discussion #8 disease

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Motivational Interviewing
For Behavior Change

Overview

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Behavior Change Conversations

n  Health care providers often find themselves having multiple
conversations with patients regarding behavior change.

n  It is sometimes difficult for them to know HOW to approach
these conversations.

n  For example:
n  Should they explain to patients what they should do differently?

n  Should they advise them or persuade them to change?

n  Should they warn them and explain the consequences of not
changing their behavior?

n  Should they refer them to a different provider specialist?

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Motivational Interviewing (MI)

n  MI has been found effective in fostering CHANGE across a
wide range of behaviors.

n  It works by activating patients’ own motivation for change
and adherence to treatment.

n  It is based on the premise that motivation for change is
malleable and formed in the context of the patient-provider
relationship.
n  When a patient seems unmotivated to change or take the sound

advice of practitioners, it is often assumed that there is something
‘wrong’ with the patient and that there is not much that can be done.
These assumptions are usually FALSE. No patient is completely
unmotivated.

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Why Use MI?

n  The way in which we talk to patients about their health can
significantly influence their motivation for behavior change.

n  MI is a skillful style that allows providers to elicit their own
good motivations for making behavior changes in the interest
of their health.

n  MI is based on guiding principles that are not directive in
nature.

n  MI can be best visualized as a dance (vs. wrestling) or as
listening (rather than telling).

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The ‘Spirit” of MI

n  COLLABORATIVE
n  Based on a provider-patient partnership and a joint decision-

making process

n  EVOCATIVE
n  MI seeks to evoke from patients what they already have instead of

attempting to giving them what they are lacking

n  HONORS PATIENT AUTONOMY
n  MI requires a certain degree of detachment from the outcome; an

acceptance that people can and do make choices about the
course of their lives. It is the acknowledging of the patient’s right
of freedom not to change that sometimes makes change possible.

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MI’s 4 Guiding Principles

RESIST – UNDERSTAND – LISTEN – EMPOWER

n  To resist the righting reflex

n  To understand and explore the patient’s own motivations

n  To listen with empathy

n  To empower the patient

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Resisting the Righting Reflex

n  Health care providers often have a powerful desire to ‘set
things right’, prevent harm, and promote well-being.

n  As such, their urge to correct another’s course often becomes
‘automatic’.

n  This inclination can have a paradoxical effect on patients
because it is natural for individuals to resist persuasion,
particularly in the face of ambivalence.

n  Because we tend to believe what we hear ourselves say, we
need to be careful in eliciting interactions that lead patients
to verbalize the disadvantages of change.

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Understanding the Patient’s
Motivations

n  Behavior change is more likely to be triggered by the
patient’s own reasons for change (not the therapists’)

n  MI explores and evokes patient’s perceptions about their
current situations and their own motivations for change.

n  It is the patient who should voice the arguments for behavior
change.

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Listening to Your Patient

n  MI involves as much listening as informing.

n  Although patients might have the expectation that providers
have all of the answers, patients are the experts when it
comes to their own behavior change.

n  Listening empathically to the patient will allow providers to
find these answers

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Empowering the Patient

n  Empowerment involves helping patients explore how they
can make a difference in their own health.

n  The provider’s role is to support the patient’s hope that
change is possible and that it can have an impact on their
health.

n  The goal is to actively involve the patient in the consultation.
Patient’s who think aloud about the why and how of change
are more likely to do something afterward.

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MI Communication

n  Providers using MI should have the feeling that they are
‘dancing’ with their patients.

n  The provider’s stance in relation to the patient is easy and
less conflict-ridden than in a directive style.

n  “People are generally better persuaded by the reasons which they

have themselves discovered than by those which have come in to
the mind of others”

– Blaise Pascal

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Communication Styles

n  A communication style refers to an attitude and approach to
helping patients, a way of talking with them that
characterizes the provider’s relationship with them.

n  Different communication styles are used for different
purposes.

n  The three MI communication styles are:
n  Following
n  Directing
n  Guiding
n  These exist along a continuum with following at one end, directing

at the other, and guiding in the middle.
n  Each style is appropriate for a particular task

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Following

n  This style has no agenda to achieve rather than seeing and
understanding the world through the other’s eyes.

n  LISTENING predominates; the provider follows the patient’s
lead.

n  It communicates the messages:
n  “I won’t change or push you”
n  “I trust your wisdom about yourself and I’ll let you work this out in

your own time and at your own pace”

n  Synonyms for “following”:
n  Go along with, allow, permit, be responsive, have faith in, go after,

attend, take in, shadow, understand, observe

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Directing

n  The provider takes charge in this approach.

n  It implies an uneven relationship with regard to knowledge,
expertise, authority, or power.

n  This style communicates:
n  “I know how you can solve this problem”
n  “I know what you should do”

n  Patients often appear to expect this take-charge approach

n  Synonyms for “directing include:
n  Manage, lead, take charge, determine, steer, prescribe, tell, point

toward, administer, authorize, show the way, take command

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Guiding

n  A guide helps others find their way.

n  The guide does not determine what others see or do

n  A good guide knows what is possible and can offer
alternatives from which to choose.

n  This style communicates:
n  “I can help you to solve this for yourself”

n  Synonyms for “guiding” include:
n  Enlighten, encourage, motivate, support, look after, accompany,

take along, elicit, awaken.

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Mix & Match

n  The three styles are often intermixed.

n  Skillfulness in communication involves flexible shifting among
them according to the patient and situation.

n  Providers should avoid falling into the ‘trap’ of expressing
themselves in a directing style when intending to assess,
diagnose, or follow-up with patients. This can compromise the
quality of care.

n  A directing style is appropriate in many circumstances and can
be used skillfully, but it should not be the only way providers
interact with patients.

n  Problems are solved more effectively with a balanced mixture of
styles.

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Conclusion

n  Health outcomes are often highly influenced by and dependent on the
patient’s own behavioral choices – on doing something new or
differently.

n  Behaviors that have a major effect on the course of a patient’s health or
illness and over which providers have little or no direct control include:
smoking, drinking, diet, exercise, medication adherence, etc.

n  Guiding is well suited to helping people solve behavior-change
problems. MI is a refined form of this guiding style.

n  A practitioner using MI will use a guiding style paying particular
attention to how to help the patient make his or her own decisions about
behavior change.

n  Although MI could be considered a form of guiding, not all guiding is
MI!!!!

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Conclusion (continued)

n  MI is specifically goal-directed. Often the practitioner has a
specific behavior change goal in mind and gently guides the
patient to consider why and how he or she might pursue that
goal.

n  In MI, the provider pays attention to certain aspects of the
patient’s language and actively seeks to evoke the patient’s
own arguments for change.

n  MI involves competence in a well-defined set of clinical skills
and strategies that are used to evoke behavior change.

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