed Scopus (71) Google Scholar reduced asthma symptoms,16Smith J.R. Mildenhall S. Noble M.J. Shepstone L. Koutantji M. Mugford M. et al.The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes.Thorax. 2005; 60: 1003-1011Crossref PubMed Scopus (33) Google Scholar, 19Magar Y. Vervloet D. Steenhouwer F. Smaga S. Mechin H. Rocca Serra J.P. et al.Assessment of a therapeutic education programme for asthma patients: “un souffle nouveau”.Patient Educ Counseling. 2005; 58: 41-46Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar and less β-agonist use.16Smith J.R. Mildenhall S. Noble M.J. Shepstone L. Koutantji M. Mugford M. et al.The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes.Thorax. 2005; 60: 1003-1011Crossref PubMed Scopus (33) Google Scholar, 19Magar Y. Vervloet D. Steenhouwer F. Smaga S. Mechin H. Rocca Serra J.P. et al.Assessment of a therapeutic education programme for asthma patients: “un souffle nouveau”.Patient Educ Counseling. 2005; 58: 41-46Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Unfortunately, the majority of self-management studies involve more than 5.5 hours of patient contact.20Cabana M.D. Le T.T. Challenges in asthma patient education.J Allergy Clin Immunol. 2005; 115: 1225-1227Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar An important limitation of both educational and self-management approaches is that they are predicated on the assumption that patients are motivated to accept treatment recommendations. These approaches might be effective for those who are ready to change but less so for those who are not ready.21Miller W. Rollnick S. Motivational interviewing: preparing people for change.2nd ed. Guilford Press, New York2002Google Scholar, 22Prochaska J.O. DiClemente C.C. Stages and processes of self-change of smoking: toward an integrative model of change.J Consult Clin Psychol. 1983; 51: 390-395Crossref PubMed Scopus (5844) Google Scholar Schmaling et al,23Schmaling K. Blume A. Afari N. A randomized controlled pilot study of motivational interviewing to change attitudes about adherence to medications for asthma.J Clin Psych Med Settings. 2001; 8: 167-172Crossref Scopus (46) Google Scholar for example, found that asthma education resulted in increased knowledge but decreased motivation to use medication. There is a need for innovative approaches to promote motivation for medication adherence that (1) build on previously validated interventions, (2) are easily integrated into standard clinical care, and (3) target both those who are ready and those who are not ready to change. The goal of this article is to describe motivational interviewing (MI), a patient-centered approach specifically designed to enhance motivation to change among patients not ready to change.21Miller W. Rollnick S. Motivational interviewing: preparing people for change.2nd ed. Guilford Press, New York2002Google Scholar A brief version of MI, described in the current article, was developed for use by health care providers (HCPs) and structured for both hospital bedside and outpatient settings.24Rollnick S. Mason P. Butler C. Health behavior change: a guide for practitioners. Churchill Livingstone, New York1999Google Scholar MI is “patient centered” in that the HCP tries to understand the patient's expectations, beliefs, and concerns regarding their health and treatment recommendations, thereby achieving an understanding of the patient and not just his or her illness.25Irwin R.S. Richardson N.D. Patient-focused care: using the right tools.Chest. 2006; 130: 73S-82SCrossref PubMed Scopus (101) Google Scholar Patient-centered communication skills have become a standard part of medical curricula and are required as a specific competency (eg, the American Board of Internal Medicine). MI overlaps with patient-centered approaches but additionally includes some concrete motivational strategies that can briefly and easily be implemented in practitioners'offices24Rollnick S. Mason P. Butler C. Health behavior change: a guide for practitioners. Churchill Livingstone, New York1999Google Scholar and is based on 25 years of social-psychological research on attitude change.26Miller W. Motivational interviewing in service to health promotion.Am J Health Promot. 2004; : 1-10Google Scholar This article will describe the method and spirit of MI as applied to asthma management, review the evidence base for MI, and discuss building MI into clinical practice. MI involves 2 key aims: (1) building patients' intrinsic motivation to adopt health recommendations and (2) resolving patients' ambivalence about behavior change (eg, adherence).21Miller W. Rollnick S. Motivational interviewing: preparing people for change.2nd ed. Guilford Press, New York2002Google Scholar In MI intrinsic motivation is strengthened by discussing how change is consistent with the patient's own values and goals.26Miller W. Motivational interviewing in service to health promotion.Am J Health Promot. 2004; : 1-10Google Scholar For example, if a patient loves to play basketball, the HCP asks how taking his or her asthma medication can help him or her play better. Intrinsic motivation is also increased by having the patient play an active role in the consultation. For example, recommendations are presented as a menu of options, and the patient's concerns and beliefs about these options are explored (eg, concerns about ICSs). The HCP becomes a consultant, rather than an educator, in the process of choosing among the options. Increasing intrinsic motivation through greater patient involvement enhances the likelihood of both initial change and sustained change.27Greenfield S. Kaplan S. Ware Jr., J.E. Expanding patient involvement in care. Effects on patient outcomes.Ann Intern Med. 1985; 102: 520-528Crossref PubMed Scopus (1194) Google Scholar, 28Greenfield S. Kaplan S.H. Ware Jr., J.E. Yano E.M. Frank H.J. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes.J Gen Intern Med. 1988; 3: 448-457Crossref PubMed Scopus (951) Google Scholar, 29Stewart M. Brown J. Donner A. McWhinney I. Oates J. Weston W. et al.The impact of patient-centered care on outcomes.J Fam Pract. 2000; 49: 805-807PubMed Google Scholar, 30Flocke S.A. Miller W.L. Crabtree B.F. Relationships between physician practice style, patient satisfaction, and attributes of primary care.J Fam Pract. 2002; 51: 835-840PubMed Google Scholar A second important focus of MI is to help patients resolve their ambivalence.21Miller W. Rollnick S. Motivational interviewing: preparing people for change.2nd ed. Guilford Press, New York2002Google Scholar Ambivalence (perceiving both the pros and cons of changing and not changing) is conceptualized in MI as a normal part of the process of change. Studies have shown that educating and confronting an ambivalent person about change can have a paradoxical effect (eg, the ambivalent person argues more fervently for not changing).31Boardman T. Catley D. Grobe J.E. Little T.D. Ahluwalia J.S. Using motivational interviewing with smokers: do therapist behaviors relate to engagement and therapeutic alliance?.J Subst Abuse Treat. 2006; 31: 329-339Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 32Fuertes J.N. Mislowack A. Bennett J. Paul L. Gilbert T.C. Fontan G. et al.The physician-patient working alliance.Patient Educ Counseling. 2007; 66: 29-36Abstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar, 33Moyers T.B. Martin T. Therapist influence on client language during motivational interviewing sessions.J Subst Abuse Treat. 2006; 30: 245-251Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar, 34Miller W.R. Benefield R.G. Tonigan J.S. Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles.J Consult Clin Psychol. 1993; 61: 455-461Crossref PubMed Scopus (657) Google Scholar In one study the number of alcoholic drinks consumed per week was predicted by the level of HCP confrontation: the more the HCP confronted, the more the patient drank.34Miller W.R. Benefield R.G. Tonigan J.S. Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles.J Consult Clin Psychol. 1993; 61: 455-461Crossref PubMed Scopus (657) Google Scholar Instead of confronting patients about the need for change, the MI HCP asks questions that elicit patients' “change talk” (positive statements about change). Research has shown that when people speak in defense of a new perspective, even one that is opposite to their prior views, their attitudes and behavior shift in the direction of the new perspective.26Miller W. Motivational interviewing in service to health promotion.Am J Health Promot. 2004; : 1-10Google Scholar, 35Bem D.J. Self-perception theory.in: Berkowitz L. Advances in experimental social psychology. Academic Press, New York1972: 1-62Crossref Scopus (3419) Google Scholar Thus the more patients hear themselves argue in favor of medication adherence, the more committed they become to adherence. Verbal commitment is associated with smoking cessation,36Marlatt G.A. Curry S. Gordon J.R. A longitudinal analysis of unaided smoking cessation.J Consult Clin Psychol. 1988; 56: 715-720Crossref PubMed Scopus (135) Google Scholar decreased opiate and cocaine use,37Amrhein P.C. Miller W.R. Yahne C.E. Palmer M. Fulcher L. Client commitment language during motivational interviewing predicts drug use outcomes.J Consult Clin Psychol. 2003; 71: 862-878Crossref PubMed Scopus (498) Google Scholar and increased medication adherence in pediatric settings.38Kulik J.A. Carlino P. The effect of verbal commitment and treatment choice on medication compliance in a pediatric setting.J Behav Med. 1987; 10: 367-376Crossref PubMed Scopus (31) Google Scholar, 39Riekert K. Drota D. The beliefs about medication scale: development, reliability, and validity.J Clin Psychol Med Settings. 2002; 9: 177-184Crossref Scopus (50) Google Scholar In MI change is viewed as a process rather than a discrete event. This idea was borne out of Prochaska and DiClemente's stage-of-change model,22Prochaska J.O. DiClemente C.C. Stages and processes of self-change of smoking: toward an integrative model of change.J Consult Clin Psychol. 1983; 51: 390-395Crossref PubMed Scopus (5844) Google Scholar in which people are theorized to go through a series of distinct stages before changing their behavior, ranging from not thinking about change at all to contemplating change to making some initial changes. Problem solving before sufficiently building motivation for change often leads to patient resistance (“I've tried keeping the medicine by my toothbrush, and it doesn't work”). These statements are often reflective of an underlying motivational problem rather than a poor self-management strategy. Educational approaches are therefore an inefficient use of clinical time because unmotivated patients are less likely to initiate and maintain treatment.21Miller W. Rollnick S. Motivational interviewing: preparing people for change.2nd ed. Guilford Press, New York2002Google Scholar, 22Prochaska J.O. DiClemente C.C. Stages and processes of self-change of smoking: toward an integrative model of change.J Consult Clin Psychol. 1983; 51: 390-395Crossref PubMed Scopus (5844) Google Scholar, 23Schmaling K. Blume A. Afari N. A randomized controlled pilot study of motivational interviewing to change attitudes about adherence to medications for asthma.J Clin Psych Med Settings. 2001; 8: 167-172Crossref Scopus (46) Google Scholar, 40Miller W. Motivational interviewing with problem drinkers.Behav Psychother. 1983; 11: 147-172Crossref Scopus (923) Google Scholar An important goal of MI is to establish a comfortable and noncoercive atmosphere so that patients feel free to discuss their feelings about the recommended treatment. This is particularly relevant for asthma medication, about which patients might falsely self-report adherence.3Krishnan J.A. Riekert K.A. McCoy J.V. Stewart D.Y. Schmidt S. Chanmugam A. et al.Corticosteroid use after hospital discharge among high-risk adults with asthma.Am J Respir Crit Care Med. 2004; 170: 1281-1285Crossref PubMed Scopus (153) Google Scholar Creating a nonjudgmental atmosphere enhances the likelihood of accurate self-report.30Flocke S.A. Miller W.L. Crabtree B.F. Relationships between physician practice style, patient satisfaction, and attributes of primary care.J Fam Pract. 2002; 51: 835-840PubMed Google Scholar Four communication components engender MI spirit: open-ended questions, affirmations, reflective listening, and summary statements (OARS). OARS has been shown to increase patient collaboration and satisfaction, treatment adherence, and patient-physician working alliance.31Boardman T. Catley D. Grobe J.E. Little T.D. Ahluwalia J.S. Using motivational interviewing with smokers: do therapist behaviors relate to engagement and therapeutic alliance?.J Subst Abuse Treat. 2006; 31: 329-339Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 32Fuertes J.N. Mislowack A. Bennett J. Paul L. Gilbert T.C. Fontan G. et al.The physician-patient working alliance.Patient Educ Counseling. 2007; 66: 29-36Abstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar, 41Moyers T.B. Miller W.R. Hendrickson S.M. How does motivational interviewing work? Therapist interpersonal skill predicts client involvement within motivational interviewing sessions.J Consult Clin Psychol. 2005; 73: 590-598Crossref PubMed Scopus (236) Google Scholar Underlying OARS is empathy, or the HCP's ability to understand the patient's thoughts, feelings, and struggles from their point of view. Empathy is a strong predictor of treatment outcome.42Miller W.R. Baca L.M. Two-year follow-up of bibliotherapy and therapist-directed controlled drinking training for problem drinkers.Behav Psychother. 1983; 14: 441-448Google Scholar Open-ended questions cannot be answered with a yes or no. They produce less biased data because they allow patients to “tell their story.” Open-ended questions elicit important information that otherwise might not be asked. Closed-ended questions often damage rapport, decrease empathic connections, and paradoxically end up taking more time.43Marvel M.K. Epstein R.M. Flowers K. Beckman H.B. Soliciting the patient's agenda: have we improved?.JAMA. 1999; 281: 283-287Crossref PubMed Scopus (585) Google Scholar, 44Boyle D. Dwinnell B. Platt F. Invite, listen, and summarize: a patient-centered communication technique.Acad Med. 2005; 80: 29-32Crossref PubMed Scopus (71) Google Scholar Affirmations are statements of appreciation, which are important for building and maintaining rapport. Efforts to make changes are acknowledged, no matter how large or small (eg, “I am impressed by your maintaining a weekly schedule during the allergy injection build-up phase”). Reflective listening involves taking a guess at what the patient means and reflecting it back, restating their thoughts or feelings in a slightly different way (Table I). Reflective listening helps to ensure understanding of the patient's perspective, emphasizes his or her positive statements about change, and diffuses resistance. Resistance occurs most often when patients experience a perceived loss of freedom or choice.45Brehm S. Brehm J. Psychological reactance: a theory of freedom and control. Academic Press, New York1981Google Scholar Reflective responses move the interaction away from a power struggle and toward change.46Moyers T.B. Rollnick S. A motivational interviewing perspective on resistance in psychotherapy.J Clin Psychol. 2002; 58: 185-193Crossref PubMed Scopus (91) Google ScholarTable ITypes of reflections1. RepeatingPatientHCPUse to diffuse resistance.“I don't want to take my medication.”“You don't want to take your medication.”2. RephrasingPatientHCPSlightly alter what the patient says to provide the patient with a different point of view.“I want to take my medication, but I have trouble fitting it into my day.”“Taking your medication is important to you.”3. Empathic reflectionPatientHCPProvide understanding for the patient's situation.“You've probably never had to deal with anything like this.”“It's hard to imagine how I could possibly understand.”4. ReframingPatientHCPHelp the patient think about his or her situation differently.“I've tried to take my medication consistently, but I just can't seem to pull it off.”“You are persistent, even in the face of discouragement. Controlling your asthma is really important to you.”5. Feeling reflectionPatientHCPReflect the emotional undertones of the conversation.“I know that not taking medication is bad for my asthma.”“You're worried about your asthma getting worse.”6. Amplified reflectionPatientHCPReflect what the client has said in an exaggerated way. This encourages the client to argue less and can elicit the other side of the client's ambivalence.“My mom is totally exaggerating my symptoms. My asthma isn't that bad.”“There's no reason to be concerned about your asthma.” (said without sarcasm)7. Double-sided reflectionPatientHCPAcknowledge both sides of the patient's ambivalence.“Taking medications just takes away my freedom. It's such a hassle.”“On the one hand, you find that medication takes away your freedom. On the other hand, you said that your asthma symptoms limit your freedom by preventing you from doing things you enjoy. What do you make of this?” Open table in a new tab Summaries are longer than reflections and used to transition to another topic, highlight both sides of a patient's ambivalence, or provide a recap at strategic points to ensure continued understanding (eg, “You have several reasons for wanting to take your asthma medication consistently; you say that your mom will stop nagging you about it and you will be able to play basketball more consistently. On the other hand, you say they are a hassle to take, and that they taste bad. Is that about right?”). Koning et al47Koning C.J. Maille A.R. Stevens I. Dekker F.W. Patients' opinions on respiratory care: do doctors fulfill their needs?.J Asthma. 1995; 32: 355-363Crossref PubMed Scopus (28) Google Scholar found that one third of patients with asthma or chronic obstructive pulmonary disease desired greater participation in decision making about their treatment. Patients with asthma who report active participation in treatment decisions are more adherent.48Chambers C.V. Markson L. Diamond J.J. Lasch L. Berger M. Health beliefs and compliance with inhaled corticosteroids by asthmatic patients in primary care practices.Respir Med. 1999; 93: 88-94Abstract Full Text PDF PubMed Scopus (162) Google Scholar However, patients might be hesitant to voice their agendas without being prompted.49Barry C.A. Bradley C.P. Britten N. Stevenson F.A. Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study.BMJ. 2000; 320: 1246-1250Crossref PubMed Scopus (427) Google Scholar MI provides a framework to actively solicit patients' agendas. The HCP provides a menu of options for discussion and lets the patient decide where to start the conversation (eg, “Would you like to talk about taking your medication, monitoring asthma symptoms, or avoiding asthma triggers? What are you most concerned about?”).50Stott N. Rollnick S. Rees M. Pill R. Innovation in clinical method: diabetes care and negotiating skills.Fam Pract. 1995; 12: 413-4