Motivational interviewing is based on 30 years of psychosocial research. A unique feature of the technique, according to Dr. Bartlett, is that it addresses patients who are not ready to change as well as those who are. Rather than giving advice or diagnosing the problem, the counselor (care provider) listens and guides patients to make their own solutions, she explained.
Motivational Interviewing Steps
Several of the steps to motivational interviewing that Dr. Bartlett outlined are as follows:
- Enhancing self-motivation. Show that you understand the patient’s perspective by expressing acceptance and affirmation. Reflect back what the patient is saying. Elicit change statements by asking open-ended questions, such as, “How important is it to you to become more physically active?”
- Resolving ambivalence. Ask why the patient wants to change a behavior and what is preventing that person from changing.
- Assessing readiness. Ask the patient, “When is the best time for you to attempt behavior change?” and, “How ready are you to make the change now?”
- Accepting resistance. If you encounter resistance to change, accept it. Summarize aloud the patient’s ambivalence. For instance: “It sounds like you want to quit smoking, but you enjoy cigarettes. It seems that you’re not ready to quit now.”
A major focus of this approach is actively eliciting “change talk” from patients. Change talk includes statements indicating that the patient recognizes that a behavior is a problem, expresses concern about his or her ability to change, or mentions reasons for changing.
“This provides opportunities to help clients visualize what life can be like when the behavior changes,” Dr. Bartlett said.
It may seem that this motivational interviewing process would take too long for a single patient visit. However, Dr. Bartlett said, “In many cases, this can be part of an ongoing conversation that takes place over multiple clinic visits.”
Patient Should Do the Work
A motivated patient is more likely to make changes in health behavior, said copresenter Dr. Hewlett, whose work in England involves helping patients with arthritis cope with and manage their disease. First, a patient must have self-efficacy, which Dr. Hewlett described as the belief that one has the ability to carry out a task. Principles of self-efficacy include group-based role modeling and homework assignments.
“People learn better in groups, and group members become a credible source for persuasion,” Dr. Hewlett said.
As evidence, Dr. Hewlett presented the recently published results of a randomized, controlled clinical trial.1 She and her colleagues showed that group cognitive behavioral therapy improves the ability of adults with rheumatoid arthritis to cope with fatigue.
Cognitive behavioral therapy, she explained, helps patients to understand the behaviors needing change and to identify the links between thoughts and feelings that drive behavior and increase the disease symptoms. This step is necessary before patients can set goals, another important component of self-efficacy. Patients should set their own goals for small, specific changes and should find solutions to any barriers to meeting the goals.
“It is crucial that the patient is the one doing the work,” Dr. Hewlett said. “The patient has to feel ownership in the goal.”
At the heart and soul of motivational interviewing is trying to talk with patients differently. We are trying to help individuals motivate themselves.
—Susan J. Bartlett, PhD
Understand Behaviors
For patients to better understand their current behaviors, Dr. Hewlett suggests they complete a daily activity chart for at least a week. With this tool, patients document their behaviors and symptoms for each hour of the day. Arthritic patients, for instance, may record when they sleep, when their energy and activity level is high or low, and when pain and fatigue cause them to “crash” and do nothing. Then the health professional can ask the patient what contributed to recorded patterns, such as sleeping during the day or “crashing” every evening. This process can help patients link behaviors with symptoms and help make changes that they can review in the following week’s activity chart, she said.
Both speakers involved the audience in role-playing patient–provider scenarios to practice the techniques discussed.
An audience member, Susan M. Oliver, RN, MSc, told The Rheumatologist that this session provided important information. Many nurses believe they cannot use cognitive behavioral approaches, said Oliver, a nurse consultant specializing in rheumatology with a consulting practice in Barnstaple, Devon, U.K.
Oliver said the presentations confirmed her experience. “The most important thing is, you’ve got to listen to what matters to the patient,” she said.
She cites another advantage to using these motivational techniques in clinical practice. “You will develop a strong therapeutic relationship with your patients because they know you care about them and that you value their opinion and take it into account when planning their treatment.”
Kathleen Louden is a medical writer based in the Chicago area.
