Motivational interviewing is an evidence-based approach to carrying out discussions around change. It is designed to encourage patients/clients to talk themselves into making a change. A key principle of motivational interviewing is that it accepts that ambivalence about change is a normal human experience.
Techniques used in motivational interviewing stem from the notion that people are more likely to change if three basic needs are attended to:
- Autonomy in making decisions
- A sense of their own competence in making the change
- Relatedness, which is a sense of being supported by key people around them (including healthcare professionals).
Evidence for effectiveness
Systemic reviews have shown motivational interviewing to be successful at producing a statistically significant and clinical effect in the majority of studies reviewed, and that the effect was greater than less-structured, more traditional advice 1. One systematic review showed motivational interviewing was successful in reducing sedentary behaviours and increasing levels of physical activity 2.
The step wise structure of motivational interviewing
- Engaging is the process of establishing a constructive working relationship with a patient.
- A common misunderstanding about engaging is that it is just about being nice and friendly, when in fact it means connecting with the patient and ensuring that they feel understood.
- Focusing is the process of establishing (with the patient’s agreement) the direction for the conversation about change. A common mistake is to jump too quickly onto a change topic without establishing that the patient agrees.
- Aim is to involve the patient in deciding a direction for change that makes the most sense both to them and to you.
- Focusing is also useful if you want to raise a difficult subject in a non-confrontational way; you can simply mention the difficult topic as one of many you could talk about.
- Evoking involves eliciting the patient’s own motivations for a particular change and can only take place with adequate focus.
- The aim of evoking is to encourage the patient to talk about why and how they might change (also known as change talk).
- Designed to strengthen personal motivation for and commitment to a specific goal.
- Involves helping the patient to come up with ideas that might work.
- These ideas should be supported with, but not driven by, your suggestions.
- The goal is to agree a concrete plan that might work.
- You will know when a patient is ready for planning by the language of motivation that they use.
- Talking about when and how to make a change, and less about whether and why.
- They may also start to talk about what it would feel like to have made the change.
Key skills in motivational interviewing
- Reflective listening
- Involves a two-step process of hearing what a person is saying, and then conveying to them that you understand this. Reflective listening involves giving a summary of what someone has told you in your own words in the form of a statement, not a question.
- Involves recognising and commenting on the patient’s strengths and abilities.
- Motivational interviewing relies on the patient’s strengths and efforts in order to bring about change. An aim of affirmation is to strengthen their confidence in their ability to do this.
- Using open questions
- This is something that most medics do when taking any clinical history. In motivational interviewing this can build and strengthen rapport with a patient.
- Open questions enable your patient/client to elaborate more on their answers, which often leads to you finding out more about their ideas, motivations for change and expectations, than close questions warranting short, specific answers.
- Useful to emphasise a patient’s strengths and motivations for change.
- Summarising is a component of reflective listening and also can be used to bring a consultation all together, clarify key elements and ensure you and your patient/client are happy nothing has been missed.
- Whilst summarising to your patient/client it often helps to use their own language – this shows you have actively listened and understand their perspective.
Motivational interviewing vs Brief Intervention
Brief intervention is another evidence-based technique, often used in primary care to change problematic lifestyle behaviours. Brief intervention is a broader concept than motivational interviewing, and whilst there is some overlap, the former is often more paternalistic, with the ‘expert’ advising a patient/client on a path to take, whereas motivational interviewing is more about guiding someone.
I hope this has been a useful summary of motivational interviewing. I you are after more information and a medical professional and a member of the BMA I thoroughly recommend the BMJ e-learning module on motivational interviewing.
- Rubak, S., Sandbaek, A., Lauritzen, T. & Christensen, B. Motivational interviewing: a systematic review and meta-analysis. Br. J. Gen. Pract. 55, 305–12 (2005).
- Lundahl, B. et al. Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Educ. Couns. 93, 157–168 (2013).