Practical Application of Motivational Interviewing

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

Introduction

When conducting an interview, it is important to create a good rapport with your patient. There are many subtle ways we can achieve this and a lot of the techniques, when practised, can be learnt and effectively applied. It is very important to consider how something is being said and the impact that can have on the individual on the receiving end. 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

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. The model views motivation as a state of readiness to change rather than a personality trait.

The Spirit of Motivational Interviewing “The Spirit of MI”:

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

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 the aspects that they are each and expert in 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 from within. This allows collaborations and offers a program that the patient is motivated to comply with.

The Tools for Motivational Interviewing:

There are five skills the therapist can practise which can lead to an effective Motivational Interview. These are:

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..
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.
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
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. 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.

Steps in Motivational Interviewing

The steps in Motivational Interviewing that allow the process to work and evoke real change include:

1. Establishing rapport
   • Rapport is the relationship you build with the patient and it is based on trust and good communication.
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.
3. Assess readiness to change
   • Assessing their eagerness to change, will give an insight into their level of motivation.
4. Re-adjust the focus
   • Make sure the focus is directed towards the patients wants and what has motivated them to seek therapy. It needs to be clear, to the therapist, what exactly they want to change.
5. Identify uncertainty
   • If the patient is uncertain, this can be a barrier to change. Be aware and try to talk through uncertainty.
6. Encourage self-motivation
   • Help to create a positive attitude in the patient and encourage them to highlight success.

Effective Communication

Motivational interviewing can help to improve the patient-therapist relationship. One anagram to remember under this umbrella and employ in your communication toolbox is OARS. This stands for open-ended questions, affirmations, reflective listening and summaries. These are crucial components of effective communication as they can  increase patient adherence, collaboration and satisfaction.

Please find a good summary of OARS in the table below:

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 patients thoughts and feelings and saying it back to them	Statements not questions
Summaries	Used for highlighting both sides of a patients ambivalence Provide recap to ensure understanding Transition from one topic to another	Longer than reflections

Psychosocial Risk Factors:

When conducting an assessment, the mnemonic, ABCDEFW, can help a therapist remember all lines of questioning that can identify any potential psychosocial risk factors. This stands for Attitudes and Beliefs; Behaviours; Compensation Issues; Diagnosis and Treatment; Emotions; Family; and Work. Gifford (2014) suggested possible starting questions and the potential information that could be gathered from each subsection. 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

While traditional interviews focus heavily on the intensity, duration, behaviour and nature of the patient’s pain, questions more associated with the patient’s beliefs may be needed. 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 forming questions to ask a patient, first ask yourself:

• What information is required
• Why is it important
• How to phrase it
• 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 qustions.

• 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

The alliance between practitioner and the patient can have a positive effect on treatment outcome (Ferreira et al, 2013; Hall et al, 2010). A biopsychosocial approach in healthcare needs the transformation of the interview toward patient-centred care, which holds the key to personal, responsive, and fulfilling communication between patients and clinicians (Roter, 2000). The PT therefore, first needs to know how the patient is doing, their perception of their own problem, how the problem impacts their life, and vice versa, and how their lifestyle impacts their problem (Jones and Rivett, 2004; Maitland, 1986). If this is not established, there could easily be a mismatch between the patient and practitioner which makes forming a therapeutic relationship very difficult (Ferreira et al, 2013).

Understanding the patient’s unique experience is essential to discovery of the patient-specific beliefs and risk factors that will serve as the “target” when educating a patient about the biology and physiology of their pain experience in a therapeutic neuroscience education (TNE) approach (Louw, Diener, Butler, and Puentedura, 2011; Moseley and Butler, 2015). Communication strategies utilised during the interview should enhance patient participation, contribute to patient engagement in problem-posing and problem-solving, and facilitate patient confidence and competence to make autonomous decisions. With good clinical communication, 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 (Bialosky, Bishop, and Cleland, 2010).

Practical Interviewing Skills

When conducting an assessment, there are a few skills we can employ that can help with improving rapport and making the patient comfortable. These will benefit you in the long run as the patient will be more likely to divulge the information required instead of keeping you at an arms length.

1. Non verbal Communication

Non verbal communication is also often referred to as body language. As opposed to verbal communication, it is thought to be stronger, quicker and more direct. Non-verbal communication is often thought of as an involuntary reflex and is therefore interpreted as more reliable and trustworthy than the spoken word. One aspect to look out for in a patient is whether the verbal and non-verbal communications are in sync or not. Both scenarios should be taken note of and responded to appropriately.

People respond better to individuals that they can relate to, and one technique to employ is to mimic their actions as this can be shown to increase the patients comfort level. Sit with your hands or legs in a similar position to the patient. This mimicry should be done genuinely and in a relaxed manner so the patient doesn’t interpret this 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

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.

The Interview

The therapist should always strive to keep control and order to the interview. This can be achieved by Signposting. Signposting is 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 help them stay engaged. This can be achieved by using phrases and words to guide the patient through the consult. There are two main types of signposting that are frequently used: introductions/ conclusions and outlining main arguments/ the direction of the argument in paragraphs/opening phrases This is a skill we can use when the patient is going off topic to bring them back to the original task at hand and the agreed upon agenda.

• Speak slowly
• Speak deliberately
• Keep questions short
• Ask one question at a time

Words That Heal

We need to think carefully when discussing medical terms with our patients. It is good to know what their base level of understanding of the condition is and to find out how much information they would like on their condition. Practitioners need to be aware that our focus is the health of our patients, that includes their metal well-being. Just because a practitioner thinks the patient should know some information, it doe not always mean that the patient is ready to hear it.

• Bias
  • Some people are open to suggestions and some are not. When constructing the questions, try not to show your bias in the questioning. If it is not possible, when you are expecting a yes, ask the question with a bias towards no. For example, when discussing the home program,  “Did you enjoy your exercises?’ Leans towards a yes, where as, “I know life is busy, did you manage to get around to the exercises this week?” is less judgemental of the answer already.
• Brevity
  • To avoid confusion and misinterpretation, keep the 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
  • This often gives the therapist a clue about the patients personality and can help contextualise the symptoms.
• Keywords
  • Sometimes there is a keyword in a patient's answer that requires further questioning. It is advised to follow up on that keyword while it is in the patient's current train of thought. Once you have clarified the point, use signposting to move the interview back to the agreed upon agenda.
• Errors in Verbal Communication
  • When speaking to a patient, a therapist needs to be sure that they are interpreting the patient's words accurately. To do this, they need to check regularly that they are still interpreting what is being said correctly. If not, they need to clarify where they were confused. There are three areas where the physio usually falls short when conducting an interview.
• Unclear statements.
  • When speaking to the patient, always remember to check that the patient is on the same page or if they have any questions.
• Misinterpreting.
  • Patients can use catastrophizing language or use words that downplay their condition, depending on their personality, pain levels and beliefs around the cause of pain. If the language used when conducting the interview is not the patients spoken language, the conversation may be broken or interrupted by hand gestures when the patient cannot find the correct word. The therapist should remain non-judgemental but sensitive to the patient's views.
• Assuming
  • Never assume, always check and confirm meaning. For example, if a patient tells you “The pain never goes away”. This might be a good time to dive deeper into 24hour pattern of pain, fluctuating symptoms, aggravating and easing factors. There help to provide a clear picture to the therapist if the patient is describing a true red flag or if they are emotionally portraying their experience.