The Stages of Change model and motivational interviewingProchaska and DiClemente2 proposed readiness for change as a vital mediator of behavioural change. Their transtheoretical model of behaviour change (the 'Stages of Change') describes readiness to change as a dynamic process, in which the pros and cons of changing generates ambivalence. Ambivalence is a conflicted state where opposing attitudes or feelings coexist in an individual; they are stuck between simultaneously wanting to change and not wanting to change. Ambivalence is particularly evident in situations where there is conflict between an immediate reward and longer term adverse consequences (eg. substance abuse, weight management). For example, the patient who presents with serious health problems as a result of heavy drinking, who shows genuine concern about the impact of alcohol on his health, and in spite of advice from his practitioner to cut back his drinking, continues to drink at harmful levels, embodies this phenomenon. Show
The Prochaska and DiClemente Stages of Change model2 offers a conceptual framework for understanding the incremental processes that people pass through as they change a particular behaviour. This change process is modelled in five parts as a progression from an initial precontemplative stage, where the individual is not considering change; to a contemplative stage, where the individual is actively ambivalent about change; to preparation, where the individual begins to plan and commit to change. Successful progression through these stages leads to action, where the necessary steps to achieve change are undertaken. If successful, action leads to the final stage, maintenance, where the person works to maintain and sustain long term change.3 Relapse is considered an important stage in the change process and is used as an opportunity to learn about sustaining maintenance in the future. Motivational interviewing (MI) is an effective counselling method that enhances motivation through the resolution of ambivalence. It grew out of the Prochaska and DiClemente model described above2 and Miller and Rollnick's1 work in the field of addiction medicine, which drew on the phrase 'ready, willing and able' to outline three critical components of motivation. These were:1
Using MI techniques, the practitioner can tailor motivational strategies to the individual's stage of change according to the Prochaska and DiClemente model (Table 1).1,2 Table 1. Practitioner tasks within the Stages of Change model1,2
Applications and effectiveness of motivational interviewingRecent meta-analyses show that MI is equivalent to or better than other treatments such as cognitive behavioural therapy (CBT) or pharmacotherapy, and superior to placebo and nontreatment controls for decreasing alcohol and drug use in adults4–6 and adolescents.7 Motivational interviewing has also been shown to be efficacious in a number of other health conditions, such as smoking cessation,8 reducing sexual risk behaviours,9–11 improving adherence to treatment and medication,12 as well as diabetes management.13 In addition, studies support the applicability of MI to HIV care, such as improving adherence to antiretroviral therapy14,15 and the reduction of substance use among HIV positive men and women.15 As such, MI is an important therapeutic technique that has wide applicability within healthcare settings in motivating people to change. In general practice, possible applications include:
The spirit of motivational interviewingMotivational interviewing is underpinned by a series of principles that emphasise a collaborative therapeutic relationship in which the autonomy of the patient is respected and the patient's intrinsic resources for change are elicited by the therapist. Within MI, the therapist is viewed as a facilitator rather than expert, who adopts a nonconfrontational approach to guide the patient toward change. The overall spirit of MI has been described as collaborative, evocative and honouring of patient autonomy.1 Miller and Rollnick1 have commented that the use of MI strategies in the absence of the spirit of MI is ineffective. Although paradoxical, the MI approach is effective at engaging apparently 'unmotivated' individuals and when considered in the context of standard practice can be a powerful engagement strategy (Case study, Table 2). Case study – using the spirit of motivational interviewingA male patient, 52 years of age, who drinks heavily and has expressed the desire to reduce drinking, but continues to drink heavily. It is easy to conclude that this patient lacks motivation, his judgment is impaired or he simply does not understand the effects of alcohol on his health. These conclusions may naturally lead the practitioner to adopt a paternalistic therapeutic style and warn the patient of the risks to his health. In subsequent consultations, when these strategies don't work, it is easy to give up hope that he will change his drinking, characterise him as 'unmotivated' and drop the subject altogether. In MI, the opposite approach is taken, where the patient's motivation is targeted by the practitioner. Using the spirit of MI, the practitioner avoids an authoritarian stance, and respects the autonomy of the patient by accepting he has the responsibility to change his drinking – or not. Motivational interviewing emphasises eliciting reasons for change from the patient, rather than advising them of the reasons why they should change their drinking. What concerns does he have about the effects of his drinking? What future goals or personal values are impacted by his drinking? The apparent 'lack of motivation' evident in the patient would be constructed as 'unresolved ambivalence' within an MI framework. The practitioner would therefore work on understanding this ambivalence, by exploring the pros and cons of continuing to drink alcohol. They would then work on resolving this ambivalence, by connecting the things the patient cares about with motivation for change. For example, drinking may impact the patient's values about being a loving partner and father or being healthy and strong. A discussion of how continuing to drink (maintaining the status quo) will impact his future goals to travel in retirement or have a good relationship with his children may be the focus. The practitioner would emphasise that the decision to change is 'up to him', however they would work with the patient to increase his confidence that he can change (self efficacy). Table 2. The spirit of motivational interviewing vs an authoritative or paternalistic therapeutic style
Motivational interviewing in practiceThe practical application of MI occurs in two phases: building motivation to change, and strengthening commitment to change. Building motivation to changeIn Phase I, four early methods represented by the acronym OARS (Table 3) constitute the basic skills of MI. These basic counselling techniques assist in building rapport and establishing a therapeutic relationship that is consistent with the spirit of MI.
Strengthening commitment to changeThis involves goal setting and negotiating a 'change plan of action'. In the absence of a goal directed approach, the application of the strategies or spirit of MI can result in the maintenance of ambivalence, where patients and practitioners remain stuck. This trap can be avoided by employing strategies to elicit 'change talk'.1 There are many strategies to elicit 'change talk', but the simplest and most direct way is to elicit a patient's intention to change by asking a series of targeted questions from the following four categories:
Alternatively, if a practitioner is time poor, a quick method of drawing out 'change talk' is to use an 'importance ruler'. Example: 'If you can think of a scale from zero to 10 of how important it is for you to lose weight. On this scale, zero is not important at all and 10 is extremely important. Where would you be on this scale? Why are you at ____ and not zero? What would it take for you to go from ___ to (a higher number)?' This technique identifies the discrepancy for a patient between their current situation and where they would like to be. Highlighting this discrepancy is at the core of motivating people to change. This can be followed by asking the patient to elaborate further on this discrepancy and then succinctly summarising this discrepancy and reflecting it back to the patient. Next, it is important to build the patient's confidence in their ability to change. This involves focusing on the patient's strengths and past experiences of success. Again, a 'confidence ruler' could be employed if a practitioner is time poor. Example: 'If you can think of a scale from zero to 10 of how confident you are that you can cut back the amount you are drinking. On this scale, zero is not confident at all and 10 is extremely confident. Where would you be on this scale? Why are you at ____ and not zero? What would it take for you to go from ___ to (a higher number)?' Finally, decide on a 'change plan' together. This involves standard goal setting techniques, using the spirit of MI as the guiding principle and eliciting from the patient what they plan to do (rather than instructing or advising). If a practitioner feels that the patient needs health advice at this point in order to set appropriate goals, it is customary to ask permission before giving advice as this honours the patient's autonomy. Examples of key questions to build a 'change plan' include:
It is common for patients to ask for answers or 'quick fixes' during Phase II. In keeping with the spirit of MI, a simple phrase reminding the patient of their autonomy is useful, 'You are the expert on you, so I'm not sure I am the best person to judge what will work for you. But I can give you an idea of what the evidence shows us and what other people have done in your situation'. Table 4. Eliciting 'change talk'1
The guiding principles of motivational interviewingIn general practice, the particular difficulties associated with quick consultation times can present unique challenges in implementing MI. Miller and Rollnick17have attempted to simplify the practice of MI for health care settings by developing four guiding principles, represented by the acronym RULE:
Resist the righting reflexThe righting reflex describes the tendency of health professionals to advise patients about the right path for good health. This can often have a paradoxical effect in practice, inadvertently reinforcing the argument to maintain the status quo. Essentially, most people resist persuasion when they are ambivalent about change and will respond by recalling their reasons for maintaining the behaviour. Motivational interviewing in practice requires clinicians to suppress the initial righting reflex so that they can explore the patient's motivations for change. Understand your patient's motivationsIt is the patient's own reasons for change, rather than the practitioner's, that will ultimately result in behaviour change. By approaching a patient's interests, concerns and values with curiosity and openly exploring the patient's motivations for change, the practitioner will begin to get a better understanding of the patient's motivations and potential barriers to change. Listen with empathyEffective listening skills are essential to understand what will motivate the patient, as well as the pros and cons of their situation. A general rule-of-thumb in MI is that equal amounts of time in a consultation should be spent listening and talking. Empower your patientPatient outcomes improve when they are an active collaborator in their treatment.17 Empowering patients involves exploring their own ideas about how they can make changes to improve their health and drawing on the patient's personal knowledge about what has succeeded in the past. A truly collaborative therapeutic relationship is a powerful motivator. Patients benefit from this relationship the most when the practitioner also embodies hope that change is possible. RULE is a useful mnemonic to draw upon when implementing the spirit of MI in general practice. If a practitioner has more time, four additional principles (Table 5) can be applied within a longer therapeutic intervention. Table 5. Four further principles of motivational interviewing
Barriers to implementing motivational interviewing in general practiceBarriers to implementing MI in general practice include time pressures, the professional development required in order to master MI, difficulty in adopting the spirit of MI when practitioners embody an expert role, patients' overwhelming desire for 'quick fix' options to health issues and the brevity of consultation times. These barriers to implementing MI in primary care represent significant cons on a decisional balance. On the other hand, the pros for adopting an MI approach with patients who are resistant to change are compelling. While we are not advocating MI for all patient interactions in general practice, we invite practitioners to explore their own ambivalence toward adopting MI within their practice, and consider whether they are 'willing, ready and able'. Practitioners who undertake MI training will have an additional therapeutic tool to draw upon when encountering patient resistance to change and a proven method for dealing with a number of common presentations within general practice. ResourceFor further information and online motivational interviewing training opportunities visit www.motivationalinterviewing.org. Conflict of interest: none declared. DownloadsMotivational interviewing techniques updated (PDF 1.7 MB)How do you coach a patient on disease prevention?Principles of Health Coaching. Educating the patient through relevant information.. Educating with disease-specific expertise.. Encouraging healthy habits.. Communicating problem-solving proficiencies.. Helping in dealing with the emotional turmoil of a chronic disease on the patient.. Assuring regular follow up.. What is coaching a patient as it relates to health maintenance?Health coaching is potentially a practical method to assist patients in achieving and maintaining healthy lifestyles. In health coaching, the coach partners with the patient, helping patients discover their own strengths, challenges, and solutions.
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