Motivational Interviewing
last authored: Jan 2011, David LaPierre
last reviewed:
Introduction
Clowngespräch, 1912 - Christian Rohlfs
Motivational interviewing (MI) is a form of counselling designed to examine and resolve ambivalence around changes relevant for health using the patient's own motivation for change.
Motivation is elicited, not imposed, and it is the task of the patient/client to identify and address ambivalence. Confrontation or persuasion have little role to play.
MI has been used successfully in the following:
- attendance at follow-up visits
- adherence to glucose monitoring
- exercise
- fruit/vegetable intake
- stress reduction
- reduced sodium intake
- food diaries
- reduced unprotected sex
- improved medication adherence
- decreased alcohol and drug use
- smoking cessation
- fewer recurrent injuries and hospitalizations
- increased sanitation rates in Zambia (Quick, 2003).
Foundations of MI
The four guiding principles of MI may be summarized as RULE:
Resist the righting reflex: Our default is frequently to urge someone to stop a poor behaviour, and this can be almost automatic. However, this can have the opposite effect as the patient resists persuasion, an automatic human tendency. This is particularly true if the patient is ambivalent about a behaviour choice.
- health care provider: "You really need to lose weight through diet and exercise."
- patient: "I know doctor, but it's so hard, my life is so busy, and I don't have enough money..."
Another key thing is that we tend to believe what we hear ourselves say. If patients are arguing AGAINST change, rather than for it, this can decrease the chances of successful change.
Understand the patient's motivations: Behaviour change will most likely occur if a patient's reasons are voiced, rather than yours.
"People are generally better persuaded by the reasons they themselves have discovered than by those which have come from the mind of others." Blaise Pascal, Les Pensees, 1670.
Listen to your patient: Frequently patients come to their health care provider for answers. However, with behaviour change, we need to listen for answers from the patient. Good listening is a skill that takes quite a bit of practice.
Empower your patient: Results are frequently better when the patient is engaged and interested in their health. It is important to inspire patients and support their hope. Get them to think aloud during the conversation, facilitating their creative expression of change talk.
All about Ambivalence
Ambivalence - seeing both sides of a question and not knowing which way to go - is very common when patients are considering behaviour change. Most people want to be healthy, but the status quo is familiar and comes with rewards. There are disadvantages to change, some behaviours may even be painful, such as glucose monitoring. Statements describing ambivalence frequently have 'but' in the middle:
- "I know I should take my medicine, but I hate the side effects"
- "I need to quit smoking, but it is so hard"
- " I want to exercise more, but I just can't seem to find the time"
Ambivalence can keep people stuck without changing. Perhaps even more hindering, though, is for others to inform the patient of the reasons, or pro's, of changing. This leaves them defending the reasons NOT to change.
It is much better to carefully watch for pro-change reasons the patients come up with and endeavour to support this 'change talk', as described below.
Change Talk
Change talk frequently signifies something within a patient that is leading them towards behaviour change. There are six types of change talk:
desire
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need
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ability
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commitment
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reasons
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taking steps
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Ambivalence is often associated with conflict around desire, ability, reasons, and need. They are critical to pick out, and can be remembered with the acronym DARN. These are precommitment sentiments, ideally leading up to commitment and then taking steps, culminating in behaviour change.
It is not as important to be able to categorize the type of change talk as to be able to identify it when present. MI involves eliciting change talk, leading towards a strengthening of commitment. DARN talk also points towards the patient's values, which can be powerful motivators for change.
You can elicit change talk directly:
- "Why would you want to lose weight?"
- "How would you lose weight, if you decided to?"
- "Name some reasons you would lose weight"
- "How important is it for you to lose weight?"
Being attuned to change talk is an ideal way of becoming better at guiding. The better you are doing at guiding, the more change talk you'll here.
Assessing Motivation
The question should not be "Why isn't this person motivated?" but rather, "What motivates this person right now?" Don't make assumptions here!
There are specific clinician behaviours that are important:
- understand the patient's perspective
- offer acceptance and affirmation, particularly of personal choice and direction
- support the patient as they identify problems, grow in motivation, and seek and embrace change
- monitor stage of change
We do many things because our motivation is high when we are feeling bad; when we work hard, we start to feel good, and when our motivation thusly disappears, we often drop the behaviour. We need to keep behaviour going; if negative feelings are short-term motivators, positive feelings are long-term motivators. These include health, control, and self-esteem.
Discussing behaviour change can occur whenever a patient is considering doing something different in the interest of health.
"Do you want to take care of yourself?" is a superficial question; also need to ask
"why do you want to take care of yourself?" and
"how hard are you willing to work to take care of yourself?"
- give patients 3 chances
"how willing are you to make choices that might increase the burden temporarily in order to improveyour health in the long run?"
Assessing Behavioural Intention
Do you know this is a problem?
Are you distressed by this problem?
Are you interested in change?
Are you ready to change now?
Ask questions; minimize statements
- We've got about 3 minutes ... what can you tell me about...?
- "do you know what I would recommend?"
- "have you ever thought about..."
- "research shows that... Are you interested in this?"
- I've heard what you're thinking; do you want to hear what I'm thinking?
To further explore, continue asking questions
- "What have you heard from other people/seen on the internet/news, etc?"
- "What else have you wondered or worried about?"
Supporting Motivation
Express empathy
- let them know you understand their choices and behaviours
- "know I understand why you..."
Develop discrepancy: Compare where the patient is and where they want to be, then get the patient to discover the why and the how to change.
Take a curious, non-judgmental stance
- "help me understand what went wrong"
Avoid arguing
- "yes, but" means "no, because" - you are in a motivational argument. stay away
- "remind me of why you want to change"
- "It's not important to me whether you"
- "I'm as worried as you are about"
Roll with Resistance
- as things don't work out, see them as challenges to overcome
Support self-efficacy
- the best predictor of change is confidence
- find things the person knows they can do
Easier choice, harder behaviour
- bring up consequences of choices (ie seeing grandchildren grow) make the choice easier
- $100 dropped from neighbour's pocket - do you give it back?
Self-esteem is critical; if activity and healthy eating become part of your identity, they will continue!
Building momentum
- "you've got a good point there. Maybe I haven't considered the impact of..."
Reframing: offer a new perspective
- "it seems like your life is very stressful, that you need a way to deal with this, and cigarettes are your primary way of dealing with this. Let's brainstorm about others."
Emphasizing personal choice and control
- "No one can make these decisions or changes but you"
- "I can't decide for you, even if I wanted to"
Summarizing
- I'd like to pull all this together so we can see where we are.
Paradox - take on the 'no change" perspective and allow the patient to fashion responses
- "It sounds like you want things to remain as they are"
- A change takes a lot of motivation. I'm not sure if you're quite there yet"
- "I find it helpful to have a little debate. I'm going to play you, and I'd like you to convince me this really is a problem."
Offer personalized feedback
- "Your blood glucose results are very high. What do you make of this?"
Offering advice
- "I'm ahppy to offer advice, but I don't want to stop your creativity. You're the expert on you"
- "This may or may not apply. It will be up to you to decide"
- "Some people have had success with... would this work for you?"
- "There isn't one way to change. Let me describe some possibilities and you can let me know what makes sense for you."
Reflection
It is important to assess your knowledge of where they are at, and this can be done by repeating, rephrasing, parahprasing, and reflecting feelings.
- it seems that you...
- from what I understand, you...
Amplified reflection uses the patient's words to bring out the opposite in their ambivalence
- you feel your drinking is having no impact on those around you
- you see now way of increasing your physical activity to lose weight
Be careful not to lapse into judgement or criticism here!!
Identifying and Navigating Barriers
Resources and References
Rubak S, Sandback A, Lauritzen T, Christensen B. 2005.
Quick R. 2003. Changing community behaviour: experience from three African countries. Int J Environ Health Res. 13 Suppl 1:S115-21.
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