Motivational Interviewing. A Way of Talking.
Firstly it’s a great honour to write this for The Pain Toolkit website so thank you to Pete for inviting me to do so. The Pain Toolkit has helped both me with my clinical practice but also many of the patients I serve at the pleasure of. An all-round fantastic resource, keep up the good work Pete.
So this article came off the back of an excellent AHP Suffolk podcast with two of my former colleagues Matt Peck who you would of heard hosting AHPSPodcasts with myself (If you haven’t, get listening) and our resident Motivational Interviewer Matt Combes. Although I would now like to think a lot of us now adopt this approach, I use the term approach loosely because for me the thing about Motivational Interviewing is I do not see it as an approach, or a treatment, or a technique but simply a way of talking to people, and considered as this way you will have some real success.
So it’s not a treatment and it’s not a technique, so what is it? It is a consultation style, a style of talking that is different to what we as physiotherapy students are taught at university. It’s open, it’s focussed, it allows the patient to feel like they have been listened to and involved; because we physiotherapists are notorious dictators…we tell the patient what’s wrong and we tell them what to do, and if it doesn’t work we probably tell them what they are doing wrong. We have that righting reflex, that desire to “fix” something, which isn’t a bad thing, but can be counterintuitive to the patient’s motivation to change. Am I right?
Now this might work for some patients, but the rest will slip through, they may or not get better, they may or may not come back to see you. I love this quote from the podcast
“A non-compliant patient is just as much about you as the physio as it is about the patient”
And I consider this to be the same for those patients who DNA. Sometimes we just need to roll out that red carpet and really engage a patient.
And Motivational Interviewing is a great way of doing this. Ask yourself what is the underlying objective of a physiotherapy intervention?
I think we want to change behaviour. We want to change a person’s behaviour so they can help themselves. However if we adopt our dictator approach and tell them what to do the defences and guards are going to come right up.
And motivational interviewing is a great way of finding a way through, round or over with the patient in control.
If you want the full definition, here it is:
“A collaborative, goal-orientated style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change with an atmosphere of acceptanceand compassion” (Motivational Interviewing: Helping people change. William R Miller, PhD, Stephen Rollnick, PhD. Guildford Press, Sep 2012)
But remember it is a way of talking to patients. And that can be ALL your patients. This is not something you have to save for those you think might need it, persistent pain patients etc. it can be used with everyone. It focuses on 3 key concepts:
Righting reflex – which is what us physios typically do and that is the telling people what to do
Ambivalence – this is the patients competing voices, they will weigh up the pros and cons of what we are saying, e.g. exercising for health vs having time to do it vs what new episode of game of thrones is on that night
Resistance – we need to roll with a patients resistance, avert conflict and evoke a patient’s own reasons for change
So how do we do this?
Motivational Interviewing involves open questions, socratic questions and active listening, we must confirm and validate what the patient is saying to allow them to feel properly listened to. E.g. use 2-3 open questions followed by a closed question to summarise and reflect. Make sure you repeat the patients change talk. Offer advice but ask permission to do so and allow the patient to guide the direction of the advice. Let’s have a look at an example, and you can hear this spoken out in full role play on the podcast.
Non MI approach to a patient with an arthritic knee:
<physio> You have arthritis in your knee. Your BMI is high and to help reduce your pain you need to lose some weight so I would advise that you change the way you are eating and do some more exercise maybe some cycling or swimming. I would also suggest you take some regular pain relief and you modify your activities, try to stop doing so much at once and pace
Sound like you? I won’t make you admit it but have a think how that might sound to the patient and more importantly how that may potentially lead to a nocebo effect.
So how might we change that in a motivational interviewing style?
MI approach to a patient with an arthritic knee:
<physio> We know you have arthritis in your knee and there are a few things you can do to help manage your pain better. If it is ok with you I would like to give you some information about these.
<patient> Yes please
<physio> Things we can talk about are pain relief, weight loss, exercise and changing your daily routine, which of these would you like to talk about first?
<patient> Let’s go with pain relief please
<Physio> Physio can then talk about pain relief and then ask – now we have talked about what would you like to talk about next?
Notice the differences. Think how this might be a totally different experience for the patient. How they will leave this clinic feeling engaged, involved and listened to.
So that way we talk to people, to patients can make a huge difference. Hope that is helpful, try it out. This just touches the surface, I could write pages going into socratic questioning, change talk, empathy etc etc, maybe leave that for next time if Pete will have me back. If you want more information, have a listen to the podcast, follow the links on there or feel free to contact me.
I’ll leave you with the key points from the podcast:
- Actively listen. Include summaries. 2:1 open to closed questions.
- Show compassion early and often.
- Ask permission to provide information (I love this one!)
And one final point, when you hear change talk you are doing it right, when you find yourself arguing for change and the patient defending status quo, you know you are off course.
Just before I go I would just like to thank Matt Combes for the podcast and for the teaching in this area.
Thanks for reading!