CHAPTER 8
Patient Engagement and Motivational Interviewing
Think about a New Year’s resolution or any behavior that you have considered changing (or someone has suggested that you consider changing) over the last year. What is it? Time management? Driving habits? Organizing finances? Exercising more regularly?
Whatever that behavior is, pause now and think through the overall situation for a minute as if you were explaining it to a good friend. What’s going on? What problems is the behavior causing? What have you tried?
The situation is likely complicated, and you might have some mixed feelings about it. You would like to do things differently, but where to start? What to do? Or maybe you know what to do, but the effort of adjusting just isn’t a priority right now. Your situation might not be a life-or-death health issue, but we’re guessing that it impacts the quality of your life to some degree, or you wouldn’t have thought of it.
Now turn your mind to someone close to you—a family member, friend, or colleague—whose behavior you wish would change. Maybe it’s unhealthy, unsafe, or just generally annoying.
Given the other person’s behavior or your own, which one do you think you have a better chance of influencing?
We’re going to assume you said your own—if you didn’t, this might be a long, tough chapter for you. And yet, even as the person in the driver’s seat of your own behavior, you recognize how challenging change is.
Have you ever heard of motivational interviewing (MI)? It is an evidence-based skill that engages people in their own health. Motivational interviewing asks you to humbly set aside your expert role and knowledge in order to explore problems and activate change from the patient’s viewpoint. In this sense, MI facilitates a human-to-human connection through reflective listening, and guides the patient in devising his or her own plan, rather than relying on you to problem-solve. We will review the basic elements of MI with the hope that you will finish the chapter with enough direction and inspiration to start practicing these skills, if even just for yourself!
Motivational Interviewing
Most of us have endured years of training, testing, and expense to assure competence. Yet how often have you had the following conversation?
You: Mr. James, have you ever considered cutting down on or quitting smoking?
Mr. James: No.
You: Well, if you don’t stop, you increase your risk for heart attack, cancer, and stroke. You don’t want that, do you?
Mr. James: Heavens, no! Thank you so much for caring enough to say something. That information really scares me. I want to quit right away. How can you help me?
If only people were so malleable! Other people don’t change when, how, and why we want them to. They change when, how, and why they want to. And if it’s not a change they’re interested in making, they generally don’t appreciate our years of experience, brilliant advice, and hearts of gold. A consultant for organizational change once said, “People don’t resist change. They resist being changed.”1 That’s why the very first thing we need to do is take off our clinical hats and set our agendas aside. This first step is absolutely the hardest part.
Motivational interviewing requires different skills than what our data-driven, “I know the answer” training conditioned us for. Specifically, MI is “a collaborative conversational style for strengthening a person’s own motivation and commitment to change.”2 This style of conversation, like all communication, relies on both context and content. Here, the context refers to leveling the relationship through a collaborative stance and recognizing that the other person must generate his or her own solutions, no matter how informed and well-intended your suggestions might be. In other words:
Acknowledging a person’s freedom of choice typically diminishes defensiveness and can facilitate change. This involves letting go of the idea and burden that you have to (or can) make people change. It is, in essence, relinquishing a power that you never had in the first place.3
It is not uncommon for clinicians to nod politely at these principles and then wrestle terribly with their egos and training, realizing that neither offers much value to patients who just need to have the right conversation to figure things out for themselves. Let’s face it: we all want to feel helpful and appear competent. With MI, we still can, but in a different, more satisfying way for both clinicians and our patients.
The content in an MI conversation, on the other hand, acknowledges that specific phrases and strategies make a difference in guiding and promoting change. The next two sections review context and content more fully, referring to them in the MI language of “spirit” and “technique.”
SPIRIT
We’ve all seen kids offer forced apologies that sound like the most hate-filled, annoyed “I’m saw-REE” ever. That’s what this section is about. When we have an MI conversation, the spirit of the approach must be congruent. Motivational interviewing is not so much a series of guided conversational techniques as it is the spirit of “we’re in this together, and I’m right here with you.” Without the spirit of MI backing our comments, the techniques below could easily morph into benevolent manipulation or, worse, a really insincere playground reconciliation. The good news is, like many things, the more we mindfully embrace the spirit of MI, the more intuitive and comfortable it feels.
According to authors William Miller and Stephen Rollnick, four interrelated attitudinal elements are necessary for MI “spirit.” These essential elements are: collaboration, acceptance, compassion, and evocation.4
Often, when the clinician despairs with, “I don’t know what to do! They need X and I’m trained in Y,” collaboration is the solution. Since our patients are the experts of their own experiences, we don’t have to know how to fix their problems. Our role is to support them to figure out how to fix it for themselves.
Acceptance, which acknowledges the person without judgment, does not always come easily. For instance, due to my own experiences, I (Krista Hirschmann) find myself having a strong internal reaction toward parents who smoke in front of their children. While I may not accept that behavior, I can accept a stressed, working mother trying to relax her nerves in the fastest, most convenient way possible.
Miller and Rollnick define the third element, compassion, as preparing to do what is in the best interest of others and not ourselves. The demands of the healthcare system and the experiences we witness sometimes place extreme stress on our ability to care compassionately for others and can lead to “compassion fatigue.”
The fourth element, evocation, recalibrates our compassion by drawing out the good reasons people have for “bad” behavior. Or, in less judgmental language, we all have good reasons for sustaining our current choices. The next section describes some basic ways to accomplish evocation.
Collectively, these four elements comprise an authentic stance that will best position us to be fully present and supportive listeners, while positioning our patients for success. Not to worry, though, if our MI spirit is more “saw-REE” and less “rah-rah-sis-boom-bah.” Self-acceptance and self-compassion are a terrific place to start—and sometimes that takes some time.
TECHNIQUE
Given that MI originated within the mental health and recovery field, it’s no surprise that the full technique embraces robust and unhurried reflective discussion. It’s also no surprise that the time to do so is what most clinicians don’t have. This section on technique provides an overview of the core skills associated with MI, as well as a distilled strategy to use in the busy office setting.
The Core Skills
In addition to embracing the intended spirit of MI, there are four steps, or stages of conversation, to negotiate with the patient. They are: engage, focus, elicit, and plan. The advantage of recognizing each distinct step is that the process can be divided into discrete conversations over the course of several office visits.
The first step, to engage the patient, relies heavily on using open-ended questions to encourage talk that is important to the other person’s experiences. When we welcome the person to share, new issues often come to light and offer insight into the situation.
Typical open-ended questions for MI include:
• “What are your thoughts on X?”
• “Tell me more.”
• “What’s a typical example?”
• “Please share a time you tried to change your behavior.”
Responding to the answers is its own subset of active listening skills. Recall from Chapter 4 that active listening means that although we may be speaking at times, our comments do not introduce new information or ideas. Rather, our responses demonstrate and confirm our ability to listen with an “inner ear,” or to what the person is saying both on and below the surface. Doing so helps check any assumptions we might have, as well as making the other person feel heard and validated, thereby strengthening the relationship.
Simple reflection skills help us understand what we are hearing, while helping the patient process the information. A reflection might sound like: “You said changing behavior has been frustrating for you.” In addition, intermittent affirmations and empathy acknowledge the emotional dimensions of the conversation. Such statements include:
• “That was a hard time for you.”
• “Many people face that challenge. You’re not alone.”
• “You did the best you could.”
Finally, summaries are simply a collection of reflections strung together at the end of the engagement process. These reflections pull the story together, confirm the listener has heard correctly, check to make sure that the story is complete, and ensure that the speaker appears engaged and ready to transition to the next discussion. A summary might state:
You’ve shared several reasons why you’d like to quit smoking, particularly with babysitting your grandchildren, and also how hard it is for you. You’ve tried several times, quit for a week or two and then fallen back into old patterns, afraid of putting on extra weight. You are willing to try again, but are not sure of the best strategy to use.
This method of asking, listening, responding, and summarizing mirrors the ART (Ask, Respond, Tell) process we introduced in Chapter 5.
Once we engage a person to this point, the second step is to focus the conversation on a particular issue. Avoid trying to tackle multiple behavior changes (e.g., diet, exercise, and smoking) in one session. Even with smoking, focusing could mean just exploring options to quit and not actually quitting. Whatever the exact focus, we can move to the third stage and elicit solutions to develop a plan that must come from the person and not from us, unless we ask permission to offer a suggestion. For instance:
• “What strategies have you thought about trying?”
• “There are a few other options you haven’t mentioned. Would you be open to hearing about them?”
Whatever ideas we elicit, we can plan (the fourth stage of conversation) for change by setting small, manageable goals that can be quickly and easily accomplished. This will build confidence and self-efficacy for the patient.
A Distilled Strategy
If the longer conversation just outlined is not possible due to time constraints, consider the following technique, which is a modified approach that still embodies the spirit of MI and introduces the strategy of engaging first through conviction, followed by building confidence. (Note that the approach encompasses skills from Chapter 5.)
To demonstrate, let’s return to the example of the grandparent who continues to smoke. You could start the conversation like this: “On a scale of 0–10, with 0 being no importance and 10 being the most important thing in your life, how important is it for you to stop smoking?”
This patient is ambivalent and responds, “Maybe 2 or 3.”
You respond, “Thank you for your honesty. What makes your answer as high as a 2 or 3? Why not a 0?”
That prompt makes it difficult not to start talking about reasons to quit smoking. This patient might talk about not wanting to smoke around the grandchildren, not wanting to set a bad example for them or affect their health. After encouraging the patient to list the reasons, you can follow with: “So what would it take to move you from a 2 or 3 to a 5 or 6?”
This question helps the patient to think aspirationally, and consider other reasons to quit smoking. Far from being a Jedi mind trick, this process highlights a way for people to think about what is possible, rather than delving into excuse after excuse about why they are entrenched or have decided it’s not important.
In many settings, clinicians want patients to stop smoking yesterday. Rather than pressing for behavior change now (which almost never happens), sometimes just getting a patient to think aspirationally unmires them from the tar pit. At this point, after exploring the reasons, you might re-ask the question about importance on a 0–10 scale. Any upward movement is a small victory, provided that you can follow up to reinforce the patient’s reasons for change before the inexorable slide back into the pit.
If you have a bit of extra time, and the patient is engaging you, you might ask: “Let’s say for a moment that you feel completely convinced that you should stop smoking—you have no doubt that it’s important. On a scale of 0–10, 0 being low confidence and 10 being really high confidence, how confident are you that you could quit?”
The patient says, “Probably an 8 or 9.”
“You sound pretty confident,” you say. “Why as high as 8 or 9?”
The patient responds, “I’m pretty sure it’s an oral fixation. If I bought those little precut carrots and put one in my mouth whenever I craved a cigarette, I think I could cut down or completely stop.”
You now have a clear map of where the patient stands: not totally convinced about quitting smoking (low on conviction) but confident that it could happen once convinced (high on self-efficacy). The goal is always to increase conviction first, and then confidence, because if it’s not at all important to the patient, why waste time trying? The real beauty of this method is that the patient might come up with a solution that you might never have considered, as the patient did in this true, and ultimately successful, example.
If you read nothing else about MI, keep this series of conviction/confidence questions in mind, as it is the shortest (and quickest) form of MI you could possibly use in an office visit. You might even feel emboldened to use them in administrative meetings, i.e., “How convinced are you that this is an issue of patient safety?” or on the home front, i.e., “How convinced are you that it’s important to rinse out the milk jug before tossing it in the recycling bin in a hot garage?”
Quick Recap
“Where are you on the conviction/confidence scale?” Asking what makes it as high as it is allows the patient to draw from past successes and strengths.
“What would have to happen for you to increase your score?”
In short, these questions give you a starting point for understanding your patient’s perspective, what it’s going to take for him or her to change—whether the patient needs information, support, or both. Motivational interviewing is like looking at a map together with the patient and having the patient (not you) mark the path.
Conclusion
You can only control you. As much as you might want MI to change your patient (or boss or spouse), MI is really meant to change you. If we, as professionals, can’t accept and embrace change for ourselves, how can we expect patients to engage in change for themselves?
On that sobering note, what have you just read that appealed to you? What is one thing that you might be willing to try? How can you imagine implementing it within the next two weeks? Obviously, the spirit and assortment of techniques work best as a whole package, but MI is a big proponent of small, manageable changes. How are you willing to slightly pivot your approach with patients?
If you’re not ready, that is OK, too. We appreciate you reading this far and considering the material. If and when you are ready to stop merely thinking about that New Year’s resolution and to start doing something about it, just keep MI in mind as a guide for supporting your own behavior change—and maybe the behavior of others.