EXCHANGING INFORMATION

The earlier successful studies of MI emphasized the importance of reflective listening during the process of giving personalized feedback of test results. How information is shared with the patient can also affect how it is received. The main reason simple advice does not work is that most people do not like being told what to do, such as

“If you continue smoking, you are going to have a heart attack.” Rather, most patients would prefer to be engaged in a decision-making process, particularly when they are considering making a choice about changing problematic behaviors. Offering healthcare–related information to the patient should not happen unless the patient gives permission. Remember that some patients may not be interested in having you provide information. When you use scare tactics, lecture, preach, ridicule, moralize, or coerce, they risk creating discord in the relationship and jeopardizing the thera-peutic work. A preferred approach to this type of encounter would be to acknowl-edge and respect the patient’s perspective and autonomy: “I respect your decision about not being interested in discussing your behavior, and we can come back to it in the future if you want.” Inviting the patient to reflect on the information you shared facilitates the discussion. Bombarding the patient with a barrage of data that we feel pressured to deliver can overwhelm the patient and negatively affect the therapeutic communication.

To share information and recommendations with a patient that is consistent with the guiding style and spirit of MI, the elicit-provide-elicit (E-P-E) is the appropriate framework. E-P-E involves a collaborative mindset when the goal is health behavior change. This approach can also be helpful in working through ambivalence related to change, agenda mapping, and treatment planning.

take my medicine every day

discuss possible new strategies with my therapist

join a gym,

start exercising 30 minutes a day, 3 times a week

limit my alcohol intake

consider daily journaling check in at my follow-up appointment to reassess

FIGURE 4.4 Agenda mapping timeline. The patient from Figure 4.3 has now identified a series of behavioral targets she is interested in discussing. To help her prioritize these topics for further discussion, the trainee can guide the patient in developing a timeline, as earlier.

53Building a Toolbox Elicit-Provide-Elicit (E-P-E)

This framework starts with asking the patients what they know already or are inter-ested in knowing about a specific topic (Elicit). Once the patients share what they already know, you can build on it (Provide). This approach allows you to then reflect on the patient’s view of what is offered (Elicit).

Elicit

Explore prior knowledge Examples of question stems:

• “What do you know about. . .?”

• “What is your understanding of. . .?”

Elicit existing emotions Examples of question stems:

• “How do you feel about. . .?”

• “What do you feel when you think about. . .?”

Querying interest Examples of question stems:

• “What are your thoughts about. . .?”

• “How would you describe your interest level in discussing. . .?”

Provide

• Engage first (through first eliciting before providing!).

• Use statements sparingly and keep them short and focused.

• Emphasize personal choice.

• Offer menu of options and add, “You know yourself the best, what do you think?”

Elicit

The goal is to get feedback from the patient on his or her thoughts, questions, inter-pretation, or understanding of the information just provided. Examples of questions to ask for the second elicit include the following:

• “What do you make of this information or these suggestions?”

• “What is your reaction about the effects of alcohol on your liver?”

• “What do you think about these strategies I shared with you to help you take your medications regularly?”

• “What do you think about what we just talked about?”

• “What do you think is the next step for you?”

• “How might what we just talked about apply to you?”

Motivational Interviewing54 Putting It All Together

Trainee:  What do you know about the effects of drinking alcohol on your liver?

(Elicit)

Patient: I know it would help to understand how my hepatitis C is affected if I con-tinue to drink.

Trainee: You are concerned about how your drinking can affect your liver and your hepatitis C. Would it be ok with you to share what we know about the impact of alcohol on patients with hepatitis C? (Asking permission)

Patient: Yeah.

Trainee: Drinking alcohol on a liver that is already injured by hepatitis C could dam-age your liver more and lead to serious consequences such as liver failure. What are you thinking now? (Provide, then Elicit)

Patient: So I don’t think I should drink at all.

Trainee: I wonder if you would be interested in some strategies that other people who have hepatitis C like yourself have used to help them not drink. (Elicit)

Patient: I think I don’t want to destroy my liver, so yes what are these strategies?

TOOLBOX Elicit-Provide-Elicit

• Elicit (Engage, Explore)

• Provide (emphasize Personal choice)

• Elicit (Effects of your feedback)

Chunk-Check-Chunk

This is a variation on the E-P-E framework that fits more under the directing style.

It is more practical when the trainee must deliver a lot of information, at the same time keeping the patient engaged in the conversation. The trainee starts with pro-viding a “chunk” of information. After delivering the chunk, the trainee stops to check in with the patient about the information. This exchange is followed by another chunk of information. This framework helps you detect and correct mis-understanding that occurs in the clinical encounter. The following is an example of this framework.

Trainee: Let me share with you the sort of treatment we will provide for your diabetes.

We will discuss your medication regimen and your lifestyle and explore with you the changes you want to make to help you better control your diabetes. You have shared your struggles with remembering to take your medication consistently, and you have been more depressed recently. You have been worried about your high HbA1c. We will get to know you better in the clinic. How does that sound so far?

(Chunk)

Patient: It makes sense. I know we discussed my concerns about controlling my dia-betes. (Check)

Trainee: That is not surprising to you.

Patient: Not at all.

55Building a Toolbox Trainee: And we will also discuss strategies to address your depression and how it

affects your ability to manage diabetes. I would like to see if you would be willing to involve your wife in your care. This will help us get a better perspective on your challenges in coping with diabetes. (Chunk)

Patient: Clearly it is important to talk about that and sure we can talk with my wife.

Trainee: We can figure out how to work together so you are better able to care for yourself.

Patient: Yes, sure.

This illustrates the chunk-check-chunk approach, where a lot of information is provided along with periodic short check-ins. The patient’s responses are brief and reflected. MI skills are used throughout the exchange. At the end of the exchange, the patient is engaged and willing to work with the trainee.

TOOLBOX

Chunk-Check-Chunk – A more practical variation on E-P-E for providing more information