Motivational Interviewing

Motivational interviewing is an evidence-based approach to carrying out discussions around change. It is designed to encourage patients/clients to talk themselves into making a change. A key principle of motivational interviewing is that it accepts that ambivalence about change is a normal human experience.

Techniques used in motivational interviewing stem from the notion that people are more likely to change if three basic needs are attended to:

  • Autonomy in making decisions
  • A sense of their own competence in making the change
  • Relatedness, which is a sense of being supported by key people around them (including healthcare professionals).

Evidence for effectiveness

Systemic reviews have shown motivational interviewing to be successful at producing a statistically significant and clinical effect in the majority of studies reviewed, and that the effect was greater than less-structured, more traditional advice 1. One systematic review showed motivational interviewing was successful in reducing sedentary behaviours and increasing levels of physical activity 2.

The step wise structure of motivational interviewing

motivational interviewing.png

Engaging

  • Engaging is the process of establishing a constructive working relationship with a patient.
  • A common misunderstanding about engaging is that it is just about being nice and friendly, when in fact it means connecting with the patient and ensuring that they feel understood.

Focusing

  • Focusing is the process of establishing (with the patient’s agreement) the direction for the conversation about change. A common mistake is to jump too quickly onto a change topic without establishing that the patient agrees.
  • Aim is to involve the patient in deciding a direction for change that makes the most sense both to them and to you.
  • Focusing is also useful if you want to raise a difficult subject in a non-confrontational way; you can simply mention the difficult topic as one of many you could talk about.

Evoking

  • Evoking involves eliciting the patient’s own motivations for a particular change and can only take place with adequate focus.
  • The aim of evoking is to encourage the patient to talk about why and how they might change (also known as change talk).
  • Designed to strengthen personal motivation for and commitment to a specific goal.

Planning

  • Involves helping the patient to come up with ideas that might work.
  • These ideas should be supported with, but not driven by, your suggestions.
  • The goal is to agree a concrete plan that might work.
  • You will know when a patient is ready for planning by the language of motivation that they use.
    • Talking about when and how to make a change, and less about whether and why.
    • They may also start to talk about what it would feel like to have made the change.

 

Key skills in motivational interviewing

  • Reflective listening
    • Involves a two-step process of hearing what a person is saying, and then conveying to them that you understand this. Reflective listening involves giving a summary of what someone has told you in your own words in the form of a statement, not a question.
  • Affirming
    • Involves recognising and commenting on the patient’s strengths and abilities.
    • Motivational interviewing relies on the patient’s strengths and efforts in order to bring about change. An aim of affirmation is to strengthen their confidence in their ability to do this.
  • Using open questions
    • This is something that most medics do when taking any clinical history. In motivational interviewing this can build and strengthen rapport with a patient.
    • Open questions enable your patient/client to elaborate more on their answers, which often leads to you finding out more about their ideas, motivations for change and expectations, than close questions warranting short, specific answers.
  • Summarising
    • Useful to emphasise a patient’s strengths and motivations for change.
    • Summarising is a component of reflective listening and also can be used to bring a consultation all together, clarify key elements and ensure you and your patient/client are happy nothing has been missed.
    • Whilst summarising to your patient/client it often helps to use their own language – this shows you have actively listened and understand their perspective.

 

Motivational interviewing vs Brief Intervention

Brief intervention is another evidence-based technique, often used in primary care to change problematic lifestyle behaviours. Brief intervention is a broader concept than motivational interviewing, and whilst there is some overlap, the former is often more paternalistic, with the ‘expert’ advising a patient/client on a path to take, whereas motivational interviewing is more about guiding someone.

I hope this has been a useful summary of motivational interviewing. I you are after more information and a medical professional and a member of the BMA I thoroughly recommend the BMJ e-learning module on motivational interviewing.

Emma x

References:

  1. Rubak, S., Sandbaek, A., Lauritzen, T. & Christensen, B. Motivational interviewing: a systematic review and meta-analysis. Br. J. Gen. Pract. 55, 305–12 (2005).
  2. Lundahl, B. et al. Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Educ. Couns. 93, 157–168 (2013).

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