Motivational Interviewing
Introduction
Many healthcare professionals find it challenging to change people's long-standing behaviours that pose significant health risks.
- Even when presented with facts and figures, individuals often persist in harmful behaviours (e.g. smoking, heavy drinking) or fail to adopt healthy lifestyle (e.g. taking medications as prescribed or exercising regularly).
- This can lead to frustration when advice is ignored or contested.
- However, in reality, behaviour change cannot occur without the individual themselves recognizing the need to do so.
Motivational interviewing is a technique that aims to motivate people to change by balancing following (good listening) and directing (giving information and advice).
- Instead of acting authoritatively, motivational interviewing techniques involve a respectful and curious approach to empower individuals to change by drawing out their own meaning, importance and capacity for change.
- Through this collaborative process, we help patients identify their own goals and develop personalized plans to achieve them.
NOTE: As Dale Carnegie aptly illustrated in "How to Win Friends and Influence People", the key to motivating others lies not in threats or force, but in inspiring them to want to do something.
The Stages of Change Model
Prochaska and DiClemente proposed the transtheoretical model of behaviour change to describe readiness for change.
The model outlines a multi-stage process, alongside the specific roles healthcare professionals play at each step:
Precontemplation: The individual is not considering change (either unaware of the issue or unwilling to change).
- Clinician role: Avoid rushing to bombard the patient with harm reduction strategies. Instead, focus on raising awareness and increasing their perception of the risks and problems associated with their current behavior.
Contemplation: The individual is actively ambivalent about change (conflicted between immediate reward and long-term adverse consequences) and is not yet ready to act.
- Clinician role: Help the patient weigh the pros and cons to tip the balance in favor of change. Visualizing potential future outcomes is a useful strategy here.
- Clinician Role: Assist in setting small, specific, and achievable goals, providing resources, and proactively identifying potential obstacles.
- Clinician role: Reinforce and reaffirm their effort, normalize setbacks, and assist in troubleshooting early challenges.
Maintenance: The individual works to maintain and sustain long-term change.
- Clinician role: Help develop long-term coping strategies, reinforce internal motivation, and monitor for potential triggers.
Relapse: The individual returns to old behaviour, which is a common, expected part of the change process.
- Clinician role: In motivational interviewing, relapse is normalized rather than treated as a failure. Use it as a constructive opportunity to refine strategies and strengthen long-term behavior change in the future.
The Spirit: PACE
While many techniques are used in motivational interviewing, the "spirit" represents the underlying mindset required when applying them.
Partnership
- Prioritize collaboration, not confrontation.
- Center the consultation around the patient's perspective, expertise and input.
- This rests on the belief that there are two experts in the room: the clinician (on the medical condition) and the patient (on their own life).
Acceptance
- Respect the patient's autonomy and right to make informed choices, even when we disagree.
- Emphasize their personal control, choice and responsibility for outcomes.
Compassion
- Actively prioritize the patient’s best interests and needs, demonstrating deep empathy for their experience.
Evocation
- Recognize that the motivation to change comes from within the patient.
- Rather than relying solely on facts or education, draw out their own goals, values, and perceptions to drive meaningful action.
Tools
OARS Counselling Techniques
- Open-ended questions
- Encourage the patient to do most of the talking.
- This allows healthcare professionals to better understand the patient’s core values, concerns, and goals.
- Affirmations
- Offer genuine, specific statements of appreciation and understanding to build rapport, validate the patient's feelings, and boost their confidence in their ability to change.
- Reflections
- Rephrase statements to capture the patient's implicit meaning and emotions.
- Accurately tuning into the patient's feelings and perspective is far more impactful than simple repetition.
- Use summarizing
- Recapitulate key discussion points to ensure mutual understanding and highlight discrepancies between the patient’s current behavior and their future goals.
- Conclude by summarizing agreements and the planned way forward.
Elicit-Provide-Elicit (Ask-Offer-Ask)
- Elicit: Explore what the patient already knows, ask what additional information they want, or request permission before sharing advice (e.g., "Would it be okay if I shared some information on this?").
- Provide: Share concise, neutral, and bite-sized information without judgment or direct commands. Use objective phrasing such as "Research shows..." or "Many people find...", or offer a brief menu of options (instead of direct orders).
- Elicit: Check the patient's understanding, reaction, and perspective on how this information fits into their life (e.g., "How do you feel about trying that?"). This helps catch misinterpretations early.
The 5As
The 5As is a key framework for organizing the provision of preventive care in primary healthcare.
- Ask
- Identify patients with risk factors.
- Assess
- Evaluate the level of risk factor, their relevance to the individual in terms of health, and their readiness to change and healthy literacy.
- Advise
- Provide written information, brief advice using motivational interviewing, and negotiate goals and targets (including a lifestyle prescription).
- Assist
- Develop a risk factor management plan tailored to the individual, which may include lifestyle education and pharmacotherapies.
- Support self-monitoring.
- Arrange
- Refer to allied health services or community programs, offer phone information or counselling services and schedule follow-up for prevention and management of relapse.
Summary
Without the spirit of Motivational Interviewing, conversations can easily devolve into casual chat without yielding fruitful results.
- The key is to resist the "righting reflex" - the urge to immediately correct the patient - and instead practice empathic listening to explore their perspective.
- We are not there to judge their behaviour or direct them to do what is right, but to understand their perspective and motivation in life (i.e. to explore what matters to the patient).
- Ultimately, we help patients convince themselves of the need for change and empower them to take action.
- For meaningful change to occur, patients must believe it is possible, gradually shifting toward "change talk" (DARN-CAT: Desire, Ability, Reason, Need, Commitment, Activation, and Taking steps).
At its core, motivational interviewing is a subtle negotiation, rather than an argument - pushing too hard only breeds resistance.
- People frequently resist change due to the increased effort required compared to maintaining the status quo. Furthermore, the fear of potential negative outcomes and a lack of confidence in the success of change can impede progress.
- Sustainable change does not begin with idealization, but with setting realistic, achievable goals.
- Time constraints at busy pharmacy counters.
- The learning curve required to master these skills in daily practice.
- Individual variation, as not every patient responds the same way, meaning MI is not a one-size-fits-all tool.
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