Motivational Interviewing Promotes Patient Behavior Change

(This article by Miriam E. Tucker was originally published in MedScape Medical News on May 9, 2016.)

Motivational interviewing, a conversational style designed to "strengthen a person's motivation and commitment to change," is more than just a technique, according to Auguste Fortin VI, MD, from the Yale School of Medicine in New Haven, Connecticut.

It is a guiding "spirit" for clinical encounters that promotes health-related behavior change in patients, he said during an interactive workshop on the subject here at American College of Physicians Internal Medicine 2016.

Essentially, rather than advising a patient to change a behavior, the physician assesses patient readiness for change and helps devise a plan for success. Published studies have demonstrated that the approach has successfully helped patients lose weight, lower blood pressure, and adhere to HIV medication.

"Motivational interviewing isn't a strategy or a trick or a way to get people to do what you want them to do. It's actually a spirit, a way of being with our patients," Dr Fortin explained. The skills "are pretty transformational for any doctor–patient interaction," he added.

"This isn't something you add to your practice, that you tack on. This is something that supplants our current communication style with a more efficient communication style," said Eric Lamotte, MD, an internal medicine resident at the University of Washington in Seattle, who has created educational motivational interviewing modules for his residency program and who attended the workshop.

In fact, not using the approach can actually end up prolonging the time a patient spends in medical settings, said Frank Parker, MD, from the University of Louisville in Kentucky, who also attended the workshop.

He explained that he first learned about motivational interviewing when he was working in the field of chemical dependency, where "it's very important to get the buy-in." In those cases, if the decision to change behavior does not come from the patient, "it's not happening," Dr Parker told Medscape Medical News.

Starting the Conversation

Although motivational interviewing is not appropriate for acute-care visits, the approach can be used by primary care clinicians and specialists treating any patient with a medical problem that involves behavior, such as poor diet, lack of exercise, substance use or dependence, lack of adherence to treatment, or various risky or unsafe activities.

"Usually the doctor uncovers the unhealthy behaviors during the history-taking," said Dr Fortin. They are often not the "focus of the visit."

The physician starts by asking the patient if he or she wishes to make any behavior changes in the next few weeks. If the patient says no, the doctor says, "That's fine. If it's okay with you, I'll check next time."

 If the patient wants to make a change but is not sure what to do, the physician can ask permission to share no more than two or three simple ideas. The physician can then ask the patient if any of those ideas might work, and end with a statement such as, "You might have some other ideas."Asking permission is important for maintaining patient autonomy. "Patients are the ones who have to change the behavior, so they're in the driver's seat. We often approach with a sense of authority and attempt to educate and correct incorrect perceptions, but that's not all that helpful," Dr Fortin pointed out.

Encouraging "Change Talk"

The core motivational interviewing skills that build rapport with a patient are asking open-ended questions, affirming, reflective listening, and summarizing.  For example, an open-ended question such as, "How has this problem affected your daily life?" is more helpful than, "How long has this been a problem?"  Affirming involves recognition, support, and encouragement of the patient's strengths. Saying, "You worked hard on this!" is preferable to saying, "I'm proud of you," which highlights the physician's authoritative position.

Reflective listening can involve a simple repeating of what the patient says, or it can involve rephrasing or expanding on the patient's statement. For example, if the patient says, "Right now, drinking doesn't help me feel better the way it used to. In fact, I feel worse now," the physician can say, "So drinking is no longer helping you and you want to find some way to feel better instead of drinking."

 Summarizing involves the physician tying the things the patient has said together to signal that he or she was both listening and affirming what was said.

The idea is to encourage "change talk," in which the patient expresses the desire, ability, reasons, need, and steps for change, as opposed to "sustain talk," in which the patient expresses the inability or lack of need for change, Dr Fortin explained.

Formulating a Plan

Once the patient has expressed a desire for change, the physician can help flesh out a plan that is specific, measurable, achievable, relevant, and time-limited. Help the patient set a precise goal with an outcome that is evident to both the patient and physician, Dr Fortin advised.

 The next step is to ask the patient, "On a scale of 0 to 10, how confident or sure do you feel about carrying out your plan?" Research suggests that a response of 7 or greater is associated with a high likelihood of goal achievement.

If the response is 1 to 6, the physician can respond with something like, "Higher than zero, that's good! Any ideas what might raise your confidence?"

If the response is anywhere from 1 to 9, instead of asking, "Why not higher?" a better question is, "Why not lower?" Dr Fortin pointed out. "This prompts the patient to express change talk rather than sustain talk."

 The final step is to arrange follow-up and accountability by asking the patient, "Would it be useful to check in with me again to review how you are doing with your plan? If so, when?" Here too, he noted, "the patient is in charge. You're not changing the behavior. The patient is."

During the workshop, Dr Fortin was asked about patients who simply cannot or will not make changes.

"Sometimes the best we can do is be empathic," he explained. "One of the factors that leads to professional burnout is when we think we have to fix everything the patient tells us about, instead of recognizing that often all we can do is witness it, sit with it, acknowledge it." In fact, "sometimes we're being our best selves as doctors when we can just do that."

Dr Fortin, Dr Lamotte, and Dr Parker have disclosed no relevant financial relationships.

American College of Physicians (ACP) Internal Medicine 2016. Presented May 7, 2016.