Motivational Interviewing for Behavioural Changes. Presented at Seminar Clinical Dietetic Updates in Cardiovascular Disease & Hypertension, Kementerian Kesihatan Malaysia. 17-18 August 2015.
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Motivational Interviewing 2015: Empowering Patients in Self-care
1. Motivational Interviewing:
Empowering Patients
in Self-care
D R . U M I A D Z L I N S I L I M
P S Y C H I A T R I ST , H O S P I T A L K U A LA L U M P U R
M D ( U K M ) , M M E D ( P S Y C H) ( U K M ) ,
F E L L O W S H I P I N C O N SU L T A T I ON - LI A I SON & W O M E N ’ S M E N T A L H E A L T H ( M E L B O U R N E )
2. References
BMJ Learning: Motivational Interviewin Brief Consultation by Professor Stephen Rollnick,
honorary distinguished professor in the department of primary care and public health, Cardiff
University.
Lecture on Motivating Health Behaviour Changes by Dr Salina Abdul Aziz, Consultant
psychiatristad Head of Department of Psychiatry& Mental Health, Kuala Lumpur
3. Objectives
Understand what motivational interviewing is
Appreciate how it can be used to improve outcomes for patients
Recognise situations where motivational interviewing is useful, as well as situations
where it is less useful
Begin to develop an understanding of theoretical explanations for motivational
interviewing
Appreciate how motivational interviewing can work in practice, within a number of
different clinical scenarios.
6. Motivational Interview: Modern Method
Accepts that ambivalence about change is a normal human experience, and often a necessary
step in the process of change.
Encourages clinicians to work with patients’ ambivalence rather than viewing it as a problem.
Aims to encourage the patient’s autonomyin decision making.
Guiding: The clinician acts as a guide, clarifying the patient’s strengths and aspirations, listening
to their concerns, boosting their confidence in their own ability to change, and eventually
collaborating with them on a plan for change.
7. Evidence
A systematicreview from 2005 found that motivational interviewing had a significant and
clinically relevant effect in three out of every four studies looked at, and that it performed better
than traditional advice-giving in around 80% of studies. In brief sessions of less than 15 minutes,
motivational interviewing was found to be effective in 64% of studies.
8. Evidence
More recent systematicreview from 2013 found an overall statisticallysignificant, modest
advantagefor motivational interviewing over comparison interventions, including traditional
advice-giving.
The technique was found to be effective in a number of studies looking at adherence to medical
advice, for example around self monitoring of blood glucose and food intake, reducing sedentary
behaviours, and increasing levels of physical activity.
9. Why it might work?
There are a number of theories for how and why motivationalinterviewing works.
A relevant psychological theory is self-determination theory. This states that people are more
likely to change if three basic needs are attended to:
◦ Autonomyin 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 (includinghealthcare
professionals).
Another theory is that when patients hear themselves (as opposed to you) speaking about
change, then their motivationimproves and outcomes are better. Within motivational
interviewing, this is described as “change talk.”
10. MI – is and isn’t
Is a style of consulting with patients
Is focused on consultations about behaviour change in patients
Relies on using people’s own reasons to change, and so can never be a way to manipulate
patients into doing something they do not consider to be in their best interests
Is something done with or on behalf of patients, not to or on them
Is not a cure-all, or necessarily a standalone intervention
Is not a quick fix, and often requires practice to carry out effectively
◦ It often also requires repeatedconsultationswith patients,as setbacks (“relapses”) are viewed as an
expected part of change
12. Directing styles
The clinician tells a patient what to do, and how to go about doing it.
Can be constructive in some situations
But if a clinician uses a directing style with a patient who is ambivalent about making a change,
this mayinadvertently elicit the patient’s arguments in favour of staying the same. Within
motivational interviewing, this is also known as “sustain talk.”
14. Following style
More passive and involves listening to what a patient has to say, supporting them while they
work the situation out for themselves.
Example of a situation in which this may be appropriate is when talking to a person who is
recently bereaved
If a clinician uses a following style with a patient who is ambivalent about making a change, this
can simply encourage the patient to go around in circles with their ambivalence.
15. Guiding styles
MI involves a guiding style, sitting in the middle of the spectrum.
The role of the guide is to listen supportively, but also to offer expertise when necessary.
f a clinician uses a guiding style with a patient who is ambivalent about making a change, they
can structure the consultation in such a way that the arguments for change become stronger
and more persuasive to the patient; this occurs when the patient hears themselves making
these arguments. Within motivational interviewing, this is known as “change talk.”
17. MOTIVATING HEALTH BEHAVIOUR CHANGE
Stagesof ChangeModel(ProchaskaandDiClemente)
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Person is not
ready to consider
a change or
unaware of the
need to change;
sometimes
demoralized
Ambivalent;
Person both
considers
and rejects
change.
Person is open
to change and
preparing for
change (often
in the next
month)
Person is
engaging in
actions to
with the
intention of
bringing
about
change.
Person is
maintaining a
change that
has already
been made.
18.
19. MOTIVATING HEALTH BEHAVIOUR CHANGE
Stages of change model
Pre-contemplation
• Patient: Unaware of problem, no interest in change
• Provider: Provide information about health risks and
benefits of weight loss
Contemplation
• Patient: Aware of problem, beginning to think of changing
• Provider: Help resolve ambivalence; discuss barriers
(AMA, 2003)
20. MOTIVATING HEALTH BEHAVIOUR CHANGE
Stages of change model
Preparation
• Patient: Realizes benefits of making changes and thinking about how to
change
• Provider: Teach behavior modification; provide education
Action
• Patient: Actively taking steps toward change
• Provider: Provide support and guidance, with a focus on the long term
Maintenance
• Patient: Initial treatment goals reached
• Provider: Relapse control
(AMA, 2003)
21. MOTIVATING HEALTH BEHAVIOUR CHANGE
Stages of Change Model: Use Different
Strategies and Activities for Different Stages
What works at one stage often does not work well at another stage.
Most behavior change programs are targeted at people in the
Preparation and Action stages – people who are ready to make a
change.
Only a fraction of people are actually in these two stages of change.
22. ‘Righting reflex’
Happens quite commonlyduring traditional advice-giving.
It is the tendency to identify another person’s problem, and immediately try to fix it, and
involves a directing style.
A common belief may be that if only you can convince a patient of the rational reasons to
change, and provide them with all of the correct information, then they will change.
At the heart of the righting reflex is usually simply the desire to help, but paradoxically it often
has the opposite effect.
23. Key communication skills: OARS
Asking open questions
Affirming (recognising and commenting on the patient’s strengths and abilities)
Reflective listening (summarising what the patient has told you in your own words, in the form
of a statementrather than a question that encourages them to continue talking)
Summarising (giving a collection of reflections, allowing you to indicate what you think were the
most important headlines of what the patient has said)
Informing and advising (giving information and advice where appropriate, for examplewhen the
patient asks, or more spontaneously, when there is good engagement).
26. Engaging
Engaging is the process of establishing a constructive working relationship with a patient, and is
not unique to motivational interviewing.
Key communicationskill:
◦ Listening involvesa two-step process of hearing what a person is saying and then conveyingto them
that you understandthis.
◦ Reflective listeninginvolvesgiving a summary of what someone has told you in your own words in the
form of a statement not a question;reflectionsoften come across as short summaries, guesses, or
hypotheses.
27. Case Example: Engaging
Mr. Smith is a 60 year old man who has come to see his GP for a medication review. He takes
verapamil (160 mg three times a day) and ramipril (5 mg once daily). His blood pressure is
currently 138/88 mmHg. He weighs 110 kg and is 172.2 cm tall, with a BMI of around 37. The GP
wants to raise the subject of weight, and soon realises that Mr. Smith is angry and that the
consultation could become difficult to manage if not handled carefully.
29. Focusing
Focussing 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.
30. Case Example: Focusing
Mrs Jones is a 45 year old man who has recently started taking treatment for hypertension. His
blood pressure is currently within the target treatment range. His BMI is 26. His GP is already
aware that Mr Jones’ father died at the age of 55 of a heart attack. At the end of a routine
consultation about another minor clinical problem, he mentions in passing to his GP that his
partner has suggestedthat he tries to “get in shape.” The GP is unsure of what he means and
wants to explore this, but is already running 50 minutes late.
32. Evoking
Evoking involves eliciting the patient’s own motivations for a particular change, and can only
take place with adequate focus – we have clarified a goal for change.
Aims to encourage the patient to talk about why and how they might change (also known as
change talk).
Designed to strengthen personal motivationfor and commitment to a specific goal. Ambivalence
(feeing two ways about making a change) is viewed as a normal part of the change process.
Central to MI, and is often the stageat which it becomes most obviously different from
traditional advice-giving.
33. Case Example: Evoking
Mr Harris is a 45 year old man with recently diagnosed type 2 diabetes who attends his GP
surgery for an annual medication review. He smokes 10 cigarettes a day, and is not interested in
stopping or reducing his smoking at this point in time. He is prescribed metformin 500 mg three
times a day, and simvastatin20 mg at night. The GP checks his most recent HbA1c result and
notes that his glucose control is good. He checks his most recent cholesterol result and notes
that this is high, and that his total cholesterol to high-density lipoprotein (HDL) ratio is also high.
Both results are slightly higher than when he was first prescribed the statin around a year ago.
The GP is concerned that the patient may not be taking his statin as prescribed, and that the
combination of diabetes, hypercholesterolaemia, and smoking puts him at high risk of
developing cardiovascular disease in the next 10 years. The focus of the role-play is to
demonstrate evoking within motivational interviewing; in real life the patient may take other
medications such as aspirin, but in the interests of simplicity we have chosen to focus on
simvastatinand metformin.
35. Planning
Using MI in change 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. Their ideas are a
form of change talk that you can support using skills such as reflective listening. The more
people hear themselves talk about change, the more likely they are to do it.
The goal is to agree a concrete plan that might work.
36. Case Example: Planning
Mrs Miller is a 63 year old woman who has made an appointment to see her practice nurse for
some advice about smoking cessation.
37. Conclusion
Motivational interviewing is a patient-centred style of consulting that can be useful in guiding
conversations about change
It relies on using people’s own motivationto change, and is done with or on behalf of patients,
not to or on them
There is a body of emerging evidence to suggestthat it is modestly more effective than
traditional advice-giving within a number of different clinical situations
38. Clinical Tips
Often patients have heard the logical arguments in favour of change manytimes before
Ambivalence (feeling two ways about making a change) is a normal part of the change process
Within motivational interviewing you can, and should, offer expert advice where appropriate,
while at the same time emphasising the patient’s autonomy and freedom of choice
You aim for the arguments in favour of change to come from the patient rather than from you
It often also requires repeated consultations with patients, as setbacks (“relapses”) are viewed
as an expected part of change
