A Guide to Motivational Interviewing

Motivational interviewing was first introduced in literature 30 years ago. Since that time, nearly 1,500 studies of its effectiveness have been published. Originally developed for individuals with alcohol use disorders, the use of motivational interviewing has expanded to support behavior change in a number of chronic diseases, including other substance use disorders, diabetes, cardiovascular disease, obesity, chronic pain, and asthma.

Motivational interviewing is a method of communication designed to encourage individuals towards a direction of change. The spirit of motivational interviewing, as it is commonly referred to, can be described through qualities such as:

• Establishing collaboration with patients as opposed to establishing an expert role
• Focusing on eliciting patients own motivations for change versus educating them about why they should change
• Honoring patients’ autonomy to decide to change, as opposed to assuming the authority to tell them how to change.

According to William Miller, PhD and Gary Rose, PhD, authors of Motivational Interviewing: Preparing People to Change Addictive Behavior, there are five main principles of motivational interviewing:

1. Express and show empathy towards patients
2. Support and develop discrepancy
3. Deal with resistance
4. Support self-efficacy
5. Develop autonomy

Practitioners express and demonstrate empathy when discussing behaviors, values, visions, and goals with patients. By expressing empathy, practitioners start to build rapport and trust which, as a result, may help patients become more open about their personal history and health concerns. Skillful, active listening is a key component of this step.

During motivational interviewing, patients may give reasons for changing their behavior, instead of viewing practitioners as authority figures ready to “prescribe” the best solution. If patients are making choices that revert from their goals, practitioners should point out the incongruence between behaviors and goals.

Oftentimes, patients may resist changing an unhealthy behavior. Practitioners should not confront the resistance, but instead try to see their point of view. Work with the patient to examine different viewpoints and allow patients to choose which point of view they want to stick with.

Patients should be made to feel that they are capable of achieve their goals. Practitioners may discuss and point out previous successes, as well as current or previous strengths and skills the patient possesses to solidify their belief that they are worthy and capable of change.

Lastly, practitioners must demonstrate to patients that change comes from within. There is no one way or right way to achieve the patient’s goals. This places emphasis on the idea that the client is ultimately responsible for changing their behavior. Practitioners should listen and help clients develop action steps for their expressed goals.

Lifestyle coaching involves a progress-focused approach to care. Once the goals and objectives have been identified through the collaborative process, follow-up meetings will focus on the patient’s success, barriers, and self-assessment.  Motivational Interviewing skills and strategies are helpful tools throughout the coaching process.

Empathy

Empathy is a learned skill that involves seeing the situation from the patient’s perspective.  Instead of trying to change a patient’s mind, the practitioner aligns with the patient and addresses the problem from the patient’s perspective. Patients are more likely to honestly engage when practitioners display empathy.

Open-Ended Questions

Open-ended questions result in deeper consideration and create momentum toward change by helping patients explore their own reasons for making a change. Open-ended questions are designed to further increase the patient’s self-awareness, capacity for thinking about new ways of being, and potential for change. This approach helps the patient to consider their situation from multiple points of view, so that new understandings and possibilities for action may arise. For example, asking a patient to tell you about his or her what their action steps would look and feel like will get a much richer response than do a yes or no question. 

Affirmations

Affirmations acknowledge patients' strengths and support self-efficacy.  To be most effective, affirmations should come from what the patient believes so that it feels genuine and meaningful to the patient.  When listening with empathy, practitioners can help patients develop congruent affirmations to support change.

Reflections

Reflections, also known as reflective listening, allow the practitioner to skillfully feed back to the patient what they have said, demonstrating empathy and inviting the patient to focus on the positive aspects of change that the patient has self-identified. Summaries are a specific type of reflection where the practitioner emphasizes what has been said and, if appropriate, highlights both sides of ambivalence to help develop discrepancy.

Change Talk

Identifying and reinforcing change talk includes things the patients has said that reveal an interest in, motivation for, or commitment to change. There are five main categories of change talk:

1. Desire for change
2. Ability to change
3. Reasons to change
4. The need for change
5. Commitment to change

By focusing on change talk, the provider reinforces the client's own reasons for wanting to change, thereby reducing resistance. Once the client is engaged in change talk, the provider can use a number of strategies to elicit and strengthen change talk, including:

• Asking evocative open-ended questions
• Using importance and confidence rulers
• Exploring the pros and cons of current behavior
• Asking the client to elaborate on a statement made in the direction of change
• Asking about the extremes of changing or not
• Looking forward or backward and exploring goals and values to identify what is important to the client

These skills may be revisited to increase change talk and subsequently increase the motivation for making a change.

Scaling Questions

In 1965, Hadley Cantril published an intervention, The Cantril Self-Anchoring Striving Scale, in which he described what is now known as one of the most popular coaching techniques, the scaling question. Scaling questions are frequently used by coaches to ask patients to assess their goals and supporting action steps by ranking their level of importance on a tenpoint scale.

For example, a practitioner might ask a patient to rate the importance of completing a 30-minute yoga program the patient set as a goal. Say the patient answers a “seven.” The practitioner might ask, “why not three?” By asking the patient why not a lower number, versus a higher number, the patient must verbalize the reasons in favor of their goal. This may result in increasing importance, maintaining the goal as-is and developing strategies for success, or the patient may need to revise the goal to make it more manageable. If a patient ranks a goal with a lower number, the practitioner might ask what outcome would make it more valuable.

Editor’s Note: This is an excerpt from the e-book, The Basic Principles of Lifestyle Coaching. To access the full text, click here.