Motivational interviewing (MI) is a technique that can be applicable to all clinical settings including primary care. MI is defined as “a person-centered, goal-oriented approach for facilitating change by exploring and resolving ambivalence” (Miller 2006). It can be useful in situations when a patient’s behavioral choices negatively impact his health condition – examples include smoking, overeating or eating unhealthily, substance use, and medication noncompliance.
MI involves a shift in the interaction between a provider and patient. It is not uncommon for providers to advise patients of the logic of behavioral change without optimally engaging patients to be their own agents of change. This typical approach relies on the authority of the healthcare provider, uses clinical information as an implied threat, and is expressed as a challenge. And quite often it does not really work well and leaves both the patient and provider feeling frustrated.
MI tries to tackle this battle to get patients to “do the right thing” or “do what is best for them” differently. The idea is that communication is patient-centered and collaborative rather than provider-driven. There is an assumption that the patient does want to do what is best for him and just needs some gentle guidance to get there. The goal is to harness the patient’s personal autonomy to make a decision for better health. The theory behind MI is that the motivation for change happens when a person perceives a discrepancy between where he is and where he wants to be. The provider can help a patient identify and resolve ambivalence about the change being considered. The person has to believe that he is capable of making the change, that he is in the driver’s seat to make that change happen, and that his provider believes that he can make the change.
Motivational interviewing is a four-step process:
- Express empathy: (ex. “It is so hard to quit for so many different reasons and it is hard to see a connection between your heart disease and your smoking.”)
- Define the discrepancy inherent in the patient’s behavior: (ex. “I can appreciate that smoking is one of your daily pleasures and that it helps you in stressful moments, but I also know that you don’t want to have another heart attack so that you can live to see your children grow up and be there for them.”)
- Support self-efficacy: (ex. “Others have been able to quit, and you are a strong person given all that you have been through. This really is a potential matter of life or death, so that can be something that can keep you motivated.”)
- Roll with resistance: (ex. “This is really hard stuff and maybe this is not the right time or the right approach, but you (and I) really want you to be healthier and to be there for your children. How else can you prepare for the change you see is needed?”)
There are 5 stages of change: Precontemplative Stage, Contemplative Stage, Preparation Stage, Action Stage and lastly Maintenance Stage. The stages of change are discussed a lot in substance abuse treatment, but can be applicable to any situation where a patient is considering making a change for the betterment of his health. It is helpful to know which stage your patient is in regarding a particular change so that the motivational interviewing techniques can be tailored appropriately to that stage.
It is helpful to define the health challenge from the patient’s own perspective and help him identify and express his life goals that the problem behavior/habit is interfering with. Accept resistance as part of the process and part of the patient’s struggle. Work to meet the patient where he is at and if at first you don’t achieve success, try again. Empathically return to his identified life goals when he gets stuck and help him find reasonable solutions that work for him.
Motivational interviewing is about the patient, not the provider, being responsible for choosing and carrying out change. This technique can be helpful in the primary care setting to help providers help patients make behavioral changes to improve their health, in a way that is less frustrating AND more rewarding for both the patient and the provider.