Personal Development

Introduction

As discussed in the previous article, motivational interviewing is ‘a particular way of talking with people about change and growth to strengthen their own motivation and commitment’ (Miller and Rollnick, 2023). It is intended to guide rather than direct the person. In terms of healthcare provision, Miller and Rollnick (2013) showed that motivational interviewing is effective in all the risk-taking behaviours – obesity, smoking, alcohol intake, poor diet and a lack of physical activity. Many healthcare professionals spend time and energy discussing lifestyle changes related to these behaviours with patients to help them to improve their health. Motivational interviewing can help guide the patient to decide to make these lifestyle changes.

Motivational interviewing aims to uncover a person’s intrinsic motivation to make changes. It is a gentle style of communication that promotes autonomy and personal choice and is a skill that can be taught (Day et al, 2017). However, motivational interviewing may require healthcare professionals to unpick their habitual approaches to communication. It may also involve unlearning or resisting the so-called ‘righting’ or ‘fixing’ reflex (Miller and Rollnick, 2013) (see below) – the desire to fix what seems ‘wrong’ with people and to set them on a ‘better’ course.
 
With motivational interviewing, change arises through its relevance to the person’s own values and concerns. Skilled assessment, occurring at the patient’s own pace and evoking their ‘story’ can help to identify their treatment priorities, which is likely to promote concordance with a treatment plan (Day et al, 2017).
 

Strategies/skills of motivational interviewing

There are useful frameworks within the concept of motivational interviewing that can be used to engage clients in discussions about behaviour change. Learning the skills of motivational interviewing includes using the ‘OARS’ framework (Rosengren, 2017).

• Open question: Avoid saying ‘why’? Instead, you could say: What is it about that? Tell me about...? How? What have you tried before to make a change? What do you want to do next?
• Affirm: Comment on an attribute (not to be confused with praise). Affirmations are statements or gestures that recognise the person’s strengths and acknowledge behaviours, large or small, that lead in the direction of positive change. Affirmations build confidence in one’s ability to change.
• Reflection: Simple – stays close to what the person says, with repetition or slight rewording, gives reassurance
                      Complex – paraphrases what the person said, adds meaning and checks understanding (discussed further below)
• Summary: Useful to shift focus or end a session. Summarising helps to ensure that there is clear communication between the speaker and listener, and can provide a stepping stone towards change.

This framework can be repeated as necessary and at different times in motivational interviewing. While most people are ambivalent towards change, the OARS framework is very good at encouraging people to articulate their ambivalence about changing their behaviour. Talking about their uncertainty helps to move people towards change, by uncovering their intrinsic motivation and tipping the balance towards ‘change talk’.
 
Listening for change talk is important as it is linked to action (Miller and Rollnick, 2013). For example, when a patient says: ‘I really need to stop smoking’, this should be supported by the practitioner as it is likely to lead to change. Other change talk statements might include ‘I would like to...’ or ‘I want to’.

Reflective listening

Reflective listening is a vital part of motivational interviewing and involves interpreting what clients say to strengthen their motivation for change (Day et al, 2017). It is meant to close the loop in discussions to ensure that breakdowns in communication don’t happen. Some people find it helpful to use standard phrases in reflective listening, such as:

• So you feel…
• It sounds like you…
• You’re wondering if…

  There are three levels of reflective listening that may deepen or increase the intimacy of a conversation:

• Repeating or rephrasing: The listener repeats or substitutes synonyms or phrases, and stays close to what the speaker has said
• Paraphrasing: The listener makes a restatement in which the speaker’s meaning is inferred
• Reflection of feeling: The listener highlights the emotional aspects of communication through feeling statements. This is the deepest form of listening.

Varying the levels of reflection is effective in listening.

Reflective listening may be a useful strategy to use with older people who have ‘heard it all before’. Change may be difficult for older people because they have familiar patterns of behaviour and may be anxious about the risks of changing their behaviour.
 

Avoiding the ‘righting’ or ‘fixing’ reflex

A strategy called ‘elicit, provide, elicit’ is useful in motivational interviewing and can help the healthcare professional to avoid providing unsolicited advice. Elicit, provide, elicit involves finding out what the patient knows, providing extra information if required, and then asking the patient what they think or understand about the specific area under discussion (Miller and Rollnick, 2013). This approach allows the practitioner to build on what the patient already knows.
 

Conclusions

Motivational interviewing can be a helpful tool to use when discussing changes in care or lifestyle with patients. It allows the healthcare professional to understand the patient’s perspective and to support the patient to suggest changes that they might be able to make and commit to, increasing the likelihood of those changes being sustained and effective.
 

References

Day P, Gould J, Hazelby G (2017) The use of motivational interviewing in community nursing. J Community Nurs 31(3): 59–63

Miller W, Rollnick S (2013) Motivational Interviewing: Helping People Change. Guilford Press, New York

Miller W, Rollnick S (2023) Motivational Interviewing: Helping People Change and Grow. 4^th edn. Guilford Press, New York

Rosengren DB (2017) Building Motivational Interviewing Skills. 2^nd edn. Guilford Press, New York