Enhancing Motivation to Change
Health promotion forms part of many primary care consultations, be it advice about exercise, weight loss, smoking or alcohol. These consultations are often fraught with difficulty, as many patients are resistant to being told what to do or ‘what is good for them’. Moving from this direct style of consultation to a more guiding style that encourages patient motivation has been shown to increase the success of health promotion.
Motivational interviewing was originally developed in the field of addiction counselling, but has also been used to promote behaviour change in a wide range of healthcare settings, such as smoking cessation, weight loss and promoting increased physical activity.
There is increasing evidence of its effectiveness,2,3 with 80% of 72 studies finding that motivational interviewing outperformed traditional advice-giving.4 It is associated with a more respectful and less combative consultation – this feels professionally better and is certainly more enjoyable for both doctors and their patients.
Motivational Interviewing (MI) by Prof S Rollnick
A consultation that leans on MI has one strong characteristic that supersedes all else: instead of adopting an expert position and using a directing style to persuade the patient why or how they might get more exercise, you adopt a guiding style. It is a more collaborative process of helping the patients to say why and how they might get more exercise. You structure the consultation and provide information (with permission) but most of the time you are eliciting their own motivation to change. This is often expressed in the form of change talk.4 The more change talk you can elicit from the patient, the better the outcome is likely to be. There is emerging evidence to support this focus on the language used by the patient.5
One useful aid might be the recently developed framework for MI6 that describes four processes in a constructive conversation about behaviour change:
They do not always emerge in a linear sequence, but the logic is this: step one is to engage with the patient and establish an agreed focus for the conversation; then the central task is evoking the patient’s own motivation to change, followed by planning if the person is ready for this. These processes are highlighted in the example below, alongside other key skills.
While conducting a full motivational interview may require more time than is available through standard consultations, adopting the guiding style even in brief interactions can have similar beneficial results.
Example MI Dialogue. By Prof S Rollnick
This example is based on a fictitious consultation between a 51 year old male and his healthcare professional (HCP). He is overweight, with borderline raised BP, who gets short of breath when walking secondary to his poor cardiovascular fitness and sedentary job. He travels to work on the bus and works on the third floor of an office.
HCP: OK, so that’s your tablets sorted out, and now I wanted to ask you whether it’s ok with you to spend just a couple of minutes talking about something completely different….. Would that be OK? (Asking permission will help a lot)
Patient: Yeah OK, what’s that then?
HCP: It’s about physical activity. Would you mind if we chatted about that if I promise not to nag at you about it?
Pt: Yeah OK, as long as you keep to that promise (laughs). (The focus is clear. Engagement is not strong, yet.)
HCP: So rather than me talk about it, could you? Could you tell me how you feel about getting more active?
Pt: Hate the thought to be honest with you.
HCP: You’re not persuaded about this one (That’s a reflective listening statement, not a question)
Pt: Well I do know that it would help my health (change talk), but the effort is really too much.
HCP: You get quite a lot done each day, and adding physical activity doesn’t seem like it could fit (another reflective listening statement)
Pt: Yeah you guessed right, I don’t just sit around all day and the thought of going to the gym just doesn’t fit for me.
HCP: Going to the gym isn’t for you, you are busy enough and yet you know it would be good for your health to get more active, have I got you? (A summary that also includes the change talk)
Pt: Yeah you’ve got me for sure. (Engagement is now much better, as a result of listening and then summarising).
HCP: Can I ask you how do you see the benefits of just a slow and steady increase in physical activity? (A question that allows the Dr to start evoking change talk)
Pt: Me? Well if it was slow, and I didn’t have to go crazy like at a gym, it might help me (change talk).
HCP: It would help you to feel healthier (a listening statement again, to reflect the change talk and it’s also a guess about why it might help)
Pt: Sort of, but at least I could fit it in, and I might succeed, and I could feel good about that. (More change talk)
HCP: Because you don’t want to take on some big task like the gym. What suits you more is something smaller to start with. (Reflecting again, trying to understand how he really feels)
Pt: If I decide to do it and I haven’t yet. (Patient backs off)
HCP: You don’t want to be pushed into this (HCP doesn’t try to win the argument or be clever – just uses a listening statement)
Pt: Exactly, but it might be worth thinking about. Thanks for not lecturing me (laughs)
HCP: HCP summarises how patient feels and keeps the door open for another time.
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Six weeks later the patient returns for another check on his borderline blood pressure.
HCP: Well thanks for coming back again. I saw you six weeks ago, didn’t I?
Pt: Yes, you asked me to come back to check the blood pressure.
HCP: (HCP checks BP) Well it’s still on the high side, so we could now ask the question what will help you to get it down and avoid this becoming a cause for concern in the future?
Pt: Well I know I don’t want any of those tablets for blood pressure if possible.
HCP: Sure, that’s fine for now. Can I raise the subject of physical activity again, if I promise not to lecture you?
Pt: You told me that last time, but fair game, you didn’t lecture me, so yes fine (laughs)
HCP: I promise again!
Pt: I believe you again, but what now?
HCP: My question would be this: are there some simple small steps you can take to introduce a little more activity into your daily life?
Pt: I’m glad you are not on about the gym.
HCP: Sure, that’s too drastic for you (reflective listening)
Pt: I don’t do drastic, my life’s busy enough.
HCP: Small things might be possible (reflective listening again – a guess about what might work)
Pt: Yes, maybe but I’m not sure what you mean by small things?
HCP: Presents a range of options, not a single idea, with the aim of encouraging the patient to select thus: So that’s a number of possibilities. You will be the best judge of what might work for you. (Reinforcing autonomy is a critical aspect of skilful consulting about behaviour change).
Pt: Well of all those things you mention, there’s only two that make sense to me: walking up the stairs rather than the lift and getting off the bus 2 stops before work and walking the last part (patient emits change talk).
HCP: You can see a way of doing these simple things (the best response to change talk is a simple reflection).
Pt: I guess I can, and if it works I might try walking that same distance after work again (more change talk).
HCP: You want to experiment and see what works for you (more reflection).
Pt: Yeah I am happy to try those two things (change talk).
HCP: Summarises all the change talk that has emerged. So you don’t want tablets, and you think you might be able to walk up the stairs at work, and get off the bus two stops early, and walk into work.
Pt: Knowing me, I’ll give it a go. It might help me to feel better about myself (change talk).
HCP: And would you mind coming to see me for a brief catch-up in six weeks?
Pt: Sure......Etc etc
Example MI Dialogue, by Prof S Rollnick
Watch this transcription role play on You Tube. The second video is a repeat, however it describes the behavioural change dialogue highlighting the stages of the Motivation process evoked.
YouTube YouTube
Read more about the Swedish MI advice here, and useful links to learn more about Motivational Interviewing are provided in Resources.