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Do you really know about motivational interviewing?

15 October 2019 - Dr Jan Orman

If you are like me you know a lot of words that you know vaguely what they mean and can provide a definition  but if asked  to write a short article about say, their history, or expand on what the concept they describe looks like in practice you might need to do a little more reading or research.

For me until recently “motivational interviewing” was one of those words. (OK, its two words, but for the purposes of this post lets call it one)

On the face of it the meaning is obvious

“Motivational Interviewing” (MI) is another of those concepts in health (like “depression”) that takes an ordinary word(s) and gives it a special meaning.

Here’s one definition:

“Motivational Interviewing is a specific clinical method of increasing intrinsic motivation to enhance motivation to change”. (I think that definition, or something very like it, comes from MI gurus Miller and Rollnick)

 That seems very straightforward doesn’t it? 

The most important word in that is “intrinsic”.

All of us in our work are dealing with a person’s need to make changes. Whether as a GP we see people who need to change their behaviour around self-care or as a mental health professional to help them change the way they think about themselves or their lives or the way they behave in their relationships with themselves or others - it’s all about change. The truth of the matter is that none of us can make the changes for them. If we were surgeons, we could approach the problem with a scalpel, but most of the problems we see are not that easy to solve.

I first encountered the formal concept of MI in the 1980s when GPs were being encouraged to change the way they approached the issue of smoking cessation. (For the rest of the paragraph whenever I say “stop smoking” translate it to almost any kind of behaviour change you wish). Some behaviours, like smoking, seem intractable and, for most people, no amount of knowledge acquisition about the impact of those behaviours seems to help motivate them to change. A GP is expected to tell you to stop smoking and you are expected to ignore it. But we know that if the idea to stop smoking is your own then maybe, with a little bit of help, you can succeed.

Low motivation is not just the other person’s problem

People’s inability to take our advice and make the changes they need to improve their lives may not be just their problem – it may also be something to do with us.

Miller and Rollnick say that “low motivation is not just a client problem but a shifting state that is very sensitive to the behaviour of the counsellor”. Motivation for change fluctuates according to the practitioner’s style and is less likely to improve in response to authoritative and paternalistic counselling styles.

The idea of using empathic listening rather than authoritative advice giving is central to MI, along with the idea that motivation for change needs to be elicited from people rather than imposed upon them.

So, how do we do it?

Many professional trainings acknowledge the importance of motivational interviewing but in my experience not many actually describe in any detail how to go about it. If you pride yourself in your interpersonal skills you may think it’s obvious and doesn’t need to be taught, but that is part of the problem. It’s possible that the more you know the more likely you are to want to share it with people and that may well boil down to just telling them what to do. (Oh, how much better off the world would be if people just did what I told them to do!)

MI emphasises the need for collaboration rather than confrontation, coercion or persuasion. It also emphasises the need to respect the person’s autonomy and their right to make decisions for themselves.

Here are the four guiding RULEs and some strategies you need to practice MI:

  • Resist the impulse to give advice and to make things right (Oh, medical model where do you fit into this!)
  • Understand the person’s dilemma
  • Listen empathically
  • Empower the person to make the change

Important strategies include:

  • Generating a gap between what exists and how the person would like things to be
  • Rolling with resistance – there is always ambivalence. People want to change and to stay the same simultaneously. Acknowledge the ambivalence. The upside of staying the same has a role in the conversation alongside the upside of change.
  • Avoid arguments
  • Encourage confidence and hope
  • Express empathy and support self-sufficiency.

Learning how

If you don’t know how to do the things in that list, you might benefit from some further training.

If you prefer to read to learn  you could start by reading Miller and Rollnick’s book - Motivational Interviewing: Helping People Change.

If not, see if you can find a face to face workshop in your local area that is dedicated to motivational interviewing rather than just adding it as a throwaway line in a workshop about something else.

Or take a look at how the Queensland University of Technology have incorporated motivational interviewing techniques in their excellent OnTrack Alcohol management program by enrolling and doing the program as though you had a problem yourself. MI is so easy you can even a computer program can do it!

References

  • Motivational Interviewing: Helping People Change. William R Miller and Stephen Rollnick. Guildford Press 3rd Edition 2012
  • OnTrack Alcohol
Dr Jan Orman
Dr Jan Orman

Jan is Sydney GP, private psychological medicine practitioner in Sydney’s inner west and a GP educator for Black Dog Institute.

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