MOTIVATIONAL INTERVIEW

Motivational Interview is a style of patient-practitioner communication that is specifically designed to resolve ambivalence about, and build motivation for, behavior change.
Focus: Motivational Interview focuses on creating a comfortable atmosphere without pressure or coercion to change.
Aim: To help patients better understand their reasons for and against change
Thus to help them make informed decisions about whether or not to change and to feel more intrinsically invested in the decisions.
Hence first it helps make patients take the crucial decision to change and only then does it provide patients with solutions or problem solving.
Process: Motivational Interviewing involves careful listening and strategic questioning, rather than teaching, in order to help patients resolve their ambivalence about change.
Requisite skills: Questions aim to help their subjects think more deeply about issues, use reflective listening to clarify and understand the subject, and approach the subject in a nonjudgmental manner so that information is shared in a truthful and unbiased manner. Focus: MI is patient-centered, in that it focuses on the concerns and the perspectives of the patient, rather than those of the practitioner. This simply means that listening first to the patient can provide invaluable information that would otherwise not be known.
In short: OARS [open-ended questions; affirmations; reflective listening; summaries]

Among thesse the process of reflective listening has been elaborated.
Reflective listening involves taking a guess at what the patient means and reflecting it back in a short statement. The purpose of reflective listening is to keep the patient thinking and talking about change. Several types of reflections are useful, all of these should be crafted as statements rather than as questions, which allows the patient to elaborate on their ideas.
Repeating. This is the simplest form of reflection, often used to diffuse resistance.
Rephrasing. Slightly alter what the patient says in order to provide the patient with a different point of view. This can help move the patient forward.
Empathic reflection. Provide understanding for the patient's situation.
Reframing. Much as a painting can look completely different depending upon the frame put around it, reframing helps patients think about their situation differently.
Feeling reflection. Reflect the emotional undertones of the conversation.
Amplified reflection. Reflect what the client has said in an exaggerated way. This encourages the client to argue less, and can elicit the other side of the client's ambivalence.However it is important to have a genuine, not sarcastic, tone of voice).
Double-sided reflection. Acknowledge both sides of the patient's ambivalence.

As practitioners we must remember that medical nonadherence is more the norm than the exception. Two critical steps must occur before educating the patient and problem-solving any barriers to change:
(1) building the patient's motivation for changing the behavior (eg, smoking, medication adherence); and
(2) building the patient's motivation for treatment .
The practitioner cannot begin to educate the patient and help remove barriers to treatment adherence unless he or she first addresses motivation. Commonly encountered problems are premature problem-solving which leads to patient resistance; for example, "I've tried that and it doesn't work" or "Your'e right, but... I really need the cigarettes to calm me down." Thus, education and problem solving may be effective for those who are ready and willing to change, but is less so for those who are not ready or are unwilling to change.


Providing education to those who are not yet ready/ not thinking about change constitutes an interventional "mismatch" in that the patient feels pressure to do something about which they are ambivalent. Education can have a paradoxical effect on motivation, actually reducing, rather than increasing, motivation to change.
People who are ambivalent about change have a natural tendency to present arguments from the opposing side of their ambivalence. Therefore, if the practitioner states the reasons for initiating change, the natural tendency of the patient is to state the reasons for not initiating change. The ambivalent person is genarally moved to the opposite side of the ambivalence by the very act of defending it.
MI capitalizes on the idea that if people can talk themselves out of change, they can also talk themselves into change.
THus the primary aim of MI is to elicit from patients their own "change talk" (positive statements about change) and their own reasons and arguments for change.Thus it is the act of verbally defending change (and hearing oneself do so) in the absence of coercion that causes the person to change in attitude and behavior. Research indicates that the more patients hear themselves argue for change, the more committed they become to that change.


Ambivalence
The concept of resolving ambivalence is central to MI. This follows Approach Avoidance Conflict Theory.
Wrong Approach-Typically, when practitioners encounter a person who is ambivalent about change, they persuade and lecture the patient to change his or her mind. This approach only entrenches the ambivalent patient further into his or her position of not changing, because the patient begins to argue the opposite side .
However ambivalence is a central part of the natural process of change, a phase that people must go through before fully committing to a decision. Accepting change without a full consideration of the pros and cons of changing could lead to "buyers' remorse" and early relapse. The role of the practitioner is to help patients resolve their ambivalence and empathize with their ambivalence, not argue for change.
Table 1. Contrasting Communication Styles
Standard Approach Motivational Interviewing Approach
• Focused on fixing the problem Focused on patient's concerns and perspectives
• Paternalistic relationship Egalitarian partnership
• Assumes patient is motivated Match intervention to patient level
• Advise, warn, persuade Emphasizes personal choice
• Ambivalence means that Ambivalence: normal part of the change process
the patient is in denial.
• Goals are prescribed Goals are collaboratively set; patient is given a menu
of options.
• Resistance is met with Resistance: interpersonal pattern influenced by provider
argumentation and correction behavior

Change as a Continuum Rather Than a Discrete Event
Prochaska and DiClemente's stages of change model, which theorizes that people go through a series of stages before taking action for change.
These stages are:
1)Precontemplation: the person is not thinking about change;
2)Contemplation: the person is thinking about change and perhaps is starting to weigh the pros and cons of change;
3)Preparation, during which the person is actually taking steps to change;
4)Action, during which the person initiates the change;
5)Maintenance, during which the person adheres to the change for at least 6 months.
Those who are in earlier stages need to build their motivation and confidence for change; those in later stages need more education about how to change and how to prevent relapse.
Practitioners can assess the stage of change as a measure of patient motivation, or simply use a 1-10 scale (like a pain scale), in which "1" is not at all motivated to change and "10" is very motivated to change. This allows the practitioner to calibrate the counseling approach to the patient's level.


Motivational advice must include 5 components, which can be remembered with the mnemonic, "RAISE":
Relationship with the patient;
Advice to change;
"I" statements ("I am not going to pressure you to change");
Support for patient autonomy when making the decision; and
Empathy.
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