Original Editors - George Prudden
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. 1991 followed the first common book “Motivational Interviewing” with Stephen Rollnick, a Professor for Health Care Communication in Wales, Cardiff.
Miller and Rollnickdefine the technique and introduce some of the language that is used to describe it.
'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.'
'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 describe MIas 'a directive, client-centred counseling style for eliciting behaviour change by helping clients explore and resolve abivalence'. MI has been used across various conditions such as diabetes, asthma, cardiac rehabilitation. Eighty per cent of studies have found that MI has superior outcomes when compared to tradition educational approaches.
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 embarassment. Unresolved ambivalence is often why clients are unable to commit to behavioural change. How a therapist handles a client's ambivalence may influence outcomes.
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 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.
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)
There are four principles of an of the inner MI-attitude:
- Partnership - the therapist and client should work together as two experts. The therapist a clinical expert. The client an expert of their own behaviours, motiviations and attitudes
- Acceptance - the therapist provides unconditional positive appreciation, support of autonomy, empathy and respect
- Compassion - promotion of the individuals physical and psychological well-being
- Evocation - the client is encouraged to develop there own plan of action from within
Miller and Rollner (2015) emphasize repeatedly that MI is not a method in order to influence or persuasive clients. Patients should draw their own solutions. One important aspect is, that the therapist shouldn`t talk more than 50% of the communication time. The communication should work like a ping pong play. Therapists want to evoke clients selfmotivation skills. Clients should formulate their own arguments of behavior change. 'They talk themselves into change...'
Is a question that cannot be answered with a yes or no but requires a developed answer.
- 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?
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.
- It shows commitment to come as far as you have
- I appreciate how open and honest you’re being with me
- That’s a very good way of expressing that
Reflective listening 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.
A reflective listening statement can be performed through repetition, rephrasig, paraphrasing, a reflection of a feeling, or a summary.
- 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.
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.
Miller and Rollnick describes four phases in the development process that occurs witha successful MI intervention.
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.
Client and therapist align their communication to one or more change targets
The both experts (patient and therapist) give rise to the self-motivation skills of behavioral change of the patient. The patient formulates his arguments for the change by himself.
This phase of MI includes a voluntary commitment to and the formulation of an action plan through the patient
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. The therapist must elicit and recognise change talk through appropriate questioning and listening.
Planning can proceed when:
- There is sufficient engagement
- A clear shared change goal
- Sufficient patient motivation for the change
Miller and Rollnick describe the role of MI as concomitant during the patient draws his action plan. 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 belief, will you be clear on that?
- Initiating any behavioural change
- Exercise prescription
- Smoking cessation
- Physical inactivity
- Giving bad news
A systematic review found that motivational interventions as an adjunct to traditional PT programs could have a positive effect to adherence to exercise. The level of evidence in the in selected studies was of medium and low quality.
A RCT 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 significant 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 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 accelometry.
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.
- Physical inactivity (i) (ii)
- Shoulder and neck pain
- Palliative care
- Intraveneous drug abuse
- Miller, W.R., Rollnick, St. Motivierende Gesprächsführung. Motivational Interviewing. 3. Auflage des Standardwerkes in Deutsch. Freiburg: Lambertus-Verlag, 2015.
- Rollnick S, Miller WR. What is Motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995 Oct;23(04):325.
- 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.
- 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.
- Miller and Rollnick (2013) Motivational Interviewing: Preparing people for change. 3rd ed Guilford Press
- Rogers, C.R. (1951) Client-centred Therapy. Boston: Houghton-Mifflin
- Rogers, C.R. (1951) Client-centred Therapy. Boston: Houghton-Mifflin
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- 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.
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