Communication

Motivational Interviewing

Motivational interviewing is an evidence-based approach designed to encourage patients to talk themselves into making beneficial changes in their lives. This technique can be used to help patients change longstanding behaviours by engaging them, promoting autonomy in decision making, clarifying both their strengths and aspirations and seeking to get patients to evoke their own motivations for change. Motivational interviewing helps participants meet the critical components of motivation as they become ‘ready', 'willing' and 'able’ for change.

"People are better persuaded by the reasons they themselves discovered than those that come into the minds of others."

Blaise Pascal

A Need for Motivational Interviewing

Motivational interviewing is necessary due to the realities of clinical medicine. Clinicians often deliver advice which advocates for a healthier lifestyle or reduction in harmful behaviours. Unfortunately, patients frequently ignore or contest this advice. The natural response for the clinician is to reiterate the advice using greater authority. This authoritative or paternalistic approach often increases resistance and does little to enact change. After several failures, future attempts to enact change may be abandoned as patients are labelled as unmotivated or lacking insight. Motivational interviewing provides a method for helping patients adopt behaviours which will improve their underlying health.

Stages of Change Model

The Stages of Change Model was proposed by Prochaska and DiClemente in 1982. Their model describes the readiness to change as a dynamic process that can fluctuate depending upon the pros and cons of the change in mind. A conflicted state can exist when an individual has opposing feelings in which they both want to change and don’t want to change. This is known as ambivalence. It is particularly evident when there is a conflict between immediate rewards and long-term adverse consequences. This model provides a framework for understanding the incremental steps that individuals pass through as they change a particular behaviour and we can use it to understand where our patient is in their current journey.

Introduction to Motivational Interviewing

Motivational interviewing is a patient centered counseling style which encourages a collaborative approach when helping a patient find solutions to their particular problem. It is based upon the assumption that people are more ambivalent about change rather than resistant to it. Change talk describes the statements individuals make to reflect their desire to change, focus their ability to change and express their commitment to change. It has been associated with successful behaviour change in clinical studies. Motivational interviewing therefore attempts to elicit and reinforce change talk in order to resolve this ambivalence.

Patients are placed foremost and feel both listened to and understood when the clinician works as a facilitator rather than the expert. Effective and enduring changes can then be achieved by liberating the patient’s intrinsic resources, ensuring their autonomy is respected and boosting the confidence in their ability to change. These changes help the patient choose to modify their behaviour when they feel ready and not when they are told. The aim of motivational interviewing is to guide the patient towards change with a collaborative and non-confrontational approach while respecting their autonomy.

Motivational Interviewing in Practice

Motivational interviewing is comprised of two steps. First you must build the motivation for change (encourage change talk) and then you must strengthen the commitment to change. These are covered in the two sections below. Let us begin with an outline of the steps within motivational interviewing:

1. Accept the patient has responsibility for changing behaviour. This does not lie with the clinician.
2. Elicit reasons for change from the patient. The clinician should not advise them why they should change.
3. Understand ambivalence to change by exploring the pros and cons of the behaviour on their life.
4. Work to resolve the ambivalence by connecting the things the patient cares about with motivation for change.
5. Emphasise the decision to change remains with the patient.
6. Boost patient confidence in their ability to change by exploring times they have successfully managed change. Offer support in this process.

Introduction to Change Talk

The four main forms of change talk are described below. Learn to recognise them and emphasise any change talk displayed by the patient. Pay particular attention to any commitment language as this presents an opportunity for further elaboration and the possibility of strengthened commitment.

Part 1: Building Motivation to Change

This first step seeks to elicit change talk from the patient. These are the ideas the patient brings to the discussion and they will form the basis of the motivation needed to resolve the patient's ambivalence. This section details the different strategies you can use in order to elicit thoughts of change.

Skills for Building Motivation (OARS)

Four skills for building motivation to change are represented by the acronym OARS. They help in building rapport and establishing a therapeutic relationship between clinician and patient.

The Importance Ruler

Importance of Change: This is a useful tool that can identify the discrepancy between the current situation of a patient and where they would like to be. Highlighting this discrepancy plays a central role in motivating people towards change. Ask the patient to elaborate on the discrepancy and reflect this back to them. For example:

“On a scale of 0 – 10, how important is it for you to stop smoking? Where would you like to be on this scale? Why are at XX on the scale and not 0? What would it take for you to go higher?”

Eliciting Change Talk in Practice

Take time to elicit change talk from the patient if they scored low on the importance ruler score. There are three areas of focus: values, exploring hopes and eliciting discrepancy.

Values

Explore the discrepancy between the client’s values and their current state:

• "Tell me what is most important in your life at this moment?"
• "Tell me about the things you value and are a priority?"
• "In what way are you living out these values?"

Hopes and Goals

Explore the client’s hopes and goals in order to explore the why of change:

• "What are some of the things you wish to move toward in your life?"
• "When you think about the future, what are some things you would like to have in it?"
• "When you were a child, what did you dream about doing with your life? How about now?"
• "If we were to be successful in our work together, what would that look like?"

Elicit Discrepancy

Place the current behavior in the context of current values or desired future.

• "Tell me about the times you are not living out your values as fully as you would like?"
• "How does your current behavior fit within your values?"
• "How can this value help you achieve the aims you set for yourself?"
• How does your current behavior support your future goals?"

Part 2: Strengthening Commitment to Change

Strengthening commitment to change involves setting goals and negotiating a plan of action. You can do this through eliciting a patient’s intention to change by asking a series of four types of question. The aim here is to discuss the patient's ambivalence in detail and to facilitate a cost/benefit anaylsis. Discuss the specific consequences of the patient's behaviour and assess the positive or negative aspects of the past, present and future. Make sure you verbalise an appreciation for ambivalence as a normal part of the change process. The goal is to help the patient resolve their ambivalence.

Self-Efficacy

A key construct in goal setting is self-efficacny. Most people will select goals they believe they can achieve and self-efficacy determines the actions they will take in reaching their goal. If a person sees no possibility of success, they will put little or no effort into trying to reach the goal. In contrast, patients with a high self-efficacy are more likely to believe they can meet their goal through their own actions. These patients tend to assume they have a high ability and will therefore adopt more challenging goals. This itself is linked to better performance. Thus, exploring the level of patient self-efficacy is crucial in any behavioural change intervention.

People who lack self-efficacy are characterised by the tendancy to focus more on their weaknesses than their strengths. They may expect results with little effort and may have low confidence levels. People with low self-efficacy tend to avoid accepting challenges because they fear failure and they will often explain failures as a result of their own personal shortcomings. They also tend to have a hard time recovering from setbacks and quickly lose interest in activities they are involved in.

The Confidence Ruler

Confidence in Change: You can assess self-efficacy using the confidence ruler. You can use this tool to build the patient’s confidence in their ability to change. Again, use a ruler to get a measure of where the patient is. Focus them on their strengths and past experiences of success. For example:

“On a scale of 0 – 10, how confident are you that you can stop smoking? Why are at XX on the scale and not 0? What would it take for you to go higher?”

You can further build on a patient's self-efficacy by asking them questions by focusing on internal strengths and increasing the optimism about the possibility of change. Try asking the following questions:

• Tell me about a time when you made changes in your life. How did you do it?
• What personal strengths do you have that would help you succeed?
• Imagine you decided to change, what about you would enable you to do it?
• What encourages and inspires you?
• Who could offer you support in making this change?

Creating a Plan

Working together you should decide on a plan for change. Set goals (SMART: specific, measurable, achievable, realistic, time-bound) and elicit the intentions from the patient. If the patient needs advice to set appropriate goals, ask for their permission before doing so. Remember, the patient is the expert, and you should not judge what will work for them. You can offer advice on what has worked for other people, but the ultimate decision rests with them.

• “What changes were you thinking of?”
• “Where do we go from here?”
• “How would you like things to turn out?”

Guiding Principles of Motivational Interviewing

Delivering therapy with motivational interviewing is guided by four main principles and four additional principles which can be applied to longer sessions. These were described by Rollnick in 2008.

Four Main Principles (RULE)

Four Additional Rules

References

• Australian Family Physician: Motivational Interviewing Techniques
• Royal College of Nursing: Supporting Behaviour Change
• Positive Psychology: Motivational Interviewing