On April 22nd we held a special event at our office, inviting both practicing and aspiring dietitians to attend a presentation on Motivational Interviewing with Dr. Colleen Fairbanks, a Licensed Clinical Health Psychologist, and a champion of the MI technique.

Throughout the afternoon, participants gained a deeper understanding of Motivational Interviewing - how it can improve patient interactions and help patients achieve more profound changes and long-term success. By the end of the presentation, practitioners in attendance had a good grasp of the basic principles of MI, and left confident that they could demonstrate the skills they had learned in a health-related context, fostering patient confidence and reducing health risks.

You can watch the full presentation with Dr. Fairbanks on our YouTube channel or read on for an introduction to this powerful technique. You can also view the full slidedeck for the presentation.

What is motivational interviewing?

Motivational Interviewing is an approach to counseling first developed by clinical psychologists William Miller and Stephen Rollnick in the early 1990’s. At its core, it is a patient-centred, collaborative, and goal-oriented approach to eliciting behavior change, recognizing that,

“People are generally better persuaded by the reasons which they have themselves discovered than by those which have come in to the mind of others.” – Blaise Pascal Mathematician & Theologian (1623-1662)

The goal of Motivational Interviewing is therefore not to instruct patients about what they should do, but to develop a deep and empathetic relationship with the patient and help them explore their own motivations for change.

When do we use MI?

Motivational Interviewing is most effective when dealing with patients that are unmotivated, reluctant, or ambivalent about making changes in the best interest of their health (and we’ve all come across someone who fits this description).

The spirit of MI

The practice is more than just a set of rules for a counseling session, it’s a shift in the overall approach to the patient relationship, a spirit of treatment based on three key principles: autonomy, collaboration, and evocation.

Autonomy

In Motivational Interviewing, the patient is wholly autonomous. While the medical practitioner is there to offer support and guidance, the power to change ultimately lies with patient. Therefore, your job is to implicitly and explicitly recognize that the patient is exercising choice, and ask permission throughout the process to reinforce that the patient has both the power and the responsibility to produce change.

Collaboration

Unlike some treatment models in which the practitioner is the authority figure, Motivational Interviewing is a truly collaborative approach. The patient and practitioner build a non-authoritarian, non-judgmental partnership, founded on rapport and trust.

Evocation

The key to Motivational Interviewing is drawing out (or evoking) the patient’s own ideas, needs, and motivations, rather than having those of the practitioner imposed upon them. Determining what is important to the patient will point to a solution that is more likely to lead to success.

As Dr. Fairbanks aptly expressed, “when you’re doing Motivational Interviewing well, your encounters with patients will feel more like dancing… not wrestling.” This is a technique that fosters collaboration and empathy and reduces the chances of confrontation. A win-win for both you and your patients.

Reflective Listening: One of the Core Skills of MI

There are four key skills to Motivational Interviewing:

1. Open-ended questions where you gain an understanding of the patient’s perspective
2. Affirmation where you recognize the patient’s efforts and strengths
3. Reflection where you gain a deepening understanding of the issue and elicit more information
4. Summary where you demonstrate understanding and reinforce change talk

We’re going to take a closer look at the third point here, reflection, or Reflective Listening.

Reflective Listening is a key element to building empathy. With it, we seek to understand a speaker's idea, then offer the idea back to them, to confirm that we have correctly understood what it is that they’re trying to say. Let’s recap:

Step 1: Hear what the patient is saying.

Ex. “I know I should check my blood sugar regularly. I’m tired of feeling this way - knowing I need to do something but not doing it. The thought of checking regularly is rather unpleasant, and it’s easy to put it off. My doctor keeps telling me I need to do this, and on some level I know she’s right, but....”

Step 2: Make a “guess” at what he/she means, verbalizing this “guess” in the form of a statement.

Ex. “So you don’t want to have to continue to think about whether or not to check your blood sugar.”

The purpose is to convey your understanding of what the patient is trying to communicate so that you can confirm you’ve understood correctly.

Reflections vs. Questions

In the beginning, forming reflections can feel awkward, so Dr. Fairbanks suggests using a “stem,” or presenting the “guess” in the form of a question or proposal with intros like,

It sounds like you are not happy about...

It seems that you are having a problem with...

It sounds like you are feeling...

So you are saying that you are having trouble...

However, as you become more comfortable, both in the patient relationship and in using the technique, the stems can naturally drop away, leaving the reflection in the form of a statement and not a question. This is an important distinction because while it’s human nature to ask questions, reflections will produce more change talk (and more change), which is the ultimate goal of Motivational Interviewing.

Change Talk

Now seems like a good time to address change talk; two simple words with important meaning.

When you are speaking with a patient about behavior change, change talk is the desired response. It is “any self-expressed language that is an argument for change,” (Miller and Rollnick, 2012). It’s an indication that the patient is ready for, well, change, and it falls into five categories:

Desire: indicates a preference for change. I want to… get a handle on my diabetes.

Ability: indicates a capacity for change. I can… do that if I control my diet.

Reason: indicates a specific argument for change. I won’t have to deal with losing my eyesight if I can manage my blood sugar.

Need: indicates feeling an obligation to change. I need… to do this so I can continue living independently.

Commitment: indicates a commitment to change behavior. I will… make a schedule for my blood sugar checks and plan my meals.

One way to encourage and elicit change talk is a reflection. Another is with open-ended questions designed specifically to get patients thinking about any of the five categories. For example,

Desire:  Why do you want to make this change?

Ability: How might you go about doing it?

Reason: What are the three biggest benefits you see if you make this change?

Need: How important is this to you?

Commitment: What steps will you take today to accomplish your goal?

Of course, patients aren’t always going to dive into change talk – change is a process, a difficult one at that, and sometimes you’ll be met with resistance. When that happens, Dr. Fairbanks recommends taking a step back, acknowledging the patient’s frustration, and returning to reflections, which will help reduce resistance and foster an environment conducive to change.

Wrap Up

Ultimately, the spirit of Motivational Interviewing is to build a collaborative relationship with your patients, to meet them wherever they’re at, and to help them on their journey, but to let them lead the way. Start using your reflections, start listening to change talk, practice rolling with resistance, and soon you’ll have stronger and better patient relationships, and healthier patients, to show for it. Thank you to everyone who was able to attend the event, and for those that are getting the abridged version here, we hope you find this a helpful start.

Dietitians at Home specializes in bringing medical treatment to underserved patients and communities in the Chicagoland area.We also help support medical practitioners through education and events like this one. For more information on upcoming events, get in touch.

If you'd like to contact Dr. Colleen Fairbanks to have her speak about Motivational Interviewing at your office or facility, please contact her via email or phone.