Motivating and Empowering Patients With Schizophrenia

Experts share the benefits of motivational interviewing when working with this patient population and how clinicians can incorporate it into their practice.


“Patients aren’t going to do things unless there’s something motivating 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 Congress of the Neuroscience Education Institute (NEI) 2022 on November 4. The goal of the presentation was to help clinicians engage patients with schizophrenia in the shared decision-making process to determine treatment goals and communicate with patients in an empathic and effective manner that promotes adherence.

Citrome and Hoberg recognized that there are barriers to positive outcomes for both patients and physicians. Barriers for patients include communication difficulties, cognitive and other adverse events associated with treatment, and the stigma of schizophrenia. Barriers for clinicians include underestimating the importance of the therapeutic relationship, transmitting 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 systematically address these barriers,” said Citrome, a clinical professor in the Department of Psychiatry at New York Medical College. 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 input from the patient or her caregiver; and long-acting injectables (LAIs) were not discussed with 50% of patients taking oral antipsychotics, but more than half of patients agreed to start LAIs after discussion with their physician. According to Citrome and Hoberg, this demonstrates the importance of building the therapeutic alliance through shared decision making.

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

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 style of collaborative conversation to strengthen a 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—no by either a to them.”

“The whole point of motivational interviewing is to help patients change,” Hoberg added. “Ambivalence is normal with patients, but what we’re trying to do is bring them to the 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 through the use of open-ended questions and the practice of reflective listening, along with the acronym RULE:

  • Resist making too many suggestions.
  • Understand the motivation of the patient.
  • Listen with an empathic patient-centered approach
  • empower the patient

The use of open-ended questions and an empathic approach is vital for positive results, according to Citrome and Hoberg. “The most important thing you can do is ask open-ended questions,” Hoberg said, adding that “how we provide counseling can make or break the effectiveness of what we do with our patients. You want to think of it like knobs on a radio: if you’re being too punitive, too confrontational, too negative in your approach, your patients are going to reject you and really don’t want to listen, and their barriers and walls are going to go up. But if we use open-ended questions, start listening to our patients and reflect what we’re hearing, the knob will go up and they’ll be really willing to interact with you and they’ll have that motivation to change.”

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

  1. Why would you want to make this change?
  2. How could I do it to be successful?
  3. What are the top 3 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’ll do?

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