Motivational Interviewing: Encouraging Healthy Behavior Change
Perhaps when you think of motivational speakers, famous individuals like Zig Ziglar, Tony Robbins, and Simon Sinek come to mind, or it could be inspiring individuals with a disability, like Nicholas Vujicic and Amy Purdy. Maybe you remember the aggressive style of Chris Farley's Saturday Night Live character, Matt Foley, who lectured his listeners about the dangers of making bad decisions and delivered his signature warning that they might end up like him, living in a van down by the river. As a parody, Farley's character deliberately exaggerated some common features and perceptions of motivational speaking—that it is a motivational speaker's job to convince others to think or act a certain way, through rational arguments, information, inspirational stories, emotional appeals, and warnings.
One approach to motivation assumes that people primarily need to be convinced in favor of a desired action, and that one of the best ways to do so is to present rational arguments. The assumption is that the pressure applied using these rhetorical tools will result in action. However, ample evidence in our common experience shows that this is not the case. Cognitive acquiescence does not automatically result in behavior change. For example, it is likely that most people who smoke have heard and even understand the rational arguments in favor of smoking cessation and the warnings about the long-term negative health consequences of continuing the habit. Yet, many continue to smoke. The common strategies of motivation often have little effect when a significant behavior change is required.
When used properly, the O&P devices we provide are likely to reduce pain, prevent deformity, improve mobility, and improve the quality of life of individuals we care for. A significant aspect of clinical care involves educating our patients about health-promoting activities and healthy habits, which often require a change in specific behaviors. When patients do not take our advice or disregard the education we provide, we often adopt the aforementioned strategies to convince our patients to comply with our recommendations.
This article describes the perspectives and principles related to a different approach to these encounters, motivational interviewing (MI), based on information from the book Motivational Interviewing in Health Care by Rollnick, Miller, and Butler. Additional resources on this topic can be found at the end of this article.
Three Communication Styles
When we are in a discussion with someone who is making a difficult decision, we can adopt several different attitudes or approaches. One approach is to listen and refrain from offering ideas, input, or suggestions. In doing this, we follow the person's lead and allow him or her to independently navigate the decision-making process. On the other end of the spectrum, we can assertively offer our opinions and insights, and advise the person what decision or action should be taken. In this approach, we direct the person, counting on him or her to respond by following our advice when making the decision. A third approach lies between these two extremes: We listen carefully and selectively give input and offer suggestions at key points in the discussion.
Clinical encounters involve all three of these communication styles. There are times when we listen without voicing our opinions (e.g., when patients respond to questions during an initial assessment), when we provide clear and specific directives (e.g., when giving wear and care instructions at delivery), or when we guide our patients through a decision-making process using a combination of these techniques (e.g., when helping them make decisions regarding optional design features of an orthosis or prosthesis). According to Rollnick et al., medical professionals rely too heavily on directing. We may take this approach because we view ourselves as experts in a clinical area, and patients have come to us to benefit from this expertise. We also have an ethical responsibility to provide certain information and instructions to patients. Additionally, reimbursement pressures may influence us to complete encounters more quickly by jumping to communicating information and instructions.
We cannot make decisions for our patients or force them to change their behaviors. We also have an obligation to affirm patients' rights to make their own decisions, even if our knowledge indicates that a different decision would be more beneficial to their health. MI takes a guiding approach to influencing behavior changes. The focus is on recognizing patients' levels of motivation to change behavior, their arguments in favor of that behavior change, and using specific skills to guide them toward the decision that we agree is most beneficial. A tour guide does not determine the clients' destinations, but rather helps them achieve goals or experiences that they have decided are important to them. Likewise, a clinician using MI listens for arguments the patients make on their own for appropriate choices or behaviors, and then skillfully encourages those tendencies.
All, Nothing, or Some
If patients express their own arguments for actions, why would practitioners need to influence them in that direction? Once the desire and willingness to change has been expressed, for example, committing to complying with an infant's remolding orthosis wear schedule or increased prosthesis use, isn't the motivational job finished? If we are to be effective in influencing behavior change, it is important to understand the concept of ambivalence. We often view motivation as all or nothing—someone is either motivated or not. If someone is motivated, he or she will change, and if not, the behavior remains the same.
However, most of us have mixed feelings, or ambivalence, about some of the most important decisions we make. As an example, it is likely that someone who smokes feels both the desire to stop smoking and the desire to continue smoking. Additionally, he or she may want to stop but has little confidence about the likelihood of success because of past failed cessation attempts. Similarly, a parent can recognize the importance of his or her child wearing a remolding orthosis and the strong pull to avoid uncomfortable situations with the child. Or a transfemoral prosthesis user may recognize the value of gait training and yet resist participation because of the hard work involved.
One of the keys of MI is to guide clients in understanding their ambivalence. For instance, a patient may understand and agree that wearing an orthosis designed to prevent contractures is important but lacks confidence in the ability to don the orthosis independently. Another may be confident about the ability to use a prosthesis correctly but does not consider it important enough to go through the hassle compared to using a mobility scooter. By listening closely, practitioners can identify where their patients fall on the importance and confidence spectrums.
Recognizing the patient's ambivalence can allow the practitioner to guide the patient carefully in a healthy direction. This can be done by asking the patient, "On a scale of one to ten, with ten being completely important and one being not important at all, how important is it to you to wear your prosthesis?" If the response is an importance of five, the tendency is to ask why it is not rated higher and then provide reasons why the patient should consider this a more important issue. By responding in this manner, however, we are asking the patient to provide an argument that supports not wearing the prosthesis.
One of the most powerful aspects of the MI process is that the MI practitioner instead asks the patient, "Why didn't you say two or three?" When the patient answers this question, he or she is giving reasons why wearing the prosthesis is important. In taking the latter approach, the practitioner creates a situation in which patients are hearing themselves give reasons for engaging in healthy behaviors. We tend to believe what we hear ourselves say, and with this approach, patients provide their own arguments for the desired change rather than thinking of arguments against the practitioners' recommendations.
As clinicians, we should strive to perfect the skills of providing information and educating our patients effectively. There is something gratifying about giving our patients good information and advice. It is even more gratifying to guide our patients to make healthy decisions based on their own motivations and to see their lives improve as a result. We cannot force patients to change their behaviors. For some patients, lack of self-care may have contributed to the condition that resulted in requiring O&P services.
The effectiveness of reason and logic is limited when convincing someone to change an established lifestyle or accept the challenges of living with an assistive device. It is unlikely that we will find the right words to convince him or her to change habits formed over a lifetime. The good news is that we don't need to perfect the skills of motivational speakers. We can, however, influence our patients in the right direction and encourage them to act on their best impulses. The principles and techniques of MI strengthen the clinical partnership between the practitioner and patient and increase the likelihood that our patients will make healthy choices.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
1. Rollnick, S., W. R. Miller, and C. C. Butler. 2008. Motivational interviewing in health care: Helping patients change behavior. New York: Guilford Press.
2. Motivational Interviewing Network of Trainers. http://www.motivationalinterviewing.org/
THE ACRONYM RULE IDENTIFIES FOUR PRINCIPLES THAT ARE FOUNDATIONAL TO MI. EACH PRINCIPLE HONORS THE AGENCY OF THE INDIVIDUAL BY AFFIRMING THE RIGHT TO MAKE CHOICES AND ACT BASED ON THOSE DECISIONS.
Resist the Righting Reflex
Human beings naturally resist persuasion— when someone tries to convince us of an opinion, we tend to provide arguments for our own. When someone is giving reasons for not wanting to do something, we tend to respond by giving reasons in favor of that action. This sets up a series of back-and- forth arguments that simply reinforce the person's resistance to change. The goal of MI is to help the patient express his or her own reasons for making a healthy decision, not reasons for making an unhealthy one.
Understand the Patient's Motivation
The defining element in the patient's behavior change is his or her level of motivation, not ours. Our focus must first be on determining how motivated the patient is, rather than on how we can motivate the patient.
Listen to Your Patient
Our focus must be on hearing the patient by using a variety of listening skills, rather than primarily giving information. If we do this, the information we eventually give will have more impact because it addresses the patient's specific needs and perspectives.
Empower Your PatientA skillful practitioner will reinforce and strengthen a patient's belief that change is possible, and will guide him or her to act on the belief. The goal is to improve the patient's life, not simply to get through a list of instructions consistent with our professional responsibilities.
FOUR SKILLS, REPRESENTED BY THE ACRONYM OARS, ARE CENTRAL TO MI. INCORPORATING THESE SKILLS INTO PRACTICE WILL IMPROVE COMMUNICATION. USING THEM AS PART OF A HOLISTIC MI APPROACH HAS THE POTENTIAL TO TRANSFORM RELATIONSHIPS WITH PATIENTS AND EMPOWER THEM TO ACT ON HEALTHY DECISIONS.
Open-ended questions are intended to draw a patient out rather than to get a specific answer. Asking closed-ended questions (i.e., those that require only yes/no or other simple answers) leaves the practitioner in charge of the interaction. Open-ended questions allow the patient to expand on his or her thoughts. Compare these two questions and the likely results in each case:
Practitioner: How long do you wear your prosthesis each day?
Patient: Four hours.
Practitioner: Can you tell me a little about how often you wear your prosthesis?
Patient: I usually put it on in the morning, but it's hard to drive when I'm wearing it, so I take it off anytime I go somewhere.
The patient may have made a good estimation of wear time in response to the first question. However, the response to the second question gives the practitioner better information about what might influence the wear pattern.
Most of us respond positively to encouraging input and resist correction. Correcting a patient when a negative belief is expressed or something is being done incorrectly does little to support him or her in making the right decisions. It also creates a defensive situation in which the patient is likely to respond by justifying the behavior. On the other hand, making comments that recognize and acknowledge positive steps the patient has taken encourages more of those steps and builds confidence.
Perhaps the most difficult skill to master is simply repeating back to the patient what we have heard. At times this seems counterproductive, but doing so not only helps the practitioner and patient confirm they are on the same page, it also provides a way for the patient to continue to say more without the practitioner getting in the way by asking a follow-up question. Reflecting statements of resistance or statements indicating the patient's level of confidence and importance allows the patient to continue to share these issues without feeling pushed in a particular direction by more questions from the practitioner. Reflections can be simple repetitions, paraphrasing, or reflections of feelings, and each can be used effectively at different points in the encounter.
Summarizing what a patient has said is a helpful way to confirm with the patient that he or she has been heard correctly and clears up any misunderstandings. This can also help to smooth transitions between important aspects of the encounter.