MOTIVATIONAL INTERVIEWING (MI) AND ITS BASIC TOOLS
Key Points of This Chapter
- Motivational Interviewing offers both a style and particular methods or techniques that can be incorporated into counselling interactions to increase the likelihood of patient behavior change.
- Motivational Interviewing is based on the assumption that individuals are motivated to change when change is connected to something they value.
- The MI method places great importance on the nature of the relationship between the clinician and the patient.
- In MI, developing discrepancy involves exploring with patients the gap between their goals or values, or how they ideally would like things to be, and their current behavior.
- The means for facilitating change is based on developing discrepancy and exploring the assumed ambivalence felt by patients regarding change.
- The spirit of MI consists of three major elements: collaboration (clinicians foster a partnership with their patients), evocation (clinicians emphasize eliciting the motivation from “within ” their patients), and autonomy (clinicians allow freedom of their patients to make their own choices).
- In implementing MI, the following major principles are being followed: express empathy (by communicating acceptance and using reflective listening), develop discrepancy (by exploring the patients’current behavior and their important goals or values), roll with resistance (by avoiding arguing with the patients), and support self-efficacy (by seeking to increase the patients’optimism and confidence that they can change).
- In MI, the four main communication skills can be used as summarized by the acronym OARS, which stands for “open questions, ” “affirmations, ” “reflective listening, ” and “summarizing. ”
As an exercise to get started, we ask how important you think it is to use Motivational Interviewing with your patients. Please select a number from the scale below:
0 1 2 3 4 5 6 7 8 9 10
No importance Extreme importance
We have used this importance ruler at the beginning of Motivational Interviewing trainings for the past several years. If your score follows the typical pattern of responses we have observed, the score would fall within a range of 3 to 8. Even among audiences that have freely chosen to take valuable time to attend our workshops, we find that most do not rate the importance of using MI as a 10. We believe that this reflects some ambivalence among participants regarding the use of MI. If this is how you answered, it is a perfect position to be in, as this chapter discusses further elements of behavior change. In Motivational Interviewing, ambivalence is viewed as typical for people who are considering a behavior change. Rather than seeing patients as resistant, the assumption in MI is that it is normal for patients to be ambivalent, therefore representing an opportunity. An opportunity exists because ambivalence, by definition, indicates that while a person may have some hesitation about change, he or she also has some interest in change.
“Motivational Interviewing is a method of communication rather than a set of techniques. It is not a bag of tricks for getting people to do what they don’t want to do. It is not something that one does to people; rather, it is a fundamental way of being with and for people — a facilitative approach to communication that evokes natural change ” (Miller and Rollnick 2002).
MI is a style or method of counselling patients that initially grew out of work to help individuals with addictions. One of the founders of the method, William Miller, had observed that whereas counsellors often favored confrontational methods of counselling, research findings pointed toward the benefit of a non-confrontational approach characterized by a strong alliance or bond between counsellor and patient (Miller 1983). Miller began to develop an empathy-based approach with a focus on the perspective of the patient in understanding the challenge of behavior change. Together with the work of Stephen Rollnick, who had been focusing on patients’ambivalence regarding change, they cofounded the development of MI (Miller and Rollnick 1991, 2002). While MI was initially most commonly associated with addiction treatment and more traditional counselling settings, it has become apparent that MI can be exceedingly useful in a wide variety of healthcare settings (Resnicow et al. 2002). For example, patients seen in dental settings are often counselled regarding oral hygiene, dietary habits, and smoking cessation. Patient engagement and adherence to clinician recommendations are also central to effective dental treatment outcomes. MI offers both a style and particular methods or techniques that can be incorporated into counselling interactions to help increase the likelihood of patient behavior change. In the sections that follow, we briefly review the research evidence for MI, particularly as it relates to counselling patients in dental settings, and then provide an overview of the underpinnings and methods of MI. For those who would like to study more, we highly recommend Miller and Rollnick’s lucid and readable book, which expands considerably on the information provided here (Miller and Rollnick 2002).
Motivational Interviewing offers both a style and particular methods or techniques that can be incorporated into counselling interactions to increase the likelihood of patient behavior change.
Research evidence for MI
The efficacy of MI has been examined in numerous studies across a wide array of behavior change domains. To date, there have been four published metaanalyses summarizing the literature (Burke et al. 2003, 2004; Hettema et al. 2005; Rubak et al. 2005) providing support for the efficacy of MI. The metaanalyses indicate that MI-based interventions are at least as effective as other active treatments and superior to no-treatment or placebo controls for a range of problems involving addictive behavior (drugs, alcohol, and gambling), diet and exercise, treatment engagement, retention, and adherence. Importantly, the reviews indicate that MI is highly efficient compared to other methods (Burke et al. 2004), with as little as 15 minutes of interaction shown to be effective in the majority of studies (Rubak et al. 2005). Furthermore, effectiveness does not appear to depend on MI being delivered by counselling experts. Rubak and co-workers found a significant effect in 80% of studies where MI was delivered by physicians (Rubak et al. 2005).
Of particular relevance to dental settings are studies of dietary habits, smoking, and oral hygiene. As the aforementioned meta-analyses indicate, MI is effective for addressing changes in dietary habits including changes in overall dietary intake (Mhurchu et al. 1998), fat intake (Bowen et al. 2002; Mhurchu et al. 1998), carbohydrate consumption (Mhurchu et al. 1998), and consumption of fruits and vegetables (Resnicow et al. 2001; Richards et al. 2006). Evidence from smoking cessation literature is less strong, with metaanalyses not finding support for MI, partially limited by a lack of studies. However, there is evidence that MI leads to more attempts to quit (Borrelli et al. 2 005; Wakefield et al. 2004), reductions in smoking level (Borrelli et al. 2005), and increased readiness to quit (Butler et al. 1999). Significant effects on smoking cessation, though less commonly observed, have been reported in some studies (Curry 2003; Pbert et al. 2006; Soria et al. 2006; Valanis et al. 2001). Given that there is currently no established alternative for motivating smokers to quit in clinical settings, MI represents a promising avenue toward progress.
Studies of MI for oral hygiene have been limited to date. Weinstein and co-workers compared MI to traditional health education among a sample of 240 mothers of young children with high risk for developing dental caries (Weinstein et al. 2004, 2006). The focus was on the use of dietary and nondietary behaviors for caries prevention and compared an MI session, six follow-up calls, a pamphlet, and a video to the pamphlet and video alone. The addition of the single MI session and follow-up calls led to significantly fewer new dental caries among the children after 2 years.
In a recent study by Almomani and co-workers, it was found that the use of MI in a controlled clinical trial was able to significantly improve oral hygiene status over a period of 8 weeks in individuals with severe mental illness (Almomani et al. 2009). Additional benefits from an MI-based counselling approach on oral hygiene status were reported in a two patient case-series study by J ö nsson and co-workers (2009). In both patients, a significant improvement of oral hygiene and gingival inflammation status was achieved and maintained over an observation period of 2 years (Jönsson et al. 2009).
What triggers behavior change?
While the research support for the efficacy of MI is strong, at this point less is known about how and why MI works. Nevertheless, MI was developed with a particular understanding of how behavior change occurs. Traditional approaches to counselling patients in settings such as dental practices tend to focus on educating patients. The implicit assumption is that increased patient knowledge (e.g., the role of plaque in dental diseases or the harmful effects of smoking) will translate into behavior change. As this is rarely the case, an educational approach alone often leads to clinician and patient frustration, poor outcomes, and a sense of futility in counselling.
MI is based on the assumption that individuals are motivated to change when change is connected to something they value. This is distinct from “external ” reasons for changing provided by a clinician, such as:
“You should quit smoking because it will prevent gum disease. ”
The MI approach instead begins with an exploration of the patient’s view of the potential benefits of changing by saying:
“Tell me about any benefits you see in quitting smoking. ”
As indicated in our opening exercise, it is also assumed that in the vast majority of cases, patients are ambivalent about change. The key point about ambivalence is that it implies individuals have both reasons to change and reasons not to change. All too often conversations become bogged down by an exclusive focus on all the reasons individuals don’t want to change. Clinicians are often drawn into a form of discussion where they are arguing for change or trying to persuade the patient, while the patient argues against change by providing obstacles and barriers. The goal of MI is to avoid this pitfall by the willingness to explore both sides of a patient’s ambivalence to help him or her consider what he or she truly values.
Motivational Interviewing is based on the assumption that individuals are motivated to change when change is connected to something they value.
Motivation and the clinician-patient relationship
The MI method places great importance on the nature of the relationship between the clinician and the patient.
As mentioned in chapter 3, the MI method also places great importance on the nature of the relationship between the clinician and the patient. This relationship is often enhanced when fostered in an environment of mutual respect, while acknowledging the common thread of humanity that links the clinician and the patient. Whereas clinicians are often cast in the “expert role, ” the strength of the bond between clinician and patient can often be enhanced when the clinician recognizes the “expertise ” of the patient regarding his or her own life. Clinicians may be more effective when they see themselves as needing to learn from the patient the opportunities for improving patient health. Viewing the relationship from this perspective encourages a mutual partnership. The patient and clinician work toward a common goal in a manner that makes the patient feel supported. Training in MI often encourages clinicians to experience the receiving end of counselling for a behavior change about which they feel ambivalent. Heightened awareness of what it is like to be a patient encourages greater empathy and the appreciation of the importance of clinician support. In the “‘Spirit’of MI ” section below, we elaborate further on elements considered essential for creating a relationship between clinician and patient that is effective in facilitating behavior change.
In MI, developing discrepancy involves exploring with patients the gap between their goals or values, or how they ideally would like things to be, and their current behavior.
MI also focuses particular attention on ways the clinician’s actions can foster or undermine patient motivation. Unfortunately, it is quite easy to undermine motivation despite very good intentions. As mentioned in chapter 3, Miller and Rollnick have coined the term “righting reflex ” (the urge to “try to put things right ”) to describe the tendency that counsellors have to lecture or persuade patients of the wisdom of making a particular change (Miller and Rollnick 2002). Often this approach leads patients to feel pressured and to, paradoxically, resist change. MI aims to avoid lecturing or persuading. Instead, the goal is to focus on developing discrepancy. Developing discrepancy involves exploring with patients the gap between their goals or values, or how they ideally would like things to be, and their current behavior. For example, research indicates that most people who are smokers actually would prefer to be non-smokers (Centers for Disease Control and Prevention 2002). While this aspiration does not necessarily translate into the desire to quit today, it does highlight that there is an underlying source of motivation to be tapped. In the vast majority of cases, individuals do ideally want to live in a healthy manner, leaving room for a discussion of that goal and how they could move closer to it.
During this process, the clinician also attempts to elicit “change talk ” or statements that are consistent with or in the direction of making a change, for example by hearing the patient say:
“Even though I’m not really doing it, I would like to be eating healthier.”
In the earliest stages of considering a change, so-called change talk often takes the form of simply recognizing or acknowledging there is a problem, again, for example, by hearing the patient say:
“I know I should brush more regularly. ”
In the later stages this often takes the form of expressing optimism or the intention to change and, therefore, the patient may say:
“I’ll definitely start brushing and flossing twice a day. ”
The key issue is that the clinician has the ability to influence the relationship between clinician and patient to either foster resistance or develop discrepancy and elicit change talk.
Giving advice is something that most of us are very familiar with. However, unsolicited advice is generally not very pleasant to receive. This is perhaps even truer when it comes to unsolicited advice about our behavior or health practices (e.g., quitting smoking, losing weight, adhering to medications). Take the following example:
Patient: “I feel like my teeth are really stained, is there anything I can do? ” Clinician: “Yes, you really need to quit smoking. ”
Patient: “Yes, but it’s not that easy. ”
Clinician: “No, it’s not easy, but you need to do it and not just for the sake of your teeth but also for your overall health. ”
Patient: “Yes, I know I should quit but it’s just not that easy for me. Isn’t there something else you can do? ”
Clinician: “Not really … Have you tried to quit using nicotine gum or patch? ”
Patient: “Yes, I’ve considered it, but that stuff’s really expensive and I’m not sure it will work for me. ”
Clinician: “It will work if you are committed. I think the real key is for you to be fully committed to quitting. ”
Patient: “I suppose, but with all I’ve got going I’m just not committed right now … So there’s nothing else that can be done? ”
This excerpt highlights the common dynamic of a clinician arguing for change, while the patient makes “yes, but ” counterarguments. If the clinician’s goal is to help the patient make a change, a different approach might be warranted.
Definition of MI
The means for facilitating change is based on developing discrepancy and exploring the assumed ambivalence felt by patients regarding change.
At this point, it is useful to consider a formal definition of MI. Rollnick and Miller have defined MI as “a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence ” (Rollnick and Miller 1995). MI is client or patient-centered in that the clinician attempts to work from the patient’s perspective. As we have discussed, rather than the clinician providing his or her reasons for recommending a particular health behavior, the clinician attempts to elicit from the patient whatever reasons he or she has for engaging in that health behavior. Research evidence indicates that these intrinsic or “internal ” reasons for change tend to be associated with greater adherence to medical recommendations, persistence, and long-term behavior change (Ryan and Deci 2000).
Although the approach is patient-centred, the clinician is nonetheless directive in that there is the goal of exploring and attempting to facilitate change in a particular direction (e.g., to brush twice daily, to floss more frequently, to avoid sugary foods, etc.). The means for facilitating that change is based on developing discrepancy and exploring the assumed ambivalence felt by patients regarding change. As an MI(− minded) clinician, therefore, you take specific steps to explore ambivalence and facilitate the patient’s resolution of ambivalence in the direction of making a healthy change.
“SPIRIT” OF MI
Miller and Rollnick have emphasized that in practicing MI it is more important to embody the “spirit ” or philosophy of MI than to employ specific techniques (Miller and Rollnick 2002). The methods and techniques of MI are useful, but only insofar as they are conducted in a manner consistent with the underlying philosophy.
The spirit of MI consists of three major elements: collaboration, evocation, and autonomy. Collaboration refers to a style of working with the patient. In the MI method, the clinician fosters a partnership with the patient rather than assuming an expert role in which the patient is a recipient. The clinician and the patient work together toward a common goal as the clinician actively seeks to diminish his or her expert role.
The element of evocation refers to a style that emphasizes eliciting the motivation from “within ” the patient rather than trying to impose motivation from the “outside. ” Rather than making arguments for change, the clinician will guide the patient to examine and resolve his or her ambivalence. The style is also calm and eliciting, with no need for the clinician to use high-energy, high-pressure, or confrontational tactics to bring about change.
The spirit of MI consists of three major elements: collaboration (clinicians foster a partnership with their patients), evocation (clinicians emphasize eliciting the motivation from “within ” their patients), and autonomy (clinicians allow freedom of their patients to make their own choices).
The evocative style is facilitated by the third element of the spirit: patient autonomy. MI emphasizes the freedom of patients to make their own choices. The responsibility for change is not in the hands of the clinician. Rather the role of the clinician is to facilitate a productive exploration of the possibility of change. At the end of the day, the final decision on what to do rests with the patient. Paradoxically, the more clinicians emphasize patients’autonomy, the greater their internal motivation to change is likely to be (Ryan and Deci 2000; Williams et al. 2000).
The implementation of these elements often leads clinicians to report that counselling is more enjoyable, less effortful, and more productive. They often feel a burden is lifted when they allow patients to have autonomy and they do not have to be the expert on how to solve the patient’s problems or feel responsible for the patient’s ultimate decision. The result is in the sense of working with the patient rather than pushing for change (see Figure 4.1).
In implementing the spirit of MI there are four major principles:
- express empathy,
- develop discrepancy,
- roll with resistance, and
- support self-efficacy and optimism.
The first principle, to express empathy, highlights the importance of the patient’s perspective. The term “empathy ” refers to understanding the perspective of another person. In MI, it is not suffi/>