Motivational interviewing

Motivational interviewing can yield excellent results and the basic skills and techniques are easy to learn. Dr Malcolm Thomas sets out the basics of promoting behaviour change

Helping patients or clients to change their behaviour can be frustrating. As professionals, we can get into a cycle of giving advice and making suggestions, only to feel that everything we suggest is being rejected. Specialist workers often have some training in more effective techniques – this article is aimed at frontline staff, most of whom will not have had such training.
There is now rather compelling evidence that the approach known as motivational interviewing produces better results than standard care (also called ‘business as usual’ or ‘finger wagging’). A full motivational interview takes between
45 and 60 minutes. The necessary training takes two, three or more days so it’s not surprising that this has been the preserve of specialists. However, the insights and techniques of motivational interviewing are available to ‘ordinary’ practitioners. I work for a training company and it’s our contention that everyone whose job includes counselling patients or clients regarding behaviour
change can enhance their professional effectiveness with some understanding, and judicious use, of relevant techniques.
Each of the following techniques takes no more than a few minutes to use and frontline practitioners can use them flexibly in relevant professional conversations. Regard the list as a toolkit from which the relevant tool can be unpacked as needed.

Many clients exhibit two or more behaviours that may profitably be changed, such as alcohol, drug use and diet. Usually it’s the professional who chooses which one to talk about, but allowing the client to choose the focus may enhance motivation. This can be achieved by running verbally through the options as the professional sees them and inviting the client to choose, such as:
‘It looks there are three things we could talk about today. Firstly your drug use, secondly your drinking and thirdly your diet. Does that sound right?’ Then, if the client agrees: ‘OK, so which would you like us to focus on today?’ People can be a bit vague about their habits. A typical answer to ‘how much alcohol do you drink’ is likely to be something like ‘Well, that’s a good question. It’s hard to say. Depends on this and that.’ It’s usually profitable to clarify what is going on at an early stage in your
professional relationship. A recommended technique is the ‘typical day’ question. For example, ‘I wonder if I could spend a couple of minutes learning more about your drinking? Can I ask you to talk me through a typical day, starting when you wake up
and finishing when you go to bed? Tell me where you go, what you do and where your drinking fits in.’ Variations on this include asking about a specific day (yesterday, last Saturday) or a typical week (which can be better for some behaviours). It’s normally very helpful to gauge the client’s readiness to change or consider changing. This may be apparent from things they have said and it certainly can emerge naturally from the conversation, but this is not always the case. While it’s rare for there to be no real clue, it can often be very unclear just how much readiness there is to change. It’s helpful to break readiness to change down into two components – importance and confidence. One strategy is to ask specifically about these in turn, using ‘scaling questions’. For example, ‘Can I just ask you a couple of questions? On a scale of one to ten, how important is it for you to cut down your drug use?’ Say the client responds with ‘Oh, I don’t know. Maybe around a three,’ your response could be ‘I see – thanks. Can I ask a similar question? On a scale of one to ten, if you decided to cut down, how confident would you be that you could make the change?’ Their response might be: ‘That’s a good question. Maybe six-ish. I cut down quite well for a while once. I think I could do that again.’

One advantage of this approach is that you can use it as a launch pad for further exploration, such as: ‘You told me you were at three or four for importance. So can I ask you why three and not one or two?’ ‘Well, it does sometimes get me into trouble. I’d like to think I had a bit more control over it and that it didn’t dominate my life quite so much.’ ‘Alright, so what would have to happen to move that score up to say five or six?’ ‘Well, if I got properly sick with it, I think that might do it.’ People aren’t daft. They indulge in unhealthy behaviours because there’s a payoff. Being overweight is a side effect of eating, which is usually pleasurable. Substance users get some sort of ‘high’ from their substance, or a relief from withdrawal effects if dependent. Behaviours have a social context and many people enjoy doing things with friends, whether smoking, drinking or injecting.
An axiom of motivational interviewing is that our client can see pros and cons to their behaviour. Rather than offering our professional opinion, we can help by allowing the client to bring these out into the open – and then feed it back to them: ‘Can I just try to understand a bit better? Can I ask you about the pros and cons of your marijuana use? First, what are the pros of smoking it from your point of view, the things you like about smoking marijuana? ‘Well, it relaxes me a bit, you know. And when I light up a joint with my mates, we have a good laugh. And to be honest, I prefer a smoke to a drink because you don’t
get the hangovers – you know what I mean?’ ‘Yes, I think I see that. Ok, what about the cons? The things you don’t like so much?’ ‘Well, it sometimes costs me quite a bit you know. And if I get really stoned, then I miss half the day, which isn’t right. And my girlfriend isn’t keen – I think she might not stand for it forever.’ ‘Can I recap then? You’re telling me that it relaxes you, that you do it with your mates and that you prefer it to alcohol. On the other hand, it can cost a lot, you sometimes miss half a day and your girlfriend doesn’t like it?’ ‘That’s about right, yeah.’ ‘Where does that leave you today?’ This can really help in our efficient use of interview time. The client response usually tells us if they are ready to go further and get involved in change talk – or alternatively it may be clear that it isn’t profitable to take things any further today.

At any point in the discussion, resistance may emerge. It is tempting to meet resistance with reasoned argument – pointing out all the scientific reasons on the side of a behaviour change. Unfortunately, this usually has the effect of stiffening resistance. For example, ‘You really need to lose weight you know.’ ‘I guess so.’ ‘I think you should go on a diet.’ ‘I can’t because…’ This is known as negative self-talk. It has been shown that an increase in the amount of negative self-talk in an interview is associated with a lower chance of behaviour change occurring. It seems prudent to avoid provoking such statements. For example, ‘I get the impression I may be pushing you a bit too far here. Shall we stop talking about this today?’ ‘No… It’s ok, go on. It’s just that this is difficult for me to get my head around.’ This is known as ‘rolling with resistance’. It can be a very effective tactic to
prevent the emergence of negative self-talk. It demands that professionals should be on the lookout for signs of resistance at pretty much any stage in a behaviour change discussion.

Most of us who work with clients develop a well-polished series of mini-lectures by way of explaining all the regular things that come up and need explaining. Unfortunately, these mini-lectures may not really be wanted. Or else, we may fail to address important questions on the mind of the client. A mini-seminar might be better. A useful way of looking at this is ‘elicit – provide – elicit’. Elicit any questions or information needs and provide answers or information in response. When it comes to action talk, it is better to provide a range of options to be chosen from. Finally, elicit a response – find out how your information has been received. An example: ‘Can I explain anything to you, answer any questions?’ ‘Well, have you got any information about how many units are in my various drinks. And what do you think I should do to cut down?’ ‘Ok. Let’s see. This leaflet is good for information about units. How does this look?’ ‘Very clear, actually. Can I have that?’ ‘Definitely – it’s for you to take away. Anything catch your eye?’ ‘Yes. Look at this about glasses of wine. I had no idea there were so many units.’ This approach can lead to more effective use of professional time, while again minimising the risk of negative self-talk developing. Motivational interviewing gives better results than ‘business as usual’ and many of the individual skills and techniques are easy enough to learn and can be used in routine conversations with patients or clients. I’ve outlined and demonstrated a range of the most useful
micro-skills, with examples of how they might fit into your conversations but a very readable and immensely practical textbook I’d recommend to any DDN reader is Health Behavior Change – a guide for practitioners by Stephen Rollnick, Chris Butler
and Pip Mason (Churchill Livingstone) – despite the spelling, it’s a British book.

Dr Malcolm Thomas is director of national training provider Effective Professional
Interactions Ltd.

Source: drinkanddrugsnews Jan 2010

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