Motivational Interviewing: Empowering Patients to Make Healthier Lifestyle Choices
This article explores the meaning of motivational interviewing in the context of medical consultations and provides ideas about how to implement this consultation style into clinical practice.
What is Motivational Interviewing?
Motivational interviewing is a patient-centred consultation style that allows you to explore a person's intrinsic motivation for making behavioural changes. It was developed by psychologists William Miller and Stephen Rollnick, who recognised that patients are often at different stages of readiness to change. Motivational interviewing promotes behavioural changes by supporting patients to explore and resolve ambivalence to change (1,2).
The Alternative to Motivational Interviewing... Lecturing
Even if we feel that certain lifestyle changes are in a patient's best interests, we must respect patient autonomy. Rather than lecture our patients about what we feel is best for them, we can enable them to weigh up the decisions themselves. Maintaining dialogue and engaging patients in the decision-making process increases the likelihood of their commitment to the proposed changes.
#Tip 1: Avoid lecturing and maintain dialogue
When should you utilise Motivational Interviewing?
You can use motivational interviewing to explore several lifestyle factors, for example:
- Smoking
- Alcohol Consumption
- Recreational Drug Use
- Caffeine Intake
- Diet
- Exercise
- Social Media Use
Why are Lifestyle Choices so Difficult to Change?
Habits are often formed early in life. The neurophysiology behind addictions is why habits are so difficult to break. Consider the impact of nicotine on a chronic smoker and how this interacts with the release of dopamine. Dopamine is released when we experience something pleasurable. When a person stops smoking abruptly, the withdrawal symptoms can be extremely unpleasant, which often drives the need to continue smoking. Dopaminergic pathways drive all addictions; this wiring in the brain creates the biggest barrier to making healthier lifestyle choices.
How to Initiate Motivational Interviewing within a Consultation
Motivational interviewing begins by identifying opportunities during a consultation to address lifestyle factors that negatively impact an individual's health. One way to initiate this approach is by incorporating open questions that prompt discussion about a patient's lifestyle choices. For instance, when exploring the social history, it may become apparent that the patient is struggling to maintain a healthy diet.
To begin, it is helpful to pose open questions to encourage the patient to share more about their diet. This allows the individual to reflect on their current dietary practices and gain insights into their motivations related to their diet.
Here are a few examples of how to start the conversation:
"Can you tell me more about your diet?"
"Could you describe a typical day in terms of your eating habits?"
"How do you currently feel about your diet?"
#Tip 2: Use open questions and actively listen to explore the lifestyle
Avoid Judgement
Whilst we might not believe a person's lifestyle choices are in their best interests, it is crucial to approach these discussions with empathy, sensitivity and without judgment. Often, there are underlying reasons why individuals engage in unhealthy behaviours.
For instance, a person may turn to drugs or alcohol to cope with complex family issues or challenging work conditions. Understanding the context behind the lifestyle choices is crucial. Social history often plays a significant role in helping us better comprehend lifestyle choices and motivations. Hence, dedicating sufficient time to exploring the social history is essential in these types of consultations.
#Tip 3: Show empathy
#Tip 4: Explore social factors that impact on lifestyle choices
Is this the Right Time for Motivational Interviewing?
The timing of implementing motivational interviewing is paramount.
Some key considerations include:
Patient Readiness:
- Is the patient open to exploring and discussing their current behaviours and considering alternatives?
- Is the patient motivated and committed to making the necessary changes?
Barriers:
- Are there significant barriers that must be addressed before initiating the changes?
- Are there external factors, such as stressful life events (e.g., grief, divorce, loss of employment), that may impact the patient's ability to focus on making the adjustments?
For instance, a patient's financial constraints could significantly impact their ability to choose healthy options over more affordable but processed meals at the supermarket.
If the timing is not conducive to immediate changes, we can still support the patient by providing guidance, resources, and strategies that may be more feasible for them in their current situation. Additionally, maintaining an ongoing dialogue and reassessing readiness for change at subsequent visits can be beneficial.
#Tip 5: Explore readiness and barriers to change
Establish Triggers
Triggers for lifestyle choices will be different for different people. It is useful to help patients identify their triggers, e.g., perhaps they drink more alcohol only in certain social settings. By assisting patients to recognise these triggers, they can be more mindful of these situations.
Stress is a common trigger for many vices. Exploring stress in the work and home environment is valuable in helping us understand the patient's struggles.
Establish the Pros and Cons
A large part of motivational interviewing is about encouraging the patient to weigh up the pros and cons of both:
- Continuing the behaviour
- Stopping the behaviour
It is important that the patient elicits the pros and cons rather than this coming from the clinician. This approach fosters a deeper level of self-reflection and empowers patient's to make more informed decisions about their lifestyle choices.
Try to establish how the changes could impact the patient's home and work life. Make it personal.
"From what you have said, I understand that it is really important to you that you can continue to be physically active for as long as possible so that you can look after your grandchildren".
It may be helpful to summarise and acknowledge what you have understood about the pros and cons the patient has discussed, as this can help them to reflect further.
"So, on the one hand, you enjoy going out with your friends and drinking alcohol at weekends, but on the other hand, you feel bad about it the next day as you are feeling lethargic and guilty about spending your hard-earned money.Does that sound like what is happening?"
#Tip 6: Encourage the patient to weigh up the pros and cons of the lifestyle choice/s.
Confidence Levels
- How confident does the patient feel about making the change/s?
- Ask the patient to rate their confidence level from 1-10 (with 10 being very confident).
- What factors influence the level of confidence?
- What would improve the confidence level?
- Perhaps the patient had given up smoking or reduced drinking alcohol in the past. What worked for them last time? What made them return to the behaviour?
- Help patients build confidence by acknowledging any past successes.
"It sounds like two years ago; you achieved the weight goals you were aiming for. It's great that you managed to achieve that. What helped you last time and kept your motivation levels up?"
This approach prompts patients to draw upon their own experiences and insights. It empowers them to identify strengths and potentially transfer those successful strategies to their current situation.
Importance Level
- How important is making the change to patients right now?
- How would they rate the level of importance from 1-10?
- How does this compare to their level of confidence in making the change?
- Is there congruency between the importance and confidence levels?
#Tip 7: Assess the levels of confidence and importance
Establish Achievable Goals
See if the patient can come up with their OWN suggestions for how they can improve their lifestyle.
If the patient struggles to generate their own solutions, work together and suggest practical solutions that fit their day-to-day activities.
Consider offering suggestions for small steps that feel achievable and manageable. For instance:
"Have you thought about incorporating exercise during your commute to work?"
"Do you think you could try getting off the bus a couple of stops earlier and walking the rest?"
"Would it be feasible for you to use the stairs at work instead of taking the elevator?"
A few years ago, I read a book by Dr Rangan Chaterjee (3). He wrote about his experiences working as a GP and how he would help his patients make behavioural changes. I recall reading about how he asked his patients to incorporate just 5 minutes of muscle strength training into their morning routines by doing a "Kitchen Workout". He suggested how they could incorporate this into the time they were waiting for their coffee to brew or porridge to cook. He used simple exercises that could be done in the kitchen to get them started. The point is that the suggestions did not sound impossible, overwhelming or unachievable.
By offering practical and feasible suggestions, we can instil confidence a patient's ability to make positive changes.
#Tip 8: Set small and achievable goals
Acknowledge Achievements
However big or small the achievements, it is essential that healthcare professionals acknowledge these milestones. By acknowledging progress, we provide validation and motivation for further growth. For example, if a patient has successfully reduced their smoking habit from 20 to 17 cigarettes per day, it is essential to acknowledge this achievement and encourage continued progress.
"Well done! It's fantastic that you've taken the first step and managed to cut down on your smoking. How would you feel about further reducing it to 15 cigarettes a day? Does that seem like an achievable goal to you?"
By recognising the patient's efforts and engaging them in a discussion about the next steps, we empower them to reflect on their progress and set attainable targets.
It is also important to inquire about the patient's desire to quit smoking entirely, as some patients may prefer quitting "cold turkey". In such cases, it is valuable to establish their readiness for this approach and offer appropriate support, e.g. through referral to a smoking cessation clinic.
#Tip 9: Praise achievements
Take One Step at a Time
Lifelong habits can take many years to break.
- Encourage patients to take small steps in the right direction.
- Small steps can make a BIG difference over time, e.g. a patient who has started to batch cook a few meals every week versus buying several takeaways will, over time, make a difference to their overall health (and finances).
- Confidence will build over time when small steps are taken.
- Don't expect to fix a person's lifelong habits in one consultation; instead, think of motivational interviewing as a journey to better health.
In Summary
- Avoid lecturing patients about lifestyle changes. This drives distance and breaks rapport with patients.
- Instead, use motivational interviewing techniques to encourage and empower patients to weigh the pros and cons of their lifestyle choices themselves.
- Encourage patients to develop their own strategies to help themselves.
- Always praise small wins and remember that making lifestyle changes takes time.
References
- Miller, W. R., Rollnick, S. (2002).Motivational Interviewing: Preparing People for Change.2nd
Edition. New York: Guilford Press - Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. Guilford Press.
- Chatterjee, R. and Bell, S. (2018) The four pillar plan : how to relax, eat, move and sleep your way to a longer, healthier life.
New Course Now Available
If you found this post useful, you might like my new OSCE course, which gives examiner guidance on the following:
- How to Prepare for OSCEs
- History Taking
- Information Giving
- Clinical Examinations
- Procedural Skills
- How to Effectively Summarise
- How to Answer Examiner Questions
- Worked Examples
