Motivational interviewing

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How best to do itStep 1: practise the guiding styleAmong the broad communication styles commonly used to address patients’ problems are directing, guiding, and following.2 Although each is appropriate to certain situations in everyday practice, a guiding style is best suited to consultations about change. When this topic comes up, shift your stance from that of a director to that of a well informed guide, and follow three principles: engage with and work in collaboration with patients, emphasise their autonomy over decision making, and elicit their motivation for change. You retain control over the direction and structure of the consultation and provide information as needed, but you ensure that your patients retain responsibility for change. Box 1 shows the contrast in styles between directing and guiding.Box 1 Contrasting styles Directing style: “OK, so your weight is putting your health at serous risk. You already have early diabetes. (Patient often resists at this point.) . . . Overweight is conceptually very simple, if you think about it. Too much in, not enough out. So you need to eat less and exercise more. There no way you can get around that simple fact.” (Patient replies with a “yes, but . . .” argument.)Guiding style: “OK, let’s have a look at this together and see what you think. From my side, losing some weight and getting more exercise will help your diabetes and your health, but what feels right for you? (Patient often expresses ambivalence at this point.) . . . So you can see the value of these things, but you struggle to see how you can succeed at this point in time. OK. It’s up to you to decide when and how to make any changes. I wonder, what sort of small changes might make sense to you? (Patient says how change might be possible.)Use three core skills—asking, listening, and informing—in the service of this guiding style to draw out your patients’ ideas and solutions.2 This shows that you want to know about and respect their ability to make sound decisions. “Ask” open ended questions—invite the patient to consider how and why they might change; “Listen” to understand your patient’s experience—“capture” their account with brief summaries or reflective listening statements such as “quitting smoking feels beyond you at the moment”; these express empathy, encourage the patient to elaborate, and are often the best way to respond to resistance; “Inform”—by asking permission to provide information, and then asking what the implications might be for the patient. Once you have practised these three skills, and once you feel comfortable with the shift from director to guide, you can add to your toolbox a set of strategies containing specific questions that are suited to different circumstances.Step 2: add useful strategies to your toolboxMotivational interviewing aims to elicit the motivation to change from the patient, rather than to try to instil this in them; it also aims to work with their strengths rather than just talk about problems and weaknesses. Different strategies are available to achieve these aims in a guiding style, eliciting the what, why, and how of change from the patient. This “menu of strategies”4 has been used successfully among college students to reduce use of alcohol, tobacco, and cannabis.5Agenda setting (what to change?)Patients often face more than one option for change. In agenda setting, rather than impose your priority on patients, you conduct an overview by inviting them to select an issue or behaviour that they are most ready and able to tackle, feeling free also to express your own views.2 For example, to reach agreement about what to deal with in the consultation you might say: “That’s very helpful. Are you more ready to focus on eating or on increased activity? Or is there some other topic that you would prefer to talk about? I’d like to talk about those test results at some point, but what makes sense to you right now?”Pros and cons (why change?)It is normal and common for patients to feel in two minds about both the status quo and change. It can be helpful to invite them to say how they see the pros and cons of a situation. Then your next step is to ask them to clarify whether change is a possibility (box 2).Box 2 Seeing the pros and cons “I want to try to understand your smoking better from your perspective, both the benefits for you and the drawbacks. Can I ask you firstly what you like about your smoking?” (Patient responds. Use your curiosity to elicit a good understanding.)“Now can I ask you what you don’t like about your smoking?” (Patient responds. Remember it’s their experience that counts, so avoid offering your perspective for the time being.)(Then you summarise both sides, as briefly as possible, capturing the words and phrases that the patient came up with.) “OK, so let’s see if I have this right? You like the fact that smoking helps you unwind and, addicted or not, you like that first smoke in the morning. On the other hand, your main concern is about its effect on your health. Is that about right? OK.” (Then you invite the patient to consider the next step.) “So where does that leave you now?” (Patient usually describes readiness and any need for advice or information.)Assess importance (why) and confidence (how)To be efficient you need to spend time where it is most needed. Those who are not convinced of the importance of change are unlikely to benefit from advice about how to change, and a focus on the why of change is pointless if the main issue is how to achieve it. This focused strategy (box 3) has produced successful outcomes in the smoking field,6 where a recent review also provides support for the efficacy of motivational interviewing.7Box 3 Assessing importance and...

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