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Motivational interviewing
Kate Hall
Tania Gibbie
techniques
Dan I Lubman Facilitating behaviour change in the general
practice setting
660 Reprinted From Australian Family Physician Vol. 41, No. 9, september 2012
The Prochaska and DiClemente Stages of Change model2 offers a
Table 1. Practitioner tasks within the Stages of
conceptual framework for understanding the incremental processes
Change model1,2
that people pass through as they change a particular behaviour. This
change process is modelled in five parts as a progression from an Patient stage Practitioner tasks
initial precontemplative stage, where the individual is not considering Precontemplation Raise doubt and increase the
change; to a contemplative stage, where the individual is actively (Not ready) patients perception of the risks
ambivalent about change; to preparation, where the individual and problems with their current
behaviour. Provide harm reduction
begins to plan and commit to change. Successful progression through
strategies
these stages leads to action, where the necessary steps to achieve
change are undertaken. If successful, action leads to the final stage, Contemplation Weigh up the pros and cons of
(Getting ready) change with the patient and work
maintenance, where the person works to maintain and sustain long
on helping them tip the balance by:
term change.3 Relapse is considered an important stage in the change
exploring ambivalence and
process and is used as an opportunity to learn about sustaining alternatives
maintenance in the future. identifying reasons for change/
Motivational interviewing (MI) is an effective counselling method risks of not changing
that enhances motivation through the resolution of ambivalence. It increasing the patients
grew out of the Prochaska and DiClemente model described above2 confidence in their ability to
and Miller and Rollnicks1 work in the field of addiction medicine, change
which drew on the phrase ready, willing and able to outline three Preparation Clear goal setting help the patient
critical components of motivation. These were:1 action to develop a realistic plan for
the importance of change for the patient (willingness) (Ready) making a change and to take steps
toward change
the confidence to change (ability)
whether change is an immediate priority (readiness). Maintenance Help the patient to identify and use
Using MI techniques, the practitioner can tailor motivational (Sticking to it) strategies to prevent relapse
strategies to the individuals stage of change according to the Relapse* Help the patient renew the
Prochaska and DiClemente model (Table 1).1,2 (Learning) processes of contemplation and
action without becoming stuck or
Applications and effectiveness of demoralised
motivational interviewing * Relapse is normalised in MI and is used as an
Recent meta-analyses show that MI is equivalent to or better opportunity to learn about how to maintain long term
than other treatments such as cognitive behavioural therapy (CBT) behaviour change in the future
or pharmacotherapy, and superior to placebo and nontreatment
controls for decreasing alcohol and drug use in adults46 and stress management
adolescents.7 Motivational interviewing has also been shown to be completion of recommended screening or diagnostic tests or
efficacious in a number of other health conditions, such as smoking specialist/allied health/psychologist referral.
cessation,8 reducing sexual risk behaviours,911 improving adherence
to treatment and medication,12 as well as diabetes management.13
The spirit of motivational interviewing
In addition, studies support the applicability of MI to HIV care, Motivational interviewing is underpinned by a series of principles
such as improving adherence to antiretroviral therapy14,15 and the that emphasise a collaborative therapeutic relationship in which
reduction of substance use among HIV positive men and women.15 the autonomy of the patient is respected and the patients
As such, MI is an important therapeutic technique that has wide intrinsic resources for change are elicited by the therapist.
applicability within healthcare settings in motivating people to Within MI, the therapist is viewed as a facilitator rather than
change. In general practice, possible applications include: expert, who adopts a nonconfrontational approach to guide
medication adherence the patient toward change. The overall spirit of MI has been
management of the SNAP (smoking, nutrition, alcohol and described as collaborative, evocative and honouring of patient
physical activity)16 risk factors autonomy.1 Miller and Rollnick1 have commented that the use
engagement in prevention or management programs for diabetes of MI strategies in the absence of the spirit of MI is ineffective.
or cardiovascular health Although paradoxical, the MI approach is effective at engaging
management of substance abuse problems apparently unmotivated individuals and when considered in
management of problem gambling or sexual risk taking the context of standard practice can be a powerful engagement
pain management strategy (Case study, Table 2).
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FOCUS Motivational interviewing techniques facilitating behaviour change in the general practice setting
662 Reprinted From Australian Family Physician Vol. 41, No. 9, september 2012
Motivational interviewing techniques facilitating behaviour change in the general practice setting FOCUS
patients confidence in their ability to change. This involves focusing Where do we go from here?
on the patients strengths and past experiences of success. Again, a What do you want to do at this point?
confidence ruler could be employed if a practitioner is time poor. How would you like things to turn out?
Example: If you can think of a scale from zero to 10 of how After reviewing all of this, whats the next step for you?
confident you are that you can cut back the amount you are drinking. It is common for patients to ask for answers or quick fixes during
On this scale, zero is not confident at all and 10 is extremely confident. Phase II. In keeping with the spirit of MI, a simple phrase reminding the
Where would you be on this scale? Why are you at ____ and not zero? patient of their autonomy is useful, You are the expert on you, so Im
What would it take for you to go from ___ to (a higher number)? not sure I am the best person to judge what will work for you. But I can
Finally, decide on a change plan together. This involves standard give you an idea of what the evidence shows us and what other people
goal setting techniques, using the spirit of MI as the guiding principle and have done in your situation.
eliciting from the patient what they plan to do (rather than instructing or
advising). If a practitioner feels that the patient needs health advice at this The guiding principles of motivational
point in order to set appropriate goals, it is customary to ask permission interviewing
before giving advice as this honours the patients autonomy. Examples of In general practice, the particular difficulties associated with quick
key questions to build a change plan include: consultation times can present unique challenges in implementing MI.
It sounds like things cant stay the same as they are. What do you Miller and Rollnick17 have attempted to simplify the practice of MI for
think you might do? health care settings by developing four guiding principles, represented
What changes were you thinking about making? by the acronym RULE:
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Motivational interviewing techniques facilitating behaviour change in the general practice setting FOCUS
Change talk Questions to elicit change talk Example of patients change talk
Disadvantages of the What worries you about your blood I guess, if Im honest, if I keep drinking,
status quo pressure? I am worried my family are going to stop
What difficulties have resulted from your forgiving me for my behaviour
drinking?
In what way does your weight concern
you?
Advantages of change How would you like your health to be in 5 If I lose weight, at least I wont have to
years time? wake up feeling guilty every morning that I
What are the advantages of reducing your am not taking care of myself
drinking?
What would be different in your life if you
lost weight?
Optimism for change When have you made a significant change I did stop smoking a few years ago for a
in your life before? How did you do it? year and I felt so much healthier. It was
What strengths do you have that would really hard, but once I put my mind to
help you make a change? something I usually stick at it
Intention to change In what ways do you want your life to be I never thought I would be living like this.
different in 5 years? I want to go back to being healthy and
Forget how you would get there for a strong, with enough energy to enjoy my
moment. If you could do anything, what friends and family. I want to manage my
would you change? diabetes better
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FOCUS Motivational interviewing techniques facilitating behaviour change in the general practice setting
Express empathy
In practical terms, an empathic style of communication involves the use of reflective listening skills and accurate
empathy, where the practitioner seeks to understand the patients perspective, thoughts and feelings without
judgeing, criticising or blaming. Building empathy and understanding does not mean the practitioner condones the
problematic behaviour. Instead, the practitioner seeks to create an open and respectful exchange with the patient,
who they approach with genuine curiosity about their experiences, feelings and values
Develop discrepancy
Assisting patients to identify discrepancies between their current behaviour and future goals or values about
themselves as a person, partner, parent, or worker is a powerful motivator that helps tip the balance toward change.
Exploring the pros and cons of change can help a patient develop discrepancy. These decisional balance exercises
are used effectively in MI to help patients tease apart their ambivalence and help the patient express their concerns
about the behaviour
to change and a proven method for dealing with a number of common References
1. Miller WR, Rollnick S. Motivational Interviewing. Preparing people
presentations within general practice.
for change. 2nd edn. New York: The Guilford Press, 2002.
2. Prochaska J, DiClemente C. Towards a comprehensive model of
Resource change. In: Miller WR, Heather N, editors. Treating addictive behav-
For further information and online motivational interviewing training iours: processes of change. New York: Pergamon, 1986.
opportunities visit www.motivationalinterview.org. 3. DiClemente CC, Velasquez M. Motivational interviewing and the
stages of change. In: Miller WR, Rollnick S, editors. Motivational
Authors interviewing, second edition: Preparing people for change. New
Kate Hall BA(Hons), DPsych(Clin), MAPS, is Senior Lecturer, Deakin York: The Guilford Press, 2002.
University, Department of Psychology and senior clinical psychologist, 4. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational
interviewing: a meta-analysis of controlled trials. J Consult Clin
Turning Point Alcohol and Drug Centre, Eastern Health, Melbourne,
Psychol 2003;71:84361.
Victoria. kateh@turningpoint.org.au 5. Hettema J, Steele J, Miller WR. Motivational interviewing. Ann
Tania Gibbie BSc(Hons), MPsych(Health), PhD, is a health psychologist, Rev Clin Psychol 2005;1:91111.
Barwon Health, Geelong, Victoria 6. Lundahl BW, Kunz C, Brownell C, Tollefson D, Burke BL. A meta-
analysis of motivational interviewing: twenty-five years of
Dan I Lubman BSc(Hons), MBChB, PhD, FRANZCP, FAChAM, is Director
empirical studies. Res Soc Work Pract 2010;20:13760.
and Professor of Addiction Studies, Turning Point Alcohol and Drug 7. Jensen CD, Cushing CC, Aylward BS, Craig JT, Sorell DM, Steele
Centre, Eastern Health and Monash University, Melbourne, Victoria. RG. Effectiveness of motivational interviewing interventions for
adolescent substance use behavior change: a meta-analytic review.
Conflict of interest: none declared. J Consult Clin Psychol 2011;79:43340.
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