How to help people change unhealthy behaviors

Motivational Interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” – Miller & Rollnick, 2002

“Helping people talk themselves into changing”

Changing behavior (or changing habits) can be very difficult for most of us. Telling a friend or family member that they need to stop smoking cigarettes often isn’t enough to change his or her behavior. 

Motivational interviewing is an evidenced-based therapeutic technique to encourage individuals to find their own motivation for change by recognizing their resistances to change.  By identifying our fears and ambivalences about change, we can work to overcome them. This is not a series of techniques therapists use to “trick” us into changing. Instead, it’s a skillful bedside manner for sparking inner motivation to make changes. 

Motivational Interviewing is about guiding more than directing, eliciting more than imparting, and listening at least as much as telling. It is effective across populations and cultures, improves adherence and retention in care (by involving individuals in their own care), and reduces clinician burnout. 

Guiding Principles of Motivational Interviewing

Resisting the “righting” reflex

It is tempting to tell people they should change. But this is rarely effective. The “righting” reflex is our immediate tendency (or urge) to advise others what they should or shouldn’t do. Although the advice comes from good intentions, it rarely works. 

Understanding and exploring the individual’s own motivation

It is important to understand why the individual wants to change and what fears or ambivalences are working against them. What are both the positives and negatives of changing a behavior? What does the individual fear will happen if he or she makes a change? What does the current behavior provide, if anything, for the individual? Many people who want to stop smoking find it difficult because they enjoy the stress-relieving qualities of smoking cigarettes. Exploring and better understanding an individual’s ambivalence is a key part of motivational interviewing. 

Listening with empathy

People are more likely to change when they feel validated rather than discouraged. Active listening is a key principle of motivational interviewing. Active listening shows a level of understanding and empathy that can be very powerful in encouraging change. 

Empowering and instilling hope and optimism

Empowering others to change requires cultivating an optimistic and hopeful attitude.

What is Motivation?

Motivation is the reason(s) one has for acting or behaving in a particular way. It is the willingness of someone to do something. Motivation is multidimensional, dynamic, and has external and internal factors. It is the key to change. Motivation can be elicited and enhanced and is an important factor in someone’s readiness to change. 

There are two important dimensions of motivation

Importance: the “why” of change

Confidence: the “how” of change

There are three components of Motivation:

(1) Ready: a matter of priorities

(2) Willing: importance of change

(3) Able: confidence to change

The ABCs of Motivation and Change:

A) Accept: The individual must accept that the behavior is a problem

B) Believe: The individual must believe that they will be better off if they change

C) Confidence: The individual must have confidence in their ability to change

 

6 Stages of Change

(1) PrecontemplationNo way I can do this. Nope. Not happening! (Denial)

(2) ContemplationOkay, maybe I can do this. (Ambivalent)

(3) Determination/PreparationLet’s do this! (Motivated)

(4) ActionI’m doing it!

(5) MaintenanceI’m continuing it. I’m living it!

(6) Relapse/RecycleUgh! Okay, I’m back to 1…

The OARS Tool

The OARS tools is a way to remember techniques and strategies for enhancing motivation in others (such as our clients or patients).
 

O: Open-Ended Questions

Open-ended questions encourage clients or patients to talk more and helps us learn about their concerns.

What makes you feel it might be time for a change?

Can you tell me more about that?

What have you noticed about your ____?

What concerns you most?

How would you like things to be different?

What will you lose if you give up drinking?

What have you tried before?

What do you want to do next?

A: Affirmations

Affirmations are statements that show recognition of a client’s or patient’s attempts at change. Examples include:

“So you’ve started walking this past week!”

“You didn’t want to come today, but you did!”

“You are down to 5 cigarettes/day?! That’s great! You were smoking 8 cigarettes last week!”

R: Reflective Listening

Reflective listening means listening and trying to understand the patient’s point of view even if you disagree with it. It means communicating your understanding of the client’s or patient’s experience, behavior and/or feelings from their point of view. The following are not congruent with reflective listening:

Ordering, directing or commanding

Warning, cautioning or threatening

Giving advice, making suggestions or providing solutions or providing solutions

Persuading with logic, arguing, lecturing

Telling people what they should do Telling

Disagreeing, judging, criticizing or blaming

S: Summarizing

Summarizing is a special form of reflective listening that ensures clear communication and is used at transitions in conversation. Try to be concise and bring up the patient’s ambivalence/resistance to change. 

“Let me see if I understand thus far…”

The four (4) major tasks of the clinician

(1) Express Empathy

(2) Develop Discrepancy

(3) Roll with Resistance

(4) Support Self-efficacy

 
Examples of questions used in MI to motivate the patient, explore ambivalence, and minimize resistance

What are some of the good things about X behavior?

People usually do X because they feel it helps in some way. How has it helped you?

What do you like about the effects of X? 

What would you miss if you weren’t doing X?

Can you tell me about the down side?

What are some aspects you are not so happy about?

What are the things you wouldn’t miss?

If you continued as before, how do you see yourself in a couple of years from now if you don’t change?

On a scale of 1-10, how important is it to you to change X behavior?

Why did you give it a higher # and not a (lower #) ?”

What would have to happen to raise that score from # to #

Below are additional resources for motivational interviewing: 

References

  1. McCarron, Robert M., et al. Lippincotts Primary Care Psychiatry: for Primary Care Clinicians and Trainees, Medical Specialists, Neurologists, Emergency Medical Professionals, Mental Health Providers, and Trainees. Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.
  2. Focus Psychiatry Review, Dsm-5: Dsm-5 Revised Edition by Deborah J. Hales (Author, Editor), Mark Hyman Rapaport (Author, Editor)
  3. Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
  4. Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
  5. Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th
  6. Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia :Lippincott Williams & Wilkins, 2000.
  7. Motivational Interviewing | Psychology Today
  8. Understanding Motivational Interviewing | Motivational Interviewing Network of Trainers (MINT)

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: