Applications of motivational interviewing in adolescent solid organ transplant

Adolescence is a developmental period that is known for the highest risk of difficulties with adoption and maintenance of health behaviors for successful transplant. Motivational interviewing (MI) has been demonstrated to be an effective strategy in the management of modifiable factors impacting adherence in both adult transplant and analogous pediatric chronic illness populations.

occurring in a stage of identity formation, in which teens have increased the desire for autonomy and independence.During this time, adolescents are considering and developing self-image, are more likely to engage in risky behaviors, 3 and are vulnerable to mental health concerns such as depressed mood and suicidal thoughts. 4For adolescents undergoing transplant, the burden of managing competing responsibilities (e.g., self-care, academics, social relationships) while managing medical expectations can be challenging.Likewise, adolescents with solid organ transplants have been found to have increased deficits in executive functioning, 5 lower maturity, and increased risk behaviors [6][7][8] compared to healthy peers, resulting in greater risk of nonadherence. 6There are multiple expected health behaviors for adolescents undergoing transplant, such as medication adherence, appointment attendance, communication with caregivers and the medical team, and diet and exercise expectations.Adherence to health behaviors are affected by individual, family, and systems level factors. 9Systemlevel factors may be very difficult for transplant clinicians to modify directly, such as the impact of health disparities and community and family resources.However, transplant clinicians across disciplines are poised to collaborate with adolescents to guide healthrelated identity development and decision-making, with the goal of making a positive impact on health behaviors.Motivational interviewing (MI) is a goal-directed style of speaking with people intended to evoke self-reflection and to strengthen motivation and commitment to change behaviors. 10Although concrete clinical applications to pediatric transplant care are underdeveloped, MI has been evaluated in adult transplant and in closely-aligned pediatric medical populations.The goal of this paper is to educate transplant clinicians about using an MI approach with adolescents and to provide concrete strategies about how to apply MI into clinical practice.

| WHAT IS MOTIVATIONAL INTERVIE WING?
Motivational interviewing (MI) is defined as a way of talking with people about change and growth, intended to strengthen their own motivation and commitment. 10One major premise of MI is appreciating that patients are not fundamentally lacking motivation; instead, people are ambivalent about perceived positives and negatives to making a change.If someone is considering adopting a healthy behavior, there are typically opposing motivations to sustain the current behavior.From an MI lens, these opposing motivations are believed to be because the perceived effort or degree of change conflicts with underlying values or goals. 11The goal of the clinician is to use thoughtful language to elicit the patient's values and goals, as well as to discuss processes that enhance readiness for change, take steps towards change, and maintain changes over time.In doing so, clinicians are approaching clinical interactions with nonjudgmental acceptance and partnership in which the clinician brings expertise in transplant and patients provide expertise on themselves.
Clinicians are encouraged to view MI as a communication style that can be used in all patient-clinician interactions (not only those perceived as problematic) to foster a collaborative partnership in the health care setting.At times, clinicians in a medical setting may be prone to a "fixing reflex," such as giving advice when observing difficulty with an adolescent's health behavior (e.g., recommending phone reminders to aid with medication adherence). 10Although the recommendation is well intended, may occur at a time when a teenager isn't ready for change while also minimizing their autonomy in the process.MI is intended to guide adolescents in making health behavior change while emphasizing the value of their opinion, readiness, and goals.MI is not a deceptive practice intended to "trick" people into doing nonpreferred tasks, and although some MI skills overlap with common clinical practice, nuanced skills in MI required continued practice and ideally, direct supervision by clinicians trained in MI. 12

| WHO C AN US E MOTIVATI ONAL INTERVIE WING?
Although MI was initially developed by psychologists in the context of clinical practice, applications are broad and can be learned and applied by clinicians from any discipline.In the most recent edition of the MI text, it is emphasized that individuals in any helping professions-not just counselors or therapists-can be effective users of MI.Although Miller and Rollnick 10 share that ability to learn MI has not been shown to relate to years of education, it is noted that preexisting skill in empathic listening may facilitate learning and demonstration of MI. 13 As such, transplant clinicians from all disciplines are uniquely positioned to partner with patients and families to discuss patient and family values, goals, culture, and how to help support health behavior changes.

| WHAT IS K NOWN ABOUT MOTIVATIONAL INTERVIE WING WITH PATIENTS UNDERGOING TR ANS PL ANT ?
To identify the evidence base for MI in adolescent transplant populations, a literature search was conducted in PubMed using the search terms (motivational interviewing) AND (transplant).To identify literature in analogous pediatric populations, the terms (motivational interviewing) AND (pediatric) were utilized.While empirical evidence of the use of MI in pediatric transplant is limited, studies in adult populations as well as in related specialty areas suggest its applicability in adherence promotion.In the only known randomized control trial of the use of MI in the adult transplant population (MAESTRO-Tx), 14 205 heart, liver, and lung transplant recipients utilized a multimodal intervention including MI administered by trained masters-level nurses.Intervention group participants demonstrated both short-and long-term gains compared to the control group, with a 5-fold-higher odds to be adherent in the 6 month study period and a 10% higher 5-year clinical event-free survival.In a study of adult dialysis patients, 15 dialysis center staff were trained in MI, which they then utilized as part of daily patient interactions.Patients in the intervention demonstrated positive, but nonsignificant changes in dialysis attendance, length of treatments, and phosphorous and albumin levels.MI interventions have likewise demonstrated promise in decreasing ambivalence in living transplant donation; donors in a randomized controlled trial conducted by Dew et al. 16 reported decreased somatic symptoms, recovery time, and residual ambivalence post-donation.
MI has also been demonstrated to be an effective strategy to improve adherence in nontransplant pediatric populations.Schaefer and Kavookjian 17 conducted a systematic review of the use of MI on adherence and symptom severity in children and adolescents with chronic illnesses (primarily HIV, diabetes and asthma).Eleven of the 12 studies meeting criteria for the review found a positive impact of MI on adherence and/or symptom reduction.Similarly positive impact has been found in separate studies of the use of MI in adolescent substance abuse, 18 diabetes 19 and oral health. 20Given the success of MI trials in other pediatric health populations and the similar adherence barriers in those populations to barriers in pediatric transplant, MI has been suggested as an important tool in pediatric transplant adherence and health behavior promotion. 21

| Spirit of motivational interviewing
In practicing MI, it is important to remember the spirit of the approach, which is essentially how one interacts with and guides people rather than specifically the skills used.The MI spirit is characterized by 4 components: working together in partnership with the patient, nonjudgmental acceptance of the patient's current behaviors and approach, compassion that includes intention to give priority to the well-being of a patient, and empowerment of patients, which includes evoking motivation and appreciating autonomy with decision-making. 10With adolescents, in particular, this approach includes affirming strengths, respecting and emphasizing the patient's independence, and evoking reasons for maintaining and/or changing a health behavior while supporting any intended changes.
The spirit of MI shares assumptions with client-centered counseling 22 and positive psychology 23 that people possess knowledge and wisdom about themselves, and in the setting of encouragement and support, they are likely to grow in a positive direction.Within this approach, Miller 24 calls clinicians to operate with humane values, including compassion, respect for persons, justice, recognizing human potential, acceptance, and collaboration.In doing so, it is necessary to be aware of personal biases that may affect clinical practice, including implicit or explicit attitudes and beliefs that may be projected onto our patients.Relatedly, consistent with an MI approach, purposeful self-reflection and cultural humility are important clinical skills in order to effectively partner with patients and families from diverse backgrounds. 25

| Tasks of motivational interviewing
Miller and Rollnick 10 outline four tasks of MI that are typically incorporated into clinical conversations, as outlined in Table 1.The tasks include engaging, focusing, evoking, and planning, and although they may occur sequentially, they may also overlap or occur in a nonlinear Planning involves helping patients to outline the steps of how they will make a change.In order to assist with planning, clinicians may find it helpful to outline possible options that were collaboratively discussed and defer to patients by indicating, "Which strategies do you think would work best for you?" or "What are you ready to try between now and next appointment?"

| Core skills of Motivational interviewing
Table 1 outlines the core skills of MI with specific examples of how to use each skill.Beginner learners of MI may choose to focus on gradual integration of one or more core skills into their practice as a way to build familiarity with the approach.For example, reflections are a valuable skill to demonstrate understanding of a patient's statement and to build rapport by showing that you are listening and attempting to understand them.Reflections require active listening into what the patient is saying in order to prioritize a deeper understanding of a person's experience. 10In hearing about an adolescent's worries about recovery from transplant, you may reflect, "You are worried about missing prom due to not being able to be around a lot of people during the first few months after transplant, and you know you want to protect your body from infection right after transplant."Statements such as these allow the adolescent an opportunity to self-reflect on these feelings of ambivalence and appreciate that both sentiments may be simultaneously true.Ask-offer-ask is another skill that is widely applicable for use by transplant clinicians.In using this multi-step approach, clinicians can: (1) ask the patient what they know already about a topic, (2) affirm accurate or helpful information, (3) offer additional information with permission, and (4) ask patients to reflect on the new information offered (Table 2).

| Recognizing and responding to change talk
Active and deep listening is central to proficient MI practice, and typically hearing patients' language choice gives an indication of their readiness to change a health behavior.Miller and Rollnick 10 use the term change talk to represent anything people say that tends to move them toward a particular action.As noted in Table 3, preparatory change talk involves expressing motivation for change without implying action, and mobilizing change talk expresses action toward change 10 patient statements such as, "I'm pretty sure I can't take my medication every day" differs from someone who says, "I could take my medicine more often (preparatory change talk)."or "I will start taking my medicine tonight (mobilizing change talk)."As clinicians, the goal is to hear the nuanced meaning that may be behind patient statements and use core skills to evoke further change talk.For example, a clinician may choose to note, "Although it seems challenging to take the medication every day, there was a time when you were taking it more frequently.What was different then that allowed you to be more consistent?"For patients who may use frequent sustain talk, or language indicating preference for staying the same or not changing, using core skills may also help to explore reasons for maintaining the status quo versus changing behavior.Patients may indicate, "I have no time for exercise," and often this may be perceived as "resistance."Clinicians may choose to affirm and explore by stating, "It's challenging to consistently exercise, and in order to be successful with that goal, you would have to find time in your schedule.Let's think about thatwhen you're ready for this change, how would you schedule it into your day?"In this example, skilled exploration may (or may not) allow patients to consider change in a different way.At a minimum, using directional language and helping patients to talk about change may help them cultivate ideas or motivation for change that they may not have otherwise considered.

| WHEN C AN MOTIVATIONAL INTERVIE WING B E US ED WITH PATIENTS UNDERGOING TR ANS PL ANT ?
MI skills may be applied in a variety of clinical situations, and it is important to distinguish when MI may be most useful.In the health care TA B L E 1 Core skills of motivational interviewing.have for their health, helping them to talk about their reasons for wanting a change, and having a collaborative discussion about how to support goal achievement. 26When discussing health behavior change and adherence, guiding is the ideal strategy, and use of MI skills is recommended.

| HOW C AN MOTIVATIONAL INTERVIE WING B E APPLIED TO TR AN S PL ANT ?
There are numerous occasions within the pre-, peri-, and posttransplant journey that provide opportunity for the use of MI.Below are some examples of ways in which MI can be used at each stage of the transplant process.

| Pre-transplant/readiness for change
For some patients, transplant is an urgent, life-saving intervention where there are often few decisions to be made.For others, however, particularly when there are short-or long-term alternatives or bridges to transplant (i.e., renal replacement therapy or mechanical circulatory support), patients and their caregivers may be asked to engage in one or more lifestyle behavior changes to improve their candidacy and/or to increase their readiness for transplant.While support person provide a reminder) unique to them that can be used to approach the adherence goal moving forward.
At times, patients may appear "resistant" or unwilling to make changes that clinicians believe will be important for transplant listing.In these situations, it is especially important to consider our own biases that may be affecting our clinical approach, and to align demeanor and language to practice in a collaborative and compassionate manner.Within the spirit of MI, it typically is helpful to look for opportunities to engage the patient and caregiver together.like to achieve.In doing so, clinicians can help patients build readiness for change and eventually plan measurable strategies to reach desired long-term outcomes (e.g., lose enough weight to be listed for heart transplant so he can no longer have a VAD) and short-term goals (e.g., limit snacking after 8 pm, schedule meeting with psychology to discuss mood and weight concerns).

| Peri-transplant/post-operative care
The use of MI strategies can also be particularly helpful during the immediate post-transplant period, where the patient's experience of pain, fatigue, and/or anxiety can interfere with the medical team's goal to have them out of bed and engaging in rehab therapies as soon as possible.In these circumstances, it is not uncommon for adolescents to interact in ways that can be frustrating for medical teams (e.g., not responding to questions, reporting somatic complaints, saying "Leave me alone"; wanting to sleep during the day and be awake at night).In these circumstances, it can be In the case of barriers around return to school, for example, helping the adolescent (and often their caregiver) identify their values (i.e., getting an education or entering the workforce, engaging with peers), their goals in alignment with those values (i.e., going back to school in-person) and taking steps towards needed behaviors (i.e., caregiver completing paperwork for adolescent to return to school; the adolescent getting up in the morning on time to attend school).
Furthermore, MI strategies are also useful in increasing patient engagement in treatment for psychological concerns that may act as barriers to adherence or school attendance, such as depression or anxiety.

| Other
The utility of using MI strategies can be expanded beyond

| CONS IDER ATIONS OF SYS TEM -LE VEL FAC TOR S AND THE CONTE X T FOR INTERVENTI ON S
Adolescent-clinician interactions are one way to influence change within the broader context of factors that affect health behaviors and decision-making.As noted previously, at times, adolescents may be inappropriately labeled "resistant" due to difficulties with making changes that align with what the clinician aspires for the patient to do.In these situations, it is necessary to have continued self-reflection of values and biases that may be affecting clinical practice and to accept that there may be adolescent and family decisions that do not align with a clinician's own morals or values.In doing so, it is imperative for clinicians to consider family-based, cultural, hospital-level, community-level, and/or societal factors may be affecting an adolescent or family.In addition to discussion about direct health behavior change targets (e.g., taking medication), clinician awareness and respect of other aspects that may be affecting health decision-making (e.g., systemic racism, cultural norms, socioeconomic status) is critical to effective partnership.For example, clinicians are recommended to ask questions like, "How does your culture affect your views towards health care?"Similarly, rather than assuming interest in adolescent or family resources to meet basic needs (e.g., transportation assistance), one might ask, "What do you think you need at this point?"Using this approach, clinicians serve as guides who evoke the ideas, motivations, and health behaviors preferred by the family.

| RE SOURCE S FOR FURTHER TR AINING
While educational sessions and readings can promote learning, con-

| SUMMARY
Given demonstrated efficacy in similar populations (adult transplant, pediatric chronic illness), MI shows great promise as a useful intervention strategy for situations that may occur throughout the stages of the adolescent transplant journey, including the evaluation period, adherence, and end-of-life care.MI's focus on supporting individual decision-making autonomy is particularly well suited to many adolescents' developmentally appropriate desire for increased autonomy.
The use of MI is not limited to licensed mental health providers; it was designed as a way of speaking with people that can be woven into many clinical conversations across multidisciplinary provider types.In thinking about when to use MI, it is important to consider the many influences on human behavior and focus on the ones that are within the patient's individual control.Furthermore, it is extremely important for the clinician to recognize their own biases that may influence decisionmaking, as the overarching goal of MI is to help patients identify and act in a manner that is consistent with their own personal values.
fashion.Engaging includes establishing a collaborative and trusting relationship with the person with whom you are speaking with the goal to build mutual respect and trust.An engaging statement could be, "I'd like to spend time talking about your treatment today, although let's start with what you care about.What would you like to make sure we talk about today?"Focusing allows the partnership to determine the purpose of the conversation, and clinicians are encouraged to speak in a directional manner to guide patients to what they hope to achieve.Focusing language may include: "I know there are a lot of changes being asked of you before transplant.From your perspective, what is most important to you to change?"By using a concept termed agenda mapping, clinicians may find it helpful to use a visual diagram of possible behavior changes to help guide the focusing conversation.Evoking is intended to elicit reasons for making a change and have patients reflect on why the change may be helpful.Evoking language could include asking patients, "What reasons do you have to change your fluid intake?" or reflecting, "Although part of you wants to keep doing what you're doing, another part of you wants to lose weight.Tell me about that." most commonly these include adhering to a medication regimen, they also may include adhering to dietary and/or fluid restrictions, increasing physical activity, losing or gaining weight, attending appointments regularly, and engaging in other medical management tasks (e.g., regular use of a percussive vest or airway clearance).In circumstances that involve improving adherence, openended questions, affirmations, and reflection about values can help adolescents consider their own priorities and how to develop health-related goals and action plans that align with those values.The clinician can use MI skills to have the adolescent reflect on current behavior, develop measurable steps to work towards health-related goals, and empower the adolescent to consider ways to achieve their goals.For example, for an adolescent on dialysis who needs to demonstrate improved medication adherence in order to become actively listed for kidney transplant, discussion around how being on long-term dialysis conflicts with their stated value of high peer engagement can be used to develop a goal (getting activated on the transplant list).Further prompting of the adolescent can help guide what they tried thus far (e.g., phone reminders, pill box) to improve adherence as well as different attitudes or behaviors (e.g., reminding self of interest in going out with friends, placing pill box in a different location, having a

TA B L E 3
For example, an older adolescent on a ventricular assist device (VAD) who values privacy and independence may report annoyance with the medical team due to being required to be in the presence of a VADtrained adult at all times.Highlighting the discrepancy between his value (independence) and current state (continued adult monitoring), can help to clarify how to reach his desired outcome (e.g., living independently post-transplant).Clinicians are encouraged to be especially mindful of patient statements of change talk (e.g., "I know I can do what it takes to get a transplant one day.")that may exist within a longer dialogue discussing frustrations with their current situation.Further clinician reflection and prompting surrounding change talk (e.g., "Even though you're frustrated currently, you know you will eventually do what it takes.Tell me about that.")can help evoke further discussion of change.Moreover, thoughtful evocationabout situations that the patient would like to do independently post-transplant (e.g., driving, visiting friends alone) may help them consider meaningful scenarios that are realistic and that they would to be able to get to the appointments."Ability"Ican get here, but it would have to be first thing in the morning."Reason"I know we need to get here so you can check her blood levels."Need "I need to figure out how to get here more often."Mobilizing Commitment "I promise I will schedule an appointment when I check out today."Activation "I could start setting reminders about scheduling."Taking steps "I called yesterday and scheduled our next visit already."Source: Adapted from Miller and Rollnick (2023), Motivational Interviewing, 4th Edition, Helping People Change and Grow.Types of change talk.

7 . 3 |
helpful to first use affirmations around the bravery that the adolescent has already demonstrated.Clinicians may also choose to use ask-offer-ask to learn more about what the patient thinks is a reasonable expectation at this time, to clarify missing information (e.g., getting out of bed is really important to help you recover quicker), while also demonstrating empathy about why this may feel hard ("I know it is very uncomfortable to get out of bed right now.") Clinicians may need to reflect on potential personal biases about "appropriate" post-transplant behavior (e.g., the adolescent should feel grateful to have gotten a transplant and therefore do exactly what they are told, people should stay awake all day and sleep all night) and utilize empathy about the range of emotional reactions to transplant (and the reality of adolescent sleep/wake patterns) to try to come to an agreement that meet both patient and team needs as much as possible.Post-transplant A common area for MI-based intervention is around adherence to the post-transplant immunosuppressant regimen.Other areas for intervention might include increasing engagement in other healthy lifestyle behaviors (i.e., increasing fluid intake or engaging in regular exercise) or managing barriers around return to school.More distally from transplant, areas for intervention might include increase in allocation of medical regimen responsibility to the adolescent/ young adult who is nearing transition to an adult transplant program.
adherence-related situations.Conversations about identification and clarification of values can benefit patients and families in a number of other circumstances in pediatric transplant.For example, throughout the course of the transplant journey, patients and families can be faced with very difficult decisions, such as whether to pursue a second transplant, opting for mechanical circulatory support as "destination therapy" for patients who are not eligible for heart transplant, or weighing different end-of-life care options.In these circumstances, embracing the MI spirit and the core MI skills can be helpful, including unbiased acceptance of patient and family choices, using ask-offer-ask to learn what the patient/family's understanding is of different options and to provide corrective information as needed, and helping the adolescent/family align their health behaviors with their stated goals.End-of-life decisionmaking is a particularly important time for clinicians to be aware of implicit and explicit biases around end-of-life care in order to prioritize the adolescent and family's values that are rooted in their culture and experiences.
tinued practice is critical to the mastery of MI.Miller and Rollnick 10 indicate that there is not a standard "dose" of training to gain proficiency in MI and encourage mastery in MI core skills as well as practice of the spirit of MI.Across disciplines, clinicians may find it helpful to practice role playing use of MI skills with colleagues as well as integrating MI content to transplant-related didactics.Supervision by individuals skilled in MI training, including (but not limited to) those in the Motivational Interviewing Network of Trainers (MINT), is one way to promote successful MI practice.Moreover, coding instruments, such as the Motivational Interviewing Treatment Integrity (MITI) scale, 27 can be utilized by trained raters to assess skill proficiency.For further information about MI, future trainings, and the state of the research, clinicians are encouraged to visit the MINT website (https:// motiv ation alint ervie wing.org/ ).

Case example A 15-year-old female is having difficulty adhering to total fluid limits, resulting in her having to attend additional dialysis sessions each week Core skills Definition Clinician examples
Inquiry to invite further conversation with a person "What will be different about your daily life once you are able to make these changes to your fluids?"You would like to continue to work on improving fluid intake.You realize it's been challenging to add total ounces during the day, and you're considering ways to make it easier.You noticed that when you drank exclusively from your water bottle in the past, this was helpful, and you're thinking about doing it again."I know if I drink too much, it's bad for my body and dialysis takes longer."Clinician: "You realize that too much fluid isn't helpful, and it's annoying when you have to stay in dialysis longer and go extra days (reflection).Would it be ok if I added some reasons it is unhealthy (asking permission) Patient: "Yes."Tasks and core skills of motivational interviewing.
26inician: <Provides education about fluid intake> (Offer)."Whatdoyouthink about that (Ask)?"Source:Adapted from Miller and Rollnick (2023), Motivational Interviewing, 4th Edition, Helping People Change and Grow.setting, conversations about health behaviors are frequent and exist on a continuum of directing, guiding, and following, and thoughtful use of MI involves matching the communication style to the goal of the interaction.26Commonto the medical model, being directive is useful when concrete information is needed while obtaining patient history or sharing information about a diagnosis.Following language (e.g., "Having to manage so many dietary and fluid restrictions must be very hard for you.") is useful when you are being supportive and empathic and sharing an emotional experience.Guiding language involves partnering with the patient to learn about what goals they TA B L E 2

year-old male who received a liver transplant 2 years ago presents with undetectable immunosuppressant levels at a routine clinic visit Tasks Possible skill application Example discussion
Patient: "I don't want to have to miss school, friends -we're trying to get this game built.My parents had to miss a lot of work too.I just want things to be easy for everyone."Patient: "Probably just take the medicine.I can do it." Clinician: "You received your transplant two years ago.In the year after your transplant, you took your medicine every day.In the past year-both your blood work shows and you're also telling me-that it's been harder to keep up with it.Today, we'll talk about what's been happening and how to possibly make this easier for you (summary).What else am I missing (open-ended question)?Clinician: "Great.I know you've been very involved in your care (affirmation).What do you know about why we ask you to take the medication every day (open-ended question; Ask)?" Patient: "I know it's supposed to help my body from rejecting the liver.I just don't think I need it every day because I don't feel any differently when I don't take it."Clinician: "You're bright (affirmation), and you know how important the medication is to prevent rejection (reflection).Would it be OK if I explain more why you need it every day (open-ended question; Ask)?" Clinician: "You want to keep things as simple as possible with your health and your goals (reflection).How do you think you can do that (open-ended question)?"