Motivational interviewing (MI) is a very popular and flexible modality to help enhance communication between patients and physicians and medical staff. It is widely utilized across health behaviors, settings and disciplines and can help boost motivation or increase positive outcomes in the brief interactions between physicians and patients during an appointment.
In a recent Grand Rounds lecture at CHOC, Dr. Sharonne Herbert, belonging, diversity, equity and inclusion (BDEI) officer at CHOC, explains how physicians can use motivational interviewing techniques to help their patients make positive changes in their lives.
Take on the spirit of motivational interviewing
MI is an evidence-based collaborative, goal-oriented method of communication for strengthening intrinsic motivation for change, says Dr. Herbert.
However, motivational interviewing is more than utilizing a set of communication techniques; it is a spirit that physicians and medical staff can take on as a “way of being” with their patients.
There are four key elements of the spirit of MI:
- Partnership: When a physician walks into a room, they have the authority. However, they’ll need to find a way to power share with their patients. Although they have medical knowledge, the patients know themselves and their health. “Physicians should take on the notion, ‘If you take a step forward, I go with you. If you step back, so do I,’ with their patients,” says Dr. Herbert.
- Acceptance: Give patients affirmations, empathy and autonomy. Physicians should find ways to emphasize and promote their ability to care for themselves.
- Compassion: Put the patient’s welfare first.
- Evocation: Ask questions in an open-ended way to get as much information as possible so physicians can find the best way to help.
Practice cultural humility
Cultural humility is a life-long process of self-reflection, self-critique, continual assessment of power imbalances and the development of mutually respectful relationships and partnerships. It is vital to enhancing physician-patient communication, says Dr. Herbert.
For physicians, practicing cultural humility shifts the focus from trying to understand other people to trying to understand themselves. They must acknowledge that their perspective may be full of assumptions and prejudices, which can hinder their ability to practice effective motivational interviewing.
The core of the process of cultural humility is to practice deliberately reflecting on one’s values and mindbugs (biases).
Recognize change talk
Change talk, or a person’s statement that displays a desire for change, can be remembered by the acronym DARN-C.
The first part of the acronym refers to preparatory language and includes:
- Desire. A wanting, wishing or willingness for change. For example, the patient may say phrases like:
- “I really wish I could cut down”
- “Part of me wants to change this.”
- Ability. Personal perceptions of capability or possibility of change. This might signify that the patient has had success in the past with statements like:
- “I’m positive that I could quit.”
- “I can do it.”
- “I have done it in the past.”
- Reasons. A particular rationale, basis, incentive or motive for change, like:
- “I’m sort of embarrassed when I can’t handle this on my own.”
- Need. A necessity, urgency or requirement for change, like:
- “I probably need to do something about the people I hang around.”
- “I guess I need to be safer.”
The “C” in Darn-C refers to a commitment statement, which will be necessary to elicit change, like:
- Commitment. An agreement, intention, or obligation to change, like:
- “I am prepared to stop _____.”
- “I intend to change.”
Reinforce change talk
“Reflections of change talk leads to more change talk!” Says Dr. Herbert. With thoughtful responses to patients’ change talk, physicians can encourage more change talk and real change.
There are two types of change talk reflections. Simple reflections stay surface level and complex reflections add something to the reflection.
A simple reflection from a physician can help lead to real change. For example:
- Patient change talk: “I know I have to turn in all this confusing paperwork, but sometimes, I just don’t want to think about it.”
- Physician reflects on change talk: “Even though the paperwork is confusing sometimes, you still try to make it a top priority to fill out.”
- Patient change talk: “Yeah. I mean, I want to get some help. I just wish it wasn’t so much to fill out.”
Physicians can repeat all or part of a change talk statement or paraphrase or slightly reword a change talk statement. For example,
- Patient change talk: “I know I should cut back on drinking and smoking and maybe some things would be different, but honestly, I don’t really see the problem.”
- Physician’s response: “You know you should cut back.” Or they can paraphrase, “You already know what you need to do.”
A complex reflection, or when a physician adds to a reflection, can be another way to help influence change in a patient’s life. For example:
“I know I should cut back on drinking and smoking, and maybe something would be different, but honestly I really don’t see it as a problem all the time.”
Four types of complex reflections
|Implication: Continuing the story, adding interpretation but staying close to the client’s statement.||“Your health is really important to you.”|
|Double-sided: Reflects ambivalence but ends with emphasizing change talk.||“On one hand, you don’t think there is an issue with your drinking and smoking, and on the other hand you wish some things were different.”|
|Feeling: Reflects positive emotion about change (or negative emotion about not changing).||Positive feelings about changing: “You would feel better if a few things changed around drinking and smoking.” |
Negative feelings about changing: “You are a little worried about the drinking and smoking.”
|Affirming: Highlights strengths, values and efforts.||“You know there are some things you may want to change.”|
Ask open-ended questions to build motivation
“What happens if you aren’t hearing any change talk from your patients?” asks Dr. Herbert. Open-ended questions can be helpful in eliciting change talk from your patients.
- Ask for the elaboration of change talk with open questions or statements like, tell me more about that. Why is that important? What makes you feel that way? Why is that?
- Ask for more change talk by asking about desire, ability, reasons and need like, why do you want to xxx? What are some reasons for xxx?
- When there is commitment, ask planning questions like, what steps do you want to take this week? What might get in the way and how you will overcome these barriers to reach your goal?
Open vs. closed question starters
|To what extent …|
How often …
Tell me about …
Help me understand …
What, if any, ….
When, if ever, …
How, if at all, …
What else …
|Did you ..?|
Motivational interviewing is a great tool that physicians and medical staff can use to positively relate to their patients. By taking on the spirit of motivational interviewing, practicing cultural humility, recognizing and reinforcing change talk and asking open-ended questions, physicians can make the most out of short appointments with patients and make real, lasting positive changes in their lives.
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