Motivational interviewing (MI) is a counselling technique that supports patients to work through their beliefs about health issues until they actively seek change and become engaged in how to effect change. It is more likely to produce an acceptable and sustained change than having the health professional dictating the best course of action to them. MI is defined by the following principles:
- Empathise: Show the patient that you can identify with them.
- Roll with resistance: When the patient presents barriers or arguments against change, investigate them further rather than dismissing them.
- Explore discrepancy: Identify inconsistencies between current health behaviours and the patient's desired health outcomes.
- Avoid arguments: Don't allow the conversation to become a conflict; motivation implies discussing health behaviours until the patient is arguing for change.
- Support self-efficacy: Work with the patient to optimise self-management of their health.
Before becoming motivated to change a health behaviour or treatment, patients should believe they can manage the changes being recommended (a belief known as self-efficacy), must believe that the health risks mean they need to change, and must be reasonably convinced that the change recommended is good for them.
What strategies are used to make interviewing motivational?
You can also use the following specific strategies for appropriate patients:
- Paraphrasing and clarifying patient statements emphasise that you appreciate what the patient has said, and gives them an opportunity to hear your interpretation of what they have said.
- Discuss the good things about 'bad' behaviours. This will help to reduce any defensiveness on the part of the patient, and helps you to understand important social and cultural issues (e.g. enjoying smoke breaks with workmates/avoiding diuretic use when you have to leave the home). It also shows the client that you understand their perspective. This will provide insight into the perceived barriers to treatment change as perceived by the patient.
- Discuss the less good things about 'bad behaviours' - just because a patient mentions a negative aspect of an unhealthy behaviour does not mean they are convinced they should change. For example, most obese people know that obesity is linked to excess calorie intake, but are not motivated to modify an inappropriate diet.
- Summarise discussions about 'good things' and 'less good things', referring to specific terms the patient used where possible. It might be something like..."so on the one hand, you realise that your medication is effective at lowering your blood pressure, but you don't seem to have a system for making sure your tablets have not run out". This summarising is essential to ensure that the client sees that benefits to current behaviours are in fact outweighed by the risks associated. Allow the patient to respond to your summary.
- Life satisfaction involves looking forward a few years from now and asking the patient where they would like to see their health. Discuss if they are likely to achieve this based on current behaviour. For younger patients, it is sometimes necessary to look at short-term goals.
- Ask for a decision about taking action if the opportunity arises. If the patient indicates the desire to change or to act, ask them directly if they have decided upon the best way to achieve change and, if not, whether or not there is anything you can do to assist that decision. Encourage the patient to discuss this at another time.
You must be prepared to confront the patient beliefs about the situation. The following steps may also help in achieving patient motivation:
- A written set of agreed goals helps the patient to visualise the end result of the medication changes and other interventions you are both deciding upon (e.g. treatment target for BP). For smoking cessation, this may involve setting a quit date.
- Underline that small steps can make a big impact on cardiovascular risk (e.g. just lose 2-3 kg weight in the next month) - don't recommend unrealistic goals.
- Explain that strategies for enabling behaviour change may alter along the way, and that relapse is often an inevitable part of the behavioural change process. Encourage the patient to raise any problems encountered with strategies being used so that 'coping 'strategies can be developed; for example, if on social occasions patients find themselves always being encouraged to have a cigarette.
- Be aware that perceived self-efficacy varies throughout the change process. For example, a patient might see themselves as capable of initially increasing their physical activity by going walking with a friend, but the exercise may stop if their friend becomes unable to join them any longer. You should continue to ask if the patient is managing to sustain the various changes. Where lapses occur, it is especially important to reassure the patient that they have the skills to reassert the changed behaviour. There is a risk of the patient perceiving a lack of recovery self-efficacy, a phenomenon whereby the patient believes either that they simply lack the ability to maintain the change, or that external factors make it impossible for them to maintain the change.