Making Sense of Motivational Interviewing: Part 1

A 2-Part Series

This article is the first of a 2-part series. This part will (1) briefly describe motivational interviewing (MI), (2) provide an example of how it works, (3) explain our approach to MI, and (4) explain why it is so effective in helping patients engage in health behaviors (eg, taking their medications, losing weight, quitting smoking). Part 2 will describe the clinical and economic effectiveness of MI compared with traditional counseling and information giving methods used by health care professionals (HCPs). The reader is referred to our book, Motivational Interviewing for Health Care Professionals: A Sensible Approach,¹ and our 8-hour continuing education accredited MI e-learning program (nacds.learnercommunity.com/motivational-interviewing) for further elaboration on these concepts and their evolution in health care.

The Origins of Motivational Interviewing

MI was originally developed by psychologist William Miller. ² Miller’s insightful reaction to the typical confrontational approach widely used in the field of addiction counseling in the 1980s was the start of MI.

Here is Miller’s principle in his own words:

Counsel in a way that evokes defensiveness and counter-argument, and people are less likely to change. . . I set out, then, to discover how to counsel in a way that evokes people’s own motivation for change rather than putting them on the defensive. A simple principle that emerged from our earliest discussions was to have the client, not the counselor, voice the reasons for change.²

Miller’s new counseling approach was eventually called MI because the term “interviewing” carries the sense of (1) respecting patients, and (2) inviting patients to talk about their own motivation to change.³

MI was widely adopted in addiction counseling and proved to be very effective in helping patients to change their behavior. Many people thought that it could be effective for other health behavior issues. In fact, subsequent research has shown MI to be effective in helping patients to change a wide range of health behaviors.⁴

MI was developed specifically for patients who are ambivalent about change (individuals who might say, “I’m not sure I want to quit smoking now”), or resistant to change (individuals who might say, “I am not going to quit smoking. Stop bugging me.”).

Only by valuing and supporting the patient, as a person, does the patient have the freedom and safety to examine his or her behaviors and their consequences on self and others.⁵

MI does 3 important things: (1) it accurately and nonjudgmentally reflects the concerns and emotions of the patient, (2) it provides insight or new information to address these concerns in a nonjudgmental and nonthreatening manner, and (3) it places ultimate decision making where it belongs…with the patient. This combination of actions is powerful. It creates safety so that the patient can be open to learning new ideas, drawing new conclusions, and, consequently, engaging in new behaviors.

An Example

The following is an example of patient counseling using a traditional approach, and then using MI. A 50-year-old man with a new diagnosis of diabetes presents a new prescription to lower his blood sugar. After the pharmacist fills the prescription, he begins to talk to the patient.

Patient: (Interrupting) OK, look, I don’t need a lecture. I’ll take the medicine once a day. I don’t plan on appreciably changing what I eat or getting more exercise to control my diabetes, so save your breath. That’s what the medicine is for.

Pharmacist: Taking the medicine alone is not enough. It can’t work as well if you don’t take in less sugar or carbs and burn more calories. So, if you want to control your diabetes, you need to do all three.

Patient: Fine, why don’t you let me worry about it? It’s my life. Are you done?

Pharmacist: OK. Sure. Here you go (hands over the prescription). But, I think you’ll find the medicine is not enough.

This patient might be labeled as difficult by a lot of HCPs. He seems defensive and unwilling to do what is necessary to really control his diabetes. Unfortunately, being lectured to and told what to do are not going to reduce his defensiveness and cause him to listen. The pharmacist insults the patient by essentially telling him, “You’re wrong, and you need to listen to me.”

Here’s an MI approach…

Patient: (Interrupting) OK, look, I don’t need a lecture. I’ll take the medicine once a day. I don’t plan on appreciably changing what I eat or getting more exercise to control my diabetes, so save your breath. That’s what the medicine is for.

Pharmacist: (1) I’m glad to hear that you are willing to take your medication to control your diabetes. (2) Sounds like you are taking this seriously.

Patient: That’s right. I am. I’ll take the medicine.

Pharmacist: (3) Glad to hear that. Would you mind if I share some thoughts with you, and then you can tell me what you think? After all, this really is your decision, and I want you to do what you think is best for you.

Patient: OK, but don’t expect me to change anything.

Pharmacist: (3) I sure won’t push. I promise. (4 and 5) Here are my thoughts. The medication prescribed is really effective at lowering blood sugar. It does have a limit, though. To give you an idea of what it can do, let’s say that it can remove 100 particles of blood sugar. Any sugar or carbs that you take in (or don’t burn) beyond that 100 start to accumulate over time, and that’s how diabetes can do serious damage to your eyes, nerves, kidneys, heart, etc. Anything you would be willing to do to decrease the amount of blood sugar over that 100 level, either through healthy eating or increased physical activity, like simply walking more, will help keep your diabetes under control and prevent problems. Very simple things like drinking water versus a sugary drink, or eating baked chicken instead of fried chicken, can really help. (6) What do you think about this?

Patient: Hmmm. Never thought about that. So even walking would help? I think I can do that. And small changes in my diet can help that much?

Pharmacist: (3, 4, and 5) Both sure can. To me, it’s important to find things to do that won’t seem like a burden to you. You don’t have to sweat to get more activity, and you don’t have to cut out everything you like to eat. Moderation is the key so you will stick with it. (7) I’d be glad to talk to with you more about this whenever you’re ready.

Patient: Let me try some things on my own, and then I might talk some more on my first refill.

Pharmacist: (7) Terrific! Glad you’re willing to consider trying some things. That will go a long way!

Notice the difference in the responses from the pharmacist and the patient. The pharmacist acknowledges the patient’s willingness to take the medication and the patient’s desire to take a step in controlling his blood sugar, rather than correcting the patient. The pharmacist asks permission to “share some thoughts” with the patient. The pharmacist is careful to point out that he realizes this really is the patient’s decision. It is his life and his diabetes. Because there is no humiliation from being corrected, the patient is willing to consider the new information and perspectives. The patient is invited to consider the new information rather than having it forced on him. As a result, change is far more likely.

An Approach Based on Sense Making

Our approach is based on human sense making. We are all sense makers. As you read this article, you are deciding if it makes sense. Patients make sense of their illness and treatment. With our approach to MI, we train HCPs to do the following:

• Listen for how the patient is making sense.
• Clarify the sense making, if needed.
• Reflect back that understanding (develop rapport).
• Identify the information that is missing or incorrect.
• Directly address the issue (with permission).
• Invite the patient to reconsider.
• Summarize and discuss next steps.

In the previous dialogue, the patient’s sense is that the medicine should be enough. When individuals are ambivalent or resistant to change, they are working with partial or inaccurate information. This patient was partially correct. Additional information was needed for him to understand why medication alone was not enough. The dialogue is numbered so you can see where each step takes place.

Summary

This article introduced you to our approach to MI. Because MI was developed for patients who are ambivalent or resistant to health behavior change; it is crucial to understand how they are making sense, to reflect that understanding to create rapport, and then to provide new information that addresses their issues and invites them to reconsider changing their behavior. Information-giving, alone, and telling these patients what to do, simply does not work. Part 2 will provide clinical and economic evidence of MI’s effectiveness.

This article is published in collaboration with the Directions in Pharmacy CE Conference program.

Bruce A. Berger, PhD, is president of Berger Consulting, LLC, and emeritus professor, Auburn University Harrison School of Pharmacy, Auburn, Alabama. William A. Villaume, PhD, is emeritus professor, Auburn University Harrison School of Pharmacy, Auburn, Alabama.

References

• Berger BA, Villaume WA. Motivational Interviewing for Health Care Professionals: A Sensible Approach. Washington DC: APhA Press; 2013.
• Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press; 1991.
• Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford; 2013:xxii.
• Lundahl B, Moleni T, Burke BL, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013;93(2):157-168. doi: 10.1016/j.pec.2013.07.012.