Consultation Skills

Motivational Interviewing

What is Motivational Interviewing?

Motivational interviewing is a counselling and consulting method that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behavior.   MI uses a guiding style to engage clients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy in decision making (Rollnick et al 2008).

MI is based on these assumptions:

  • how we speak to people is likely to be just as important as what we say
  • being listened to and understood is an important part of the process of change
  • the person who has the problem is the person who has the answer to solving it
  • people only change their behaviour when they feel ready – not when they are told to do so
  • the solutions people find for themselves are the most enduring and effective.

In this scenario, the person makes an instant decision to quit smoking. There’s an emotional stimulus which causes a shift in perception and meaning resulting in increased readiness to change.   He must have had been at a stage of ambivalence before today (i.e. wanting to stop but also not wanting to stop) and this moment has resulted in a resolution of that ambivalence and the crystallisation of discontent (i.e. the last straw).

What is so great about Motivational Interviewing?

Motivational interviewing (MI) evolved from Carl Roger’s person-centered, or client-centered, approach to counseling and therapy.  It is a method that helps people commit to the difficult process of change. And the great thing about it is that it doesn’t require many sessions to do it.  The other great thing is that it’s not hard work.   Sometimes, when we tell patients things they ought to do, it’s hard work when they become defensive.  It’s even harder when they then become so defensive to the point of being angry with you and then pursuing a verbal fight with a breakdown in the doctor-patient relationship.  Motivational Interviewing is a more pleasurable and positive activity compared to just telling patients what to do because we consider ourselves to be “the expert”.

MI differs substantially from more aggressive styles of confrontation. It is not:

  • arguing with the client who has a problem and needs to change
  • offering direct advice or prescribing solutions to the problem without the person’s permission or without actively encouraging the person to make their own choices
  • using an authoritative/expert stance that leaves the client in a passive role
  • where the health care professional does most of the talking, or only gives information
  • imposing a diagnostic label
  • behaving in a coercive manner.

How does it work? ... in a nutshell

The process is twofold. The first goal is to increase the person’s motivation and the second is for the person to make the commitment to change. And the other great thing about this process is that it moves away from us telling patients what to do towards a position of where patients TELL THEMESELVES what they should do.    

People are more likely to engage in change behaviour when they tell themselves the need for that change then someone else doing it.  For example, my sister once told me that I needed to lose weight because I was looking a bit chunky!  My immediate reaction was to be defensive and be a bit curt back!    I thought to myself that she was a bit cheeky and had no right to comment.  A few months later, before I went on holiday, I stepped out the shower, looked in the mirror and said to myself “My goodness, you do need to lose a bit of weight don’t you”.   Isn’t it odd how we readily accept what we say to ourselves and not what others say, even though the messages may be the same.

In a similar way, Motivational Interviewing get’s the patient to tell themselves things.  As opposed to simply stating a need or desire to change, hearing themselves express a commitment out loud has been shown to help improve a client’s ability to actually make those changes. The role of the Motivational Interviewer (in this case, the doctor) is more about listening than intervening. 

It's not just for people with addictions like alcohol, smoking or drugs!

I love Motivational Interviewing because you can use it to “move” people in a whole variety of clinical contexts.   And by move, I mean move them from one position of thought to another which hopefully then leads to a change in behaviour.   And it does this without having a verbal wrestling match,.   

For example, a patient might have COPD and might not at first be keen on Pulmonary Rehabilitation.  Through dialogue and discourse, you might have a neutral discussion about what they would love out of life and whether breathing better would help achieve that.  And whether Pulmonary Rehab might help make that happen. (I’ve over-simplified it a bit here).    

I recently used Motivational Interviewing techniques with a 76 year old lady who was looking after her grandaughter (age 4) every day from 6am til 5pm whilst her daughter had to work.   It was having a terrible effect on her life with her arthritis and at first, she was extremely reluctant to say anything at all to the daughter and felt guilty for not doing her “grandma duties”.  We explored all of this in a neutral way, and she then came to the realisation that she wasn’t saying no to looking after the grandchild, but just not every day for 11 hours!  She owed it to herself to think about her own life too.  We did most of this through Motivational Interviewing techniques.   (Once you know what they are, you’ll see how you can apply them in all sorts of ways).     

Remember, the fundamental principle of Motivational Interviewing is ASKING NOT TELLING.

Motivational Interviewing - principles

  • In a nutshell, Motivational Interviewing techniques simply help you work with the patient and find a way forwards.  
  • Motivational Interviewing stops you from using inflammatory language that the patient will then resist against or become defensive towards.
  • Motivational Interviewing helps you to “dance” with the patient rather than “fight” with them.  Have any of your patient consultations sometimes felt like a little verbal fight – for instance, when trying to convince someone they need to do more exercise, lose weight or eat healthily?

The 4 RULES for Motivational Interviewing

  • R – resist the urge to change the individual’s course of action through didactic means
  • U – understand it’s the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour
  • L – listening is important; the solutions lie within the individual, not the practitioner
  • E – empower the individual to understand that they have the ability to change their behaviour. (Rollnick et al 2008)

The 5 Principles of Motivational Interviewing:

      1. Express empathy through reflective listening.    When patients feel listened to and that their feelings matter, they are more likely to listen to you.
      2. Develop discrepancy between patient’s goals or values and their current behavior.    Do this gently.  Where do they want to be?  How is what they are doing now in keeping with that?  Is it okay?    Be neutral in tone when asking these questions.  Get patients towards “change talk” where they are the ones who say “I need to stop don’t I” or,  “Well, mmm, I don’t wanna carry on smoking forever though”.
      3. Avoid argument and direct confrontation.    If you argue, patients will either argue back or lose respect for you.  And would you listen to someone you had little respect for or was not fond of?
      4. Adjust to client resistance rather than opposing it directly.  If the patient shows signs of resistance, don’t judge it and certainly don’t immediately come out with an opposing comment.  Instead, explore the resistance on neutral territory.  Exploring it alone might help change the patient’s viewpoint as new perspectives are gently realised.
      5. Support self-efficacy and optimism.  Giving patients self-worth and belief in themselves is the first step to success.   Be genuine and honest in what you say.  If you do this in a “lip-fashion” style, they will pick up on the disingenuous intent and lose respect for you.

Does MI work?

Clinical trials have shown that patients exposed to MI (versus treatment as usual) are more likely to enter, stay in and complete treatment, participate in follow-up visits, decrease alcohol and illicit drug use and quit smoking. 

Look how the patient changes from an aggressive state to a change-talking state in this video clip.   Prof. Rollnick uses Motivational Interviewing skills exceptionally well to work WITH the patient and not react adversely to the patients aggrievances. 

(PS On a medical note –  I’m more interested in the lesion on this patient’s nose!)

“A few well chosen words or a thoughtful question can be worth more than many mouthfuls of busy talk”

But I don't want to change my consultation skills...

  • No one is asking you to change what you have learnt.  It’s more about adjusting your skills to be better equipped to deal with your patients.  And some of MI skills you will be doing naturally anyway.
  • Techniques taken from the motivational interviewing approach can be integrated into your consultation with your patients. This webpage provides you with resources to help build on your MI skills.
  • Look how this doctor does it.  It’s quite an amazing set of skills to have.  

Compare these two approaches

Without doing any deep analysis – which is better in terms of engaging and working WITH the patient?  If you were the patient – step into their shoes for a moment – which would scenario would you feel most comfortable in?

A NON-Motivational-Interviewing Approach

A Motivational-Interviewing Approach

Motivational Interviewing Videos - lectures

Rollnick on MI – me, my skills, my setting

The changing face of MI by Rollnick

The Theory and Practice of MI

Motivational Interviewing by Miller himself

Motivational Interviewing in Practice

Dr. Jonathan Fader Demonstrates Motivational Interviewing Skills

Five Essential Strategies in Motivating Clients to Change
 

The Spirit of MI

Motivational Interviewing Videos - specific skills

Core Skills in Motivational Interviewing (OARS)

OAR skills

Decision Balance Tool in Motivational Interviewing

Motivational Interviewing Videos - specific clinical scenarios

Asthma

Alcohol 1

Alcohol 2

Alcohol 3

Alcohol 4

Alcohol 5

Anger & Domestic Violence

Anxiety

Behaviour – teenager & computer

Behaviour  – bad behaviour

Behaviour – more bad behaviour

Depression 1

Depression 2

Diabetes

Diet & Weight 1

Diet & Weight 2

Drugs 1

Drugs 2

Drugs 3

Drugs 4

Exercise

Hypertension

Smoking Cessation 1

Smoking Cessation 2

Please leave a comment if you have a tip, spot an error, spot something missing or have a suggestion for a web resource.
And of course, if you have developed a resource of your own, please email it to me to share with others.

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