Motivational Interviewing

• Developed from the Stages of Change model.
• Enhances motivation by resolving ambivalence.
• Involves three components: willingness, ability, and readiness for change.
• Tailors motivational strategies to individual’s stage of change.

Stages of Change Model

1. Precontemplation: Not considering change.
2. Contemplation: Ambivalent about change.
3. Preparation: Planning and committing to change.
4. Action: Taking steps towards change.
5. Maintenance: Sustaining long-term change.
6. Relapse: An opportunity for learning and maintaining future change

Effectiveness of MI:

• Comparable or superior to other treatments (CBT, pharmacotherapy) for addiction.
• Efficacious in smoking cessation, sexual risk behaviors, treatment adherence, diabetes management, etc.
• Applicable in various healthcare settings, including HIV care, substance abuse, pain and stress management.

The Spirit of Motivational Interviewing:

• Based on collaboration, evocation, and honoring patient autonomy.
• Views the therapist as a facilitator, not an expert.
• Avoids authoritarian stance, focuses on eliciting patient’s reasons for change.

MI in Practice:

• Consists of two phases: building motivation and strengthening commitment.
• Uses techniques like OARS (Open-ended questions, Affirmations, Reflections, Summarizing).
• Emphasizes eliciting ‘change talk’ and setting a ‘change plan’ with the patient.

Guiding Principles of MI

1. RULE Acronym: Resist the righting reflex, Understand patient’s motivations, Listen with empathy, Empower the patient.
2. Additional Principles: Express empathy, Develop discrepancy, Roll with resistance, Support self-efficacy.

The guiding principles of Motivational Interviewing (MI) are crucial to its effective implementation. Here are more details on these principles:

1. Resist the Righting Reflex
   • Definition: The righting reflex is the natural tendency of healthcare professionals to correct a patient’s behavior or thoughts towards what is perceived as the ‘right’ path for their health.
   • In MI: Practitioners suppress this reflex to avoid creating a counterproductive dynamic. Instead of dictating what should be done, they work collaboratively with the patient.
   • Example: A patient mentions they haven’t been taking their medication regularly. Instead of immediately advising or correcting them (“You should take your medication every day”), the practitioner asks, “Can you tell me more about your routine and what makes taking medication regularly challenging for you?” This approach avoids direct confrontation and allows exploration of the patient’s perspective and barriers.
2. Understand the Patient’s Own Motivations
   • Focus on Patient’s Reasons: MI emphasizes the importance of understanding and exploring the patient’s own reasons for change. It’s these personal motivations, not the practitioner’s arguments, that will ultimately drive behavioral change.
   • Exploration: The approach involves exploring the patient’s interests, concerns, and values with openness and curiosity.
   • Example: A patient expresses a desire to quit smoking but has failed multiple attempts. The practitioner might say, “It sounds like quitting is important to you. What are some of the reasons that make you want to quit?” This helps uncover the patient’s personal motivations and values related to quitting, rather than assuming or imposing external reasons.
3. Listen with Empathy
   • Effective Listening: MI requires active and empathetic listening to fully understand the patient’s perspective. This involves more than just hearing words; it’s about understanding the emotions and motivations behind them.
   • Balancing: A rule of thumb in MI is to spend an equal amount of time listening as talking during consultations.
   • Example: When a patient talks about their struggles with dieting, the practitioner responds with, “It seems like you’ve been feeling really frustrated with these dietary restrictions. It must be hard to balance this with your lifestyle.” This response shows understanding and validation of the patient’s feelings, promoting a more open and trusting conversation.
4. Empower the Patient
   • Collaboration: The patient is seen as an active collaborator in their treatment plan.
   • Drawing on Patient’s Strengths: This involves recognizing and building upon the patient’s own knowledge, past successes, and ability to make changes.
   • Example: After discussing various strategies for managing a health condition, the practitioner might say, “You’ve shared some great insights into what works for you. How do you feel about these options, and which ones do you think you’d like to try?” This encourages the patient to take an active role in their healthcare decisions, reinforcing their autonomy and capacity for self-management.

Additionally, Miller and Rollnick, the founders of MI, identified four further principles for a more in-depth therapeutic intervention:

1. Express Empathy
   • Communication Style: Involves reflective listening and showing genuine understanding of the patient’s situation without judgment.
   • Building Trust: This approach fosters a respectful and open exchange, creating a supportive environment for change.
2. Develop Discrepancy
   • Identifying Disparities: Practitioners help patients recognize discrepancies between their current behaviors and their broader goals or values.
   • Use of Decisional Balances: This involves weighing the pros and cons of change to help patients clarify their ambivalence.
3. Roll with Resistance
   • Avoiding Confrontation: In MI, resistance is met without judgment. The practitioner doesn’t confront it directly but rather ‘rolls’ with it, exploring it as an expression of the patient’s perspective.
   • Strategies: These include simple reflection of the patient’s resistance, emphasizing their freedom and choice, shifting focus, or reframing the discussion.
4. Support Self-Efficacy
   • Belief in Ability to Change: This principle involves promoting the patient’s belief in their capacity to make changes.
   • Focusing on Strengths: The practitioner acknowledges the patient’s past successes and strengths to build confidence in their ability to change.

These guiding principles of MI create a holistic and patient-centered approach, making it a powerful tool for facilitating behavioral change in healthcare settings.

Barriers to MI in General Practice

1. Challenges: Time pressures, professional development requirements, shifting from expert to facilitator role.
2. Benefits: Effective for resistant patients, adds to therapeutic tools in general practice.