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Motivational Interviewing

An Evidence-Based Approach for Medical Professionals in Promoting Behavior Change

Stephanie V. Straeter, Ph.D.Certified Health & Wellness Coach

Objectives

• Gain a basic knowledge of Motivational Interviewing (MI).

• Identify MI principles in promoting health behavior change with diabetic clients.

• Understand the four guiding processes of MI and identify related coaching tools.

• Introduction to the brief adaptation of MI, the Brief Negotiation Interview (BNI).

Motivational Interviewing

• An evidence-based, client/patient-centered, directive method for eliciting behavior change in a variety of health-related behaviors by exploring & resolving ambivalence.

• Conceived in the early 1980s by American psychologist William R. Miller, PhD, as an effective therapeutic approach for people with alcohol problems. Stephen Rollnick PhD aided Miller in further development of fundamental concepts.

• In general, it is based on principles of humanistic psychology as embodied in Carl Rodgers’ client-centered therapy. However, it is a directive version of that approach.

• Assumes that motivation is fluid and can be influenced.

• It is focused & goal-oriented, helping resolve ambivalence by increasing the discrepancy between current behaviors and desired goals, while minimizing resistance.

Motivational Interviewing

• MI is effective for a wide range of substance use disorders in addiction treatment settings & for hazardous drug & alcohol use in medical settings.

• Studies suggest that medical practitioners & students can be trained to implement MI effectively.

• Research indicates brief adaptations of MI are effective in reducing a broad range of health-risk behaviors in illnesses such as asthma, diabetes & hypertension, in meeting goals related to smoking, diet & exercise & in treating problems of substance abuse (e.g., alcohol, cocaine, heroin, and marijuana) with the result of reducing overall cost of health care & improving treatment adherence & health outcomes.

The Spirit of Motivational Interviewing has 3 Components

1. Collaborate and empower the patient/client (“Let’s put our heads together and review the options.”).

2. Support & respect patient/client autonomy & problem-solving capability.

3. Develop intrinsic motivation by eliciting change talk from the patient/client regarding the target behavior & behavior change.

Collaborate, Empower, Support &

Respect Patient/CLT Autonomy &

Problem Solving

Capability

Respect the patient’s/client’s ability, autonomy & freedom of choice (and consequences)for determining what’s best for themselves, given the proper support & guidance.

MI is not direct questioning, persuading, education, confrontation, advice-giving or consequence driven contingences (e.g. “take your medication or lose your health”).

Instead, help facilitate patient’s/client’s own decision making process (patient/client makes the argument for change).

Ambivalence is the Core of Patient/Client Resistance to Change

• The goal is to understand & facilitate resolution of patient/client ambivalence in the direction of a healthier lifestyle.

• It’s the patient’s/client’s task, not the medical professional’s to articulate his/her ambivalence.

• The patient/client is given opportunity to express the perceived cost & benefits to making a behavior change.

• “I know if I exercise it will help control my diabetes, but I am afraid I won’t stick with the exercise and will feel like a failure.”

Resolving Ambivalence is the Key to Eliciting Change

• Patients/clients have mixed feelings about making changes & may feel stuck regarding a course of action.

• The specific strategies of MI are to elicit, clarify, and resolve ambivalence in a patient/client-centered & respectful atmosphere.

Understand Patient/Client Resistance

• Most interventions try to push or pull patients/clients to temporary change when they are not ready.

• Patient/client resistance is an outward expression of an internal conflict & should be seen as a normal part of the change process.

• Patient/client resistance is often a signal the provider is assuming greater readiness to change than is the case, & it is a cue for the provider to modify motivational strategies.

Recognize Patient’s/Client’s Readiness to Change

Listen for and notice signs (i.e. change talk) for patient’s/client’s level of motivation

What is change talk?• Problem recognition• Concern about the problem• Commitment to change• Belief change is possible

Preparatory Change Talk - DARN

• DESIRE to change (want, like, wish ….)

• ABILITY to change (can, could …)

• REASON to change (if….then)

• NEED to change (need, have to, got to …)

MI Interaction Techniques (OARS)

• Open-ended questions: elicit information from the patient/client instead of yes/no responses (i.e. “What are your thoughts about taking medication for your diabetes? "or “What are your thoughts about walking as a way of increasing your activity?”)

• Affirmations: favorable comment on patient’s capacities, strengths, characteristics & traits for change. Must be congruent and genuine (“You didn’t feel like making an appointment but the value you place on health won out!”) (“You’re resourcefulness guided you in finding affordable ways to eat healthy.”) These will positively impact both patient self-efficacy & self-esteem.

MI Interaction Techniques

• Reflective Listening Statements: function like mirrors, enabling patients/client to see themselves in new ways and muster motivation for change. Perceptive & timely reflections lie at the heart of MI when it comes to developing discrepancy.

• MI uses more reflective listening statements than questions of any type. A good rule of thumb is to strive to provide two reflections to each question asked.

• The 4 types of reflections used by MI practitioners to develop discrepancy are: Simple, Amplified, Double-Sided and Shifted Focus

4 Types of Reflections

• Simple: A repeating exactly what the patient/client said. Might sound like ‘parroting back.’ You use the participants’ words/language so they can hear themselves.

• Amplified: Might also be called an exaggerated reflection. The exaggeration can be expressed thru the words and/or tone of voiced used. “NO ONE in your life exercises?”

• Double-sided: Reflect the ‘both sides’ of the story you hear them describing. “You have shared a number of reasons why exercise has such benefit for you and the fact your schedule does not appear to allow for it.”

• Shifted-focus: If a patient/client is spiraling down & deeply stuck on a topic, you might shift their attention to another topic of interest to them. “Getting more sleep is quite a challenge with three kids in the middle school years, what else rejuvenates your spirit and energy?”

• All reflections come from a place of empathy; a non-judgmental acceptance of where the patient is coming from. However, some reflections are purely empathic in nature as described above.

MI Techniques

• Summaries: at the end of your conversation, it is often helpful to summarize the conversation to allow you & the patient/client to reflect on your discussion & identify next steps.

• Summarizing the main points of the discussion helps patients/clients know you have been listening to them while giving them an opportunity to correct any misunderstandings.

• Asking for Permission Prior to Seeking Information, Giving Advice or Information if Patient/Client Hasn’t Asked for It: This is a simple but, effective empathy technique similar to the knock on the door of health care practitioners prior to entering the examination room. It’s empowering & communicates respect.

(“Do you mind if I ask you a few personal questions?” or “With your permission, I’d like to purpose a plan.” or “If you don’t mind may I share a bit of information?”)

MI Principles

• Express Empathy- see the patient’s situation through his or her eyes & express that understanding

• Click on the link below to view a 6 min video clip example of MI with an African American male struggling with diabetes & depression.

• Notice the counselor’s use of reflective listening and expression of empathy during the session.

https://youtu.be/Td2CmihAQcg

MI Principles

• Develop Discrepancy – between a patient’s/client’s current behavior & his/her own goals, interests, & values

• Click on the link below to view a 6 minute video demonstrating a physician using MI with a patient’s mother who struggles with quitting smoking.

- Note the physician guiding the mother to examine the discrepancy between the smoking behavior & her values of not wanting to model the behavior for her child. Also note use of affirmations & support of self-efficacy with having past success of smoking cessation during her pregnancy.

https://www.youtube.com/watch?v=URiKA7CKtfc

MI Principles

• Roll with Resistance – is a specific type of empathy, wherein arguing is avoided and attempts are made to thoroughly understand a patient’s reluctance to change. Resistance is not challenged instead use the MI interaction techniques (OARS) to further explore the patient’s views.

• Click on link below to view a 4 minute video The Ineffective Pharmacist: Non-Motivational Approach

https://www.youtube.com/watch?v=dmmvAR6K1TQ&t=187s

• Click on link below to view a 4 minute video The Effective Pharmacist: Motivational Interviewing Demonstration

https://www.youtube.com/watch?v=5UU63mfNnD4

MI Principles

• Support Self-Efficacy: a patient’s/client’s belief that one has the capacity to initiate or sustain a desired behavior, is crucial to the change process.

• Empowerment and offering choices are critical to the development of patient self-efficacy.

• Potential solutions are elicited from patients rather than prescribed.

• Click on the link below to view a 14 minute video Optimizing Patient Care Series: Motivating Patients to Promote Adherence.

It’s a demonstration of how a pharmacist's need to jump in & give advice contributes to an overall ineffective interaction with an individual with Diabetes. Overview of how to do MI and demonstration of pharmacist utilizing the MI approach leads to an effective interaction with an individual with Diabetes. https://www.youtube.com/watch?v=8C1CKyyJtHU

•

Overview of Motivational Interviewing

• Specifically, MI aims to increase intrinsic motivation for change by the following strategies:

1. Engaging patients/clients with reflective listening, open-ended questions, and affirmations, as well as supporting patient/client autonomy & “rolling with resistance”.

2. Focusing patients/clients through a discussion about discrepancies between their stated values & goals & their current behaviors.Click on the link to see example Engaging and Focusing stages Motivational Interviewing Diabetes Medication Compliance (9:42)

https://www.youtube.com/watch?v=U8053kzlnEo

Overview of Motivational Interviewing

3. Evoking patients’/clients’ motivations for change with evocative questions.

4. Planning collaboratively designed action plans to reduce health-risk behaviors.

Click on the link to see example Evoking & Planning stage Motivational Interviewing - Diabetes - Pulling His Own Strings (6:11)

https://www.youtube.com/watch?v=6aA27IAm15g&t=38s

The Four Practice-Oriented Steps of the Brief Negotiation Interview (BNI) Adaptation for Medical Settings

1. Ask for permission to discuss the difficult topic/decision and reinforce autonomy.

• If you get a refusal respect the wish and give the relevant info without discussing it.

• Explicitly reinforce their autonomy in making medical decisions with statements such as:

• “I’ll tell you what I think would be medically prudent to do in this situation, but the ultimate decision is up to you.”

2. Give feedback on the client’s/patient’s response to the information.

• This step requires specifically, reflecting the client’s/patient’s reaction to the information, any verbalizations that indicate a willingness to engage in or even consider the recommendation-change talk.

The Four Practice-Oriented Steps of the Brief Negotiation Interview (BNI) Adaptation for Medical Settings

3. Enhance motivation with the following strategies:

a) After determining what is motivational in the client’s/patient’s initial resistant statement (step 2 above), ask why the client/patient has even some amount of motivation (the “Why-Change?” question). Goal is to evoke compelling, heartfelt, personally relevant reasons for change.

b) Assess motivation (i.e., “On a scale of 1 -10, how ready are you to change any aspect of this issue?”).

c) Ask, “Why didn’t you pick a lower number on the scale?” or “Why not less ready or motivated?”

d) Repeatedly ask and talk about these “seeds” of motivation more than the client’s/patient’s reasons for resistance.

The Four Practice-Oriented Steps of the Brief Negotiation Interview (BNI) Adaptation for Medical Settings

4. Ask, “What’s the next step, if any?”

a) Stress the phrase, “if any”, in the question to reinforce once again the client’s/patient’s autonomous decision-making (i.e., say, “If there is a next step, and only you can decide, what would that be?”).

Click on the link below to see BNI with middle age woman reluctant to see how use of alcohol could be affecting her HTN:

https://www.youtube.com/watch?v=QUMWNjSH2R0&t=2s

Click on the link below to see BNI used with middle age man needing SA treatment referral:

https://www.youtube.com/watch?v=WLmNS1oaa-I&t=499s

Click on the link below to hear an over view of BNI and commentary on BNI used in the two prior BNI videos:

https://www.youtube.com/watch?v=KymgL-vtXFs&t=6s