23 August 2021

Getting your patients onside

Patients Psychology

Motivational interviewing techniques can help patients effect positive behavioural changes.

The importance of patient engagement in health care is long and well established. There can be no doubt that knowledge related to discipline is essential; however, the skills of “being” with another person, in addition to the skills of supporting sustainable behavioural change are vital to patient outcomes.

In many medical disciplines related to chronic disease, interventions delivered by the provider must be supported by behavioural change and accommodations on the part of the patient.

The field of health coaching is growing rapidly worldwide, including here in Australia. One element of the many skills developed as part of a coaching approach is the use of motivational interviewing (Miller and Rollnick 2012).

Motivational interviewing first emerged as a means of supporting people to manage significant and enduring addictions; however, its efficacy generally in supporting behavioural change is well documented. It is a collaborative and conversational engagement with the patient that does not give primacy to expert knowledge. Rather, this knowledge is offered “just in time” and only when absolutely necessary to support behavioural change

One of the very useful elements of motivational interviewing is the conceptualization of ambivalence. Coming from two Latin words, ambivalence literally represents the idea of “both options having strength” to the person. In practise, ambivalence is often seen as a problem to be overcome in the patient and this can lead very quickly to the health care provider engaging in an ultimately unhelpful tug of war – trying to pull the patient towards a particular behavioural change, while the patient resists equally strongly, to argue for the value they see in not changing.

But ambivalence need not be seen this way. It is a very normal and common human experience. Anyone who has ever scanned a restaurant menu and felt an urge for two different main courses, or experienced the pleasurable dilemma of being invited to two social events occurring simultaneously has had an experience of ambivalence. If ambivalence can be conceptualised in this way, it ceases to be a “problem to be solved” and can be looked upon as an energy or impetus within the patient to be worked with – much better to have a desire for multiple possible outcomes, than no desire for any.

How can clinicians work effectively with ambivalence, to support patient autonomy, and to create the conditions most favourable to health behaviour change in a patient?

Firstly, employ the fundamental tools of powerful communication and connection – deep listening, reflection of what is being said, and open inquiry to understand more. While there are many types of reflection in interpersonal communication, two approaches that particularly support working with ambivalence are the “empathy” and “double-sided” reflections (Moore, Tschannen-Moran and Jackson 2016). An empathy reflection seeks to reflect the emotion embedded in a person’s words:

Patient: I really wanted to get to 30 minutes of continuous walking this week, but I just couldn’t.

Physician: You’re feeling disappointed that you didn’t reach the goal you set for yourself.

A double-sided reflection seeks to capture all aspects of a person’s feelings about change (not only those related to the benefits of change):

Patient: I know that moving more could help, but I’m just so afraid of ending up in the sort of pain I was in last year.

Physician: You’re keen to experience the benefits of more movement, and wary of unintended setbacks too.

Learn the signs that indicate ambivalence. It frequently shows up in clinical consultations as a combination of “change talk” and “sustain talk” (Miller and Rollnick 2012) or as the patient beginning to redirect or correct your efforts to influence their choice.

Change talk embodies the patient expressing desires, abilities, reasons or needs to make a change. Sustain talk, on the other hand, represents views expressed by the patient which seek to justify or legitimise not changing.

As a practise point, it’s important to avoid what Miller and Rollnick refer to as “the righting reflex” – the tendency of the practitioner to respond to sustain talk with change talk. This leads to a polarising interaction in which the practitioner more and more strongly occupies the “change talk” space and be patient strongly occupies the “sustain talk” space. If this continues, the patient will likely become irritated or agitated with the clinician and feel unheard and misunderstood.

In practice, the polarising interaction could look like this:

Physician: If you were to begin to gently increase the amount of exercise that you do, what do you think might be the benefits?

Patient: Well… I’m not sure. Last time I tried that, the pain in my knees was unbearable.

Physician: A short term increase in pain is to be expected here, but it’s important that you understand that your condition won’t improve if you don’t start moving more.

If you think you recognise ambivalence, don’t do something – just sit there. Resist the urge, if present, to convince the patient through force, facts or fear about the imperative of change. Instead, take time to listen and to understand the value that the patient sees in continuing along their current path. This can be done by using the decisional balance tool (Miller and Rose 2015).

The decisional balance tool provides a means for dispassionately exploring the patient’s perceived benefits and disadvantages of modifying their behaviour, and also of continuing as they are; however, it is best approached in a particular order, beginning with the perceived advantages of not changing. This “meets the patient” at the strongest point of their ambivalence. It also demonstrates a desire to understand the reasons for this and avoids the perception on the part of the patient, that the physician may be pushing for change.

From here, move to inquiring of the patient the disadvantages they perceive in modifying or changing their behaviour. Once this has been explored and reflected, inquiry about the disadvantages of not changing may be explored and finally conclude with a discussion about the perceived advantages of modifying behaviour.

When undertaken in this way, the patient has walked logically through all areas of their perceptions and concerns and, if appropriate, the discussion can continue, focused on what the patient might do to begin the process of change. A decisional balance process may look like this:

Physician: What are the benefits you see for yourself in not making any changes to your exercise and activity habits?

Patient: Well for one thing I won’t get the pain – it’s a killer when that happens. I really can’t stand it.

Physician: Mm-hmm– what about the disadvantages you see in increasing the amount of exercise that you do?

Patient: Apart from the pain, I guess I’d have to re-organise some things in my day to make time for it. And I’m really not sure if I’d be doing the right thing – it’s a long time since I exercised. And I don’t know what’s going to be helpful and what may not be.

Physician: OK…tell me about the risks you see in not making any changes?

Patient: All the things you and I have spoken about already – my mobility will continue to decline; the pain I get probably won’t ever really go away completely. And in a few years’ time I may find that I’m even less able to do things I want to do. And as I say that now, I worry about that because I really want to travel after I retire.

Physician: Right – so what are the benefits to you of making a change to your patterns of exercise?

Patient: I do know that exercise will help – and I do really want to be able to move around more freely and without pain. My wife and I have been talking for years about walking the Camino de Santiago when we retire…

Lastly, remember the central role that autonomy plays in human behaviour. Autonomy is a primary psychological need of all sentient creatures. If you want to see it in action, observe your dog next time you try and encourage him or her to move away from a scent that’s exciting and interesting. The drive to preserve autonomy may be particularly strong in those who have experienced some trauma.

Nothing guarantees that any particular patient will engage in behavioural change; however, the honouring of autonomy maximises the likelihood that the patient will engage in a behaviour that has meaning and value to them and which they will be able to sustain in the long term.

Simon Matthews is a psychologist and health coach who consults nationally and internationally in the areas of health coaching, behaviour change, positive psychology and lifestyle medicine. This article is based on a session he presented at the 2021 ARA ASM, Motivational interviewing: getting your patients onside.

References

Miller WR and Rollnick S (2012). Motivational interviewing: Helping people change: Guilford press.

Miller WR and Rose GS (2015). Motivational interviewing and decisional balance: contrasting responses to client ambivalence. Behavioural and cognitive psychotherapy 43 (2):129-141.

Moore M, Tschannen-Moran B and Jackson E (2016). Coaching psychology manual. 2nd ed: Wolters Kluwer Health/Lippincott, Williams & Wilkins Philadelphia, PA.

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