Medical Journal - HoustonPage 8 August 2018. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INTEGRATIVEMEDICINE
. . . . . . . . . . . . . . .
Motivational Interviewing: Enhancing healthy change
BY VICTOR S. SIERPINA, MD, ABFM, ABIHM, Director, Medical Student Education Program, WD and Laura Nell Nicholson Family Professor of Integrative Medicine, Professor,
Family Medicine University of Texas Distinguished Teaching Professor
Reflect on how you feel when a patient or client does not follow your well-intended, evidence-based, even profound health-
promoting recommendations. Do you feel frustrated, angry, impatient? Do you label the person “non-compliant” or “difficult?”
Perhaps what we have here is a failure to communicate. I just completed a course on Advanced Motivational Interviewing (MI) at the University of Colorado Anschutz Medical Campus. It was hosted by skilled facilitators from the Behavioral Health and Wellness Program and attended by counselors, tobacco cessation specialists, psychologists, health coaches, and physicians. We worked collaboratively in teams to discover how to improve our abilities to communicate, facilitate change, and unlock motivation.
According to MI developers, W.R. Miller and S. Rollnick: “Motivational Interviewing is a collaborative, goal orientated style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting
and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”
This turns on its head the frequent pattern of physicians and other healthcare providers to educate, inform, lecture, and try to persuade a person to adopt a new behavior, whether it be taking medication regularly, adopting a change in lifestyle such as exercise or nutrition, to eliminate harmful substances, or change other non-wellness habits.
The first strategy in the process is
recognizing the stage of change the patient or client brings to us. Pre-contemplation, contemplation, preparation, or action stages all require different communication and motivational strategies.
By identifying the person’s own readiness to change and their core values, ambivalences, and discrepancies amongst these, the healthcare provider follows the person’s lead to foster self-determination, personal agency, and self-efficacy. Rather than arguing or feeling responsible to “fix” the patient or their problem, the MI approach is one of discovery and gentle guidance to identify and mobilize the person’s own levers for change.
This is truly a revolutionary and powerful way of being with others. It emphasizes reflective listening skills along with open-ended questions, affirmations rather than judgment, and internal rather than external
Please see INTEGRATIVE MEDICINE page 13
Medical Journal - Houston Page 13August 2018. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
locus of control.
This approach originally evolved from Miller’s work in New Mexico with people with alcohol and substance abuse. As the process evolved through the 1980’s and 1990’s, it became more structured and teachable beyond his own personal methods and is now largely accessible in a variety of training sessions, online resources, books, and organizations. (1,2,3,4, 5)
Some additional principles of MI are to approach each person with a “MI spirit” including partnership, acceptance, compassion, and evocation. The processes of MI include engaging, focusing, evoking, and planning.
The acronyms DARN CAT are about change talk involving two levels, preparatory and mobilizing. Preparatory change includes noting D for Desire, A for Ability, R for Reasons, and N for Need. Mobilizing change talk is indicated by for C for Commitment, A for Activation, and T for Taking Action. One simple MI strategy for information exchange is called E-P-E, Elicit-Provide-Elicit. It involves asking permission to clarify information gaps by building on the person’s existing understanding, providing information that is clear, prioritized, and fosters autonomy, and then checks the person’s understanding or response. This is different than offering unsolicited, though well-intended information which the person
may already know or which they may not have the ability or present willingness to understand.
Other useful MI tools are the Importance
and Confidence rulers. These helps identify the levels on a scale of 1 to 10 that changing a given behavior has for a person at that time. For example, though they may wish
to quit smoking, with a lot of other current stressors going on in their life, they may rate it low in Importance like a 4 out of 10. Given those life circumstances and past attempts to quit, they may also have
a low Confidence score, such as 3 out of 10 of following through. This gives all parties a realistic view of the likelihood of success at this time. It is provocative to
ask why the score isn’t even lower, as this tends to scratch out the reasons the person is considering change at all, e.g., expense, health, social censure, insurance premiums, etc. in addition to identifying what factors are sustaining barriers to change.
There is much more to MI than can be covered here but please consider your personal or organizational training and human resource development strategies. In my view, all clinicians, clinics, hospitals, and health care providers ought to be familiar with this method of respectful, positive, and highly interactive communication. Consider training in Motivational Interviewing and see how it shifts the dynamic in the conversations we have and makes them more effective. ▼
Resources: 1. http://www.motivationalinterviewing.org2. Miller WR, Rollnick S. Motivational
Interviewing: Helping people change. NY:Guilford Press; 2012(3rd ed)
3. University of Colorado Behavioral Health & Wellness Program videos: https://www.bhwellness.org/resources/videos/conversations-for-change-series.
4. Motivational Interviewing Network of Trainers (MINT) streaming videos: http://www.motivationinteviewing.org/mi-streaming-videos
5. Pocket Guide to Motivational Interviewing: http://www.buildingbetterprograms.org/wp-content/uploads/2016/03/mi_pocket_guide.pdf
animal that was treated using a special mixture of sugar and detergent to eliminate all cells and blood in the lung, leaving only the scaffolding proteins or skeleton of the lung behind. This is a lung-shaped scaffold made totally from lung proteins.
The cells used to produce each bioengineered lung came from a single lung removed from each of the study animals. This was the source of the cells used to produce a tissue-matched bioengineered lung for each animal in the study. The lung scaffold was placed into a tank filled with a carefully blended cocktail of nutrients and the animals’ own cells were added to the scaffold following a carefully designed protocol or recipe. The bioengineered lungs were grown in a bioreactor for 30 days prior to transplantation. Animal recipients were survived for 10 hours, two weeks, one month and two months after transplantation, allowing the research team to examine development of the lung tissue following transplantation and how the bioengineered lung would integrate with the body.
All of the pigs that received a bioengineered lung stayed healthy. As early as two weeks post-transplant, the bioengineered lung had established the strong network of blood vessels needed for the lung to survive.
“We saw no signs of pulmonary edema, which is usually a sign of the vasculature not being mature enough,” said Nichols and Cortiella. “The bioengineered lungs continued to develop post-transplant without any infusions of growth factors, the body provided all of the building blocks that the new lungs needed.”
Nichols said that the focus of the study was to learn how well the bioengineered lung adapted and continued to mature within a large, living body. They didn’t evaluate how much the bioengineered lung provided oxygenation to the animal.
“We do know that the animals had 100 percent oxygen saturation, as they had one normal functioning lung,” said Cortiella. “Even after two months, the bioengineered lung was not yet mature enough for us to stop the animal from breathing on the normal lung and switch to just the bioengineered lung.”
For this reason, future studies will look at long-term survival and maturation of the tissues as well as gas exchange capability.
The researchers said that with enough funding, they could grow lungs to transplant into people in compassionate use circumstances within five to 10 years.
“It has taken a lot of heart and 15 years of research to get us this far, our team has done something incredible with a ridiculously
small budget and an amazingly dedicated group of people,” Nichols and Cortiella said.Researchers find new way to target flu virus
There’s a hitch in the swing of a protein that delivers the flu virus. Rice University and Baylor College of Medicine researchers believe this mechanism may be a useful target to stop the virus from infecting cells.
The protein, hemagglutinin, sits on the surface of flu viruses and helps them attach to and transport through the protective membranes of target cells.
The paper begins to define the mechanism that allows the protein to unfold and refold in a snap, changing its form to expose a peptide that attaches the virus to a cell and begins infection. The researchers believe therapeutic drugs can use this mechanism to shut the virus down.
“This protein starts in a folded state and goes through a global transformation, refolding in a completely different state,” said Onuchic, co-director of Rice’s Center for Theoretical Biological Physics (CTBP). “But there’s a small part in the center that evolution has conserved.”
That single conserved amino acid residue is the hitch that makes the protein pause in the process of refolding. It allows a fusion peptide buried inside to bind to the target cell and begin infecting it. Without the pause, the refolding would be too quick for
binding to take place.
Lead author and Rice postdoctoral researcher Xingcheng Lin modeled that part of the protein, the B-loop of the HA2 domain. HA2 sits beneath another domain, a cap known as HA1 that mutates to escape past defenses. Lin explained that HA1 is a common target for flu medications because the exposed cap domain is more accessible than the protected HA2 domain.
The problem is that HA1 mutates constantly to resist drugs, he said. That influences how effective flu vaccines are every year. Lin and Onuchic said HA2 presents a better target for drugs because the mechanism is highly conserved by evolution.
“If a drug targets HA2, the domain cannot escape by making mutations because the mutations themselves would make it nonfunctional,” Lin said. “That kind of drug could become a universal vaccine.”
HA2 is a trimeric structure that, when triggered by acidic conditions in the environment near a target cell, transforms itself from a random loop to a coiled coil. Even with the pause, it unfolds and refolds in a fraction of a second, far too fast for microscopes to see. But a computer simulation of the process can be slowed down.
That happens to be a specialty of the CTBP,
PHARMACEUTICALcontinued from page 1. . . . . . . . . . . . . . .
Please see PHARMACEUTICAL page 16
INTEGRATIVE MEDICINEcontinued from page 8. . . . . . . . . . . . . . .
