Motivational Interviewing (MI)

MI is an evidence-based treatment for alcohol use disorder, smoking, and other substance-use disorders.^[1] There is also moderate evidence for its use in weight loss, blood pressure management, diabetes, and medication adherence.^[2]

MI explores and resolving ambivalence, and centres on the motivational processes within an individual that facilitate change. This method differs from more “coercive” or externally-driven methods for motivating change. Thus, it does not impose change (that may be inconsistent with the person's own values, beliefs or wishes), but rather supports change in a manner congruent with the person's own values and concerns.

1. Precontemplation – denying the problem
2. Contemplation – acknowledging problem, but unwilling to change
3. Preparation/determination – preparing for behavioural changes
4. Action/willpower – changing behaviors
5. Maintenance – maintaining changes
6. Relapse – (if applicable) returning to old behaviors and abandoning changes

Several mmemonics below can be helpful to remember the core aspects of MI:

1. Genuine value for the spirit of MI (PACE)
2. Proficiency in client-centered interview skills (OARS)
3. Carefully listening and nurturing the expression of “change talk” while softening “sustain talk” (DARN CAT)

The spirit of MI can be remembered by the acronym DEARS:

• D - Develop discrepancy
• E - Express empathy
• A - Amplify ambivalence
• R - Roll with resistance
• S - Support self-efficacy

There also needs to be a genuine value for the spirit of MI. The acronym PACE can be used to remember this:

• P - Partnership (working together)
• A - Acceptance (4’A’s, affirmation, autonomy, absolute worth, accurate empathy)
• C - Compassion (caring about a person’s interest)
• E - Evocation (bringing out a person’s wisdom rather than educating them)

The therapist needs to be proficient in client-centered interview skills. The mnemonic OARS can be used to remember this:

• O - Open-ended questions (to explore depth and shift focus)
• A - Affirmations (genuine statements about a person’s strengths, values, and efforts)
• R - Reflections (strategic guesses about what the person just said, uttered by you as statements, which subtly influence what the person might say next)
• S - Summaries (especially helpful in marking transitions in a conversation)

• The therapist needs to listen to the patient and nurture the expression of “change talk“ while softening “sustain talk”.
  • There are two types of change talk: preparatory change talk and mobilizing change talk.
• Preparatory change talk does not necessarily lead to change, but often precedes stronger change talk.
• Mobilizing change talk takes it one step further and there is research evidence that if it is spontaneous, it is most predictive of positive outcomes in MI.

1. Be curious, not an expert
   • Our training and expertise can get in the way of hearing the patient's story. Take a step away from the expert role and listen to the patient as a non-clinician.
2. Arguing is never productive
   • Arguing patients is a sure fire way to not change their behaviour in the way you are seeking!
3. Listen more than you talk
   • It’s easy to get into the trap of telling people what to do. MI is about getting patients to articulate why they think they need to change and how they think they can do it. If you're talking more than the patient – the wrong person is doing the talking! Ask questions to get the process going, but then get out of the way and listen. Use reflective statements to help move the client forward.
4. Find out what the patient knows first
   • For example, if discussing about medication side effects, ask the patient: “Tell me what you know about the side effects of this medication.” If talking about assertiveness skills, ask: “What works for you when you’re trying to deal with somebody who is being aggressive?” Or, if talking about relapse, ask: “How have you managed cravings in the past?” Once you know what the patient already knows, you can offer more targeted and helpful information.
5. Pay attention to change statements
   • If you hear some change statements from your patient, perk up and do plenty of reflecting. If you hear sustain statements, be more silent. Don’t reinforce sustain talk by giving it lots of attention—be silent or alternatively look for the change element. It is surprising how readily clients may take cues from you, and the more you can reinforce change talk, the better.

There are structured tools to give observation-based feedback on the quality of MI given, including the Motivational Interviewing Treatment Integrity Code (MITI 4).^[3]