Motivational interviewing (MI) is a technique that can be applicable to all clinical settings including primary care. MI is defined as “a person-centered, goal-oriented approach for facilitating change by exploring and resolving ambivalence” (Miller 2006). It can be useful in situations when a patient’s behavioral choices negatively impact his/her health condition – examples include smoking, overeating or eating unhealthily, substance use, and medication noncompliance.
MI involves a shift in the interaction between a provider and patient. It is not uncommon for providers to advise patients of the logic of behavioral change without optimally engaging patients to be their own agents of change. This typical approach relies on the authority of the healthcare provider, uses clinical information as an implied threat, and is expressed as a challenge. And quite often it does not really work well and leaves both the patient and provider feeling frustrated.
MI tries to tackle this battle to get patients to “do the right thing” or “do what is best for them” differently. The idea is that communication is patient-centered and collaborative rather than provider-driven. There is an assumption that the patient does want to do what is best for him/her and just needs some gentle guidance to get there. The goal is to harness the patient’s personal autonomy to make a decision for better health. The theory behind MI is that the motivation for change happens when a person perceives a discrepancy between where s/he is and where s/he wants to be. The person has to believe that s/he is capable of making the change, that s/he is in the driver’s seat to make that change happen, and that their provider(s) believe that they can make the change.
Motivational interviewing is a four-step process:
- Express empathy (ex. “It is sure hard to quit for all sorts of reasons and I guess it is tough to know that there is a connection between your heart disease and your smoking.”)
- Define the discrepancy inherent in the patient’s behavior (ex. “I can appreciate that smoking is one of your daily pleasures and that it helps you in stressful moments, but I also know that you don’t want to have another heart attack so that you can live to see your children grow up and be there for them.”)
- Support self-efficacy (ex. “Others have been able to quit, and you are a strong person given all that you have been through. This really is a potential matter of life or death, so that can be something that can keep you motivated.”)
- Roll with resistance (ex. “This is really hard stuff and maybe this is not the right time or the right approach, but you (and I) really want you to be healthier and to be there for your children. How else can you prepare for the change you see is needed?”)
It is helpful to define the health challenge from the patient’s own perspective and help him/her identify and express his/her life goals that the problem behavior/habit is interfering with. Accept resistance as part of the process and part of the patient’s struggle. Work to meet the patient where s/he is at and if at first you don’t achieve success, try again. Empathically return to their identified life goal when they get stuck and help them find reasonable solutions that works for them.
Motivational interviewing is about the patient, not the provider, being responsible for choosing and carrying out change. This technique can be helpful in the primary care setting to help providers help patients make behavioral changes to improve their health.