The phrase "motivational interviewing" (MI) is a phrase that has recently gained familiarity in the vernacular of health care professionals, particularly in regards to patient activation and patient empowerment. MI represents a coherent and evidence-based approach to behavior change counseling that is rooted in several existing models of psychotherapy and health behavior change theory. Although MI developed several decades ago from the world of substance abuse and addiction counseling, the basic concepts and philosophy are finding a place with healthcare professionals dealing with chronic conditions such as diabetes. Anecdotal success stories by clinicians are now being joined by peer-reviewed evidence demonstrating the feasibility and utility of MI strategies as part of the overall primary care encounter.
Motivational Interviewing is a particular type of counseling style, generally seen as more patient-centered than the conventional didactic style of health education. The goal of MI is to elicit a positive behavior change in patients by helping them explore and resolve their own ambivalence. One of the main purposes of the technique is to have a conversation that stimulates a patient's desire to change and gives him or her the confidence to change. MI is very different from most conventional medicine encounters, and especially acute care, where the focus is on a clinician-driven treatment plan that aims to "fix" a broken patient. Rather, the objective of MI is not to solve the patient's problem or even to develop a plan; the goal is to help the patient resolve his or her ambivalence, develop some momentum, and begin to believe that behavior change is possible.
Regular practitioners and trainers of MI spend years perfecting their skills, and it would be foolish to think that a simple handout can effectively teach the many nuances of this therapeutic technique. However, the reason why MI shows such promise for today's time-crunched clinicians is that basic elements can be learned and successfully applied in brief patient encounters. Furthermore, much of the MI literature emphasizes how the "spirit" of MI is the driving force behind any success, rather than particular techniques or training. Think about MI as another kind of approach to health behavior change consultations with patients, whereas the clinician's primary goal is to provide high-quality listening rather than ready-made answers or advice. Most importantly, the clinician offers genuine empathy for the patient's difficulty in making changes and does not take the previous lack of change as a personal affront of the clinician's "problem to fix."
The "OARS" acronym offers a foundation for patient discussions. "OARS" stands for Open-ended Questions, Affirmation, Reflective Listening, and Summaries. A common fear from busy clinicians is that asking open-ended questions will literally open the door to long, rambling conversations with multiple opportunities for new problems and complaints. However, the literature notes that clinicians experienced in the MI counseling style report that patients only need 3 to 4 minutes of active, high-quality listening in order to discuss their ambivalence regarding a targeted behavior change. Such discussions often lead to the next step, finding the motivation.
For more information on MI, visit the extremely comprehensive Web site http://www.motivationalinterview.org. Additional references for this handout are below.
Welch G, Rose G, Ernst D. Motivational Interviewing and Diabetes: What is it, how is it used, and does it work? Diabetes Spectrum (2006). Vol 19;1:5-11.
Miller WR, Yahne CE, Moyers TB, et al. A randomized trial of methods to help clinicians learn motivational interviewing. J Consult Clin Psychol (2004). Vol 72:1050-1063.
Hettema J, Steele J, Miller WR. Motivational Interviewing. Ann Rev Clin Psychol (2005). Vol 1:91-111.
Open-ended questions. Avoid asking questions that can be answered with a "yes" or "no." Broad questions allow patients maximum freedom to respond.
___ "What's been going on with you since we last met?"
___ "If you had one habit to change in order to improve your health, what would that be?"
___ "What goal would you like to set?"
___ "What might be one thing you could consider doing/changing?"
___ "You seem _____ (feeling). Tell me about that."
Affirmations. Never underestimate the power of expressing empathy during tough spots or in celebrating patients' accomplishments. When you review patients' goals, take joy in their success and show your joy.
___ "You seem happy with your __________ (weight, blood pressure, energy). That's great."
___ "It sounds like you are really trying to____________ (eat less junk food). I'm proud of you."
___ "You're doing such a nice job at ____________ (getting up early to walk). I'm putting a gold star in your chart."
Reflective listening. Patients often have the answers; the clinician's role is to help guide them. Reflective listening involves letting patients express their thoughts and then, instead of telling them what to do, capturing the essence of what they have said without judgment. It is also appropriate to acknowledge the patient's mood about what he or she is telling you.
Patient: "I wish I didn't eat so much fast food."
Doctor: You eat fast food fairly often."
Patient: "Pretty much every day. I know I shouldn't, but it's just easier."
Doctor: "It's easier because you don't have to plan and cook meals."
Patient: "And I can just run over to the drive-through."
Patient: "Right... I guess there are some healthy items on the menu."
Doctor: "So you don't want to give up the convenience of fast food, but you would like to eat healthier."
Summaries. This involves recapping what the patient has said, calling attention to the salient elements of the discussion, and allowing the patient to correct any misunderstandings and add anything that was missed. Summaries are particularly helpful in bringing the visit to a close.
___ "I am wondering what you're feeling at this point"
___ "I am wondering what you think your next step should be."
___ "It sounds like you are saying..." ___ "... did I get that right?" (summarize in about 10 words)
The open-ended questions in Tool 12 are adapted from: William R. Miller and Stephen Rollnick. Motivational Interviewing: Preparing People for Change. 2nd ed. The Guilford Press, New York, 2002.