Motivational Interviewing

 

  • A negotiating style for helping people to change behaviour – a method of producing behaviouralchange by helping patients to explore and resolve ambivalence,increasing motivation to change
  • Aims to increase internal motivation for change rather than impose change
  • Motivation when provided externally does not lead to long term adherence
  • Helps change by exploring and resolving ambivalence
  • Persuasion and coercion are not appropriate

Key elements:

  • Feedback—afterassessment of patient’s current condition
  • Responsibility—emphasison patient’s personal responsibility for change
  • Advice—clearadvice that things need to change
  • Menu—providing alternativestrategies to help the patient change his or her behaviour
  • Empathy—activeunderstanding of patient’s experience
  • Supporting self efficacy—encouragingpatient to believe he or she can change using examples fromtheir past

Principles

  • Express empathy
    • Acceptance facilitates change
    • Skilful reflective listening is fundamental
    • Ambivalence is normal
  • Develop discrepancy
    • The argument for change comes from the person not you
    • Change is motivated by perceived discrepancy between present behaviour and important personal goals or values
  • Roll with resistance
    • Avoid arguing for change
    • Resistance is not directly opposed
    • New perspectives are invited, not imposed
    • Resistance is a signal to respond differently
    • The person is a primary resource in finding answers and solutions.
  • Support self efficacy
    • A person’s belief in the possibility of change is an important motivator
    • The person, not you, is responsible for choosing and carrying out change
    • Your belief in the person’s ability to change becomes a self-fulfilling prophecy

Key skills

  • Open ended questions
  • Affirmations
  • Reflective listening
  • Summarise
  • Elicit self motivational statements.

Stages of change

  • Pre-contemplation (Inactive and no intention to change)
  • Contemplation (Inactive, but intending to change in the next 6 months)
  • Preparation (Active but not regularly)
  • Action ( Regularly active, but only began in the last 6 months)
  • Maintenance (Regularly active for more than 6 months)

Look at how we change at the different stages

Ambivalence and the decisional balance

  • Current behaviour the pros and cons for staying the same
  • The pros and cons for change

Self efficacy is one’s capability to organize and execute the sources of action required to manage prospective situations. It does this by influencing

  • The choices we make
  • The effort we put in
  • How long we persist when we confront obstacles and face failure
  • How we feel

The sources of self efficacy

  • Mastery of experience (We get better by doing it better)
  • Vicarious experience (We get better by sharing in others experiences)
  • Social persuasion (including verbal persuasions and peer support)
  • Physiological states (We feel good when it goes well)

What do we do to influence the stages of change?

  • Pre-contemplation – Raise awareness
  • Contemplation – Tip the balance by evoking reasons for change and strengthen self efficacy
  • Preparation – Clarify goals plan course of action
  • Action – Help and advice to guide towards change and prevent relapse
  • Maintenance – Reinforce the benefit of change and identify and use resources to maintain goal

The processes of change cognitively

  • Give increased knowledge
  • Make aware of risks
  • Make aware of benefits
  • Look at consequences to others
  • Make aware of opportunities for change

The processes of change in behaviour strategies

  • Substitute alternatives
  • Enlist social support
  • Encourage they reward themselves
  • Encourage them to specify their commitment
  • Set up a system of reminders about the changes

The spirit of the method

  • Patient centred approach
  • Negotiation

Five key strategies (OARS)

  1. O Open ended questions
  2. A Affirmation
  3. R Reflective listening
  4. S Summarise
  5. Elicit self motivational statements

Open questions should

  • Be evocative and trigger an answer that is change talk
  • Avoid causing an answer that is resistant and committed to the status quo

Affirmation

  • The process of expressing genuine empathy, appreciation, understanding and support
  • Showing it with lots of positive reinforcement

Reflective listening

What the speaker says Hearing What the listener heard
Encoding Decoding
What the speaker means Reflection What the listener thinks the speaker means

A good reflective listening response is a statement and the inflection should turn down at the end. You is a good word:

  • It sounds like you
  • So you feel
  • So you think that

Beware that your expertise, wisdom and experience doesn’t keep you from listening to their individual problem. Their understanding of the problem is what matters.

Levels of reflection

  1. Repeat Adds nothing and changes nothing
  2. Reword Substitutes a synonym for one component
  3. Paraphrase Gives back perceived meaning that has not been overtly stated
  4. Emotive A level 3 response that includes reflection of feeling
  5. Summary A reflection that brings together a number of previously stated

Elements

  • Reflection can be simple and communicates that you have heard the person and it is not your intention to get into an argument with them.
  • It can be amplified so you exaggerate what you have heard to try and trigger a response. It can provide conflicting statements that have been given one noting resistance and another with a statement that change is desired.
  • Affirming statements can make positive empathic points of support. (E.g. “That must have been difficult for you” or “That’s a good suggestion”)
  • Summarising statements reflect the key points made.

Eliciting change talk

  • DESIRE I want to—
  • ABILITY I can—
  • REASONS I feel there are good reasons for me to—
  • NEED I really need to—
  • READINESS I’m ready to do this—
  • COMMITMENT I’m going to—

How do we elicit change talk? Use EVOCATIVE QUESTIONS that trigger a response

  • EXTREMES What is the worst thing that could happen?
  • LOOK BACK What were things like before the problem?
  • LOOK FORWARD What will they be like after you change?
  • EXPLORE GOALS And look at the discrepancy between important goals and the behaviour
  • ELABORATION Helps reinforce the motivation to change

Are they ready to change? Look at the PROS and CONS of change versus no change

Set SMART GOALS and use them to look at PROCESS and OUTCOME

  • SPECIFIC
  • MEASURABLE
  • ADJUSTABLE/ACHIEVABLE
  • REALISTIC
  • TIME BASED
  1. Explore view of problems
    • “What do you see the problem as?”
    • “What about other people?”
  2. Feed back what doesn’t fit together (the Columbo scam)
  3. Identify pros and cons – a balance sheetNOT doctors orders – must be non-judgemental
  4. Then discuss motivation“What do you enjoy about eating/drinking/smoking?”

    Acknowledge negative, while reinforcing positive –

    “I hear what you are saying, but…”

    Explore in detail reasons for changing behaviour –

    “Why do you want to stop?”

  5. Tackle denial – the Columbo scamTackle poor motivation – “It’s your choice”

    Tackle self-esteem – “Let’s look at what you’ve acheived”

  • Avoid confrontation
  • Stay neutral
  • Formulate agenda – make it explicit
  • Avoid conflict of agendas – “I can’t talk to anybody (= I can’t talk to you)”
  • Negotiate
  • Summarise

Motivational interviewing and smoking

  1. Define behavioural cycle of change
  2. Define strategies for change
    • What makes people stop smoking?
    • What makes them carry on?
    • Needs:
      • Motivation
      • Encouragement
      • Support
  3. How can we help?
    • Thinking about stopping
      • Raise the issue
      • Build up a picture of smoking habit
      • Deciding to stop
      • Reinforce the interest in stopping
      • Help the patient decide to stop
    • Stopping
      • Give practical advice on stopping
        • PLAN A DAY
        • STICK TO IT
        • PREPARE FOR DANGER TIMES
        • CHANGE ROUTINE
        • PLAN LOTS TO DO
        • SPEND TIME WITH NON-SMOKERS
      • Work out coping strategies
    • Staying stopped
      • Maintain interest
      • Give positive encouragement

Motivational interviewing

Group work: give scenarios (in pairs):

Define:

  • Where on the behavioural cycle of change they are
  • What interventions would you try with each patient
    • in the consultation today
    • over time

Motivational interviewing

 

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