Communication Strategies: Motivational Interviewing

Motivational interviewing (MI) is a patient-centered method for enhancing intrinsic motivation to change health behavior by exploring and resolving ambivalence. Numerous studies have illustrated the efficacy of MI as a promising strategy to encourage positive health behavior change around substance abuse, oral health and diet and exercise. Specifically using brief motivational interviewing around nutrition and physical activity in the context of an office visit has shown positive results in terms of health behavior change and weight lost in both the pediatric and adult populations. MI has been found to be more effective than no treatment and in many cases more effective than other active treatments. Furthermore, MI is also believed to be more cost effective than other treatments.

Using Motivational Interviewing in the Clinical Setting

Research and many years of experience indicate that motivational interviewing is an effective method for facilitating behavior change. Pediatricians are often concerned that motivational interviewing will take too much time. However, once a clinician masters the techniques of motivational interviewing, he or she will realize that this does not have to take long periods of time. In fact, it can be used very effectively in brief sessions. Furthermore, motivational interviewing can reduce your own stress and frustration by removing the burden of having to problem solve and come up with all the answers on your own. By involving your patients in the problem-solving process, you are actually increasing the odds that they will find a solution that works for them.

Motivational interviewing is a set of patient-centered communication techniques—focused on being empathetic, nonjudgmental, and supportive—which helps individuals express their own reasons for change and take responsibility for their own behavior. Some tools in your motivational interviewing toolkit include asking open-ended questions, reflective listening, sharing the agenda setting, eliciting pros and cons of change, providing information using the elicit-provide-elicit technique, inquiring about the importance and confidence of making a change, and summarizing the conversation.

Let’s look at an example…

Imagine a pediatrician speaking to a mother and son about obesity. At first, the most direct approach might seem like the best.

DOCTOR: So we need to talk about Ralph’s TV habits. He says, on average, he watches 3-4 hours of TV a day. That might seem harmless, but it’s actually very dangerous considering Ralph’s issues with weight. His time would be much better spent being active and doing something outdoors.

MOTHER: Well, doctor, we don’t have a backyard or someplace safe for Ralph to play by himself, and I don’t have time to take him to the park every day. I prefer for him to be safe with me, watching TV in the apartment, than running around in the street.

Here the doctor offered the family expert advice, but the mother seemed to get defensive and resist the doctor’s good intentions.

Now let’s see this same information conveyed, using the elicit-provide-elicit tool from our motivational interviewing toolbox…

DOCTOR: Would it be okay if we discussed Ralph’s TV habits?

MOTHER: Um, okay.

DOCTOR: We see a lot of kids these days who are watching over three hours of TV a day. This can affect their health and even their performance at school. Watching a lot of TV can contribute to weight gain, since that’s time they’re not playing outside and being active, and a lot of time kids are eating snacks like chips and sodas while they watch TV. Plus, on TV they see advertisements for unhealthy snacks and drinks that encourage them to eat even more of these foods at other times. For these reasons, the American Academy of Pediatrics recommends that children watch fewer than two hours of TV each day. How do you feel about that?

MOTHER: Well, I see what you’re saying. And I know Ralph isn’t getting as much exercise as he probably needs. I’m just not sure what to do about it.

This time, the doctor first elicited permission to discuss the boy’s TV habits. This reinforced the family’s autonomy, lowered their resistance, and made them more willing to hear what he had to say. When the doctor did provide information, he/she stated only the facts and let the family interpret the information for themselves. Finally,  the doctor elicited from the mother again, asking, “How do you feel about that?” This encouraged  the mother  to share  her  feelings and be a full partner in the conversation. This seemed like the start of a much more productive conversation than the first example we saw.
 
Now let’s look at one more tool of motivational interviewing that might be used later in this conversation: the importance-and-confidence scale...

DOCTOR: On a scale of 0 to 10, with 10 being the highest, how important is it for you to control Ralph’s screen time?

MOTHER: Um, maybe an 8.

DOCTOR: And, using that same scale from 0-10, with 10 still the highest, how confident are you that you will be able to control Ralph’s screen time?

MOTHER: (laughs) Maybe a 4.

DOCTOR: Okay, let’s talk about what factors are making you feel less confident than you want to be… In other words, what are some of the barriers that are going to make it difficult to control Ralph’s screen time?

This technique has opened the dialogue about the value the family associates with a desired behavior and their confidence in changing that behavior. From here you can begin a dialogue about desires,set specific realistic goals and simultaneously identify strategies to overcome barriers and build confidence. The way you talk with your patients really does matter and can make a difference. Consider incorporating these techniques into your practice!