Sustaining long-term behaviour change is a challenge for many people with cardiac disease. Individuals need to not only understand the importance of lifestyle changes, but they need to also build the confidence to make and sustain such changes.
Motivational interviewing (MI) is a means of assisting people with a chronic disease to improve their lifestyle and self-management and to sustain the changes that they make. [#fisher-eb-brownson-ca-otoole-ml-et-al.-2005,#clark-m-hampson-se.-2001,#scales-r-miller-jh.-2003] Using a collaborative and respectful approach, the individual is assisted to explore their personal values and motivators of change. They are then empowered to strengthen their motivation and move towards change by exploring and resolving ambivalence. Motivational interviewing now has a strong evidence base for assisting people to change a variety of health behaviours such as smoking, exercise, diet and drinking.
Are you finding some patients are reluctant to change their behaviour? How much time you spend discussing with the patient how important change is to them?
How much time do you spend building confidence that they can change?
Key to motivational interviewing is creating a relationship with the patient. The motivational interviewing spirit focuses on: [#coull-aj-taylor-vh-elton-r-et-al.-2004,#miller-wr-rollnick-s]
- Expressing empathy through respectful communication
- Developing two minds (raising awareness of ambivalence)
- Avoiding any arguing (ask, not tell)
- Not pushing; rolling with resistance
- Increasing the individual’s confidence (self-efficacy)
Through motivational interviewing, clinicians are able to assist individuals to identify their goals and values and how these factors may influence their lifestyle choices. This process is achieved by helping patients to verbalise personal arguments or motivators for change that are specific for them. Key components of this “change talk” are listed in the table below. Clinicians should listen out for these in order to structure the interview effectively.
Table 1: Listening for change talk
|Desire for change
Relates to things the individual would like to change.
Eg. “ I would really like to exercise more”
|Ability to change
Relates to how the individual might act on the plan to change and strategies that might be used. The clinician may evoke the individual’s thoughts and ideas to help formulate an action plan.
Eg “ I think if I could find somewhere flat to walk, I would exercise more often”
|Reasons for change
Relates to the individual’s reasons and motivation for changing.
Eg “ I think if I exercised more I might find it easier to lose weight”
|Need for change
Relates to why the change is important or why it matters? This often reflects the individual’s personal values.
Eg “ I need to improve my health so I can have more energy to play with my kids. Maybe then I would be a better father”
|Commitment to change
Relates to how strong the commitment to change is. Commitment language often predicts the likelihood of action.
Eg “ This is really important to me. I am going to start this afternoon by driving to the park down the road and walking for 15 minutes”
Core skills that clinicians should integrate into consultations for effective motivational interviewing include the following:
- Ask open questions
- Use affirmations
- Use reflections
The table below provides examples of how clinicians may use the core skills listed above to evoke “change talk” during the interview.
Table 2: Motivational interviewing core clinician skills
||Example questions or comments
|Ask open questions
||“What would you like to change about your diet?”
||“If you did decide to change your diet, how would you go about it?”
||“What are your 3 biggest reasons for making this change?”
Scaling questions helps to determine importance and confidence
“On a scale of 1-100, how important is it for you to make this change?” “What makes it important to you?”
“What makes you give yourself a “(insert number given as answer above)” and not 0?”
||“What will you do next about changing your diet?”
Goals and values
These questions enable discrepancies to be identified
“What is important to you as a parent/ teacher/ daughter?”
“How does your current diet fit in with that?”
Affirmations can be aligned with goals and values to assist the patient to argue for change
“It sounds like you know a lot about the benefits of eating a healthy diet?”
“Last Saturday when you had no alcoholic drinks for the day, that was you being a responsible father.”
||Reflections involve restating things that the patient may have just said and can be simple or complex. Complex reflections usually involve the clinician offering a suggestion of how the patient may feel as in the example given. In this way the clinician expresses empathy and assists the individual to continue talking.
Patient: “I’m really worried about exercising because I might have another heart attack.”
Clinician: “It must be frightening when you remember back to how you felt when you had your heart attack”
Patient: “Yes, it makes me want to avoid exercising, even though I know it is probably good for me.”
Clinician: “By going to the shopping centre last week, that was you starting to do more activity in a very safe way.”
Giving advice is important for clinicians but it can also be challenging. Despite good intentions, clinicians often instruct patients about what to do, thus creating a hierarchical relationship. This approach unfortunately often evokes resistance. Giving advice in a manner that works collaboratively with the patient and is therefore less likely to evoke resistance, is often more successful. One example of this is an “ask tell ask” approach such as listed below.
- Ask what the patient knows already – “What do you know about smoking and heart disease?”
- Ask permission – “Is it OK if I tell you a few things about what I know (about smoking and heart disease)?”
- After giving advice, check in by asking – “how does that information (about smoking) sit with you?”
Underpinning motivational interviewing, is that the patient, rather than the clinician needs to make the argument for change. The clinician’s role, in the context of a safe therapeutic relationship is to help the patient to navigate between their own arguments for change and arguments against change. Using careful listening skills the clinician validates and accepts the patient’s arguments against change (sustain talk) and then gently guides them towards considering their arguments towards change (change talk), thereby helping them to elaborate and build this case for change.
Next time you are with a patient, consider these 3 simple tips:
Tips for successful motivational interviewing
- Try to do more listening than speaking. Try speaking for <50% of the total talk time of the interview.
- Try to use more reflections than questions. Avoid the interview feeling like an interrogation for the patient by using twice as many reflections or every question.
- Try to ask mainly open questions. A few closed questions are OK but aim for open questions being >70% of all questions
For further information about motivational interviewing, refer to: www.MIoceania.org or Motivational interviewing.org
A limited supply of Motivational Interviewing kits (including practical CDs) is available from the National Heart Foundation of Australia.