Motivational interviewing is a technique in which you become a helper in the change process and express acceptance of your client. It is a way to interact with substance-using clients, not merely as an adjunct to other therapeutic approaches, and a style of counseling that can help resolve the ambivalence that prevents clients from realizing personal goals.
Motivational interviewing builds on Carl Rogers’ optimistic and humanistic theories about people’s capabilities for exercising free choice and changing through a process of self-actualization. The therapeutic relationship for both Rogerian and motivational interviewers is a democratic partnership. Your role in motivational interviewing is directive, with a goal of eliciting self-motivational statements and behavioral change from the client in addition to creating client discrepancy to enhance motivation for positive change.
Essentially, motivational interviewing activates the capability for beneficial change that everyone possesses. Although some people can continue change on their own, others require more formal treatment and support over the long journey of recovery. Even for clients with low readiness, motivational interviewing serves as a vital prelude to later therapeutic work.
What are the 4 principles of motivational interviewing?
The four guiding principles of motivational interviewing in general practice for health care are represented by the acronym RULE:
- Resist the righting reflex
- Understand the patient’s own motivations
- Listen with empathy
- Empower the patient.
Resist the righting reflex. The righting reflex describes the tendency of health professionals to advise patients about the right path for good health. This can often have a paradoxical effect in practice, inadvertently reinforcing the argument to maintain the status quo. Essentially, most people resist persuasion when they are ambivalent about change and will respond by recalling their reasons for maintaining the behavior. Motivational interviewing in practice requires clinicians to suppress the initial righting reflex so that they can explore the patient’s motivations for change.
Understand your patient’s motivations. It is the patient’s own reasons for change, rather than the practitioner’s, that will ultimately result in behavior change. By approaching a patient’s interests, concerns, and values with curiosity and openly exploring the patient’s motivations for change, the practitioner will begin to get a better understanding of the patient’s motivations and potential barriers to change.
Listen with empathy. Effective listening skills are essential to understand what will motivate the patient, as well as the pros and cons of their situation. A general rule of thumb in MI is that equal amounts of time in a consultation should be spent listening and talking.
Empower your patient. Patient outcomes improve when they are an active collaborator in their treatment. Empowering patients involves exploring their own ideas about how they can make changes to improve their health and drawing on the patient’s personal knowledge about what has succeeded in the past. A truly collaborative therapeutic relationship is a powerful motivator. Patients benefit from this relationship the most when the practitioner also embodies the hope that change is possible.
RULE is a useful mnemonic to draw upon when implementing the spirit of MI in general practice. If a practitioner has more time, the following four additional principles as presented in the table below can be applied within a longer therapeutic intervention.
Four Additional Principles of Motivational Interviewing
In practical terms, an empathic style of communication involves the use of reflective listening skills and accurate empathy, where the practitioner seeks to understand the patient’s perspective, thoughts, and feelings without judging, criticizing, or blaming. Building empathy and understanding does not mean the practitioner condones the problematic behavior. Instead, the practitioner seeks to create an open and respectful exchange with the patient, who they approach with genuine curiosity about their experiences, feelings, and values.
Assisting patients to identify discrepancies between their current behavior and future goals or values about themselves as a person, partner, parent, or worker is a powerful motivator that helps ‘tip the balance’ toward change. Exploring the pros and cons of change can help a patient develop discrepancies. These ‘decisional balance’ exercises are used effectively in MI to help patients tease apart their ambivalence and help the patient express their concerns about the behavior.
|Roll with resistance
Often when a practitioner attempts to move a patient toward change too quickly because the risks of the behavior are significant or they perceive that there are time pressures for change, they adopt a coercive or authoritative style. If the patient is ambivalent about change, this approach will commonly be met with resistance from the patient. Resistance takes many forms but most commonly can be described as interrupting or arguing with the practitioner, discounting the practitioner’s expertise, excusing their behavior, minimizing the effects of their behavior, blaming other people for their behavior, being pessimistic about their chances to change or being unwilling to change altogether. In MI, rolling with this resistance involves approaching resistance without judgment and interpreting these responses as a sign that the patient holds a different perspective from the practitioner. MI then uses strategies such as simple reflection of the resistance, emphasizing the individual’s choice to change or not (‘it’s up to you’), shifting the focus of the discussion, or simply reframing what the person has said, in order to roll with resistance and prevent resistance from affecting engagement.
Many people with enduring behaviors that have negative impacts on their health have made their own attempts to change at some time or other and been unsuccessful. They may have attempted to cease smoking and only lasted a week, or tried to lose weight but been unable to sustain a diet. They may have attempted to comply with their medication several times in the past but found it difficult because of side effects or a complicated dosing regimen. By highlighting the patient’s strengths and reflecting on times in their life when they have successfully changed, even if just in one small area, self-efficacy can be promoted. The practitioner’s belief in a patient’s ability to change is a powerful way to promote self-efficacy. By promoting self-efficacy, the practitioner can help the individual develop the confidence that they are capable of change