Motivational Interviewing
last authored: Aug 2010, David LaPierre
last reviewed:
Introduction
Motivational interviewing is a form of psychotherapy designed to be directive, patient/client centred, and designed to examine and resolve ambivalence around changes relevant for health. Motivation is elicited, not imposed, and it is the task of the patient/client to identify and address ambivalence. As such, confrontation or persuasion have little role to play.
There are specific clinician behaviours that are important:
- understand the patient's perspective
- offer acceptance and affirmation, particularly of personal choice and direction
- support the patient as they identify problems, grow in motivation, and seek and embrace change
- monitor stage of change
We do many things because our motivation is high when we are feeling bad; when we work hard, we start to feel good, and when our motivation thusly disappears, we often drop the behaviour. We need to keep behaviour going; if negative feelings are short-term motivators, positive feelings are long-term motivators. These include health, control, and self-esteem.
MI has been used to increase sanitation rates, from 14% to 78%, in Zambia (Quick, 2003).
The question should not be "Why isn't this person motivated?" but rather, "What motivates this person right now?" Don't make assumptions here!
Assessing Motivation
"Do you want to take care of yourself?" is a superficial question; also need to ask
"why do you want to take care of yourself?" and
"how hard are you willing to work to take care of yourself?"
- give patients 3 chances
"how willing are you to make choices that might increase the burden temporarily in order to improveyour health in the long run?"
Assessing Behavioural Intention
Do you know this is a problem?
Are you distressed by this problem?
Are you interested in change?
Are you ready to change now?
Ask questions; minimize statements
- We've got about 3 minutes ... what can you tell me about...?
- "do you know what I would recommend?"
- "have you ever thought about..."
- "research shows that... Are you interested in this?"
- I've heard what you're thinking; do you want to hear what I'm thinking?
To further explore, continue asking questions
- "What have you heard from other people/seen on the internet/news, etc?"
- "What else have you wondered or worried about?"
Supporting Motivation
Express empathy
- let them know you understand their choices and behaviours
- "know I understand why you..."
Develop discrepancy: Compare where the patient is and where they want to be, then get the patient to discover the why and the how to change.
Take a curious, non-judgmental stance
- "help me understand what went wrong"
Avoid arguing
- "yes, but" means "no, because" - you are in a motivational argument. stay away
- "remind me of why you want to change"
- "It's not important to me whether you"
- "I'm as worried as you are about"
Roll with Resistance
- as things don't work out, see them as challenges to overcome
Support self-efficacy
- the best predictor of change is confidence
- find things the person knows they can do
Easier choice, harder behaviour
- bring up consequences of choices (ie seeing grandchildren grow) make the choice easier
- $100 dropped from neighbour's pocket - do you give it back?
Self-esteem is critical; if activity and healthy eating become part of your identity, they will continue!
Building momentum
- "you've got a good point there. Maybe I haven't considered the impact of..."
Reframing: offer a new perspective
- "it seems like your life is very stressful, that you need a way to deal with this, and cigarettes are your primary way of dealing with this. Let's brainstorm about others."
Emphasizing personal choice and control
- "No one can make these decisions or changes but you"
- "I can't decide for you, even if I wanted to"
Summarizing
- I'd like to pull all this together so we can see where we are.
Paradox - take on the 'no change" perspective and allow the patient to fashion responses
- "It sounds like you want things to remain as they are"
- A change takes a lot of motivation. I'm not sure if you're quite there yet"
- "I find it helpful to have a little debate. I'm going to play you, and I'd like you to convince me this really is a problem."
Offer personalized feedback
- "Your blood glucose results are very high. What do you make of this?"
Offering advice
- "I'm ahppy to offer advice, but I don't want to stop your creativity. You're the expert on you"
- "This may or may not apply. It will be up to you to decide"
- "Some people have had success with... would this work for you?"
- "There isn't one way to change. Let me describe some possibilities and you can let me know what makes sense for you."
Reflection
It is important to assess your knowledge of where they are at, and this can be done by repeating, rephrasing, parahprasing, and reflecting feelings.
- it seems that you...
- from what I understand, you...
Amplified reflection uses the patient's words to bring out the opposite in their ambivalence
- you feel your drinking is having no impact on those around you
- you see now way of increasing your physical activity to lose weight
Be careful not to lapse into judgement or criticism here!!
Identifying and Navigating Barriers
Resources and References
Rubak S, Sandback A, Lauritzen T, Christensen B. 2005.
Quick R. 2003. Changing community behaviour: experience from three African countries. Int J Environ Health Res. 13 Suppl 1:S115-21.
 |