Motivational Interviewing

By: Stephen Pont, MD, MPH, FAAP
Assistant Professor of Pediatrics
Medical Director, Texas Center for the Prevention & Treatment of Childhood Obesity
Medical Director, Austin ISD Student Health Services
UT Southwestern, Austin - Department of Pediatrics / UT Austin - Department of Advertising
Dell Children's Medical Center of Central Texas
SJPont@seton.org  
On Twitter: @DrStephenPont

No more shoulda’, coulda’, woulda’ ….

Motivational interviewing (MI) is a technique used to produce positive behavior change through allowing individuals (a.k.a. patients) to convince themselves that they should change, that they can change, and that they will change. No more shoulda’, coulda’, woulda’, but, instead, through MI, individuals will decide that they should (importance), could (confidence), and will (commitment) make a change.

Some older models of doctor-patient communication have included confrontation (you must lose weight), education (obesity is harmful), and authority (you should listen to me because I’m your doctor). Motivational interviewing uses a different model. Instead of confrontation, education, and authority, MI relies on collaboration (walk alongside or partner with the patient), evocation (the clinician elicits the patient's arguments for change), and autonomy (the patient decides what and if to change).

Brief Background

Motivational interviewing was developed by William Miller and Stephen Rollnick for use in addictive behavior counseling and has been used effectively since the early 1990s. Miller and Rollnick describe MI as “a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal." (1
 
In recent years, the field of MI has expanded rapidly as more applications are recognized. The excitement continues as elements of MI are now being distilled into “brief components,” which may lend themselves to be incorporated more easily and successfully into the busy clinic day. Many clinicians now use brief components of MI to enhance patient counseling and to increase the likelihood that their patients will adhere to treatment plans and behavioral modifications requiring changes in behavior. Hundreds of published reports, including many randomized trials, discuss and document MI’s success.

Motivational interviewing assumes that people usually are not ready to change. They may have thought about changing, but they feel two ways about it: the yes…, but. “Yes, I’ve thought about exercising more, but…” Motivational interviewing helps people convince themselves that they can and should make a change. The individual makes the argument for change. Motivational interviewing puts the control into the hand of the “client,” either the patient (if sufficiently mature) or the parent/child for younger children. With the practitioner’s careful and thoughtful direction, the individual can develop a plan and enhance his or her motivation; thus, the likelihood for actually following through with the plan increases. The treatment of obesity is a relatively new area for the use of MI, but it is a powerful tool with a lot of potential and should definitely be added to our arsenal. In the nonauthoritative spirit of MI, may I invite you to read on and decide for yourself?

The Basics

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
Express Empathy
Develop Discrepancy
Support Self-Efficacy

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.

Express Empathy

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. 

Develop Discrepancy

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.

Support Self-Efficacy

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

Open-ended Questions
Affirmations
Reflective Listening
Summaries

A little more detail please?

Open-ended Questions

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.

Affirmations

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

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

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.”

Decisional Balance

This tool can be used to help patients explore their ambivalence regarding a change. The patient is asked to list the good and the not-so-good things regarding a given behavior. The patient then lists the good and the not-so-good things about changing the behavior. Using the adjective “not so good” is an important subtlety. In the spirit of MI, we discuss the good and the not-so-good, rather than the good and the bad. Describing things as bad or as negative can lead to blame or shame regarding an activity, and these are two feelings that can be counterproductive to the MI session. After the good and the not-so-good have been listed, the clinician can summarize the not-so-good things about the status quo and then summarize the good things about making the change. This summary ends on a positive note, supporting a change, and can lead to more conversation, as the patient contemplates his or her interest, confidence, and commitment to making a change.

Confidence Ruler

The confidence ruler is another MI tool. It is best used after the patient has expressed interest in making a change in a specific area, perhaps through a decisional balance exercise followed by the clinician's summary. The clinician then asks the patient to rate on a scale of 1-10 how important making the change is to the patient, with 1 being "not at all" and 10 being "very important." Whatever the patient response is, the clinician should commend the patient for his or her answer and then ask why the patient did not choose a lower number. This then results in the patient describing all of the positive reasons for choosing the particular number. Next, the clinician may ask what it would take to rate the change higher on the importance scale. The questions can then be repeated, using confidence as the metric. Some patients may prefer to place their finger on a visual ruler, marking their position. 

Not at all     1   2   3   4   5   6   7   8   9   10     Very Important

Change Talk

This is what we seek. When the patient begins to use this language, it signals that we are moving toward behavior change. Change talk can be remembered by the acronym DARN-C.

D = Desire
These statements express that a patient would like to or desires to make a change.

A = Ability
These statements describe the patient’s confidence or ability to make a change.

R = Reasons
These statements describe why the patient should change.

N = Needs
These statements speak to the patient’s need to make a change.

C = Commitment
These are actual statements of commitment (e.g., I will change) or proximal statements (e.g., I may change). The stronger the statement of commitment, the greater the likelihood that the patient will change his or her behavior. Thus, the goal of MI is to skillfully lead the patient toward strong statements of commitment, through recognizing and helping the patient to elaborate, verbalize, and develop his or her desire, ability, reason, and need for change. 

Addendum: Assessing Readiness to Change

The "stages of change," developed by Prochaska and DiClemente, provide a framework to conceptualize the process for how people change by categorizing the stages through which people progress when contemplating a behavior change. Because the stages of change are sometimes mentioned with MI, a brief description is provided here. Motivational interviewing can facilitate and/or support change during any of the stages; however, many feel that it is most helpful for those in the precontemplation and contemplation phases, where ambivalence plays the greatest role. The stages of change are generally a cyclical process; however, one could quickly progress from one stage to the next or fall backwards. Furthermore, a person may progress back and forth through the cycle multiple times before the change becomes permanent, and different behaviors are likely to manifest at different positions in the stages of change cycle.

The Six Stages of Change:

Precontemplation

The individual is not thinking about changing a behavior.

“What would you think about exercising more?”

“I haven’t really thought about it.”

Contemplation

The individual is considering a change, but has not decided. Some add the time component of contemplating a change during the next six months.

“Have you considered exercising more?”

“Yes…, but…”

Preparation

The individual has decided to change and is taking some steps toward making the change happen. Some add the time component of contemplating a change during the next month. A key in this stage can be to encourage the patient to commit to making a change by setting a date for the change to begin.

Action

The individual has begun the new activity (or stopped the old one).

Maintenance

The individual has maintained the behavior for a period of time (some say at six months). After six months of maintaining a change an individual will be less likely to regress than during the action phase.

Relapse and Recycle

The individual has ceased the new activity, has returned to an earlier stage, and may or may not desire to resume the change. This is a normal stage in the process of making a change permanent and is to be expected.

Motivational interviewing is a rich, powerful mechanism to encourage behavior change. This has been a very brief introduction. Please consider further reading and taking an introductory training course. A large amount of free information and information about vetted MI courses can be found at http://www.motivationalinterviewing.org/

Further reading:

               online toolkit_MI        online toolkit_MI in healthcare
 


References:
1.    Mid-Atlantic Addiction Technology Transfer Center. Motivational Interviewing: Resources for Researchers, Clinicians, and Trainers. Available at: http://www.motivationalinterviewing.org/

Additional Resources: 

Martino S., Ball SA, Gallon SL, et al. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficien Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University; 2006. Available at: http://www.motivationalinterviewing.org/

Miller WR, Rollnick S. Motivational Interviewing: Preparing People