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Guided learning

Motivational interviewing 1: background, principles and application in healthcare

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Motivational interviewing can help people improve their lifestyles but nurses need to understand its principles to spot opportunities to encourage this

Author

Gill Scott, PGCE (Adult), BSc, Dip Therapeutic Nursing (Palliative Care), RNT, RGN, is personal health coach, Humana Europe, and education facilitator, Doncaster Primary Care Trust.

Abstract

Scott G (2010) Motivational interviewing 1: background, key principles and application in healthcare. Nursing Times; 106: 34, early online publication.

This first in a two part unit on motivational interviewing explores how nurses can use the technique to motivate and empower patients in healthcare and wellbeing. It discusses the core principles of motivational interviewing and gives examples of its proven use in managing long term conditions and general health and wellness. The widespread application of the technique may also successfully address productivity issues in the NHS.

Keywords Motivational interviewing, Behaviour change, Health promotion

  • This article has been double-blind peer reviewed

 

Learning objectives

1. Understand the theory behind motivational interviewing.

2. Know how to apply its principles in daily practice to improve client health and wellbeing.

 

Background

Motivational interviewing is being increasingly used in the areas of health promotion, public health and primary care to support lifestyle/behaviour change. When first developed two decades ago, it was used mainly in the fields of addiction and substance misuse. It may now prove to be useful in helping to address rising levels of obesity and associated increases in diabetes, liver disease and cardiac disease (Cook, 2009). Results of this therapeutic intervention have been extremely promising as a precursor or complement to other treatments and interventions. Motivational interviewing could play a significant role in services being developed in an increasingly client directed healthcare climate (Department of Health, 2008).

Originating from the Rogerian, client centred counselling approach (Mason, 2009; Rogers, 1980) and formulated into theory by Miller and Rollnick (1991), motivational interviewing is a “well known, scientifically tested method of counseling [sic] clients… and viewed as a useful intervention strategy in the treatment of lifestyle problems and disease” (Rubak et al, 2005).

The skills that motivational interviewing practitioners need are those that also are needed for enabling communication in healthcare: reflection, active listening and open ended questioning.

Unlike Rogerian approaches, the technique can include elements of “direction” and is balanced with elements of “following”. This shows a guiding style rather than the leading style seen in consultations over medical treatment or where advice is given.

Central to motivational interviewing is a belief in clients’ inherent resources rather than extrinsic problem solving, which contrasts with the expert-novice dynamic of some professional-client relationships.

Box1outlines the key features of motivational interviewing.

Features of motivational interviewing

  • Motivational interviewing relies on identifying clients’ intrinsic values and goals and using them as a basis to stimulate behaviour change.
  • Motivation to change is elicited from clients, not imposed on them.
  • It is designed to elicit, clarify and resolve ambivalence.
  • Resistance and denial is often a signal to modify motivational strategies.
  • Eliciting and reinforcing clients’ ability to carry out and succeed in achieving a specific goal is essential.
  • The therapeutic relationship is a partnership that respects client autonomy.
  • It is both a set of techniques and counselling style.

Source: Rubak et al (2005)

 

The evidence base

Since 1983, an up to date online bibliography has been maintained (www.motivationalinterview.org/library/biblio.html).

Rigorous systematic review indicated that motivational interviewing has not led to any negative consequences for clients (Rubak et al 2005). In 80% of the 72 combined psychological and physiological outcome trials reviewed, the technique outperformed simple advice giving. There were estimated combined effects made for body mass index, blood cholesterol, blood alcohol levels and systolic blood pressure, coming from both improved medication regimen adherence and behaviour changes (Rubak et al, 2005).

Key aspects of motivational interviewing

Motivational interviewing coaches may sometimes wish they could lend clients the benefit of insight, whether through clinical or personal experience, but then wonder “Who am I to suggest it anyway?” However, clients suggest all this to themselves, essentially enabled by the coach’s guiding and non confrontational style.

Research has shown that change talk is the most important predictor of successful change (Miller and Moyers, 2006), and coaches’ role is to try to elicit these kinds of phrases from clients. Change talk indicates recognition of relevant actions directed towards a meaningful and achievable goal which clients consider significant as a desired outcome. It reveals that clients are shifting from a perspective of ambivalence about proposed or potential change towards one of increased confidence and motivation. Change talk is shown by increasing use of phrases that move speech from “I could” or “I might” to “I will”, “I can” and “I’ll do”. The coach’s role is to elicit such phrases from clients.

Rollnick et al (2008) described a simple mnemonic, with six steps of change talk through which clients are guided: it describes a progression through Desire, Ability, Reasons and Need to a change in perception resulting in Commitment and Taking steps (DARN-CT).

Although it is more sophisticated than health education through information giving, motivational interviewing still incorporates information giving as one of its more directive elements. Client permission must be sought before coaches make suggestions, as practitioners prefer to guide clients to finding solutions for themselves rather than presenting them. Nevertheless, offering more than one option, preferably three, increases the effectiveness of motivational interviewing in eliciting change behaviour.

Choice is an empowering tool in securing resolution and, ultimately, commitment to change. Jarvis et al (1995) outlined five basic principles of motivational interviewing: expressing empathy; developing discrepancy; avoiding argument; rolling with resistance; and supporting client responsibility and choice. Control and choice truly rest with clients. The risk of bias and leading/directing patient consent or of missing any wrongly held beliefs or assumptions is much reduced with this technique.

The full scope of motivational interviewing is enhanced by setting it in the context of its sister model, usually known as the transtheoretical or stages of change model (Prochaska et al, 1994). Here, a comprehensive programme is presented to help clients overcome bad habits and progress their lives with changes for good.

Prochaska et al (1994) discovered that change follows a six stage process, including an action stage where clients start to act on their desires. Once these authors had determined that only 20% of clients are ever in the action stage, they recommended that therapists redirect their efforts into motivational interviewing techniques which would better help clients at all states of readiness to reach the critical stage of action.

Another complementary assessment framework is the STAR model (see Keller (2008) for more details).

Using scaling tools

A fundamental aspect of motivational interviewing practice involves using scaling tools such as confidence and conviction scoring.

The scaling and rating tools and templates incorporated in the assessment process enable a numerical means of measuring clients’ self perceived progress. Such tools can record and direct coaches in response to a scaled conviction and confidence rating.

Essentially, they allow further exploration of clients’ feelings about making change and indicate the most productive conversational strategies for both deepening the quality of the client-coach relationship and eliciting change talk from clients (Keller and White, 1997).

The DARN-CT mnemonic below illustrates this lead into a pivotal change of perception (Box 2).

Change talk hierarchy

Desire: the preference for a change or to leave the status quo

Ability: what is perceived to be possible

Reasons: for a certain change

Need: what is imperative

These stages above occur before commitment.

Commitment: what “I will” do

Taking steps: literally moving in a certain direction of change

These last two stages accompany commitment to change.

Conclusion

Motivational interviewing skills are transferrable to everyday face to face or telephone consultations (Dale et al, 2009; Bennett et al, 2008; Wahab et al, 2008).

A strong feature of skill development and mastery is that coaches continually learn and hone their practice from direct client experience. Reflection on practice in peer, expert and line managerial supervision is possible using motivational interviewing quality audit tools such as MITI (Moyers et al, 2010).

For more on learning and teaching motivational interviewing, an international network of accredited trainers can be found at www.motivationalinterview.org.

Client motivation towards behaviour change is a result of various factors that come into play in the enabling process that motivational interviewing offers. Some of the key influencing factors have been shown to be the therapist’s motivational style and the technique used in motivation.

  • Part 2 of this unit, to be published in next week’s issue, shows how nurses can use MI in practice

For more information contact Gill Scott at gill.scott@humana.co.uk

Acknowledgement

I would like to thank Linda Koncewicz for her careful and constructive reviewing, and to the clients of Humana Europe’s Choosing Health Programme, Stoke on Trent PCT.

 

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