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.

Copyright 2008, all rights reserved.