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Motivational Interviewing for Busy Health Care Professionals
Do you feel frustrated at times with your patients? You tell them what they need to do to improve their health and why they need to do it. Then, the next time you see them nothing has changed. You may advise them again and again, hoping that the more they hear the arguments for change, the more likely they will change.
In the busy world of health care when caseloads are high, time is limited and pressure to improve health outcomes are great, the “traditional approach”—in which the patient comes to a practitioner with a problem or concern and the practitioner offers a solution—is often used. However, this approach does not lead to a positive change in health behavior or adherence to treatment most of the time.
Health behavior research shows that a counseling style called motivational interviewing (MI) can help the most ambivalent patients change health behavior. MI was first practiced in the early 1980s helping people recover from alcoholism. Since then, many different specialists have applied MI including allied health care professionals, therapists, social workers, dietitians, addictions counselors, guidance counselors, teachers, probation officers and others.
In the directing style of counseling, a practitioner would be dominant and the patient would be passive. For example, a doctor might say, “You need to take your blood pressure medication to lower your risk of a stroke.” The opposite approach would be following. This is where that patient would lead the consultation and the practitioner would actively listen and affirm the patient’s statements without offering advice. The doctor instead says, “You feel overwhelmed with your new diagnosis and taking your blood pressure medication is difficult for you.” The guiding style, which is conducive to MI, sounds like this, “Taking your blood pressure medication and exercising are some of your options. What works for you?”
The goal of MI is for the patient to voice arguments for change. This is called change talk, in which the patient is talking about the why and how of change. Ways this is expressed include:
- Desire. “I would like to…”
- Ability. “I could…” or “I can…”
- Reasons. “I would probably have more energy.”
- Need. “I should…” or “I have to…”
- Commitment. “I am going to…” or “I will…”
- Taking steps. “I joined a gym.” “I filled my prescription.”
Use these 4 basic MI skills to evoke change talk.
- Open-ended questions. Starting a question with “what”, “why”, “how” or “tell me more” encourages the patient to elaborate. Examples:
- “What would be most helpful for you?”
- “Why is taking your medication important to you?”
- “How did you lose weight the last time?”
- Affirmations. Affirming a patient’s statements builds rapport, trust and confidence.
- “Your hard work is paying off.”
- “You are managing your health well.”
- “You’ve been mindful about eating.”
- Reflections. A good reflections to questions ratio is 3:1. Simple reflections include repeating back what the patient said. Paraphrasing repeats back what the patient said with a slight change in wording. The most effective reflections are complex and evoking. Hypothesis-testing involves the listener taking a guess at what the speaker meant and reflecting back the feelings behind the statement.
- “You don’t take your medication because you don’t like the way it makes you feel.”
In a double-sided reflection, the practitioner states the pros and cons of behavior change.
- “On the one hand you want to eat more healthy and on the other hand you don’t’ have the time to prepare meals at home. You also do not have enough money to buy health food.”
- Summaries. Summaries can happen throughout the consultation and at the end. The practitioner can highlight the patient’s arguments for change and reflect back these to the patient.
MI leads patients to find their own solution(s). At times when you need to give advice or offer information, use the ask-offer-ask approach.
- Ask. Ask the patient what she/her already knows about a particular subject. For example, “What do you already know about managing your blood pressure?” You could also ask permission, “If It is ok with you, I would like to share some ideas that have helped other patients.”
- Offer. “Meditation has helped some people and also walking outside can help relieve stress.”
- Ask. “What would you prefer: Making a lifestyle change or taking a new medication?”
For more information on facilitating behavior change in your patients, you might want to research the following topics: brief action planning, brief negotiation, and brief motivational interviewing.