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Motivational interviewing in primary care

Motivational Interviewing is a way of building and strengthening people’s drive to change longstanding behaviours that pose a significant risk to their health. It is an art as much as a science and practice is required to consistently apply the method successfully. Health professionals who develop the skill of Motivational Interviewing have an additional approach to use when they encounter patients who do not want to change or are ambivalent.

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Published: 6 September 2019 | Updated:


Key practice points:

  • Motivational Interviewing is helpful for facilitating change in many situations where there is a modifiable risk factor with a behavioural component
  • The method involves patients talking about their behaviour and motivations for change while the health professional listens and guides the conversation so that the patient voices these motivations
  • The motivation for change comes from the patient who is encouraged to consider the benefits of change and why they may want to continue as they are
  • Respecting the autonomy of the patient and displaying a non-judgemental attitude are especially important during Motivational Interviewing
  • Assess that the patient is ready for change before negotiating an action plan that is specific and measurable

Motivational Interviewing is an evidence-based method of discussing health issues with patients that helps increase motivation to change long-standing detrimental behaviours. A core principle of Motivational Interviewing is that health professionals elicit reasons for change from the patient by discussing the patient’s values and goals, and contrasting them with their current behaviour.1 This process encourages patients to consider how their life might be improved if they were to change their behaviour.

When to consider Motivational Interviewing

Motivational Interviewing may be helpful for facilitating change whenever there is a modifiable risk factor with a behavioural component. The method is well suited to primary care where negative health-related behaviours are commonly encountered. Specifically, motivational Interviewing is useful when a patient:

  • Recognises there is a health risk but is ambivalent about change, e.g. not wanting to stop smoking or drinking because they do this with family and friends
  • Is not engaging in self-care behaviours, e.g. not adherent to glucose-lowering medicines for type 2 diabetes
  • Is unaware of the health risk, e.g. not using condoms during intercourse
  • Has an entrenched belief, e.g. regarding vaccination

Health conditions that Motivational Interviewing may be appropriate for in primary care include:1

  • Smoking cessation
  • Alcohol and substance misuse
  • Weight management or improving nutrition
  • Increasing physical activity
  • Improving medicine adherence
  • Managing problem gambling
  • Reducing sexual risk taking
  • Encouraging vaccination
  • Stress management
  • Pain management

The challenge facing health professionals in primary care is the limitation of time.2 If appropriate, have a clinical staff member, e.g. a nurse, trained in Motivational Interviewing who other health professionals in the practice can refer patients to for extended consultations.

Training in Motivational Interviewing for healthcare professionals

Details on training courses for Motivational Interviewing are available from: https://anzasw.nz/motivational-interviewing-interactive-engaging-online-mi-course-key-workers/

The University of Canterbury offers papers on Motivational Interviewing suitable for primary healthcare professionals, that can be taken as distance courses:

  • HLTH430: Motivation Behaviour Change I
  • HLTH431: Motivation Behaviour Change II

Motivational Interviewing uses strategies that are already familiar

Motivational Interviewing is the structured application of skills that most health professionals are already using, e.g. open-ended questions, empathic listening, affirming positive behaviour and providing advice. These skills also need to be applied in a way that is consistent with the “spirit” of Motivational Interviewing, otherwise it is unlikely to be successful (Table 1).1 Crucially the process highlights the freedom of the patient to make decisions and drive behaviour change (similar to shared decision-making). This method is very different to the outdated paternalistic approach of reiterating health advice in an increasingly authoritative or coercive manner when patients appear to ignore it.1 Patients who are not used to a partnership approach to healthcare may need to be encouraged during the process of Motivational Interviewing to accept the responsibility of decision-making.

Motivational Interviewing is consistent with Māori health models

Elements of Motivational Interviewing are consistent with Māori customs and protocols (tikanga).3 For example, the philosophy of partnership between the patient and the health professional (whanaungatanga) respects the autonomy and status (mana) of the patient and creates a safe and welcoming environment (manaakitanga) that empowers (whakamana) the patient. Through the process of engagement the patient and health professional are able to identify any barriers that need to be overcome before they can agree and focus (whakamārama) on the relevant issues (kaupapa).3

Table 1: The spirit and the process of Motivational Interviewing2, 3

The spirit of Motivational Interviewing The process of Motivational Interviewing

Partnership: a shared journey between the health professional with the skills and the patient who has the strength and the potential for change

Engaging by establishing a trusting relationship that enables an honest and non-judgemental discussion.

Acceptance: honouring the autonomy of the patient and acknowledging their worth

Focusing on the problem by identifying areas of potential change. This process may need to be repeated as additional issues arise.

Compassion: the process is conducted with the best interests of the patient at heart

Evoking the patient’s desire for change and how they want things to be different. This may occur early or late in the process depending on the patient’s readiness for change.

Evocation: helping the patient identify their motivation for change

Planning together for how change can be brought about

Ask open-ended and non-judgemental questions and encourage the patient to discuss their motivations, for example:

Tell me why you decided to come here today?

Open-ended questions are also a good way to initiate discussions about detrimental behaviour that has not been raised by the patient, for example:

What do you think is causing you to cough like that?

One of the key goals in Motivational Interviewing is to encourage the patient to engage in “change talk”, i.e. statements that indicate the patient is considering behaviour change.1 Change talk contrasts with “sustain talk” which are statements the patient makes in favour of the status quo, and a predictor of poorer clinical outcomes.2

Change talk can be evoked by focusing on four areas:1

  1. The disadvantages of the status quo, e.g. What effect do you think your smoking is having on your children?
  2. The advantages of change, e.g. What would the benefits be if you stopped smoking?
  3. Optimism for change, e.g. What would increase your confidence that you could quit smoking if you decided to?
  4. Intention to change, e.g. What is it that you would be willing to do as a first step if you did decide to stop smoking?

Avoid creating resistance

Resistance to change can be avoided by the health professional maintaining a non-judgemental attitude and working in partnership with the patient. The health professional empathises with the patient and helps them to voice their motivations for change,3 for example:

I understand that you don’t want to change the way you eat because it is important for you to provide meals that your family enjoys. What do you think the benefits of changing your diet would be? Perhaps we can talk a little bit about ways that you can change your weekly meal routine before you decide one way or the other?

Throughout the consultation the health professional affirms the patient’s freedom of choice rather than trying to push change on them.

Affirm the positive

The patient’s strengths and efforts should be affirmed to build rapport and increase confidence in their ability to change,1, 3 for example:

It took a lot of courage for you to come here today.

You have been really determined to go an entire week without a drink.

Overemphasis on praise is generally avoided in Motivational Interviewing, e.g. phrases such as “well done”, “good work”.

Use reflections to strengthen change talk

Reflections involve rewording the patient’s statements and speaking them back, so that the patient again hears their own change talk.1 This also demonstrates to the patient that the health professional is listening and understands them. Successful reflections invoke further change talk and the amount of talking the patient does can be used to judge the success of a reflection.3 For some health professionals, reflections are a normal part of their consulting style, others may need practice to generate reflections naturally and which encourage the patient to speak more. A beginning level of skill in Motivational Interviewing is to provide one reflection to the patient for every question, taking care not to interrupt, allowing pauses for the patient to think and waiting until they have finished speaking,3 for example:

Patient – I want to quit smoking for my children but I’m not sure I can.

Reflection – So part of you is not sure you can make this change, and part of you knows that quitting smoking is important for your children.

Indications that reflections are not successful include the patient disagreeing or interrupting, changing the subject or seeming distracted or disinterested.3

Summarise at the conclusion of each topic

Summaries are a useful way of changing topic, introducing a new strategy or finishing a conversation. For example:3

OK, so what you’re telling me is your wife’s criticism of your gambling has become too much to bear. You’re also worried about the effect it is having on your son because he stole some money so he could play the pokies. If you’re okay with it, I’d like to move on and talk about the amount of money you’re spending on gambling – talk me through a typical week in terms of how much you’re spending.

Providing feedback or advice to the patient

It is important to respect the autonomy of the patient when providing feedback or advice,3 for example:

Would you be interested in hearing what the guidelines recommend for a healthy diet?

Asking the patient what they already know about the topic before you share feedback or advice with the patient is also a good step. It shows respect for the patient’s knowledge and saves you time sharing something that they already know.

Share feedback or advice with the patient in a neutral way, for example:

Your blood pressure was 160/100. The general guideline is that blood pressure over 140/90 is considered high.

There are a number of ways of changing your drinking – some people decide to stop drinking for a certain period of time or forever, others decide to reduce their drinking to within guidelines for safe drinking, or to limit drinking to special occasions only. You are the one to best decide what will work for you.

If there are ethical reasons why a patient needs to be told something, e.g. an immediate risk to themselves or others, the information can be prefaced with by an expression of concern,3 for example:

I am very concerned about you and feel that I need to share something with you.

Determine if the patient is ready, willing and able to change

For patients who have expressed some interest in behaviour change, assess their readiness for change.1 This involves determining:1

  • Readiness – whether change is an immediate priority
  • Willingness – the importance of change for the patient
  • Ability – the confidence of the patient to change

Ask the patient to rate their level of readiness/willingness/ability to change on a scale of zero to ten.3 This technique highlights the discrepancy between where the patient is currently and where they would like to be.1 This is a key aspect of Motivational Interviewing as it displays the gap that the health professional needs to help the patient bridge before can change occur. For example:

On a scale of zero to ten, where zero is not a priority at all and ten is the highest priority, how ready are you to change?

On a scale of zero to ten, where zero is not important at all and ten is really important, how important is it for you to change?

On a scale of zero to ten, where zero is not confident at all and ten is really confident, how confident are you that you could change?

For each of these, the patient can be asked why they chose that number rather than zero. This prompts them to engage in positive change talk by discussing the reasons why it is a priority for them.

Patients should not be asked to explain why they did not choose a higher number as they will inevitably be encouraged to talk about why change is not a high a priority for them, i.e. sustain talk.3 An important question to encourage further positive change talk is to ask:3

What would it take for you to increase that number from four to six?

This helps the patient to imagine the change becoming more important.3 The hypothetical number should not be more than two points higher than the number the patient has chosen so they do not feel like they are being pushed.3

Create an action plan for change

Work with the patient to create a plan for behaviour change, but only once they are ready and they need or want a plan, otherwise it is likely to reduce their motivation for change.3 The possibility of a plan can be introduced by asking the patient questions such as:1, 3

  • Where to from here?
  • What steps will you take next?
  • Would you be interested in discussing a plan?
  • Would you be interested in hearing what has worked for other people?

The goals of the plan should be specific and measurable, e.g. only drinking alcohol on one night a week.3 Optimistic and hopeful language is useful to encourage the patient’s belief that the goal is achievable.3

A worksheet for creating action plans for change is available on page 32 of Takitaki mai: A guide to Motivational Interviewing for Māori, available from: www.matuaraki.org.nz/uploads/files/resource-assets/Takitaki-mai-a-guide-to-motivational-interviewing-for-maori.pdf

Provide ongoing support for behaviour change

After an action plan for change has been agreed, make an offer of ongoing support to the patient, for example:

  • What can I do to help you stick to this plan?
  • Are there any resources that I can give you that will help?

It is useful to discuss strategies to overcome potential obstacles that the patient has identified or experiences when they start making the change. For example:

You feel that your friends are no longer including you because you aren’t drinking. Perhaps you could host an event at your house to show that just because you aren’t drinking it doesn’t mean that you no longer want to socialise.

Arrange a follow-up appointment before the patient leaves to provide further support.

Accept that change is a process

If at the next consultation the patient reports that they have experienced difficulties with making the change, explore the reasons for this using Motivational Interviewing methods, for example:

Why do you think you started smoking again last week?

Help the patient to see this as an opportunity to learn and consider strategies that make it more likely they will be able to achieve and maintain the behaviour change.

Additional resources on Motivational Interviewing, including instructional videos are available from: www.healthnavigator.org.nz/videos/m/motivational-interviewing-for-clinicians/motivational-interviewing-explained

Acknowledgement

Thank you to Associate Professor Eileen Britt, Director of the Clinical Psychology Programme, School of Health Sciences, University of Canterbury for expert review of this article.

N.B. Expert reviewers do not write the articles and are not responsible for the final content.


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