Motivational Interviewing Tool

Motivational interviewing (MI) is a person-centered, goal-oriented counseling method for resolving ambivalence and promoting positive change by eliciting and strengthening the person’s own motivation for change. From an MI perspective, behavior changes are best sustained if they are driven by internal motivators. Thus, the provider’s objective is to help the patient discuss his/her own reasons and ambivalence to engage in change, and to offer advice when the patient is ready to have a discussion about making those changes. 
 
Spirit & Principles of MI
MI is not scripted and should not be viewed as a cookbook or set of strategies that can be applied to all patients. The spirit of MI refers to the style of interaction with the patient.  It emphasizes openness in collaboration about behavior change by being respectful of autonomy yet evocative in eliciting personal concerns for change and in the negotiation of treatment. Patients are viewed as experts of themselves (or their children) and as possessing the abilities (i.e., personal values, motivations, abilities, skills) to make a change, without necessarily needing the expertise of the provider to make a change. Moreover, patients are responsible for their own health-related behaviors and subsequent consequences of those choices, whether or not the provider agrees with the decision. 

The four foundational principles central to conveying the spirit of MI include:

  1. Express Empathy – The provider displays and communicates a genuine understanding of the patient’s feelings and perspective, accepts the patient’s ambivalence, and uses skilled reflective listening in the interaction.
  2. Roll with Resistance – The provider avoids arguing with the patient, as this is counterproductive to the encounter and can increase the patient’s resistance to engage in change behavior.
  3. Support Self Efficacy – The provider helps support the patient’s belief in his/her own ability to make a change, acknowledging past successes and reinforcing intentions to change.
  4. Develop Discrepancy – The provider addresses the inconsistencies between the patient’s current behaviors and broader goals to guide the patient to consider discrepancies. It is the patient’s responsibility to articulate the incongruence between actions and goals and to present the rationale for change.

Strategies for effective MI include

  1. Ask permission – The provider pointedly addresses areas of concern, while offering the patient the freedom to choose to discuss these topics (or not).
    • “There are some things that concern me here, would it be ok for us to discuss this now, or at another time?”
      “Would you be interested in learning more about…?”
  2. Use open ended questions – The provider offers the opportunity for the patient to express details and to describe his/her situation, without being directed to respond in a specific manner.   
    • “How have you tried to change…?”
    • “Tell me what concerns you about………”
  3. Assess importance and ability – The provider focuses on the patient’s perceived reasons, readiness, and confidence to engage in change behaviors and allows the individual to evaluate personal reasons and ability to make those changes.
    • A provider using the importance ruler might ask: “On a scale from 1 to 10, with 1 being the lowest and 10 being the highest, how important is it for you to change ….?”
    • Once the patient has chosen his/her value, the provider may then follow with a statement inquiring about a lower number, such as “Why not a 2 instead of a 4?”
    • Asking about the lower (rather than higher value) opens an opportunity not only to understand the extent to which the patient currently views the prospect of making changes in his/her life, but also to direct the course of the interaction by focusing on topics relevant to the patient. 
  4. Affirm the patient’s desires – This conveys the positive aspects of a patient’s intent to engage in actual behavior change, as well as to enhance self efficacy.
    • “What you are experiencing is not unusual. Many people report…”
    • “That is great that you…. What is going to be the best way for you to.…?”
  5. Respond to (“Roll with”) resistance – The provider responds in a way that decreases resistance.
    • Do not argue with the patient about reasons to change.
    • Acknowledge the reflection, defuse it, and refocus on change.
  6. Look forward – Help the patient to express optimism about making changes by inquiring about how his/her life might be different without the problematic behavior.
    • “Imagine how you your life would be different if you didn’t have the struggles with……”
    • “How might you see yourself in 5 or 10 years if ….. is still a problem?”
  7. Listen reflectively – Reflective listening employs clarifying statements and conveys an understanding of the meaning of patient responses.
    • “So you know … is important, but you don’t like …”
    • “It seems like you would like to…but… What have you tried?”
    • “It sounds like you are feeling…..about making a change in … but are concerned about…”
  8. Summarize the encounter – The summary extends reflective listening and provides a synopsis of the themes discussed and of the patient’s reasons and abilities to make a change. Areas of reluctance to change, if appropriate, are also acknowledged in the summary. Commitment to change is reflected and summarized. If commitment is strong, the provider can elicit/negotiate a change plan.
    • “So putting it all together, you are concerned about….., ……, and …….”
    • “What I hear you saying is……… Is there anything else that I’ve missed?”

To view the tools for Motivational interviewing, select stage one or stage two.

References:
Dixon SD, Stein MT. Encounters with Children: Pediatric and Behavior Development, Third Edition. St Louis, MO: Mosby Inc; 2000.

Miller WR, Rollnick, S. Motivational Interviewing: Preparing People for Change, 2nd ed. New York: Guilford Press; 2002.

Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. American Psychologist. 1992; 47:1102-1104.

Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London, UK: Churchill Livingstone; 1999.

Rollnick S, Miller WR, Butler, C. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press; 2008.

Rollnick S, Miller, WR: What is MI? http://www.motivationalinterview.org/clinical/whatismi.html

Suarez M, Mullins S. Motivational interviewing and pediatric health behavior interventions. Journal of Developmental and Behavioral Pediatrics; in press.

  
 
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