Top Tips: Using Motivational Interviewing Strategies

Dr Vasumathy Sivarajasingam offers seven top tips on adopting motivational interviewing techniques in primary care to guide patients to make behavioural changes

Lifestyle and behaviour have an important impact on health, longevity, and quality of life, and this is particularly true for patients with chronic diseases. One of the key commitments of the 2019 NHS long term plan is to tackle some of the most significant causes of ill health by supporting people to make healthier lifestyle choices.^1,2 The NHS long term plan states: ‘Wider action on prevention will help people stay healthy and also moderate demand on the NHS.’¹

Preventing ill health can require patients to change their behaviour. Although a need for change on the part of the patient is most commonly associated with behaviours such as smoking, excessive drinking, lack of physical activity, and consuming an unhealthy diet, discussions about changing patient behaviour are central to almost every branch of medicine.³ Healthcare professionals are often required to engage in discussions with patients about making lifestyle and behavioural changes; however, achieving a sustained change in patient behaviour can be a long and complex process, and demands appropriate resources.

One of the major challenges of counselling patients on making beneficial changes is ambivalence or lack of motivation on the part of the patient, which can result in it being unrewarding and ineffective.³ The traditional approach is to advise patients on the changes needed using a directing style, with the clinician acting as the expert.³ This approach can generate resistance in the patient;³ people who are ambivalent about making a change and who receive this mode of advice often report feeling angry, defensive, uncomfortable, and powerless.⁴ It is perhaps unsurprising that it can be extremely difficult to convince patients to do what is in their best interests using this method.

These observations suggest that when motivation is provided by an external source it does not lead to long-term adherence. Patients are often aware of the arguments in favour of change, but are more likely to make behavioural changes when they personally see the need for that change. Therefore, when encouraging patients to make beneficial changes, GPs need to modify their approach by adopting consulting methods that better suit patients’ needs and attitudes. Several effective, structured counselling strategies have been developed for use in primary care settings—these include:⁵

• the transtheoretical (stages of change) model
• the five As (ask, advise, assess, assist, arrange)
• FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of options, empathy, self-efficacy enhancement)
• BATHE (background, affect, troubles, handling, empathy)
• motivational interviewing (MI).

MI is an alternative, evidence-based approach in which discussions around change are based on a patient’s values and goals.^3,5 It is designed to guide patients to find their own motivation for making a change.³ This article will explore the benefits of incorporating MI into everyday practice in primary care. 

1. Understand the principles of MI

Miller and Rollnick define MI as ‘a collaborative, goal-oriented style of communication with particular attention to the language of change’.^4,6 MI involves use of a guiding rather than a directing style,³ in which the clinician engages with the patient as an equal partner to support them to reflect on their situation and options.^6,7

MI is nonjudgemental—it honours the patient’s autonomy, seeks to understand their perspectives and experiences, and respects their right to make informed choices about their care.^4,6 It also recognises that the responsibility for change lies with the person, and that patients already possess the skills needed for change.⁶

The general principles and key techniques of MI are summarised in Box 1.^8–10

Box 1: Core components of MI^8–10

Four general principles of MI^8,9

R —resist the urge to change the individual’s course of action through didactic means

U —understand that it is the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour

L —listening is important; the solutions lie within the individual, not the practitioner

E —empower the individual to understand that they have the ability to change their behaviour.

Five techniques that can be integrated into your current approach¹⁰

1. Ask open-ended questions —asking closed questions can feel like an interrogation, whereas asking open-ended questions encourages the patient to do most of the talking
2. Listen reflectively —listening to patients and then repeating their comments back to them confirms what they are feeling and communicates that you have understood what they have said
3. Affirm and clarify —affirmation shows that you recognise the patient’s struggles, strengths, and past successes, and clarification helps to refine and consolidate what you have discussed
4. Summarise —expand the discussion by relating or linking what patients have already expressed
5. Elicit self-motivational statements —assess patients’ confidence in their ability to change, and prompt them to make statements to support self-efficacy.

MI=motivational interviewing

Royal College of Nursing website. How motivational interviewing works. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/motivational-interviewing   
Rollnick S, Miller W, Butler C. Motivational interviewing in health care: helping patients change behavior. New York, NY, USA: Guilford Press, 2008.
Royal College of Nursing website. Five key skills. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/five-key-skills
Adapted and reproduced with permission.

2. Recognise how MI differs from other consulting styles

MI differs considerably from other, more confrontational styles of consultation.⁸ Rather than something that is done ‘to’ or ‘on’ patients, MI is something that is practised ‘with’ or ‘for’ them.³ It is not a way to persuade patients to act, nor is it a ‘quick fix’—it takes time, practice, and discipline on the part of the clinician.^6,7

It is also important to recognise ways in which MI could be used inappropriately. Examples of misuse of MI are provided in Box 2.⁸

Box 2: Inappropriate uses of MI⁸

MI does not involve:

• arguing with a person who has a problem and needs to change
• offering direct advice or prescribing solutions for a problem without the person’s permission, or without actively encouraging the person to make their own choices
• using an authoritative or expert stance that leaves the person in a passive role
• the healthcare professional doing most of the talking, or only giving information
• imposing a diagnostic label
• behaving in a coercive manner.

MI=motivational interviewing

Royal College of Nursing website. How motivational interviewing works. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/motivational-interviewing  Adapted and reproduced with permission.

It is understandable that clinicians may feel frustrated if they see the same patient repeatedly but do not see any evidence of beneficial change.¹¹ However, according to the principles of MI, if a patient is not ready for change, their decision must be respected; clinicians should aim to leave the door open and part on good terms.¹¹

3. Know when to use MI

Although MI has applications in a wide range of scenarios,³ the technique is particularly useful when:⁶

• ambivalence is high —people are stuck in mixed feelings about change
• confidence is low —people doubt their ability to change
• desire is low —people are uncertain about whether they want to make a change
• importance is low —the benefits of change and disadvantages of the current situation are unclear.

In these circumstances, MI can help people to identify and resolve any hesitancies or uncertainties that may be making them reluctant to change. Healthcare professionals should reiterate that they are in a partnership with the patient, and highlight the importance of working together to achieve the desired outcome. 

4. Be aware that patients change at different rates

An awareness that change is needed is sometimes not enough to motivate a patient to act. Before change can take place, patients must accept that there are benefits to changing, and must be willing to put effort into deciding what to do and when and how to do it.¹²

Different patients may be at different stages in their readiness to change, and clinicians must tailor their approach accordingly. The first step is to identify where the patient is on their ‘change journey’.¹² The different stages of change are illustrated in the model provided in Figure 1.^12,13

Motivation can change from day to day—by understanding the patient’s readiness to change, healthcare professionals will be better prepared to tailor their approach.¹⁴

In addition, it is important to recognise that, once a patient is ready to make a change, the speed at which this change is enacted may also vary between patients.

5. Integrate MI techniques into everyday primary care practice

Primary care clinicians understand the benefits of making healthy choices and spend a lot of time counselling patients, so are uniquely placed to help them to make positive lifestyle changes. Through their relationships with patients, primary care clinicians may be able to develop a sense of what motivates or hinders patients regarding behavioural changes. In turn, primary care clinicians are trusted by their patients, who often turn to them when they are thinking about making a change.

To incorporate MI into routine practice in primary care, clinicians do not need to disregard their training; instead, they need to adjust their skills and mindset.⁸ MI is more about listening than intervening, and repeated consultations with patients are often required because setbacks are an anticipated part of the process.

For MI to be successful, clinicians need to be clear on the patient-set goals they are trying to achieve, and interact with patients using the techniques outlined in Box 1, which include asking open-ended questions, practising reflective listening, clarifying, and reiterating statements back to the patient.¹⁰ Examples of open-ended questions include:³

• ‘What changes would you most like to talk about?’
• ‘How confident do you feel about changing?’
• ‘How do you see the benefits or drawbacks of changing?’
• ‘What would make the most sense to you?’

6. Appreciate the benefits of MI for patients

Encouraging patients to articulate why and how they should change, supporting them to make their own choices, and empowering them to commit to making a change can lead to better treatment outcomes for patients. Compared with people who receive traditional consultations, those who receive MI are more likely to enter, stay in, and complete treatment, and participate in follow-up visits.⁸ To date, no studies have found MI to be harmful or to have any adverse effects.¹⁵

MI has been applied by various healthcare professionals—including psychologists, doctors, nurses, and midwives—in many different therapeutic areas.¹⁵ MI is known to help patients make healthy lifestyle changes such as decreasing alcohol and illicit drug use and quitting smoking.¹¹ In patients with type 2 diabetes, MI has been shown to improve patient motivation and autonomy, and is associated with increased participation in follow-up meetings, self-care activities (including reducing alcohol consumption and smoking), and awareness of the importance of disease control.¹⁶

The effectiveness of MI as an intervention tool has been evaluated by a systematic review and meta-analysis.¹⁵ In the study, MI was shown to outperform traditional advice-giving when used in the treatment of a diverse range of physical and psychological problems.¹⁵ Further studies comparing MI with usual care in the treatment of multiple medical conditions have found that MI strategies have beneficial effects on outcomes such as blood pressure, body weight, and HIV viral load, and that these benefits can be achieved after brief consultations.^5,17,18

MI also helps patients to realise that they have the power to change their lives themselves. Use of a change plan worksheet is a good way for patients making a beneficial change to state their goal, identify potential obstacles, and define a successful outcome. An example worksheet is shown in Box 3.

Question	Respondent’s answers
The changes I want to make are:
The reasons I want to make these changes are:
My main goals in making these changes are:
I plan to do these things to reach my goals:plan of actiontiming of action
Other people could help me change in these ways:personpossible ways to help
Some things that could interfere with my plan are:
I will know that my plan is working if:
What will I do if my plan is not working?

7. Harness the secondary benefits of MI

As patients take charge of their wellbeing and make lifestyle changes beneficial to their health, there are potential secondary benefits, such as reduced medication use, that may in turn lessen the impact of the health service on the environment and relieve financial pressure on the NHS.^19,20  The knowledge that patients can have a positive impact on the environment and health service by making beneficial changes may increase their intrinsic motivation to do so.²¹

Summary

MI is an empathetic, supportive, and patient-centred style of consultation in which healthcare professionals work with patients to clarify their strengths and aspirations, discovering their motivations for change and promoting autonomy in decision making.³ It is a guiding approach to communication between doctor and patient that avoids unproductive discussion and focuses on the changes that make a difference.³

MI can be used in any consultation about beneficial changes to patient behaviour. Better communication with patients equates to greater success in supporting behavioural change, in turn leading to healthier patients. 

Key points

• Preventing ill health can require patients to change their behaviour; however, achieving a sustained change in patient behaviour can be a long and complex process
• The traditional approach, in which the clinician acts as the expert, can generate resistance in the patient
• MI is a collaborative approach based on patients’ values and goals that is designed to guide patients to find their own motivation for change
• Inappropriate uses of MI include offering advice without the patient’s permission, using an authoritative stance that forces the patient into a passive role, and behaving in a coercive manner
• To support changes in behaviour, healthcare professionals must identify where the patient is on their ‘change journey’
• Primary care clinicians are uniquely placed to help patients to make positive lifestyle changes, and can adjust their approach to adopt MI techniques in everyday practice
• Encouraging patients to articulate why and how they should change, supporting them to make their own choices, and empowering them to commit to making a change can lead to better treatment outcomes
• Use of a change plan worksheet is a good way for patients making a beneficial change to state their goal, identify potential obstacles, and define a successful outcome
• MI may have secondary benefits for the financial burden on and environmental impact of the NHS.

MI=motivational interviewing

References

1. NHS England. The NHS long term plan. London: NHS England, 2019. Available at: www.longtermplan.nhs.uk/publication/nhs-long-term-plan/
2. NHS England. The NHS long term plan—a summary. London: NHS England, 2019. Available at: www.longtermplan.nhs.uk/publication/nhs-long-term-plan/
3. Rollnick S, Butler C, Kinnersley P et al. Motivational interviewing. BMJ 2010; 340: c1900.
4. Miller W, Rollnick S, McLouth C et al. Motivational interviewing: helping people change. Third edition. London: Guilford Press, 2012.
5. Searight H. Counseling patients in primary care: evidence-based strategies. Am Fam Physician 2018; 98 (12): 719–728.
6. Motivational Interviewing Network of Trainers website. Understanding motivational interviewing. motivationalinterviewing.org/understanding-motivational-interviewing (accessed 9 February 2022).
7. Miller W, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother 2009; 37: 129–140.
8. Royal College of Nursing website. How motivational interviewing works. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/motivational-interviewing (accessed 9 February 2022).
9. Rollnick S, Miller W, Butler C. Motivational interviewing in health care: helping patients change behavior. New York, NY, USA: Guilford Press, 2008.
10. Royal College of Nursing website. Five key skills. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/five-key-skills (accessed 9 February 2022).
11. Royal College of Nursing website. Summary. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/mi-summary (accessed 9 February 2022).
12. Royal College of Nursing website. Understanding behaviour change. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/understanding-behaviour-change (accessed 9 February 2022).
13. Prochaska J, Diclemente C. Toward a comprehensive model of change. In: Miller W, Heather N, editors. Treating addictive behaviors. Applied clinical psychology volume 13. Boston, MA, USA: Springer, 1986: 3–27. doi.org/10.1007/978-1-4613-2191-0_1
14. Royal College of Nursing website. Readiness to change. www.rcn.org.uk/clinical-topics/supporting-behaviour-change/readiness-to-change/ (accessed 9 February 2022).
15. Rubak S, Sandbœk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005; 55 (513): 305–312.
16. Rubak S, Sandbœk A, Lauritzen T et al. General practitioners trained in motivational interviewing can positively affect the attitude to behaviour change in people with type 2 diabetes. Scand J Prim Health Care 2009; 27 (3): 172–179.
17. Lundahl B, Moleni T, Burke B et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns 2013; 93 (2): 157–168.
18. VanBuskirk K, Wetherell J. Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med 2014; 37 (4): 768–780.
19. Sivarajasingam V. Working together towards carbon footprint reduction. www.guidelinesinpractice.co.uk/view-from-the-ground/working-together-towards-carbon-footprint-reduction/455996.article (accessed 9 February 2022).
20. Royal Pharmaceutical Society. Medicines optimisation: helping patients to make the most of medicines. London: RPS, 2013. Available at: www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy/helping-patients-make-the-most-of-their-medicines.pdf
21. Klonek F, Kauffeld S. Sustainability goes change talk: can motivational interviewing be used to increase pro-environmental behavior? Proc Meas Behav  2012; 297–302.