The Institute for Motivation and Change

The Three Styles used in Motivational Interviewing

http://www.miinstutue.com

The Three Styles
Gary Rose, Ph.D.

Health education is a sophisticated form of interpersonal communication and when we are engaging in this endeavor, we usually adopt one of three communication styles: Instruct, Guide, or Listen.
The three styles are defined as follows:
1. Instruct: Give information or advice. Other activities associated with this style include directing, informing, leading, educating, telling and using one’s expertise. These are used when there is specific information that one wants to provide, hopefully which the person wants to receive.
2. Listen: Understand the person’s experience. Other activities used include gathering information, following, eliciting, attending and empathizing. These are used when one wishes to understand how the person feels or what has happened to them.
3. Guide: Encourage person to set his/her own goals and find ways of achieving them. Other activities associated with this style include coaching, negotiating, mobilizing and motivating. These are used when the person is facing change, having to make decisions and to act upon them.
The guiding style is best understood as a style of communication that integrates elements of both instruction and listening, but differs fundamentally from these other two styles. Critical to effective guiding are activities such as collaboration, empowerment, affirmation and the entertaining of alternatives.
The following observations are worthy of note:

1. No one style is better or more patient-centered than another. Which one to use depends on the circumstances.
2. Each style can be used with more or less skill. For example, a few, carefully chosen, well-matched words of instruction can sometimes make all the difference, while its opposite is not difficult to imagine. So it is with both listening and guiding.
3. A mismatch between the style and problem at hand is conceivable, for example, if we were to instruct a child that has burst into tears.
4. Over-reliance on one style might prove unfruitful. For example, it might be of value to listen to a child who refuses to get out of the bath, but perhaps not for hours while the child and the water get cold!
5. Flexible shifting between styles is probably the norm in most helpful consultations.

Motivational interviewing is best understood as a refined, evidence-based example of the guiding style, which makes use of both listening and instruction, in the service of supporting the individual’s resolution of the dilemmas of why and how shall I change.

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Empowering Your Client

One of the most important points in using Motivational Interviewing in health behavior change counseling is the idea of empowering the patient or client. While the practitioner may be the authority in diagnosing what the patient should change, the patient is the authority in deciding what is most important and possible in the context of his or her life. Rather than adopting “the practitioner is the expert and the patient will be taught” approach, MI assumes a “dual expertise” between patient and practitioner.* MI assumes that patients have all the answers they need, and our job is to help them find these answers. As clinicians, we step back from being the experts to collaborate with patients in finding their own answers.

Although clinicians have ideas about what each patient ought to do, we must respect their ultimate right to choose a course of action. While remaining invested in their positive outcomes, we accept that the “what” and “when” decisions of lifestyle changes belong to the patient alone, not the practitioner. While we absolutely care what happens to them, we respect and accept our patients’ decisions about health behavior change. As my colleague, Gary Rose, says, we have “no preconceived ideas about the patient’s timetable for initiating action or the specific nature of this action.”

In my work as a nutrition therapist with patients who have eating disorders and other problems with food, I find myself having very strong opinions about what my patients should do. For instance, when I am working with a patient with active bulimia or uncontrolled diabetes, I have very clear clinical recommendations about what the patient should do; and I explain them fully. However, my MI training helps me to respect my patient’s right to choose whether to continue to live with her problem and whether or not to change.

As an MI trained clinician, my job is not to force change, but rather to help the patient clarify her goals and values and to examine how closely these jibe with her behavior regarding food and her health related outcomes. By empowering our patients to change, MI clinicians successfully bypass the (at times) counterproductive force of authority traditionally associated with our roles.

* Stephen Rollnick, William Miller, and Christopher Butler. Motivational Interviewing in Health Care, Guilford Press, 2007.

The Patient-Centered Relationship

by Gary Rose, PhD

Motivational Interviewing is an evidence-based approach to health behavior change counseling. Being both patient-centered and directive, MI brings a fundamental shift to the consultative relationship – the practitioner is more guide than director. This stylistic shift springs from two observations: one, a growing understanding of ambivalence as a powerful and central force in health behavior change conversations; and two, recognition that over-relying on the traditional directing/educative style can actually decrease a patient’s readiness to change.

MI uses both relational and technical components. The relational components operationalize the patient-centered core of MI and serve as a foundation for the technical, directive features of this interview style. The acronym RULE (Rollnick, Miller & Butler, 2008) captures the essence of the MI relationship: Resist the Righting Reflex; Understand patient motivation; Listen well; Empower. Let’s look at each element in turn:

Resist the Righting Reflex: The righting reflex (Miller & Rollnick, 2002) refers to the practitioner’s impulse to use information and persuasion to increase a patient’s motivation to change. Direct persuasion is indeed an effective motivational tool in the absence of ambivalence, and when the patient already presents with a high degree of readiness. In these circumstances, direct persuasion serves as an effective “final push.”

However, when used with less motivated and more ambivalent patients, the educative/persuasive technique often backfires. A patient’s autonomy is threatened, and he starts to defend his right to sustain the typically higher risk lifestyle. The resulting verbal volley often resembles a college debate, with point matched by counterpoint ad nauseam – an ‘argument’ practitioners rarely win.

The MI practitioner resists the righting reflex by expressing a keen interest in the patient’s point of view. Through reflective listening, the practitioner demonstrates an understanding of both sides of the change/don’t change dilemma and asks key questions inviting the patient to voice the argument for change.

Understand Motivation: Traditional health educational methods presume that patients will voluntarily pursue healthiness when they clearly understand that their health is at risk or already impaired. Unfortunately, most of the time this simply is not true. Improving health typically does not rise to priority one until the patient faces an acute and omnipresent danger.

For most patients, health is a means to an end – something that allows them to gain or sustain a non-health goal. Examples abound in clinical practice. For instance, the teenager who joins a health club and cuts calories to become a better wrestler; the college student who quits smoking to be an attractive smoocher; and the renal patient who controls fluid intake to have the post-dialysis energy to enjoy her grandchildren are all examples of patients whose positive health behavior delivers a personal goal tied to their life context and not their body, per se.

The MI practitioner demonstrates a keen interest in the patient’s life context, personal values, and core beliefs; and he uses this knowledge to create a motivational bridge to health maintenance and lifestyle change.

Listen Well: Reflective listening is the principal component of the MI guiding style. Accurate empathy develops around a structure of reflective listening, and it serves to both support the patient and to guide his awareness toward the benefits of health behavior change.

Empower: Lifestyle changes entail both initiating and maintaining change. The empowered patient will more likely sustain changes that involve sacrificing short-term comfort and convenience for long-term health risk reduction. MI practitioners empower patients by offering options, not unsolicited advice, and by maintaining a balance of power in the consultative relationship.

Considerable evidence shows that practitioners who adhere to RULE have patients who are more engaged in treatment and more likely to change. RULE creates a foundation on which to place the technical components of MI: the interview strategies which elicit and reinforce change talk, and the client utterances that signal an interest in and commitment to behavioral change. Next month we’ll investigate the nuts and bolts of change talk.

Does what we say really matter?

by Gary Rose, PhD

One of the basic tenets of Motivational Interviewing holds that motivation and resistance derive from the communication between practitioner and patient. We say things, and patients respond–sometimes indicating their resistance and at other times signaling their motivation to change.

In MI parlance, when practitioners voice MI-consistent statements, they increase the probability of patients responding with change talk. Conversely, clinicians who use MI-inconsistent language often elicit resistance or counter-change talk from their patients, thereby decreasing the likelihood of progress.

What are these MI-consistent and MI-inconsistent verbal behaviors, and does the evidence suggest that they really have the power to motivate or de-motivate patients?

MI-consistent behaviors include a variety of practitioner activities that support the patient’s autonomy, acknowledge his/her personal control, and help create a collaborative relationship. These include asking permission before offering advice or information, eliciting patient ideas, opinions, and preferences, collaborative agenda setting, and providing support. Support includes demonstrating a willingness to listen to and accept any reluctance the patient may have regarding the targeted health behavior change.

MI-inconsistent behaviors include a variety of “top down” behaviors that stand in direct opposition to the MI-consistent actions. For instance, delivering unsolicited advice, confronting, arguing, exhorting, shaming, and controlling are all included herein.

Much of the evidence supporting these hypotheses comes from the work of Dr. Teresa Moyers and her colleagues at the University of New Mexico (www.casaa.unm.edu). Here are several of their observations:

Practitioners who more successfully demonstrate the collaborative patient-centered style of MI engender more trust, involvement, openness and readiness to change in their clients.

Practitioners who confront, argue, or direct engender increased resistance in their patients, and less positive change.

Clinicians who demonstrate MI-consistent behavior elicit increased change talk from their clients and patients.

Clinicians who use MI-inconsistent behavior elicit counter-change talk from patients.

Patient counter-change talk is associated with the absence of positive behavior change.

Patient change talk leads to further change talk which leads to behavior change. In other words, there is a positive snowball effect.

So, it turns out that what we say really does matter. If you want your patients to demonstrate positive behavior change, get them to talk about it. The more they talk about wanting to, being able to, or being committed to changing, the better.

A particularly effective way to elicit change talk is by bringing the spirit of MI into your consultation. Ask permission before putting on the expert’s hat. Support autonomy, empower, and remain patient-centered. Use reflective listening to demonstrate a keen interest in the client’s point of view. The result is often a process of positive movement that builds upon itself.