After the Evidence Motivational Interviewing

Key Points

The most promising technique of active listening to help patients change behavior is motivational interviewing.

The three essential tools of motivational interviewing are:

• An importance "ruler"

• A confidence "ruler"

Resistance is to be expected and provides the physician with the best opportunity to assist patients to work on what they need to do for themselves.

The previous studies are adequate to meet information objectives, but this alone is insufficient. To help patients make changes in their lives—and each of these lifestyle habits represents major behavior change—it is necessary to help them discover their own motivations to make changes and to help build confidence in their ability to undertake the task. Providing information is a physician behavior that is usually well supported in traditional medical education and training. The pitfall, however, is that most primary care physicians were trained to use this information as the basis for giving advice to patients. Experience confirms that simply giving advice usually is ineffective, and to the contrary, the usually unwelcome advice often heightens resistance to new behaviors.

Physicians cannot provide the motivation for patients to undertake lifestyle change, so it is necessary to ask patients what they want to do. What are their reasons for continuing a lifestyle habit that they usually know is associated with some adverse effects on their health? All patients have such reasons, or the behavior would simply go away.

Unhealthy lifestyles are perpetuated when internally the "pros" in favor of a given behavior have reached a stalemate with the "cons," and a search for new behavior stops. The role of physicians is to help patients break the stalemate by creating opportunities for patients to reflect on their own behavior and values. A physician demonstrates respect for patients' autonomy and their right to make decisions for themselves when, after an examination of the pros and cons, the physician accepts wherever patients are with change in their life and allows them to guide the clinician to the areas where they are most motivated to change. The greatest problem is that family physicians were never trained to do this; it does not just happen.

The way to make it happen is by listening. This is true regardless of which evidence physicians believe and what attitudes patients have. "Long before there was any scientific basis for health care, there were healers who had learned to listen carefully" (Rollnick et al., 2008, p. 65).

The most promising new technique of "active listening" for health care practitioners is motivational interviewing (MI). It is beyond the scope of this chapter to provide detailed instructions in the related skills, which must be experienced and practiced over at least a few months. This section discusses the underlying principles and simple ways to start implementing these skills in medical practice. The development of skills requires sufficient understanding of the basic theory of MI to try the related clinical style with patients. Patients will then provide enough direct and immediate feedback to help physicians quickly refine their skills. The relevant basics of theory and practice are readily accessible (Rollnick et al., 1999, 2008; see also Web Resources).

The clinical method of MI was first described in 1983 as an approach to problem drinking (Stockwell and Gregson, 1986). MI is a "skillful clinical style for eliciting from patients their own good motivations for making behavior changes in the interest of their health" (Rollnick et al., 2008, p. 6). MI is a collaborative partnership between patients and their physicians based on the assumption that motivation for behavioral change is "malleable" and is formed particularly in the context of relationships. In addition, MI requires of physicians a "certain detachment from outcomes—not an absence of caring, but rather an acceptance that people can and do make choices about the course of their lives" (Rollnick et al., 2008, p. 7).

Rollnick identifies four core guiding principles of MI, using the mnemonic RULE, as follows:

Resist the "righting reflex" (i.e., "Don't try to fix it, and don't give advice").

Understand the patient's motivations.

Listen; use empathic, active listening throughout the clinical interview.

Empower the patient.

The physician needs to support patients' beliefs that change is possible and will make a profound difference in their life.

The key change in physician behavior required is a transition from asking multiple, "get to the point," close-ended questions, often mistakenly assumed to be efficient, to a style that employs fewer and predominantly open-ended questions. This allows patients the time to tell their stories. The benefit for patients is the feeling of being heard. For physicians, the benefit can be greater patient satisfaction; patients often feel they had more time with the physician and received more attention, whether or not the visits are actually longer. The challenge is to allow the patient to be in control.

Another good example of a systematic approach to MI in the clinical setting is the Kaiser TPMG educational program. The Brief Negotiation Roadmap offers a practical six-step sequence for physicians in practice: (1) open the encounter; (2) negotiate the agenda; (3) assess readiness; (4) explore ambivalence; (5) tailor the transition; and (6) close the encounter. The Kaiser example offers a good illustration of the use of the three basic tools of MI: a "menu" for the agenda, a motivational "ruler," and a confidence "ruler."

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