Motivational Interviewing

Description

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Motivational Interviewing (MI) is a behavioural change intervention that is growing in popularity within physiotherapy practice.

William R. Miller, a distinguished Professor of Psychology and Psychiatry in New Mexico, wrote the first article about MI in 1983. In 1991 the first related textbook was published titled “Motivational Interviewing” by W. Miller and S. Rollnick, a Professor for Health Care Communication.[1]

Miller and Rollnick[2] defined the techniques and introduced some of the language that continues to be used to describe MI.

Lay definition

'MI is a co-operative way of talking. MI empowers clients in their own motivation to change their behavior.'

Definition for therapists

'MI is a client-centered therapeutic method. MI is suitable for treating the frequent problem of ambivalence against behavior change of clients.'

Therapeutic craftsmanship

'MI is a co-operative, goal-oriented communication form with special attention for the language of change (change talk). This method is designed to empower the individual motivation and self-commitment to a specific aim. MI elaborates the clients motives of change in an atmosphere of acceptance and sympathy.'

Rollnick and Miller[3] describe MI as 'a directive, client-centred counselling style for eliciting behaviour change by helping clients explore and resolve ambivalence'. MI has been used across various conditions such as diabetes, asthma, cardiac rehabilitation[4]. Approximately eighty percent of studies have found that MI has superior outcomes when compared to traditional educational approaches[5].

The Approach

Ambivalence

Ambivalence is a conflict between two courses of action each of which has perceived costs and benefits associated with it. An example might be going for a jog: the benefits would be all of the health gains, however, a cost might be the perceived risk of social embarrassment. Unresolved ambivalence is often why clients are unable to commit to behavioural change. How a therapist handles a client's ambivalence may influence outcomes.[2]

Righting reflex

Therapists have the desire to want to help the people under their care and this is often expressed as the 'righting reflex'. Clinicians beliefs and aspirations for the patient determine the use of language and interventions used. When a therapist sees a discrepancy between how things are and how they ought to be they want to fix it.

When patient ambivalence is confronted by the righting reflex of the therapist, outcomes tend to be poor. Patients can feel unvalidated, want to resist the clinician, or withdraw from the consultation. Ultimately, people want to be understood and accepted without judgement[6].

Rolling with Resistance

Resistance can be met with any talk of change behaviour in a client and may be found in interrupting, arguing, excusing behaviour and blaming others. If met with resistance the therapist can use various techniques to roll with the resistance such as avoiding judgment, affirming their fears and concerns, reflecting other concerns and offering assistance.

Empathy

Empathy is the ability to accurately understand your client's meaning and accurately reflect back to your client.

'Empathy is the listener's effort to hear the other person deeply, accurately, and non-judgmentally. Empathy involves skilful reflective listening that clarifies and amplifies the person’s own experiencing and meaning, without imposing the listener’s own material.' Rogers (1951)[7]

The Spirit of MI

There are four principles that embody what MI is about or as Miller and Rodnick[2] have termed “The Spirit of MI”:

  1. Partnership - the therapist and client should work together as two experts. The therapist a clinical expert. The client an expert of their own behaviours, motivations and attitudes
  2. Acceptance - the therapist realises that everyone has inherent worth, provides unconditional positive appreciation (affirmations), support of autonomy, empathy, and respect
  3. Compassion - promotion of the individuals physical and psychological well-being
  4. Evocation - the client is encouraged to develop their own plan of action from within

Miller and Rollner (2015) emphasize repeatedly that MI is not a method in order to influence or persuade clients. Patients should draw their own solutions. One important aspect is, that the therapist should not talk more than 50% of the communication time. The communication should work like a ping pong play using the various communication skills and techniques. Therapists want to evoke clients self motivation skills. Clients should formulate their own arguments of behavior change. 'They talk themselves into change...'[8]

Core Interviewing Skills

Open-ended questions

An open-ended question is a question that cannot be answered with a yes or no but requires a developed answer.

Examples:

  • Can you tell me about your back pain?
  • What's your story?
  • Can you tell me about your problem?
  • What are you struggling with at the moment?

Affirmations

An affirmation is a direct statement of support provided by the therapist. The statement is focused on a positive aspect of a patient’s effort and commitment or strength. It demonstrates to the client that the therapist is trying to understand and appreciates what the patient is dealing with. Affirmations help build a therapeutic relationship, they also reduce defensiveness and maintain an open, accepting relationship.

Examples:

  • You have done very well for coping so far
  • It shows commitment to come as far as you have
  • That’s a very good way of expressing that

Reflections

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Using reflections in the interview requires the therapist to be interested in what the person has to say and respect the client's point of view and thought processes. This is achieved by temporarily suspending assumptions and avoiding imposing them. Reflective listening allows the therapist to test a hypothesis and check their understanding of what the patient has said. Reflections allow the therapist to check their understanding of the client's point of view, they reduce defensiveness and can reinforce change talk.

A reflective statement aims to capture the main thing and reflect the therapist's understanding. They can be performed through repetition, rephrasing, paraphrasing, a reflection of a feeling, or a summary.

Examples:

  • Physiotherapy hasn't worked for you in the past and you feel that it wont for you now.
  • After a hard day's work all you would really like is a cigarette and that helps you relax.
  • You don’t like being unfit.

Summarising

Summarising is often used at the end of a consultation or to draw different aspects together. Meaning is inferred to what was said and reflected back with new words. Summarising adds to and extends what was actually said.

The Process of MI

Miller and Rollnick[2] describes four phases in the development process that occurs with a successful MI intervention.

Engaging

Both Partners, client and therapist, build a therapeutic alliance from the very beginning. It belongs to the agreement on tasks and goals Evaluation of the therapeutic alliance through the client predicts the outcome of the therapy, vice versa not always[9].

Focusing

Client and therapist align their communication to one or more change targets

Evocation

Both experts (patient and therapist) give rise to the self-motivation skills of behavioral change of the patient. The therapist uses the various communication skills and techniques in the interview to help evoke change talk and strengthen motivation to change in the client. The patient formulates his arguments for the change by himself.

Planning

This phase of MI includes a voluntary commitment to and the formulation of an action plan from the patient

Change talk

Change talk is self-motivating speech. Therapists can identify markers within the language used by the client which identify readiness for behavioural change. The individual can express a Desire, an Ability, Reasons why or a Need to change (DARN). The therapist must elicit, recognise, and reinforce change talk through appropriate questioning and listening.

Planning

Planning can proceed when:

  • There is sufficient engagement
  • There is a clear shared change goal
  • Sufficient patient motivation for the change has been achieved

Miller and Rollnick describe the role of MI as concomitant during the patient draws his action plan.[1] They created three forms of change talk for this special stage in the MI-process.The three forms can be summed up with the acronym CAT: Commitment, Activation and Taking steps

The therapists work is to evoke CAT-statements from the client. He can do this through questions like the following:

  • How high is your willingness to do that?
  • When do you believe you will be clear on that?

Providing Information in MI

The spirit if MI is centred around evoking change from the client by resolving ambivalence. There is however, room for providing information. Miller and Rodnick[2] advocate the use of the Elicit-Provide-Elicit technique.

  1. Elicit - explore the gaps or inconsistencies in the clients knowledge, ask permission to provide information, query for interest
  2. Provide- provide information using no medical jargon and in small manageable chunks
  3. Elicit- check for understanding

An example would be as follows

  1. Elicit- “Would you like me to give you some ideas on exercises that would be beneficial to you”
  2. Provide- “Walking or cycling on a stationary bicycle may be a good place for you to start”
  3. Elicit- “How does that sound”

Indication

  • Initiating any behavioural change
  • Exercise prescription
  • Smoking cessation
  • Physical inactivity
  • Educating
  • Giving bad news

Examples

Evidence

A systematic review[10] found that motivational interventions as an adjunct to traditional PT programs could have a positive effect on adherence to exercise. The level of evidence in the in selected studies was of medium and low quality.

A RCT[11] examined a patient-centered approach (coach2move) for frailty over 70 years old adults, which included MI. The primary outcome was moderate-intensity PA and total PA per day, measured per LAPA-Questionnaire. The experimental group showed a significantly longer improvement in moderate-intensity PA (p= 0.012) with broad 95%-CIs (4.0 to 34.9 min.) and for total PA (p=0.182) with broad 95%CIs, too (-6.6 to 34.9 min.) per day. The secondary outcomes (frailty, cost saving, QALY) frailty decreases significant, the cost saving and the improvement in QALYs were significant, too, with narrow 95%CIs for frailty and QUALYs.

RCT[12] looked for effects of MI in enhancing PA in people with subacute spinal cord injury. The MI group showed significant longer PA times, with although wide 95% CIs. PA was measured by accelerometry.

SR with Meta-Analysis found modest improvements in PA for people with chronic health conditions, the standardized mean difference between intervention and control groups was significant (0.19, p= 0.004), the 95%CIs (0.06 to 0.32) were wide.

A systematic review[13] on using motivational interviewing for people with Chronic Pain found that MI may increase short term adherence to interventions. More research is needed to confirm this finding.

Case Studies

References

  1. 1.0 1.1 Miller, W.R., Rollnick, St. Motivierende Gesprächsführung. Motivational Interviewing. 3. Auflage des Standardwerkes in Deutsch. Freiburg: Lambertus-Verlag, 2015.
  2. 2.0 2.1 2.2 2.3 2.4 Miller and Rollnick (2013) Motivational Interviewing: Preparing people for change. 3rd ed Guilford Press
  3. Rollnick S, Miller WR. What is Motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995 Oct;23(04):325.
  4. Chilton R, Pires-Yfantouda R, Wylie M. A systematic review of motivational interviewing within musculoskeletal health. Psychology, Health and Medicine. 2012 Aug;17(4):392–407.
  5. Lauritzen T, Rubak S, Sandbæk A, Christensen B. Motivational interviewing: A systematic review and meta-analysis. Review Article. 2005 Apr 1 [cited 2016 Feb 2];55(513):305–312. Available from: http://bjgp.org/content/55/513/305.short.
  6. Rogers, C.R. (1951) Client-centred Therapy. Boston: Houghton-Mifflin
  7. Rogers, C.R. (1951) Client-centred Therapy. Boston: Houghton-Mifflin
  8. Crits-Christoph, P., Gibbons, M.B., Hamilton, J., Ring-Kurtz, S., Gallop, R. The Dependability of Alliance Assessments: The Alliance– Outcome Correlation is Larger than You Might Think. J Consult Clin Psychol. 2011; 3; 79; 267–278. doi:10.1037/a0023668.
  9. Critcher, C.R., Dunning, D., Armor, D.A. When Self-Affirmations Reduce Defensiveness: Timing Is Key. Personality and Social Psychology Bulletin 2010; 36; 7; 947 –959.
  10. De Vries, N. M., Staal, J. B., van der Wees, P. J., Adang, E. M., Akkermans, R. Patient-centred physical therapy is (cost-) effective in increasing physical activity and reducing frailty in older adults with mobility problems: a randomized controlled trial with 6 months follow-up. J Cachexia Sarcopenia Muscle 2015; 1-14; DOI: 10.1002/jcsm.12091 published on: wileyonlinelibrary.com https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4864107/ (accessed on 27 Aug 2016)
  11. Nooijen, C. F., Stam, H. J., Bergen, M. P., Bongers-Janssen, H. M., Valent, L. A. Et al. Behavioural intervention increases physical activity in people with subacute spinal cord injury: a randomised trial. J Physiother 2016; 2; 1; 34-41.
  12. O'Halloran, P. D., Blackstock, F., Shields, N., Holland, A., Iles, R. Et al. Motivational interviewing to increase physical activity in people .with chronic health conditions: a systematic review and meta-analysis. Clin Rehabil 2014; 28; 12; 1159-71.
  13. Alperstein D, Sharpe L. The efficacy of motivational interviewing in adults with chronic pain: a meta-analysis and systematic review. The Journal of Pain. 2016 Apr 1;17(4):393-403.