Motivational Interviewing

Introduction

Many healthcare professionals find it challenging to change people's long-standing behaviours that pose significant health risks.

• Even when presented with facts and figures, individuals often persist in harmful behaviours (e.g. smoking, heavy drinking) or fail to adopt healthy lifestyle (e.g. taking medications as prescribed or exercising regularly).
• This can lead to frustration when advice is ignored or contested.
• However, in reality, behaviour change cannot occur without the individual themselves recognizing the need to do so.

Motivational interviewing is a technique that aims to motivate people to change by balancing following (good listening) and directing (giving information and advice).

• Instead of acting authoritatively, motivational interviewing techniques involve a respectful and curious approach to empower individuals to change by drawing out their own meaning, importance and capacity for change.
• Through this collaborative process, we help patients identify their own goals and develop personalized plans to achieve them.

NOTE: As Dale Carnegie aptly illustrated in "How to Win Friends and Influence People", the key to motivating others lies not in threats or force, but in inspiring them to want to do something.

The Stages of Change Model

Prochaska and DiClemente proposed the transtheoretical model of behaviour change to describe readiness for change. This model outlines a five-part process:

• Precontemplation: The individual is not considering change (either unaware or unwilling).
• Contemplation: The individual is actively ambivalent about change (conflicted between immediate reward and long-term adverse consequences) but not yet ready to take action.
• Preparation: The individual is ready to take action and begins planning and committing to change.
• Action: The necessary steps to achieve change are undertaken.
• Maintenance: The individual works to maintain and sustain long-term change.
• Relapse: The individual returns to old behaviour, which is a common occurrence.

Healthcare professionals play different roles at different stages of change.

• For example, in the precontemplation stage, we should not rush to bombard patients with harm reduction strategies, but aim to raise doubts and increase their perception of the risks and problems associated with their current behaviour.
• In the contemplation stage, we should help patients weigh the pros and cons and work towards tipping the balance in favour of change.
• Relapse is normalized in motivational interviewing and is used as an opportunity to learn how to maintain long-term behaviour change in the future.

Building Motivation to Change

Four basic counselling techniques are used to assist in building rapport and establishing a therapeutic relationship that aligns with the spirit of motivational interviewing.

• Ask open-ended questions
• This allows the patient to do most of the talking and provides the healthcare professional with an opportunity to learn more about what the patient cares about (e.g. their values and goals).
• Make affirmations
• Compliments or statements of appreciation and understanding can help build rapport, validate the patient and support them during the change process.
• This can make the patient feel more confident in their ability to change.
• Use reflections
• Rephrasing a statement to capture the implicit meaning and feeling of a patient's statement can be used to amplify or reinforce their desire for change.
• Use summarizing
• Ensuring mutual understanding of the discussion so far and pointing out discrepancies between the patient's current situation and future goals demonstrates listening and understand of the patient's perspective

The 5As

The 5As is a key framework for organizing the provision of preventive care in primary healthcare.

• Ask
• Identify patients with risk factors.
• Assess
• Evaluate the level of risk factor, their relevance to the individual in terms of health, and their readiness to change and healthy literacy.
• Advise
• Provide written information, brief advice using motivational interviewing, and negotiate goals and targets (including a lifestyle prescription).
• Assist
• Develop a risk factor management plan tailored to the individual, which may include lifestyle education and pharmacotherapies.
• Support self-monitoring.
• Arrange
• Refer to allied health services or community programs, offer phone information or counselling services and schedule follow-up for prevention and management of relapse.

Summary

Without the spirit of motivational interviewing, conversations can feel like casual discussions without fruitful results.

• The key is to resist the urge to correct and practice empathic listening.

Most people resist persuasion from the external world.

• We are not there to judge their behaviour or direct them to do what is right, but to understand their perspective.
• Ultimately, we help them convince themselves of the need for change and ultimately carry out the plan with our assistance.

After all, motivational interviewing is a negotiation in disguise, not a means to raise arguments that produces more resistance to change.

External Links

• Motivational interviewing techniques Facilitating behaviour change in the general practice setting, 2012
  
• RACGP Smoking, nutrition, alcohol, physical activity (SNAP), 2015
  
• Understanding Motivational Interviewing