What is Motivational Interviewing in Patient Care Management?

September 20, 2017 - Motivational interviewing is a patient engagement strategy geared toward overcoming a significant challenge in patient care: convincing a patient to make a health behavior change.

“A central challenge for many providers is persuading patients to adopt and stick with healthful changes—from losing weight or starting an exercise program to keeping up with a medication regimen or accepting alcohol or drug treatment,” says Harvard Pilgrim Health Plan in its description of motivational interviewing.

Originally developed in the 1980s to help clinicians guide patients through overcoming drug and alcohol abuse issues, motivational interviewing has emerged as a key strategy for persuading patients to make different types of health behavior improvements.

“[Motivational interviewing] is a method for changing the direction of a conversation in order to stimulate the patient's desire to change and give him or her the confidence to do so,” the American Academy of Family Physicians (AAFP) wrote on its website.

“In contrast to many other change strategies employed by health care professionals (such as education, persuasion and scare tactics), motivational interviewing is more focused, goal directed and patient centered.”

READ MORE: Top 4 Patient Motivation Techniques for Health Improvement

Patient-centeredness is a core tenet for motivational interviewing, as providers put patients in the drivers’ seats of their health behavior change journey. The motivation for change needs to come from the patient, not the provider, to fuel a successful transformation.

The goal for clinicians is not to identify the behavior change for the patient, but instead to guide her toward creating the change plan herself. The clinician should also help the patient identify her values and goals in health improvement and help her understand when she has setbacks.

Successful motivational interviewing hinges on a baseline positive interpersonal relationship between patient and provider, AAFP explained. From there, clinicians can ensure that the behavior change process is entirely patient-centric.

“This requires that the physician have empathy toward the patient and recognize that a patient's resistance to change is typically evoked by environmental conditions rather than a character flaw or the desire to make the physician's life more difficult,” AAFP wrote.

“The physician needs to ‘let go’ of the outcome, support self-efficacy, allow the patient to be responsible for his or her own progress, and let the patient identify and articulate his or her intrinsic values and goals,” the organization continued.

READ MORE: Overcoming Patient Barriers to Chronic Disease Management

Harvard Pilgrim’s guide to motivational interviewing also advocates for clinician empathy as a driving factor in the technique. Clinicians must support self-efficacy and help patients recognize that viewpoints counter to the behavior change can serve as motivation toward achieving that change goal.

Healthcare professionals must also “roll with resistance,” Harvard Pilgrim maintained. Clinicians will need to recognize that the present may not necessarily be the time to make a certain health behavior change, and that berating or scaring the patient is not going to make that behavior change more likely or easier in the future.

When beginning a motivational interviewing session, many healthcare organizations, including both Harvard Pilgrim and the AAFP, advocate the OARS acronym:

• Open-ended questions
• Affirmations (expressing empathy and celebrating even small successes)
• Reflective listening (repeating words back to patients)
• Summarizing

These steps will put behavior change goals into the hands of patients while clinicians support patients on their journey toward achieving those goals.

For example, asking open-ended questions can help point to a tangible health improvement goal.

“Start small with just one question, such as ‘If you had one habit that you wanted to change in order to improve your health, what would that be?’ or ‘What goal would you like to set that you are willing to accomplish?’” AAFP suggested. “An open-ended and non-confrontational question usually gets the conversation started.”

At MissionPoint Health, a Tennessee-based accountable care organization, Jordan Asher, MD, uses open-ended questions to motivate his patients. Asher, who is the ACO’s Chief Clinical Officer and Chief Innovation Officer, uses motivational interviewing to become a partner in his patients’ care.

“’What are the issues that you have, how do I help you deal with those?’” Asher previously told PatientEngagementHIT.com he asks his patients. “During that process, how do I activate the patient and engage the patient with the end result being improved health?”

Patients aren’t usually trying to move a needle on a certain health metric, Asher pointed out. Patients are just trying to live their everyday lives a little bit better, and in some cases that means making positive health behavior changes.

For example, one patient, whom Asher called Mrs. Smith, wasn’t persuaded to simply lose weight, but found motivation in other areas of her life.

Asher said Mrs. Smith wanted to be able to go to an amusement park with her grandchildren, but was too overweight to go on a certain ride. Conducting motivational interviewing helped Asher first identify the health goal, and then help Mrs. Smith self-direct her own motivation. This made any strategies to improve her health more successful.

The Harvard Pilgrim guide reinforces Asher’s attitude, saying that the patient’s personal motivator will be more effective than any statistic or lecture from a clinician.

“The chances of a new behavior taking root are greater when a coach helps a member identify their individual rationale for making the change,” the health payer explained. “The patient’s own reasons for changing are much more powerful motivators than outside persuasion or coercion.”

Clinicians need to maintain an air of positivity and patient-centeredness when engaging in motivational interviewing, AAFP explained. Healthcare professionals will likely see more success in creating behavior change by putting the person first.

AAFP advocates the following principles during motivational interviewing:

• Motivation to change is elicited from the patient, not imposed from outside
• It is the patient's task, not the physician's, to resolve his or her ambivalence
• Direct persuasion is not an effective method for resolving ambivalence
• The counseling style is a quiet one, with a focus on eliciting the patient's thoughts
• The physician is directive in helping the patient examine and resolve ambivalence
• Readiness to change is not a patient trait but a fluctuating product of interpersonal interaction
• The therapeutic relationship is more like a partnership or companionship; expert/recipient roles can impede the process

Healthcare professionals must ensure motivational interviewing takes a patient-first approach, and accounts for patient preferences, needs, and goals. This will help providers overcome previous hurdles in front of patient behavior change.

“Often, what patients ‘should do’ is obvious to the physician – e.g., lose weight, stop smoking or start exercising,” AAFP stated. “What is not so obvious is where these patients are on their journey toward change, and why they are so reluctant to take the next step.”

Putting patients at the center of the behavior change makes it more feasible that patients will determine effective paths to success.

“Many times these courses of action are confusing, contradictory and deeply personal,” AAFP concluded. “Allowing the patient to explore these issues increases the chances that the patient may find an acceptable resolution.”