The Institute for Motivation and Change

Motivational Interviewing was originally developed as an alternative to traditional 1:1 counseling methods, and it evolved without much concern for session length. Many of us who currently use MI, however, do work with time constraints (typically 5, 15, or 25-minute consultations). How does the free flow of MI fit into the real, time-constrained world of professional counseling?

Our challenge is to skillfully use the relational and technical elements of MI in brief conversations – those elements that both promote the spirit of MI and also help guide the client toward behavior change. The components of MI that build your relationship with your client include the three “E’s": Empathy, Elicitation, and Empowerment.

Even the briefest MI intervention promotes a positive relationship when you collaborate, promote your client’s self-advocacy, and demonstrate a keen interest in your client’s point of view. Techniques you can use to achieve these goals include: asking permission before providing advice or information, offering your client a menu of options for change, and using reflective listening to demonstrate understanding.

MI’s technical components consist of interview strategies used to elicit and reinforce change talk – the things your client says that signal an interest in and commitment to behavioral change. Toward this end, brief MI interventions often employ the importance/confidence scaling technique, which both assesses readiness to change and helps set the agenda for brief advice-giving.

For example, here’s is a punch list for a brief discussion of teen smoking:

1. Set the Stage
a. Explain the purpose of the brief conversation.
b. Ask permission to proceed.

2. Build Rapport
a. “Tell me about yourself and your smoking.”
b. Listen well for 3-5 minutes.

3. Scale Importance
a. “How important is it for you right now to quit smoking?"(scale from 0 - 10)
b. “Why is it so important?”
c. “What would have to happen to make it even more important?”

4. Inform
a. Provide a small dose of pertinent information.
b. Avoid jargon.

5. Action Planning
a. Offer a menu of options.
b. Small first steps are most effective.

6. Scale Confidence
a. “How confident are you that you can succeed with our plan?”
b. “What would have to happen to raise your confidence?”

7. Summarize and Affirm
a. Support self-efficacy.
b. Set a follow-up date.

MI is a collaborative approach to health care consultation. It has been described as a guiding rather than a leading style of relating to our patients or clients. The MI style manifests itself in the practitioner’s attitude.

There are three components to the attitude or “spirit” manifested by the MI practitioner: evocation, autonomy support, and collaboration.

1. Evocation acknowledges that effective health behavior change starts with the patient/client and not with the practitioner. Questions and concerns about life-style changes are most sustainable when patients voice them independently. Remember, people are most persuaded to change when they articulate the ideas themselves.

2. Autonomy Support means that when patients choose their own way of changing (or not), they are more likely to persist in that change. In MI we avoid coercive or overly persuasive methods. The reasons for making behavioral changes must be personally relevant to our patients/clients.

3. Collaboration, the third component, reinforces this spirit by emphasizing the distribution of power in the patient-practitioner relationship. The idea is that we assume patients/clients are the experts in how they will change, so we acknowledge a “dual expertise” and a 50-50 power sharing.

Some practitioners new to MI may be concerned that this approach doesn’t allow them to direct the conversation and thus will hamper their ability to teach patients/clients what they need to learn. Quite the opposite is true. The MI approach makes it much more likely that patients/clients will be interested in listening to our health care advice. MI empowers patients/clients and therefore allows them to be more receptive partners to change.

The ‘non-diet’ approach involves eating when you are hungry, eating what you really prefer to eat, eating consciously, and stopping when you are full. In this way, we eat in response to physical needs and gain satisfaction from eating in our physical, emotional and spiritual realms.

This approach to teaching dietary behavior change works beautifully with Motivational Interviewing because the work is client centered. When we teach conscious eating, we focus on helping clients discover their own hunger, fullness and satisfaction signals, all of which are intensely personal experiences. Using MI, we guide our clients through a process of learning about physical hunger and fullness sensations.

It’s important to note that the ‘non-diet’ approach may not be appropriate for all who need to change their eating habits. It requires both the ability for insight and the willingness to forgo immediate gratification in order to learn about true hunger and satiety.

Tip for Teaching the ‘Non-Diet’ Approach: Try thinking about these ideas in terms of three questions. You are thinking about eating. Stop, and ask:

* Am I hungry, physically hungry?
* If yes, what do I really want to eat?
* How much of this food do I need to be satisfied?

Remind your client (and yourself!) that the answers are very personal and unique to each individual. You might be able to tell others how these internal experiences feel to you, but not how they might feel to someone else. Working with your clients, you embark on an investigation into their experiences of hunger and satiety. Each client leads his or her own journey, with you, the counselor, as a guide.

The MI guiding style puts a premium on evocation - the act of eliciting from clients their questions and concerns in setting the agenda for a health education session. The more the practitioner allows the client to set the agenda, the more likely is it that the material covered will be greeted with open ears.

However, there are always moments when the clinician must bring up a difficult topic, one that the client is, at best, reluctant to discuss. These topics vary from profession to profession. Pediatricians, for example, list these among their difficult topics: domestic violence, second hand smoke, untreated parental depression, obesity, harsh parenting, and the overuse of antibiotics.

We are always challenged to maintain rapport during these difficult consultations, and effective clinicians keep their message short and simple. MI teaches the advantage of using brief discussions which are more about listening than about delivering a compelling dose of information.

Here are six (6) simple steps:

1. Introduce the topic and goal of the conversation.
2. Ask permission to proceed. If necessary, gently impose.
3. Deliver no more than three (3) simple, jargon-free facts: an ear opener, a simple fact, and a confidence builder.
4. Elicit a response.
5. Listen, listen, listen. Use reflective statements to acknowledge patient concerns.
6. Summarize and affirm.

A pediatrician using MI might handle a conversation about second hand smoke like this:

Step 1: I like talking to all of my patients about second hand smoke and their children’s health.
Step 2: I know this is not your favorite topic, but please bear with me for a few short minutes.
Step 3: Ear Opener + Simple Fact + Confidence Builder:

3a. When kids are exposed to second hand smoke, it’s like they are themselves smoking.
3b. Kids exposed to second hand smoke have more frequent illnesses and sometimes fail to grow as well as their peers.
3c. When it comes to second hand smoke, anything a parent does to reduce exposure helps; quitting is the best but any changes are positive.

Step 4: What do you think?
Step 5: You are concerned about your child’s asthma, but you don’t feel ready to quit right now.
Step 6: So, your plan is to smoke outside and use nicotine gum for those long car trips. I appreciate how seriously you’re taking this.

These six (6) simple steps will help create an opportunity to address just about any difficult topic. Since behavior change is more a function of motivation than education, try to keep the message simple and listen well to the patient’s response.

High levels of empathy are key to the MI guiding style. Empathy is traditionally understood as the expression or demonstration of kindness, agreement, acceptance, or concern for the patient.

We define empathy a little differently in MI.

In Motivational Interviewing, empathy is simply the demonstration of a keen but neutral curiosity for the patient’s ideas and attitudes regarding all sides of the targeted behavior change. The MI practitioner refrains from using too many emotional cues.

Empathy is best demonstrated through the use of effective listening and communication skills, not necessarily through any measure of smiles, kind words, or enabling gestures. By truly listening to our patients we can provide them the highest quality attention and care that they deserve. Helping our patients achieve their goals is the best expression of empathy that we can aspire to.