Motivating and Empowering Patients With Schizophrenia

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CONFERENCE REPORTER

“Patients aren’t going to do things unless there is something that motivates them.”

Leslie Citrome, MD, MPH, and Amber Hoberg, MSN, APRN, PMHNP-BC, discussed the benefits of motivational interviewing for patients with schizophrenia and their families in a presentation at the 2022 Neuroscience Education Institute (NEI) Congress on November 4. The aim of the presentation was to help clinicians involve patients with schizophrenia in the shared decision-making process of determining treatment goals and to communicate with patients in an effective, empathetic manner that encourages adherence.

Citrome and Hoberg acknowledged that there are barriers to positive outcomes for both patients and clinicians. Barriers for patients include communication difficulties, cognitive and other adverse events associated with treatment, and stigma of schizophrenia. Barriers for clinicians include underestimation of the importance of the therapeutic relationship, conveyance of hopelessness to the patient, and lack of interest in the patient’s life goals and other issues that are important to the patient.

“We need to address these barriers in a systematic way,” said Citrome, who is a clinical professor in the New York Medical College Department of Psychiatry. Citrome and Hoberg also shared that, according to research, 91% of patients with serious mental illness want to be involved in decisions about their care; 67% of treatment decisions involving oral antipsychotics were made without the input of either the patient or their care partner; and long-acting injectables (LAIs) were not discussed with 50% of patients who were taking oral antipsychotics, but more than half of patients agreed to start LAIs after discussing them with their clinician. According to Citrome and Hoberg, this demonstrates the importance of building the therapeutic alliance through shared decision-making.

“This is very important when you’re talking to any patient with mental illness, but particularly schizophrenia patients because they want to trust you, and part of that trusting thing is developing that relationship with your patients,” said Hoberg, who is a nurse practitioner with Morning Star Family Medicine.

Citrome and Hoberg stated that motivational interviewing (MI) is a very important tool for clinicians, particularly when working with patients with schizophrenia and other serious mental illnesses. Defined as a collaborative conversation style for strengthening the patient’s own motivation and commitment to change, MI “is really part of modern medicine today,” Citrome said, adding that “it means we do something with someone—not for or to them.”

“The whole goal of motivational interviewing is to help the patients change” Hoberg added. “Ambivalence is normal with patients, but what we’re trying to do is get them to that other side, using their ability to set their goals and make those decisions for themselves.”

Citrome and Hoberg stated that clinicians can effectively incorporate MI into their work with patients by using open-ended questions and practicing reflective listening, along with the acronym RULE:

• Resist making too many suggestions
• Understand the patient’s motivation
• Listen with a patient-centered empathetic approach
• Empower the patient

Use of open-ended questions and an empathetic approach is vital to positive outcomes, according to Citrome and Hoberg. “The most important thing you can do is ask open-ended questions,” said Hoberg, who added that “the way we’re counseling can either increase or decrease the effectiveness of what we’re doing with our patients. You want to think of it like knobs on a radio: If you’re being very punitive, very confrontational, very negative in your approach, your patients are going to turn you off, and they’re really not going to want to listen, and their barriers and their walls are going go up. But if we use open-ended questions, we start to listen to our patients, and we reflect back what we’re hearing, the knob is going to be turned up and they’re really willing to engage with you and have that motivation to change.”

Citrome and Hoberg also shared 5 questions for clinicians to consider in incorporating MI into their work with patients:

1. Why would you want to make this change?
2. How might you go about it in order to succeed?
3. What are the 3 best reasons for you to do it?
4. How important is it for you to make this change, and why?
5. So, what do you think you will do?