You likely already use many MI principles and techniques without realizing it. Motivational interviewing strives to help direct individuals to use their own energy and insight to discover the best solutions for themselves. Motivational interviewing uses good counseling skills, with genuineness, empathy, and an unconditionally positive regard. A clinician using MI expresses empathy, develops discrepancy, reduces resistance, and supports an individual’s self-esteem. Upon encountering a stumbling block resulting in resistance to change, the clinician adjusts the course, acknowledging without judgment that there may be strong reasons why a person may not want to change.
The spirit of MI can be summarized by four principles.
So what are they?
Four Principles: REDS
Roll with Resistance
So what do these mean?
Roll with Resistance
Resistance occurs when the individual argues against a change. If the clinician begins by making an argument for change, then the natural response from the patient will be to argue why he or she should not change. In MI, this is a red flag indicating the need to change directions and take a different approach. When the individual argues against change, he or she is likely to begin to convince him/herself to maintain the status quo. Instead, the goal for the clinician is to lead that individual in describing the reasons to make changes. The individual, not the practitioner, should make the arguments for change. Ultimately, the power remains with the individual. Too much resistance could also indicate that this may not be the right time for this particular change and that a different topic may need to be chosen. For example, if a patient is adamant about not discussing the removal of the TV from the bedroom, then the clinician may need to shift the discussion and ask instead what the patients thinks about reducing the amount of sugary beverages or spending more time playing outside.
This is a core MI principle that sets the correct, supportive environment for a productive and positive encounter. Empathy cannot be insincere; it is acceptance and understanding, but does not necessarily require approval. Reflective listening (see below) can help convey empathy during a visit.
A goal of MI is for the individual to make the argument for change. The clinician facilitates the process through an intentional conversation leading the individual to recognize the discrepancy between where he or she is now in life (i.e., with current behaviors) and where he or she wants to be. Small discrepancies between current behavior and future goals build together, eventually forming the motivation and momentum for change. Creating a decisional balance (see below) for which pros and cons of behaviors are listed can help develop this discrepancy.
Not only must the individual be interested in making a change, but also he or she must be confident about success. Examples of when an individual has succeeded in the past can help build confidence for future changes. Even if a previous attempt at change was only successful for a brief time, it can be seen as a success. Patients can draw from what helped them make changes and then try to trouble-shoot and work through whatever happened, resulting in the return to baseline. A confidence ruler (see below) is one mechanism to gauge self-efficacy. The clinician may also increase the individual’s self-efficacy by expressing confidence in the individual’s ability to make the change. Even better is when the individual describes all of the reasons why he or she will succeed.
Four Basic Methods (to establish rapport, work through resistance, and express empathy): OARS
A little more detail please?
Medical questioning with the goal of a correct and efficient diagnosis requires thoughtful questions that often seek yes/no answers. Motivational interviewing has a different goal, that of the patient self-realizing the need, ability, desire, and commitment to make a change. To reach this goal, clinicians must carefully select their questions and style of questioning. Yes or no answers decrease patients’ active participation. Motivational interviewing allows the patient to work actively during the conversation, slowly becoming self-aware of the need for change. Open-ended questions allow the patient to set the direction of the conversation, compared to yes/no questions, which allow the patient to become passive and wait to respond to the clinician’s questions. Initially, this shift in questioning style may feel awkward as the pace of the conversation may seem slower than a typical series of medical, symptom-based questions. And sometimes a moment of silence will be enough to encourage a helpful answer from the patient, moving the conversation forward.
Providing the patient with regular affirmations helps to set the correct environment ― open, understanding, and nonjudgmental ― for the MI session. Affirmations also help to support and build a patient's self-efficacy. Even simple responses can promote or erode the supportive environment. A patient may say that he has purchased some diet soda. One response could be, “Yes, but are you going to drink it?” A more affirmative response would be: “That’s great, now you will have the diet soda available if you get the craving for a soda!” Everything we say can contribute positively to an environment conducive for change.
Reflective listening is a key tool for helping a patient resolve ambivalence about a particular area for change. Becoming skilled in reflective listening will take some time and practice, neither of which will be fully covered through merely reading this section. There are many types of reflections; we will cover only the most basic ones. Simple reflections involve restating what the patient has just told you with a simple interpretation. It is a statement and not a question. The reflection should end with the tone of your voice remaining the same, and not going up at the end – which makes statements sound much more like questions. Say the phrase to yourself: “Being teased about your weight upsets you.” If the tone of your voice goes up at the end, the statement becomes a question. While the goal of reflective listening is to encourage a response from the patient, statements should not be phrased as questions, because they could be answered with a simple yes or no and thus slow the pace of the conversation. Maintaining an even tone produces a statement and allows the patient to elaborate.
Summaries are very much as they sound. A summary gives you an opportunity to make sure that you understood what the patient has told you and it gives the patient an opportunity to correct Summaries are very much as they sound. A summary gives you an opportunity to make sure that you understood what the patient has told you and it gives the patient an opportunity to correct you if you have misunderstood something. “Let me make sure that I understand. You are very concerned about your daughter’s health, particularly that she eats a lot of fried food and no vegetables, but whenever you ask her to eat anything healthy, she refuses and a fight ensues.”you if you have misunderstood something. “Let me make sure that I understand. You are very concerned about your daughter’s health, particularly that she eats a lot of fried food and no vegetables, but whenever you ask her to eat anything healthy, she refuses and a fight ensues.”