Session 5: Motivational interviewing: unlocking the patient’s own motivation
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WHO training course for nutrition, physical activity and obesity in primary care settings
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Session 5: Motivational interviewing: unlocking the patient’s own motivation
- 1. Assess Readiness to Change Motivational interviewing: unlocking the patient’s own motivation Session 5 Acknowledgements Obesity Canada
- 2. Overview – aims • What is motivational interviewing (MI)? • Evidence to support MI. • Four guiding principles: o resisting the righting reflex o understanding and exploring the patient’s motivation o active listening o empowering the patient • Case studies
- 3. What is motivational interviewing (MI)? •MI is patient-centred counselling; it involves agenda- setting, reflective listening and shared decision- making. •MI is the opposite of finger-wagging; the aim is to explore the problem from the patient’s point of view.
- 4. MI can achieve behaviour change •MI assumes that behaviour change is stimulated by motivation rather than information. •Ambivalence to change is explored, but so are the benefits of change. •The answers lie within our patients, not us – our job is to unlock those answers.
- 5. Extensive evidence supports MI in a variety of health areas Low-intensity MI interventions are effective in many health-related areas where patient engagement is key to achieving long-term behaviour change. • Alcohol, smoking and substance abuse • Medication adherence – e.g. asthma/COPD • Cardiovascular health, hypertension, diabetes • Health promotion, dentistry, obesity, physical activity • Domestic violence, family relationships, gambling • Mental health, eating disorders For further information, see http://www.motivationalinterviewing.org
- 6. The Spirit of MI – enabling responsibility to lie with the patient rather than the doctor MI differs from the traditional “doctor assesses, then informs patient of the problem and solution”. Instead, it aims to: •collaborate with the patient to understand their perspective; •evoke – or unlock – solutions that already lie within the patient; •recognize that a patient’s personal goals, values and aspirations may differ from the health professional’s.
- 7. The four guiding principles: RULE • Resist the “righting reflex”. • Understand the patient’s own motivations by exploring feelings behind why a change is wanted and what options the patient wants to try. • Listen – actively and with empathy. • Empower the patient, encouraging hope and optimism. Develop a “guiding” style rather than a “directing” style: “How can I help you find your way?” rather than “Go that way!”
- 8. The consultation – tools • Ask open questions. • Listen by reflecting. • Help to weigh up pros and cons. • Set SMART goals. • Use a ruler “scale of 1 to 10”. • Use hypotheticals – “What might it take for you to make a choice to ...?”
- 9. Resisting the “righting reflex” • The urge to “correct” problems that patients present to us is very strong. • Yet humans naturally resist persuasion, especially if they feel ambivalent – for instance, drinkers (or teenagers!). • Even positive changes require effort – staying put is always easier than making a change. • Urging a patient to do something obviously beneficial can, paradoxically, produce more and more reasons why the change seems impossible. Doctor: “I suggest you …” Patient: “Yes, but …” “All you need to do is …”
- 10. Active listening • Key moments for active listening: o first “golden minute” o cues – points when the patient seems confused, anxious, disengaged or annoyed o moments after you ask an open question. • Listening by reflecting – reflect back a short summary of your understanding: “You feel very concerned about your weight, but you are not confident about the approaches you’ve tried.” • Work through ambivalence.
- 11. Active listening • I should … • I wish … • I want to … Help to change these phrases to: • I will
- 12. Roadblocks to listening Silence is an important part of listening. Interrupting a patient means that they have to deal with this “roadblock” before continuing with their agenda. Limit the following interruptions: • agreeing/disagreeing • instructing • questioning • warning • reasoning • sympathizing • suggesting • analysing/interpreting • persuading
- 13. Have you heard this? • “I can’t see why I need to change.” • “I can see what you mean but …” • “Just tell me what to do.” • “I really can’t cope at all.”
- 14. What we can do Be clear about expectations and minimize the risk of misunderstandings. This will: • demonstrate respect for patients; • acknowledge the patient’s autonomy; • increase engagement in treatment.
- 15. Listening by reflecting • Each reflection is a short summary statement (not question) of what is happening at that moment. • After you reflect back what the patient means (hypothesis), the patient then confirms or refutes the hypothesis. “You find it hard to exercise because of your knee pain.” – “Yes, I’m worried exercise will make it worse.” • Acknowledge the value of what you have heard. “You’ve given me a clear picture …” “That has helped me understand …”
- 16. Listen out for “change” talk and “resistance” talk • Change talk – where the patient volunteers ideas, suggestions and plans about making a change. • Resistance talk – excuses as to why solutions will not work or comments about feeling ambivalent or defeated.
- 17. Choose carefully what to reflect • Where a patient is using change talk, reflect this back to empower the patient. “You plan to choose smaller portions by using a smaller plate.” • Reflect back a patient’s ambivalence or resistance talk. This can unlock “the other side of the argument” from the patient. “Despite your weight you feel your eating habits are quite healthy.” – “Well, I suppose they are not that healthy – I have a weakness for cake at teatime.” “Your diet is mainly OK but you have some weaknesses.” – “I might try making a fruit smoothie or a piece of toast.”
- 18. Help the patient (not you) to voice arguments for behaviour change Task is to elicit change talk from patient rather than resistance talk Desire: statement about preference for change I want to… I wish… Ability: statement about capacity I could… I might be able to... Reasons: specific arguments for change I would probably feel better if… Need: statements about feeling obliged to change I ought to… I really should… Commitment: statements about likelihood of change I am going to... I will… Taking steps: statements about action This week I started… I actually went out and…
- 19. The importance and confidence rulers • Use the importance ruler to determine a patient’s level of commitment to making a proposed change. “How important would you say it is for you to make this change? On a scale from 0 to 10, where 0 is not at all important and 10 is extremely important, where would you say you are?” Use the ruler positively: “Why are you at 8, not 4?” • Use the confidence ruler to determine how confident a patient is that they will follow through on a proposed change. “And how confident are you that, if you decided to make the change, you would succeed? On the same scale from 0 to 10, where 0 is not at all confident and 10 is extremely confident, where would you say you are?” Use hypotheticals: “What might it take to go from a 7 to a 10?”
- 20. Example: using the importance and confidence rulers “You are planning to start attending the weight management group each week. On a scale of 0 to 10, how important is attending this group to you?” – “Well, I’d say it’s about an 8.” “8 tells me it is important to you, but how confident are you that you’ll make it happen? Again, use the 0 to 10 scale.” – “Hmm, that’s trickier. I sometimes get held up in the evenings. I’d say it’s more like a 6, as I’m not sure I’ll get there every week.” “As you rated it as important, what might help you make it happen regularly? How could you push that 6 up to an 8 or 9?” – “I think I just need to be organized. I sometimes get bogged down with housework when I get home from work, but the club meetings aren’t very long, so there’s no reason why I couldn’t do the chores after the meeting.” “So, because you feel it is important, you’ll do what you can to make it happen.” –“Yes, I shall start this Wednesday.”
- 21. Informing “Giving the answers” may produce little or no change in behaviour if the patient has become … •bewildered – too much information or delivered too quickly •passive – glazed over, “switched off”, bored; information seems irrelevant or too complex •highly emotional – angry, frightened, anxious •depressed or distracted – poor concentration due to depression or recent events
- 22. Make informing effective (1) Ask permission “May I make a suggestion?” This emphasizes collaboration between you and lowers resistance. Offer choices “There are several ways you could address this. Would you like me to explain some options?” Talk about what others do “In this situation other patients have found the following approach quite helpful.”
- 23. Make informing effective (2) Elicit–provide–elicit Elicit – “What would you like to know?” Provide – give information requested. Elicit – “What does this mean to you?” Beware the righting reflex Avoid making patients feel scared, humiliated, ashamed, guilty, etc. Aim to be supportive, compassionate, empathic and inspiring. What does this information mean to you? Relate what you are suggesting to the patient’s specific situation to enable their concerns to come forward.
- 24. Focusing on the impact of weight on health Question GP’s hidden agenda Patient perception Have you sensed that your weight has affected your joints? What is level of understanding re inflammatory properties of adipose tissue? Understanding my condition better may help me to help myself. Were you aware of the link between weight and periods? ... diabetes? ... sleep apnoea? Weight loss may be the best treatment option, so I want the patient to feel positive. I didn’t realize the solution may lie with me. What things have you tried to improve your lifestyle? What are the lifestyle priorities for this patient? I might mention I gained weight after I stopped smoking. We know weight can affect the safety of doing an operation – has anyone talked to you about this? How can I gently broach the fact that you are unfit for an operation? Understanding the health risks can help me make the right decision about surgery.
- 25. OARS summarizes the overall approachO Open questions questions that encourage patients to think before answering and allow a choice in how to respond A Affirm acknowledge patient’s efforts, strengths and volitional choice R Reflective listening capture patient’s meaning S Summarize pull together what’s been said
- 26. Exercises: unlocking the patient’s own motivation Split into pairs Exercise C1: Importance and confidence rulers Role play: try using the importance and confidence rulers to challenge Mrs A’s sustain talk in the examples in your workbook. Exercise C2: Reflecting back sustain talk Read the example of how reflecting back, or restating, the patient’s sustain talk – rather than offering your own solution – can create a space for the patient to present their own solution. Role play: try the examples given to see if you can unlock change talk from the patient.
- 27. Your future practice Please consider your future practice. • How will you balance active listening and empathy with the time constraints of a busy practice? • Do you have personal examples of utilizing the various styles of motivational interviewing (following, guiding, directing)? If so, please discuss.
- 28. Might a health professional’s own shape affect confidence when they mention weight?
- 29. Can slim people have any idea of what fighting obesity is really like? Could a health professional with obesity have credibility in recommending weight loss to another person?
- 30. Does our own shape actually matter? • Self-help support groups run by fellow sufferers are often the most successful formats of all – there is nothing like personal experience to aid empathy. • Understanding a patient’s perspective can come from active listening – it does not necessarily need to be experienced. Answer – Not if our aim is to help patients explore their own goals.
- 31. Group discussion questions • What is it like living with obesity or a chronic condition? (patient experiences) • Do weight bias and stigma affect health outcomes and quality of care?
Notas del editor
- Speaker notes In this session we will provide an overview of obesity as a chronic disease and outline causes and consequences.
- Speaker notes MI involves a quite subtle change in the way we question our patients; the aim is to elicit reasons and intentions for behaviour change from patients themselves, rather than using the more familiar approach of giving advice. Telling someone what to do does not mean that they will do it, however logical the advice or earnest our pleas to make the change.
- Speaker notes Just telling people what to do does not work. “Go and lose weight!” will not help anyone. What we want to explore is: “What is stopping you from making the change that you want to make?” Then: “Can I help you overcome that barrier?”
- Speaker notes It takes effort to make any change – even positive ones. It is easier to just tick along and put up with all the troubles around us. If we can unlock the motivation within someone, then they will be able to make use of whatever supportive information is available. But without that vital motivation to change, then any amount of information, fear, threat or encouragement will fail to induce change. The question should be: “What do you think you can do about it?” Not: “This is what I think you ought to do about it.”
- Speaker notes MI is valuable as a technique because it is a generic skill that can be applied to any number of topics where patient motivation is key to behaviour change. However, it is a subtle skill that requires practice because it involves stepping back from “stating the obvious” approach that we were traditionally trained to use. This session gives an introduction to the techniques. Further experience, reading and/or training would be required to become proficient in bringing this type of approach into regular patient discussions.
- Speaker notes Without listening carefully, it is easy to imagine that our patients want the same things as we do. However, not only might our aspirations differ markedly, but the enablers and barriers that influence our choices may differ also. The variation in tolerance of poor health, symptoms, risk and uncertainty is as great as the variation in people themselves. Very few people are aiming for “perfect”, so we should start by understanding what our patient’s concept of “something less than perfect” might be.
- peaker notes MI uses lots of acronyms! The RULE acronym sums up how MI encourages us to stand beside our patients to understand their perspective and what goals they may feasibly wish to explore – rather than confronting them with our own wise words of advice. We will look at each point in turn.
- Speaker notes MI has a set of “tools”. Again, some are quite subtle, and we may have already used (some of) them in other situations. SMART goals are Specific, Measurable, Achievable, Relevant and Time-bound (or Time-limited).
- Speaker notes Traditionally, our role as health workers is simple: the patient tells us what the problem is, we tell the patient what the answer is. Yet – particularly for behaviours that generate immediate pleasure or reward, such as eating, smoking, alcohol consumption and TV viewing – information on risk is a weak driver of behaviour change. The longer-term the gain (“if you do this now, you will benefit in 20 years’ time”), the weaker its ability to drive behaviour change. Try telling a teenager to clean their bedroom! What lengths might a parent have to go to, to achieve compliance: bribes? threats? arguments? screaming fits? throwing things? violence? Where the gain appears small or – to a teenager – completely invisible, the chance of achieving compliance is small or remote. “If you’re so bothered, then do it yourself!” By resisting the righting reflex – by avoiding the “if that’s the problem, then here’s the answer” type of response – we can hopefully avoid the common “Yes, but …” response, which signals the tendency to give more and more reasons why solutions won’t work. Think about the patient’s psychology: “Not only have I had to admit I have a problem and you smugly have all the answers – but now you’re telling me I’ve got to do it your way? Not a chance!”
- Speaker notes Active listening is much more than showing that you are giving your full attention to the patient – it is a process whereby the patient is helped to listen to themselves. The first moments (“golden minute”) of a consultation are particularly important to establish rapport, trust and set the tone of the conversation Silence is a very important tool – allowing the patient time to convey what is important. Pick up on cues – points of hesitation or doubt, or changes in body language, that might indicate that there is more to the story than the patient has so far conveyed. The point of “reflecting back” a short summary of what has been said is that the patient has an opportunity to “hear” what might have been quite a jumbled accumulation of thoughts.
- Speaker notes Active listening: when you hear your patient say phrases such as “I should” and “I wish”, how can you support and encourage them to change to “I will”?
- Speaker notes Even positive and supportive comments and interruptions can interfere with the flow of the patient’s story – or prevent emergence of those points of hesitation that sometimes indicate what the real sticking points are. Being silent can take practice!
- Speaker notes “I can’t see why I need to change”: often, when health professionals hear this statement, they assume that the patient is in denial. It is important to reflect on this, however, because the literature suggests that health professionals do tend to assume that the patient is in denial. They have an unproductive tendency to blame the patient, but it is important to bear in mind that denial is a response that people have when they feel under pressure – it is a natural human tendency. “I can see what you mean but …”: this may indicate that the patient is not sure about making a change. This suggests that there may be an opportunity to explore the area a bit more with the patient. “Just tell me what to do”: traditionally, people have the expectation that we are the experts and that we should be telling them what they should be doing. Sometimes, this can be appropriate in the context of a therapeutic relationship, but again it is always important to ask: “But how would that work for you?” “I really can’t cope at all”: this is a red flag indicating that the individual is feeling overwhelmed, so it is important to step back and see where the place of readiness is. Maybe the patient is not ready to embark on a particular stage? What is going on in their lives? Are there lots of barriers in their lives?
- Speaker notes Be clear about our roles and expectations of what services we can and cannot provide. A patient often arrives with traditional expectations about receiving some kind of treatment, but it is important to clarify that treatment involves lifestyle modification/behaviour change and requires their active participation.
- Speaker notes The first benefit of listening by reflecting is the chance to reflect back summary statements – not questions – that the patient can then either agree with or correct. This enables the patient to expand on their concern – to get to the nub of the problem. So: First, the patient has given an unstructured outline of the problem. Second, you have pulled together a summary statement of the main issue. Third, the patient has agreed that this sums up the main issue and expanded on why this is important; or the patient realizes that this is not exactly what the concern is and is able to correct the focus of the discussion. For example: Reflection: “You find it hard to exercise because of your knee pain.” Response: “Well, no, not my knee pain exactly. All my joints hurt in fact. I suppose what I am really worried about is that exercise might cause a heart attack – that’s what happened to my father. I think the knee pain just gives me an excuse not to do too much.”
- Speaker notes Reflecting back change talk is a good way to endorse your patient’s commitment to change. “You are going to alter your routine by parking in a more distant carpark and walking a bit further to your office.” This invites agreement – and perhaps embellishment – from the patient. “Yes, I think a bit of fresh air might perk me up for the day.” But an even bigger benefit of listening by reflecting is the ability to reflect back ambivalence or resistance talk. This helps patients to “hear themselves”, which then encourages them to respond to their own suggestion rather than responding to yours. Instead of saying “Yes, but …” to your constructive suggestion, they are saying “Yes, but …” to their own ambivalence.
- Speaker notes In order to elicit these sorts of response, we can see that our aim is to ask the patient for ideas – rather than simply giving the information ourselves. Hence, in response to your statement “We know that being active is beneficial for arthritis”, rather than continuing with obvious suggestions such as “I would recommend that you try to walk more/join a dance club/try swimming”, try prompting the patient to provide suggestions: “We know that being active is beneficial for arthritis … … How important does physical activity feel to you?” … How feasible would it be for you to be more active?” … Is physical activity something you have considered?”
- Speaker notes Assessing importance is one of the key factors when homing in on motivation. We are simply not going to make a big effort to achieve things that don’t seem important. Use the importance ruler to build commitment to suggested changes. By reflecting the patient’s stated view of its importance, and then double-checking by assessing how confident they are that it will happen, you are confirming the degree to which the patient has signed up to this change.
- Speaker notes You could read out this case scenario with someone else playing the part of the patient.
- Speaker notes Sometimes, despite our best consultation skills, the conversation does not seem to flow. Why not? Consider whether any of the factors listed here might apply to your patient. Depression will commonly affect concentration and confidence in setting personal goals. Is weight management the top priority right now? Sometimes it is better to put the topic on hold and come back to it when the patient feels in the right frame of mind.
- Speaker notes Rather than “giving the answers”, we are aiming to elicit patient-generated answers. But what if the patient has drawn a blank and really does not know what to suggest? Informing then becomes relevant and helpful – as long as we do not create the “Yes, but …” scenario. The suggestions here can help you arm the patient with ideas that they can pick up and run with. (Analogy: instead of dressing the person, you are showing them a wardrobe for them to choose what to wear.) Use of the third person “People find that …” rather than the first person “You could/should …” – this makes it less likely that the “Yes, but …” response materializes. Sensing that there is a choice is always a good starter for engagement. But importantly, the conversation should progress to exploring those choices in order to commit to a decision. “There are lots of things you could do. Shall we explore what are you actually going to do?”
- Speaker notes One way to explore how the patient is weighing up the suggestions you have mentioned is to use the elicit–provide–elicit concept. Double-check after setting out your suggestions: “What does this mean to you?” Remind yourself to avoid emotive reasons for change. Consider the individual circumstances that your patient is in, especially when exploring confidence and feasibility of the suggested changes. For example, might childcare needs, working patterns, transport issues, financial constraints or disability limitations have an impact on the feasibility of some potential choices?
- Speaker notes One of the reasons you may be discussing weight or activity levels is because of the presenting condition of your patient. It may be important to discuss that weight control or increased activity might improve their condition. Ensure that factual information is provided without burdening the patient with a sense of guilt or blame for their condition. Use the third person to convey facts and explain links between conditions: “People with diabetes will find that …” “Studies show that …” Discussing the relevance of a person’s weight to their anaesthetic risk or benefit from potential surgery (e.g. knee replacement) may be very valuable in helping the patient to understand the risks involved and to get a sense of how they can personally take steps to reduce that risk by improving health pre-operatively.
- Speaker notes This acronym neatly sums up the approach. Remember that silence is a valuable tool. Check out how important change is and explore what degree of confidence the patient has in achieving it. Use reflective listening both to show that you are listening and to help the patient listen to their own viewpoint. Pull the discussion together by affirming the intentions the patient has suggested.
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- Speaker notes This is recognized as an increasingly important issue. Health workers share roughly the same weight range statistics as the rest of the population, which means that a significant number of health professionals are overweight or obese.
- Speaker notes Ask the group for their views. Ask for a show of hands: Who thinks that an obese health worker would find it difficult to give credible weight management advice? Who thinks that slim health workers have a bit of a nerve telling overweight patients how to live?
- Speaker notes If we were out to lecture or wag a finger at our patients, then we could expect trouble! However, far from wishing to confront our patients, an effective conversation involves walking alongside our patients to see their viewpoint, trying to understand their issues from their perspective and doing what we can to help them find their way. Acknowledging our own weight may be helpful and does not require anything more than a glancing comment to convey a shared understanding. Examples might include: “I know just how it feels”; “You can see I am fighting the same thing”; “It’s a real struggle, I know”. To move the conversation straight back to the patient, and away from the health professional, ask about importance. “How important is your weight to you at the moment?”
- Speaker notes Explore the group’s views on these questions. Living with obesity. Consider: furniture – e.g. hospital bed size has increased, now catering for patients weighing up to 285 kg (previously around 150 kg) transport bullying work opportunities daily symptoms – breathlessness, pain, hunger, sense of shame, depression Weight bias and health care. Consider: blame rudeness disgust pity lack of understanding rationing of health care due to weight How can we address this?