Practical Application of Motivational Interviewing

Original Editor - Carin Hunter based on the course by Nick Rainey
Top Contributors - Carin Hunter and Jess Bell

Introduction[edit | edit source]

When conducting an interview, it is important to create a good rapport with your patient. There are many ways this can be achieved and, with practice, these techniques can be effectively applied. It is useful to consider how something is said and the impact this can have on the individual receiving the information. It has been shown that a person is far more willing to divulge information if they believe you are genuinely interested in them and the information they are sharing. Communication is an interactive process which involves the constructing and sharing of information, ideas and meaning through the use of a common system of symbols, signs, and behaviours.

Motivational Interviewing[edit | edit source]

Motivational Interviewing (MI) is an evidence-based intervention that helps to support health behaviour change. It was originally used to help treat substance dependency, but is now seen as an effective way to promote behaviour modification and to manage chronic diseases.[1] The model views motivation as a state of readiness to change rather than a personality trait.

Click here for more theory on Motivational Interviewing

The Spirit of Motivational Interviewing “The Spirit of MI”[edit | edit source]

There are essentially four principles, known as “The Spirit of MI” by the authors Miller and Rollnick.[2] These principles encapsulate the aim of MI and are:[3][4]

  1. Partnership
    • While the therapist is known as the clinical expert, the patient is the expert of their behaviours, motivations and attitudes. The two should respect each other and work together for the best possible outcome.
  2. Acceptance
    • The therapist should strive to hold a non-judgemental and accepting space for the patient to present their problems. They should provide positive appreciation or affirmation, support autonomy, empathy, and respect.
  3. Compassion
    • The therapist should always advocate for a patient's physical and psychological well-being.
  4. Evocation
    • A therapist should encourage the patient to develop their own plan of action themselves. This allows collaboration and offers a programme that the patient is motivated to comply with.
The Tools for Motivational Interviewing[edit | edit source]

There are five skills the therapist can practise, leading to an effective Motivational Interview. These are:[5]

  1. Expressing empathy
    • When the therapist shows empathy, it shows they are interested, accepting and understanding of the patient's situation. This in itself improves the rapport and often allows the patient to open up more.[5]
  2. Avoiding arguments
    • The therapist needs to learn to manage conflict. Starting an argument creates an unpleasant environment and the patient is unlikely to participate in the treatment plan.[5]
  3. Supporting self-efficacy
    • The therapist should show support in any optional change suggested by the patient. This helps them build confidence in their belief that they could change.[5]
  4. Developing goals
    • The patient should be the driving force behind the goal setting. The therapist should not force any goal on the patient as they won’t always align with the patient's thoughts and beliefs.[5]
  5. Rolling with resistance
    • This is a technique employed by the therapist whereby they offer ideas which could influence a patient to change their perspective. These perspectives should never be forced, argued or imposed.[5]
Steps in Motivational Interviewing[edit | edit source]

The steps of Motivational Interviewing that allow the process to work and evoke real change include:[5]

  1. Establishing rapport
    • Rapport is the relationship you build with the patient and it is based on trust and good communication.[5]
  2. Setting the agenda
    • Throughout the course of treatment, realistic targets should be set, but not imposed on the patient. The agenda should be reconsidered often and changes are welcome. Try and encourage realistic goal setting as reaching a target is very motivating.[5]
  3. Assess readiness to change
    • Assessing their eagerness to change, will give an insight into their level of motivation.[5]
  4. Re-adjust the focus
    • Make sure the focus is directed towards the patient's wants and what has motivated them to seek therapy. It needs to be clear, to the therapist, what exactly they want to change.[5]
  5. Identify uncertainty
    • If the patient is uncertain, this can be a barrier to change. Be aware and try to talk through uncertainty.[5]
  6. Encourage self-motivation
    • Help to create a positive attitude in the patient and encourage them to highlight success.[5]
Effective Communication[edit | edit source]

Motivational interviewing can help to improve the patient-therapist relationship. There are four core communication skills in motivational interviewing, which are known by the acronym OARS (see table below).[6] This stands for open-ended questions, affirmations, reflective listening and summaries.[6] These are crucial components of effective communication as they can  increase patient adherence, collaboration and satisfaction.[7]

OARS Purpose Goal
Open Ended Questions Gather crucial information that cannot be gathered from closed ended questions Cannot be answered yes or no

Allows the patient to tell their story

Affirmations Used to show acceptance and understanding Statement of appreciation
Reflective Listening Understanding the patient's thoughts and feelings and saying it back to them Statements not questions
Summaries Used for highlighting both sides of a patient's ambivalence

Provide recap to ensure understanding

Transition from one topic to another

Longer than reflections

Table 1. Core Communication Skills in Motivational Interviewing (OARS).[6]

Psychosocial Risk Factors[edit | edit source]

When conducting an assessment, the mnemonic, ABCDEFW, can help a therapist remember all relevant lines of questioning that can identify potential psychosocial risk factors.[8] This stands for Attitudes and Beliefs; Behaviours; Compensation Issues; Diagnosis and Treatment; Emotions; Family; and Work.[9][8] In 2014, Louis Gifford suggested possible starting questions and the potential information that could be gathered from each subsection.[8] Follow-up questions are often needed for further understanding.

Please see the table below with some examples of how to question for psychosocial risk factors in a patient utilising the ABCDEFW criteria.

Topic area Question Information gained
Attitudes and

Beliefs

What do you think is the cause of your pain? Fear/avoidance

● Catastrophization

● Maladaptive beliefs

● Passive attitude toward rehabilitation

● Expectations of effect of activity or work on pain

Behaviours What are you doing to relieve your pain? ● Use of extended rest

● Reduced activity levels

● Withdrawal from ADLs and social activities

● Poor sleep

● Boom–bust behavior

● Self-medication – alcohol or other substances

Compensation

Issues

Is your pain placing you in financial difficulties? ● Lack of incentive to return to work

● Disputes over eligibility for benefits, delay in income assistance

● History of previous claims

● History of previous pain and time off work

Diagnosis and

Treatment

You have been seen and examined for your pain?

Are you worried that anything may have been missed?

● Health professional sanctioning disability

● Conflicting diagnoses

● Diagnostic language leading to catastrophizing and fear

● Expectation of “fix”

● Advice to withdrawal from activity and/or job

● Dramatization of back pain by health professional producing

dependency on passive treatments

Emotions Is there anything that is upsetting or worrying you about the pain at this moment? ● Fear

● Depression

● Irritability

● Anxiety

● Stress

● Social anxiety

● Feeling useless or not needed

Family How does your family react to your pain? ● Over-protective partner/spouse

● Solicitous behavior from spouse

● Socially punitive responses from spouse

● Support from family for return to work

● Lack of support person to talk to

Work How is your ability to work affected by your pain? ● History of manual work

● Job dissatisfaction

● Belief work is harmful

● Unsupportive or unhappy current work environment

● Low educational background

● Low socio-economic status

● Heavy physical demands of work

● Poor workplace management of pain issues

● Lack of interest from employer

Table replicated with permission from Ina Diener, author of Listening is therapy: Patient interviewing from a pain science perspective.

While traditional interviews focus heavily on the intensity, duration, behaviour and nature of pain,[8] it is also necessary to ask questions associated with the patient’s beliefs. More in-depth questions should include: the patient’s current beliefs regarding their pain; their perspective on their pain experience including treatment effects; and perspective on their outlook in regards to recovery.

When considering questions to ask a patient, first ask yourself:[8]

  • What information is required?
  • Why is it important?
  • How can I phrase this question?
  • What are possible outcomes?
  • Does this knowledge affect the examination or treatment?

Immediate Response Questions and in depth questions often convert statements of fact into comparisons. They often explore a patient’s cognitions, beliefs, and experiences  regarding their pain. Below are some examples of helpful phrases and questions.[8]

  • How does that compare with….?
  • Is there any difference between…?
  • In what way….?
  • What do you think is going on with...?
  • What do you think should be done for...?
  • Why do you think...?
  • What would it take for you to get better?
  • Where do you see yourself in 3 years in regard to...?
  • What have you found to be most helpful for your...?
  • You have obviously seen many people seeking help. What are your thoughts on this?
  • What gives you hope?
  • What is your expectation?
  • If I could flip a switch and remove all your pain, what things that you have given up on would you do again?
  • How has your pain impacted your family and friends?
  • Are you angry at anyone about...? Tell me about it.
  • Has anyone made you feel like you’re “just making it up” or “it’s in your head?” Tell me about it.

Therapeutic Alliance[edit | edit source]

A strong therapeutic alliance can have positive effects on treatment outcomes for patients.[10][11] The therapist needs to be aware of how the patient is coping, their perception of the problem they are presenting with, and the impact of this problem on their life and activities of daily living.[8][12] If this is not communicated effectively at the start of an interaction, the mismatch in knowledge and beliefs could affect the therapeutic alliance.[8]

The therapist has to understand the problem from the patient's point of view - they must be aware of patient-specific beliefs and patient-specific risk factors. This will help the therapist explain the biology and physiology of the condition to the patient using a therapeutic neuroscience education (TNE) approach.[8]

Any communication strategies used during an interview need to enhance a patient's participation, and enable them to become engaged in both "problem-posing" and "problem-solving".[8] Communication strategies should enhance the patient's confidence, as well as their competence to make autonomous decisions.[8] It has been found that if clinicians are able to engage with patients with good communication skills, "patients are more satisfied with the care they receive, there is a better recall and understanding of information, and healthcare professionals experience greater job satisfaction and less work stress."[13]

Practical Interviewing Skills[edit | edit source]

When conducting an assessment, certain skills and techniques can help improve rapport and make the patient comfortable. These are beneficial in the long run as the patient will be more likely to divulge the information required instead of keeping the therapist at an arm's length.

1. Non verbal Communication[edit | edit source]

Non verbal communication is often referred to as body language.[14] It is thought to be stronger, quicker and more direct that verbal communication. Non-verbal communication is "reflex in type".[15] It is, therefore, often interpreted as more reliable and trustworthy than the spoken word. Consider if a patient's verbal and non-verbal communications are in sync or not, but remember it is important to respond appropriately to both scenarios.[15]

People respond better to individuals they can relate to. One technique that can help to increase a patient's comfort level is to mimic or match their actions.[15] This should be done naturally and in a relaxed manner,[15] so the patient doesn’t interpret it as mockery or belittling.

Always remember to acknowledge a non-verbal response as a valid answer.

Practitioner: “How has it been?"

Patient wrinkles nose.

Practitioner: “That doesn't look good. Has it been worse?”

Patient cringes.

Practitioner: "I'm sorry you feel this way. Let's chat more to try and get to the root of the problem"

2. Verbal Communication[edit | edit source]

The starting point in the relationship and treatment of a patient is effective communication. Whether this comes naturally to you or not, there are some skills that can be learnt which will make the subjective assessment more effective.[15]

The Interview[edit | edit source]

The therapist should always strive to keep control of the interview. This can be achieved by signposting. Signposting is a verbal marker indicating the direction you are taking your subjective assessment or where you are presently at in order to help your patient move through different concepts, connect the dots, and stay engaged. This can be achieved by using phrases and words to guide the patient through the consultation. There are two main types of signposting that are frequently used: introductions/ conclusions and outlining the main arguments/ the direction of the argument in paragraphs / opening phrases. We can use this skill when a patient is going off topic in order to bring them back to the original task and the agreed upon agenda.[15] Maitland[15] encourages practitioners to:

  • "Speak slowly
  • Speak deliberately
  • Keep questions short
  • Ask one question at a time"
Words That Heal[edit | edit source]

We need to think carefully when discussing medical terms with our patients. It is good to know what their base level of understanding of their condition is and to find out how much information they would like on their condition. The practitioner's focus is the health of their patients, including their metal well-being. Even if a practitioner thinks the patient should know some information, the patient may not be ready to hear it.

  • Bias[15]
    • Some people are open to suggestions and some are not. When constructing your questions, try not to show your bias in the questioning. If this is not possible, when you are expecting a yes, ask a question with a bias towards no. For example, when discussing a home exercise programme, the question “did you enjoy your exercises?’ might be biased towards a yes answer, whereas the question “I know life is busy, did you manage to get around to the exercises this week?” is more neutral.
  • Brevity[15]
    • To avoid confusion and misinterpretation, keep questions short and direct. They can be open ended, but the main goal is to let the patient talk as much as possible.  
  • Spontaneous Information[15]
    • This often gives the therapist a clue about the patient's personality and can help contextualise their symptoms.
  • Keywords[15]
    • Sometimes there is a keyword in a patient's answer that requires further questioning. It is advisable to follow up on this keyword while it is still fresh in the patient's mind. Once you have clarified the point, use signposting to move the interview back to the agreed upon agenda.
  • Errors in Verbal Communication[15]
    • When speaking to a patient, a therapist needs to be sure that they are interpreting the patient's words accurately. To do this, the therapist needs to check regularly that the patient is still interpreting what is being said correctly. If not, the therapist needs to clarify and explain areas of confusion. There are three key areas a therapist may need to work on when conducting an interview:
      • Unclear statements[15]
        • When speaking to the patient, always remember to check that the patient is on the same page as you and ask if they have any questions.
      • Misinterpreting[15]
        • Patients can use catastrophising language or use words that downplay their condition, depending on their personality, pain levels and beliefs around the cause of pain. If the interview is not conducted in the patient's main language, there may be additional communication challenges. The therapist should remain non-judgemental and sensitive to the patient's views.
      • Assuming[15]
        • Never assume, always check and confirm meaning. For example, if a patient tells you “The pain never goes away”, it might be a good time to dive deeper into the 24 hour pattern of their pain, fluctuating symptoms, aggravating and easing factors. This helps provide a clear picture to the therapist if the patient is describing a true red flag or if emotions / other factors are impacting the portrayal of their experience.

Please see the two examples below regarding interviews. The video on the left shows an example of a poor interview while the video on the right shows an example of a good interview.

References[edit | edit source]

  1. Bischof G, Bischof A, Rumpf HJ. Motivational interviewing: An evidence-based approach for use in medical practice. Deutsches Ärzteblatt International. 2021 Feb;118(7):109.
  2. Rollnick S, Miller WR. What is Motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995 Oct;23(04):325.
  3. Johnston L, Hilton C, Dempsey F. Practical guidance on the use of motivational interviewing to support behaviour change. ERS Monograph: Supporting Tobacco Cessation. European Respiratory Society. 2021:56-75.
  4. Svensson M, Wagnsson S, Gustafsson H. Can motivational interviewing be a helpful professional tool? Investigating teachers' experiences. Educational Research. 2021 Oct 2;63(4):440-55.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 Bundy C. Changing behaviour: using motivational interviewing techniques. J R Soc Med 2004;97 Suppl 44:43-47.
  6. 6.0 6.1 6.2 Breckenridge LA, Burns D, Nye C. The use of motivational interviewing to overcome COVID‐19 vaccine hesitancy in primary care settings. Public Health Nursing. 2022 May;39(3):618-23.
  7. Borrelli B, Riekert KA, Weinstein A, Rathier L. Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. J Allergy Clin Immunol 2007;120(5):1023-30.
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 Diener I, Kargela M, Louw A. Listening is therapy: Patient interviewing from a pain science perspective. Physiotherapy theory and practice. 2016 Jul 3;32(5):356-67.
  9. Anzelmo A. Healthcare/Patient Interactions and the Possible Pitfalls – A Narrative Review. Journal of Rheumatology, Orthopedics and Sports Sciences.2022
  10. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy. 2013 Apr 1;93(4):470-8.
  11. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy. 2010 Aug 1;90(8):1099-110.
  12. Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiotherapy theory and practice. 2016 Jul 3;32(5):385-95.
  13. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Physical therapy. 2010 Sep 1;90(9):1345-55.
  14. Burgoon JK, Manusov V, Guerrero LK. Nonverbal communication. Routledge; 2021 Sep 6.
  15. 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 15.12 15.13 15.14 Maitland GD. Vertebral manipulation. Elsevier Health Sciences; 1986 Mar 20.