Helping Patients Understand the Voice WithinFriday, March 02, 2012
Motivational interviewing is a way for providers to counsel their patients helping them to understand the differences between their current behaviors and guide them to a path towards desired behaviors. Susan Dopart, RD, CDE, (pictured here) uses the technique with her diabetes patients as an alternative for those ambivalent clients who know they need to make lifestyle changes but cannot move forward.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
If motivational interviewing had to be broken down to the simplest of terms, it might be best defined as helping people organize their thoughts by facilitating the right set of questions to the patient, so that they can have an “Aha” moment and realize what is keeping them from their goals.
Motivational interviewing is delivered to patients as a gentle non-confrontational way to help people understand their desires and how to reach them as goals. It may be seen being one-part compassion, one-part assertive coaching.
Motivational interviewing was developed by two clinical psychologists, William Miller, PhD, and Stephen Rollnick, PhD, who later collaborated on two books on the subject. Miller and Rollnick’s technique was originally used as a way to assist people with substance abuse issues in therapy. With motivational interviewing being very effective in that realm, it was adopted by the healthcare industry several years.
For medical providers who are interested in learning and applying it to patients there is a great deal of complexity. Providers who practice motivational interviewing have to learn how to give patients reflections as well as be able to recognize what stage of change the patient is in.
Susan Dopart, MS, RD, CDE, was already well-established in the nutrition industry working in private practice for several years when she began exploring ways to varying her style and approach with some of her clients. Dopart found that you could provide unmotivated clients with lifestyle advice, but if they were not ready to make changes, not much was going to be accomplished.
In trying to break through that wall and be more effective with these clients, she picked up Miller and Rollnick’s book, Motivational Interviewing: Preparing People for Change. She later attended a two-day workshop given by psychologist Joel Porter. While she was intrigued by the concept, it wasn’t until she attended a motivational interviewing conference in Switzerland where she made the decision to pursue it. Dopart went on to enlist the help of a coach, and after years of utilizing it in her practice, she now teaches it to other medical providers.
Dopart’s practice is multifaceted as she sees children and adults with varying degrees of insulin resistance. On a given day, she might see a child with type 2 diabetes, an adult with metabolic syndrome, and a pregnant woman with gestational diabetes. Dopart believes motivational interviewing is most effective in clients who are ambivalent about making a change in their self-management, and are not moving forward to achieve a desired behavior.
DiabetesCare.net spoke to Dopart about how she uses motivational interviewing in her practice, and why she believes it can be more effective than traditional methods.
Diabetescare.net: Can you provide an overview of what motivational interviewing is?
Dopart: I believe it is a better way to talk to patients to help them get to the place they want to go. You are gently guiding the person, using reflections and looking for the back story for what someone is not telling you.
Once you understand what that back story is or reason for their inertia, you as the provider try to reflect that back to them and begin to get them to realize why they are not moving forward with a desired behavior.
For example, if someone is telling you he wants to change his behavior and isn’t showing it, you might do reflections around that.
We have two types of reflections in motivational interviewing--simple and complex. A simple reflection would be simply restating what someone told you. A complex reflection may be guessing at what someone is telling you and reflecting that back to them. For example, if someone is saying to me, ‘I want to exercise, but I don’t have the time. A simple reflection would be, ‘So you don’t have time to exercise.’ On the other hand, a complex reflection might be, ‘you like exercise, but it’s not important to you.’
Motivational interviewing is a whole hour of giving someone the dignity of being with their thoughts, which can be quite powerful. How many times does someone actually allow you to be in their heads?
When you help people put together the pieces of their thoughts, and you see the light bulbs go off in their heads, it is magical. You are not pushing them; you really are allowing them to be where they are at that moment of their lives.
We use stages in motivational interviewing to help people know where they are at. The multiple stages include: pre-contemplation, where people don’t have any reason to change; contemplation, where they are seriously considering changing their behavior; preparation, where they are getting ready to change; action, which is the change itself; and after action is maintenance, or keeping up with the change.
I think people want to be in “action”, but they are still in contemplation. You cannot force people to force themselves to take action, when they are still dealing with their thoughts. They can’t reconcile how they are going to get to that action.
DiabetesCare.net: Can you discuss how you incorporate motivational interviewing into your practice with people with diabetes?
Dopart: You really only use it when people are in limbo, not when someone is highly-motivated. Typically in this latter class of people I will still do reflections, so they still understand they are going in the right direction.
DiabetesCare.net: Let’s say a person with type 2 diabetes is obese and the person is struggling to gain control of their weight, is there a way to understand how motivational interviewing works with these clients?
Dopart: Yes. I would draw out for them what stage they are in. We use a scale with this technique and we ask them how important is the lifestyle change to them and how motivated they are. For example, if the person is motivated but it’s not important to the person, then it won’t happen; people need to have both elements.
A doctor might say to a patient, ‘you really should be exercising.’ Human nature says a patient will give the doctor all the reasons why he can’t exercise. This is not a direction in motivational interviewing in which you would go.
Instead, I might say to the person, ‘on a scale of zero to ten, zero not being motivated at all, ten being the ultimate motivation, how motivated are you to exercise? This is an example of a technique called, “change talk.”
If the person says, a four; then I would reply, ‘what made you give me a four versus a zero?’ After he or she gives me some reasons, I’ll reflect back to that person what they just told me.
When people state the reasons why they have to change, and their brain hears their voices say it, this realization motivates them to start changing. Likewise, if someone is telling me all the reasons they can’t exercise, hearing this in their own voice reinforces why they should not exercise.
DiabetesCare.net: How can fellow providers incorporate motivational interviewing to help PWD in trying to overcome their unhealthy self-management habits?
Dopart: It is a process. For providers to get into motivational interviewing, they need to go to workshops, get a coach, and work at it. Reading a book or going to a conference is not going to be enough. When I went to the first conference, as much as I was enlightened, I was also frustrated because I saw this beautiful way of talking to people and I didn’t know how to use it. Applying motivational interviewing is like trying to learn a new language.
Now I’m teaching workshops in motivational interviewing to other healthcare professionals. Initially, when I was going to begin teaching, it terrified me because I thought, ‘I have to teach 20 people, and when you teach it, you have to know it.’
One thing to note to healthcare professionals, we cannot fix people. We have to give people the dignity of where they are at and lead them to the place where they want to go—partly in a gentle way, and partly in pointing out the discrepancies between their current behavior and the desired behavior.
Motivational interviewing can be partly gentle and partly honest in making an assertion.
DiabetesCare.net: Why is motivational interviewing effective as opposed to the traditional style of meeting with clients and patients about what they need to do?
Dopart: The main reason is because people already have the solution inside them; you just have to draw it out. They might not have the right solution about what type of eating they are doing, but the behavior--they already have the solution.
When people say to me, ‘I just can’t motivate myself to exercise, please tell me what to do.’ A traditional dietitian might say, ‘you could take a walk or you could ride your bike.’ Clients already know that.
I might say, ‘When you have been successful with exercise in the past, tell me what worked.’ I’m pulling for change here.
The client might say, ‘when I was successful I used to take walks in the morning with my dog, or I had a buddy who would go with me. I would then reflect that back by saying, ‘so the only time you have been successful is when you have had a partner that you were accountable to and did not want to disappoint.’ That would be more of a complex reflection. I’m helping them to come up with their own solution.
DiabetesCare.net: For fellow medical professionals who might be interested in pursuing motivational interviewing what resources do you recommend?
Dopart: I would first recommend the Miller and Rollnick book and there is another book by them along with author Christopher Butler. This book is called Motivational Interviewing in Health Care: Helping Patients Change Behavior. I would start by reading one or both of those books, then go to a conference to see if this is something you really want to pursue.
To find local workshops, check out the Motivational Interviewing Network of Trainers (MINT) site. For anyone interested in finding out more about Dopart’s practice or buy her book, A Recipe for Life by the Doctor`s Dietitian, readers can go here.