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Psychological strategies
Motivational interviewing
Kate Hall techniques
Tania Gibbie
Dan I Lubman Facilitating behaviour change in the general
practice setting
Background One of the biggest challenges that primary care practitioners
One of the biggest challenges that primary care practitioners face is helping people change longstanding behaviours
face is helping people change longstanding behaviours that that pose significant health risks. When patients receive
pose significant health risks. compelling advice to adopt a healthier lifestyle by cutting
Objective back or ceasing harmful behaviours (eg. smoking,
To explore current understanding regarding how and overeating, heavy drinking) or adopting healthy or safe
why people change, and the potential role of motivational behaviours (eg. taking medication as prescribed, eating
interviewing in facilitating behaviour change in the general more fresh fruit and vegetables), it can be frustrating and
practice setting. bewildering when this advice is ignored or contested.
Discussion A natural response for a practitioner who encounters
Research into health related behaviour change highlights such opposition (termed ‘resistance’ in the psychological
the importance of motivation, ambivalence and resistance. literature) is to reiterate health advice with greater authority
Motivational interviewing is a counselling method that or to adopt a more coercive style in order to educate the
involves enhancing a patient’s motivation to change by means patient about the imminent health risks if they don’t change.
of four guiding principles, represented by the acronym RULE: When these strategies don’t succeed, the practitioner
Resist the righting reflex; Understand the patient’s own may characterise the patient as ‘unmotivated’ or ‘lacking
motivations; Listen with empathy; and Empower the patient. insight’. However, research around behaviour change shows
Recent meta-analyses show that motivational interviewing that motivation is a dynamic state that can be influenced,
is effective for decreasing alcohol and drug use in adults and and that it fluctuates in response to a practitioner’s style.
adolescents and evidence is accumulating in others areas Importantly, an authoritative or paternalistic therapeutic
of health including smoking cessation, reducing sexual risk 1
behaviours, improving adherence to treatment and medication style may in fact deter change by increasing resistance.
and diabetes management. The Stages of Change model and
Keywords motivational interviewing
communication; doctor-patient relations; patient centred care; 2
psychotherapy, brief; motivation Prochaska and DiClemente proposed readiness for change as a
vital mediator of behavioural change. Their transtheoretical model
of behaviour change (the ‘Stages of Change’) describes readiness to
change as a dynamic process, in which the pros and cons of changing
generates ambivalence. Ambivalence is a conflicted state where
opposing attitudes or feelings coexist in an individual; they are stuck
between simultaneously wanting to change and not wanting to
change. Ambivalence is particularly evident in situations where there
is conflict between an immediate reward and longer term adverse
consequences (eg. substance abuse, weight management). For
example, the patient who presents with serious health problems as a
result of heavy drinking, who shows genuine concern about the impact
of alcohol on his health, and in spite of advice from his practitioner to
cut back his drinking, continues to drink at harmful levels, embodies
this phenomenon.
660 Reprinted From AuSTRAliAn FAmily PhySiCiAn Vol. 41, no. 9, SePTembeR 2012
2
The Prochaska and DiClemente Stages of Change model offers a Table 1. Practitioner tasks within the Stages of
conceptual framework for understanding the incremental processes 1,2
Motivational interviewing that people pass through as they change a particular behaviour. This Change model
change process is modelled in five parts as a progression from an Patient stage Practitioner tasks
initial precontemplative stage, where the individual is not considering Precontemplation Raise doubt and increase the
techniques change; to a contemplative stage, where the individual is actively (Not ready) patient’s perception of the risks
ambivalent about change; to preparation, where the individual and problems with their current
Facilitating behaviour change in the general begins to plan and commit to change. Successful progression through behaviour. Provide harm reduction
practice setting these stages leads to action, where the necessary steps to achieve strategies
change are undertaken. if successful, action leads to the final stage, Contemplation Weigh up the pros and cons of
maintenance, where the person works to maintain and sustain long (Getting ready) change with the patient and work
term change.3 Relapse is considered an important stage in the change on helping them tip the balance by:
process and is used as an opportunity to learn about sustaining • exploring ambivalence and
alternatives
maintenance in the future. • identifying reasons for change/
motivational interviewing (mi) is an effective counselling method risks of not changing
that enhances motivation through the resolution of ambivalence. it • increasing the patient’s
2 confidence in their ability to
grew out of the Prochaska and DiClemente model described above
1 change
and miller and Rollnick’s work in the field of addiction medicine,
which drew on the phrase ‘ready, willing and able’ to outline three Preparation – Clear goal setting – help the patient
1 action to develop a realistic plan for
critical components of motivation. These were:
• the importance of change for the patient (willingness) (Ready) making a change and to take steps
• the confidence to change (ability) toward change
• whether change is an immediate priority (readiness). Maintenance Help the patient to identify and use
using mi techniques, the practitioner can tailor motivational (Sticking to it) strategies to prevent relapse
strategies to the individual’s stage of change according to the Relapse* Help the patient renew the
1,2
Prochaska and DiClemente model (Table 1). (Learning) processes of contemplation and
Applications and effectiveness of action without becoming stuck or
demoralised
motivational interviewing * Relapse is normalised in MI and is used as an
Recent meta-analyses show that mi is equivalent to or better opportunity to learn about how to maintain long term
than other treatments such as cognitive behavioural therapy (CbT) behaviour change in the future
or pharmacotherapy, and superior to placebo and nontreatment
4–6
controls for decreasing alcohol and drug use in adults and • stress management
7
adolescents. motivational interviewing has also been shown to be • completion of recommended screening or diagnostic tests or
efficacious in a number of other health conditions, such as smoking specialist/allied health/psychologist referral.
8 9–11
cessation, reducing sexual risk behaviours, improving adherence The spirit of motivational interviewing
12 13
to treatment and medication, as well as diabetes management.
in addition, studies support the applicability of mi to hiV care, motivational interviewing is underpinned by a series of principles
14,15
such as improving adherence to antiretroviral therapy and the that emphasise a collaborative therapeutic relationship in which
15 the autonomy of the patient is respected and the patient’s
reduction of substance use among hiV positive men and women.
As such, mi is an important therapeutic technique that has wide intrinsic resources for change are elicited by the therapist.
applicability within healthcare settings in motivating people to Within mi, the therapist is viewed as a facilitator rather than
change. in general practice, possible applications include: expert, who adopts a nonconfrontational approach to guide
• medication adherence the patient toward change. The overall spirit of mi has been
• management of the SnAP (smoking, nutrition, alcohol and described as collaborative, evocative and honouring of patient
16 1 1
physical activity) risk factors autonomy. miller and Rollnick have commented that the use
• engagement in prevention or management programs for diabetes of mi strategies in the absence of the spirit of mi is ineffective.
or cardiovascular health Although paradoxical, the mi approach is effective at engaging
• management of substance abuse problems apparently ‘unmotivated’ individuals and when considered in
• management of problem gambling or sexual risk taking the context of standard practice can be a powerful engagement
• pain management strategy (Case study, Table 2).
Reprinted From AuSTRAliAn FAmily PhySiCiAn Vol. 41, no. 9, SePTembeR 2012 661
FOCUS Motivational interviewing techniques – facilitating behaviour change in the general practice setting
Case study – using the spirit of Motivational interviewing in practice
motivational interviewing The practical application of mi occurs in two phases: building
A male patient, 52 years of age, who drinks heavily and has motivation to change, and strengthening commitment to change.
expressed the desire to reduce drinking, but continues to
drink heavily. Building motivation to change
It is easy to conclude that this patient lacks motivation, his in Phase i, four early methods represented by the acronym oARS
judgment is impaired or he simply does not understand (Table 3) constitute the basic skills of mi. These basic counselling
the effects of alcohol on his health. These conclusions techniques assist in building rapport and establishing a therapeutic
may naturally lead the practitioner to adopt a paternalistic relationship that is consistent with the spirit of mi.
therapeutic style and warn the patient of the risks to his
health. In subsequent consultations, when these strategies Strengthening commitment to change
don’t work, it is easy to give up hope that he will change
his drinking, characterise him as ‘unmotivated’ and drop This involves goal setting and negotiating a ‘change plan of action’.
the subject altogether. In MI, the opposite approach is in the absence of a goal directed approach, the application of the
taken, where the patient’s motivation is targeted by the strategies or spirit of mi can result in the maintenance of ambivalence,
practitioner. Using the spirit of MI, the practitioner avoids where patients and practitioners remain stuck. This trap can be
an authoritarian stance, and respects the autonomy of 1
avoided by employing strategies to elicit ‘change talk’. There are many
the patient by accepting he has the responsibility to strategies to elicit ‘change talk’, but the simplest and most direct way
change his drinking – or not. Motivational interviewing is to elicit a patient’s intention to change by asking a series of targeted
emphasises eliciting reasons for change from the patient, questions from the following four categories:
rather than advising them of the reasons why they should • disadvantages of the status quo
change their drinking. What concerns does he have about • advantages of change
the effects of his drinking? What future goals or personal • optimism for change
values are impacted by his drinking? The apparent ‘lack
of motivation’ evident in the patient would be constructed • and intention to change (Table 4).
as ‘unresolved ambivalence’ within an MI framework. The Alternatively, if a practitioner is time poor, a quick method of drawing
practitioner would therefore work on understanding this out ‘change talk’ is to use an ‘importance ruler’.
ambivalence, by exploring the pros and cons of continuing example: ‘if you can think of a scale from zero to 10 of how
to drink alcohol. They would then work on resolving this important it is for you to lose weight. on this scale, zero is not
ambivalence, by connecting the things the patient cares important at all and 10 is extremely important. Where would you be on
about with motivation for change. For example, drinking this scale? Why are you at ____ and not zero? What would it take for
may impact the patient’s values about being a loving you to go from ___ to (a higher number)?’
partner and father or being healthy and strong. A discussion This technique identifies the discrepancy for a patient between
of how continuing to drink (maintaining the status quo) their current situation and where they would like to be. highlighting
will impact his future goals to travel in retirement or have a
good relationship with his children may be the focus. The this discrepancy is at the core of motivating people to change. This
practitioner would emphasise that the decision to change can be followed by asking the patient to elaborate further on this
is ‘up to him’, however they would work with the patient to discrepancy and then succinctly summarising this discrepancy and
increase his confidence that he can change (self efficacy). reflecting it back to the patient. next, it is important to build the
Table 2. The spirit of motivational interviewing vs an authoritative or paternalistic therapeutic style
The spirit of motivational interviewing Authoritative or paternalistic therapeutic style
Collaboration: a partnership between the patient and Confrontation: the practitioner assumes the patient has
practitioner is formed. Joint decision making occurs. The an impaired perspective and consequently imposes the
practitioner acknowledges the patient’s expertise about need for ‘insight’. The practitioner tries to persuade and
themselves coerce a patient to change
Evocation: the practitioner activates the patient’s own Education: the patient is presumed to lack the insight,
motivation for change by evoking their reasons for change. knowledge or skills required to change. The practitioner
The practitioner connects health behaviour change to the tells the patient what to do
things the patient cares about
Honouring a patient’s autonomy: although the practitioner Authority: the practitioner instructs the patient to make
informs and advises their patient, they acknowledge the changes
patient’s right and freedom not to change. ‘It’s up to you’
Adapted from Miller and Rollnick, 2002
662 Reprinted From AuSTRAliAn FAmily PhySiCiAn Vol. 41, no. 9, SePTembeR 2012
Motivational interviewing techniques – facilitating behaviour change in the general practice setting FOCUS
Table 3. OARS: The basic skills of motivational interviewing
Ask Open-ended questions* Example
• The patient does most of the talking I understand you have some concerns about your drinking.
• Gives the practitioner the opportunity to learn more Can you tell me about them?
about what the patient cares about (eg. their values Versus
and goals) Are you concerned about your drinking?
Make Affirmations Example
• Can take the form of compliments or statements of I appreciate that it took a lot of courage for you to discuss
appreciation and understanding your drinking with me today
• Helps build rapport and validate and support the You appear to have a lot of resourcefulness to have coped
patient during the process of change with these difficulties for the past few years
• Most effective when the patient’s strengths and Thank you for hanging in there with me. I appreciate this is
efforts for change are noticed and affirmed not easy for you to hear
Use Reflections* Example
• Involves rephrasing a statement to capture the You enjoy the effects of alcohol in terms of how it helps you
implicit meaning and feeling of a patient’s statement unwind after a stressful day at work and helps you interact
• Encourages continual personal exploration and helps with friends without being too self-conscious. But you are
people understand their motivations more fully beginning to worry about the impact drinking is having on
• Can be used to amplify or reinforce desire for change your health. In fact, until recently you weren’t too worried
about how much you drank because you thought you had
it under control. Then you found out your health has been
affected and your partner said a few things that have made
you doubt that alcohol is helping you at all
Use Summarising Example
• Links discussions and ‘checks in’ with the patient If it is okay with you, just let me check that I understand
• Ensure mutual understanding of the discussion so far everything that we’ve been discussing so far. You have been
• Point out discrepancies between the person’s current worrying about how much you’ve been drinking in recent
situation and future goals months because you recognise that you have experienced
• Demonstrates listening and understand the patient’s some health issues associated with your alcohol intake, and
perspective you’ve had some feedback from your partner that she isn’t
happy with how much you’re drinking. But the few times
you’ve tried to stop drinking have not been easy, and you are
worried that you can’t stop. How am I doing?
* A general rule-of-thumb in MI practice is to ask an open-ended question, followed by 2–3 reflections
patient’s confidence in their ability to change. This involves focusing • Where do we go from here?
on the patient’s strengths and past experiences of success. Again, a • What do you want to do at this point?
‘confidence ruler’ could be employed if a practitioner is time poor. • how would you like things to turn out?
example: ‘if you can think of a scale from zero to 10 of how • After reviewing all of this, what’s the next step for you?
confident you are that you can cut back the amount you are drinking. it is common for patients to ask for answers or ‘quick fixes’ during
on this scale, zero is not confident at all and 10 is extremely confident. Phase ii. in keeping with the spirit of mi, a simple phrase reminding the
Where would you be on this scale? Why are you at ____ and not zero? patient of their autonomy is useful, ‘you are the expert on you, so i’m
What would it take for you to go from ___ to (a higher number)?’ not sure i am the best person to judge what will work for you. but i can
Finally, decide on a ‘change plan’ together. This involves standard give you an idea of what the evidence shows us and what other people
goal setting techniques, using the spirit of mi as the guiding principle and have done in your situation’.
eliciting from the patient what they plan to do (rather than instructing or The guiding principles of motivational
advising). if a practitioner feels that the patient needs health advice at this interviewing
point in order to set appropriate goals, it is customary to ask permission
before giving advice as this honours the patient’s autonomy. examples of in general practice, the particular difficulties associated with quick
key questions to build a ‘change plan’ include: consultation times can present unique challenges in implementing mi.
• it sounds like things can’t stay the same as they are. What do you 17
miller and Rollnick have attempted to simplify the practice of mi for
think you might do? health care settings by developing four guiding principles, represented
• What changes were you thinking about making? by the acronym Rule:
Reprinted From AuSTRAliAn FAmily PhySiCiAn Vol. 41, no. 9, SePTembeR 2012 663
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