Center for Integrated Primary Care. University of Massachusetts Medical School. An Introduction to Guiding Patient Health Behavior Change with Motivational Interviewing. Daniel Mullin, PsyD Center for Integrated Primary Care Department of Family Medicine and Community Health.
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September 25, 2013
You should be flossing your teeth more often than you do.
What are some reasons that people change their behavior?
Miller, William R. (2002-04-12). Motivational Interviewing, Second Edition. Guilford Press.
When patients are viewed primarily from a deficit perspective (e.g., being in denial; lacking insight, knowledge, and skills), it makes little sense to spend time eliciting their own wisdom. Instead, the clinician would be inclined to confront denial, explain reality, provide information, and teach skills. Within this perspective, consultation is clinician-centered, and it revolves around the clinician providing what the patient lacks: “I have what you need.”
It can be quite a cognitive jump from this expert stance to MI, wherein the clinician instead communicates a respect for the patient’s own perspectives and autonomy. The MI clinician seeks to evoke the patient’s own motivations for change (“You have what you need”) rather than installing them. A willingness to entertain this patient-centered perspective is a starting point in learning MI.
Adapted from Miller and Rollnick
Ironically, it is acknowledging the other’s right and freedom not to change that sometimes makes change possible.
Rollnick, Miller, and Butler (2008)
* Fundamental Attribution Error is not an MI Concept
Reasons for change which originate with the clinician are not associated with patient health behavior change
Reasons for change which originate with the patient
are associated with patient health behavior change
After assessing the patients thoughts/feelings/knowledge you may begin to shift to offering the patient information.
However, before providing information, first assess the patient’s interest in hearing what you have to say.
Asking permission to educate about behavior change:
- promotes collaboration
- communicates respect for the patient’s expertise
- encourages patient to voice his or her perspective
- focuses the patient’s attention on what you say
Examples of asking permission:
“I have an idea here that may or may not be relevant. Do you want to hear it?”
“I think I understand your perspective on this. I wonder if it would be OK for me to tell you a few things that occur to me as I listen to you.”
If after asking the patient’s interest in hearing your advice, the patient declines, do not proceed with education.
If some patients decline to hear your advice you know you are building strong relationships with your patients. They are comfortable being honest with you.
Telling someone what to do when they don’t want to hear your thoughts will damage your relationship with them.
Telling someone what to do when they don’t want to hear your thoughts has almost no chance of changing their behavior.
After sharing your advice and thoughts follow up with the patient to confirm you were understood and elicit reactions
“Now that I have shared some of my thoughts I wonder how you they strike you.”
“Tell me a bit about how what I have shared fits with your thoughts and feelings about smoking.”
“Now that you have shared your thoughts, and I have shared mine, I wonder where we should go from here.”
Communicate listening, non-verbally:
Eye contact, head nods, hands off keyboard
Confirm understanding by repeating back, or reflecting what you have heard:
“Let me make sure I understand, you said...”
“I can tell that you have given this some thought. Your understanding is that...”
Pollak, K. I., Alexander, S. C., Coffman, C. J., Tulsky, J. A., Lyna, P., Dolor, R. J., et al. (2010).
Physician Communication Techniques and Weight Loss in Adults.
American Journal of Preventive Medicine, 39(4), 321–328.
The more MI inconsistent behaviors, such as giving
the more weight gain.