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."
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.
Pre-Contemplation (Not Ready)
Individuals: No intention of change. They see advantages of current behaviour, deny the problem, avoid thinking about it and sometimes view their situation as hopeless. They may change if enough external pressure is applied but will quickly revert back once pressure is removed.
Clinician: Raise doubt and increase the patient’s perception of the risks and problems associated with their current behaviour. Clinicians may offer harm reduction strategies and help patients realise that feelings of resistance are a natural feeling that can be worked through.
Contemplation (Considering Change)
Individuals: They acknowledge they have a problem and begin thinking about solving it but make no commitment to do so. They acknowledge the dangers and risks of their current behaviour and consider the pros and cons of changing. They may form plans for change, but they are often vague and rarely lead to action.
Clinician: Help patients weigh up the pros and cons of change by exploring the alternatives, identifying reasons for change, discussing the risks of not changing and increasing the patient’s confidence in their ability to change.
Individuals: Patients have realised that a change is beneficial and achievable. They are intent on taking action and begin making concrete plans to change within the next month. They will often make their intention public but may still need convincing that this is the best step.
Clinician: Help create a detailed action plan with clear goal setting. This plan should be realistic and include steps necessary to make the change.
Action (Give It a Go)
Individuals: Patients overtly modify their behaviour and surroundings in an attempt to complete the change successfully.
Maintenance (Sticking to It)
Individuals: Patients successfully avoid former behaviours and maintain their new behaviours. They must learn to deal with temptation in order to avoid relapse. They become more assured in the change as time continues.
Clinician: Help the patient identify and use strategies to prevent relapse.
Individuals: Relapses are common and occur when a patient resumes their previous behaviour. They might feel disappointed, frustrated or that they have failed.
Clinician: Help the patient renew the process of contemplation and action. Clinicians should help the patient see that relapse is a normal step and provides an important opportunity to learn about how to maintain the long-term change in the future
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.
The clinician acknowledges the patient’s expertise and forms a partnership with the patient in order to achieve joint decision making.
The clinician connects behavioural change to things the patient cares about, thereby activating the patient’s own motivation by using their own reasons.
The clinician acknowledges the patient’s right and freedom not to change.
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:
- Accept the patient has responsibility for changing behaviour. This does not lie with the clinician.
- Elicit reasons for change from the patient. The clinician should not advise them why they should change.
- Understand ambivalence to change by exploring the pros and cons of the behaviour on their life.
- Work to resolve the ambivalence by connecting the things the patient cares about with motivation for change.
- Emphasise the decision to change remains with the patient.
- 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.
Indicate a desire to make a change. "Getting in shape would make me feel so much better about myself."
Speak to the patient's self-efficacy or belief in their ability to make changes. "I think with some help, I might be able to cut back."
Reflect the reasons the client gives for considering a change. These tend to be rational. "I have to quit smoking because of my asthma."
Indicate a need for change where the emphasis is more emotional. "Something has to change, or my marriage will fall apart."
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.
Ask Open-Ended Questions
Definition: These allow patients to tell their stories. It encourages patients to do most of the talking and allows clinicians the opportunity to learn what the patient cares about. Promoting dialogue enables clinicians to reflect thoughts back to the patient.
Examples: “What makes you think it might be time for a change?”
Definition: These show that the clinician understands and can empathise with the patient. They can take the form of statements or compliments and will help build rapport with the patient, as well as highlight their strengths and efforts. Affirmations validate the patient’s views and enable them to build on past successes.
Examples: “I can see it took a lot of courage for you to discuss quitting smoking with me today. I appreciate this is not easy for you.”
Definition: These involve listening to patients and repeating their comments back to them. It allows clinicians to clarify their understanding of matters and helps patients to feel heard. Furthermore, it encourages continual exploration and promotes deeper understanding of motivations. If a reflection or clarification is incorrect it will give the patient an opportunity to state their reasons for this.
Examples: “It sounds like you’re not ready to quit smoking.” Or “I get the sense that you want to change but have concerns about the effect this will have on your family.”
Definition: These link discussions, demonstrate listening and ensure mutual understanding of what has already been expressed. They can be used to expand the discussion and point out discrepancies between the patient’s current situation and their future goals. They can also be used to finish a conversation.
Examples: “Over the past four weeks you have been talking about giving up smoking, and it seems that you recently started to recognise you are coming up with excuses for not doing this.”
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.
- 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.
Disadvantages of Status Quo
- What worries you about your blood pressure?
- In what way does your weight concern you?
- What difficulties have arisen from your drinking?
Advantages of Change
- What are the advantages of losing weight?
- How would your life be different if you stopped drinking?
- Where would you like your health to be in 5 years?
Optimism for Change
- When have you made a significant change before? How did you do it?
- What strengths do you have that would help you make a change?
Intention to Change
- How do you want your life to be different in 5 years?
- If you could do anything, what would you change?
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)
Resist the righting reflex. Try not to change the individual’s course of action through didactic means. This often has a paradoxical effect of inadvertently reinforcing the argument for the status quo. Individuals tend to resist persuasion when ambivalent about change and will recall their reasons for maintaining a behaviour.
Understand your patient’s motivations. It is their motivations, not yours, that will elicit a change in behaviour. Approach their interests, concerns and values with curiosity. Explore their motivation for change and seek to understand the potential barriers to change.
Listening with empathy. The patient has the solutions, not the clinician. This will help you understand the pros and cons of the situation.
Empower your patient. Help them understand they have the ability to change their behaviour. Explore their ideas about how they can make changes and draw on their personal knowledge of what succeeded in the past. Give them confidence in their ability to change.
Four Additional Rules
Attempt to understand the patient’s perspective, thoughts and feelings without passing judgement, criticism or blame. Establish an open and respectful exchange by approaching patients with genuine curiosity about their experiences, feelings and values.
Help patients identify discrepancies between their current behaviour and future goals or values. This might involve exploring the pros and cons of change, helping patients express their concerns about a particular behaviour and finding reasons to tip the balance in favour of change.
Roll with Resistance
You will meet resistance if the patient is ambivalent about change and you move too quickly. Resistance comes in many forms and includes interrupting, arguing, discounting advice, blaming others or excusing their behaviour. Interpret resistance as a sign that the patient holds a different perspective to you. Attempt to shift the focus of the discussion or reframe what the patient has said by using simple reflection and emphasising the individual’s choice. Do not judge what they have said.
People will have made attempts to change their behaviour in the past. They will have been both successful and unsuccessful on different occasions. Reflect on times in their life when they successfully managed a change and highlight their strengths at this time. This promotes self-efficacy and shows your belief in their ability to master change. Help them grow in confidence.