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Medical Interviewing and the Doctor-Patient Relationship
W. Altman, MD
Tufts University School of Medicine
"Motivational interviewing is a directive, patient-centered counseling style for eliciting behavior change by helping patients explore and resolve ambivalence"— Stephen Rollnick & William R. Miller
Assess patient’s readiness to change:
4 Principles of Motivational Interviewing — “REAL”
R – Righting reflex
Doctors are trained to make things right, and do this with our "righting reflex". We want to tell patients what to do in order to fix them. Techniques often used are: suggesting, advising, persuading and giving speeches. These techniques usually shut patients down.
Avoid the righting reflex. Avoid arguing, ordering, directing, commanding, warning, threatening, telling patients what they should do, advising, suggesting solutions, persuading with logic, disagreeing, judging, criticizing, probing, interrogating.
In order to help patients, try to listen and engage them. Dance-don’t wrestle- with resistance (Rolling with resistance example: sounds like quitting smoking will never happen for you → I didn’t say never). Allow patients to explore barriers in a nonjudgmental, supportive manner to help them to change.
E – Empathy
Express empathy. This helps to build trust and collaboration, legitimizes patient’s struggle, and communicates respect.
Ask for permission: "Would you be willing to discuss your smoking?"
Reflective listening: "What I hear you saying is that drinking helps you manage your stress."
Open ended questions: "What do you think it would be like to take your insulin?"
A - Ambivalence
Explore ambivalence and uncover discrepancy through active listening. This helps patients figure out what they are doing vs. what they want to be doing (uncover discrepancies between the patient’s behavior and values).
Open ended questions about specific concerns: "What concerns you most about your smoking?"
Facilitating recall about times before the behavior was a problem: "What was it like for you before your drinking started affecting your work?"
Facilitating patient imagination of future both with/without behavior: "What do you think your life will be like in five years if you don’t change the way you are eating?"
Connecting patient’s values with behaviors/Explore ambivalence: "What do you like about smoking? What do you not like about smoking?"
Use scaling questions: "How important is it for you to do this on a scale of 1-10- 10 being most important. Why did you pick a 6 instead of a 3? What would it take for you to be a 9?"
L- Listen in order to Understand and Empower
Listen to what your patients are really saying, listen to the changes they are willing to make, and support their self efficacy. Use active listening techniques, open ended questions, and reflect and clarify what you hear.
Support your patient’s strengths, successes and provide encouragement.
Communicate to patients that they are in control of their decisions. You’re there to provide support/guidance.
When the patient "owns" the plan they’re more likely to execute it.
Facilitate follow-up on the plan.
Evidence to support Motivational Interviewing"
A meta-analysis done by Vasilaki in 2006 reviewed 9 studies comparing brief motivational interviewing with other interventions for treatment of excessive alcohol use and found that it was more effective than the traditional approaches.
Motivational interviewing was also found to be effective in studies looking at behavioral interventions in teens with type 1 diabetes (Channon et al 2007) and obese women with type 2 diabetes (West et al 2007). In a study of a behavioral weight loss modification program, adding motivational interviewing led to increased weight loss, improved physical fitness, and improved dietary intake as compared to the group without motivational interviewing (Carels et al 2007).
Carels RA, Darby L, Cacciapaglia HM, Konrad K, Coit C, Harper J, Kaplar ME, Young K, Baylen CA, Versland A. Using motivational interviewing as a supplement to obesity treatment: a stepped-care approach. Health psychology: official journal of the Division of Health Psychology, American Psychological Association 26(3):369-74
Channon SJ, Huws-Thomas MV, Rollnick S, Hood K, Cannings-John RL, Rogers C, Gregory JW. A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. Diabetes care 30(6):1390-5
Motivational Interviewing Course: Arizona Center for Integrative Medicine; Integrative Medicine in Residency 2013
Rollnick S & Miller WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 23:325-334
West DS, DiLillo V, Bursac Z, Gore SA, Greene PG. Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes care 30(5):1081-7
Vasilaki EI, Hosier SG, Cox WM. The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta-analytic review. Alcohol and alcoholism (Oxford, Oxfordshire) 41(3):328-35