Motivational Interviewing for Medical Students

Department of Psychiatry and Behavioral Sciences

Adapted and excerpted from "enhancing motivation for change in substance abuse treatment," Treatment Improvement Protocol series 35, William R Miller, Ph.D., consensus panel chair.

Why do people change? What is motivation? Can individuals' motivation to change their behaviors be modified? Do physicians have a role in enhancing motivation for change?

Over the past 15 years, research and clinical attention have focused on ways to better motivate patients to consider, initiate and continue positive changes and to stop or reduce maladaptive behaviors. A related focus has been on sustaining change in avoiding a recurrence of problem behavior following treatment. Motivational interviewing is a therapeutic style that may be effective at a number of points in the change process. Motivational interventions are promising clinical tools that can be put into all phases of behavioral change by all types of physicians.

Lack of motivation has been used to explain the failure of patients to begin continue comply with and succeed in treatment. Until recently, motivation was viewed as a personality trait that person had or did not have. If the patient was not motivated for change it was viewed as the patient's fault. Motivation for treatment indicated a willingness to go along with the physician's prescription for change. Motivation was viewed as the patient's responsibility, not the clinician's (Miller and Rollnick, 1991).

Motivational interviewing is based on a number of assumptions including: motivation is the key to change, motivation is dynamic and fluctuating, motivation can be modified by physicians, and the physician's task is to enhance motivation.

What influences people's motivation for change?

Research and clinical observation suggests that the following can be instrumental in change:

  1. Distress levels may prompt individuals to change and seek help during periods of distress. This could include pain, severe anxiety or nausea.
  2. Critical life events can stimulate motivation to change. Critical life events might include dramatic accidents, severe illnesses, becoming a parent or losing a job.
  3. Cognitive evaluation of the impact of certain behaviors on a patient's life can lead to change. For example, the weighing of pros and cons in substance use accounts for 30 to 60% of the changes reported in natural recovery studies (Sobell et al. 1993).
  4. Recognizing negative consequences of harmful behaviors can help motivate some people to change (Varney et al. 1995). The physician may help patients see the connection between their behaviors and the negative consequences.
  5. Positive and negative external incentives can also influence motivation. Supportive and empathic physicians, friends, rewards or coercion of various types can stimulate motivation for change. An example of this is court ordered substance abuse treatment.

How does the physician's style influence patient's motivation?

Research has found dramatic differences in the rates of patient dropout or completion in counseling in the same program with the same techniques. Physician style may be one of the most important variables for predicting patient response to an intervention, accounting for more of the variance than the clients' characteristics (Miller et al. 1993). A strong therapeutic alliance and good interpersonal skills were more important than professional training or experience (Najavits and Weiss, 1994). The most important qualities in the physician include non-possessive warmth, friendliness, genuineness, respect, affirmation, and empathy. A direct comparison of different counseling styles suggests that a confrontational and directive approach leads to more resistance in patients and poor outcomes. For example, research suggests that the more frequently physicians use aggressive confrontational techniques with substance using clients, the less likely clients will change (and the more they will use substances). Controlled clinical trials place confrontational approaches among the least effective treatment methods (Miller et al. 1993, 1996). In contrast, a client- centered, supportive and empathic style that uses reflective listening and gentle persuasion (Miller et al. 1963) leads to better outcomes.

Motivational Interviewing Techniques

Feedback:

Personal and individualized feedback can be a successful motivational technique. Nonconfrontational feedback about a patient's problematic behavior based on information from objective assessments can be particularly helpful. This type of feedback usually compares the client scores or readings and standard tests or instruments with normative data from a general population. An example of this in general medical practice would be comparing a smoking patient's peak expired flow with the normal range.

Feedback is useful when it is offered in a straightforward and respectful way. The point is to present the information in a manner that helps the patient recognize the problem and the need for change. Not all clients respond in the same way to feedback. One person might be alarmed to see a decrease in pulmonary function while another might be relatively unconcerned. Feedback about improvements is especially helpful to reinforce progress and behavioral change.

Responsibility:

People have the choice of continuing their behavior or changing. Motivational interviewing allows patients to be active rather than passive by insisting that they choose to treatment and take responsibility for changing. The physician does not impose his or her views or goals on the patient. The physician asks patients for permission to talk about the problematic behavior and to invite them to consider new information. There is a twofold benefit in patients making their own treatment choices: the physician is less frustrated and more satisfied because the patient is doing the work and the patient often experiences a better outcome. An example of asking permission to offer information is, "Can I tell you what I've seen in the past in this situation?"

One way that patients can feel that they have responsibility for change is by having a menu of options. Patients benefit from hearing the alternative approaches to treatment as well as the physician's best guess about what the likely outcome will be of each particular path. This is also the core of informed consent, a required element of all medical treatment. When using motivational interviewing techniques, ask your patients what they think is effective or what has worked for them in the past. The physician's role is to improve the patient's ability to make informed choices. When the patient makes the choice, he or she is more likely to be committed to it and to follow through.

Advice:

As in supportive psychotherapy, the simple act of giving gentle advice can promote positive behavioral change. Research shows that short sessions in which a physician offers suggestions can be effective in changing smoking and drinking behaviors. As with feedback, it is the manner in which a physician offers the advice that determines how the patient will use it. It is better not to tell people what to do - suggesting yield better results. A motivational approach to offering advice may be either directive (making a suggestion) or educational (explaining information).

Another element of advice to patients is offering realistic models for change. Physicians should let their patients know that most change does not occur overnight. Change is best viewed as a gradual process with occasional setbacks, much like hiking up a bumpy hill. Difficulties and set backs can be reframed as learning experiences and not failures.

Empathy:

As in all other effective counseling, empathy is the key ingredient. Without empathy, all of the other skills and knowledge lack an ability to help patients change. In motivational interviewing, a specific technique used to convey empathy is reflective listening. This is the process of the physician listening attentively to each client statement and then reflecting it back in different words and not in a question format. That way the patient knows that the doctor understood him or her and as well as the meaning. Reflective listening conveys warmth, respect and active interest. It is not always easy for physicians to adapt their style to nondirective listening, but it is a very effective and high yield technique.

Self efficacy:

For success in making changes, patients must believe that they are capable of change. They must have the skills and confidence. The most important role of the physician is to foster hope and optimism by reinforcing the patient's beliefs and their own capabilities. One way the physician can do this is by helping the patients recall how they have successfully cope to with problems in the past by asking, "How did you get from where you were to where you are now?" Identifying strengths can help patients build on past successes. It is important to affirm small positive changes.

Decisional balance exercises:

This motivational interviewing technique explores the pros and cons of change. Most people naturally look at the benefits and drawbacks of life changes such as changing jobs. From medical related changes. The patient weighs the pros and cons of changing versus not changing their behavior. The physician can assist this process by asking the patient to articulate the good and less good aspects of their current behavior and listing them on a sheet of paper. This process is called decisional balancing. The purpose of exploring the pros and cons of a behavior is to tip the scales towards a decision for positive change. The actual number of reasons patient lists on each side of the decisional balance is not as important as the personal value of each one. (See example)

Discrepancies between goals and current behavior:

Motivation techniques can help patients recognize at the gap between their future goals in their current behavior. Physicians can clarify discrepancies by asking, "How does your goal to see your granddaughter graduate from high school fit in with your current health status?" When a patient sees that his or her present actions conflict with important personal goals such as health, success or family happiness, change is more likely to occur.

Motivational Interviewing Targets (Stages of Change)

Precontemplation:

Before a patient is ready to consider behavior change, he is in the precontemplation stage. The physician's task is to increase the patient's awareness of the problem and motivation for change. This task can be accomplished by establishing rapport, asking permission to talk about the underlying issue and building trust. The physician can raise doubts in the patient about his behavior by eliciting the patient's perception of the problem. The physician can also offer factual information about the risks of the behavior and provide personalized feedback about assessment findings, such as laboratory tests. With the patient's permission, the physician can lead an exploration of the pros and cons of a specific behavior. The physician can also examine discrepancies between the client's perceptions of the behavior and others' perceptions of the behavior. Lastly, the physician can express concern and keep the door open.

Contemplation:

When a patient is in the contemplation stage, he acknowledges concerns and is considering the possibility of making changes but is ambivalent and uncertain. The physician can offer a number of motivational interviewing techniques to help the client "tip the decisional balance scales" towards change. One way is to normalize ambivalence and acknowledge that everyone is uncomfortable with some types of changes. Another tool the physician can use is to revisit and weigh the pros and cons of the current behavior and of change. It might be useful to examine the patient's personal values and relation to change. The contemplation stage patient also benefits from reinforcement of his free choice, responsibility and self efficacy for change. Highly effective physicians are able to elicit self motivational statements of intent and commitment from the client. (See example)

Preparation:

A patient who is in the preparation state is committed to making a change in the near future but is still considering what to do. For patients in this stage of change, the physician may help clarify the patient's goals and strategies and offer a menu of options for change or treatment. With the patient's permission, the physician can offer expertise and advice. It is often helpful to consider barriers to change and to see what practical steps can be made to lower the barriers. Some physicians are able to enlist the patient's significant other in supporting change. Another approach for patients in the preparation stage is to find out from the patient what has worked in the past either for him or for others whom he knows. The physician can also encourage the patient to announce plans for change, such as informing colleagues at work and family that he is quitting smoking.

Action:

A patient who is in the action stages actively taking steps to change that has not yet reached a stable state. The physician's role for this stage is reinforcement of the importance of remaining on track and making realistic changes through small steps. Physicians can also acknowledge difficulties in the early stage of change and help the patient identify high-risk situations. Once the situations are identified, together the physician and patient can talk about appropriate coping strategies to manage the situations. It may be helpful to identify new reinforcers of positive change. For example for a patient who has lost 20 pounds, not only are her lab results improved, but her improved exercise tolerance may also be a reinforcer of the positive change.

Maintenance:

A patient who has achieved maintenance has made important lifestyle changes. The physician's role for this stage is to reinforce and support the changes. This can be done through affirmations of the client's resolve and self efficacy, practice and reinforcement of new coping strategies and the maintenance of support of contact. It is also useful to look at "fire escape" plans for slips in the behavioral change. A patient and maintenance also benefits from for slips in the behavioral change. A patient and maintenance also benefits from reviewing long-term goals with the physician.