At any given time, I’m typically involved in planning training for healthcare staff on one topic or another. One of the projects I’m currently working on is teaching staff some of the basics of motivational interviewing (MI). MI is considered a form of nondirective psychotherapy, originally conceptualized and piloted for use with problem drinkers, and pioneered by two psychologists, Bill Miller and Steve Rollnick.
MI is “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” It’s not as much a form of psychotherapy as it is a way of guiding a conversation between a healthcare provider and a patient in order to help people think a little differently about their situation.
MI couldn’t have come too soon — according to some experts, between 80 and 90 percent of all healthcare problems come about because of poor health behaviors. So, if we could help these patients make better choices somehow, well, we’d all be better off!
In order to understand the basic premise of MI and why it was so completely revolutionary to the practice of psychotherapy, mental health counseling, and healthcare in general; you have to consider what the default, traditional approach in any healthcare relationship has been, and pretty much continues to be. You go to a doctor, they tell you what you need to do to get healthier, and then you do it. I call it the “directive” approach, based on convincing (or some would call ‘nagging,’ perhaps) — the desire or the aim is to “fix” a patient.
MI’s basic premise is that human beings have a strong drive to be independent, to make our own decisions, and that motivation comes from within.
MI changes that dynamic. Instead of just trying to nag, convince, and direct a person to do what they need to do (and eliciting what in the clinical parlance is termed variously as resistance, reactance, and noncompliance), MI instead employs a basket of tactics and approaches, such as active listening, the use of open-ended questions, and reflections in order to help the client discover their inner motivation for change. Here is a nice, simple acronym to remember the basic skillset involved in using MI — called OARS — or, Open-ended questions, Affirmations, Reflections, and Summary statements (there are other skills and approaches used by MI practitioners, far too many to cover in a short article, but you can read more about it here).
Counseling a Patient on Health Behavior Change — The Case of Fictional Mr. Jones
Let’s use a fictional example to illustrate how to counsel a patient on changing their health behaviors for the better — the case of Mr. Jones. Mr. Jones is overweight and he smokes. His family ‘nags’ him about it from time to time, and he eventually decides to go visit his doctor, perhaps just to placate them. Mr. Jones knows his eating habits and smoking are unhealthy, but he feels that with the stresses he has at work and home, he can’t imagine making big changes in his health behaviors just yet.
Here’s the exchange:
Physician: “Hello Mr. Jones, it’s been awhile, how have you been?”
Mr. Jones: “I guess I’m alright. My family has been encouraging me to come and talk to you about my weight and my smoking habit. Otherwise I have no complaints.” (Mr. Jones take a deep breath, not sure what comes next)
Physician: “Yes, you’re mildly obese and I understand you smoke about a half-pack of cigarettes a day. Obviously, you need to stop eating so much and you should quit smoking right away, or else you’re risking an early death.”
Mr. Jones: “I know all that, doc, but I don’t think it’s all that easy. I have a lot of stress at work and I’ve been eating this way for years.” (Mr. Jones starts getting annoyed – he knows all of this and feels belittled.)
Physician: “I can prescribe you some nicotine gum, that might help. And here’s a pamphlet that tells you how to start counting calories. You just need to start doing it and making it a habit.”
Mr. Jones: “OK, I’ll take the pamphlet, and you can prescribe me the gum, but I don’t think I’m ready to do this all just yet.” (Mr. Jones gives up on arguing, feeling defeated. Wants to talk about something else.)
Physician: “Well, how about just cutting down on smoking then? Maybe skipping dessert every other meal and cutting down on snacks?”
Mr. Jones: “OK doc.”
So, how do you imagine Mr. Jones is feeling here? How likely do you think he is of changing his behavior, cutting down on the smoking and overeating?
This is the thing — the traditional biomedical / counseling approach is really not much more than this. Someone has a health problem, and so the default stance is, well, we just convince them (via education and perhaps some nagging) to straighten up and fly right.
But obviously, Mr. Jones knows his health is at risk because he’s overweight and smoking. He doesn’t need the doctor to tell him that – yet the doctor does, anyways — and basically he leaves the medical appointment feeling somewhat angry (much like he feels when his family nags him about his health), not listened to, and perhaps even a bit pushed around. His likelihood of changing his behavior is still fairly low.
MI’s basic premise is that human beings have a strong drive to be independent, to make our own decisions, and that motivation comes from within — and can’t be imposed from without. Moreover, as caring professionals, caregivers, and family members ratchet up our attempts to direct our loved ones to change their health behaviors for the better, our loved one’s will, more often than not, ratchet up their resistance to change — because sometimes, that’s all one can do to maintain one’s own independence.
Instead of ratcheting up one’s attempts at directing / convincing Mr. Jones to straighten up and fly right (perhaps to somehow “break through” Mr. Jones’ resistance), the MI approach recommends that the doctor instead utilize a different set of approaches. The exchange might instead look more like this:
Physician: “Hello Mr. Jones, it’s been awhile, how have you been?”
Mr. Jones: “I guess I’m alright. My family has been encouraging me to come and talk to you about my weight and my smoking habit. Otherwise I have no complaints.”
Physician: “OK. It sounds like your family has been expressing some concern about your smoking and weight. How do you feel about that?” (Physician provides a summary statement, and follows it with an open-ended question.)
Mr. Jones: “Oh, well, I guess sometimes I get annoyed by my family. I know the smoking isn’t healthy, and I know my eating sometimes gets out of control, but I have a lot of stress and sometimes I just need my crutches.”
Physician: “So, it sounds like you’re aware your smoking and overeating are unhealthy, and at the same time, you have lots of stress from work and your family’s way of expressing their concern for your health doesn’t help that.” (Physician provides a double-sided reflection.)
Mr. Jones: “Yes, doc. I think you’ve got it. I have really no idea how to start making healthy changes when I’ve got all this on my plate.”
Physician: “Well, I think you’re doing a great job being so honest with me about the difficulties you’re clearly facing. Can we talk some more about some healthy changes you might be able to make?” (Combines an affirmation with an empathetic statement.)
Mr. Jones: “OK doc.”
See the difference? Mr. Jones ends up in a much better place after the second exchange — because of the physician’s use of open-ended questions and summarization, empathetic statements, and affirmations, Mr. Jones ends up feeling listened to and respected in the exchange with his doctor, and much more likely to calmly reflect with the doctor on what he needs to do to start making healthy changes.
Older Adults and Behavior Changes
Older Adults are frequently asked to make health behavior changes more often than younger adults. How can this be? Well, when you think about it, aging is often full of changes. In general, the longer you’ve been on this earth the more likely you are to develop a chronic health condition (or two), which may require some adaptations to one’s lifestyle and behaviors. Older adults are asked to take new medications, restrict their activities beyond what they’re used to (perhaps give up driving, etc.), and take new measures to improve their safety and functioning that may take some getting used to.
Classic example: using a walker. I like the example of using a walker because it really gets to the heart of the struggle faced by our older adult loved ones and clientele. Again, at the heart of MI is the idea that basically, positive therapeutic change only tends to come about when we feel that it’s our idea, not when the idea is imposed upon us by others. And what is a better example of how to threaten the independence of an older adult then telling them they need to use this walker thing to get around, or else?
The rest of us — when we want to get up from the couch and go to the refrigerator for a snack or what have you — we can just do it. When we’re in public, we can be like everyone else, but those of us who have to use walkers? We have to be marked as older adults, dependent — it’s a tough pill for a number of older adults to swallow. Add on top of that the interpersonal element of family and friends, defaulting typically to the traditional, convince-and-cajole approach — again, where the stance is we just need to educate, direct, and perhaps even threaten a person to do something until they do it — and you end up with a lot of “stubborn” older adults who fall a lot.
Motivational Interviewing Has Endless Applications
Aside from the above issue of using a walker, I can imagine MI as having endless applications/benefits with older adults in other areas — again, aging is sometimes a process that brings with it many changes, some that are often very difficult to cope with. Some other examples:
- Giving up driving
- Having to test one’s blood sugar
- Change one’s eating habits
- Living with a family member or caregiver
- Taking new medications
- Restricting one’s physical activities as per doctor’s recommendations
And yet, in my research, I have not seen a lot of material featuring older adults in the works of MI practitioners. I found this curious, because as the aging of the Baby Boomers continues apace in this country, I am betting that this will change. In my personal (not my professional) experience, Baby Boomers are one of the most stubborn groups of older adults I’ve encountered.