The Soft Skills: Motivational Interviewing (Part 3)

By Laura McKenzie, MHK, RCC

Finally, the third and final installment of my 3-part series. My sincere apologies to those of you who have been waiting for this, I promise I have good excuses for my tardiness, but I won’t bore you with them.

Here we go! Motivational Interviewing. Not unlike Parts 1 and 2, this topic is typically covered in an entire textbook rather than a blog post, but I will do my best to be brief and get to the “nitty-gritty” parts, namely, “How the heck can I use this?!”.

Let’s start by defining MI. 

““MI is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion””

In MI, the patient is the expert and the clinician acts as a guide, rather than directing or following. It is up to the patient to decide how to interpret or integrate the info that is received and whether or not it is relevant for his/her own situation. 

Often health care seems to involve giving patients what they lack, be it medication, knowledge, insight, or skills. MI instead seeks to evoke from patients that which they already have, to activate their own motivation and resources for change.  

“You have what you need and together we will find it.”

WHAT DOES THE RESEARCH SAY?

Generally speaking there are very few controlled studies evaluating the efficacy of MI with any kind of health issue. Little is known about the best way to structure sessions and which elements are essential. More research is needed, however Lundahl et al (2013) did a meta analysis and systematic review to investigate MI’s efficacy in medical care settings and had some interesting results:

• Patients receiving MI enjoyed statistically significantly better outcomes on physical strength and disability-related behaviours targeted by PT compared to those without MI. 

• Statistically significant advantage for other quality of life indicators: worry, anxiety, depression, pain, and adjustment to diseases such as diabetes, stroke, and chronic heart failure.

• In terms of adherence to medical advice, MI had a statistically significant effect on patients’ self-monitoring (blood sugar levels, food intake) as well as encouraging non-sedentary behavior (increasing physical activity, strength training, and reducing TV watching)

• MI also produced an increase in patients’ sense of confidence about approaching change when dealing with various diseases.

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Now that we’ve had a very brief overview of what MI is and why it might be relevant to you, let’s talk about how you can implement it in your practice. Here are a few strategies, listed in recommended order of use, that you can apply with your patients.

1.  Let the patient speak & ask open questions

   1. “tell your story” – get lifestyle info and how this injury/health concern affects their daily life. Take note of any links between physical and mental (thoughts, beliefs, fears, etc)

   2. This process is meant to build rapport, learn challenges, barriers, stressors, supports.

   3. Ask them to walk you through a typical day in their life.  In addition to building rapport, this can help the patient talk about current behaviours in detail within a non-pathological framework. It helps you assess their readiness to change and will help you to understand the context of the behaviour in question. Focus on both behavior and feelings, with simple open questions being your main contribution. Try not to inject any of your own hypotheses about problems.

   4. When they’re done, summarize it back to them to make sure you’ve heard them correctly and understand.*If after hearing their story you feel that your patient is unaware that a change is necessary or just isn’t ready to consider change (precontemplators), then MI might not be your best approach. MI cannot be used to manufacture motivation where it doesn’t exist. Pushing precontemplators too hard will often produce the opposite reaction.

2. Provide information:This is routine healthcare, and can be done with almost anyone (even precontemplators), most important thing is HOW you do this.

   1.  Take your time; test the waters first

   2. Ask permission: some people don’t need or want info (for any number of reasons)

   3. Stay positive, don’t scare them e.g. “If you don’t start an exercise program, then recovery will be very difficult” vs. “If you start exercising, you’ll build up your strength and ability”

   4. Deliver with care and check for understanding

3. Explore their concerns

   1. Let them explain their reasons for concern and their arguments for change; you do neither. Just listen and let them work it out.

   2. This can highlight ambivalence and incongruities between thoughts and actions

   3. Let them go back and forth between changing and staying the same – you just want to support their autonomy; roll with resistance

   4. This is an important strategy as it elicits from the patient their reasons for concern about their behaviour

4. Skillfully use scaling questions

   DISCLAIMER: you NEED to have good rapport to do this.

   1. Once you get the impression that they’re ready to make a decision, use rulers. “On a scale of 1 to 10, how important is this behaviour change to you?” This will tell you about their motivation AND elicit change talk

   2. Once they’ve given you a number (e.g. 6), probe deeper and ask WHY they’re at that number. 

   3. On a scale of 1 to 10, how confident are you that you can make this change? Why that number? Why not a 1? What would help you get closer to a 10? What can I do to help? These type of questions elicit strengths talk

   4. Take Note: if they’re high on importance but low on confidence, then they need encouragement (how). If they’re low on importance but high in confidence, then they need information (why)

5. Help with decision making

   1. This can be a delicate stage of your session, don’t rush it

   2. Discuss options, offer choices, support their autonomy

   3. Emphasize that “you are the best judge of what will work best for you”

   4. Keep in mind that resolutions and commitment to change often fluctuate. Its ok to tell patients this and remind them that you are there to support them

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A few more take aways

Research tells us that brief interventions are good for jump-starting motivation, but repeated contact may be required in order to initiate the behaviour change process, to shape new behaviours, and to provide the ongoing support central to behaviour change. Briefer approaches can be strengthened by providing adjunctive materials, calls, follow ups etc. 

Just because they’re far along in their readiness, doesn’t mean you should just tell them what to do and how to do it – IT IS possible to provide info and give advice without undermining the patient’s autonomy.

Laura McKenzie MHK, RCC, AMP Consultant!

If you sense resistance, just roll with it. Don’t oppose or argue, it will just have the opposite effect. 

If you can demonstrate genuine curiosity and develop good rapport, the patients’ own motivations will arise in conversation.