MOTIVATIONALINTERVIEWING IN HEALTH CARE
Applications of Motivational Interviewing
Stephen Rollnick and William R. Miller, Series Editors
Since the publication of Miller and Rollnick’s classic Motivational Interviewing,
MI has become hugely popular as a tool for facilitating many different kinds of
positive behavior change. This highly practical series demonstrates MI approaches
for a range of applied contexts and with a variety of populations. Each
accessible volume reviews the empirical evidence base and presents easy-toimplement
strategies, illuminating concrete examples, and clear-cut guidance on
integrating MI with other interventions.
Motivational Interviewing in the Treatment of Psychological Problems
Hal Arkowitz, Henny A. Westra, William R. Miller,
and Stephen Rollnick, Editors
Motivational Interviewing in Health Care: Helping Patients Change Behavior
Stephen Rollnick, William R. Miller,
and Christopher C. Butler
MOTIVATIONAL INTERVIEWING
IN HEALTH CARE
Helping Patients Change Behavior
Stephen Rollnick
William R. Miller
Christopher C. Butler
THE GUILFORD PRESS
New York London
© 2008 The Guilford Press
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72 Spring Street, New York, NY 10012
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All rights reserved
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Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Rollnick, Stephen, 1952–
Motivational interviewing in health care : helping patients change behavior / by
Stephen Rollnick, William R. Miller, Christopher C. Butler.
p. ; cm. — (Applications of motivational interviewing)
Includes bibliographical references and index.
ISBN-13: 978-1-59385-613-7 (hardcover : alk. paper)
ISBN-10: 1-59385-613-X (hardcover : alk. paper)
ISBN-13: 978-1-59385-612-0 (pbk. : alk. paper)
ISBN-10: 1-59385-612-1 (pbk. : alk. paper)
1. Health counseling. 2. Motivational interviewing. 3. Health behavior.
4. Behavior modification. I. Miller, William R. II. Butler, Christopher, 1959–
III. Title. IV. Series.
[DNLM: 1. Behavior Therapy—methods. 2. Interview, Psychological.
3. Motivation. WM 425 R754m 2008]
R727.4.R65 2008
362.1′04256—dc22
2007020536
To my dear father, Julian. Thank you for many things,
including your lucid advice and support
in the writing of this book. —S. R.
To my son, Jayson. May I always be for you
the same loving, guiding presence
with which my parents blessed me. —W. R. M.
To Judith and our children,
Caitlin, Eva, and Charles, who helped me
so much to find a way. —C. C. B.
About the AuthorsAbout the Authors
About the Authors
Stephen Rollnick, PhD, is a clinical psychologist and Professor of Health Care
Communication in the Department of Primary Care and Public Health at Cardiff
University, Wales, United Kingdom. He practiced in a primary care setting for 16
years and then became a teacher and researcher on the subject of communication.
Dr. Rollnick has written books on motivational interviewing and health behavior
change and has a special interest in challenging consultations in health
and social care. He has published widely in scientific journals and has taught
practitioners and trainers in many countries throughout the world.
William R. Miller, PhD, is Emeritus Distinguished Professor of Psychology and
Psychiatry at the University of New Mexico, where he joined the faculty in 1976.
He served as Director of Clinical Training for UNM’s American Psychological
Association-approved doctoral program in clinical psychology and as Codirector
of UNM’s Center on Alcoholism, Substance Abuse, and Addictions (CASAA).
Dr. Miller’s publications include 35 books and more than 400 articles and chapters.
He introduced the concept of motivational interviewing in a 1983 article.
The Institute for Scientific Information names him as one of the world’s most
cited scientists.
Christopher C. Butler, MD, is Professor of Primary Care Medicine and head of
the Department of Primary Care and Public Health at Cardiff University. He
trained in medicine at the University of Cape Town and in clinical epidemiology
at the University of Toronto. For his doctoral work, under the direction of
Stephen Rollnick, he developed and evaluated behavior change counseling and
conducted qualitative research into patients’ perceptions of advice against smoking
from clinicians. Dr. Butler has published more than 70 papers, mainly on
health behavior change and common infections. He has a general medical practice
in a former coal-mining town in south Wales.PrefacePreface
vi
Preface
This book is for any health care practitioner who spends time encouraging
patients to consider behavior change. The list is quite a long one:
nurses, doctors, dieticians, psychologists, counselors, health educators,
dentists, dental hygienists, social workers, physical and occupational
therapists, podiatrists, and sometimes even people who answer the office
telephones. The list of behaviors that might need to be changed is also
long: smoking, diet, exercise, medication changes, alcohol consumption,
fluid intake, the learning of new procedures, use of new aids, uptake of
services, and so on.
It was health care practitioners who brought the potential for motivational
interviewing in health settings to our attention. Each day they
see patients whose health could be greatly improved by behavior change.
Usually, their patients are not asking for help with this. The practitioners
do their best to encourage, persuade, cajole, counsel, or advise their patients
to make changes. They have seldom received training and preparation
in how to promote health behavior change, and often have only a
few minutes per patient to do so in the face of many other competing
clinical imperatives. We have listened to the problems, frustrations, and
practical constraints of frontline health care practitioners:
“I tell them and tell them what to do, but they won’t do it.”
“It’s my job just to give them the facts, and that’s all I can do.”
“These people lead very difficult lives, and I understand why they
smoke.”
“I’m not a counselor; I diagnose and manage medical conditions.”
“Some of my patients are in complete denial.”
We found that passion (and compassion) ran high about patient predicaments
and how best to respond to them.
vii
When we first wrote about motivational interviewing we had counselors
in mind, and we focused on patient problems with alcohol and
other drugs. These patients had tough behavior change problems and
their lives frequently lay in ruins. Despite the devastating consequences
of their drinking or drug use, their ambivalence about change was striking.
We quickly learned that lecturing, arguing, and warning did not
work well with ambivalent people, and over time we developed the more
gentle approach that would come to be called motivational interviewing.
The focus was on helping these people talk about and resolve their ambivalence
about behavior change, using their own motivation, energy,
and commitment to do it.
Soon after publication of the first edition of Motivational Interviewing
(Miller & Rollnick, 1991), it became apparent to us and others
that this method could be useful outside the addiction field. Indeed,
struggles with ambivalence about change are not at all unique to
addictions, but are characteristic of being human. Presently, much of
health care involves helping patients to manage long-term conditions
where outcomes can be greatly influenced by lifestyle behavior change.
Yet patients often resist well-intentioned efforts to persuade them into
change. There are certainly limits to what a practitioner can do, but
there is also great potential for change. Certainly, motivation to change
is better elicited than imposed. Humane, respectful, and effective conversations
about behavior change clearly have a place in many health
care settings.
Within a few years, publications were appearing on the use of motivational
interviewing in managing hypertension, diabetes, obesity, heart
disease, medication adherence, and a range of psychiatric and psychological
problems. There are now over 160 randomized clinical trials of
motivational interviewing, with publications on the method doubling every
3 years (see www.motivationalinterview.org).
We have now taught motivational interviewing to a diverse range of
practitioners. It is being used by providers in family practice, cardiac and
cognitive rehabilitation, renal medicine, diabetes care, physical therapy,
fitness coaching, dental care, mental health counseling, vocal/speech
therapy, and public health education. The challenge for us has been to
find a way for health care practitioners to use elements of motivational
interviewing in the “hurly-burly” of everyday clinical practice.
A first step in this direction was a book called Health Behavior
Change (Rollnick, Mason, & Butler, 1999). Cautious about diluting and
simplifying motivational interviewing beyond recognition, we all but
avoided any reference to it. The book merely described some useful,
practical strategies, many of them developed in health care settings that
adhered to the essential spirit of motivational interviewing—using good
viii Preface
rapport to help the patient explore and resolve ambivalence about
change.
Teams of researchers followed a similar path, developing and testing
a variety of adaptations of motivational interviewing that spanned
many settings and problem areas. By the time the second edition of Motivational
Interviewing (Miller & Rollnick, 2002) was published, adaptations
had emerged with names such as brief negotiation, behavior
change counseling, a behavior “check-up,” and brief motivational interviewing.
Behind them all was the same idea about evoking patients’ own
motivations for change.
This book is a new synthesis on how to bring the heart of motivational
interviewing into everyday health care practice. Few practitioners
have the time, need, or inclination to become counselors. Our goal here
is to convey just enough of the essential method of motivational interviewing
to make it accessible, learnable, useful, and effective in health
care practice.
We have tried to capture the essence of the approach without resorting
to foreign-sounding technical jargon. In this book we use the metaphor
of a guide. We suggest that a guiding style is something used naturally
in everyday life to help other people, particularly with changing
their behavior or learning new skills. We contrast it with two other everyday
communication styles: directing and following. Directing has
come to predominate in health care practice, precisely as it did in addiction
treatment during the 1970s and 1980s, and with the same predictable
problems and limitations. The art of skillful guiding is all too often
lost in the hectic pace of modern health care. Some think that there is no
longer time for it in health care. But we believe that when time is short
and behavior change is vital, a guiding style is most likely to efficiently
produce better outcomes for patients and practitioners alike.
From this simple starting point come a number of implications for
training and practice. Motivational interviewing is a refined form of the
familiar process of guiding. The skillful practitioner is someone who can
shift flexibly among directing, guiding, and following styles in response
to patients’ needs. In other words, motivational interviewing does not
displace, but rather complements, the communication skills you have already
developed.
This method is something that you can continue to learn and refine
throughout a lifetime of practice. This is so precisely because you can
learn it from your patients. Once you know what to listen for, every patient
consultation becomes a source of learning and gives you feedback
about how you’re doing. When you finish reading this book, you won’t
be proficient in this guiding style of motivational interviewing. Instead,
Preface ix
if we have written well, you will know how to learn it from your own
patients.
In Part I we begin by offering an overview of motivational interviewing,
its evidence base, and how it fits within the broader context of
health care. We then describe the three communication styles of directing,
guiding, and following, and present three specific core skills: asking,
informing, and listening. In Part II we show how these skills can be
refined and used in the service of the guiding style of motivational interviewing.
Finally, in Part III we offer some practical examples and guidelines
for improving your comfort and skill in using motivational interviewing
in practice. A final chapter looks beyond the individual
consultation to how the service environment might also enhance health
behavior change.
STEPHEN ROLLNICK, PHD
WILLIAM R. MILLER, PHD
CHRISTOPHER C. BUTLER, MD
REFERENCES
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people
to change addictive behavior. New York: Guilford Press.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing (2nd ed.): Preparing
people for change. New York: Guilford Press.
Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change: A guide for
practitioners. Edinburgh, UK: Churchill Livingstone.
x Preface
AcknowledgmentsAcknowledgments
Acknowledgments
We acknowledge with heartfelt thanks the contributions of practitioners
we have met in training, too many to mention, who helped us clarify our
thinking and understanding.
The inspiration and suggestions from colleagues in MINT, the Mo
tivational Interviewing Network of Trainers (www.motivationalinterview.
org), were a regular source of support. It was typical of this group to
shower us with ideas when we put questions to them in meetings and on
the electronic mailing list that connects us in lively discussion. Jeff
Allison and Gary Rose helped us to clarify, in training efforts and
through discussion, the content and boundaries of the three-styles framework.
Feedback and suggestions from Tom Barth and Pip Mason enriched
the material on aspirations for behavior change in Chapter 10.
Bob Mash and colleagues from the South African MISA (Motivational
Interviewing in South Africa) trainers’ group provided stories, vignettes,
and suggestions that were used to construct case studies and accounts of
consultations and services in the HIV/AIDS field. Colleagues from PATA
(Pediatric AIDS Treatment in Africa), particularly Dr. Paul Roux, provided
countless examples of the triumph of hope, commitment, and creativity
in the face of adversity. Ralf Demmel fed us with papers on parental
scaffolding; Michael Robling gave his time and experience to
discussions about diabetes care; and Claire Lane, Linda Speck, and
Adrienne Cook gave us feedback about cardiac rehabilitation and lucid
accounts of their efforts to change the culture of services. Peter Prescott
and Carolina Yahne wrote to us on more than one occasion about the
principle and practice of conveying hope. Conversations with Valerie
xi
Dougall in the software design world helped enormously in considering
how ideas can be made accessible to learners. We also thank Carrie
McCorkindale, Barbara B. Walker, Anne E. Kazak, and Sheila K. Stevens
for their help in reviewing an earlier draft of the manuscript.
Our families helped us in more ways than one. We thank our partners,
Sheila, Kathy, and Judith, for supporting our writing efforts, and
Jacob Rollnick for highlighting the role of high emotion in motivational
interviewing when helping others to change at home (no names mentioned).
Julian Rollnick scrutinized every word and offered invaluable
advice and encouragement. Finally, we thank our editors at The Guilford
Press, Jim Nageotte and Barbara Watkins, for their truly expert help in
shaping the structure and content of this book.
xii Acknowledgments
ContentsContents
Contents
PART I. BEHAVIOR CHANGE
AND MOTIVATIONAL INTERVIEWING
1 Motivational Interviewing: Principles and Evidence 3
2 How Motivational Interviewing Fits into Health Care Practice 11
PART II. CORE SKILLS
OF MOTIVATIONAL INTERVIEWING
3 Practicing Motivational Interviewing 33
4 Asking 44
5 Listening 65
6 Informing 86
PART III. PUTTING IT ALL TOGETHER
7 Integrating the Skills 111
8 Case Examples of a Guiding Style 121
xiii
9 Getting Better at Guiding 140
10 Beyond the Consultation 157
Epilogue: Some Maps to Guide You 173
Appendix A. Learning More about Motivational Interviewing 177
Appendix B. A Topical Bibliography of Research
on Motivational Interviewing
183
Index 205
xiv Contents
PART I
BEHAVIOR CHANGE
AND MOTIVATIONAL
INTERVIEWING
BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWINGPrinciples and Evidence
CHAPTER 1
Motivational Interviewing
Principles and Evidence
During the 20th century remarkable advances occurred in curing acute
illnesses. The successful treatment and control of infectious diseases significantly
prolonged life expectancy. Traumatic injuries that were once
fatal or permanently disabling are now treatable. Some forms of organ
failure can be addressed through dialysis, transplantation, and bypass
surgery. From the perspective of health care capabilities, populations in
developed nations should be healthier than ever before.
Yet there are signs that today’s young adults may be the first generation
in modern history to be less healthy than their parents. Respiratory
diseases and cancers, diabetes and obesity, heart and liver disease, and
some psychological problems, such as depression, are all strongly linked
to health behavior and lifestyle. A majority of the maladies that now
cause people to consult health care professionals (e.g., physicians,
dentists, nurses, chiropractors) are largely preventable or remediable
through health behavior change.
In the developing world, and in the underbelly of large cities everywhere,
people in inadequate living conditions also struggle against a
level of adversity that threatens their health. They consult health care
practitioners in difficult circumstances in which a similar range of health
behavior concerns arise, and they often feel that their health is not necessarily
something they can control. Yet here, too, behavior change is a key
component of many risks to health, from smoking, excessive alcohol
use, and poor diet to water purification, infant feeding practices, and the
prevention of infectious diseases.
3
In the 21st century, health care is increasingly about long-term condition
management and thus about health behavior change—those
things that people can do to improve their health. And so it is hard to
think of a health care setting or professional role, a clinical diagnosis or
a health care problem, in which patient behavior change is not a potentially
important contributor to prevention, to treatment, or to the maintenance
of health. However, most people who seek health care still seem
to be looking for a medical cure. They expect the practitioner to ask a
series of questions and then prescribe
a treatment that will restore
them to health or, at least, alleviate
their symptoms. In other words, no
matter how they may mistreat
themselves, the responsibility for
curing them is seen to lie with the
physician, the nurse, or the overall
health care system.
If you are a doctor, nurse, physical therapist, health social worker,
dentist, dental hygienist, dietician, podiatrist, counselor, health psychologist,
or other health care professional, you probably have many conversations
about behavior change in the course of your typical work day.
What is often less clear is how a practitioner should approach this topic.
Should you:
Explain what patients could do differently in the interest of their
health?
Advise and persuade them to change their behavior?
Warn them what will happen if they don’t change their ways?
Take time to counsel them about how to change their behavior?
Refer them to a specialist?
This book was written to help you have productive conversations
with patients about behavior change. In particular, we describe a gentle
form of counseling known as motivational interviewing (MI), which has
been found effective in fostering change across a wide range of health
behaviors.
The clinical method of MI, first described in 1983, was initially developed
as a brief intervention for problem drinking, in which patient
motivation is a common obstacle to change. Starting in the 1990s, MI
began to be tested with other health problems, particularly chronic diseases,
in which behavior change is key and patient motivation is a common
challenge. There have been positive trials of MI in the management
of cardiovascular disease, diabetes, diet, hypertension, psychosis, and
pathological gambling and in the treatment and prevention of HIV infec-
4 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
In the 21st century, health care is
increasingly about long-term
condition management and thus
about health behavior change—
those things that people can do to
improve their health.
tion. Clinical trials of MI have been published across a broad range of
behavior-change problems.
MI works by activating patients’ own motivation for change and
adherence to treatment. Patients exposed to MI (vs. treatment as usual)
have been found in various clinical trials to be more likely to enter, stay
in, and complete treatment; to participate in follow-up visits; to adhere
to glucose monitoring and to improve glycemic control; to increase exercise
and fruit and vegetable intake;
to reduce stress and sodium intake;
to keep food diaries; to reduce unprotected
sex and needle sharing; to
improve medication adherence; to
decrease alcohol and illicit drug use;
to quit smoking; and to have fewer subsequent injuries and hospitalizations.
It is not a panacea, of course; not all trials have been positive, and
the size of effect has varied widely. Readers interested in the research
base can find a bibliography of outcome studies at the back of this book
and also at www.motivationalinterview.org.
THE MYTH OF THE UNMOTIVATED PATIENT
Conversations about behavior change arise within a consultation whenever
you or your patients are considering their doing something different
in the interest of health. That “doing”
might be taking a medication
regularly, using a walker, flossing
teeth, changing diet, exercising, and
so on. It might also involve cutting
down or quitting behaviors that are
harmful to health: smoking, heavy
drinking, drug abuse, overworking,
or eating junk food. Across health care specialties, the scope of possible
health behavior change that can be discussed broadens considerably to
include such subjects as patients’
footwear (in diabetes), fluid intake
(kidney disease), condom use, attendance
at a clinic, use of hearing
aids, and so on. For the purposes of
this book, a strict definition of
health behavior might not be neces-
sary.
When a patient seems unmotivated
to change or to take the sound
Principles and Evidence 5
MI works by activating patients’
own motivation for change and
adherence to treatment.
Conversations about behavior
change arise whenever you or your
patients are considering their doing
something different in the interest
of health.
When a patient seems unmotivated
to change or to take the sound
advice of practitioners, it is often
assumed that there is something the
matter with the patient and that
there is not much one can do about
it. These assumptions are usually
false. No person is completely
unmotivated.
advice of practitioners, it is often assumed that there is something the
matter with the patient and that there is not much one can do about it.
These assumptions are usually false. A starting point for this book is that
motivation for change is actually quite malleable and is particularly
formed in the context of relationships.
The way in which you talk
with patients about their health can
substantially influence their personal
motivation for behavior change. No
person is completely unmotivated.
We all have goals and aspirations.
You can make a difference and have
a long-term influence on your patients’
health. How, then, should one respond when what patients need
is behavior and lifestyle change?
THE “SPIRIT” OF MI
MI is not a technique for tricking people into doing what they do not
want to do. Rather, it is a skillful clinical style for eliciting from patients
their own good motivations for making behavior changes in the interest
of their health. It involves guiding more than directing, dancing rather
than wrestling, listening at least as much as telling. The overall “spirit”
has been described as collaborative, evocative, and honoring of patient
autonomy.
• Collaborative. MI rests on a cooperative and collaborative partnership
between patient and clinician. Whereas the patient-centered clinical
method is a broad approach to the consultation, MI addresses the
specific situation in which patient behavior change is needed. Instead of
an uneven power relationship in which the expert clinician directs the
passive patient in what to do, there is an active collaborative conversation
and joint decision-making process. This is particularly vital in
health behavior change, because ultimately it is only the patient who can
enact such change.
• Evocative. Often health care seems to involve giving patients
what they lack, be it medication, knowledge, insight, or skills. MI instead
seeks to evoke from patients that which they already have, to activate
their own motivation and resources for change. A patient may not
be motivated to do what you want him or her to, but each person has
personal goals, values, aspirations, and dreams. Part of the art of MI is
connecting health behavior change with what your patients care about,
with their own values and concerns. This can be done only by under-
6 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
The way in which you talk with
patients about their health can
substantially influence their
personal motivation for behavior
change.
standing patients’ own perspectives,
by evoking their own good reasons
and arguments for change.
• Honoring patient autonomy.
MI also requires a certain degree of
detachment from outcomes—not an
absence of caring, but rather an acceptance
that people can and do make choices about the course of their
lives. Clinicians may inform, advise, even warn, but ultimately it is the
patient who decides what to do. To recognize and honor this autonomy
is also a key element in facilitating
health behavior change. There is
something in human nature that resists
being coerced and told what to
do. Ironically, it is acknowledging
the other’s right and freedom not to
change that sometimes makes
change possible.
These three characteristics describe
the underlying “spirit” of MI, the mindset with which one approaches
conversations with patients about behavior change.
FOUR GUIDING PRINCIPLES
Relatedly, the practice of MI has four guiding principles: (1) to resist the
righting reflex, (2) to understand and explore the patient’s own motivations,
(3) to listen with empathy, and (4) to empower the patient, encouraging
hope and optimism. These four principles can be remembered
by the acronym RULE: Resist, Understand, Listen, and Empower.
R: Resist the Righting Reflex
People who enter helping professions often have a powerful desire to set
things right, to heal, to prevent harm and promote well-being. When seeing
someone headed down the wrong path, they will usually want to get
out in front of the person and say, “Stop! Turn back! There is a better
way!” This is a laudable motivation; it is often what calls people into
service to others. Given this motivation, the urge to correct another’s
course often becomes automatic, almost reflexive.
A problem is that this first inclination can have a paradoxical effect.
The reason is not that patients are flawed, recalcitrant, lazy, or in the
grip of pernicious denial. Rather, it is a natural human tendency to resist
persuasion. This is particularly true when one is ambivalent about somePrinciples
and Evidence 7
Often health care seems to involve
giving patients what they lack, be it
medication, knowledge, insight, or
skills. MI instead seeks to evoke
from patients that which they
already have.
There is something in human
nature that resists being coerced
and told what to do. Ironically, it is
acknowledging the other’s right and
freedom not to change that
sometimes makes change possible.
thing. Problem drinkers, for example, often know perfectly well that
they are drinking too much and that it is having some adverse consequences.
But they also enjoy drinking and don’t like to think of themselves
as “having a problem,” and thus they prefer to see their drinking
as reasonably normal. Virtually every problem drinker we have treated,
if allowed to explore it, has felt two ways about drinking.
When a health professional takes up the “good” side of the patient’s
internal argument and tries to set the patient right, what happens? If you
say, “I think you are drinking too much, and should cut down or quit,” the
patient’s natural response is to argue the other side of the ambivalence:
“It’s not that bad, and I’m doing fine.” The temptation then is to turn up
the volume, to argue all the more forcefully that the person is in trouble
and needs to make a change. The patient’s response, again, is predictable.
PRACTITIONER: Well, if you did decide to exercise more, that would not
only help your knee but also help you lose weight and improve your
mood, you know. Exercise makes people slimmer, fitter, and feel better.
PATIENT: Yes, I know all that. But I can’t help thinking that if I exercise
while my knee hurts, even with gentle things like swimming, that I
am doing more damage to it, despite what you say about those studies
you read. . . .
This acting out of the patient’s internal dilemma might be therapeutic in
some way were it not for another well-documented basic principle of human
nature: We tend to believe what we hear ourselves say. The more
patients verbalize the disadvantages of change, the more committed they
become to sustaining the status quo. If you converse in a way that causes
patients to defend the status quo and argue against change, you may
well inadvertently decrease rather
than increase the likelihood of behavior
change actually happening.
In sum, if you are arguing for
change and your patient is resisting
and arguing against it, you’re in the
wrong role. You are taking all the
good lines. It is the patient who should
be voicing the arguments for change.
MI is about evoking those arguments from the patient, and that means first
suppressing what may seem like the right thing to do—the righting reflex.
On many, if not most, issues of health behavior change, patients are
ambivalent. They want to; they might be able to; they see good reasons
to; they know they need to; and then they hit that “but.” That’s where
8 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
We tend to believe what we hear
ourselves say. The more patients
verbalize the disadvantages of
change, the more committed they
become to sustaining the status
quo.
patients’ thinking may stop unless you help them through the ambivalence.
Fortunately, there is much you can do to make that happen, starting
with the next guiding principle.
U: Understand Your Patient’s Motivations
It is the patient’s own reasons for change, and not yours, that are most
likely to trigger behavior change. And so a second guiding principle is to
be interested in the patient’s own concerns, values, and motivations. In
MI one proceeds in a way that evokes and explores patients’ perceptions
about their current situations and their own motivations for change.
This may sound like a prolonged process, but it need not be. It can be
done within the normal length of your consultation. We believe, in fact,
that if your consultation time is limited,
you are better off asking patients
why they would want to
make a change and how they might
do it rather than telling them that
they should. It is the patient, rather
than you, who should be voicing the
arguments for behavior change. We
address the practicalities, the “how to,” of this and other principles in
Part II.
L: Listen to Your Patient
MI involves at least as much listening as informing. Perhaps the normal
expectations of a health care consultation are that the practitioner has
the answers and will give them to the patients. Often you do have answers,
and patients come to you for this expertise. When it comes to behavior
change, though, the answers most likely lie within the patient,
and finding them requires some listening.
Good listening is actually a complex clinical skill. It requires more
than asking questions and keeping quiet long though to hear patients’
replies. In their book Making the Patient Your Partner, psychologist
Thomas Gordon and surgeon Sterling Edwards discussed how such
quality listening is a vital part of good medical care in general.* It involves
an empathic interest in making sure you understand, making
guesses about meaning—a skill discussed in more detail in Chapter 5.
Principles and Evidence 9
If your consultation time is limited,
you are better off asking patients
why they would want to make a
change and how they might do it
rather than telling them that they
should.
* Gordon, T., & Edwards, W. S. (1995). Making the patient your partner: Communication
skills for doctors and other caregivers. Westport, CT: Auburn House.
E: Empower Your Patient
It is increasingly clear that outcomes are better when patients take an active
interest and role in their own health care. A fourth guiding principle
in MI is empowerment—helping patients explore how they can make a
difference in their own health. Again, the patient’s own ideas and resources
are key here. You know that regular exercise is important, but it
is your patients who know best how they could successfully build it into
their daily lives. Patients in essence become your consultants on their
own lives and on how best to accomplish behavior change. An important
role for you in this process is to support their hope that such change
is possible and can make a difference
in their health. A patient who
is active in the consultation, thinking
aloud about the why and how of
change, is more likely to do something
about this afterward. You, the
practitioner, are an expert in facilitating
the patients’ bringing their
expertise to the consultation.
Encouraging health behavior change by applying MI effectively
within the space of a few minutes and in conjunction with other health
care tasks is a highly skillful process. Through working in health care
and listening to countless consultations over the years, we have developed
deep admiration for the level of skillfulness that so many frontline
clinicians already manifest in practice each and every day. Our hope in
providing this book is not to displace these naturally honed skills and instincts
but rather to offer what assistance we can in supporting your desire
and ability to help patients change.
CONCLUSION
This chapter has described the rationale for using MI when talking to
patients about behavior change. In the next chapters we discuss in more
detail how MI fits into the normal communication processes of health
care. Chapter 2 places the guiding style within a continuum of communication
styles that you normally use in practice. We describe MI as a refined
form of guiding. We also discuss three core communication skills
that are also part of normal practice. The purpose of all of this is to help
you place MI within the context of your day-to-day work. In Part II we
explain how these basic skills can be used in the service of guiding behavior
change.
10 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
A patient who is active in the
consultation, thinking aloud about
the why and how of change, is
more likely to do something about
this afterward.
BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWINGHow MI Fits into Health Care Practice
CHAPTER 2
How Motivational Interviewing Fits
into Health Care Practice
How do you take MI, developed by psychologists for counseling, and
use it in your everyday practice? Your time is often short, and we are
asking you to absorb not just technical matters but also a different way
of thinking about promoting change in others. MI can seem both
comfortingly familiar and difficult to integrate. Is it something completely
different from what you do normally? Our answer is no.
This chapter aims to link MI and everyday health care practice
through examination of three common
styles of communication in
health care: directing, guiding, and
following. MI is a refined form of
guiding. In this chapter we also look
at three core communication skills:
asking, informing, and listening.
These skills are simple and basic in
themselves, but, used in combination, they are the tools that make for either
effective or ineffective directing, guiding, and following.
“BUT I USE THIS METHOD EVERY DAY . . . ”
“This MI method is nothing new. I do this every day.” This is a common
reaction among practitioners who are presented with a description of MI
11
MI can seem both comfortingly
familiar and difficult to integrate.
Is it something completely different
from what you do normally? Our
answer is no.
for the first time. You may have recognized explanations and even recalled
recent consultations characterized by some of the principles described
in Chapter 1. Perhaps a patient was talking about behavior
change in a constructive way, and your role seemed almost effortless.
Perhaps you were not trying to convince the patient to change at all.
Your role was a quieter, more supportive one. As the 17th-century
French polymath Blaise Pascal wrote in his Pensées, “People are generally
better persuaded by the reasons which they have themselves discovered
than by those which have come in to the mind of others.” Indeed,
eliciting motivation for change from patients themselves is not a new
idea, and neither is the supportive approach that we call guiding. MI is
built on this platform.
THREE COMMUNICATION STYLES
One of the most striking features of MI is a feeling that you get in the
consultation, almost tangible, that your stance in relation to the patient
is easy and less conflict-ridden. As a colleague once remarked, “It’s like
dancing rather than wrestling.” This experience is not just a reflection of
the patient’s attitude and behavior but of yours as well. It is linked to
how you approach the whole topic of behavior change. Shift your style,
and the consultation feels different.
The term “style” captures nicely this strategic approach to helping
patients. In this book a communication style refers to an attitude and approach
to helping patients, a way of talking with them that characterizes
your relationship with them. Different communication styles are used
for different purposes. The guiding style seems particularly suited to difficult
conversations about behavior change. However, other styles are
better suited to other purposes. Here are some concrete examples.
Imagine that you are sitting down with a good friend to talk over
something that is distressing her. In particular, she is torn about whether
to stay in a relationship with someone she has cared about for years. It’s
a decision with far-reaching implications. How will you respond?
One approach is to listen carefully and follow along as she pours
out her story, seeking to be sympathetic and supportive as she sorts out
what she wants to do. By listening and taking the time to understand
what she is experiencing, you are also helping her to voice and clarify
her own feelings. You don’t offer any answers for her. Rather, you try to
be a good companion on this journey that is clearly hers to make.
Suppose, however, that you have a very clear opinion as to what she
should do. A second approach would be to offer your straightforward
advice as her close friend. By telling her how you see her situation, mak-
12 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
ing a clear suggestion, and explaining your rationale for it, you hope to
be helpful in getting her unstuck and moving in a healthier and happier
direction. In this approach you respond to a person in distress by telling
her what she should (or at least could) do, helping her solve her prob-
lem.
A third approach goes down the middle between the other two,
combining some of the better qualities of both. You listen carefully and
empathically to understand your friend’s dilemma. Then you ask her
about the various options she is considering, and you both explore together
the pros and cons of each. Here or there you may offer a bit of
what you know about her or about people and relationships more generally,
recognizing and honoring that ultimately it is her life and her decision
to make. As some clarity emerges, you help her to move in the direction
that she has chosen.
These three examples correspond, respectively, to the three communication
styles to be discussed in this chapter: following, directing, and
guiding. All three are legitimate and important methods of communication.
All three are used in everyday life, as well as in health care practice,
and each style has contexts in which it fits and works best. We therefore
make no value judgments about the worthiness of each style. Instead, we
suggest that problems emerge when there is an incongruity between style
and task. One way of thinking about these three styles is to imagine
them along a continuum, with following at one end, directing at the
other, and guiding in the middle. Another is to imagine that you are sitting
in the center of a circle, able to reach out to use the appropriate style
as needed (see Figure 2.1).
In a way, each of these styles reflects different attitudes about your
role in the relationship. For a helping professional, they reflect different
How MI Fits into Health Care Practice 13
FIGURE 2.1. Three communication styles.
assumptions about how one is to go about the process of being helpful
in different situations.
Following
Everyone likes a good listener, and most people believe that they are
good listeners. A truly good listener suspends his or her own “stuff” in
the interest of giving full attention to understanding the other’s experience.
Good listening does not involve instructing or directing, agreeing
or disagreeing, persuading or advising, warning or analyzing. It has no
agenda to achieve other than seeing and understanding the world
through the other’s eyes.
In the style of following, listening predominates. You follow the
other person’s lead. With regard to
behavior change, a following style
communicates “I won’t change or
push you. I trust your wisdom
about yourself, and I’ll let you work
this out in your own time and at
your own pace.” A patient who is in
tears after you deliver bad news
needs a following style from you.
So, too, at the beginning of a consultation, a brief period of following
helps you to understand patients’ symptoms and how these fit into the
larger picture of their life and health.
Directing
The directing style bespeaks quite a different interpersonal relationship.
In this approach you take charge, at least for the time being. It implies
an uneven relationship with regard to knowledge, expertise, authority,
or power. Sometimes this approach saves lives. A director, in essence,
tells a person what to do, with or
without explaining the rationale. In
everyday life, a director is usually
responsible for seeing that you perform
your job properly, for judging
your performance, and for overseeing
appropriate consequences for a
job well or poorly done. There are,
of course, other styles of management,
but a clear line of authority is
involved in being a director, man-
14 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
Some synonyms for “following”:
Go along with Go after
Allow Attend
Permit Take in
Be responsive Shadow
Have faith in Understand
Observe
Some synonyms for “directing”:
Manage Prescribe
Lead Tell
Take charge Show the way
Preside Govern
Rule Authorize
Reign Take the reins
Conduct Take command
Determine Point toward
Steer Administer
ager, supervisor, or chief. With regard to behavior change, the directing
style communicates, “I know how you can solve this problem. I know
what you should do.” The expected complementary role is adherence or
compliance. Many health care practitioners will recognize this as one of
the cornerstones of their education. A directing style seems appropriate
for countless situations in which a patient depends on you for decisions,
action, and advice. Patients often appear to expect and want this kind of
take-charge approach from you.
Guiding
A guide helps you find your way. It is not within the guide’s authority to
determine what you want to see or do. You decide where to go, and you
hire a knowledgeable guide or travel
agent to help you get there. Consider
the guide and director roles in
education. In a director role, medical
faculty determine what their students
will study, what learning activities
are required, and what
standards constitute acceptable performance.
A more guiding role is that of a tutor, who is a resource to
help students in more self-directed learning. A good guide knows what is
possible and can offer you alternatives
from which to choose. With regard
to behavior change, the guiding
style communicates, “I can help
you to solve this for yourself.”
Mix and Match
All three of these styles—following, directing, and guiding—are used in
everyday life. They are suited to different types of circumstances and relationships,
and a mismatch can cause problems. A student who takes a
directing tone with a teacher is stepping out of role and may thereby get
into trouble. A parent who follows
along passively while a wild child
rampages around a restaurant is
likely to be regarded as irresponsi-
ble.
More often these three communication
styles are intermixed, and
skillfulness in communication inHow
MI Fits into Health Care Practice 15
Some synonyms for “guiding”:
Enlighten Look after
Encourage Take along
Motivate Accompany
Support Awaken
Lay before Elicit
With regard to behavior change,
the guiding style communicates, “I
can help you to solve this for
yourself.”
All three of these styles—following,
directing, and guiding—are used in
everyday life. They are suited to
different types of circumstances and
relationships, and a mismatch can
cause problems.
volves flexible shifting among them. Watch a skillful parent and young
child for an hour, and you will probably see all three styles. Good
parenting requires good following—being willing and able to listen to a
child’s feelings and imagination, hopes and fears, successes and adventures.
Good parenting also requires some directing, such as when a child
is about to wander out into traffic on a busy street. The setting of consistent
limits involves directing: “Get out of the bath now!” “Homework
first, then we’ll play.”
Skillful parents also guide. By the age of 6 or so, children ordinarily
develop the ability to self-regulate, to form a plan and direct their behavior
toward it without external enforcement. Children vary widely, however,
in the extent to which they can self-regulate, and parenting style is a
contributing factor. Research shows that parents whose children develop
solid self-regulation skills tend to use a guiding style in helping their children
to learn. Imagine a parent and a 4-year-old child seated together at
a table. The child’s task is to use the various-sized blocks on the table to
build a tower as tall as possible. What does the parent do? The directing
parent tells the child what to do at every step along the way, immediately
corrects mistakes, and may even take over block placement for the child:
“Let me do that!” The following parent sits back and watches the child’s
trial and error without offering help. The guiding parent does a little of
both: watching patiently and with interest, but also stepping in now and
then perhaps to whisper a tip in the child’s ear—“Try putting the big
ones on the bottom!”—then stepping back again to let the child try.
An art teacher could similarly work anywhere along this continuum.
A highly directing teacher might ask the student to copy step by
step or might literally hold and direct the hand that holds the brush or
chisel. A following teacher might provide the raw materials and then sit
back, letting students explore freely without direction. In between is the
guiding style, in which the art teacher walks around the room, watching
attentively, providing encouragement, asking what the student has in
mind, now and then offering a suggestion if the student wants it. The
same teacher may use all three styles flexibly within the same class session
or may begin with more directing early in the course and then step
back to more guiding and following as students progress.
Think back to your own favorite teacher—the one in whose class
you were particularly motivated and engaged, the one who saw possibilities
and brought out the best in you. Though it is not always the case,
this person was probably skillful at guiding you.
Across the wide range of circumstances you meet in everyday health
care practice, there is a place for each style. A skillful practitioner is
someone able to shift flexibly among these styles as appropriate to the
patient and situation. What is described as “an old-fashioned, good bed-
16 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
side manner” is probably a reflection
of much more than a friendly
doctor or nurse. It is someone with
the skill to switch among communication
styles and the wisdom to seek
and understand what style the patient
needs.
The Overuse of Directing
Skillful practitioners abound, and they often seem like the unsung heroes
in the maelstrom of modern clinical practice. Yet a disturbing pattern
seems evident in health care, in both practice and management, with the
balance of communication shifting toward directing while the value of
following and guiding is often ignored. The well-intentioned efforts of
service providers to assess, prioritize, diagnose, provide, measure, promote,
follow up, and reach targets can express themselves in a directing
style that compromises quality care, permeates most conversations, and
all too often renders patients the
passive recipients of doses of care.
Under pressures of time to check off
boxes, conduct standardized assessments,
adhere to competency frameworks,
and reduce costs, an actionoriented
culture sometimes prevails,
and directing is the style that expresses
this value. The difficulty, however, is that many problems are
more effectively solved by a better balanced mixture of styles. It is often
better to follow and contemplate a little, to support and guide, before
using a directing style.
Stefan is 14-year-old boy who attends the diabetes clinic every few
months, where he goes through a routine of weight and blood glucose
testing with familiar, friendly faces. He has failed to bring his
diary along (was he even keeping it properly?). His meeting with the
doctor starts with some friendly chat, then proceeds through a series
of investigative questions to the main concern: a poor blood
glucose test result. He is strongly advised to keep his diary more
faithfully and to maintain a good injecting routine. He leaves feeling
guilty. He did not expect his struggles with puberty and diabetes to
be raised, and they weren’t. But at least on this occasion, he wasn’t
told to watch his diet and get more regular exercise. That was a re-
lief.
How MI Fits into Health Care Practice 17
A skillful practitioner is someone
able to shift flexibly among these
styles as appropriate to the patient
and situation.
A disturbing pattern seems evident
in health care, with the balance of
communication shifting toward
directing rather than following and
guiding.
A directing style is appropriate in many circumstances and can be
used skillfully, but it ought not to be the only way you interact with patients.
There are times when it is not
essential or even possible for you to
be the expert director, and that is particularly
true in discussions of patients’
lifestyle and behavior change,
in which it is crucial to engage the patient’s
own motivation, energy, and
commitment. A guiding style is probably
called for, something Stefan
might have responded to better. If
you want cooperative patients, directing
is not your only option.
Guiding, MI, and Behavior Change
Health care ethics emphasize human autonomy, the right of the person
to make informed decisions about the course of his or her own life.
Much as one might like to step in and make the “right” choices for a
patient (or child, or student), the practitioner’s ability to do so is constrained.
Health outcomes are often highly influenced by and dependent
on the patient’s own behavioral choices—on doing something new
or differently. Smoking, drinking, diet, exercise, medication adherence—these
are examples of important health behaviors that can have
a major effect on the course of a patient’s health or illness and over
which health care practitioners have little or no direct control. Yet letting
go of some control does not mean lack of influence. In human relationships,
it is quite possible to influence that which we do not personally
control.
Guiding is well suited to helping people solve behavior-change
problems. MI is a refined form of this guiding style. A practitioner using
MI will conduct the discussion in
line with a guiding style, paying
particular attention to how to help
the patient make his or her own decisions
about behavior change.
Thus, although all MI could be considered
a form of guiding, not all
guiding is MI! In contrast to the more general guiding style, MI:
• Is specifically goal-directed. Often the practitioner has a specific
behavior-change goal in mind and gently guides the pa-
18 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
There are times when it is not
essential or even possible for you to
be the expert director, and that is
particularly true in discussions of
patients’ lifestyle and behavior
change, in which it is crucial to
engage the patient’s own
motivation, energy, and
commitment. A guiding style
is probably called for.
Guiding is well suited to helping
people solve behavior-change
problems. MI is a refined form
of this guiding style.
tient to consider why and how he or she might pursue that
goal.
• Pays particular attention to certain aspects of patient language
and actively seeks to evoke the patient’s own arguments for
change.
• Involves competence in a well-defined set of clinical skills and
strategies that are used to evoke patient behavior change.
To help you understand the heart and nature of this way of talking
with patients, we next look at three basic communication skills. Used in
combination, these skills are your tools for creating the communication
styles we have been discussing, including MI.
THREE CORE COMMUNICATION SKILLS
Asking, informing, and listening are three basic but important communication
skills. They are the means by which any of the three communication
styles just discussed can be put into practice. These skills are
observable behaviors, the things that you actually do to implement the
style you are adopting. Health professionals regularly ask, listen to,
and inform patients in their consultations. Using these tools well increases
your freedom to conduct the consultation in a time-efficient
and productive manner. They are the communication equivalent of
technical proficiency in music; the more proficient, the wider the range
of application, skillfulness, and enjoyment. Here is a brief synopsis of
each skill:
• Asking. The practitioner’s intent in asking questions is usually to
develop an understanding of the patient’s problem(s). Some nuances,
functions, and consequences of using this tool within a guiding style are
described in Chapter 4.
• Listening. Good listening is an active process. It is a check on
whether you understand the person’s meaning correctly, and it also communicates
“What you are saying is important to me. I want to hear
more.” Done well, it also encourages
the patient to explore and reveal
more, and it sometimes does so
within a surprisingly short period of
time. In many ways, good listening
is the core skill when using the guiding
style.
• Informing. The principal veHow
MI Fits into Health Care Practice 19
Asking, listening, and informing are
the communication equivalent of
technical proficiency in music; the
more proficient, the wider the range
of application, skillfulness, and
enjoyment.
hicle for conveying knowledge to the patient about a condition and its
treatment is informing. The practitioner usually informs the patient
about a range of facts, diagnoses, and recommendations. When informing
is not done well it can result in poor adherence or glazed looks from
patients as the practitioner talks to them.
What Is Your Preference?
Of these three core communication skills, is there one that you particularly
favor in practice? You do use all three, of course, but perhaps you
tend to rely on one of these more
than others in talking with your patients.
Practitioners tend to develop
consistent habits in health care consultations.
Do your consultations
tend to lean more heavily on one of
these communication tools, or perhaps
a combination of two out of
the three? The same question applies
to the three communication
styles described earlier. Do your current consultations lean more toward
directing, guiding, or following?
When we ask which tools practitioners use most, the most common
answer we hear is, “Asking and then informing,” and practitioners report
using these skills mostly in the service of a directing style. For example,
“I find out what’s wrong with the patient [asking and listening],
then I diagnose and recommend treatment [informing].” This one–two–
three combination is obviously useful in practice, but when it comes to
behavior change, it also contains some unintended consequences; more
on this later.
One practitioner we met reacted with consternation to the possibility
of incorporating some new evidence about the management of a particular
problem. “Oh, no,” he laughed. “Now I’m going to have to develop
a completely new line of patter.” Then he explained that he had
developed a very comfortable routine for managing his consultations.
He asked a few questions about specific symptoms and then delivered information,
suited to the circumstances, about diagnosis and treatment.
This was his modus operandi. It involved mostly asking and informing,
and he could do it in his sleep. Now he felt obliged to consider broadening
his repertoire. His “line of patter,” as well as his attitude toward
helping his patients, began to change.
20 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
Practitioners tend to develop
consistent habits in health care
consultations. Do your
consultations tend to lean more
heavily on one of these
communication tools, or perhaps a
combination of two out of the
three?
STYLES AND SKILLS:
YOUR ATTITUDE AND YOUR BEHAVIOR
All three skills (asking, listening, informing) are used in all three styles
(following, guiding, directing), but the skill mix in each style may be
quite different. The key difference among the three styles is in the underlying
attitude and assumptions about how to address a patient’s problem.
Of course, your attitude is not expressed just in the skill mix but
also by complementary signals from your tone of voice, the quality of
eye contact, body language, and such things as the seating arrangement
in your consulting room.
Figure 2.2 presents a model of the relationship between styles and
skills. In general, the directing style tends to be heavy on informing,
whereas a following style relies heavily on listening. All three styles involve
a certain amount of asking. The guiding style features perhaps the
most equitable balance in use of the
three tools.
Figure 2.2 describes the frequency
with which skills might be
used across styles. However, there is
another important difference across
styles: the way in which they are
used and the purposes they are used
for. Thus asking in the service of directing will often look and sound
quite different from asking in the service of a following or a guiding
How MI Fits into Health Care Practice 21
FIGURE 2.2. Styles and skills: How often are skills used within different styles?
Adapted with permission from Barbara B. Walker.
Asking in the service of directing
will often look and sound quite
different from asking in the service
of a following or a guiding style.
Similarly with listening and
informing.
style. So, too, with listening and informing. As an example of the skill of
asking, “How much do you smoke each day?” is often phrased in a way
that’s indicative of a directing style, whereas “What would it take for
you to stop smoking?” might be more indicative of a guiding style. Table
2.1 provides more examples.
Directing and Core Skills
A directing style can be just what patients expect and well suited to the
demands of the clinical situation.
Done well, directing has a quality of
being well timed, personally relevant,
clear, and compassionate. To
achieve this, you might have to begin
with a following style.
Poor Directing
Directing can also be used with a lack of grace, in a way that leaves patients
feeling unheard and dissatisfied. Here is an example of directing
gone wrong. A patient with a hip problem consults a specialist who has
the latest X-ray results:
22 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
TABLE 2.1. Asking, Informing, and Listening Vary According to the Style
Being Used
Asking
• “How may times has that happened?” [directing]
• “What kind of change makes sense to you?” [guiding]
• “How have you been since your son died?” [following]
Informing
• “Your best option is to take these tablets.” [directing]
• “Changing your diet would make sense medically, but how does that feel for
you?” [guiding]
• “Yes, it’s a common experience; many patients also feel quite shocked and
unsettled about simple things like going to the toilet.” [following]
Listening
• “So you understand what’s going to happen this morning, but you want me to
tell you more about what will happen later on.” [directing]
• “You’re feeling concerned about your weight, and you are not sure where to go
from here.” [guiding]
• “This has been a huge shock.” [following]
Done well, directing has a quality
of being well timed, personally
relevant, clear and compassionate.
. . . It can also be used with a lack
of grace.
PRACTITIONER: How have you been getting along with the hip? [asking]
PATIENT: Well, since that operation its been really hellish, to be honest.
The pain is still really hard to bear and sometimes those pills just
don’t help. I wonder if there is something still wrong with it.
PRACTITIONER: Have you been in to see your family doctor? [asking]
PATIENT: Yes, she’s given me these pills that she said you recommended.
PRACTITIONER: Good, because I think they will help you. I can tell you
that the X-ray shows that you have made a very good recovery and
that your hip appears to be in good condition. [informing]
PATIENT: Well, uh, it still hurts so much, I tell you, doctor, yesterday it
was unbearable.
PRACTITIONER: It will get better with time, if you are doing all the right
things like I told you. Take your medication and take a walk twice a
day. I’d like to see you again in 3 months. [informing]
PATIENT: Yes, OK, but have you any idea why it hurts so much?
PRACTITIONER: Well, my examination of your hip and the X-ray tells
me that the hip is healing, and sometimes this just takes time. [in-
forming]
PATIENT: Is there any other medicine that might help?
PRACTITIONER: Well, we’ve got you on the best medicine we can give
you. The process of mobilization is often painful to begin with. We
could arrange some extra physical therapy for you if you like. I’ll
sort it out. You’ll get a letter or a telephone call within the next
week or so.
In this example, the practitioner exclusively used a directing style,
with a lack of listening. This suggested a lack of interest in the patient as
a person and even communicated disrespect. It also undermined the opportunity
to gain important diagnostic information.
Better Directing
The habitual use of an “ask–inform, ask–inform” pattern of skill usage
can be quite off-putting to patients. It can be done differently (the same
scenario as preceding):
PRACTITIONER: How have you been getting along with the hip? [ask-
ing]
PATIENT: Well, since that operation its been really hellish, to be honest.
How MI Fits into Health Care Practice 23
The pain is still really hard to bear and sometimes those pills just
don’t help. I wonder if there is something still wrong with it?
PRACTITIONER: It sounds like you are going through a difficult time.
[listening]
PATIENT: Terrible. I mean I expected pain, but there’s something about
this that doesn’t feel right, so much so that my son is convinced that
something went wrong in the operation, and he says I must ask you
about this.
PRACTITIONER: I honestly don’t think so, when I look at your hip itself
and the X-ray [informing], but tell me, when and how does it hurt?
[asking]
PATIENT: You see, I have taken the tablets that you and my family doctor
recommended, but it’s no good. When I get up from my chair or
bed, it’s really terrible. I don’t complain easily.
PRACTITIONER: Let’s have a look at the X-ray together. If you look just
here, what we look for is whether the new joint is in the right place
and the bones are all OK, and on this one of yours it looks fine.
PATIENT: So you don’t see a problem there?
PRACTITIONER: No. Mobilization after these operations can sometimes
be pretty tough, but if you soldier on, I think it will get better [informing].
But it sounds like you will feel more reassured if we keep a
much more careful eye on your progress and arrange for some extra
help with getting you properly going again.
PATIENT: I’d really appreciate that.
PRACTITIONER: I will ask for the physical therapist to see you again to
help you more with that. She will be able to guide you about that
tough trade-off between pain and activity. [informing]
PATIENT: So you don’t think there is anything really wrong with my hip?
PRACTITIONER: Based on what I see here, it doesn’t seem like it, but I do
think we need to keep a close eye on your progress. [informing]
PATIENT: Is there any other medicine that might help?
(The patient and practitioner
discuss medicine and physical therapy
assessment and support.)
The small increase in listening,
based on a genuine desire to take on
board the concerns and experiences
of the patient, clearly enriches the
24 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
The small increase in listening,
based on a genuine desire to take
on board the concerns and
experiences of the patient, clearly
enriches the use of a directing style
and the diagnostic task.
diagnostic task. The use of a directing style in this example leaves the patient
feeling better understood and, indeed, with a more helpful plan for
his or her recovery.
Following and Core Skills
Following and Gathering Information
It is easy to appreciate the value of a following style when working with
a patient facing distressing circumstances. However, probably more
common is the use of this style at the beginning of the consultation:
PRACTITIONER: How are things going?
PATIENT: Well, not so good, to be honest, I’ve been in a lot of pain.
PRACTITIONER: Tell me what’s happened. [asking]
PATIENT: Well it’s one thing to have arthritis, another thing to be having
this. (Bends to one side, rubs left knee.)
PRACTITIONER: I can see that you’re in pain now, as you speak. [listen-
ing]
PATIENT: Yes, I am, and it’s driving me crazy, slowly but surely.
PRACTITIONER: It’s one thing to have the arthritis you’ve had for some
time, but this is something different. [listening]
PATIENT: No, it’s not different, it’s the same damn knee, but the pain is
now too much.
PRACTITIONER: It’s getting hard for you to bear, and it’s dominating
your life. [listening]
PATIENT: Exactly. My wife drove me down here, but you should see how
I hobbled into the clinic.
PRACTITIONER: Tell me about what this pain is like and how it’s affecting
you. [asking]
PATIENT: Well, I don’t know. I can hardly get out of the chair. I can’t go
down to the shops any more. Even if I got there, the pain is just eating
me up . . .
PRACTITIONER: Most of the time, this pain is there and it’s gnawing
away at you. [listening]
PATIENT: That’s a good word, because it’s always there, slowly driving
me crazy.
(The discussion continues, and the patient talks about how it’s affecting
almost every part of his life.)
How MI Fits into Health Care Practice 25
PRACTITIONER: (shifting style to directing) Can I ask you now about
pain relief? Tell me, . . . [asking]
Following a Request for Treatment
Following is also an appropriate style when a patient makes a request
and it is appropriate for you to go along with this.
PATIENT: I’ve heard about those patches to help you quit smoking. I
want to give them a try. Will you prescribe them for me?
PRACTITIONER: You really want to quit. [listening]
PATIENT: I do. I’ve made the decision, and tomorrow is the day, if you
can let me have those patches.
PRACTITIONER: Good for you. You feel that patches is the right way to
go. [listening]
PATIENT: Yes, I cannot go cold turkey without nicotine replacement. I
tried that before. I felt sick, even vomited once, jumpy, I just couldn’t
cope. Another time, I even tried hypnosis. What a waste of
money that was. My partner tried the patches and they worked for
him. I think I want to try them, too.
PRACTITIONER: So it’s worked for your partner and you are determined
to do so as well. [listening]
PATIENT: Yeah. If he can do it, so can I. In some ways he was more addicted
than me. He’s really supportive now, and together I think we
can beat it this time.
PRACTITIONER: Great. I just need to check a few things with you . . . [in-
forming]
Following an Upset Patient
Most practitioners would agree that following is highly recommended
when a patient is distressed, angry, or very anxious.
PATIENT: I’m shattered. I think you know that they told me yesterday
that I will probably die in just a matter of months.
PRACTITIONER: This must have come to you as quite a shock. [listen-
ing]
PATIENT: A terrible shock. I was afraid of this (bursts into tears).
PRACTITIONER: Your worst fears were confirmed. [listening]
26 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
PATIENT: Exactly. It’s not like I hadn’t thought of this before, but to hear
someone actually say it, just like that. I was stunned.
PRACTITIONER: You wish the news had been broken to you more gently.
[listening]
PATIENT: No, I knew, really, as soon as I saw his face. I just keep hearing
him say it over and over again.
PRACTITIONER: You’re lying here, alone most of the time, with this running
through your mind. [listening]
PATIENT: It’s terrible. I just don’t know what to do.
PRACTITIONER: Is there anything I can do to help? [asking]
PATIENT: No, I don’t think so. It’s just such a shock. Thank you for ask-
ing.
PRACTITIONER: Well, I’ll be here most of the day today, and I’ll pop in
and see you a little later. I know that your pain medication needs reviewing,
and I’d like to talk to you about this. [informing]
Guiding and Core Skills
Next we present a brief example of how the three core skills can be used
in the service of guiding. Parts II and III of this book contain many more
examples of guiding.
Encouraging a Referral
Helping a patient with a referral to another colleague is an example of
behavior change. The motivation to actually attend a new appointment
can be influenced by your communication style. In this case, the practitioner
(a social worker, nurse, counselor, doctor) would like to refer a
patient with diabetes to a dietician for consultation about cooking and
eating habits. One approach might be to simply tell the patient, “You
need to go see the dietician for advice about your eating habits. Here is
the number to call.” How might this same task be approached within a
guiding style?
PRACTITIONER: From your lab tests, your blood sugar level is still high,
and that worries me. [informing] If you’re willing to take a few minutes
to talk about this, could you tell me a little about your eating
habits? [asking]
PATIENT: Well, I try to be careful, and I stay away from sweets and junk
food mostly.
How MI Fits into Health Care Practice 27
PRACTITIONER: You’re avoiding some foods that really drive up
your blood sugar. [listening] What about fixing food at home?
[asking]
PATIENT: I do most of the cooking for the family. Everybody likes different
things, so it’s a challenge. I could probably do a little better there
in preparing healthier meals.
PRACTITIONER: You see a little possible room for improvement in how
you cook. [listening]
PATIENT: Yes, I think so.
PRACTITIONER: That’s a common challenge for people with diabetes,
and a good place to think about making some changes. Would you
like a little help with thinking about ways to fix food that would
help you manage your diabetes? [asking]
PATIENT: I think I know the basics, but sure, I could learn more.
PRACTITIONER: Good! I can tell you a little here, but we have staff who
really specialize in helping people with diabetes think about how
they cook and eat. [informing] How would you feel about talking
with somebody knowledgeable like that? [asking]
PATIENT: I guess so. I work during the day, though, and I had to take off
time to come see you today.
PRACTITIONER: You’re willing to give it a try, particularly if you
could come in at a time that doesn’t interfere with work. [listen-
ing]
PATIENT: Yes. I mean, I couldn’t get here often during the day, but after
work would help.
PRACTITIONER: OK, good. I know they have some evening times available.
[informing] Let’s call over there and see when they can fit you
in. Would that be OK? [asking]
PATIENT: Sure.
Taking an extra minute to negotiate a referral in a guiding style may
make all the difference in whether the patient actually gets there. Placing
the call yourself or asking a colleague to do it while the patient is still in
the building also significantly enhances a referral. This short exchange illustrated
three of the principles of motivational interviewing noted in
Chapter 1: understanding the patient’s motivation, listening, and empowering
the patient. The outcome, reflected in the patient’s responses,
was change talk, a topic discussed in detail in the next chapter. Attendance
at the referral is more likely to take place.
28 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
FLEXIBILITY WITHIN A CONSULTATION
In health care settings the shifting of styles can take place a number of
times within a consultation, and this is one marker of good practice.
Consider this example:
A practitioner has 20 minutes for a consultation, and he decides to
spend the first 5–7 minutes using a following style with an anxious
and distracted-looking elderly woman. The questions are open
ended and give her time to tell a story about what has been going
on. He deliberately slows down the pace of the consultation, and
she calms down and becomes engaged in telling her story. The aim
of his listening is to understand. He occasionally uses informing just
to reinforce what she is saying. He is mostly saying such things as,
“I see, you’re worried about falling over” (listening), or “Tell me
what exactly worries you about this medicine?” (asking).
He then turns quite firmly to a directing style. He signals the
shift by summarizing what she has said. “You are worried about the
side effects of this medicine, and also whether you are taking the
right dose as well. . . . ” The patient feels understood, and this provides
the practitioner with the opportunity to take his turn to be
more actively involved. “I’d like to change direction now, and ask
you some questions about your medicine use and its effect on you.
Is that OK?” He then uses the skills of asking, listening, and informing
to establish how best to make adjustments in the treatment and
medication regimen. The questions are much more pointed, the information
is clear and simple, and listening is used to clarify her understanding
so that he can adjust the content and amount of information
he provides. “What time of day do you take them?” “What
have you noticed soon after you take them?” He provides advice
and direction. “I’d like to suggest that you try this new medication,
which is slightly stronger, but I don’t believe that the side effects will
get worse” (informing). “Yes, it’s important that you take these tablets
at the same time each day” (informing).
Then there is a shift to a guiding style, because he wants to help
her adapt to a new regimen of treatment and consider how she
might cope at home. The purpose and content of the questions
change, and the use of listening and informing reflect a conviction
that motivation will be enhanced if as many solutions as possible
come from her. “How do you see yourself succeeding this time?”
“What’s going to be the best
regimen for you?” “What do
you feel most confused about?”
The other tools are also used.
“Yes, that’s right, and if your
meals are more frequent, it
How MI Fits into Health Care Practice 29
In health care settings the shifting
of styles can take place a number
of times within a consultation, and
this is one marker of good practice.
might help” (informing), and “You are worried about the change,
but you want to make it work” (listening). He summarizes the plan,
and she agrees to return for a review.
A less flexible approach might affect outcome. If this practitioner
had worked more rigidly within a directing style for most of the consultation
and then turned to see what the patient thought and felt, engagement
would have been undermined
and commitment to change rendered
much less likely. Flexible
shifting among styles is a reflection
of the desire to use your expertise
effectively and to get the best out of
the person you are serving.
CONCLUSION
Patients seldom present with problems neatly wrapped up and responsive
to a formulaic approach to communication. Asking, informing, and
listening sound like rather simple tasks, perhaps not deserving of the label
“skill.” Compared with the complex things you need to be sure to
get right in practice, these seem easy.
Yet these simple tasks can be done in very different ways and to different
ends, and it becomes a highly skilled business to ask, listen, and
inform in the right way to achieve your goals for the patient in the clinical
situation. The precise choice of words, taken together with your
body language, your use of silence, and the overall atmosphere of the
consultation, can be a powerful tool. The way you communicate with
patients can have a real effect not
just on how they feel but on what
they do and on their health outcomes.
Your communication skills
are themselves a treatment toolbox.
The tools of asking, informing, and
listening can be combined in a manner
that is more or less efficient, effective,
and skillful. How you use them depends on your purpose, and
they can be used in different ways in the service of a directing, guiding,
or following communication style.
30 BEHAVIOR CHANGE AND MOTIVATIONAL INTERVIEWING
Flexible shifting among styles is a
reflection of the desire to use your
expertise effectively and to get the
best out of the person you are
serving.
The tools of asking, informing, and
listening can be combined in a
manner that is more or less
efficient, effective, and skillful.
PART II
CORE SKILLS OF
MOTIVATIONAL INTERVIEWING
CORE SKILLS OF MOTIVATIONAL INTERVIEWINGPracticing MI
CHAPTER 3
Practicing Motivational Interviewing
In this section, we present core skills of MI. These are not unfamiliar
skills but, rather, are ones that you use in everyday practice. The difference
is that these familiar skills are used in particular strategic ways in
MI; they have a clear goal of health behavior change. The methods described
here are for the particular (and common) situation in which the
patient’s path to optimal health calls for personal behavior change, a situation
in which skillful guiding can be especially helpful and effective.
As we discussed in the last chapter, particular forms of communication
are appropriate for guiding, and in this part we devote a chapter to each
of them.
A good guide will:
• Ask where the person wants to go and get to know him or her a
bit.
• Inform the person about options and see what makes sense to
them.
• Listen to and respect what the person wants to do and offer help
accordingly.
As we explained in Chapter 1, the guiding style of MI works by enhancing
patient commitment to change and adherence to treatment.
Why does this happen? How can a relatively brief consultation trigger
an enduring change in health behavior? A key to understanding this process
is knowing the phenomenon of ambivalence.
33
AMBIVALENCE
People usually feel ambivalent about change. This is particularly so for
change that is “good” for them in some way. Most people want to be
healthy and are willing to do some things in the interest of their health.
Most people are also comfortable with their familiar routines, and there
are disadvantages to change. Some important health behaviors are unpleasant
or even painful: lancing a finger for glucose monitoring, exercising
after surgery, or enduring the ongoing side effects of adherence to
a necessary treatment. Chances are that your patient already knows
some good reasons for the behavior change that you have in mind, such
as exercising more, quitting smoking, or eating healthier food. Chances
are that your patient also enjoys the status quo—a sedentary lifestyle,
smoking, or eating unhealthy food—and anticipates a downside to
change. Conflicting motivations—to simultaneously want and not want—
are normal and common. Consider the ambivalence in these patient
statements:
“I need to lose some weight, but I hate exercising.”
“I want to get up, but it hurts.”
“I should quit smoking, but I just can’t seem to do it.”
“I mean to take my medicine, but I keep forgetting.”
A telltale sign of ambivalence is the but in the middle.
People can and do get stuck in ambivalence. It is as if the arguments
on either side of the but cancel each other out, and so nothing changes.
Ambivalence is often experienced as first thinking of a reason to change,
then thinking of a reason not to change, and then to stop thinking about
it.
However, things can happen to move a person toward or away from
behavior change. Your consultation with a patient can be one of these
things. For some people, just receiving a diagnosis and a bit of advice
can be enough to prompt significant changes in lifestyle. Often, however,
patients go through a process of internal deliberation, conscious or
not—a weighing of the pros and cons of behavior change. You can think
of your patients as moving in one direction or the other during your
health care consultations, as shown in Figure 3.1.
Perhaps your consultations sometimes seem to leave patients totally
unmoved: “I’ve told him and told him, but he just won’t
change.” How common this frustration is in health care! You explain
over and over to patients what they need to do, how they could, why
they should, and yet nothing happens. Remember the “righting reflex”
discussed in Chapter 1? When you take a directing style with an am
34 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
bivalent person, you are taking up one side of their own ambivalence—
the pro-change side.
“Exercising and losing weight would decrease your risk of a heart at-
tack.”
“It’s important for you to get out of bed and move around.”
“I want you to stop smoking.”
“This medicine won’t help you if you don’t take it faithfully.”
A common patient response to these pro-change arguments is to fill in
the other side of the ambivalence, to say, “Yes, but. . . .” When this happens,
patients are making the arguments against change and literally
talking themselves out of changing. What you want instead is for patients
to talk themselves into changing, if it is compatible with their personal
values and aspirations. In other words, your task is to elicit
“change talk” rather than resistance from your patients.
LISTENING FOR CHANGE TALK
A first step in helping your patients make the arguments for change is
being able to recognize change talk when you hear it. You already have
an intuitive sense for it, learned from
everyday social interaction.
Suppose you are asking
whether a friend will do something
for you. There is a rich and welldeveloped
vocabulary for this kind
of negotiation, which is learned from life experience. Consider the following
possible responses from your friend whom you have asked for a
favor:
“Yes, I will.”
“I might be able to.”
Practicing MI 35
FIGURE 3.1. People can and do become stuck in ambivalence.
Your task is to elicit “change talk”
from your patients rather than
resistance.
“I wish I could.”
“I’ll try to get to it.”
“I’ll help if I can.”
“I promise I’ll do that for you tomorrow.”
“I’ll consider it.”
What does each of these responses communicate? In particular, how
likely is it that your friend will actually follow through on what you
have asked? Each statement signals a different level of intention, and we
understand its meaning from shared experience. These signals are also
quite culture-specific. Someone from a different culture might well miss
the subtleties and misunderstand what is being communicated.
Such communications are useful precisely because they actually do
predict behavior. Not perfectly, to be sure. People may intentionally deceive
you or for other reasons say what they think you want to hear, but
within a relationship of goodwill
and trust there is valuable information
in such statements if you know
what to listen for. By listening to
what your patients say, you can tell
how likely they are to change. Furthermore,
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.
So what exactly is change talk? When you are speaking with a patient
about behavior change, there are six different themes you may hear,
six different types of change talk. These are listed with examples in Table
3.1. Each type tells you something about the person’s motivation.
Desire
The first theme of change talk is desire. Desire verbs include want, like,
and wish. These tell you something that the person wants. These are desire
statements:
“I wish I could lose some weight.”
“I want to get rid of this pain.”
“I like the idea of getting more exercise.”
Desire statements tell you about the person’s preferences either for
change or for the status quo.
36 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
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’re off course.
Ability
A second type of change talk reveals what the person perceives as within
his or her ability. The prototypical verb here is can and its conditional
form, could.
“I think I can come in twice a week.”
“I could probably take a walk before supper.”
“I might be able to cut down a bit.”
“I can imagine making this change.”
Notice that ability-related change talk also signals motivational
strength. “I definitely can” reflects much stronger confidence than “I
probably could” or “I might be able.”
Reasons
Change talk can express specific reasons for a certain change. There are
no particular verbs here, although reasons can occur along with desire
verbs.
Practicing MI 37
TABLE 3.1. Six Kinds of Change Talk
• Desire: Statements about preference for change.
“I want to . . . ”
“I would like to . . . ”
“I wish . . . ”
• Ability: Statements about capability.
“I could . . . ”
“I can . . . ”
“I might be able to . . . ”
• Reasons: Specific arguments for change.
“I would probably feel better if I . . . ”
“I need to have more energy to play with my kids.”
• Need: Statements about feeling obliged to change.
“I ought to . . . ”
“I have to . . . ”
“I really should . . . ”
• Commitment: Statements about the likelihood of change.
“I am going to . . . ”
“I will . . . ”
“I intend to . . . ”
• Taking steps: Statements about action taken.
“I actually went out and . . . ”
“This week I started . . . ”
“I’m sure I’d feel better if I exercised regularly.”
“I want to be around to see my grandchildren grow up.”
“This pain keeps me from playing the piano.”
“Quitting smoking would be good for my health.”
Need
Imperative language bespeaks a need or necessity. Marker verbs here include
need, have to, got to, should, ought, and must.
“I must get some sleep.”
“I’ve got to get back some energy.”
“I really need to get more exercise.”
Ambivalence often involves conflict among these four motivational
themes: desire, ability, reasons, and need. In the following examples, the
first phrase favors change, whereas the second phrase, separated by a
but, favors the status quo:
“I really should [need] but I can’t [ability].
“I want to [desire] but it hurts [reason].”
“I’d like to cut down my cholesterol [desire] but I do love eggs and
cheese [desire].”
These first four kinds of change talk can be remembered by the acronym
DARN—Desire, Ability, Reasons, and Need—and they have
something in common. They are precommitment forms of change talk.
They are leading in the direction of change, but by themselves they do
not trigger behavior change.
To say “I want to” is not to say “I am going to.”
To say “I can” is not the same as “I will.”
To express reasons for change is not the same as agreeing to do
it.
To say “I need to” is still not saying “I intend to.”
For illustration, think of a person being sworn in as a witness in
court*: “Do you swear to tell the truth, the whole truth, and nothing but
the truth?” What is missing in the following answers?
38 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
* We thank Dr. Theresa Moyers for this example.
“I would like to [desire].”
“I could [ability].”
“It would help you if I did [reason].”
“I should [need].”
None of these is a satisfactory answer. What is missing is a fifth form of
change talk.
Commitment
How does commitment sound? The quintessential verb here is will, but
commitment has many forms. Some statements of strong commitment
are:
“I will.”
“I promise.”
“I guarantee.”
“I am ready to.”
“I intend to.”
Do not miss lower levels of commitment, however, because they are also
steps along the way. People signal an opening door with such statements
as:
“I will think about it.”
“I’ll consider it.”
“I plan to.”
“I hope to.”
“I will try to.”
These are meaningful statements to be encouraged. The latter two
(“I hope to” or “I will try to”) indicate a desire to change but signal that
there is some doubt about the ability to do so. The language of conversations
about change is rich with these signals.
Taking Steps
There is a sixth form of change talk you may encounter, particularly
when you see patients repeatedly over time. These statements indicate
that the person has taken, even if haltingly, some step toward change. He
or she has done something that moves him or her in the direction of
change:
Practicing MI 39
“I tried a couple of days without drinking this week.”
“I borrowed a book from the library about aerobic exercise.”
“I bought some condoms.”
“We went the whole month of February without eating any meat.”
“I quit smoking for a week, but then started up again.”
“I got one of those new test kits.”
“I walked up the stairs today instead of taking the escalator.”
Statements such as these can trigger some skepticism:
“Yes, but did you read it?” [the book on aerobics]
“Well, are you using them?” [the condoms]
“February—the shortest month!” [not eating meat]
What you should not miss is that actions such as these involve taking
important tentative behavioral steps toward change, and such steps
should be encouraged.
Do not worry about classifying change talk into the proper category.
As you can see, there is some overlap. The same statement can contain
two or more of these elements:
“I wish I could stop smoking [desire] because I’d have whiter teeth
[reason].”
“I probably could lose ten pounds [ability] and I’d look better [rea-
son].”
“I’ll try [communicates some desire but uncertainty about ability].”
“I’ve got to do something to get my strength back, and I think I can
[need, ability, and reason].”
The point is to attune your ears to change talk, to recognize and affirm it
when you hear it.
How do these six forms of change talk fit together? The process begins
with the precommitment types (DARN). People first talk about
what they want to do (desire), why they would change (reasons), how
they could do it (ability), and how important it is (need). When you
evoke a patient’s own desire, ability, reasons, and need for change, you
are fueling the human engines of change. As DARN motivations are
voiced, commitment gradually strengthens, and the person may take initial
steps toward change. It is commitment and taking steps that predict
durable behavior change. As indicated earlier, DARN statements in
themselves may not trigger change, but they do presage the strengthening
of commitment. Figure 3.2 shows how this looks.
It is worth noting here that when you explore DARN, you are
40 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
touching on the patient’s values and aspirations. When you hear DARN
language, you are learning something about what your patients hope for,
what matters to them. It gives you hints about more deeply held values.
A patient who says, “I want to be there for my grandchildren” or “I
don’t want to be a burden to my family” is telling you something about
the place of family in his or her priorities. These are important themes
worth exploring a bit, rather than just letting them pass. The reason is
that a deeply held value can be a powerful motivation for change. Help
your patients talk about how a behavior change is consistent with what
matters to them. When a behavior such as smoking truly collides with a
more deeply held value, change can result. That is one reason that asking
for DARN statements is a good idea.
“Why would you want to quit smoking [desire]?”
“How would you do it, if you decided to [ability]?”
“What for you are the three best reasons for quitting [reasons]?”
“How important is it for you to quit [need]?”
GUIDING THROUGH CHANGE TALK
Imagine an open meadow in a clearing surrounded by forest. In the
meadow all manner of rich vegetation is growing. There is a carpet of
green grasses, from which colorful wildflowers emerge. There are also
clumps of green plants that in a garden might be regarded as weeds.
Practicing MI 41
FIGURE 3.2. How change talk fits together.
Your color vision allows you to differentiate the flowers from the carpet
of green and from the clumps of weeds.
The carpet of grass is like the background of speech that you will
hear from people when you listen. The person’s own motivations for
change are the flowers that pop up from the grass. The weeds are the
person’s arguments against change that, if encouraged, can choke out
the flowers. The guiding style of MI is a process of gathering a bouquet.
Because it is the patient who should be making the arguments for
change, your task is to collect change talk. Each DARN change talk
statement is like a flower. You collect these flowers into a bouquet that
you periodically show to the patient, then continue to add to.
Here is another analogy: In successful MI, the change talk statements
you collect from the patient are like little weights placed on the
“pro-change” side of a balance. Helping patients to voice pro-change arguments
gradually tips the balance in the direction of change.
This process of evoking change talk from the patient need not require
a long time. You may be able to elicit significant change talk
within the space of a few minutes of conversation. You also probably
will have other chances when you see the patient for future consultations.
Long-term health behavior change can emerge gradually over time
with your successive guiding and encouragement. Success in evoking behavior
change has more to do with your skill in the guiding style than
with the length of time that you have to do it.
Listening for change talk offers another important benefit: It is how
you learn to get better at guiding. Although we can give you some guidelines
for using MI in practice, your real teachers are your patients.
Whenever you try the guiding style,
you get immediate feedback. If you
hear more change talk, you know
you’re doing it right. When you
seem to be eliciting arguments
against change, your patient is telling
you to try a different approach.
CONCLUSION
So far we have summarized, in Chapter 1, the overall spirit of MI (collaboration,
evocation, and honoring patient autonomy) and its basic
principles, using the acronym RULE (Resist the righting reflex, Understand
the patient’s motivations, Listen to your patient, and Empower
your patient). Chapter 2 placed MI within the context of a guiding style
used naturally in everyday life. In this chapter we have explained the role
42 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Although we can give you some
guidelines for using MI, your real
teachers are your patients. If you
hear more change talk, you know
you’re doing it right.
of ambivalence and how to help patients get unstuck by listening for
change talk. We outlined six types of change talk and how they fit together,
leading to behavior change. In the next three chapters we return
to the three core communication skills of asking, listening, and informing
for a deeper look at how they can be used to help patients talk
about, commit to, and undertake health behavior change.
Practicing MI 43
CORE SKILLS OF MOTIVATIONAL INTERVIEWINGAsking
CHAPTER 4
Asking
Asking seems simple enough. You pose a question and the patient responds.
It’s how you gather information. If only it were this straightfor-
ward!
This chapter is divided into two sections. The first deals with asking
in general, and the second focuses on how asking is used in MI.
ASKING: SOME GENERAL CONSIDERATIONS
Diagnostic decision trees often require that you ask the right questions
in order to make choices and recommendations. It is a familiar routine.
Patients coming for health care expect you to ask a series of questions,
some of which may be unexpected, as you deduce what is happening
with their health. Asking a question places a demand on the other person
to provide an answer. But the patient’s expectation is that after you
have finished asking all your questions, you will have the solution. This
is especially true when you ask a series of closed questions, ones that
elicit short answers such as “Yes” or “No” or a simple fact. With questions
such as these, you are taking charge and implicitly taking responsibility
to come up with the answer.
Closed Questions
Closed questions are an efficient way to gather specific information. The
expected answer to a closed question is brief. Here are some examples:
44
“What is your address?”
“Where does it hurt?”
“Has your daughter had a fever?”
“How long have you been feeling dizzy?”
“Are the letters clearer with lens number one, or lens number two?”
“How often do you floss your teeth?”
“Have you been taking your medication?”
“When you do drink, how many drinks do you normally have?”
“Does it seem worse in the morning or in the evening?”
Open Questions
Open questions allow more room to respond. Whereas closed questions
ask for specific information that the questioner regards as important,
open questions invite responders to say what is important to them.
Using open questions helps you understand what the person is experiencing
and perceiving. Both closed and open questions elicit information.
However, open questions often elicit more useful information than
closed questions and also invite relationship.
“How are you feeling today?”
“Tell me from the beginning about how your pain developed.”
“How can I help you?”
“How do you fit brushing and flossing into your daily routine?”
Asking even a few open questions and attending carefully to the
person’s responses can transform the quality of a health care consultation.
Patients rightfully perceive
open questions as showing personal
interest and caring. When practitioners
ask a few open questions and
listen, patients tend to appreciate
the amount of time the doctor spent
with them and to be satisfied with
the exchange. The skillful practitioner asking open questions appears to
be taking lots of time yet can actually be making efficient progress.
When you ask open questions, you give your patient more active involvement
in and influence over the course of the consultation. Open
questions also allow patients to tell you things that you have not asked
about but that are potentially important. In addition, asking open questions
can give you a chance to catch your breath, to stop, look, and listen
in the midst of a busy day. The social etiquette of open questions is
to make eye contact when asking them (rather than, for example, readAsking
45
The skillful practitioner asking
open questions appears to be taking
lots of time yet can actually be
making efficient progress.
ing or writing in a chart) and to listen carefully to what the person has to
say.
Open questions are those to which there is not an obvious short answer.
They invite the person to offer their own experiences and perceptions.
Here are some further examples:
“In what ways has this interfered with your life?”
“Tell me about a typical day when you drink.”
“Tell me about your headache.”
“Before we begin the exam, what are the things that concern you
most today?”
“How are things going in your family?”
“What are you most worried about?”
“What are the things that you like and don’t like about smoking?”
“This diagnosis must have been a shock. How are you dealing with
it?”
Skillful Asking
Consider the difference between the two following consultations. In
both of them, the practitioner is concerned that an elderly patient is not
taking her medicines for asthma according to the prescription. Both rely
on asking—the first through closed questions and the second with open
questions.
Poor Practice: Relying on Closed Questions
The following begins with what we call a “spoiled” open question, evident
later on as well—one that starts out open, but ends up closed.
Practitioner: Doctor, nurse.
Setting: Outpatient, primary care, or asthma clinic appointment.
Challenge: Brief review of medication use; to promote self-
management.
PRACTITIONER: How are you getting on with the medicines? [open question]
Have you been taking them regularly? [closed question]
PATIENT: I take them most of the time, and I feel OK except when I have
an attack.
PRACTITIONER: The preventor inhaler is most important to take every
day. Do you take that one regularly? [closed question]
PATIENT: Yes, most of the time.
46 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
PRACTITIONER: And what do you mean by most of the time? Is that every
day, or do you miss days at a time, because that can be a problem.
[closed question]
PATIENT: I wouldn’t say that I miss many days, but it’s not always so
easy.
PRACTITIONER: You’re on the high-dose regimen here, and it’s important
to take it every day, OK?
PATIENT: Yes, I know it’s important, and I do try, honest I do.
PRACTITIONER: And what happens when you have your attacks [open
question]? Does using your other inhaler help? [closed question]
PATIENT: Sort of. My husband gets scared.
PRACTITIONER: Well, it’s good that you have him to help you like
that. Will you remember to take your preventor inhaler every day,
and not just the reliever when you have an attack? [closed ques-
tion]
PATIENT: Yes.
The practitioner in this example was clearly capable of formulating
useful open questions but managed to carelessly tag on it a closed question,
which “spoiled” the value of the open question. A good illustration
of this needless use of extra words is “And what happens when you have
your attacks [open question]? Does using your other inhaler help [closed
question]?” If the second question had been omitted, the first open question
would have elicited how the inhaler was used and probably more
information about other things, as well. Practitioners in training often
make an interesting observation when reflecting on their use of closed
questions: “Its exhausting, I feel rushed, and I always have to come up
with the next question.”
Better Practice: Carefully Chosen Short Open Questions
PRACTITIONER: How have you been doing? [open question]
PATIENT: Not too bad, thank you. I feel OK most the time, but when I
have an attack it’s different, you know.
PRACTITIONER: What happens? [open question]
PATIENT: Well, my husband gets really scared, and he yells at me to take
my inhaler. He says that one of these days he’s going to phone you
up because he gets so scared.
Asking 47
PRACTITIONER: So what do you do then? [open question]
PATIENT: I use my reliever inhaler and things calm down, so I suppose
we sort of manage, if you know what I mean. I’m not too worried,
so I have to calm him down as well!
PRACTITIONER: And are you using the preventor inhaler? [closed question]
PATIENT: Yes, sort of.
PRACTITIONER: How are you getting on with it? [open question]
PATIENT: I don’t really like it, to be honest, because I don’t like the
thought of taking all that steroid into my body. I get bruises from
the steroid, which I find embarrassing. My hands look frightening
and the bruises scare my grandchildren and my skin tears easily. But
I know I should use it and my husband nags at me when I don’t take
it. You can imagine what goes on.
PRACTITIONER: And how can I be most helpful to you today? [open
question]
PATIENT: Well, can you tell me what would happen if I didn’t take the
preventor in such high doses? Is it really essential, every day, to use
the high dose? How about if I try the lower dose one if I guarantee
to take it every day?
A number of qualities characterize skillful asking, many of which
are apparent in the preceding example: The questions are short and the
phrasing of them is simple; it feels to the patient as if it’s a normal conversation
connected to her experience. Important information (e.g.,
about the embarrassment at her bruised hands) is elicited via open questions,
which do not necessarily have to extend the length of the consultation.
Above all, open questions allow a practitioner to convey genuine
interest in the patient. The practitioner in the first example might well
have been interested in the patient, but poor communication skills prevented
him or her from expressing this.
Most consultations, of course, call for both open and closed questions.
A common approach is to build the exchange around initial key
open questions, with closed questions being used only to funnel down
and elicit specific information as necessary.
Some Useful Open Questions
If you need simply to obtain a few facts, such as whether certain symptoms
have been experienced, then asking can be quite a simple matter. A
few closed questions will suffice. Often health care is more complicated
48 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
than that. Good open questions can serve multiple purposes. In addition
to clarifying patients’ symptoms, you might also want to know about
their degree of discomfort, about their experience of something (e.g.,
pain relief), about their explanation for what happened (e.g., change in a
child’s condition), or about their concerns at quite a deeply personal
level (e.g., after breaking bad news).
Here are a few examples of questions that cover multiple purposes,
that are brief, and that, if accompanied by skillful listening (Chapter 5),
can serve your purposes much more efficiently than asking a string of
closed questions.
1. “What’s worrying you most today about this illness?” This is a
useful question for locating the patient at the center of the consultation.
Responding respectfully to this concern will improve your rapport
and provide a good platform for dealing with topics on your
agenda.
2. “What concerns you most about these medicines?” If this patient
is not taking her medicines properly and seems unhappy with them, a
question like this will reveal a lot about her attitude, her behavior, and
where the problem lies.
3. “What exactly happens when you get that pain?” Here, the door
is open for the patient to tell a story. The use of the word exactly signals
an intention to get to the bottom of the patient’s concern. If you listen a
while to the account, the answers to all sorts of factual and other questions
may emerge.
4. “What did you first notice about your child’s condition?” The
word notice can be very useful. People usually respond well, because this
word invites them to be the expert commentator about their experience
of events and behavior. Information often comes flooding out, and they
feel heard.
5. “Tell me more about. . . .”
An open question is an invitation. “May I ask you . . . ?” is a question
that captures very well the polite and respectful quality of a service
that is designed to meet the needs of the patient.
The Question–Answer Trap
It’s easy to forget how anxious, bewildered, or preoccupied patients can
be when they enter the consultation. Combine this with your own feeling
of being tired or bored or going through a familiar routine, and the
potential is there for a dysfunctional consultation. It can result in a pattern
that we have called the question–answer trap.
Asking 49
Asking questions is easy; it can become routine, controlling, and
overused to the exclusion of informing and particularly of listening.
Your agenda predominates, and the patient can become a passive recipient
of an investigation. It also sets you up to be the answer-giving expert.
That can be quite appropriate in many forms of acute health care. However,
as we shall see, when the subject is patient behavior change, a different
and less directing style is needed.
One common manifestation of the question–answer trap in consultations
about health behavior is the quantity–frequency investigation,
which starts with “How much do you smoke?” and is followed by a
family of questions such as “When did you start smoking?” and “Does
your boyfriend smoke?” This approach
tends to evoke resistance in
the patient and frustration in the
practitioner. It can feel like hard
work because the onus is on you to
think of the next question for the
passive patient. Serial questions also
tend to evoke defensiveness, often leading to answers that are half-truths
as a means of protecting self-esteem.
In some circumstances, of course, you do need to ask many questions,
and patients are often quite tolerant of this. If you do have a series
of questions to ask, you can alert your patient beforehand, explaining
that a rather question-ridden conversation is about to unfold, for particular
reasons. This signals that the question–answer pattern is not your
normal way of relating to people.
Routine Assessment: “Can I Just Ask You . . . ?” (Yawn)
One of us (Rollnick) went to a family physician with a distressing acute
problem, and the consultation began thus: “How long ago did you stop
smoking?” Asked the purpose of this question, the practitioner became
slightly defensive and said with a wry smile: “It’s not me who really
wants to know, it’s the computer!” This doctor was obliged to conduct
routine assessments of lifestyle behaviors.
A familiar situation that can generate a stream of questions is the
use of a standardized assessment form or intake procedure. There are
usually good reasons for such procedures, but, when they are institutionalized,
they can result in interviews that ignore the needs and concerns
of the patient. When asked why patients in a diabetes clinic were
stripped seminaked, weighed, and processed with questions before receiving
any more conventional consultation, a service manager said,
“Well, that’s the way we have always done things around here.” The
50 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Serial questions also tend to evoke
defensiveness, often leading to
answers that are half-truths as a
means of protecting self-esteem.
familiarity of routine can cause one to overlook the social impact of
the experience.
Even when routine questions are required, services can be designed
to avoid institutionalized questioning as the dominant style in practice.
When a standard questioning format is being used, one can still start in a
natural manner with a series of open questions, acknowledging that
some more specific questions will follow. The patient’s responses to open
questions often provide the answers to specific closed questions. Then
you can use closed questions to fill in other needed information that did
not emerge in response to the open questions.
There are more structured ways of avoiding what one practitioner
called, perhaps unfairly, “death by assessment.” One especially useful
way of conducting a routine assessment is to use the “typical day” strategy
as a framework for completing a form. Table 4.1 describes its use.
Of course, with practice, the framework could be used at any point in a
consultation when you want information, not just at the beginning. It
can be used to ask about a “typical episode of pain,” the “recent use of
medication,” or other things.
Summary
The ability to use asking thoughtfully and effectively is close to the heart
of good quality patient care, whatever the problem being discussed and
whatever communication style is being used. The tone, pacing, wording,
and clarity of questioning, combined with a sense of curiosity and good
listening, are some of the building blocks of quality communication. We
turn now to how asking is used specifically within the guiding style of
MI.
ASKING IN MI
Carlos, a seasoned professional football coach, was in the park with
his 4-year-old daughter. She fell over on her bicycle on the grass and
burst into tears. He went down on one knee to comfort her, stayed
in that position, and asked her a series of questions, waiting patiently
for her to make up her mind each time.
“Why did you fall over?”
“I was going slow.”
“Yes, that’s right, you went too slowly. And how could you go
quicker?”
“On the pavement.”
“And what could happen then?”
“It would hurt if I fell over.”
Asking 51
52 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
TABLE 4.1. Routine Assessment Using a “Typical Day”
Aims
To initiate an assessment that is lively and patient-centered in which many of your
standard questions are answered. To have a normal conversation lasting 2–10
minutes in which rapport is enhanced, patients do most of the talking, and you
learn a great deal about their personal and social context (including readiness to
change). The formal assessment can be completed immediately afterward.
Principles
1. Convey acceptance. Do not pass judgment. Consider anything the patient says
or does as acceptable, or at least as something that does not surprise you.
2. Know your assessment schedule. As the conversation unfolds, make a mental
note of which areas of assessment are being covered and which are not.
3. Fit the assessment into the interview, not the interview into the assessment. It
helps to place the paperwork aside, on the table.
4. Stay curious. Don’t hesitate to interrupt with a request for help with more
detail.
5. Resist the investigative impulse. Invading the patient’s account with questions
about problems can kill off the atmosphere of acceptance and curiosity.
6. Focus on both behavior (“What happened then?”) and feelings (“When you
closed the front door, heading for the shops, how were you feeling?”).
Practice
1. Acknowledge assessment and ask permission. “I have a whole lot of questions
on this form here, but I find it much easier to put this to one side and ask you
to spend 5 to 10 minutes just taking me though a recent typical day in your
life. I might go back to the form once we’ve done this to fill in the gaps; is that
OK?”
2. Locate a day. “Can you think of a recent day that was fairly typical for you,
an average sort of day?”
3. Go through a “typical day.” Be mindful of time and the pacing. Slow it down
if the patient runs too quickly through the story. Speed it up if you think it
might take more than about 10 minutes.
4. Check whether the patient wishes to add anything. “Is there anything else
about yesterday you want to say more about?”
5. Ask any questions of your own.
6. Go back to your assessment to fill in the gaps, or do this later on. Most
patients do not mind your doing this after you have gone through a “typical
day.” In fact, if you remember to keep the form off your lap and avoid
entering an investigative mode, many patients will actively help you complete
the gaps quite willingly.
7. Practice. You know you are getting better when you interfere less and less with
the “typical day” story. The patient’s degree of comfort in telling the story is
your indicator of success.
Note. Data from Rollnick, S., Mason, P., & Butler, C. (19990. Health behavior change: A guide for
practitioners. Edinburgh: Churchill Livingston.
“So what do you feel like doing?”
“I am going on the pavement, bye, Papa . . . ”
Carlos showed that the solutions should and could come from his
daughter. He asked questions as Socrates did, leading his daughter to a
solution. He created a supportive atmosphere, avoided the inclination to
solve the problem for her, and elicited
an informed choice by asking a
series of purposeful questions. This
is what we mean by asking in the
service of a guiding style. It is one of
the cornerstones of MI. It is an invitation
to weigh the choices and to
consider change. By asking such questions, you are evoking the person’s
own motivations, and by listening you come to understand the patient’s
perspectives—two of the core principles described in Chapter 2.
Agenda Setting
A good guide first finds out where the person wants to go. This can be
particularly important in health care consultations, in which there may
be many possible behavior changes that a patient could make to achieve
better health. When there are multiple possible paths toward better
health, who chooses what path to discuss?
We use “agenda setting” to refer to a brief discussion in which the
patient is given as much decision-making freedom as possible. There
might be topics that you are particularly concerned about, and a good
guide will not hesitate to say what these are. But if you charge in, having
decided about the topic yourself without consulting the patient, you lose
an opportunity to learn what behavior change the patient is most ready
to discuss. Consider the following example of a practitioner in a consultation
about heart disease:
“OK, it sounds like you’re doing well with the medication. Now can I
ask you now about smoking? Any thought of giving it up?”
This is what we call the premature focus trap. The practitioner did
not give the patient a chance to consider talking about other lifestyle
changes.
In another form of premature focus, the practitioner, within a discussion
about a specific behavior, focuses too soon on action. Let’s assume
that the patient in the preceding example was happy to talk about
smoking. The practitioner’s question, “Any thought of giving it up?”
Asking 53
This is what we mean by asking in
the service of guiding. . . . It is an
invitation to weigh the choices and
to consider change.
contains an immediate focus on a
particular action, which might be
premature for the patient, who is
not all that ready. It might have
been better to ask, “How do you
feel about your smoking at this
point?” This at least gives the patient
a chance to get going and to
feel comfortable talking about a difficult
addiction.
Usually it is wise to start with understanding the patient’s perspectives
and preferences. Starting with patients’ own concerns also tends to
increase their willingness then to listen to yours. Often, as in the case of
preventing or reversing disease,
there is a menu of options to consider.
Health-threatening behaviors
tend to cluster in individuals. The
patient might make healthful
changes in diet, exercise, smoking,
alcohol use, medication adherence, stress, anger, or social activities.
Guiding questions, accompanied by listening, are a key to solving this
problem.
It is possible to provide a finite set of topics from among which patients
can choose. One simple way to do this is with a “bubble sheet”
that has a series of shapes, each containing one possible topic for conversation,
including blank ones that the patient might like to fill in. In an
outpatient cardiac clinic, for example, such a sheet might contain the
bubbles shown in Figure 4.1, as well as a few empty bubbles (the ones
with question marks in them).
Offering such a sheet, the practitioner can say, “If you like, we can
talk about some changes you could make to improve your health. Here
are some areas that can be important in controlling this illness that we
could talk about, where people in your situation often consider changes.
Are there any of these areas that
you would like to talk about today?
Or are there perhaps other things
you want to raise that feel more important
right now?”
Then, after a few moments, it is
usually feasible to mention those
topics that you want to talk about,
as well. Agenda setting is working well when the patient chooses one
54 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
The premature focus trap is sprung
when the practitioner does not give
the patient a chance to consider
talking about other lifestyle
changes. A second form of this trap
occurs when the practitioner,
within a discussion about a specific
behavior, focuses too soon on
action.
Usually it is wise to start with
understanding the patient’s
perspectives and preferences.
This brief strategy usually takes a
minute or so to complete, before
you and the patient settle down to
talk about an agreed focus for
behavior change.
topic about which you have a constructive conversation and when you
have also aired your view about the topic. If your topic does not coincide
with that chosen by the patient, a good general guideline is to start
with the patient’s priority. Agenda setting works well when the patient
feels free to say, “No, thanks, not today.”
This brief strategy usually takes a minute or so to complete, before
you and the patient settle down to talk about an agreed focus for behavior
change. With practice, you might not need a sheet of paper to
guide you. Not every patient likes a visual aid. Agenda setting can be returned
to at any point in the consultation
if you get a bit lost or if you
reach natural closure in discussing a
particular change in behavior.
You might feel concerned that
allowing patients to choose topics
for discussion is risky because you
are, after all, best placed to know
which behaviors carry the greatest threats to health. Might you end up
“letting the patient off the hook” by talking about something the patient
chooses (e.g., exercise) but that you feel is less a problem than something
else (e.g., smoking)? Many patients have been hearing the same talk
about smoking over numerous years, with little benefit. If they make
progress in one area, no matter how apparently unimportant, they might
begin to learn the habit of success in a context in which failure is often
the norm. Small successful steps in one area may lead to progress in an-
other.
Asking 55
Priorities
FIGURE 4.1. Sample agenda-setting sheet for use in a cardiac outpatient clinic.
eating ?
exercise
? alcohol
stress
smoking medicine
Agenda setting can be returned to
at any point in the consultation if
you get a bit lost or if you reach
natural closure in discussing a
particular change in behavior.
PRACTICAL SUGGESTIONS
FOR ASKING THE RIGHT QUESTIONS
How do you decide which questions to ask in order to promote health
behavior change? What question would be really helpful for this person?
What will give a helpful perspective on his or her dilemma? What will
elicit defensiveness versus change talk? It is a bit like finding the right
path through a forest. Some paths lead in circles, go nowhere, or even
lead one over the edge of a cliff; get it right and you can save a lot of
time. Consider the difference between these two examples on the subject
of diet:
Example 1: Policing “Bad” Behavior
PRACTITIONER: I need to ask you now, have you been keeping to the diet
sheet you were given?
PATIENT: Yes, uhm, well, sometimes, but I forget, and its hard making
separate meals from the rest of the family.
Example 2: A Helpful Guiding Question
PRACTITIONER: You’re working on changing your diet. What would be
most helpful for us to talk about today?
PATIENT: Its been really hard. I want to find meals that are good for me
and the family, so that I don’t have to make separate food for my-
self.
The first example has a policing tone to it, introduced by the closed
question, which was in essence: “Have you been good?” Closed questions
can elicit a feeling of being interrogated. The second consultation
begins with an invitation in the form of an open question, giving the patient
room to choose what to discuss. The question is delivered using a
guiding style and helps the patient to take center stage. Change talk
emerges right away.
How you respond to change talk is one of the core challenges in MI.
In the preceding example, each of the four principles (RULE) discussed
in Chapter 1 is relevant when considering
what to say next. You
would want to avoid the Righting
reflex by not jumping in too soon
with practical suggestions and to
Understand this patient’s motivations
so as to elicit solutions from
56 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
The question was delivered in a
guiding style and helped the patient
to take center stage. Change talk
emerged right away . . . How you
respond to change talk is one of
the core challenges in MI.
him or her. Listening might be the most productive next step (see Chapter
5), and you would want to Empower the patient by conveying a
belief that change is possible and that together you can locate workable
solutions.
The rest of this chapter focuses on providing some maps for locating
useful guiding questions, which effectively open the door to change
talk.
DARN!
One simple guideline is to ask open questions that can be answered with
change talk. Remember the types of change talk discussed in Chapter 3?
The DARN acronym can help you generate questions that elicit change
talk.
• Desire. “What do you want, like, wish, hope, etc.?”
• Ability. “What is possible? What can or could you do? What are
you able to do?”
• Reasons. “Why would you make this change? What would be
some specific benefits? What risks would you like to decrease?”
• Need. “How important is this change? How much do you need
to do it?”
Here are more generic questions about change, phrased to elicit all
six types of change talk.
“Why might you want to make
this change?” [desire]
“If you did decide to make this
change, how would you do
it?” [ability]
“What are the three most important benefits that you see in making
this change?” [reasons]
“How important is it to you to make this change?” [need]
“What do you think you will
do?” [commitment]
“What are you already doing to
be healthy?” [taking steps]
Each of these questions pulls
for an answer that involves change talk. Questions such as these tend to
activate the patient toward change, eliciting his or her own motivations
and creative ideas. You do not really know the answer ahead of time,
Asking 57
One simple guideline is to ask open
questions that can be answered
with change talk.
Questions such as these tend to
activate the patient toward change,
eliciting his or her own motivations
and creative ideas.
unlike Carlos, who led his daughter to a conclusion he clearly foresaw.
For example, the most important reasons (benefits) that occur to you
may not be the ones that most motivate the patient. The kinds of questions
that frustrated practitioners sometimes want to ask elicit defensive-
ness:
“Why don’t you want to ____________?”
“Why can’t you ____________?”
“Why haven’t you _______________?”
“Why do you need to ____________?”
“Why don’t you _____________?”
The answer to each of these questions is a defense of the status quo. Ask
people why they do not change and they will gladly tell you, and, in the
process of telling, they reinforce the status quo.
The guiding questions that we present in this chapter are just examples.
The underlying principle (Chapter 2) is to understand and explore
the patient’s own motivations for change. Our experience is that patients
tend to move in healthy directions
when offered this guiding style,
much more so than when they are
directed to do so.
You know you are asking good
guiding questions when some or all
of these things happen:
• You feel connected with patients and interested in their answers.
• Your patients are talking about behavior change in a positive
way.
• Your patients are wondering aloud about why and how they
might change.
• A patient looks puzzled and engaged and is trying to work things
out.
• A patient asks you questions about how or why he or she might
change.
• Even when time is short, the consultation seems unhurried.
Using a Ruler
A ruler, or rating scale, from 1 to 10 can come in handy. These are already
used in health care to ask for subjective ratings of, for example,
the amount of pain a patient feels. Within MI, rulers have a dual pur-
58 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Our experience is that patients tend
to move in healthy directions when
offered this guiding style, much
more so than when they are
directed to do so.
pose. They not only tell you about
the patient’s motivation but can also
elicit change talk. A 1–10 ruler can
be used to ask about various motivational
dimensions, including readiness, desire, or commitment. Most
patients are able to do this in a purely verbal form, although it is sometimes
useful simply to draw a line on a piece of paper, place 0 and 10 at
either end, and ask the patient to tell you where he or she is along this
dimension.
For example, you can take the first step by asking such questions as:
“How strongly do you feel about wanting to get more exercise? On a
scale from 1 to 10, where 1 is ‘not at all,’ and 10 is ‘very much,’
where would you place yourself now?”
“How ready do you feel to make this change? On a scale from 1 to
10, where 1 is ‘not at all ready,’ and 10 is ‘completely ready,’
where would you place yourself now?”
“How important would you say it is for you to stop smoking? On a
scale from 1 to 10, where 1 is ‘not at all important,’ and 10 is ‘extremely
important,’ what would you say?”
A second step is to ask the patient why he or she has given you one
particular number, say 5, and not a lower number. The answer to this
question is change talk, and you are now able to explore this in some detail.
Another useful variation is to ask what would have to happen to
make the chosen number go up. But beware—frustration or the righting
reflex might lead you to ask the opposite question: “Why are you at 5
and not 10?” The answer to that question is defense of the status quo.
One other warning about using rulers: They are only as good as the
quality of rapport between you and the patient. If you launch into this
assessment in an investigative manner, too soon, without genuinely
wanting to understand and encourage the patient, you might well elicit a
defensive rating of some kind. “Oh, yes, I’m very ready to stop smoking
. . . ” might come from a patient who is really just telling you what she
or he thinks you want to hear. The fact that you are using a ruler does
not mean that the answers are always reliable. Good rapport and the use
of a guiding style can help enormously to improve the reliability of the
exercise.
Some practitioners and services keep a record of the results of this
kind of assessment. You might find this particularly useful when you see
the same patient again, just to remind you (and the patient) about how
things might have changed.
Asking 59
Rulers not only tell you about the
patient’s motivation but can also
elicit change talk.
Assessing Importance and Confidence
Among the most productive questions are two simple ones about the
importance of change to the patient and his or her confidence in succeeding.
Here the ruler can be very
useful. The goal is to use these questions
as a platform for developing
understanding and for eliciting
change talk and to make sure that
you efficiently focus your energies
on the area of greatest need. If your
inquiry is a genuinely curious one,
and if your rapport with the patient is good, a patient’s own motivations
arise in the conversation with ease.
The first step is to ask about the importance of change and then,
if it seems appropriate, to elicit a numerical rating. “How important is
it for you to ____? Could you tell me, on a scale from 1 to 10, where
1 is ‘not at all important,’ and 10 is ‘extremely important,’ how important
is it for you to __________?” Ask 100 overweight patients this
question about weight loss, and you’ll get numbers all along the scale,
but mostly between 3 and 7. The
second step, just like that mentioned
earlier, is to ask: “Why did
you give yourself a score of ____
and not 1?” The answer to this
question will be the reasons that
the patient sees the change as important
(i.e., change talk). You
learn not only how important the change is subjectively but also why
it is important to the patient.
The same questions can be asked about confidence in his or her
ability to change: “On a scale from 1 to 10, where 1 is ‘I’m certain that I
could not,’ and 10 is ‘I’m certain that I could,’ how confident are you
that you could __________ if you decided to? What number would you
give yourself right now?” Then, after getting the rating, you ask, “And
why did you give yourself a ____ and not 1?” Here, the basis for the patient’s
confidence in his or her ability to change will be expressed. It can
also be helpful to look up the scale and ask questions such as “What
would help you to get a higher score?” or “How can I help you to move
higher up the scale?”
Patients can need different kinds of help from you depending on
their ratings on these two scales. Consider these two patients: Both lie
somewhere around the midpoint of a readiness-to-change continuum;
60 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Among the most productive
questions are two simple ones
about the importance of change
to the patient and his or her
confidence in succeeding. Here
the ruler can be very useful.
If your inquiry is a genuinely
curious one, and if your rapport
with the patient is good, his or her
own motivations arise in the
conversation with ease.
both express ambivalence and reluctance to quit smoking; but they have
very different underlying motivations.
Smoker A: “Here I am, 55 years old, and I’m diagnosed with emphysema.
I really need to quit smoking, but how? I’ve tried so many
times and failed. It just seems pointless to try.” [Importance: 9
Confidence: 2]
Smoker B: “Sure, I know you think it’s bad for me, and in the long
run it probably is, but smoking is part of my social life. I tell you,
I’ve been in international competition as an athlete, and if I decide
to do something, I know I can succeed. This just isn’t a priority
for me right now.” [Importance: 2 Confidence: 9]
Patients who are high on importance but low on confidence, like
Smoker A, need encouragement that change is possible and some specific
ideas about how to do it. They are quite different from patients
who are high on confidence but low on importance, such as Smoker
B. If you talked about the why of change (importance) with Smoker
A, and the how of change (confidence) with Smoker B, you would
probably be wasting your time, because these are not the areas in
which they need your help. Assessing your patients on these dimensions
allows you to use the precious time you have in the consultation
in a way that is most congruent
with their greatest need. If the major
obstacle to change is low importance,
using these questions will
allow you to understand that and
efficiently address the issue of importance.
The same is true for
confidence. Far from adding to the
length of consultations, substituting
this kind of approach for a “one size fits all” style of intervention
allows greater efficiency and patient engagement, with added opportunities
for eliciting change talk.
Pros and Cons
Asking about the pros and cons provides you with a set of key guiding
questions that are particularly useful if someone seems uncertain about
change. This gives you the opportunity to explore ambivalence. It gives
the patient time to come face-to-face with uncertainty in an accepting atmosphere
in which his or her inner motivations are free to surface. This
lies at the heart of MI.
Asking 61
Assessing your patients on
importance and confidence in their
ability to change allows you to
use the precious time you have
in the consultation in a way that
is most congruent with their
greatest need.
First, ask your patient what is good about the way things are now.
Asking this gives you some momentum to ask about the not-so-good
things about the status quo. These
two general questions can be applied
to any change topic. Notice
that the first question elicits arguments
for not changing, and the second
elicits change talk. The most
common effect of asking either one
of these questions is that the patient will present you with both sides of
his or her ambivalence.
With regard to smoking, the first question might be: “What do you
like about smoking?” Note that this question is asked without any shade
of disapproval or sarcasm. If your voice tone implies “What could you
possibly like about smoking?” you will elicit defensiveness. The question
is asked with honest interest and curiosity about the perceived benefits
of continuing to smoke. Once you have elicited the patient’s perceptions
of the good aspects of the behavior, you can follow up with a second
question. For example, “And what’s the downside for you? What are the
not-so-good things about smoking?”
A useful way to conclude this conversation is for you to summarize
briefly your understanding of the patient’s account of pros and cons of
the behavior as he or she sees it, using his or her own words whenever
possible. Asking a key question such as “Where does this leave you
now?” often provides patients with an invitation to take things a step
further, to be in the driver’s seat of change in their lives.
Key Questions: What Next?
A “key question” is one that tests the patient’s level of commitment to
change. A key question is a good follow-up after any of the preceding
discussions: DARN motivations, rulers, importance and confidence, or
pros and cons. The essence of a key question is “What next?” Here are
some examples of key questions:
“So what do you make of all of this now?”
“So what are you thinking about smoking at this point?”
“What do you think you’ll do?”
“What would be a first step for you?”
“What, if anything, do you plan to do?”
“What do you intend to do?”
Notice that the normal answer to any of these questions would be commitment
language. The strength of commitment expressed by the patient
62 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Asking about the pros and cons
provides you with a set of key
guiding questions that are
particularly useful if someone
seems uncertain about change.
gives you a read on how likely the change is to happen. Low commitment
suggests a need for further exploration of DARN themes in this or
a subsequent visit.
As a patient expresses some intention to change, it can be useful to
get more specific. When will the patient make or begin this change? Exactly
what will the patient do? How will the patient succeed? Research
shows that people are much more likely to carry through with behavior
change when they express their intentions in more specific terms of
what, when, and how. But do not press for a commitment that the patient
is not ready to make. The question is, what is the person ready,
willing, and able to do now?
Using Hypotheticals
For patients who are less ready to change, it is less threatening if you
take one step back with them and talk in hypothetical language. This allows
them greater freedom to envision change. Here are some guiding
open questions phrased in hypothetical language:
“What might it take for you to make a decision to ______?”
“If you did make a change in __________, what might be some of the
benefits?”
“Suppose that you did decide to _____________. How would you go
about it in order to succeed?”
“Let’s imagine for a moment that you did ____________. How
would your life be different?”
“What would it take for you to go from a 5 to an 8 [on impor-
tance]?”
“How would you like things to
be different?”
“Suppose you continue on without
making any change in
___________. What do you
think might happen in 5 years?”
Imaginative leaps are also possible if you have good rapport with
the patient and if she or he is clearly comfortable with the discussion.
Consider the use of this kind of question:
“What currently impossible thing, if it were possible, might change
everything?”
“If you were in my shoes, what advice would you give yourself
about_______?”
Asking 63
For patients who are less ready to
change, it is less threatening if you
take one step back with them and
talk in hypothetical language.
“How has [this behavior] kept you from growing, from moving for-
ward?”
“What do you most want to be happening in your life a year from
now, 5 years, or even 10 years down the road?”
CONCLUSION
This chapter has outlined the use of questions both in general and in the
service of a guiding style. When it comes to the latter, taking your time
often leads to faster progress. Consultations about behavior change call
for this attitude. A few well-spent minutes can sow the seeds for change
later on. Many practitioners have had the experience of a returning patient
saying something like: “There was one thing you said that made all
the difference. . . .” At the heart of your use of MI is a conviction that
patients have most of the answers within them. Once you enter this
frame of mind, the right questions usually follow.
64 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
CORE SKILLS OF MOTIVATIONAL INTERVIEWINGListening
CHAPTER 5
Listening
Long before there was any scientific basis for health care, there were
healers who had learned to listen carefully. There is something about being
heard and understood, about being the focus of full compassionate
attention, that is in itself healing. Such listening is, we believe, one reason
why patients so frequently seek out and appreciate the services of
alternative healers and those health care practitioners who listen well.
Although some people seem to have an almost innate talent for listening,
the outcome of our research efforts matches our experiences in training:
You can become more skilled and efficient with this tool, and it makes a
difference to the outcome of the consultation and beyond.
This chapter takes you through the skill of listening in some depth.
We begin with some general considerations and then turn to the use of
listening within a guiding style, a skill that lies at the heart of MI.
THE CASE FOR LISTENING
To be sure, the pressures of practice can discourage taking such apparently
“unproductive” time. Yet there are some good reasons to hone
your listening skills.
• Listening helps you to gather important information that you
might otherwise miss.
• Even a little high-quality listening can greatly promote your relationship
with a patient. It can take as little as 1–2 minutes. Long after
65
the specifics have faded, patients often remember that nurse, doctor, or
social worker who really listened to them.
• Patients whose providers listen to them are more comfortable and
satisfied with their care, more likely to be open and honest, and, we believe,
more likely to adhere to advice.
• When you take time to listen, patients feel as though you’ve spent
a longer time with them than you actually have. On the other hand, a
consultation that is limited to asking and informing often feels shorter
than it really is; patients tend to underestimate how much time you spent
with them.
• Perhaps most important, there is something very helpful about
good listening itself. You may have the impression that you are “not doing
anything,” but good listening is
a large component of those important
“nonspecific” aspects of healing.
Just listening can foster change.
Beneath all the technical aspects
covered in this chapter is a simple
notion: Listening involves an attitude
of curiosity and acceptance of
the patient while you are engaged in
this process. The more skilled you
become, the easier you will find it to
integrate brief episodes of listening
into routine practice. This can save
you time, because you develop an
ability to quickly grasp the essence of the patient’s concerns. This allows
you to move on to another topic more easily.
LISTENING: SOME GENERAL CONSIDERATIONS
A practitioner who is listening, even if it is for just a minute, has no
other immediate agenda than to understand the other person’s perspective
and experience. There is no intent
to intervene or fix things. The
practitioner is simply present with
the person, open to whatever he or
she is experiencing and wishes to
say.
When might you use listening?
Quite simply, at any point in the consultation. It can and should be integrated
into routine practice and form a normal part of whatever assess-
66 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
When you take time to listen,
patients feel as though that you’ve
spent a longer time with them than
you actually have.
Listening can save you time,
because you develop an ability to
quite quickly grasp the essence of
the patient’s concerns. This allows
you to move on to another topic
more easily.
A practitioner who is listening, even
if it is for just a minute, has no
other immediate agenda than to
understand the other person’s
perspective and experience.
ment, diagnostic, or management task you are carrying out. It is a tool
that can be used very effectively in the service of a directing style, combined
with asking and informing. Here are some key situations for use of
listening:
• The first part of a consultation. In fact, it’s risky not to listen at
the start of consultation. Interrupt this activity and you can sow the
seeds of dysfunction quite rapidly. The patient might withdraw, become
frustrated, or bring you back to the concerns that you ignored in the first
place. Often patients have plucked up some considerable courage to
come for a health care appointment and to tell their story to their practitioner.
One of the commonest patient criticisms of consultations is not
being allowed to tell this story. An early interruption sets the scene for a
developing sense of not being heard.
• Brief episodes throughout the consultation. Patients signal the
need for this when they seem confused, anxious, disengaged, upset, or
annoyed. For your part, when you are not sure about a diagnostic or management
matter, listening is a powerful way of unraveling what is going on.
• After you ask an open question. It is an invitation to the patient
to speak, and your opportunity to listen and understand.
There are other situations in which a directing style can be put to
one side and a following style is called for, in which listening is paramount.
Here are some specific examples.
• You walk into the examining room, and the patient says, “I have
just had a terrible experience this morning.”
• You have had to break some bad news to a patient, and now it is
time to let him or her absorb it and respond.
• You sit down at the bedside of a dying patient who is just awakening.
He or she smiles and says “Hello.” There is nothing that
you need to ask or do immediately.
There are times when the most important and the most healing
thing you can do is simply to be there with your patients, to take the
time to listen and understand. Here you would use a following style.
You might provide information and ask questions, but your primary
purpose is to follow the needs of the patient—for example, when breaking
bad news or when talking to someone who is particularly distressed
or anxious.
The next sections discuss some practicalities of listening in health
care. We explore some uses of listening, provide some tips, and touch on
some pitfalls to avoid.
Listening 67
Opening the Door
You open the door to listening by extending an invitation. Most often
this takes the form of an open question, accompanied by signals that you
intend to listen. “How are you?” has become a superficial greeting, offered
in passing without the expectation that the other will actually elaborate.
What, then, distinguishes a disingenuous “How are you?” from a
real invitation to talk and be heard? How do we tell the difference in
normal conversation?
Two key signals are eye contact and lack of distraction. Consider
the differences in the meaning of “How are you?” when asked by:
• A person while passing in the hallway without pausing or making
eye contact.
• A nurse who is paging through a medical chart and readying a
blood pressure cuff.
• A physician who walks into the examining room, makes eye contact,
smiles, sets aside whatever she or he is carrying, and pulls
up a chair.
The latter is communicating not only verbally (“How are you?”)
but also nonverbally that right at the moment listening is the most important
thing on the agenda. These nonverbal cues are even more important
than the words of invitation. One commonly used training exercise
requires a speaker to talk about a topic on which he or she can continue
for some time with minimal support from the listener. The listener’s task
is the harder one: to communicate to the speaker that he or she is listening,
hearing, and understanding but without speaking a word or even
making vocal sounds, such as “uh huh.” The listener has only nonverbal
cues to communicate listening and understanding, such as eye contact,
facial expression, head movement, and so on.
The verbal part of the invitation to be listened to is a simple opening.
Here are a few examples:
PATIENT: I just had a terrible experience this morning.
PRACTITIONER: Tell me about it.
PRACTITIONER: (coming bedside) Hello, how are you feeling this eve-
ning?
PRACTITIONER: (entering the consulting room) Good morning! Tell me
what’s on your mind today.
PRACTITIONER: (with some standard questions to ask) In a little while
I’ll need to get some specific information from you, but before we do
68 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
that, let me just take a few minutes to hear about what made you decide
to come here today.
Asking Is Not Listening
What is a good listener? After you open the door with an invitation and
are paying attention, what should you do next?
Many people confuse listening with asking questions, but these
are two different communication tools. A question places a demand on
the person to give you an answer. A question also points the person in
a particular direction, putting the spotlight on one particular topic or
area that is of interest to the questioner. The psychologist Thomas
Gordon called questions “roadblocks” to listening. For the person to
continue down the road they were on before the question, they have
to deal with the roadblock, go around it, and then get back on the
path. Ask two or three questions in a row, and surely the person is derailed
from his or her original course. You are the one who is in
charge, not the speaker. That is not necessarily a bad thing; asking is
also part of your job. If someone is
acutely ill and you need to make a
diagnosis by working your way
through a mental decision tree, you
probably need to ask a series of
questions. But for pure listening, the only question you need is an
opening invitation.
Silence
Silence is often a good teacher. If you are silent, even for a brief moment,
you are not voicing all of the roadblocks that people normally throw in
each other’s way: agreeing, disagreeing,
instructing, questioning, warning,
reasoning, sympathizing, arguing,
suggesting, analyzing,
persuading, approving, shaming, reassuring,
interpreting, and so on. Silencing
these spoken roadblocks is a
good start toward real listening.
A next step is to silence your
inner chatter and focus full attention on understanding the person who
is with you. Even without voicing the roadblocks, you may be thinking
them. How easy it is, while seeming to listen, to be thinking ahead to
what you need to do next! To fully listen, even that inner chatter is
Listening 69
Asking and listening are not the
same thing.
Roadblocks to listening include
agreeing, disagreeing, instructing,
questioning, warning, reasoning,
sympathizing, arguing, suggesting,
analyzing, persuading, approving,
shaming, reassuring, and
interpreting.
hushed, and you give your full attention
to listening, hearing, and
understanding. Here’s a new meaning
for attending physician!
Facilitative Responses
Pure silence can also make some people uneasy. Despite your best nonverbal
attending, if you say absolutely nothing, some patients will start
to wonder what you are thinking or whether you are actually listening at
all. A simple step is to reengage the
vocal cords a bit and offer a few
small facilitative responses as simple
as “mm hmm,” or “I see,” or “say
some more about that.” Of course,
responses such as these could be
programmed into a computer, and
thus they are not proof positive that
you are listening.
In Somewhat Different Words: Listening by Reflecting
Proof positive that you are listening, hearing, and understanding is to reflect
back to the person a short summary of how you understand what
he or she said. Parrots cannot do this—it involves more than repeating.
We have also found that actors cannot do this without special training.
Actors are perfectly good at being silent, attending, and giving facilitative
responses, but reflective listening is a skill that takes special practice.
Actors can on demand look like they are listening, but the real thing is
more challenging.
So what is the real thing? Let’s start with an example in which the
practitioner, after asking an open question, and for purely illustrative
purposes, does absolutely nothing but reflective listening:
PRACTITIONER [social worker, doctor, psychologist, dietician, nurse,
physical therapist, counselor]: We’re coming toward the end of our
session, but you said quite quickly a moment ago that there was
something that made you feel not quite right.
PATIENT: Well, yes, I haven’t been feeling that great. It started about a
month or two back, and at first I thought I was just imagining it,
possibly because I was working so hard and hadn’t been exercising
much, you know what I mean?
70 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Even without voicing the
roadblocks, you may be thinking
them. . . . To fully listen, even that
inner chatter is hushed.
Proof positive that you are
listening, hearing, and
understanding is to reflect back to
the person a short summary of how
you understand what he or she
said. Parrots cannot do this—it
involves more than repeating.
PRACTITIONER: You’re working a lot and haven’t been feeling quite
right.
PATIENT: Well, I thought it was just that, but then I sort of felt tired and
weak when I had any kind of exertion, like I was short of breath,
and I have never had that before. Not even when I have been out of
shape. Even walking up the stairs at home, I notice it.
PRACTITIONER: That’s definitely unusual for you.
PATIENT: Yes, that’s right, on the stairs, but also sometimes when I was
just sitting down not actually doing much. At first I thought it was
the stress. Now I wonder if it’s my lungs or heart.
PRACTITIONER: You’re not 100% sure what’s going on, and it’s got you
a little scared.
PATIENT: Yes, it’s been sort of creeping up on me, I mean I’m usually the
rock of the family, and even at work, but now this.
PRACTITIONER: You’re used to being in charge.
PATIENT: Not necessarily in charge, but reliable, you know? But I think
it’s beginning to get too much for me, and I feel like things are getting
out of control.
PRACTITIONER: Like there’s not enough time to look after yourself.
PATIENT: That’s exactly right. I have to sort this out.
PRACTITIONER: You want to know what’s going on and do something
about it.
PATIENT: Well, this is the first step, I said to myself, I want to mention
this to you.
What is going on here? This
practitioner is being a very active
partner in the communication process
and is taking a minute or two
to understand the patient’s own perceptions and concerns. In order to do
this kind of listening, the practitioner must attend to the patient, hear
the words accurately, and then form a hypothesis about (literally reflect
on) what the patient means so as to be able to say it back in somewhat
different words. The practitioner reflects those “different words” back
to the patient, and then something interesting happens. The patient either
confirms or disconfirms the practitioner’s hypothesis. The patient
either says, in essence, “Yes, that’s right” and continues to elaborate, or
“No, that’s not quite right” and continues to elaborate. There’s no penalty
for guessing wrong here. Either way the patient is likely to tell you
Listening 71
Each reflection is a short summary
of what is happening at that
moment.
more, as long as you reflect in somewhat different words. Even direct
repetition can have this effect sometimes, but usually parroting falls flat
in short order. Sometimes a reflection takes the form of “continuing the
paragraph,” anticipating what the patient might say next but that is yet
unsaid.
Sound complicated? It is; it
takes practice. The good news is
that it’s a learnable skill, and one
that is clinically quite useful. Furthermore,
your patients are your
teachers. Each time you try a reflection,
you get immediate feedback
about its accuracy, and so over time
you get better at it.
Here is a somewhat longer consultation in which, again, just for
purposes of illustration, the practitioner again uses only reflective listening.
If you enjoy a challenge, cover the page with a sheet of paper and reveal
one line at a time. For each patient response, before you look at
what the practitioner says next,
consider how you might reflect
what the patient has said.
A patient in the hospital needs
to decide whether or not to have an
operation, and your colleague is
frustrated because she cannot get a
clear answer from him. “Every time I ask him, he just breaks down
weeping. Could you talk with him?”
PRACTITIONER: [psychologist, social worker, nurse, doctor, counselor]:
You said you were worried about your possible operation.
PATIENT: Worried is not the word, it’s so complicated I don’t know
where to begin.
PRACTITIONER: And it’s causing you quite a lot of distress. [continuing
the paragraph]
PATIENT: Last night I hardly slept, I was so worried. (Begins to weep.)
PRACTITIONER: (Stays silent, hands him a tissue.) It’s like things are
coming to a head.
PATIENT: It’s not like me to cry like this.
PRACTITIONER: This is really important.
PATIENT: This is the big one. (Continues to weep.)
72 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
The practitioner forms a hypothesis
about what the patient means so as
to be able to say it back in
somewhat different words . . . and
then something interesting happens.
The patient either confirms or
disconfirms the hypothesis.
Your patients are your teachers.
Each time you try a reflection, you
get immediate feedback about its
accuracy, and so over time you get
better at it.
PRACTITIONER: It feels like a big decision that you have to make, one
way or another.
PATIENT: That’s right, as every day goes by I get closer and closer to having
to decide.
PRACTITIONER: But not much clearer. [again continuing the paragraph
with a guess]
PATIENT: That’s the problem, because if have the operation, I know I
might not last long afterward. It’s a big risk. That’s what I’ve been
told, as simple as that.
PRACTITIONER: And if you don’t have the operation, it’s not that easy
either.
PATIENT: Well, not exactly, it’s a question of time, you see. They say I
might have just a few months left, and all I know for sure is that I
want to be there for my family.
PRACTITIONER: That’s the most important thing for you right now.
PATIENT: You should see my son (laughs), he says I’m still the same old
rude rascal, nothing’s changed, even though I am supposed to be so
ill.
PRACTITIONER: Sometimes you almost feel back to normal.
PATIENT: When I’m with him, its great, but then, there’s no escaping
this, really.
PRACTITIONER: You feel trapped.
PATIENT: Yes, that’s it, I lie here and think about taking the chance and
having the operation, then I imagine it going badly, then I try to stop
thinking about it.
PRACTITIONER: You’re just not sure what to do.
PATIENT: Sometimes I think that, well, you people do these operations,
and I should put my trust in you.
PRACTITIONER: If you had the operation and it worked out well, that
would be a good outcome.
PATIENT: I think I’ll probably go along with this, but I just need some
time to get used to the idea, and then I’ll let you know.
PRACTITIONER: You need some time to work through this decision
about the operation.
PATIENT: I will decide soon.
PRACTITIONER: (offering a little longer summary of what has been said)
Let me see if I understand what you’ve been telling me, and do let
Listening 73
me know if I’ve missed anything. This decision is not an easy one for
anyone to make. Whichever way you go, there’s a risk that you
might not be there for your family. You’ve been told that without
the operation you have only a few months, but the operation is also
risky. You’re getting closer to making the decision, though, and you
just need more time to think it over. You feel especially good when
you see your family, and you are thinking as much about them as
you are about yourself.
PATIENT: Yeah, that’s quite right, I don’t really need any more information,
and this isn’t a decision you can make for me. It’s just good to
talk this through with you.
Note a few things about the reflections in this example. First, they
are all statements rather than questions. The practitioner is not asking,
“Is this what you mean?” If you
were listening to an audiotape, you
would also hear that the practitioner’s
voice inflection turns down at
the end of a good reflection and not
up as when asking a question. This
can feel odd at first, but only to you, not to the patient. Offering reflections
as statements rather than questions makes patients more comfortable,
and they keep talking. A patient is more likely to elaborate if you
say:
“You’re feeling anxious about this.” [voice inflected down at the
end]
rather than:
“You’re feeling anxious about this?”[voice inflected up at the end]
Also note that the practitioner’s skillful responses in the above example
sometimes reflected content that the patient had not actually said but
that might be what the patient meant or was thinking. Reflections need not
be restricted to what the person has said directly. Sometimes you are continuing
the paragraph by offering what the next as-yet-unsaid sentence
might be rather than just repeating the one that has gone before.
The Skill of the Summary
In the final response of the preceding case example, the practitioner collected
the main themes that the patient had offered and pulled them together
in a summary. In a way, each reflection is a short summary of
74 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
The practitioner’s voice inflection
turns down at the end of a good
reflection, and not up as when
asking a question.
what is happening at that moment,
but this kind of collecting summary
looks back over part or all of the
conversation and offers an abstract.
There is skill to knowing what to include
in such a summary. Later on in this chapter we give you some specific
guidelines for choosing what to include in summaries when listening
is used in MI. Here, however, the practitioner just attempted to pick
up the main themes that the patient had raised.
Summaries can serve several very useful functions:
• A good summary shows in a powerful way that you have been listening
carefully to and remembering what the patient said. This is in itself
a positive message that can strengthen your working relationship.
• Giving a summary causes you to draw together the pieces of the
picture and to see whether you have missed something important. To do
this, you can follow a summary by asking “What else?”
• A summary allows you to reemphasize certain aspects of what the
patient has said by including and highlighting these themes. This aspect
of summaries is particularly useful within the guiding style.
• A summary frees you to change direction. It is a gentle and positive
way to draw your period of listening to a close and move on to the
next task.
Asking and Listening
Although they do represent two different tools of communication, asking
and listening fit naturally together and complement each other. A
therapeutic approach known as client-centered or person-centered counseling,
introduced by psychologist Carl Rogers, relies primarily on a
skillful combination of asking and listening. This is also a natural combination
to use in health care.
For most people, asking questions is much easier than reflecting. As
a result, even when practitioners try to be good listeners, it is common
for them to ask a series of questions in a row with little or no reflective
listening in between.
We offer three practical recommendations about questions while
you are listening.
1. Try to ask open rather than closed questions.
2. Try not to ask two questions in a row.
3. Try to offer at least two reflections for every question you ask.
Listening 75
Offering reflections as statements
rather than questions makes
patients more comfortable, and
they keep talking.
A resulting rhythm would be an open question followed by reflective listening
to what the patient offers. For example:
PRACTITIONER [nurse, doctor, podiatrist]: So you’ve been having quite a
bit of pain in your feet. Tell me about that.
PATIENT: Sometimes it hurts so much that I have trouble walking. I have
to go up and down stairs at work, and that’s really hard.
PRACTITIONER: And that pain is fairly constant, every day. [reflection, a
guess]
PATIENT: Just about, yes. Less on the weekends when I’m not working.
PRACTITIONER: There’s something different about the weekends. [reflec-
tion]
PATIENT: Well, like I said, I’m not at work, and I stay home more.
PRACTITIONER: What kind of shoes do you wear on the weekend?
[closed question]
PATIENT: I usually wear bedroom slippers or go barefoot around the
house.
PRACTITIONER: And that feels better. [reflection]
PATIENT: My feet still hurt, but not as much. But if I go out on Saturday
night, then I wear spikes.
PRACTITIONER: High heels—higher
than you wear to work. [reflec-
tion]
PATIENT: A little maybe, but I wear
heels at work, too.
Some Concerns about Listening
It is hard to do harm with good listening, in which a sense of genuine
warmth and curiosity is present. If your reflections are too similar to
what the person said, if there is too much a straight repetition, you can
go around in circles.
However, there can be a downside to listening that you will quickly
discover. Most people experience so little good-quality listening in their
lives that they are quite hungry for it. When they meet someone who actually
takes the time to listen, hear, and understand, it is such a rewarding
experience that they could literally talk for hours. That, we find, is a
great worry among practitioners about listening to their patients. It is an
76 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
While you are listening, try to offer
at least two reflections for every
question you ask.
understandable worry, but one that is actually quite manageable. Most
practitioners already know good and gentle ways to bring a consultation
to an end when it is time to move on. A closing summary is just one of
these. The truth also works: “Thank you for sharing this with me. What
you have told me today has really helped me get a much better understanding
of the situation. I wish I could listen longer, but I have to see
someone else now, and I don’t like to keep people waiting. Let’s talk
more about this the next time I see you.”
Some practitioners also worry
that if they pull the cork out of the
bottle, it will overflow: “If I listen to
my patients in this way, will they
fall apart right there in my consulting
room? After all, I’m not a psychologist.”
And, again, time is often
a concern. It certainly can happen
that when a compassionate listener
takes even a little time to understand,
the person can be moved to
tears. It’s a question of balance. No
one would endorse not listening to patients; nor could you justify losing
control of the time and of other tasks that you need to carry out. Patients
also do not necessarily want to experience their fear, anger, sadness,
or frustration in large doses.
These concerns about letting the genie out of the bottle are, we believe,
more than offset by the clinical value of spending some time in
pure listening. We have alluded to the healing power of listening for the
patient and its positive impact on practitioner–patient relationships. Listening
in this way can also do much to enrich your own practice. So rare
are good listeners that even a little good-quality listening will open to
you the rich inner experience of the people you serve. Few people are so
privileged to share in the intimate inner world of so many fellow human
beings. One such experience can uplift a day of otherwise routine practice.
Good listening, you see, enriches not only the one to whom it is
given as a gift but the giver as well.
LISTENING IN MI
Reflective listening itself—the pure listening skill—can be surprisingly
effective in helping people change. If all that this book inspired you to
do is to become a good listener in this skillful way, you would have an
important gift to give to others. Once you are comfortable with reflecListening
77
Effective and gentle ways of
bringing listening to a close:
• Summarize what you have
understood and suggest a change
in direction.
• Be honest about your time
limitations.
• Acknowledge the value of what
you have heard.
tive listening, you can become more conscious and intentional about
how you listen, while retaining the warmth and genuine curiosity that
lies at the heart of good listening. In MI, what you choose to reflect back
to a patient can make a difference.
The remainder of this chapter discusses
what to reflect and why,
when your goal is to encourage
health behavior change.
Choosing What to Reflect
When you listen, even for a short time, you quickly discover that you
have some decisions to make. As patients talk to you about their experience,
they typically offer a rich array of material. You cannot begin to
reflect all of it. Which comments will you pick, and how will you decide?
Consider this exchange in which a practitioner opens the door with an
invitation and then follows with pure listening.
PRACTITIONER [pediatric nurse or doctor]: Well, it looks like your boy’s
arm is going to be fine. I’ve patched up the wound and it should heal
quickly. His tetanus vaccination is up to date, and the nurse is finishing
up with him next door. Now, you mentioned that you’ve been
more generally concerned about his behavior, and I have a few
minutes before I see another patient. Tell me a little more about
that.
PATIENT [mother]: It just seems that he’s getting harder to control. He
won’t listen to us. Homework, meals, bedtime—it’s all a struggle.
He can’t seem to sit still, and sometimes it seems like he just doesn’t
pay attention to what he’s doing. That’s how he cut his arm this
time, you know. He wasn’t looking where he was going and ran into
our board fence with a rusty nail sticking out. I don’t know how
many times I’ve told my husband to fix that fence. [What part of all
this might you choose to reflect at this point?]
PRACTITIONER: It’s hard for you to manage him. [reflection]
PATIENT: Yes, and my husband and I don’t agree on how to discipline
him. He spanks him, and I think that’s wrong. We’ve had a lot of
fights lately.
PRACTITIONER: You and your husband. [reflection]
PATIENT: Yes. (Tears come.) I’m sorry, doctor. It’s just all been so hard
for me lately. I’ve heard about ADHD. One of the boys in his class
has it, and I wonder if that might be what’s wrong with him.
78 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
In MI, what you choose to reflect
back to a patient can make a
difference.
In the space of 1 minute of listening, the pediatrician suddenly has a
rich array of issues from which to choose. Should she focus on the
mother’s feelings of distress, the struggles with homework and bedtime,
the concerns about attention or activity level, the spanking, or perhaps
the conflicts between husband and wife? How do you decide what to re-
flect?
For this particular situation, it could be useful to move from listening
to agenda setting in the asking style, as described in Chapter 4. For
present purposes, however, this conversation illustrates that a practitioner
who listens must often choose what to reflect from among options.
Within MI, there are some decision rules to help you in deciding what to
reflect.
Reflect Resistance
When talking with a person who is ambivalent about change, you are
bound to hear some resistance, some arguments for the status quo. The
righting reflex is to refute these, to effectively argue against them and set
the person straight. But as we’ve described earlier, if you argue for
change, the patient will tend to voice the arguments against it. Because
people who feel ambivalent have both sides of the argument within
them, they will often back away from resistance when you reflect it
nonjudgmentally. Even if they do not, you will get a clearer picture of
the patients’ reluctance. Here is a typical example from our work with
problem drinkers:
PRACTITIONER: And tell me a little about your drinking. [open question]
PATIENT: Well, I do drink most days, but not that much, really.
PRACTITIONER: You’re a pretty light drinker. [reflection]
PATIENT: Well, I’m not sure about that. I can hold it pretty well, more
than most.
PRACTITIONER: You can drink a fair amount and it doesn’t seem to affect
you. [reflection]
PATIENT: Yeah, that’s right. I can drink quite a bit.
PRACTITIONER: And you do sometimes. [reflection, continuing the para-
graph]
PATIENT: Sure, I’ll have five or six beers after work on the way home.
PRACTITIONER: [At this point the righting reflex is screaming, but the
practitioner sticks with a guiding style to see what happens.] What
do you think about drinking that much? [open question]
Listening 79
PATIENT: I don’t really think about it that often.
PRACTITIONER: Sometimes you do, but not often. [reflection]
PATIENT: Well, sometimes I think, you know, I’m getting older and I
ought to cut back.
PRACTITIONER: What have you noticed? [open question]
PATIENT: These stomach pains, like I’ve been having, and I guess I’m not
as sharp sometimes in the mornings. But don’t misunderstand, I
don’t have a problem with drinking.
PRACTITIONER: It hasn’t really caused any problems for you. [reflection]
PATIENT: Well, I wouldn’t say that. . . .
The temptation is great to jump
in using a directing style, and indeed
it might not be entirely inappropriate
for you to do so. Some clear information
and advice from a health
professional can make a difference.
For example, you might well talk
about safe drinking limits with this patient (see Chapter 6 on informing).
We invite you, however, to try out this reflective way of responding to
patient reluctance. Very often, it is then the patient who comes up with
the other (pro-change) side of the argument, sometimes the very points
you were about to voice yourself.
Reflect Change Talk
In the directing style, it is usually the practitioner who presents the case
for change. Within a guiding style, it is the patient who does this.
Change talk emerges, and this is what you reflect.
In Chapter 4 we discussed the strategic use of questions—asking
those questions to which the answer is likely to be change talk. Such
open questions often evoke a mixture of change talk and other language.
Consider the forest meadow image we used earlier in this book. You are
watching for the flowers, and as they appear, you pick some. In other
words, what you particularly want to reflect, when you hear it, is change
talk (statements of desire, ability, reasons, need, commitment, and taking
steps). When you hear change talk, pick it out and reflect it back to
the patient. In the following example, the patient’s change talk is highlighted
in boldface italic type. Places where the practitioner uses reflective
listening are indicated by [R].
80 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Patients who feel ambivalent have
both sides of the argument within
them, and they will often back
away from resistance when you
reflect.
PRACTITIONER: [audiologist]: Well, Mr. Sanchez, we’re done with your
testing, and there are some clear frequency ranges at which you’re
not hearing as well, which must be what your wife was noticing.
That’s not too unusual for your age, but the fact that there are these
particular gaps suggests that there’s something else going on besides
normal aging. The nerve conductance test was normal, no apparent
problem there. When have you been exposed to loud noises in your
life, and how recently?
PATIENT: When I was younger I used to go trap shooting more, and we
didn’t always use the earplugs. Also I rode motorcycles—still do
sometimes—and they can be loud.
PRACTITIONER: You’ve been around loud noises when shooting and riding
motorcycles, which you still do sometimes. [R] What else?
PATIENT: I use some power tools, like a chain saw and a leaf blower.
They’re kind of loud.
PRACTITIONER: Right. And you don’t always use ear protection. [R]
PATIENT: I never do, really, when I’m using tools.
PRACTITIONER: [resisting the temptation to immediately tell him why he
should, and reflecting instead] It hasn’t seemed important to you.
[R]
PATIENT: I guess I haven’t really thought about it. It’s not all that loud, is
it?
PRACTITIONER: [responding to the invitation to inform] I recommend
that for anything above about 50 decibels people should protect
their ears, and those tools would definitely be in that range. But it’s
kind of a hassle for you to put on ear protection every time you
want to use a tool. [R—still rolling with resistance rather than disagreeing
with it]
PATIENT: Well, not that big a deal, really. It’s simple enough if it’s im-
portant.
PRACTITIONER: So popping in earplugs is something that you could do if
you thought it was important enough. [R]
PATIENT: Sure. I could do that. [ability, not yet commitment]
PRACTITIONER: The problem has been that you didn’t think it really
matters that much. [R]
PATIENT: Or I just wasn’t worrying about it, I guess. Didn’t think about it.
PRACTITIONER: Well, while we are thinking about it together, let me ask
you this. In what ways has your hearing loss been inconvenient for
Listening 81
you so far? [This open question is particularly intended to evoke the
patient’s own motivations for behavior change.]
PATIENT: Not too much, really. My wife gets frustrated with me when I
don’t hear her. [reason]
PRACTITIONER: She gets a little irritated. [R] What else?
PATIENT: It’s embarrassing sometimes when I don’t understand what
somebody said and I have to ask once or twice more. That seems to
happen more often lately. [reason]
PRACTITIONER:Twice sometimes. [R]
PATIENT: Especially if the person has like an accent or something, or if
we’re in a noisy restaurant. Sometimes I just pretend that I understand
if I don’t get it the second time, or don’t ask at all, and then I
miss things. I don’t like that. [reason and desire]
PRACTITIONER: You told me that your wife thinks you may need a hearing
aid, and perhaps you’re wondering, too. [R]
PATIENT: No, that would really be embarrassing. I don’t want to go
around with hardware in my ears.
PRACTITIONER: You don’t like how hearing aids look. [R—still rolling
with resistance rather than arguing against it]
PATIENT: They make you look old, and also they’re a hassle, the batteries
and all that. And sometimes they squeak or screech out in public,
and people look at you.
PRACTITIONER: Sounds like you hope you never have to wear one.
[R]
PATIENT: Well, probably sooner or later I’ll need one, but I’d rather it be
later. [need]
PRACTITIONER: So you might be interested in doings things now to protect
the hearing you have left. [R]
PATIENT: Yes, definitely. [beginning of commitment to behavior change]
PRACTITIONER: And it sounds like not wearing ear protection around
noises—that wasn’t because of embarrassment so much as just not
thinking about it, not realizing that it’s important. [R]
PATIENT: Right. I can do that if it’s going to keep me from needing a
hearing aid. [ability]
PRACTITIONER: It would be worth it to you; seems like a small price to
pay. [R]
PATIENT: Sure, I’ll do that. [commit-
ment]
82 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
When you hear change talk, pick it
out and reflect it back to the patient.
Working Through Ambivalence
Why take this time to reflect the patient’s own motivations to change?
The reason is that lifestyle patterns have substantial inertia, and the default
is to continue unchanged. Past behavior predicts future behavior.
We do not mean to be pessimistic about behavior change, because we see
it all the time. It’s just that unless something dislodges a current behavior
pattern, it is likely to continue.
Isn’t that an argument, then, for confronting patients with the consequences
of their behavior, to jar them loose and rather forcefully persuade
them to change? Although that sounds logical, such a frontal assault
is actually more likely to entrench than to dislodge an established
behavior, such as smoking, for example. When reflective listening is used
within a guiding style, behavior change is more likely to occur.
Ambivalence can be a muddy meadow. People can stay mired there
for some time. As discussed earlier, it’s common to think about one reason
why it might be good to make a
change, then to think about a counterbalancing
disadvantage of changing,
and then to shut down and stop
thinking about it. The guiding process
of listening helps the person
keep talking and moving in one direction toward change. You help the
person keep thinking about and exploring the reasons (and desire, ability,
need) for change instead of bouncing back and forth between pros
and cons and then shutting down.
How does that happen? When you reflect something that a person has
said, you express interest in it and invite the person to say more about it, to
elaborate. By being particularly interested in and focusing on the person’s
own motivations for behavior change—the flowers in the meadow—you
encourage the person to keep on exploring and expanding on those.
You cannot know ahead of time what flowers will pop up, but
bloom they do when you ask and listen. When you ask questions that
elicit change talk, patients voice their own motivations for change and
hear themselves expressing and exploring them. Then, when you reflect
their own change talk, they hear you saying again (in slightly different
words) what they themselves have said, and they explore it further. That
lays the groundwork for yet one more use of listening to facilitate
change.
Summaries: The Bouquet
Remember that in listening you periodically draw together what the person
has said into a summary. In MI, these summaries have a particularly
Listening 83
When listening is used within a
guiding style, behavior change is
more likely to occur.
important function, because they contain the person’s own motivations
for change. You collect these flowers, the patients’ own change talk
statements, into a bouquet and periodically offer it back to them. It is
particularly useful for the person to hear her or his own accumulated
motivations for change collected all together, perhaps for the first time.
This is different from the usual immobilizing process of ambivalence:
thinking of one argument for change, then an argument against it, then
stopping the process.
All of this means that you need
to be able to recognize a change talk
flower when you see it (Chapter 3).
Within MI, asking is used to elicit
change talk (and eventually commitment),
and listening is used to
selectively reflect change talk and
draw it into summaries. Here is an
sample summary, following from the audiologist consultation earlier in
this chapter:
PRACTITIONER: Let me see if I’ve heard you right, Mr. Sanchez. You’ve
got some gaps in your hearing, and you’ve told me about past exposure
to loud noises that might account for these. You notice that you
are having more difficulty understanding people, especially if they
speak with an accent or you’re in a noisy place. Sometimes you have
to ask people to repeat themselves once or twice, and you don’t like
that. This has also been a source of some friction between you and
your wife, because she gets frustrated at having to repeat herself. She
thinks maybe you should have a hearing aid, but you really don’t
want to do that yet because you would feel embarrassed, it might
make you look older, and there are some practical hassles. You think
you’ll eventually need one, but you want to put it off as long as possible.
So what you want to do is to preserve the hearing you have left
as best you can, and for as long as you can, before it’s time to get a
hearing aid. So far so good?
PATIENT: That’s right, yes. Well done! Nothing wrong with your hearing.
(Grins.)
PRACTITIONER: So what makes sense to you is to take care of your hearing
by using ear protection whenever you’re going to be around loud
noises. That would protect you from further damage and help keep
these problems and embarrassments from getting worse. Is that
what you’re going to do?
PATIENT: Yes, I’ll start using ear protection. [commitment]
84 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
When listening, you periodically
draw together what the person has
said into a summary. In MI these
summaries have a particularly
important function, because they
contain the person’s own
motivations for change.
PRACTITIONER: Great! Makes sense to me. Now how can I help you
with that? Is there any information that would be useful about the
kind of ear protection you can use, how to know when you should
use it, anything like that? [asking permission to inform, a skill that
we take up in the next chapter]
CONCLUSION
This chapter has described some of the breadth and depth of listening,
with an emphasis on its use on the service of a guiding style. It’s a practical
skill that demands alertness, patience, and an ability to capture the
patient’s experience in a few well-chosen words. What you actually do is
quite simple—you make a reflective listening statement—but your attention
to detail and nuances of feeling will be appreciated by patients, and
this allows them the freedom to resolve ambivalence about behavior
change.
Listening 85
CORE SKILLS OF MOTIVATIONAL INTERVIEWINGInforming
CHAPTER 6
Informing
Informing is probably the most commonly used tool in health care communication,
woven into the fabric of most consultations. This chapter
starts with some general considerations about informing and then turns
to its use within MI.
SOME GENERAL CONSIDERATIONS
Informing is used in a wide range of situations. Here are some examples:
• Telling what has happened
• Explaining what is going to happen or what may happen
• Clarifying what something means
• Breaking bad news
• Sharing evidence
• Obtaining informed consent
• Mastering a task such as using a medical device
• Giving advice
“Some patients seem to hear, but others, I tell them time and again
but it never seems to sink in.” How difficult can it be to give patients information?
Unfortunately, things do go wrong with this task. You may
give what seem to be perfectly clear instructions, yet the patient does not
fill a prescription or follow through with the next appointment. You go
through what is or could be involved with a procedure, but later the pa-
86
tient is dissatisfied and complains that you did not adequately explain it.
Many litigation cases in health care arise from disruptions of communication.
And, commonly, the information you provide does not match the
patient’s hopes or expectations. “So you’re not going to give me anything
for this?” says the patient after your long explanation about managing
her problem. “Aren’t you going to do anything?”
A common-sense guideline is to be friendly and provide information
in a clear and concise manner. Decades of research on informationgiving
and patient compliance have
identified some essential ingredients
of clarity when informing: Do not
overload patients, provide simple
information in chunks, be careful
about using jargon and technical
terms, check back to ensure that the
patient has understood, and so on.
Health care providers with little or no training in how to improve their
informing skills often adhere to these guidelines but then find that things
quickly become more complicated.
Put simply, patients may not be ready to hear what you have to say
or may not agree with you about the importance of the information.
They come from different cultures, backgrounds, and language groups,
and a whole host of forces can affect their interest in and ability to absorb
information you offer. These forces can include the following:
• Bewilderment. You provide information, and the patient just
seems confused or bewildered. Is it the speed of the informing process,
the patient’s cognitive functioning, his or her attitude toward you, the
words you used, or something else?
• Passivity. It seems to be going well until you take a more careful
look at the patient, whose eyes are glazed over in a state of passivity, sitting
back in the chair, waiting for you to get through your routine. Your
duties sometimes demand that you get through large chunks of information
with patients; for example, when you are required to inform patients
for medical–legal and other good reasons. In the process of “getting
through,” you may yourself tune out a bit, feeling anxious, rushed,
or bored. In the process it is easy to miss the cues that your patient has
“switched off,” that somewhere along the way you lost him or her. In
the midst of informing, you may discover that your patient is no longer
beside you.
• High emotion. Informing is easier when all is calm in the consultation
and you have time to think and to do a good job. High emotion in
yourself or your patient can change all that. Patients can feel angry,
Informing 87
Things can and do go wrong with
the informing process. You may
give what seem to be perfectly clear
instructions, yet the patient does
not fill a prescription or follow
through with the next appointment.
frightened, or anxiously expectant. You may feel rushed, worried, tired,
or irritated. High emotion blocks understanding.
• Mood and distraction. Relatedly, patients who are depressed may
not hear and understand clearly what you are saying. Others may be distracted
by recent events or worries and have trouble concentrating. (The
same, of course, can happen to you.) The effects of alcohol, age, medication,
or illicit drugs may impair the patient’s ability to understand and
remember.
Working Within a Relationship
Successful communication involves not just the transmission of technical
expertise but interpersonal skills as well. A relationship, even if it lasts
no more than a few minutes, lies at the heart of informing. The other
two tools, asking and listening, are also needed to maintain working
rapport with the patient, whose concerns, aspirations, and confusions
express themselves in the consultation in many forms and affect your
progress. “Information provision” is an inadequate description of what
actually happens in practice. “Information
exchange” is a more accurate
phrase; you become immersed
in improving your understanding,
improving the patient’s understanding,
and reaching agreement about the issue at hand. This is a two-way
process.
Here are a few practical guidelines for improving information ex-
change.
Slow Down, and Progress Can Be Quicker
The more hurried you feel, the less likely it is that you will be able to understand
and respond to the challenges posed by patients. A common
and understandable tendency is to hit “automatic pilot” and simply do
the basics, giving patients the information
that you feel it is your duty
to provide. However, if you slow
down a little and create the opportunity
for both of you to be reflective,
you will find the small silences
very useful for giving the patient
space and for giving yourself the
time to make good judgments about the best way to get information
across.
88 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
A relationship, even if it lasts no
more than a few minutes, lies at the
heart of informing.
“Information provision” is an
inadequate description of what
actually happens in practice.
“Information exchange” is a
more accurate phrase.
Better judgments can save time. Your questions and carefully chosen
bits of information develop a quality of gravitas that patients pay attention
to. One of us (Rollnick) attended an outpatient appointment
with a worried spouse, in which the obstetrician conducted an examination
and dealt with all of our concerns and questions in an apparently
seamless consultation that lasted a matter of 10 minutes. It felt as
though he had spent a much longer period of time with us. His manner
was slow and thoughtful. A colleague once described this approach as
being like a duck or swan gliding peacefully across the water, with legs
nevertheless working hard under the surface. Skillful informing lay at
the heart of the obstetrician’s repertoire.
It’s a Person, Not an Information Receptacle
This principle is so easily overlooked in the rushed world of everyday
practice that it’s worth the risk of stating the obvious. Well-intentioned
efforts to “get through” and “make them understand” so that information
“sinks in” often create the unfortunate impression of the patient as
a passive recipient of information. The considerable skillfulness of practitioners
who provide information closely tailored to the patient’s personal
needs often goes unappreciated.
Consider the Broader Priorities of the Patient
Inevitably, your concern is with your area of expertise, but the patient’s
priorities are much broader. He or she has to integrate the information
and apply it to everyday life. What may be straightforward information
to you can be much more for the patient. Simply conveying your acceptance
of this reality can make a substantial difference to the outcome.
How does the information that you are providing fit in with the patient’s
life and perspective?
Positive Messages Matter
Often in health care information can be divided into good news and
not-so-good news. For example, when you are informing a patient of a
new diagnosis, there will likely be a mix of troubling information with
some positive messages. How do you strike the balance between the
two? Some practitioners are concerned that providing positive
messages might “gloss over the hard facts” and compromise frankness.
Including truthful positive messages, however, can actually increase
a patient’s receptiveness to hard facts. Consider the difference be-
tween:
Informing 89
“If you continue to smoke, breathing is only going to become more
difficult.”
and
“If you stop smoking, you may find that breathing is easier.”
Consider the Amount of Information
People vary widely in their desire for information. When facing a surgical
procedure, some patients want great detail about what will be done.
They want to know exactly what to expect, and having more information
decreases their distress. Some practices maintain a video library
showing common procedures and lend these to patients who want this
level of detail. Other patients prefer to know as little detail as possible,
and having more information frightens them. It makes sense, then, to
ask patients their preferences about being informed. On a particular
topic, how much do they already know? What would they like to know,
and in what detail? Whether to withhold or provide information is not a
decision to make by yourself. Find out your patient’s wishes.
Deliver Information with Care
Give the message in an accessible way. If the medium of the instruction is
the spoken word, make sure the words are understandable to the patient.
Avoid the abbreviations much loved by health care practitioners.
Avoid technical terms when possible, and, when not possible, check as to
whether your patient knows their meaning. Avoid words your patient
may consider “infantile.” If you use written material, it should be appropriate
to the patients’ educational level, vision, time, and anxiety state.
Sometimes verbal instruction is best; sometimes a combination of
media will be best. A leaflet, a website, and a book, for example, may
complement an initial verbal instruction. Some patients may value the
opportunity to tape-record your instructions. Check with the patient
about what medium or combination of media best suits him or her.
Always use informing in combination with asking and listening.
Check: Are the messages being received by your patients? Have they
heard you? Have they understood what you are trying to convey? How
is the pace of information delivery suiting your patients? A simple question
such as “How are we doing so far?” will often help you to decide
how best to proceed.
Directing with Care
A directing style can be used in routine practice to exchange information
to very good effect. This involves more than just being pleasant and
90 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
clear, and the countless examples of
good practice observable in busy
consulting rooms bear witness to
this fact. It involves attentiveness
and skillful responding to both your
mood and needs and those of the
patient.
INFORMING WITHIN MI
MI is based on a guiding style, and a competent guide provides good information
but does it in a particular way. This section offers some specific
guidelines on how to inform within MI.
Ask Permission
Providing information with permission from the patient is fundamental
to the use of a guiding style. Informing is most likely to go wrong and
elicit resistance when the patient is unready or unwilling to receive it.
Within the principle of respecting patient autonomy (Chapter 2), the
practitioner informs or advises only when he or she has permission to do
so. There are three ways to obtain such permission.
The first and simplest form of permission involves your patient asking
you for information or advice. Here the patient has opened the door
for you. Sometimes we are still a bit cautious under this circumstance
and first ask what the patient already knows (information) or what ideas
the patient may have for how to proceed (advice). In general, though, it
is fine to inform when the patient asks you to do so.
A second way is to ask for permission to inform. This is analogous
to knocking on the door before you enter. Before you charge into informing
or advising, ask if that would be all right with the patient.
“Would you like to know some things that other patients have
done?”
“Would it be all right if I tell you one concern I have about this
plan?”
“There are several things that you can do to keep the level of sugar
in your blood under control. Do you want to hear them, or are
there other things that we should talk about first?”
“May I make a suggestion?”
Asking for permission in this way has several good effects. First, it directly
honors and reinforces patients’ autonomy and active involvement
Informing 91
Skillful informing is more than just
being pleasant and clear. It involves
attentiveness and skillful responding
to both your mood and needs and
those of the patient.
in their own health care. It emphasizes the collaborative nature of your
relationship. It also lowers resistance. Asking permission to offer information
or advice often makes the
patient more willing to hear it. Furthermore,
it can give you important
information. If there is something
much more pressing on the patient’s
mind, you’re likely to find out
about it.
In most situations, these first
two ways of getting permission will
suffice. That leaves the less common
situation in which you feel impelled
to give information and advice and are not be willing to accept a “no”
answer when you ask for permission. There are several things you can
do in this case:
• Announcing. One good option is simply to tell the truth. “There
is something that I need to tell you here.”
• First choice. Another possibility is to ask the patient whether you
should do this now or whether there is something else that he or she
wants to talk about first. This implies that sooner or later you are going
to do the informing or advising, but it still gives the patient some latitude
about when it happens.
• Prefacing. Another good option is to preface the informing or advising
with a comment that directly acknowledges the patient’s autonomy.
Telling them that they are free to disregard what you are about to
say somehow makes them more willing to hear it.
“I don’t know if this will make sense to you or not . . .
“This may or may not concern you, but . . . ”
“You can tell me what you think of this idea . . . ”
Obviously these three components can be used in combination:
“I have a concern about your plan that you may or may not share,
but I feel like I need to express it. Would it be all right if I explained
it now, or is there something else that you want to ask about
first?”
Obtaining the patient’s permission in one of these three ways is a
fundamental element when informing within MI.
92 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Asking for permission has several
good effects. It directly honors and
reinforces patients’ autonomy and
active involvement in their own
health care. It emphasizes the
collaborative nature of your
relationship. It also lowers
resistance.
Offer Choices
When informing, offer choices when possible. This supports patient autonomy.
For example, a rock-climbing guide, committed to helping people
learn by making their own judgments, might say: “If you look above
you to the left, you will see that pointed rock, which could be unstable.
One option is to reach up and try it. Another is to move over to your
right, where you can stretch across to that ledge. Which move makes
more sense to you?” Expert information is used to help the person make
an informed choice. That’s what we mean by informing in the service of
guiding. You stop short of telling someone what to do; instead, you provide
useful, well-tailored choices.
“It’s a common fear that exercise might actually cause another heart
attack. If you do this gently, there’s no evidence at all that this is
harmful. It’s a question of what will suit you. Some of our patients
walk longer distances each day, some use a machine at home, others
come down here to use our machines. It’s your choice. I wonder what
would make sense to you right now, or is this all a bit too much too
soon?”
This illustrates a broader guideline about offering choices within
MI. When you discuss options, offer several simultaneously. There is an
obvious trap in discussing choices
one at a time. You present one possibility,
and the patient tells you
what is wrong with it. So then you
raise another option, and the patient
tells you why that one won’t work. Suddenly you are back in the
persuasion trap in which you argue for change and the patient argues
against it. Instead, offer a variety of options, and ask the person to
choose among them. “Pick a card, any card” creates a different mindset
from, “What do you think about this possibility?”
Talk about What Others Do
When giving information, particularly if it contains implications for action,
consider the value of talking about how this has affected other patients,
and avoid suggesting what the patient should do. This is an example
of avoiding the righting reflex. Patients then have the freedom to say
what might work for them, usually in the form of change talk. This
leaves you in a position of neutrality. In other words, you provide, and
the patient interprets. For example, there’s a difference between:
Informing 93
When you discuss options, offer
several simultaneously.
“You clearly need to cut down on
your intake of fatty foods, and
stopping smoking is a top priority
as well.”
and
“Some patients in your situation reduce
their intake of fatty foods,
others tackle their smoking. I
wonder what makes sense to
you? . . . ”
Two Strategies for Informing
Chunk–Check–Chunk
A common exhortation in the teaching of students in health care is to
use the “chunk–check–chunk” approach to providing information to patients.
You provide a chunk of information, check patient understanding,
provide another chunk, and so on. Its value lies in respectful checking
to see that the patient has
understood before moving on to the
next chunk of information. It is
used most often in the service of a
directing style, in which the “check”
phase is used merely to ensure that
the patient has understood the information,
which is appropriate in
many circumstances. When it comes
to behavior change and the use of a
guiding style, the “check” step involves a bit more than asking, “Got
it?” Rather, you stop to ask for the patient’s perspective. What does the
patient think about this chunk? Is there any part of it that the patient did
not understand or would like to ask about further?
PRACTITIONER: So it does look like you have some nerve damage in
your feet, and there are some things you might want to do to protect
your feet. I recommend that you not walk around barefoot, but
wear slippers, even at home. Be careful about hot water. Use padded
socks, and examine your feet once a day to look for any cuts, blisters,
or other injuries. Use a mirror if you need to in order to see the
soles of your feet. [chunk] That’s quite a few recommendations from
me! Do they make sense to you? [check]
PATIENT: Yes, I think so.
94 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Avoid the righting reflex by
talking about how the
information has affected other
patients, and avoid suggesting
what the patient should do.
This leaves you in a position
of neutrality. In other words,
you provide, and the patient
interprets.
The chunk–check–chunk approach
is most commonly used in the
service of a directing style, quite
appropriately in many
circumstances. However, it can be
adapted for use in the service of a
guiding style to talk about behavior
change.
PRACTITIONER: Is there anything in this you want to ask me about?
[checking further]
PATIENT: Well, you said to be careful about hot water. Do you mean that
I shouldn’t take a warm bath? Is hot water somehow bad for my
feet?
PRACTITIONER: Thanks for asking. No, it’s not that warm water is bad
for you. The danger is that sometimes people use their feet to test
the temperature of water in a bath. That can be a problem. I see patients
with diabetes who have burned their feet badly before realizing
that the water was too hot. The feet become insensitive, and people
get burned before they realize it. [chunk] Does that make sense?
[check]
PATIENT: Oh, I see. It’s just to make sure I don’t burn my feet without realizing
it. OK, I’ll be careful. I guess I’ll use my hand or something.
PRACTITIONER: Good! Now if you happen to find any cut, blister, or
other wound on your feet, or if you have any other concerns about
your feet, please come in to see me right away. [chunk] Will you do
that? [check]
PATIENT: Yes. I don’t want to have problems with my feet, so I need to
check them daily and let you know if I see anything.
PRACTITIONER: Right. Very good. And are you OK with the padded
socks idea? [check]
This rhythm of asking for patients’ responses in between chunks is
good for several reasons. First, it continues to actively engage patients in
their own care, even when you are informing. It communicates patience
and respect. It also helps you detect and correct misunderstandings that
you might otherwise miss. Too often the information-giving process in
health care goes primarily in one direction, from the practitioner to the
patient. The patient is rendered a passive recipient, which makes it easy
to overlook miscommunication and inhibits the exploration and expression
of motivation to change. Chunk–check–chunk can turn the informing
process into a conversation rather than a lecture, at least when
“check” means a genuine checking in for the patient’s understanding
and perspectives.
Elicit–Provide–Elicit
This phrase provides a different guideline for information exchange that
is more congruent with the principles of MI. It places considerable value
on drawing from the patients what they need and want to know and,
Informing 95
critically, what new information means to them. This again emphasizes
patients’ active involvement in their own health care and is intended to
enhance motivation for behavior change. Elicit–provide–elicit (EPE) is
not meant to be a linear sequence of steps but rather a cyclical process of
guiding through information exchange. Although it revolves around informing,
EPE also requires both asking (often open questions) and lis-
tening.
In EPE, the information exchange begins with you asking patients
an open question to focus your informing. We suggest two general forms
of this eliciting question. The first is to ask, “What would you most like
to know about ?” Here you invite the patient to tell you what
seems most important to know from his or her own perspective. A second
form is to ask, “What do you already know about ?” This
latter form has several advantages. It can save you time and prevent you
from lecturing patients about what they already know. It allows you to
correct misconceptions that you might otherwise overlook. Furthermore,
having the patient voice this knowledge often serves as a form of change
talk by at least implicitly stating the need for health behavior change and
the consequences of not doing so.
The second part of the EPE cycle—provide—involves providing information
in a manageable chunk. If you have asked what the patient
would like to know, you already have permission to inform. The second
opening question—what the patient
already knows—also often leads to
a request for you to inform, but if
there’s any doubt you can simply
ask permission: “Would you like for
me to tell you a bit about . . . ?” Focus
initially on information more
than your own interpretation of
what it means for this patient. You may talk about other patients’ experience
as part of this information-providing step.
The third part of EPE is again to ask an open question to elicit the
patient’s response to the chunk of information you just provided. Some
possibilities are:
“What do you make of that?”
“What does this mean for you?”
“What more would you like to know?”
The difference between using a directing style and the elicit–
provide–elicit framework is in your attitude. Often in chunk–check–
chunk, the mindset is that there is a certain amount of information that
96 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
Focus initially on information more
than your own interpretation of
what it means for this patient. You
may talk about other patients’
experience as part of this
information-providing step.
you, the expert, want to provide to the patient. The “check” questions
are mostly to make sure that the patient is getting what you say. You
give the information, and the patient’s job is to understand it.
EPE involves a more collaborative mindset that is appropriate when
the topic is health behavior change. The question in your mind is not so
much how to get information across as how to help the patient make
sense of it and make good decisions about behavior and stick to them.
To do this, you find out about the patient’s own concerns, current
knowledge base, and interests in
knowing more. One way of striking
this balance is to remember the following:
You have considerable expertise
in what has been good for
other patients in similar circumstances;
your patients, on the other
hand, are usually more expert about
what works best for them. Keeping this in mind can be very helpful. Fill
in the information gaps and see what the patient makes of it all.
One of the very first applications of MI involved using exactly this
EPE approach. We advertised the availability of a “free checkup for
drinkers who wonder whether alcohol is harming them in any way.” The
announcement made it clear that this was not a treatment program and
that the person was free to decide what, if anything, to do about the personal
health information provided. A surprising number of people responded,
seeking this “drinker’s checkup,” which included a variety of
measures of physiological and psychological functions that tend to be affected
earlier by heavy drinking. A counselor then met just once with the
patient to present the findings of the checkup, comparing the person’s
own scores with normal ranges. Instead of giving advice and concluding
what the patient should do, the counselor asked for the person’s own interpretation
of the findings, filling in any further information requested.
Virtually all of those who responded were heavy drinkers and were already
experiencing harmful consequences. In randomized trials, patients
who received the drinker’s checkup showed significant reductions in
drinking without further intervention relative to those assigned to a
waiting list for the checkup. It also
mattered how the counselor presented
the feedback. Within an empathic
EPE style, patients voiced
about twice as much change talk
and half as much resistance relative to a more directing and confronting
style. In fact, the more the counselor confronted, the more the client was
drinking at follow-up.
Informing 97
You have considerable expertise in
what has been good for other
patients in similar circumstances;
your patients, on the other hand,
are usually more expert about what
works best for them.
You provide and the patient
interprets.
One useful guideline is to consider the difference between a “teachable
moment” and a “learning opportunity.” The former is often driven
by an insertion approach to information giving, whereas the latter characterizes
many of the qualities embedded in the EPE framework.
Beware the Righting Reflex
Again, it is wise to tame your righting reflex when informing. Some
practitioners believe that if someone is sufficiently scared, he might
change or take greater notice of the information provided. However, fear
is a complex motivation, and scare tactics can backfire. A common response
to fear is to become defensive and shut down, as illustrated by
some patients whose response to bad news about their health is to have
a drink or light up a cigarette at the first opportunity. One patient we interviewed
told us, “Every time I go in there, he tells me that smoking is
bad for me, as if he’s telling me some new breathtaking secret, yet I see
the health warning on the packet every time I light up.” There is very little
evidence for the belief that people will change if you can just make
them feel bad (scared, ashamed, humiliated) enough. To the contrary, it
is the supportive, compassionate, empathic practitioner who is most effective
in inspiring behavior change.
Another pitfall of the righting reflex is premature focus. It can put
the patient off when you rush in with your perspective or solution:
“You’ve got to take a proton pump
inhibitor to really get on top of your
gastric reflux.” Some problems may
not be major problems from the
viewpoint of a practitioner, but they
are for a patient, and vice versa. In
many situations, the best solutions
come from the patients, not from
practitioners rushing in to solve the
problem: “Well, actually, I don’t
like taking medicine, and I’ve already
started losing weight, and my reflux is already much improved,
thank you!”
PRACTICAL EXAMPLES
Here are a few examples from everyday practice. The chunk–check–
chunk approach is used in the service of a directing style, to highlight its
98 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
There is very little evidence for the
belief that people will change if you
can just make them feel bad
(scared, ashamed, humiliated)
enough. To the contrary, it is the
supportive, compassionate,
empathic practitioner who is most
effective in inspiring behavior
change.
vulnerability to the righting reflex when talking about behavior change,
and to provide a strong contrast with the EPE approach.
Promoting Adherence
Research on medication adherence has pinpointed the importance of
clear communication about medicine use and the need to consider the
patient’s concerns. This is particularly challenging when you are pressed
for time, knowing that you have little control over forces outside the
consultation that influence adherence, such as cultural values, social
conditions, personal habits, memory, and so on. The EPE framework is
intended to enhance your ability to absorb and respond constructively to
these challenges. The hypothesis is that adherence will be improved, because
a guiding style and the use of this framework elicit the patient’s
own motivations to address these problems.
Here is an example that illustrates the contrast between the chunk–
check–chunk approach used in the service of a directing style and the
EPE strategy used in the service of a guiding style.
Chunk–Check–Chunk
Practitioner: Nurse, counselor, doctor, pharmacist, or patient advo-
cate.
Setting: Treatment for HIV/AIDS.
PRACTITIONER: It’s very important for your health that you take the
medicines properly. [chunk] Have you been taking them properly?
[check; closed question]
PATIENT: Yes, well, it’s difficult to take everything at the right time, and I
am starting to feel a bit better, so that’s good.
PRACTITIONER: You know that you need to take them every day, at exactly
the right time, and you must not miss any, even if you are feeling
better [chunk]. How often are you taking the medicines? [check;
closed question]
PATIENT: Yes, but it’s hard, you see. If my mother sees me taking them,
then she will figure out what’s going on, and that will bring bad
things for me. She doesn’t know, you see.
PRACTITIONER: Maybe you could go into the bathroom to take them.
[chunk]
PATIENT: Yes, but I also have the baby, and it gets very busy to do everything
just at the right time.
Informing 99
PRACTITIONER: How often have you been missing your medications?
[check; closed question]
Comment: The righting reflex has its limitations, despite the well-intentioned
efforts of a concerned practitioner. Indeed, the more concerned
you feel, the easier it is to fall into this trap. With a shift in style, the
chunk–check–chunk approach could be adapted constructively for use in
this kind of consultation. In this next example, we illustrate the use of
the EPE strategy.
Elicit–Provide–Elicit
Practicer and setting: Same as above.
PRACTITIONER: How are you feeling about the medicines you are taking?
[elicit; open question]
PATIENT: I take them like you told me to.
PRACTITIONER: Many people in your situation find it hard to take them
all at the right time. [provide; what others do] What’s the best way
for you to take them? How do you do it? [elicit; open question]
PATIENT: I try to take them like you said, but it’s not so easy, with my
mother around all the time. She doesn’t know, you see.
PRACTITIONER: It must be hard for you to keep this secret and take your
medicine at the right time. [listening]
PATIENT: That’s right. I can’t tell her now. Is it a big problem if I miss
some of the tablets?
PRACTITIONER: Actually, that is a problem. For these medicines to work,
people have to keep taking them faithfully, and it’s important to take
them right on time. [provide after permission-granting question from
the patient] Does that make sense to you? [elicit; open question]
PATIENT: So you say that even if I feel better I should take the medicines
all the time?
PRACTITIONER: That’s right, it’s very important to take them faithfully
even if you start to feel better. [provide] What’s going to be the best
way for you to do that? [elicit; open question]
PATIENT: It’s my mother always looking at me, and if I tell her I’ve got
HIV it will be bad. She might even kick me out, or try to take away
my baby.
PRACTITIONER: You don’t feel ready to tell her about this. [listening; reflecting
resistance]
100 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
PATIENT: No, not now. Maybe later, but I don’t feel strong enough.
PRACTITIONER: I wonder how you can manage, then, to take your medications
as you need to? [elicit change talk]
PATIENT: One thing I do is go in my bedroom and close the door when
it’s time for my medicine. [change talk]
PRACTITIONER: That sounds like a possibility. Can I tell you what some
mothers do? [asking permission to provide; talk about what others
do]
Comment: The second example did indeed take a little longer, perhaps a
minute more. However, this does not need to become a protracted counseling
process. Most patients understand that you are busy. After a few
minutes of eliciting and providing, you can usually summarize what they
have said and shift to another topic or issue. In this case, it might have to
be the difficult matter of disclosure of HIV status.
Sharing Test Results
Another example of using the EPE framework is in informing patients
about test results. Opportunities for discussing test results exist across
the board in both acute care and long-term-condition management.
These often have implications for medicine use, adherence, and health
behavior change. In Chapter 2 we described the case of Stefan, a 14year-old
boy who attends the diabetes clinic to receive the news of his
blood test result from a practitioner who feels strongly, and with genuine
concern, that this information could have a bearing on his future wellbeing
and health. A chunk–check–chunk approach used in the service of
a directing style often restricts attention only to that which is of interest
to the practitioner. The patient usually senses this and responds accordingly.
Stefan’s experience of the contrasting approaches is illustrated here.
Chunk–Check–Chunk
Practitioner: Doctor or nurse.
Setting: Treatment for diabetes.
Challenge: The practitioner feels strongly that the test result has important
implications for health.
PRACTITIONER: [after some preliminary friendly everyday conversation]
Now, Stefan, I’d like to move on to the blood test results, if I may,
which have just come in from the lab. I know we have been through
this before, but it’s important to keep an eye on these to see how
you’re doing. [chunk] Is that OK with you? [check]
Informing 101
PATIENT: Yes, OK.
PRACTITIONER: Well it’s 11.5 today, so that’s a rise from last time I
saw you. Let me see, that was 3 months ago, and then it was 9.2,
so that’s quite a big increase. [chunk] Do you understand?
[check]
PATIENT: Yeah.
PRACTITIONER: Now we need to talk about what we can do about this,
because we don’t want to see you back here in the hospital when
you’re older with all sorts of problems. I mean, it’s not that I don’t
like seeing you (laughs), but you know what I mean, this result tells
us that all is not well with your diabetes. [chunk] Do you see what I
mean? [check]
PATIENT: Yeah, well, you know, I do try, like, I do take my injections like
you tell me.
PRACTITIONER: What’s most important is that you really get on top of
monitoring your sugars and giving yourself the insulin exactly like
we agreed, four times a day. Last time we agreed we would go for
tight control because this will give you the best chance of avoiding
problems later on, with your eyes and other organs. [chunk]
PATIENT: Yes, I see, I do try my best.
PRACTITIONER: Well, it’s a bit of a problem. This test result is up from
the last time I saw you. [chunk] Do you understand what that
means? [check]
PATIENT: Yea, sometimes that happens, I guess, but I am trying.
Comment: In this example, a clearly concerned practitioner, pressed for
time, sacrificed a few minutes of listening and rapport building at the
outset (a following style) for the immediate use of an installation approach
to informing. The righting reflex prevailed, however, and the patient
closed right down in the face of a meeting that felt a bit like a visit
to the school principal’s office. Chunk–check–chunk can be used to
greater effect with more listening in the “check” phase. The EPE sequence
is often more rewarding.
Elicit–Provide–Elicit
Practitioner and setting: Same as above.
PRACTITIONER: [after some preliminary following of the patient’s account
of his everyday life] I’d like to talk about the blood test result,
102 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
but we can first talk about any aspect of your life and diabetes.
School, home, how are things going? [brief agenda setting]
PATIENT: OK. I get by, but I get embarrassed at school, like if I have to
ask the soccer coach to leave to go get something to eat.
PRACTITIONER: I remember you like your soccer. So this is embarrassing
for you. [listening]
PATIENT: It’s OK, most of my friends understand, but the coach, he
makes a thing of it.
PRACTITIONER: He makes you feel abnormal and stand out. [listening]
PATIENT: Yeah. So I try to keep going without doing anything about it.
PRACTITIONER: And that’s not always easy. [listening]
PATIENT: Most of the time it’s OK, but sometimes I just have to stop,
and he makes a big deal of it and embarrasses me.
PRACTITIONER: Would it be helpful for me to have a talk with this
teacher, or would you prefer to handle this on your own?
PATIENT: No, I’ll handle it.
PRACTITIONER: Well, then, what would you like to know about the
blood results? [elicit]
PATIENT: Not much, because I knew it was going to be high today.
PRACTITIONER: You were a little nervous about this one. [listening]
PATIENT: Yeah. (Laughs nervously.)
PRACTITIONER: What would you guess the number is, if it was 9.2 last
time?
PATIENT: 10?
PRACTITIONER: A little higher!
PATIENT: That bad?
PRACTITIONER: 11.5. It’s quite a bit higher than usual. You had been doing
quite well in trying for tight control. A useful idea for some
young people is to think of just a few small things that are manageable
in helping them achieve tighter control. [provide]
PATIENT: Oh.
PRACTITIONER: You’re not too shocked about this. What sense do you
make of it? [elicit]
PATIENT: I haven’t been eating right, and I haven’t been monitoring my
sugars very often. I hate doing it, I hate going off to the toilet in
school to do the monitoring.
Informing 103
PRACTITIONER: You try to cope with the diabetes, and you want to feel
normal. [listening]
PATIENT: Yeah, I know, its hard, I’m not doing very well, and my eating
is not right.
PRACTITIONER: You know that you haven’t been taking good enough
care of yourself. [listening] How can I help? [elicit]
PATIENT: What do you think . . . ?
Comment: With the patient’s concerns center stage, the practitioner now
has an opportunity to guide him to find ways of managing without
standing out among his peers. There may not be easy solutions here, but
the service being offered to the boy is at least attuned to his needs. Information
provision was a central part of that process.
What Does This Information Mean for Me?
Sometimes patients feel sufficiently provided with information itself but
are less clear about its personal implications. This is where your ability
to elicit their own thinking about the information is critical, and this can
be done in just a minute or two. The guideline to follow is this: You provide
the information, and you encourage the patient to interpret it:
Practitioner: Doctor or nurse
Setting: Primary care, a cholesterol result
Challenge: Simple solutions in the mind of the practitioner appear
more difficult for the patient. How do you elicit decisions about
behavior change in a brief consultation?
PRACTITIONER: Well, Mr. Brazier, the cholesterol test is back, and it is
still slightly raised. Just so I don’t concentrate on the wrong stuff, I
wonder if I could ask you what you already know about raised cholesterol
and what you would like to know? Are you happy to discuss
this now? [elicit] Or would it be better if I gave you something to
read in the meanwhile and we discussed things, perhaps together
with your wife, next time?
PATIENT: No, I’m fine to talk now. Actually I know a quite a bit about
cholesterol already. My brother, as it turns out, had a test, and his
cholesterol was raised a bit, so we looked on the Internet together.
PRACTITIONER: You understand about the problems with high cholesterol.
So what do you think this test result means for you? [elicit]
PATIENT: Well, I’m not really sure what’s best to do about it.
104 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
PRACTITIONER: What is confusing you about this? [elicit]
PATIENT: OK, it’s raised, but how do I get it down, without stopping
smoking or changing my diet, or have I got this wrong?
PRACTITIONER: No, you’ve got it right, those kinds of changes can make
a big difference. [provide]
PATIENT: But I am worried about what effect quitting smoking may have
on my diet.
PRACTITIONER: So you are worried that quitting smoking might increase
your weight and be bad for you [listening].
PATIENT: Yes, that’s it. My weight shot up when I quit last year. Is it
better to quit smoking even if I pick up a bit of weight, or should I
just focus on my eating for now and leave the smoking for later?
PRACTITIONER: Well, on average, the biggest risk by far for most people
of having a stroke or heart attack, especially when they have raised
cholesterol, is smoking. Smokers who have raised cholesterol, even
if they are eating well, have a greatly increased risk of having a heart
attack or stroke. [provide] So what do you make of this? [elicit]
PATIENT: Well, I guess I kind of knew that while diet is important, overall,
smoking is probably worse than the eating, and even if I gain
some, if I crack the smoking, overall, I will be better off. To be honest,
I have been worried about my smoking for a while now. My dad
died of a heart attack. OK, he was old, but now with my brother
also having raised cholesterol and now me. . . .
PRACTITIONER: I can tell you how other patients like you have stopped
smoking, and what might help. Would that be of interest?
PATIENT: OK, I guess so.
Comment: By going back and forth between eliciting and providing, the
practitioner moves the discussion along toward behavior change while
taking into account the patient’s concerns.
Messages of Hope in 60 Seconds*
In the course of everyday practice, there is often much to discuss with a
patient, and you do not want to completely neglect the topic of behavior
change. In Chapter 1 we mentioned four core principles of MI, the last
of which is to support optimism and hope for change. Even when a paInforming
105
* We thank Drs. Gary Rose and Chris Dunn for helping us construct this dialogue.
tient is not ready to change, simply talking about what he or she could
do to make a difference can help. You are planting a seed of hope.
Practitioner: Doctor or nurse.
Setting: Primary care.
Challenge: Depression and lifestyle change: A man who lives alone
and works in a job he describes as unbearable presents in primary
care with low mood. He agrees to medication and returns for a
follow-up appointment. You discuss his situation, and because he
is also obese, you decide to provide advice in 60 seconds about
lifestyle change while still using a guiding style.
PRACTITIONER: You were talking about feeling low in energy, and I am
wondering if I could briefly ask you about your diet and exercise.
[elicit]
PATIENT: OK.
PRACTITIONER: Little changes, little new habits in either of these things
will help with mood, and they would also help reduce your weight,
which is a concern for me. [provide] These things are all linked, if
you see what I mean.
PATIENT: Yes, I do see.
PRACTITIONER: This is really your choice, and I hope you don’t mind my
raising it. I’m wondering, how do you really feel about this? [elicit]
PATIENT: I know what you are saying, but I don’t know, really, it’s all I
can do to get out of bed on time and make it through the day.
PRACTITIONER: It takes a lot of your energy just to get through the day.
In fact, you don’t feel like you have lots of choices. [listening]
PATIENT: Yeah, I mean the effort to do all these things. . . . I can’t see
myself changing. . . .
PRACTITIONER: You wish you had more energy, but you don’t. [listen-
ing]
PATIENT: That’s exactly right.
PRACTITIONER: There might well be some things you could do to feel
better and have more energy, but you will know when the right time
is to try them. You’ve agreed to come back and see me, and for now,
you’re not sure how to make changes in diet and exercise. I don’t
want you to feel guilty about not making any changes. We’ve got
time, and perhaps you can just think about what small changes
106 CORE SKILLS OF MOTIVATIONAL INTERVIEWING
might make sense to you. We can talk more about this next time,
and I’ll do whatever I can to help you get through this difficult time.
PATIENT: Thank you very much.
Comment: If you were to take a few more minutes, you could evoke and
explore further some of the patient’s own motivations to improve diet
and exercise, but even planting the seed is helpful.
WITHIN YOUR GRASP
A great deal of modern health care focuses on providing patients with
information, and it often does so in a way that fails to evoke behavior
change. The search is on for new media aids and technologies to convey
information to patients more effectively and efficiently. Meanwhile, an
answer may be right there within your grasp—to mix skillful informing
with listening and asking for the patient’s own perspectives. You have
the potential to shift style from directing to guiding when appropriate.
This requires a shift away from feeling responsible for the patients’
changing behavior and toward helping them realize (and verbalize) their
own reasons and means for change. The prescription that “You have to
make these changes” is an empty one, for, in fact, patients do not have to
do what they are told. They make choices. Informing from your expertise
is still an important part of MI, from which you help patients ask
themselves, “What does this information mean for me? What changes
should I and can I make?“ Seen in this light, informing can be a powerful
tool indeed. The more active the patient is in this discussion, the
better.
CONCLUSION
This chapter has described the rationale for using information close to
the heart of good practice in MI. The elicit–provide–elicit framework
has been presented as one way of conducting the discussion so that the
patient is an active participant in making decisions about behavior
change. In Part III we turn to the integration of these skills in motivational
interviewing (Chapters 7–9) and conclude with attention to how
the method might fit into the broader service you deliver to patients
(Chapter 10).
Informing 107
PART III
PUTTING IT ALL TOGETHER
PUTTING IT ALL TOGETHERIntegrating the Skills
CHAPTER 7
Integrating the Skills
We have discussed how communication skills that you commonly use in
ordinary practice—asking, listening, and informing—can be applied to
guiding patients toward behavior change. We have also discussed how
the righting reflex and the directing style, appropriate in so many situations,
can backfire when you would like a patient to consider behavior
change. A switch to a guiding style allows you to explore the patient’s
own motivations for health behavior change and encourages the patient
to voice them to you. This need not take a long time; it is just a different
and often more effective method of communicating when the challenge
is to encourage behavior change.
Within MI, a specialized use of the guiding style, you set an agenda
and then ask about particular things (Chapter 4), namely, the patient’s
own desire, ability, reasons, and
need (DARN) to make a change,
such as stopping smoking. Instead
of asking patients why they have
not stopped smoking, you are interested
in why they might want to,
how they would do it, what their
reasons would be, and how important
it is to them.
Each such question is followed by listening, by reflecting back in
somewhat different words what the person has told you and perhaps anticipating
what may lie beneath the surface of what you have heard
(“continuing the paragraph”; see Chapter 5). You are listening in partic-
111
In MI, ask about the patients’ own
desire, ability, reasons, and need
(DARN); ask why they might want
to change, how they would do it,
what their reasons are, and how
important it is to them.
ular for the “flowers,” the patient’s own DARN statements. Each time
you hear one, you tuck it away in memory, and then you offer them back
to the person in a “bouquet” summary (Chapter 5). You will also still be
using informing but probably less than is accustomed practice. In the
style of a guide, informing is done with permission and by helping the
patient to express what the information means for him or her (Chapter
6).
CREATIVE COMBINATIONS
No one works purely with one communication skill. Consultation involves
moving back and forth flexibly among asking, listening, and informing.
Consider the following combinations of the three core skills.
The aim here is not to suggest that these combinations are guidelines for
structuring the consultation; rather, it is simply to encourage you to recognize
different patterns of skills usage.
Informing and Asking
Practitioner: Nurse, doctor, counselor.
Setting: Trauma.
Challenge: To encourage the patient, a young woman, to consider
the role played by alcohol in a car accident.
PRACTITIONER: [at the bedside of a young woman] We’ve got you stabilized
now, Heather, but you’re going to be in this specialized unit for
a day or two, and then probably in the hospital for a few more days
after that until it’s safe for you to go home. [informing] So tell me
what happened that led to the crash? [asking]
PATIENT: I don’t remember the accident itself. I just woke up here in this
bed with my legs up like this. I remember getting into the car,
though. We were at a party, out meeting guys, and by the time we
headed home it was after midnight. I hadn’t had too much to drink,
just two or three beers all night, but I know Lisa had a lot more. I
should have been the one driving (crying).
PRACTITIONER: You were both badly hurt, but your injuries are worse.
We sent Lisa home, and she’s going to be all right. You have some
internal injuries, though, and your legs are both broken in several
places, so you’ll be on crutches for a couple of months at least after
we get you home. [informing] Is there anything I can do for you?
How is your pain? [asking]
112 PUTTING IT ALL TOGETHER
PATIENT: I’m all right—I feel pretty drugged up. Just get me out of
here.
PRACTITIONER: We’ll get you home as soon as we can. I see this a lot,
you know—people riding with someone who shouldn’t be driving.
[informing]
PATIENT: Yeah. Lisa shouldn’t have been driving.
PRACTITIONER: Did you realize that at the time, when you got in the car
with her? [asking]
PATIENT: I kind of knew. She drank a lot more than I did.
PRACTITIONER: I’m worried about you. Not just because of your injuries.
They could have been a lot worse. But of all the people who
come in here, how many would you guess are back within a year, injured
again? [asking, implicit permission to inform]
PATIENT: I don’t know. Not very many, I would think.
PRACTITIONER: About one out of four we see here again in this trauma
center within 1 year. [informing]
PATIENT: Wow! Really! Why?
PRACTITIONER: People who drink and drive also tend to take other
risks, but the biggest risk is that they get in another crash. And it’s
not just the drinking drivers. Like you, those who ride with drinking
drivers, even if they were sober themselves, wind up back here at the
same rate as the drivers. [informing] What sense do you make of
that? [asking]
PATIENT: I can see it, really. It could just as well have been me. I’ve been
drinking plenty of nights before driving home.
Asking and Listening
This conversation with Heather continues, with the trauma surgeon now
intermixing asking and listening. Remember that listening, as discussed
in Chapter 5, is not a passive process but one in which the listener actively
reflects back what the person has said. Notice also that this reflecting
process is not limited to what the patient has actually said; good listening
statements may continue the paragraph or make a guess about
unspoken meaning.
PRACTITIONER: Tell me a little more about that. [asking; open question]
PATIENT: Well, last night—it was last night, wasn’t it?—I just didn’t feel
like drinking much, so I only had a few brews.
Integrating the Skills 113
PRACTITIONER: Just two or three beers, because you weren’t feeling
well. [listening, and a guess]
PATIENT: I didn’t feel bad, like sick or anything. I was just bummed out.
PRACTITIONER: About what? [asking; open question]
PATIENT: About my friend. He’s in trouble because I called the police on
him. He was hurting me.
PRACTITIONER: Beating you up. [listening]
PATIENT: Kind of. He was slapping me and pushing me around, and I
got scared.
PRACTITIONER: Has this happened before? [asking; closed question]
PATIENT: Yeah. He’s hurt me before, but never this bad.
PRACTITIONER: It’s getting worse,
more serious, and that scares you.
[listening]
PATIENT: He drinks, too, and he was
drinking that night when he beat
me up. I didn’t know what he
might do, so I called the cops.
Listening and Informing
Now the practitioner shifts to a mixture of listening and informing.
PRACTITIONER: You did the right thing. I see girls in here who didn’t
draw the line soon enough. [informing] You decided he’d gone too
far. [listening]
PATIENT: I mean, we’re still together, but he’s mad at me.
PRACTITIONER: That must be scary. [listening]
PATIENT: You mean because he’s mad at me?
PRACTITIONER: Well, I’m thinking that this guy was beating you up before,
and now he’s angry because you called the cops on him. That
kind of cycle just tends to keep escalating. It isn’t going to just disappear.
[informing]
PATIENT: I know. I ought to break up with him and find somebody who
treats me better.
PRACTITIONER: You’ve thought about it. [listening]
PATIENT: In fact, I was kind of looking around at the bar last night.
114 PUTTING IT ALL TOGETHER
Listening is not a passive process,
but one in which the listener
actively reflects back what the
person has said. Good listening
statements may continue the
paragraph or make a guess about
unspoken meaning.
PRACTITIONER: I’d like you to take better care of yourself so I don’t see
you back here again. You’ve been allowing yourself to be in some
pretty dangerous situations. [informing]
PATIENT: Yeah, well this is kind of a wake-up call.
PRACTITIONER: This got your attention, being strapped up here like this.
You’re thinking maybe it’s time to wake up. [listening]
The preceding conversation clearly falls within the guiding style
of MI that we have been describing, but other uses of the very same
communication tools would not. Consider this example, also making
use of asking, informing, and listening, but with a skeptical, directing
style.
Practitioner: Doctor, nurse, physical therapist.
Setting: Cardiac rehabilitation or primary care.
Challenge: The patient leads a lifestyle that places him at risk for further
problems.
PRACTITIONER: Hello, Mr. Bell. It’s been 3 months since we did your bypass
surgery, and I’m glad to see your test results. It looks like your
heart is working well at this point. [informing] But I see from our records
that you’re still smoking. Is that right? [asking]
PATIENT: Yes, I am.
PRACTITIONER: Well, that’s a problem, because, as you know, smoking
is hard on your heart. [informing] You haven’t quit yet? I’m sure
you’ve been told about this? [asking]
PATIENT: It’s just hard to quit. I’ve tried, really I have, but I just can’t
seem to do it.
PRACTITIONER: Can you see that places you at much higher risk for another
heart attack? [asking]
PATIENT: I’ve been walking almost every day, like you told me.
PRACTITIONER:Almost every day. [listening] And yet you’re still smoking.
What about the diet we gave you? [asking]
PATIENT: I’ve still got it at home, and I’m trying to eat better.
PRACTITIONER: Aren’t you using it? [asking]
PATIENT: Some, yes.
PRACTITIONER: Are you keeping to the diet? [asking]
PATIENT: I’ve tried some of the recipes, but I just don’t enjoy them, and it
Integrating the Skills 115
takes a lot of work to cook that way. It’s going to take me a while to
get used to it.
PRACTITIONER: So you’re making an effort, that’s good. [listening]
There are more changes I’d recommend if you want to keep healthy.
You don’t want to have another heart attack, do you?
PATIENT: No.
PRACTITIONER: Then you should try to quit smoking, use that diet we
gave you, and get exercising as soon as possible. [informing]
This clinician is also asking, informing, and listening, but the tone
of the consultation is distant from the guiding style of MI. It has an adversarial
tone, with the clinician in the driver’s seat telling the patient
what to do and why to do it. Though asking questions, the clinician
takes responsibility for making the change happen and does not seem to
be interested in understanding the patient’s own perspectives. The questions
being asked do not elicit the patient’s own motivations for behavior
change. The clinician listens only minimally, just long enough to hear
the patient’s reply and then argue with it.
What is missing here is an honoring of the patient’s autonomy,
along with the collaborative, evocative style described in Chapter 1. It is
within this “spirit” of motivational
interviewing that the three communication
tools come together to
guide rather than badger, to encourage
rather than shame, to negotiate
rather than dictate. The guiding
style is considerably more effective
than lecturing when behavior change is needed, and it’s also a lot more
interesting and enjoyable for the clinician.
RESOLVING AMBIVALENCE
How does collaborative exploration of ambivalence start the process of
behavior change moving? In talking about and reflecting on her or his
own motivations for change, something clicks for the patient. You might
think of it as the tipping of a balance or the flipping of a switch. In talking
about why change is important, patients decide that it really is important.
By voicing the good reasons to do it and how they might succeed,
patients make change seem possible. There’s a spark, and they
quietly make the internal decision that behavior change may be worth
the effort after all. They have literally talked themselves into doing it.
116 PUTTING IT ALL TOGETHER
The three communication tools
come together to guide rather than
badger, to encourage rather than
shame, to negotiate rather than
dictate.
This is not usually accompanied
by any fanfare. In fact, it may
not be apparent to you that anything
has happened. We have been
through a guiding process with patients
who seemed not to move at
all, only to have them come back at
the next visit and tell us they’ve made a change. One practitioner told us
this:
“I had been seeing a patient who hadn’t worked for years and was depressed.
I had tried just about everything with him: medications, advice,
encouraging him to exercise, get a job, and become active in social
circles. Nothing seemed to help. He just seemed stuck, and I was
feeling rather stuck and discouraged myself. Aware of how disheartened
I was feeling, I looked at him and realized that he must be feeling
all the more so. Not knowing what else to do, I offered a simple
reflection: ‘You must be feeling pretty fed up with all this.’ All that he
said was ‘Yeah,’ looking sullen as usual, and soon after that he left
the office.
“A few months later I saw him again for a minor medical problem,
and I asked how he was getting on more generally. ‘Wonderful!’
he said brightly. ‘I’ve got a job as a bus driver and I’m feeling
great!’ You could have knocked me over with a feather.
“ ‘What happened?’ I asked.
“ ‘It was something that you said last time.’ I had no idea what I
had said that could possibly have had such an impact. ‘When I left
your office I realized that you were right: I was fed up with my life
as it was, and I needed to do something about it. I saw an ad in the
newspaper that the city was looking for bus drivers to train, and I
called them up, and now I’m working a regular route and feeling
great.’ ”
Listening for Commitment
Such surprises happen, but remember that there are also tangible cues to
watch for as you talk with patients. There is, in particular, one reasonably
reliable indicator that change is percolating: commitment language,
as described in Chapter 5. It may emerge spontaneously as you practice
MI (“I think I’ll give this a try”), and there is also a way to assess
whether the person is ready to move on. After giving the patient a
summary of his or her own stated motivations for change (that DARN
Integrating the Skills 117
In talking about why change is
important, patients decide that it
really is important. By voicing the
good reasons to do it and how they
might succeed, patients make
change seem possible.
bouquet of flowers), ask a simple question the essence of which is, “So
what are you thinking at this point? What are you going to do?”
There is a subtlety here in how you ask. When assessing commitment,
use language such as:
“What will you do?”
“What are you going to do?”
“What are you willing to do?”
“What are you prepared to do?”
This is different from asking questions that merely elicit DARN statements:
“What do you want to do?” [desire]
or
“What could you do?” [ability]
or
“What do you need to do?” [need]
Consider this example, described to us by a colleague:
“I was treating a man whose wife was threatening to leave him and
take the children away with her because of his drinking. He was a
committed family man, had a good business, and all in all had experienced
few of the ravages of overdrinking. His liver function tests
were fairly normal except for raised GGT, which is often the first to
go up in heavy drinkers. He was nevertheless drinking an astonishing
amount on a daily basis, and it was causing real conflict at home.
I tried motivational interviewing with him, and heard several change
talk themes. His biggest concern, however, was loss of his wife and
children, and as he talked about that possibility he volunteered, ‘I
guess that I just need to quit drinking.’ After a few more minutes of
listening, I offered him this summary:
‘You certainly don’t think of yourself as an alcoholic, or even a
problem drinker. The main trouble has been at home, where
you and your wife have been having a lot of arguments, mostly
but not only about your drinking. It really shook you when she
said she was thinking of leaving and taking the kids. Losing
them, you said, would be the worst thing that could possibly
happen to you. You were also surprised to see how much you
were drinking when we added it all up. We also realized that
you’ve been driving around legally intoxicated most mornings,
given how long it takes to break down the alcohol that
118 PUTTING IT ALL TOGETHER
you drink at night. Most of all, though, you want to keep your
family, and that’s the biggest reason you came in. It sounds like
you’ve decided that what you need to do is to stop drinking, at
least for half a year or so, and see how you’re feeling then. So is
that what you want to do?’
“ ‘No,’ he said.
“No? No? Damn! My thoughts were racing. I had just done my
very best guiding summary, using exactly his own change talk, and
led up to what he had told me was his plan. How could he now be
saying no?
“ ‘No,’ he said again. ‘It’s not what I want to do. It’s what I’m going
to do.’
“And he did.”
The answer you are listening for is some level of commitment language
as a signal of what is going on inside with regard to readiness. In
essence, you are listening for what the patient is ready, willing, and able
to do in the way of health behavior change. Don’t push for it, though.
Just give the patient opportunities to arrive at it. If the patient is not
quite ready, pushing is just likely to
evoke resistance. Instead, if you
have a little more time, continue exploring
DARN themes and leave the
door open. If you will see the patient
again, you can always resume
the discussion at your next visit.
You know that you are doing
well with the guiding style when
your patients happily keep talking to you, when they are expressing their
own desire, ability, reasons, and need for behavior change. Done well,
the guiding style opens patients to consider what they might do differently
on behalf of their own health and to commit to taking such steps.
Clinicians cannot make these decisions for patients; otherwise, many of
us probably would. It is possible, however, to spend some time picking
flowers in the meadow of ambivalence, to share the bouquet, and in the
process to help patients find their own way into a healthier life.
Most likely, in considering this guiding style, you have thought
about some of your patients who “just want to be told what to do.”
There certainly are such patients. They are scared and are ready, willing,
and able to do whatever it takes to get better. What they want is not
counseling but some clear direction about what they can do to restore or
improve their health. It can be counterproductive to spend time discussIntegrating
the Skills 119
In essence, you are listening for
what the patient is ready, willing,
and able to do in the way of health
behavior change. Don’t push for it,
though. Just give the patient
opportunities to arrive at it.
ing why to change with a patient who has already decided to do so.
When someone says, “I need to stop smoking. How can I do it?” the appropriate
response is advice about the most effective strategies. Clearly,
that is what the patient is requesting. There are many other patients,
however, who haven’t yet reached that point of committed action. For
every patient who says, “I plan to quit smoking,” there are at least five
other smokers who have not yet reached that point. At some level, patients
know the changes they need to make in the interest of their health,
but. . . .
CONCLUSION
MI is for helping that majority of your patients who are ambivalent to
find within themselves their own motivations to change. In the next
chapter we provide some case examples. We then turn to ways in which
you can improve your MI skills (Chapter 9), and we end the book with
attention focused on improving matters outside of the individual consultation
(Chapter 10).
120 PUTTING IT ALL TOGETHER
PUTTING IT ALL TOGETHERCase Examples of a Guiding Style
CHAPTER 8
Case Examples of
a Guiding Style
In this chapter we offer some extended case studies drawn from our own
clinical experience, to show what a guiding style might look like in everyday
practice. If you like case examples, read on. If not, feel free to
skip ahead to Chapter 9.
CASE 1: “MY STOMACH HURTS”
Setting: A general medical hospital ward.
Practitioner: Doctor, counselor, nurse, social worker, psychologist,
addiction specialist.
Length of consultation: 4 minutes.
Challenge: A 52-year-old married woman is admitted to a hospital
with abdominal pain and vomiting blood. The practitioner notices
an elevated GGT value (a liver enzyme that is frequently elevated
by excessive alcohol use) on the serum chemistry and suspects
that drinking is involved. They have met once before. This
woman might feel challenged and defensive if she were confronted
about problem drinking. The prevention of readmission
and promotion of health are worthy goals, but how does one
raise the subject? The practitioner has just completed a review of
her condition and continues . . .
121
122 PUTTING IT ALL TOGETHER
PRACTITIONER: Well, you’ve had quite a
shock, but I hope you are at least getting
a rest here.
Open with an empathic
statement.
PATIENT: Yes, thank you, I am feeling a little
better. I don’t get much rest at
home—just rushing around in the car,
go, go, go, like I’m on a mission, looking
after the kids, the job, the food,
you name it.
PRACTITIONER: You do a lot, and you get
a lot done.
Listening.
PATIENT: Funny that you should say that.
That’s right, they call me supermom,
and at work, I am the one who has to
sort things out when it all goes crazy
with stress and arguments about who’s
going to do this and that, and how
we’ll meet a deadline.
PRACTITIONER: I did want to ask you a little
about your lifestyle. I’m not sure,
but I wonder if there might be a connection
here with what’s going on in
your stomach. Could we talk for a few
minutes about this?
Brief agenda setting;
raises the topic of lifestyle
in general. Asking
permission.
PATIENT: No, that’s OK. Superwoman has
landed in trouble. What are you think-
ing?
First hint of change
talk.
PRACTITIONER: I’m not sure. Diet, alcohol,
running around too much? I’m not
sure. You’ll be the best judge of this,
but it sounds like you lead a pretty hectic
life.
Only gentle informing.
Promotes autonomy
and returns to her story
about her lifestyle.
PATIENT: Hectic’s not the word.
PRACTITIONER: You must enjoy living in
the fast lane.
Listening; a guess.
PATIENT: I do like getting things done. It’s
kind of a buzz, zooming from one thing
to the next.
Case Examples of a Guiding Style 123
PRACTITIONER: Do you ever move over
into the slow lane?
Asking: a guiding question,
making use of the
driving metaphor.
PATIENT: It’s hard—it’s no joke, there’s so
much to do, I just don’t relax.
She seems much more
emotional.
PRACTITIONER: What things do you do to
take care of yourself?
Asking; a guiding question,
seeking to understand
where alcohol
may fit in.
PATIENT: At night when the kids are in
bed, sometimes I watch movies and
open a bottle of wine. That’s my time.
The only time I get, really.
She raises the topic of
drinking within a normal
everyday context.
PRACTITIONER: That helps you slow down,
maybe relax a little at night.
Listening.
PATIENT: And sometimes on weekends I go
out with my friends and we have a few
drinks.
PRACTITIONER: Drinking is a way you relax.
Tell me, what do you know about
how alcohol can affect the stomach?
Listening. Information
exchange: Elicit by asking
what she knows.
PATIENT: It can make you hungry, like an
appetizer. Do you think that’s what’s
causing this? Is that what you’re say-
ing?
A little defensive.
PRACTITIONER: It might be part of what’s
happening. I noticed on your blood
tests that one value was up in the abnormal
range, a liver function test that
is often elevated by alcohol.
Information exchange:
Provide.
PATIENT: Oh great! The one thing I do for
myself, and you want to take it away.
Defensive.
PRACTITIONER: I don’t want to jump to
conclusions, and in any case, it’s your
choice what to do. I can’t decide that
for you.
Avoids premature focus
and emphasizes choice
and autonomy.
124 PUTTING IT ALL TOGETHER
PATIENT: I just want a normal life. I want
my stomach to stop hurting, and I want
to get out of here.
PRACTITIONER: You’ve had a pretty rough
ride lately. And I want those things for
you, too—a life that works for you and
doesn’t put you back here in the hospi-
tal.
Listening and encour-
agement.
PATIENT: Now what about that blood test
you mentioned? That scares me a little.
Question gives permission
to inform.
PRACTITIONER: It’s one that often goes up
when a person is drinking more than
the body can handle. You’re pretty
slim, which means that a little alcohol
goes a long way. Also women don’t
break down alcohol in the liver as well
as men do.
Information exchange:
Provide.
PATIENT: So are you telling me I need to
cut back?
PRACTITIONER: It’s up to you, but it seems
like that’s what your body is telling
you. Also, a stressful life can be hard
on the stomach, and adding alcohol on
top of that can cause problems.
Emphasizing choice
and autonomy.
Informing.
PATIENT: How does that work? Question gives permission
to inform.
PRACTITIONER: Alcohol itself irritates the
gullet and stomach lining. Have you
ever drunk straight liquor and felt the
burn?
Informing.
PATIENT: Sure.
PRACTITIONER: That burning is alcohol’s
effect. It also releases stomach acid,
which is why it can increase your
Informing.
Case Examples of a Guiding Style 125
appetite, and that can add to the problem
if your stomach is already weak
from stress, and you can wind up with
ulcers. What are you thinking at
this point?
Information exchange:
elicit her personal
interpretation.
PATIENT: I don’t want an ulcer. Do you
think that’s what I have?
Change talk—reason to
do something.
PRACTITIONER: It could be. There are
tests that can look into this. If it is,
what do you think you will do?
Open question.
PATIENT: I assume you’ll have some medicine
for me to take. But I guess I also
need to cut down my drinking, even if I
don’t have an ulcer.
Change talk (need).
PRACTITIONER: How hard would that be
for you?
Guiding question—
looking for change talk
(ability).
PATIENT: Not hard, really. I’d just have to
find another way to relax.
Change talk—ability.
PRACTITIONER: So you could cut down
your drinking if you decided to. Even
quit drinking?
Reflective listening.
Guiding question.
PATIENT: I’m not so sure.
PRACTITIONER: So why would you want to
cut down or quit?
Guiding question.
PATIENT: For my health! It sounds like I
might be eating a hole in my stomach,
and my liver is getting abnormal. I
think it’s time.
Change talk.
PRACTITIONER: Seems like it to me, too.
What will you do?
Asking for commit-
ment.
PATIENT: I can just not keep any alcohol in
the house to tempt me. I think that’s
what I’ll probably do.
Change talk.
First indication of
commitment.
CASE 2: PROMOTING SAFE SEX
This next scenario occurs all over the world. In places where the rates of
HIV/AIDS are high, the practitioner is faced with a health promotion
challenge that could be a life-or-death matter not just for the patients but
also for those with whom they have sexual contact.
Setting: A busy primary care clinic in an area with high HIV/AIDS
rates.
Practitioner: Doctor, nurse.
Length of consultation: 5 minutes.
Challenge: A man comes in with a sexually transmitted bacterial infection
and is examined and given antibiotics. The practitioner
wonders about him being HIV-positive and about the possibility
of multiple partners and the value of his using condoms. This
man is in his 40s, he’s single, most often unemployed, and lives
with a wider extended family on the outskirts of a large city. The
practitioner uses mostly information exchange to raise concerns
about unprotected sex.
126 PUTTING IT ALL TOGETHER
PRACTITIONER: OK, I think we’ll get this
infection under control if you take this
medicine faithfully for the next 10 days.
Will you do that?
Asking for
commitment.
PATIENT: Sure.
PRACTITIONER: Good! It’s important to
finish it all. I wonder if it would be all
right for me to talk with you for a few
more minutes. I’m interested not only
in helping you deal with medical problems
but also in keeping you healthy.
Would that be all right?
Asking permission.
PATIENT: OK, sure. What do you want to
talk about?
PRACTITIONER: It’s part of my job to talk
with you about avoiding all sorts of infections,
including HIV/AIDS. What do
you already know about HIV?
Agenda setting, raising
a difficult subject.
Asking (information
exchange: Elicit).
Case Examples of a Guiding Style 127
PATIENT: If you get it, you die. But I’m
pretty careful. I just didn’t use a condom
this one time. Just one of those
things that happens.
PRACTITIONER: Good! So usually you do
use a condom. It just happens sometimes
that you don’t, and you caught
this infection.
Affirming.
Reflective listening.
PATIENT: Bad luck, I guess. I just met this
girl, and she didn’t look unhealthy.
Who knows where she got it from.
PRACTITIONER: Makes you wonder. Maybe
she didn’t know either.
Listening.
PATIENT: So I got unlucky and got it from
her. It happens.
PRACTITIONER: You’ve mentioned that several
times now—that it’s just a matter
of luck or chance. These infections just
go around and around.
Listening.
PATIENT: Yeah, see, I’ve never had a problem
like this before. I have this one
steady girlfriend, and this was just a
one-night thing with this other girl.
PRACTITIONER: I hope you don’t mind my
asking you about this. I really don’t
want to make you uncomfortable by
asking about your personal life, but I
do care about your health.
Asking permission and
respecting autonomy.
PATIENT: No, it’s OK.
PRACTITIONER: So you had unprotected
sex with this one girl, and you have a
steady girlfriend. What kind of protection
do you use with your regular girl-
friend?
Listening.
Asking.
PATIENT: We always use a condom, or
most of the time, anyway.
128 PUTTING IT ALL TOGETHER
PRACTITIONER: Sometimes you don’t, but
most of the time you do. OK. Now, tell
me what you know about how worse
infections like HIV spread.
Listening.
Asking (Information
exchange: Elicit).
PATIENT: Oh, God! You’ve got to be joking.
Do you think I have AIDS?
PRACTITIONER: I have no idea at all
whether you might have picked up HIV
along the way. We can test you to find
out while you are here today, if you
want. What I’m asking, though, is what
you know about how people do get
HIV and AIDS.
Avoiding premature
focus.
Acknowledging choice.
More eliciting.
PATIENT: Well, you get unlucky, and you
get very sick, I’ve seen it, but I don’t
lead that kind of life, sleeping around
with dirty girls.
PRACTITIONER: I don’t know if this will
make sense or matter to you, but I can
tell you that infections like HIV often
spread quietly among all sorts of people
who look healthy for many years before
they get sick. The infection can be
passed without either person knowing
it. What do you think about that?
Asking permission.
Information exchange:
Provide.
Information exchange:
Elicit.
PATIENT: I just had this one night with a
new girl!
PRACTITIONER: And you’re really not at all
worried about that.
Listening, continuing
the paragraph (no tone
of sarcasm).
PATIENT: Well, maybe I have to be more
careful.
First change talk.
PRACTITIONER: In what way? Asking.
PATIENT: Like I guess I shouldn’t sleep
around too much, and be sure to use
condoms if I do.
Change talk.
Case Examples of a Guiding Style 129
PRACTITIONER: It is certainly true that having
just one partner does decrease your
risk. So do condoms, if you use them
all the time. How important is this for
you?
Informing.
Asking for change talk.
PATIENT: I don’t know.
PRACTITIONER: Let me ask you this. On a
scale from 1 to 10, where 1 is not at all
important and 10 is extremely important,
how important would you say it is
for you to use condoms every time,
even with your steady girlfriend?
Using an importance
ruler.
PATIENT: Probably 8 or 9. Change talk.
PRACTITIONER: OK—you have a little
doubt, but it’s very important to you,
for your health, to protect yourself.
And you’re protecting other people,
too.
Reflective listening.
PATIENT: Yeah, I hope I didn’t give this infection
to my girlfriend. She’d go crazy.
PRACTITIONER: Yes, infections can spread
quickly and quietly among people who
look and feel perfectly healthy. So
you’ve had unprotected sex with your
girlfriend after this other girl.
Informing.
Listening.
PATIENT: Yeah, well, we used a condom,
but they don’t always work, right?
PRACTITIONER: They’re not 100% effective,
but they do give you good protection.
If she develops any symptoms, I
can treat her, too.
Informing.
PATIENT: I just hope that girl didn’t have
HIV.
PRACTITIONER: Me, too. It just takes one
time, as you see. It takes a while to get
the results, but the test for HIV is easy.
Shall we do it?
Informing.
Asking.
130 PUTTING IT ALL TOGETHER
PATIENT: Oh, man. I don’t know. I don’t
think it’s very likely.
PRACTITIONER: Maybe not. You really
can’t tell from looking at someone, and
people can be healthy for a long time
before they get sick. There is much
better treatment available these days,
and knowing early on if one is positive
or not can help plan treatment.
Resisting the temptation
to argue.
Informing.
PATIENT: I guess I ought to know. Change talk.
PRACTITIONER: OK, good. I’ll draw a
blood sample and make an appointment
for you to come back, when we
can have a discussion about what the
test means and that sort of thing.
So to summarize, you have been
using condoms most of the time
but not all the time. You picked up
this infection from one time when
you didn’t, and you hope you
haven’t already passed it on to
your girlfriend. It’s unpleasant to
think about, but you want to be
tested for HIV so you know. And
what about using condoms?
Offering a short sum-
mary.
Asking for commit-
ment.
PATIENT: I need to use them all the time, I
guess.
Change talk.
PRACTITIONER: How confident are you
that you’ll succeed?
Asking for commit-
ment.
PATIENT: Yeah, I’ll try. It’s hard some-
times.
Moderate commitment.
“I’ll try” bespeaks
doubt about ability.
PRACTITIONER: Good for you! I’m glad.
And maybe when you come back we
can talk a little about the times when
it’s harder to use protection.
Affirming. Setting the
stage for discussion to
increase ability in more
difficult circumstances.
CASE 3: A MATTER OF THE HEART
Setting: An outpatient cardiovascular rehabilitation clinic. This same
discussion might also take place in a primary care clinic or an inpatient
setting.
Practitioner: Nurse, doctor, occupational therapist, physical therapist,
counselor, psychologist.
Length of consultation: About 20 minutes.
Challenge: The patient had a heart attack 12 weeks ago and is being
seen for follow-up. The practitioner might want to encourage
change in many interrelated behaviors: smoking, exercise, diet, or
alcohol consumption. The patient has a cheerful disposition,
works as a clerk, enjoys life (with cigarettes, alcohol, and good
food!) and is surrounded by a busy family life, including two adolescent
children.
Case Examples of a Guiding Style 131
PRACTITIONER: Can we spend some time
now talking about how you are doing
at home, because all sorts of things can
affect the health of your heart. It’s not
just the medication that matters. Would
that be OK?
Asking permission.
Start of agenda setting.
PATIENT: Yes, I suppose I’m due for a lecture
about what a bad boy I am and
how I have to stop everything I enjoy.
(Laughs.)
PRACTITIONER: Well, actually that is not
what I’m going to do. I promise. It’s totally
up to you what you want to do
about your health. It sounds, though,
like you were hoping the pills would do
the whole trick for you.
She avoids the temptation
to argue for lifestyle
change, emphasizes
autonomy, offers
a listening statement.
PATIENT: Well, you said that I’m making a
good recovery and that the medicine
seems to be the right one.
PRACTITIONER: Yes, indeed, I’m pleased
with how you have recovered from the
bypass surgery. What it comes down to
now is what you want to do among all
Informing and agenda
setting.
132 PUTTING IT ALL TOGETHER
the things that can reduce your chances
of another heart attack and help you
have a good quality of life. I could give
you some facts and figures that might
surprise and encourage you, but to start
with let’s take a look at the bigger picture
of your life and see what makes
sense for you.
PATIENT: All right. What do you think I
should do first?
An invitation.
PRACTITIONER: That’s really up to you to
decide. You’re in charge of your own
life. We could talk about exercise,
smoking, diet, monitoring your blood
pressure, decreasing stress, meditating,
or just being faithful about taking your
medications. What makes sense to you?
She declines the initial
invitation, emphasizes
autonomy, and sets an
agenda by offering a
menu of possible topics
for the patient to
choose from.
PATIENT: Well, where do you think I
should start?
Gives permission to inform
and advise.
PRACTITIONER: I do have some information
I can give you, if you want, and
my own opinion about what changes
might help most. But you probably already
know the score. What’s your
guess about what I’ll say?
She offers to give information
and advice but
tries just once more to
elicit it from him first.
PATIENT: I’ll bet you start with telling me
to quit smoking.
And it succeeds.
PRACTITIONER: Good guess! I do think
that quitting smoking is the one thing
you could do that would likely have the
biggest and quickest impact on your
risk of dying prematurely. But what do
you think about that?
Affirming.
Informing.
A key question in the
service of guiding.
PATIENT: Smoking is completely part of my
life.
PRACTITIONER: Smoking is a tough one for
you—a hard place to start.
Reflective listening.
Case Examples of a Guiding Style 133
PATIENT: Well, I know it’s bad for me, and
I did ask you what you think.
Change talk.
PRACTITIONER: You’ve got your own feelings
about smoking, though, no matter
what anyone else thinks.
Listening statement.
Avoids temptation
to take up the
antismoking side.
PATIENT: I feel like, look, it’s just not going
to happen right now. I’m having a
hard enough time getting back on my
feet.
PRACTITIONER: Quitting smoking is just
too hard for you right now, and you
have other priorities.
Listening. She resists
temptation to take up
the pro side of quitting.
PATIENT: Right, I’ve got to get back to
work now, for a few hours a week at
least. And I want to get my stress level
down while I get back to normal activi-
ties.
Change talk.
PRACTITIONER: That’s your top priority
right now—to get back to work and
manage your stress.
Listening.
PATIENT: Well, I want to get back to work.
But to be perfectly honest, I do sometimes
feel like I could have another attack
any moment and whack, I’d be
gone.
Change talk.
PRACTITIONER: So you feel like you just
need to rest right now.
Listening.
PATIENT: Not exactly. I’m not just resting
all the time. I’m moving around, doing
this and that, trying to get a little exer-
cise.
The practitioner’s guess
was not quite right,
and the patient corrects
it.
PRACTITIONER: You’re trying to get the
balance right.
Listening—trying again.
PATIENT: Yes, that’s it. A balance.
134 PUTTING IT ALL TOGETHER
PRACTITIONER: So what you’ve told me so
far is that you’re taking your medications,
resting up a bit, but also trying
Collecting summary,
emphasizing change
talk themes.
to get some exercise, which is good for
your heart. You already knew that quitting
smoking is one of the biggest
things you could do for your heart, but
that just seems impossible right now.
And you’re eager to get back to work,
at least part time, as soon as possible,
and get your life back in balance. Did I
miss anything?
PATIENT: Well, not back in balance exactly.
I don’t think I ever had a very
good balance before this heart attack,
and that was part of the problem. I’m
just not sure where to start.
Change talk.
PRACTITIONER: You did mention decreasing
your stress level, too. How might
you do that?
Asking.
PATIENT: I think this gives me a chance to
do that. I think I need to start turning
some things over to other people. I’m
the kind who always thinks, “If you
want something done right, do it yourself.”
Then I’m stressed out with how
much I have to do.
PRACTITIONER: It could help to take some
things off your plate.
Listening.
PATIENT: Now there you go with lecturing
me about diet! (Laughs.) No, that’s
what I need to do—trust the people
around me to do their jobs, and focus
on what’s really important. I can’t
change everything at once.
Change talk.
PRACTITIONER: If you could do just that
much—reduce the burden of what you
have to do—that would help.
Listening.
A key moment has been reached in the consultation, a crossroads of
sorts. What would you say next? This man has said a lot already, and it
is heartfelt material. Suppose you have a little longer to listen. Where
would you go next? If you look at what he’s said, you could focus on
(1) his gradual return to work, (2) more specific plans about exercise,
(3) when he might be ready to quit smoking, (4) stress management, (5)
how to delegate responsibilities he has been carrying, or (6) pick up on
the passing invitation to talk about diet. Or you could go off in an entirely
different direction. Reflecting on any one of these themes will focus
the discussion and lead off in a particular direction. This is what we
mean by listening in the service of guiding. It’s your choice, and it makes
a difference what you choose.
As this example continues, the practitioner does try a different direction,
responding to an intuition that this patient doesn’t seem to have
something to live for, except perhaps his work. Its an exploration of core
values. Why then, the practitioner wonders, would he want to make
healthy changes? What would motivate him to do so?
Case Examples of a Guiding Style 135
PRACTITIONER: You know, I really like
your idea that this heart attack is an
opportunity for you to make some
changes and to consider what is really
important. Could I ask you, what are
the most important things in your life?
What are you living for?
Affirming.
Asking permission.
Open question.
PATIENT: Oh, uh, that’s a good question. I
like my work. My family—I want to
see that my kids get started off in the
right direction. In fact, I’d like to be
there for my grandchildren, if we have
them. That looks like fun.
PRACTITIONER: Your work, your kids,
maybe grandchildren some day. What
else? What really matters to you?
Listening.
Open question.
PATIENT: I thought about that in the hospital
bed. Since I’m alive, what do I want
to do with the life I have left?
PRACTITIONER: Yes. What is it you want
to do?
Open question.
136 PUTTING IT ALL TOGETHER
PATIENT: Help others, my family, and be
there for them, if you see what I mean?
PRACTITIONER: That’s what’s really important
for you, being around for a reason,
and for helping others.
Listening.
PATIENT: To think about someone besides
myself. To remind me what I have to be
grateful for.
PRACTITIONER: You know, you kind of
light up when you talk about this.
Listening.
PATIENT: Well, I’ve been out of touch, and
there’s lots I can do for my family and
other people, even in a club, which I
used to volunteer for.
Change talk.
PRACTITIONER: We’ve talked about a lot so
far, and you’re developing a pretty good
list of things you can do to make your
life longer and happier. Is there anything
else from that list I gave you earlier
that you’d like to talk about?
Summary. She decides
to change direction and
see where behavior
change might fit into
this bigger picture. Returns
to agenda setting.
PATIENT: Maybe diet and exercise.
PRACTITIONER: What concerns you about
that?
Asking a guiding ques-
tion.
PATIENT: I’m not concerned, really. I’m just
wondering what I should be doing in
that area.
The practitioner chose
a word, “concerned,”
that didn’t quite fit.
PRACTITIONER: There’s quite a lot of
things you could do. Making small,
gradual changes in what you eat. Increasing
fruits and vegetables to five or
so a day. Building some modest exercise
into your regular daily routine. Would
any of that be workable for you?
Offering a menu of
options.
Asking.
PATIENT: Well, maybe the exercise thing,
but I don’t really want to go to a gym
or anything like that. I don’t want to
have another heart attack!
Change talk.
Case Examples of a Guiding Style 137
PRACTITIONER: Adding some kind of exercise
might be OK for you, but definitely
not the gym yet. What kind of exercise
do you get at the moment?
Listening.
Guiding question.
PATIENT: Not enough. I just do a bit of
walking a few times a week. Sometimes
when I do that I get these feelings in
my chest, and I worry I’m pushing myself
too hard.
PRACTITIONER: That’s really a common
worry, and our experience suggests that
as long as people do things gradually,
no harm comes their way. We could
help you develop a gradual, step-bystep
program to increase your exercise.
If you’d feel better about it, you could
even use the facilities here, and we can
monitor your heart rate at first to make
sure it’s safe.
Informing.
PATIENT: That sounds good. But mostly I
think walking is what will work for
me. I could do more of that.
Change talk.
PRACTITIONER: And that’s what’s important—to
find what you can do that
works for you and fits with your normal
life. And if you do have any of
these feelings while you’re walking on
your own, just stop, rest, and manage
them as we’ve discussed before.
Informing.
PATIENT: OK. Maybe I’ll take you up on a
little monitoring while I exercise here.
Change talk.
PRACTITIONER: Fine! We can set that up.
Well, we’ve covered a lot of ground today
in a short time. Help me remember
it all. First and foremost, you are
choosing to think about this heart attack
as an opportunity for you to make
some good changes in your life and to
get your priorities straight. You are
Closing summary.
She puts the positive
motivations up front.
CONCLUSION
There’s no single “correct” way to conduct a consultation, so if you have
found places where you might have done things differently, take this as a
138 PUTTING IT ALL TOGETHER
devoted to your work and also to your
family, and you want to be around to
help your children and maybe grandchildren
get a good start in life. You’re
also feeling a desire to get more involved
in helping others, at home and
in other places like the club. To do
that, there are some lifestyle changes
that you’re planning to make. One of
these, as you gradually get back to
work, is to decrease the volume of
work that you take on and perhaps
find some other ways to decrease your
stress and get your life in balance.
Smoking is something we’ll talk about
later, because right now that seems too
difficult to change. If you decide to
tackle that later, I have some ways to
help you with it. You’re already doing a
good job taking your medications, and
you’re doing at least a little walking,
which you want to increase. We can set
you up for some modest monitored exercise
here—we can do that as you
leave today. That sounds like a lot of
change right there. I look forward to
seeing you over the months ahead to
see how you’re doing with this and
help in any way I can with these or
other changes. Is that what you are going
to do? Anything I missed?
Then she talks about
specific changes they
have discussed.
She accepts and acknowledges
the situation
with smoking,
leaving the door open.
Affirming.
Asking for commit-
ment.
PATIENT: That sounds about right. I feel
like I’m headed in the right direction,
like there is something I can do.
Change talk.
stimulus to be creative in your own consultations. Our intention here
was to illustrate the underlying style of MI, difficult when using only the
written word, and to indicate where relevant skills and strategies such as
listening and agenda setting were used. The next chapter turns to some
of the more subtle things to look out for as you refine your skills in MI.
Case Examples of a Guiding Style 139
PUTTING IT ALL TOGETHERGetting Better at Guiding
CHAPTER 9
Getting Better at Guiding
GETTING USED TO GUIDING
Guiding is not just about what one says to patients; it is also about how
one is with them. This was nicely illustrated in a recent workshop with
prison officers. The simulations were going well enough with the participants
standing up, but when it came to a sequence of guiding, one of
them announced, “I can’t do this standing up. I need to sit down with
this person.”
A common observation made by practitioners is “it doesn’t feel natural.”
Indeed, this way of working with patients is often very different
from prior practice, from following
the righting reflex of just directing
someone what to do and why. Try
out this style in easier situations
first, when time feels manageable
and your patient seems engaged. As
you become more proficient, you
can move on to more difficult challenges.
It can take a while for the guiding style to begin feeling natural. It’s
a bit like learning to drive a car. On your first time behind the wheel, you
were probably highly self-conscious, and understandably so. You drove
slowly, with heightened awareness, trying not to stray into the next lane.
You had to focus on tasks inside the car yet also had to keep an eye out
to make sure you weren’t about to run someone over. You had to think
about where you were going and attend to so many new tasks simulta-
140
Try out this guiding style in easier
situations first, when time feels
manageable and your patient seems
engaged.
neously. But you didn’t give up learning to drive just because it didn’t
feel natural at first.
As you become more comfortable with the component skills of any
new endeavor—whether driving or guiding—you do not have to think
about them so consciously. The skills become mostly automatic, and you
can concentrate instead on where you are going, how you will get there,
and what you will do when you arrive. Learning is like that, and learning
the guiding style is no different. At first you are self-conscious, particularly
when being observed. Are you asking an open or closed question?
Are you reflectively listening? Focusing directly on the guidelines is
necessary at first, but it also keeps you from seeing where you are going.
In time, comfort with these skills gives rise to other freedoms. It becomes
easier to notice other things that are also important in skillful guiding.
Think now about the role of the driving instructor. He or she might
take the wheel in an emergency, but, in general, the task is to encourage
the learner to make progress with as little intervention from the instructor
as possible. This is similar to your role in guiding the patient. It is the
patient who has to do the changing; you let go of control more and
more.
As you become more comfortable with the specific techniques involved
in MI, your attention is freed to monitor the guiding process itself.
Your attention can switch between three aspects of the consultation:
your relationship with the patient, what he or she is saying, and where
you might go next. With practice, you can move between these roles
with relative ease. Here are examples of these three processes.
Watching the Relationship
Your awareness of the relationship is a barometer of skill and good outcome.
Keeping a keen eye on the relationship will help you to decide
where and how to proceed. Check in with yourself by asking: How are
we getting on in this discussion? How is the patient reacting? Is she or he
comfortable, or frightened, perhaps? Am I pushing this person too hard?
Am I being genuine and frank?
Staying in the Present
Psychotherapists refer to being “in the moment” with the patient. There
are important periods when your own aspirations, feelings, and personal
reactions are put to one side and you focus your full attention on the patient’s
experience. The more you are able to do this, the more effective
your guiding response is likely to be, whether it is a listening reflection, a
well-chosen question, or offering important information.
Getting Better at Guiding 141
Some commentators say that this attentiveness is in itself a powerful
nonspecific route to healing, leading to an empathic relationship that
frees the person to change. When
patients sense this clear understanding
of their experience from you,
things begin to happen, and change
often follows. Acceptance of a
patient’s experience is not the same
as agreeing. It is relatively free of
judgment—whether positive or
negative—and therein lies the potential for you to be a good guide.
Looking Ahead
Sometimes your attention moves ahead to where the consultation is going,
how it will end, and, indeed, what it will be like when the patient
steps back into everyday life. With increasing skill, you find that you are
able to consider the route ahead and watch for obstacles, often during
short pauses in the conversation. At these moments, you can learn to
find the short cuts, the kind of guiding question or reflective listening
statement that gets you closest to what is helpful for the patient and
saves time, as well.
As you trust patients to take control, you give them more room to
talk, and this gives you freedom to concentrate on where you are going.
This letting go of control is not an
all-or-nothing matter. One clinician
emerged from a simulated exercise
and said, “I get it. There’s no need
to worry about control. Instead of
push this way and shove that way,
it’s just nudge, listen, and summarize,
nudge, listen, and summarize. . . .” After a while you realize that
you actually don’t lose your capacity to encourage change; quite the opposite.
Guiding then begins to feel natural.
“But I Can’t Let Go of Responsibility”
Many a discussion about the skill involved in guiding returns to the subject
of responsibility. “It’s all very well,” someone usually says, “but I’ve
got a job to do. I must raise these subjects. It’s my responsibility. I can’t
just let them decide for themselves!” This can lead into the trap of
“either–or thinking,” of the falsely limiting choice between directing or
142 PUTTING IT ALL TOGETHER
Acceptance of a patient’s experience
is not the same as agreeing. It is
relatively free of judgment—
whether positive or negative—and
therein lies the potential for you to
be a good guide.
“I get it. There’s no need to worry
about control. Instead of push this
way and shove that way, it’s just
nudge, listen, and summarize,
nudge, listen, and summarize. . . .”
following. “I either tell them what to do [direct], or leave them to work
it out by themselves [follow].” Sitting in the middle ground between directing
and following means taking responsibility for the structure and
direction of the consultation and encouraging patients to come up with
their own solutions to behavior-change problems. As you get better at
guiding, you will be able to sense when it is the right time to move on in
the consultation, to summarize and
shift direction, or even to adopt a
directing style and consider another
topic. When you are listening to patients,
try to focus not on what is
happening to the time but on how
you might capture your understanding
of their dilemma in a useful way.
Brief reflections or longer summaries
are particularly useful here. Often,
you can emerge from a few minutes of this activity with both parties
clearer about the way ahead. Seen in this light, you are the guardian of
the journey as a whole, much like the driving instructor, but the patient
is the guardian of motives and strategies for changing behavior. A good
guide promotes freedom of choice and provides high-quality support
and advice when needed.
OVERCOMING OBSTACLES
Obstacles to guiding are everywhere! As you become more skillful, you
develop an ability to overcome them not through forceful or clever effort
but by clear agenda setting, curiosity, and a genuine concern and respect
for patients’ ability to clarify what’s best for them, a fertile ground for
the use of listening skills. New avenues open up, and things feel easier.
One of the origins of MI came from the realization that when things
are difficult in the conversation, there is often an unproductive tendency
to blame the patient. When rapport is undermined, which invariably is
the case when things get tough, what can you do to repair this and return
to the kind of constructive conversation described previously?
The following discussion focuses on common challenges from three
overlapping perspectives: that of the patient, that of the practitioner, and
the relationship between the two. Sometimes the way the patient reacts
(e.g., defensiveness) and your response (e.g., irritation) provides a clear
signal that all is not well. Responding flexibly and creatively is a challenge
that can bring rewards fairly immediately.
Getting Better at Guiding 143
Sitting in the middle ground
between directing and following
means taking responsibility for the
structure and direction of the
consultation and encouraging
patients to come up with their own
solutions to behavior-change
problems.
The Patients: Their Struggles
Patients can feel bewildered, frustrated, defensive, passive, and overwhelmed
by circumstances. Talking about change can be difficult, and a
temptation to label and blame the person can undermine your best intentions
to use a guiding style. Consider the following common scenarios.
“I Can’t See Why I Need to Change”
“They are in complete denial” is a phrase that is used widely across
many health care settings. Patients apparently shut down when faced
with efforts to encourage them to consider change or to consider the seriousness
of their situation. If you use a directing style in this situation
by arguing for change, progress can freeze entirely. The more you push
someone into looking at something, the more he or she will resist and
defend him- or herself. If you come
alongside him or her, and clarify
what is important to him or her in
some form of agenda setting (see
Chapter 4), the denial will often
subside, and you might be able to
make progress. Denial is not a fixed
property inside someone but a reaction
that arises during communication between two people in a particular
circumstance, often when someone’s self-esteem is under threat.
Refusal to consider change can arise even when you use a guiding
style, perhaps because you have prematurely focused on behavior
change. Someone who has just had surgery or an acute medical crisis
might feel so preoccupied that he or she does not want or cannot absorb
even skillful and well-meant efforts to raise the subject of behavior
change. This is common in cardiac rehabilitation, diabetes, and the care
of all long-term conditions. Something else is of greater concern, or the
patient’s experience of illness lies hidden behind whatever conversation
unfolds. Some patients with asthma, for example, resist efforts to encourage
the use of prophylactic medicine because they do not share your
view about exactly what the problem is. Your use of listening is the key
to unlocking this impasse. Five minutes of seeking clarity can lay open
the path to behavior change and prevent wasted time and visits.
“I Can See What You Mean, but . . . ”
You get so far, and they back off. A moment is reached when patients’
words veer away from talk about change and a voice of defensiveness
144 PUTTING IT ALL TOGETHER
Denial is not a fixed property
inside someone but a reaction that
arises during communication
between two people in a particular
circumstance, often when someone’s
self-esteem is under threat.
expresses precisely the opposite. Subtle moment-to-moment shifts in
willingness to consider change are normal and common when a patient
is feeling ambivalent. At this point just a slight overemphasis on your
part on encouraging change can lead
to a corresponding counterreaction.
If you are prepared for this and accept
it as completely normal, you
can stay calm enough to respond
appropriately—for example, by reflecting
both sides of the person’s ambivalence. Patience and acceptance
of this seemingly irrational process are usually most helpful.
“Just Tell Me What You Think I Should Do!”
Some patients look up to you for the answer. Perhaps that is the way
people in a particular neighborhood, culture, or language or age group
seem to use health care services. If they do not seem keen to come up
with their own ideas, it is quite feasible to switch from eliciting solutions
from them to providing information and advice, all within a guiding
style. You simply offer one or more suggestions and use a guiding question
to check that this makes sense, for example, “How will this work
for you?”
“I Really Can’t Cope at All”
A patient is lonely, overwhelmed by poor housing, has no spare money,
has a chronic health problem such as diabetes, and now you want to
raise the possibility of behavior change. All the dangers of not listening
lie before you. Conveying your understanding of his or her predicament
and affirming his or her strengths in coping with these circumstances can
provide the platform for a more focused agenda-setting process that considers
ways of enhancing control of his or her situation. A discussion of
genuinely helpful behavior change often follows.
Trouble in the consultation about behavior change often goes both
ways. It is the meeting place for a marriage of sorts between your aspirations
and those of the patient. We turn now to what you may feel in the
guiding consultation, sometimes an obstacle to progress as well.
The Practitioner: Your Feelings
It is very common to feel different things about different patients. You
like some, and others less so. You can feel concerned, frustrated, annoyed,
or even outraged by their predicaments, their attitudes, or the
Getting Better at Guiding 145
Subtle moment-to-moment shifts in
willingness to consider change are
normal and common when a
patient is feeling ambivalent.
pressure you are under to undertake different tasks. The calmness at the
heart of guiding is not always easy to achieve.
You cannot be expected to be in a state of perfect calm in the
midst of busy everyday practice; neither can you become a psychotherapist,
practiced in the art of monitoring feelings and their effects on
the relationship with the patient. Yet feelings can run high, and your
own emotional state affects the process and outcome of the consultation.
One senior physician we worked with threw into a conversation
the following phrase: “If I work on automatic pilot, and I am even a
little bit stressed, I produce tired, automatic responses.” Then he explained
about the importance of awareness and acceptance of what
one is feeling: “After so many years at this, I’ve learned to check on
what I am feeling at any point in time. It’s funny, but I know my
moods. If I realize I am too stressed out to really help a patient, I
don’t get worked up about it, I just accept it. Then I settle down, and
I feel more flexible.”
Aspirations for Behavior Change
Some of the most powerful forces affecting patient progress toward
change are your own thoughts and
feelings about what might be good
for the patient. We have called these
your aspirations for patient behavior
change (ABCs). They are common
and perfectly normal, but if
they are allowed to dominate the
consultation, they can make it difficult
to honor the autonomy of patients
to decide what is best for themselves.
You raise the subject of behavior change, and you want to succeed.
Wanting someone to change, however, comes in many colors,
and strong feelings can prevail: hope, enthusiasm, determination, irritation,
anger, and even hopelessness can take their own toll on your
well-being and skillfulness. Mindfulness about how you feel before
and during the consultation might provide the key to doing a better
job. Consider these examples, in which most practitioners would want
the patient to change:
• She is working as a prostitute to feed her heroin addiction, and
she is about to lose custody of her child.
• If he does not cut down his liquid intake soon, his heart will begin
to fail, and he will die.
146 PUTTING IT ALL TOGETHER
If your aspirations for patient
behavior change (ABCs) are
allowed to dominate the
consultation, they can make it
difficult to honor the autonomy of
patients to decide what is best for
themselves.
Practitioners often have a silent internal monologue going while
in conversation with patients such as these. The monologue often contains
what could be called practitioner change talk. “I want to help
him get to the bottom of this, and turn things around” (desire). “I
think I can make a difference here” (ability). “She really must change
because that child is going to suffer terribly” (reasons). “I must raise
the subject” (need). “I’m going to give her the extra time she needs
now” (commitment). These aspirations can reflect deeply held personal
values: “This is why I came into this job, to help people like
this turn their lives around.” They can also have negative aspects:
“Oh, no, the situation just seems hopeless. I don’t know where to
begin.”
Health care is replete with people in predicaments that practitioners
want to change, thus setting up a conflict with practitioners’ simultaneous
desire to respect patients’ freedom to make their minds up for
themselves. Here is an example of how this conflict appears in a conversation
between colleagues:
Practitioner A: “I want to get this patient to change her diet so we
can lower her blood sugar levels.”
Practitioner B: “But you can’t get her to do anything. It’s up to her.”
It is not uncommon for a practitioner to hold both of these views simultaneously.
Your aspirations for behavior change are high, and you
also respect the patient’s freedom to make up his or her own mind.
These are not necessarily incompatible. They are part of the delicate
challenge that characterizes the behavior-change consultation. An adept
and sure-footed rock-climbing guide might watch the struggle of the
climber and very much want him or her to succeed but will also be very
mindful that he cannot do it for him or her. Allowing the climber to find
his or her own way within clear safety parameters and accepting the outcome
with patience and respect is what makes for a good working relationship
between them.
There are also situations in which these ABCs are not highly
charged and you do not really care whether the person changes his or
her behavior or not; this situation is sometimes called a position of equi-
poise.
• “This is tricky, whether to use this medication or not. It’s his de
cision, the arguments for and against are finely balanced.”
• “I can see problems looming with her feet, but she has other priorities
in the control of her diabetes. I don’t mind if we don’t talk
about feet right now.”
Getting Better at Guiding 147
Just as you can view a patient’s readiness to change on a continuum,
you could consider your desire for the behavior change along similar
lines, say from 1–10, where 1 means that you are in equipoise and 10
means that you feel very strongly about the value of change.
How might this help you in the consultation? Simply being aware
that you have high ABCs should help you to back off. The goal is to
avoid letting the ABCs dominate the exchange with the patient. If you
do not succeed, you might fall into any of a number of traps. Here are
some examples.
ABCs and Some Common Traps
The stronger your feelings about wanting the patient to change, the
more mindful you might need to be about your own behavior. There is
nothing wrong with wanting and
hoping for behavior change in your
patients, but strong ABCs can mislead
you into the righting reflex and
other difficulties. Monitoring how
you are feeling is the first step. Then you might want to be careful not to
fall into a pattern of responding that strays some distance from guiding.
Here are some examples.
DESCENDING INTO DIRECTING
Sometimes you choose a directing style not because you sense that the
patient expects this but because of your feelings about how important it
is for him or her to change. You might be feeling under time pressure or
simply so keen to promote change that you adopt a directing style. The
outcome is some distance from guiding. This can happen in the opening
seconds of a discussion:
PRACTITIONER: [feeling quite determined] Now I’ve been meaning to
ask you, have you done anything about your smoking, because it’s a
big worry for your health.
PATIENT: [shutting down immediately] Well, I never lasted long when I
quit before, so I am just getting on with my life.
PERSUADING TOO HARD
Your desire to encourage change can lead you into a persuasion–resistance
trap: The harder you persuade, the more the patient resists. A
good guide never gets too far out in front.
148 PUTTING IT ALL TOGETHER
Monitoring how strongly you feel
about patient behavior change is
the first step in avoiding difficulties.
PRACTITIONER: [feeling great concern for the patient] Unless you quit
using drugs, you are going to lose your child. Have you thought
about some treatment that might help with this?
PATIENT: My problem is the money, like I take these men in [prostitution]
to feed me and my baby, and the heroin helps me to survive.
RESCUING THE PATIENT
Another common response to strong feelings of wanting patients to
change is to try to rescue them. This can take many forms, from excessive
enthusiasm, urging, and pleading to offering lots of support or even
breaking role and visiting them at home to putting your hand into your
pocket to offer money, and so on. Perversely, rescuing can sometimes be
the last thing the person needs, because you might be unwittingly reinforcing
his or her role as a victim awaiting your solution. Kindness can
be taken too far, particularly when it substitutes for actions that patients
themselves could take.
JUST FOLLOWING THE PATIENT AND GETTING LOST
If someone is struggling with bad news or loss, your heart goes out to
him or her, and you know that just being with him or her and following
his or her struggles can be quite helpful. A similar pattern can unfold in
the discussion of behavior change, when your strong desire to help leads
you to just listen (follow), and you lose control over the direction of the
discussion. In some settings, in which you develop a relationship with
the patient over numerous meetings, this pattern can go on for months
or even years. If behavior change is one of the key issues facing the person,
it can be productive to regain a little control over the direction of
the discussion, perhaps by asking a guiding question or two, without
losing your good relationship with the patient. Agenda setting can be a
productive way of helping both of you stand back from the situation and
consider options for behavior change. Being frank about this with the
patient can also help.
OVERLOADING PATIENTS WITH INFORMATION
You feel very concerned; perhaps you don’t have a lot of time, so you
simply launch into providing information. There is a problem, you are
the professional, you right the things that go wrong, and information
transfer is in your toolbox. Combine this with a strong desire for the patient
to change, and this tool can come out of the box in a flood of information
that soon loses the attention of the passive patient.
Getting Better at Guiding 149
PURSUING PROBLEMS AND WEAKNESSES
You sometimes feel so strongly about getting the job done and about
where you feel the problem lies that you forget the patient’s view and focus
on the troubled zone of problem behavior with a determination that
flattens the patient into defensiveness. Policing “bad” behavior replaces
the opportunity to elicit the patient’s strengths and aspirations.
Your positive aspirations for change in the patient can be a reflection
of considered judgment and genuine concern, or they can be externally
driven by guidelines and service protocols. The former can be used
to good effect; the latter perhaps requires greater watchfulness on your
part. Our aim here is not to turn you into a budding psychotherapist but
simply to encourage you to be mindful of your own emotional reactions
and how they can derail the guiding process.
Behavior-change consultations contain a mixture of your aspirations
and those of the patient. How you steer a constructive path
through this challenge is the next topic.
The Relationship: When Agendas Differ
Consider how a consultation might proceed under the circumstances
presented in the simple two-by-two diagram in Figure 9.1. The most difficult
scenarios are those in which there is a mismatch of aspirations (labeled
with a danger sign in the figure).
When there is a mismatch between you and the patient—most commonly
when your ABCs are high and the patient’s aspirations are low—
time can be wasted if you proceed as if the mismatch does not or should
not exist. You might even feel that you are quietly trying to get around
150 PUTTING IT ALL TOGETHER
Your Aspirations for Behavior Change (ABCs)
High
Low
High Low
FIGURE 9.1. Aspirations for behavior change.
PatientAspirations
this mismatch, effectively nudging or even manipulating the patient this
way and that. The empathy with and acceptance of the patient that lie at
the heart of MI are soon undermined. In this situation, taking stock with
the patient might help, and agenda setting is designed to do just this. A
similar approach is also called for in the reverse situation, where patient
aspirations are high and yours are low. For example, a patient very much
wants a referral for surgery, while you are not at all convinced about
this. At some point you might need to have an open discussion about
this.
Agenda Setting
Agenda setting, introduced in Chapter 4, is a routine strategy for developing
a compromise between your aspirations and agenda and
those of the patient. The more you feel the need to impose your aspirations
on the patient, the greater the need for clear agenda setting of
this kind.
“I want her to get more exercise and prepare for a return to work;
she wants yet another note from me excusing her from work.”
“I want to focus on smoking, and he seems to think that a change in
medication will solve everything.”
“Now he wants yet another referral for a scan, and he knows that I
want him to look at the pressures in everyday life that probably
cause these headaches.”
“She wants more and more pain killers, and I want to her to be more
active.”
Good rapport is invaluable in resolving these difficulties. In Chapter
4 we described a structured process of laying out all the possible topics
one might talk about, providing
both you and the patient the opportunity
at the outset to agree on the
way ahead. However, one can turn
to a less structured form of agenda
setting in the middle of a consultation
in order to tackle a divergence in aspirations between you and the
patient. For example, in the fourth scenario just described, in which the
patient wants more pain killers and you feel that exercise might be
better, you might do the following:
• Summarize how the patient is feeling and your understanding of
her aspirations. This enhances rapport and ensures that the patient does
not feel that you have misunderstood or are ignoring her needs.
Getting Better at Guiding 151
The more you feel the need to
impose your aspirations on the
patient, the greater the need for
clear agenda setting.
• Proceed with agenda setting; for example:
“Let’s just take a step back for a minute and look at our progress.
We both want you free of pain, that’s for sure, and we can
talk about different ways of getting there. There’s taking more
pain killers, something you want and that I have some concerns
about, and then there’s getting more exercise, which I
favor and you have concerns about! So where do we go from
here? Have I missed something?”
It is not advisable to be prescriptive about where you might go next
in a difficult consultation such as this. However, agenda setting does give
you more freedom, for example, to talk about your concerns about pain
killers, particularly if you ask permission first. Conveying concern about
the patient’s well-being and using agenda setting to be open about different
aspirations often leads to a more productive route through the im-
passe.
Tougher Consultations: Where Directing Seems Essential
Everyday practice yields pressures and predicaments that can confuse
both you and your patient. You might ideally want to adopt a guiding
style, but you have other roles as well, often defined by the service you
work in. This can mean that you must at times depart from guiding and
impose certain topics on the patient. Here are some examples.
• You want to help a troubled mother with behavior change because
she might benefit from more social contact with others, from
drinking less alcohol, and from new approaches to the behavioral problems
of her children; but it is also your duty to consider the welfare of
the children if they are at risk.
• Your service requires you to raise the subject of lifestyle change in
a way that is not easy to integrate with a guiding style. There is a routine
assessment that must be done.
• You feel obliged to warn a patient that a test result has some very
clear implications for behavior
change.
• A patient is in the habit of
driving to the clinic intoxicated and
is clearly a danger to others.
If your service, role, or clinical
judgment obliges you to adopt a di-
152 PUTTING IT ALL TOGETHER
You might ideally want to adopt a
guiding style, but you have other
roles as well, often defined by the
service you work in. This can mean
that you must at times depart from
guiding and impose certain topics
on the patient.
recting style and impose a discussion of difficult topics on the patient,
how might this obligation be integrated with a guiding style to be used
for addressing behavior change? Here are some guidelines you might
find useful, using the first example of the troubled mother.
• Put extra work into rapport building and listening, as close as
possible to the beginning of the consultation.
• Clarify the challenge for both of you as soon as possible, ideally
at the beginning of the consultation. You or your patients might find the
metaphor of switching hats useful. Consider this approach:
“A very important part of my job is to help you, in whatever
way seems right for you. And I’d like to spend some time on
this today [the guiding hat]. Then there’s another part of my
job [the directing hat] that means I must think about what’s
best for the children. So I switch between these two jobs. But
I’d like to start with how I might be able to help you, because I
know that a happier mother means happier children, if you
see what I mean.”
• If the problem arises in the middle of a consultation, take a break.
Summarize where you are, step back with the patient, and address this
problem. Try to be clear and honest, making sure that conveying respect
for the patient is a high priority.
• If possible, start with the patient’s concerns, and use a guiding
style. Work hard on expressing acceptance and on demonstrating, with
reflective listening, that you understand the patient’s predicament, even
if this is done briefly in just a few reflective listening statements.
• Make the changing of roles between guide and director explicit.
This is what we mean by “changing hats.” Try not to fudge or blur the
distinction between these roles by
winding your way through the conversation
in a manner that might
confuse the patient. For example,
you might say:
“I’ve talked about my different
jobs, and we have spent
quite a lot of time on how
you might manage the kids
better and get out of the
house more, for your own
sanity. Now I’d like to switch hats and talk only about the children,
because I do have some concerns I’d like to ask you
about. Is that OK?”
Getting Better at Guiding 153
Make the changing of roles between
guide and director explicit. This is
what we mean by “changing hats.”
Try not to fudge or blur the
distinction between these roles by
winding your way through the
conversation in a manner that
might confuse the patient.
YOUR OWN HEALTH
Feeling responsible for changing the behavior of others can be wearing.
As you get better at the guiding style of MI, you may find that this
source of stress diminishes and that you learn to care for and about the
patient without necessarily taking on the heavy burden of making behavior
change happen.
With some release from feeling responsible come other challenges of
a completely different kind: Your good work can take you close to the
heart of the suffering associated with a patient’s efforts to consider
change. This, too, can take its toll
on your well-being. Guiding is a
delicate balance between coming
close enough to your patients to understand
and empathize with their
experiences and retaining your separate
role as a healer. In the biblical
story, Moses finds his calling in life
when his attention is captured by a bush that is burning and yet is not
consumed. That is the healing balance: to burn without being consumed.
A very experienced pediatrician once put it this way:
“Every family that comes to my attention has a story, and every story
is interesting, and every story is different. I am never going to get
burned out because I am interested in their stories. It’s when I start to
treat patients by checklists and formulas that I get bored, and that’s
when I am at risk for burnout.”
LOOKING INTO YOUR OWN CONSULTATIONS
Something else that may help you to get better at guiding is to listen to
recordings (made with patient permission, of course) of your own consultations.
It is like an athlete watching a video of his or her own performance.
You can observe more clearly where things went right and where
they went wrong.
“At first, it felt like I was handing all control over to them, and that
there was no way I could even control the time, let alone get through
what I wanted and needed to do. Then when I was listening to the recording
of a consultation, I noticed this one open question that I
asked. I was in control, but the patient was still moving. The consul-
154 PUTTING IT ALL TOGETHER
Guiding is a delicate balance
between coming close enough to
your patients to understand and
empathize with their experiences
and retaining your separate role
as a healer.
tation had completely changed. I never knew at the time quite what
had happened.”
PRACTICING YOUR SKILLS IN EVERYDAY LIFE
There is a body of literature on mother–infant interaction that suggests
that guiding is an apparently universal and natural communication style
for helping infants to gain mastery over their new environment. Scaffolding
or guided participation are terms used to describe how a good
parent or tutor naturally structures a conversation so that the needs and
abilities of the child are carefully addressed. The skillful parent or tutor
does neither too much for the child (direct) nor too little, leaving the
child to flounder (follow). Skillful guiding produces better learning out-
comes.
Opportunities to practice guiding may include a conversation with a
friend talking about a difficult decision. The temptation to leap in with
solutions using a directing style is often strong. Listening, asking, suggesting,
supporting, and encouraging are probably more useful and effective.
Toward the end of life, elderly people frequently need to discuss
difficult problems. What combination of listening, asking, and informing
does one use? There is no formula here, but using these skills in the
service of guiding is often more effective than simply directing them
about how to resolve matters.
Listening can be practiced in almost any conversation, not only in
the service of guiding. The first thing you may notice when trying to use
reflections in everyday life is that attending
to the wording of your reflection
can take your focus away
from a genuine interest in what the
other person is saying. It is that initially
clumsy feeling as you acquire
skillfulness, but don’t let it deter you. Keep going, because quite soon it
should feel less contrived, and the reward will be there for you to reap.
Beneath all this focus on your skills lies something more important
that extends beyond the technical. Through skillful listening and guiding,
you are conveying a message of acceptance, hope, and compassion.
This cannot be conjured up in an artificial way. In one sense, compassion,
acceptance, and hope are your own internal experiences, but they
are not of much use to patients until you communicate them. You can
voice these things directly, of course: “I care”; “I think everything is going
to be fine.” Yet there is something particularly powerful about a
compassionate, listening, guiding style that communicates hope and acGetting
Better at Guiding 155
Listening can be practiced in almost
any conversation, not only in the
service of guiding.
ceptance not just in what you say but in how you are with your patients.
Chances are that the desire to be a healing presence for others is one of
the reasons you chose your profession. The skills of reflective listening
and the accompanying guiding are among the best ways to communicate
your caring and acceptance. Practicing them also builds your capacity
for acceptance and compassion.
CONCLUSION
This chapter concludes the account of the method of MI and how it can
be used in some quite difficult circumstances in everyday health care.
The next and final chapter turns to the application of MI in the wider
clinical environment in which a service is delivered.
156 PUTTING IT ALL TOGETHER
PUTTING IT ALL TOGETHERBeyond the Consultation
CHAPTER 10
Beyond the Consultation
The primary purpose of this book is to define and describe an approach
to one-to-one health care consultations. We have encouraged you to use
consultations to help patients explore their own ambivalence about
change and to maximize their control over their own health. In this
chapter we offer some examples in which MI was afforded a happy marriage
with the system within which it was used. We hope they show how
MI can be successfully integrated into services that meet the needs of patients
and also promote behavior change.
Individual consultations clearly have their limits. Forces outside of
the consultation, in the clinic and beyond, pose obstacles to patient
change. Economic and social conditions often hold sway over people’s
efforts to improve their health and lifestyles. Forces within the service
also affect your work. For example, if the service or health care system
reinforces patient passivity, your best efforts to promote change through
individual consultations can be undermined.
“Next, please [after a 1-hour wait in a full waiting room]. Thank you,
Ms. Evans. Can I ask you to please get undressed to your underwear
and put this gown on? I’ll come back and do your vital signs, OK?
Then you’ll see the nurse and then. . . .”
If you have a consultation about behavior change after the patient
has been subjected to this kind of routine, it will be that much harder to
accomplish guiding successfully, with its emphasis on the patient who is
actively considering options and taking charge of changes in his or her
157
life. Moreover, if many of your colleagues are not committed to adopting
a more collaborative approach to their communication with patients,
you might well wonder about the impact of your individual work.
These barriers within the health care system and beyond will influence
your patients’ motivations for health change behavior. Can a health
care system be changed so that barriers are removed and practitioners
are better able to integrate a guiding style into their everyday practice?
Our starting point here is that we can and should be doing these things.
Our goal is to identify signposts of change in health service delivery. We
do this fully aware that this challenge of changing systems has been addressed
by others with experience and knowledge far greater than ours.
However, thoughtful changes in a health care practice or system can
make a big difference in what happens in the consulting room and can
make a guiding style easier to use and more effective.
The accounts that follow come from actual clinical practice settings.
We have spoken to the practitioners involved at some length and have
come to know them and their services quite well. The descriptions and
quotations are accurate in spirit but have been adjusted to preserve anonymity
where appropriate. The first set of examples focuses on removing
general system obstacles; the second set involves efforts directly to use
MI in health care.
REMOVING BARRIERS TO CHANGE
In these two examples, system changes helped to make the service more
accessible to patients and their needs and encouraged them to make
choices about behavior change whenever possible. Before the changes, it
seemed all but impossible to integrate MI into the system. Afterward, it
became something that the staff was eager to embrace.
1. Redesigning a Service
Setting and problem: Outpatient clinic for detoxification and treatment
of substance abuse.
Goals: To improve attendance; to engage patients more actively in
treatment; to promote change in substance use.
Before
The program staff members were competent and well intentioned but
also discouraged and demoralized. Every day they saw people whose
158 PUTTING IT ALL TOGETHER
lives had been devastated and who were dependent on alcohol and other
drugs of abuse. The medical staff provided high-quality outpatient detoxification
services, after which substance abuse treatment was available
on site. Yet many patients failed to keep their appointments, even
for initial evaluation. Many who did complete the evaluation and detoxification
never returned for ongoing treatment. Some of them would appear
again months later, once again acutely ill. There was a general attitude
of pessimism and helplessness among the staff that these patients
were generally ungrateful, rude, resistant, unmotivated, and in denial.
Staff turnover was high, as was absenteeism. Quarrels among different
members of the team were common.
Now look for a moment through the eyes of a patient trying to get
help through this service. Appointments could not be made over the telephone.
Rather, patients, most of whom were poor, had to report by 8:00
A.M., when the intake window opened. The clinic itself was located in a
warehouse district some distance from the nearest transportation line,
and it could be a 2-hour journey to reach the clinic via public transport.
The intake window was literally that: a small glass window in a wall behind
which the staff worked. The window opened onto a hallway that
was rather dark and often cold in wintertime. There were four or five
old chairs in the hallway, and other patients had to stand. The normal
morning traffic passed by them: staff members arriving for work, patients
coming in for daily methadone, police and security personnel. By
the time the window opened at 8:00, there was usually a line of people
waiting. Because of the complexity of the intake process, only five or six
could be seen. The rest were told to wait until the afternoon or to go
home and try again the next day. The atmosphere at the intake window
was often surly and chaotic.
Those who stayed were taken, one at a time, back into the medical
clinic area. Some waited 2 hours before being taken inside. They first
saw a nurse, who took vital signs and screened for acute detoxification
needs. Next they spent about half an hour with a case worker, who determined
their employment status, examined income verification (such
as a paycheck stub), and asked a series of questions to determine eligibility
for insurance or public support. If they were not screened out at this
step, they next met with a different intake worker to complete a series of
forms and a structured interview that asked a series of highly personal
questions.
After this, they were given an appointment to return for the orientation,
or “O,” group, one of two weekly groups intended to prepare people
for treatment. It also served as a holding system until patients could
be assigned to a counselor, as well as a screen for “motivation.” The O
group was presented with a series of lectures and films about the harms
Beyond the Consultation 159
of substance abuse, and patients on average attended 4–6 sessions before
being assigned to a counselor. Then they would be given the name of
their counselor and an appointment time to return to begin treatment.
Only a small fraction of patients who appeared at the intake window
made it all the way to a first counseling appointment. For those who did,
the treatment they received was whatever the counselor deemed appro-
priate.
System Changes
New management offered some new resources and the opportunity to
create changes in this service delivery system. The goal was to create a
clinic that was welcoming and accessible and that delivered effective services
as quickly and to as many patients as possible. A set of “seven C’s”
was developed as guiding principles for this new patient-centered model
of care:
1. Courtesy: Every patient, caller, and colleague is treated in a courteous
and respectful manner every time.
2. Collaboration: Staff members have a sense of common purpose
and cooperation toward shared goals. Most goals are met
through collaborative rather than solo efforts.
3. Contribution: Every person carries a fair share of the work to be
done, looking for ways to make personal contributions to common
mission and goals.
4. Conscientiousness: Every person is committed to promoting excellence
of services and is conscientious with regard to work
schedules and standards.
5. Communication: There is open communication throughout the
clinic. Concerns are raised and information is checked directly
with those involved.
6. Connection: Members of each unit understand their connection
to the whole organization and are committed to the common vision
and mission of the clinic.
7. Community: Every person shares a sense of common responsibility
for the atmosphere, appearance, and services of the clinic and
for the welfare of all patients.
Many practical changes were made over the course of a year. The
intake window wall was torn down, creating a comfortably lighted and
heated waiting area with ample seating, separated from the entry hallway.
Patients were welcomed and offered coffee on arrival. Both walk-in
and appointment options were available throughout the day. A patient
160 PUTTING IT ALL TOGETHER
feedback box was installed, with encouragement to comment both on
problems and on good service received. The intake system was streamlined.
Much of the essential information was collected via a questionnaire
completed in the waiting room, with help available for patients
who had difficulty reading or understanding it. The first person they saw
was not a caseworker asking them questions but an experienced senior
counselor who said, “I will need to ask you a few questions after a
while, but right now I just want to hear what brings you in today. Tell
me what’s happening.” A half hour of high-quality listening followed,
which usually provided most of the specific information needed. The
goal was to enhance motivation for change and to provide a service that
would likely be helpful even if this were the patient’s only visit.
The clinic also developed a menu of different evidence-based group
and individual treatment options, which were available at various times
of the day or evening. Hours of service were extended without increasing
overall staffing. The orientation group was discontinued, and instead
patients were given, at intake, a list and explanation of the services available
and were helped to choose from the menu the services they wanted
and needed. Every effort was made to get each patient connected with a
counselor and started in treatment within 1 week. Often the patient was
able to meet his or her counselor during the intake or detoxification pro-
cess.
The impact on both patients and staff was remarkable. Patient retention
increased dramatically, and, after some turnover of staff members
who preferred the old system, so did staff retention. Instead of
blaming patients for being unmotivated, staff members came to see ambivalence
as normal and thought of tackling low motivation as part of
their job. The clinic survived through a managed-care era in which many
others closed, and a comprehensive follow-up evaluation showed excellent
patient outcomes comparable to those seen in well-controlled clinical
trials.
A sense of shared common values runs through the heart of this
story, even though the initial impetus for change came about in a topdown
manner, with a shift in management. The latter is not essential for
redesigning the service. We have encountered a service for adolescents
with diabetes in which a team of practitioners decided to take a new approach
to the problem of poor attendance and low levels of glycemic
control among their patients. The patients were asked what they would
prefer, and the clinic’s hours of service were shifted to late afternoon to
give them time to arrive from school and college. Then a subtler shift began
to take place. The clinic staff moved from a “weight and bloods”
service to something more relaxed, thoughtful, and attuned to patient
needs. This quiet transformation ended up in something very different
Beyond the Consultation 161
from the starting point: a service in which the young people walked in
and were asked, “Who would you like to see first today?” The atmosphere,
the conduct of consultations, and the selection of treatment options
followed a very similar pattern to those just described in the substance
abuse clinic. Attendance improved. The team started with shared
values and a single innovation. This next example illustrates further how
following this principle can bear fruit.
2. A Single Innovation
The following example, which we have tracked for a number of years,
comes from the developing world. The team, working in one of the largest
teaching hospitals in Africa, was faced with a desperate situation:
poor adherence to treatment for a life-threatening condition among poverty-stricken
patients.
Setting and problem: Inpatient and outpatient service for children
with HIV/AIDS; poor adherence to treatment.
Goals: To promote adherence to antiretroviral therapy; to improve
economic and social integration of mothers; to change the program
to encourage healthier lifestyles in patients.
Before
More than 150 mothers were registered with the service, and they
needed to give their children a regular regimen of medication for a lifethreatening
condition. The team could not stress the importance of adherence
highly enough; good timing was essential, each day. The rates
were low, and it was demoralizing for all concerned. The referral rates
were rising. The mothers and their children had HIV/AIDS.
A typical journey for the mothers started in the acute pediatric admission
ward. If the baby or child survived an acute infection, he or she
was transferred to outpatient care. Then the trouble began. Attendance
at subsequent appointments was sporadic, and it seemed difficult to “get
through to” the mothers about the importance of adherence. They had a
bewildered look about them. Communication difficulties abounded, and
staff members regarded many mothers as being “in denial.” Very few
had jobs; they mostly lived in grossly substandard housing; and they
found it very difficult to afford transportation to attend their routine
outpatient appointments. In their culture, HIV was a source of shame. If
they did take Western medicines, many stopped when they or their children
seemed better, leading to multiple medical and public health problems.
“When the mothers get angry,” one nurse remarked, “we know we
are starting to make progress. It means there is hope.” Mostly, however,
162 PUTTING IT ALL TOGETHER
passivity was the norm. Antiretroviral therapy had recently become
available, but how could adherence be improved?
System Changes
The change in service design and delivery can be described quite well by
following the journey of a new mother. She is literally penniless and lives
with 12 others in a shack in a large township. She is brought by ambulance
to the hospital with her very sick child. She spends most of the
next fortnight on the ward, and the child starts to recover from a serious
acute respiratory infection. Soon after arrival, the mother is taken down
the corridor to the outpatient waiting area, where she is introduced to
one of the counselors, who gives her a cup of coffee and a sandwich. She
meets other mothers, who sit around a table. This waiting area is alive
with the atmosphere of a small market. Mothers are making beadwork.
A candle is placed in the middle of the table for cutting the nylon thread
they use. The new mother learns about how she can get work. She starts
to talk with others about the life she leads. Children are playing on and
around the floor, taking turns being seen by a doctor to monitor their
condition and the use of antiretroviral medicine. They seem mostly quite
well.
When the child is discharged from inpatient care, the mother is
given an outpatient appointment and a single bag of beads and some
thread, having been taught to make strings for conference badge holders
by another mother. She returns the next week. She and her child are seen
by a doctor. On either side of this consultation, she meets more mothers,
and the best of her beadwork is bought from her at the nurse’s duty
desk, to be sold by a small charity.
Over the next few months, she learns from other mothers about
antiretroviral medication use. She forms friendships and talks about the
difficult issue of HIV status disclosure. She also has the opportunity to
talk informally or privately with any of the counselors working in the
clinic, many of whom are HIV-positive themselves and have volunteered
to help others. She uses the income from her first bag of beads to buy
more, and she now has full-time work and makes regular return visits to
the clinic, where they have set up a bank account for her.
“Just imagine,” said the lead pediatrician, “the lives these patients
lead. It’s really impossible to imagine. I try, but I cannot.” Looking back,
the change process emerged from an experience of profound empathy.
Glimpses into their lives prompted action.
“We were treating only one part of the problem,” he remarked
some years later. “If people don’t have adequate food in their stomachs,
it impacts on our treatment, and if we do nothing about this, the medical
problems return to haunt us. The point is this: Our responsibilities can
Beyond the Consultation 163
and should go beyond the treatment of the individual. We decided to develop
a socioeconomic intervention within the walls of our hospital.”
What started as an apparently narrow innovation designed to provide
work and money for transportation now helps to break down other
barriers: social isolation, difficulty with status disclosure, understanding
how medication works, and overcoming a wide range of personal and
social obstacles. Treatment for the children, if they adhere to their medication
regimens, is starting to look like the management of other chronic
illnesses such as diabetes, rather than like terminal care. This model of
good practice is being replicated elsewhere (see www.kidzpositive.org).
The staff members have now received initial training in MI, which is
entirely congruent with the ethos of the service and the emphasis on
patient empowerment. The counselors are developing a professional
identity, they meet with the pediatrician each week, and they also network
with other teams treating children in other African countries
(www.teampata.org).
This kind of innovation is not unique. Simply moving a clinic from
a hospital into the community can make a big difference. Indeed, the
growth of primary care across the world could be seen as an effort to improve
access and continuity of care that makes a real impact on people’s
lives. Numerous examples of community initiatives in health and social
care illustrate the value of reaching out to improve awareness, to educate
people about important issues, to provide better care, and even to improve
their economic circumstances. Health behavior change is more
likely to occur under these circumstances.
IMPLEMENTING MI
In the preceding examples, the use of MI emerged as a by-product of
more fundamental service improvement. In this section, attention turns
to direct efforts to introduce MI into a system. In the first example,
training in MI led to complementary changes in service delivery. In the
second, MI was used as the framework for health promotion in a water
purification program in a developing country.
Training in MI and Other Changes
Setting and problem: Inpatient and outpatient hospital service; cardiac
rehabilitation.
Goals: To change the program to encourage healthier lifestyles in patients;
to encourage staff to learn MI; to adjust routines and procedures
in line with a guiding style.
164 PUTTING IT ALL TOGETHER
This brief account describes work in progress, which should afford
you the opportunity to get a better feel for the unfolding nature of
change within a system and for the challenges involved. It could be of interest
to virtually any team working within primary or secondary care.
Before
By the time the patients had passed through their immediate crises, they
seemed passive, frightened, and sometimes depressed, whether they had
undergone surgery or not. They were used to being told of the need to
get more exercise, to control their diets, to stop smoking, and so on. If
they had had problems before they came into the hospital, they now had
quite a few more to contend with. They came from diverse cultural
backgrounds. On discharge, they were invited back into the cardiac rehabilitation
service as outpatients. Attendance was reasonable, but many
dropped out before completing the program.
Staff morale was low, primarily as a result of feeling the pressure of
working with a high caseload and of feeling that it was their responsibility
to make patients change their behavior. The team, comprising many
nurses, a psychologist, a physiotherapist, and a dietician, offered a
multiphased rehabilitation program, which began with an assessment
and included such components as educational group meetings, relaxation
training, and individual consultations. The emphasis was on helping
people with long-term conditions to learn to make healthier choices
of many kinds, much of the latter being lifestyle changes. Practitioners
were clearly united by values that centered on helping patients to maximize
opportunities for improving their health. The urgency of the need
for changes in the patients’ lifestyles confronted all involved. Education,
education, education seemed to be the modus operandi of the service.
Resistance, denial, and stubbornness were qualities frequently attributed
to their patients. Could a shift in the way they talked with patients about
change improve matters?
After
The team leader, a psychologist, showed an article on MI to a lead nurse,
and they agreed that they were spending too much time deciding patient’s
priorities for them, giving advice and providing them with education
of all kinds. Perhaps the attendance rates might improve if the team
was offered the opportunity to learn a different approach. They organized
a 2-day workshop on MI. They knew the direction they wanted to
go in but were able to tolerate uncertainty about the pace and outcome
of the change process. The team had never met together before outside
of conventional case management meetings.
Beyond the Consultation 165
They closed the service for 2 days. Fourteen practitioners turned up
at a country house, the training venue. They were soon engaged in
pretraining simulated consultations, with actors playing roles of typical
patients. Most had never heard about MI, and moving in and out of simulated
exercises was also new to them. Struggles with shifting styles between
directing and guiding were well matched by difficulties in actually
formulating listening statements rather than asking questions. Handing
over elements of responsibility for decisions to the patient seemed to be a
major underlying challenge.
Then reality struck. The pace of routine clinical practice left many
with no apparent alternative to the standard educational approach of
advising patients why and how they should change. Putting MI skills
into practice was clearly quite a challenge. It was not easy to remember
what they had learned in the workshop. With no others around to observe
their practice, or at least to discuss this with them, breaking old
habits was not easy. Yet some had clearly made progress. One said, “I
know sometimes I am talking with a patient and I think ‘Ooooh—that
was MI!’ and I’m thinking I should do that more often. I try to be more
conscious about using it.” Another reported that the coronary care staff
(not part of their team) saw him with patients and asked why he was not
yelling at them about their smoking and telling them to stop eating junk
food. He suggested that maybe these patients got tired of people standing
at the end of their beds telling them that they will die if they do not
do this and do that. One nurse summed it up along these lines: “You
know when you’ve got it right because you get a nice buzz back from the
patient, and you know when you’ve got it horribly wrong because you
get a negative response—it’s the in-between that’s tricky; you’re missing
subtleties, aren’t you?”
Discussion in the coffee room about further learning included suggestions
about shorter booster workshops, peer-support meetings, reading
transcripts, listening to audio recordings, sitting in on each other’s
consultations, and scoring one’s own consultation using a checklist. Yet
the senior practitioners who had initiated the workshops and had participated
with enthusiasm were not inclined to follow these ideas. They had
a larger idea: culture change, to examine together the way in which the
service routines reinforced or undermined behavior change.
TEAM MEETINGS
The team was offered a series of 2-hour “team meetings” to consider
how the service might be adjusted in line with the principles of a guiding
rather than a directing style. Initially, the facilitator tried to elicit from
the members what changes they would like to make, after which their at-
166 PUTTING IT ALL TOGETHER
tention focused on two topics, assessment and groups. They had five
meetings in all, spread out over a period of 3 months, and all involved
agreed that it got better as they went along. To begin with, they said,
things seemed a little unfocused. As they got better at working together
and reaching agreement about changes to the service, their everyday
practice became more innovative and mutually supportive. The term culture
change was widely used in their discussions, and they seemed better
able to tolerate individual and professional differences. “Now,” said one
practitioner, “I get e-mails and telephone calls from others in the team
asking for help with problems.”
CHANGING ASSESSMENT PROCEDURES
The first meeting with a new patient involved a lengthy assessment that
took, on average, 30 minutes. The typical pattern was for the practitioner
to use a directing style to elicit answers to a sequence of set questions
and to fill this information in as they went along. Initial efforts to make
the changes agreed on in the team meetings were frustrating, because the
practitioners felt that the forms still dictated the course of the conversation
and that the patients merely responded to this process. They wanted
the assessment to have a less “clinical” feel, to be more of a two-way
process, one in which the patient was also given the chance to consider
his or her aspirations for behavior change.
They made more substantial changes to the order of questions.
They inserted some new ones that elicited the patient’s views about the
origins of their heart disease and about their beliefs and aspirations for
lifestyle change. Some questions of a factual nature were left to the end.
The assumption was that if the patient was active in the assessment process,
answers to these questions would probably emerge in the natural
course of the conversation. A new “crib sheet” was constructed so that
the discussion could flow freely from the patient’s perspective, with the
practitioner making sure that all the topics were being covered. Then the
form was completed.
The assessment process clearly became more interesting for both
parties. One practitioner commented, “I’m astounded at the stories I get
told by people who maybe have had angina for 20 years, but their understanding
of it is really bizarre sometimes.” Another noted:
“I find the new bits of the assessment very useful because asking the
patient what they think happened to them and what brought them
here is just such a useful tool. There was no space for that in the previous
form. And also things like asking them what their primary concern
is, which is often not their cardiac condition, but their heart
Beyond the Consultation 167
attack is meaningless against the fact that their wife is really ill, or
children taking drugs, and it does put it into context—they will come
to our service but they may not find it as interesting as you expect
them to. I find that really useful.”
Getting a feel for the whole person, including his or her views about
where lifestyle change might fit in, made it easier to decide what to focus
on in later consultations. Some claimed that this assessment took longer
than the old procedure; others disagreed and teased their colleagues for
being “slow coaches.”
PATIENT EDUCATION GROUPS
The team ran a sequence of educational topic-driven “talks” each week.
They decided to rely less on PowerPoint presentations, they changed the
order of topics, and they constructed guidelines for handling questions
and observations from patients. The most radical change was a newly
constructed final session with an open-ended format to explore struggles
with behavior change, following the principles of MI.
The groups provided practitioners with their one opportunity to actually
work together in pairs. One of the problems with a less structured
format was letting go of the well-intentioned impulse to provide patients
with every bit of information they felt they needed. The payoff was
greater involvement from the patients.
“It’s difficult. It’s more difficult because I’m so used to just giving the
information and that’s it, and then you ask questions at the end, but
this is almost like open forum and you know what—I think they get
more from it. . . . More people start throwing in their ideas, then
somebody else will and somebody else. The person you would least
expect to say something just comes out and says something and you
think, fantastic. . . . And they seem more enthusiastic about things
then. Instead of just standing up there and giving them the information
we’re now looking at the patients’ needs and what they need is
not always what you imagine . . . so I think I’ve become more sympathetic
toward patients that way, emotionally. Definitely.”
Over the first few months, the team learned about the circumstances
in which particular questions were useful in group discussions.
Asking about importance and confidence (see Chapter 4) was apparently
very helpful in talk about medication use. Use of a pros-and-cons strategy
(Chapter 4) they found more generally applicable and especially useful
in talk about exercise: “This is very good for finding gaps in their un-
168 PUTTING IT ALL TOGETHER
derstanding, like it seems that 90% of the patients don’t think of
walking as exercise.” On the subject of feedback, one nurse said, “Well,
I think it’s stopped us pussyfooting around the patients as well. You
know, we allow patients to tell us what they think ought to be the feedback,
and they allow us to tell them what we think ought to be in feedback,
and I think we meet in the middle.”
Changes in one part of the program affected others. One practitioner
was heard to say, “After trying this out for the first time in groups, I
have this sort of conversation outside of the group as well, so the one
feeds into the other for me.” This process affected even those who had
not attended the initial MI training. “There are some members of the
team who never came into the training, and they’ve learned from the
way we are managing the groups, and they’re changing what they do,
which is really interesting.”
In interviews a year later, staff members agreed that throwing everyone
together in the same workshop on a subject they knew little about
was a great leveler. It brought them together across professional boundaries
with a legitimate focus. The use of practical exercises was not
suited to everyone’s taste or learning style. One nurse said, “I hated the
groups (simulations), sitting around and dragging things out of people,
but I loved the MI.”
Commentary
With commitment and creativity, change in an organization or service is
achievable and will enhance patient health behavior change. The process
of gradual change mirrors the most frequent pattern of behavior change
among patients. Attention is focused on both the why and the how of
behavior change. In the preceding example, team meetings and training
events served to highlight not just what to do—the how of change—but
also the why of change—their commitment to shifting their service in
line with more effective and respectful ways of promoting health behavior
change. Tolerance of uncertainty and ambivalence, setting achievable
goals, and reviewing progress are all individual-practitioner behaviorchange
issues that required mindfulness and a firm guiding style from
team leaders themselves. Essentially, the whole team became better at
guiding:
“It’s useful for me to talk to that person as an individual and find out
what is important to them about becoming fitter. It might be something
simple like being able to do the housework, or somebody else
could be wanting to run a marathon, so it’s good really to find out
what that individual’s needs are really and how far they want to go—
Beyond the Consultation 169
and how far they can go with other problems as well. So that has
helped me as well to sort of relate to them as an individual.”
The interest in using groups conducted along these lines of MI has
grown considerably in recent years. Table 10.1 contains some general
guidelines constructed with two colleagues who have worked on this
topic in a number of settings.
MI and Public Health Promotion
In the developing world, access to safe drinking water is a major health
problem, and diarrhea caused by water-borne organisms is a leading
cause of death for children under the age of 5. Relatively simple and inexpensive
water purification methods are available and effectively reduce
disease and death from contaminated water supplies. The most
common methods used to persuade families to adopt water purification
methods are educational in nature, passing on “why” and “how” information.
However, for a variety of reasons, such educational strategies
can be ineffective in promoting this life-saving behavior change.
Such was the case in regions of Zambia. In an attempt to address
this problem, Dr. Angelica Thevos and her colleagues tried a unique experiment.
They identified two communities without water systems, in
which utilization of chlorine for water purification remained low. Ten
health promotion volunteers serving these areas were divided into two
teams of five. The team serving one area received no additional training
and continued to use the educational materials (fliers, flip-chart-guided
talks) to introduce families to the chlorination procedures. The team
serving the other area was given 5 hours of training in MI specifically
adapted to the subject of water purification, including role-play practice
exercises.
Over the next 8 months, the team used a simple, unobtrusive measure
to evaluate the adoption of water purification: the number of bottles
of sodium hypochloride sold in each locale. They reported a large effect
(p < .001), with chlorine sales being two to four times higher in the
community visited by MI-trained volunteers.* A single study seldom
provides definitive answers. You might wonder, for example, what exactly
the trained health promotion volunteers did in their conversations
with people. However, both this example and that of the cardiac rehabilitation
team strongly suggest that trainers, researchers, and practitioners
170 PUTTING IT ALL TOGETHER
* Thevos, A. K., Quick, R. E., & Yanduli, V. (2000). Application of motivational interviewing
to the adoption of water disinfection practices in Zambia. Health Promotion International,
15(3), 207–214.
Beyond the Consultation 171
TABLE 10.1. Guidelines for Guiding in Groups
Principles
In addition to the fundamental principles of collaboration, evocation, and
honoring autonomy (see Chapter 1), consider these additional possibilities that
apply specifically to the group setting:
Avoid traps
• Don’t conduct multiple individual consultations in a group setting.
• Avoid question and answer sessions conducted by you, the expert.
• Avoid allowing the group to become either too unfocused or too serious.
Golden rules
• Remember your goal: to bring everyone together to focus on a topic and gain
support from one another.
• Link individual stories to topic and experience of others. Extract the essence of
the patient’s story and broaden it out. A skillful facilitator will reframe
“interrupting” as redirecting.
• Encourage the quiet, soften the loud. For example, you might ask quiet
members to summarize some part of the group discussion and discuss how it fits
for them. You might ask talkative members to summarize their points and pose
a question to the group.
• Minimize negative interactions. Participants can overdo giving advice to others
or even confront their apparent “denial” or excuse for avoiding change. Don’t
let negative interactions escalate. Remain empathic and supportive, but act
immediately to regain control when group processes are going in a negative
direction. Ask participants to reframe their advice to others into statements of
“what has worked for me.”
• Keep the focus of the group on enhancing motivation to change, increasing
hope, and reducing the sense of burden that change imposes. Don’t allow the
groups to become exploratory psychotherapy groups or complaint sessions.
Topics and strategies
• Past successes: Focusing on things that participants have achieved can help to
restore self-confidence and spark creativity in regard to the current change.
• Ambivalence: Focusing on participants’ mixed feelings about change can help
reduce defensiveness while preparing them to both initiate change and prevent
relapse.
• Values: Supporting participants in examining how their current behavior fits
with their core values can enhance motivation to change and help them find an
internal source of direction to rely on when the status quo is threatening to take
the upper hand.
• Looking forward: Helping participants envision a better future, rather than
falling into a pattern of begrudgingly acknowledging and exploring past failures,
can positively affect the relationship between the participants and their struggles
to change.
• Exploring strengths: Eliciting participants’ sense of their own strengths can
enhance their self-esteem and help them find internal resources that can support
their current change effort. With mature groups, leaders can facilitate sharing of
impressions of one another’s strengths. This can be a quite powerful, supportive
experience.
• Planning change: Using discussion and worksheets to plan change alone, in
pairs, or as a large group can help transform vague motivation into concrete
(continued)
themselves can explore, evaluate, and implement strategies that are
based on the principles and practice of MI. A listing of research studies
can be found in Appendix B.
CONCLUSION
The preceding examples illustrate various ways in which changes were
made in service systems beyond the individual office consultation to promote
patient well-being and health behavior change. A happy coincidence
exists between the goals of patient empowerment initiatives such
as those described in this chapter and the use of MI. The former makes
the latter easier to use. Both need attention to succeed, and both involve
practitioners who respond creatively to patient predicaments, who convey
respect, hope, flexibility, and skill inside the consultation and beyond.
It is one thing to sit with an individual patient and demonstrate restraint,
tolerance of uncertainty, and trust in his or her ability to make
good decisions; it is quite another to offer a service in which there is collective
adherence to these values and skills.
In essence, we encourage you to try this collaborative, empathic
guiding style in your individual practice and to think creatively about
how health care delivery systems can be modified to be more consistent
with this patient-empowering approach. In so many modern health
problems, patient behavior change is a vital component of prevention
and treatment. Practitioners have much control over prescriptions and
procedures but little direct control when it comes to patients’ behavior,
in which a more collaborative approach is needed. MI is often effective
in evoking behavior change when education and exhortation have failed.
It is not every clinician’s cup of tea, but if you like the flavor of it, you
have a lifetime of practice ahead of you in which to try it out. We conclude
the book with a brief, practical epilogue and two appendices with
information about learning and research.
172 PUTTING IT ALL TOGETHER
TABLE 10.1. (continued)
plans that help in initiating and maintaining change. Encourage participants to
state one small change they are committing to rather than making a grand but
vague plan. Follow up on how these commitments went in the next group
meeting.
• Exploring importance and confidence: Using importance and confidence rulers
to examine the relationship between participants and their change plans helps
participants to see that these internal cognitive and emotional elements can
either support them in their change efforts or hold them back.
Note. Written with Drs. Karen Ingersoll and Chris Wagner. Reprinted with permission from the
authors.
EpilogueEpilogue
Epilogue
Some Maps to Guide You
LEARNING MI
Acquiring skill in MI is more complex and more satisfying than just
learning a few new techniques. There is a more fundamental learning
process in which you become comfortable with a shift to a guiding style,
let go of the righting reflex, and instead trust the wisdom of your patients.
Once you feel comfortable with this shift in approach when talking
about health behavior change, more learning follows.
Oversimplifying a bit, we break the learning process down into
three phases.
Phase 1: Shifting Styles with Comfort
Here you grasp the differences between styles (directing, guiding, and following),
and how the three core skills (asking, listening, and informing)
vary in both quality and quantity across them (Chapter 2). You notice
what happens with your patients when you shift styles and develop the
ability to do this comfortably and naturally. When you shift into guiding,
try to retain control of the direction of the consultation, but leave it up to
the patient to voice why and how he or she might change. This lifts from
you the constant burden of being responsible for making change happen.
Practice verbally expressing the four RULE principles (Chapter 1)
with patients during normal consultations. Choose your moment, shift to
a guiding style, and let them know that you don’t want to rush in and provide
solutions (Resist the righting reflex), that you want to know how they
173
really feel about change (Understand their motivations) by Listening, and
that you believe that they can find solutions (Empower them). Consider
using practical aids such as an agenda-setting chart or a readiness ruler to
help you (Chapter 4) clarify what the patient wants to talk about and how
ready he or she is to change. Use more open than closed questions (Chapter
4). Practitioners often find that they get quite different responses from patients
when they shift into a guiding style, even early in the learning process.
You can see the fruits of learning relatively soon, and sometimes consultations
take on a dramatically different tone than they have before.
One other technique in this early phase is very useful: the summary
(Chapter 5). When you make the shift to guiding, the patient usually becomes
verbally more active, and quite a lot is said, often in just a minute
or two. It can feel a little overwhelming. You might wonder whether you
are losing control of both the time and the direction of the discussion.
Offer a summary of what’s been said. You’ll find the patient appreciative
and able to change direction if you so wish.
You know you are making progress when shifting back and forth
between styles starts to feel less like a major event and more like an easy
part of a normal conversation. This kind of experience can provide you
with encouragement to learn more.
Phase 2: Getting Better at Guiding
Once you are comfortable with the value of a guiding style, you start becoming
more skillful at it. You develop time-efficient ways of setting an
agenda (Chapter 4). This usually ensures that the patient is “on board”
and that good rapport is maintained. Formulate simple open questions
about behavior change (Chapter 4) and use listening statements as a way
of weaving your way through brief explorations of the why and how of
change (Chapter 5). Practice using longer summaries to bring together
what’s been said, encourage progress, and shift direction as needed
(Chapter 5). Through all of this, keep a sense of curiosity and patience,
holding back your righting reflex more consistently. Again, a saving
grace is that practitioners often see significant shifts in behavior-change
consultations when they try out even a few of the skills, such as asking open
questions, reflecting, and summarizing, in the course of daily practice.
Phase 3: Refining Your MI Skills
Once you get comfortable with the appropriate shift of a guiding style
and how to use the basic core skills in this way, the rest is refinement. As
described earlier, you learn to hear and attend to your patients’ change
talk, which tells you when you’re doing it right. Your patients become
your teachers. You find a range of open questions that work for you to
174 Epilogue
open up conversations about behavior change and to elicit change talk.
The simpler the better. You begin identifying the rich array of change
talk in patients’ speech. You notice what happens when you make a listening
statement immediately afterward. Try reflecting different elements
of patients’ speech, particularly their change talk. Practice collecting
change talk in longer summaries using the patient’s own language,
connected to his or her values and aspirations.
In the course of training and research, we have found that within
the good practice of MI there is a wide range of personal approaches.
The three of us, in fact, practice rather differently, yet we are manifesting
the same underlying guiding style. It is in this third phase that you make
MI your own, finding what works for you in helping your patients make
health behavior changes.
A CONSULTATION GUIDE
No two consultations are alike, yet patterns often arise, for better or
worse, usually highlighted by junctions that signal a shift in topic or perhaps
in the style used by the practitioner. In a constructive consultation
with a patient who has recently received bad news, for example, most
practitioners would use a following style to begin with, and then ask
whether the patient has any questions. Elements of a guideline for good
practice can thus be constructed, as long as they contain flexibility that
allows for the uniqueness of each consultation and the participants
within it.
In the consultation about behavior change the most important element
we have highlighted in this book is what we called the spirit of the
conversation, where a guiding style is used to elicit from the patient their
own good reasons for change.
Some practitioners report a sort of “freezing” experience, where all
is going well, until they suddenly feel unsure about where to go next.
The guideline that they simply adhere to the spirit of the method seems
insufficient to help them through this kind of impasse. Might a more
concrete guideline be helpful?
We’ve constructed one below, despite concerns about inadvertently
promoting a formulaic approach to behavior change consulting. It’s a
deliberately rough guide, one that is best viewed as an adjunct to the basic
need to keep to the spirit of the consultation emphasized in so many
places in this book.
1. Agree on the Focus
Establish rapport. Fundamental to good practice is the simple notion
that the more friendly and supportive the atmosphere, the more the
Epilogue 175
patient feels understood by you, the better will be progress within and
beyond the consultation.
Set agenda (Chapters 4 and 9). If there is only one behavior that is
relevant (e.g., smoking), then this task is usually straightforward. You
raise the subject and ask permission to talk about it. If there are a number
of interrelated behaviors that could be addressed, invite the patient
to consider the range of possibilities, paying attention to their preferences
and readiness to change (Chapter 4), while being honest about
your concerns. Reach agreement about a specific behavior on which to
focus.
Emphasize the spirit of your approach to the consultation (Chapter
1). Simple messages can convey a great deal. They also help you to settle
into a guiding style, and to make this clear to the patient. For example, a
single sentence or two can convey quite a lot: “I see my job as not to lecture
you about what you could change, but more as guide, using my experience
with other patients to help you make decisions that make sense
to you. I’d like to start by understanding what you really feel about
change, is that OK?”
2. Explore and Build Motivation to Change
This is the heart of the discussion about behavior change, where
you are listening for change talk, and inviting the patient to amplify why
and how they might change. Among the possibilities open to you are:
Exchange information (Chapter 6). Using something like the elicit–
provide–elicit framework can do much to enhance motivation to change.
Ask useful guiding questions (Chapter 4). Combine these with reflective
listening (Chapter 5), effectively an invitation to clarify how the
patient feels and to consider different perspectives, with a keen eye on
the link between behavior change and their core values.
Consider using structured strategies (Chapter 4). For example,
“Pros and Cons” and “Assessing Importance and Confidence” are designed
to open the door to eliciting the patient’s own motivation to
change (change talk).
3. Summarize Progress
Among the possibilities here are:
Provide a long summary (Chapter 5). Follow this by asking the patient
what the next step might be.
Return to agenda setting (Chapter 4). To clarify progress and agree
on the way ahead.
Consider the next step. Clarify any plans for the future that you and
the patient have agreed upon (e.g., follow-up visit, work on a specific
and achievable goal).
176 Epilogue
Appendix AAppendix A
APPENDIX A
Learning More about
Motivational Interviewing
“Could you come and teach us motivational interviewing over the noon hour? A
drug company is providing lunch.” Such invitations are common, and they bespeak
a misunderstanding of MI as a quick trick, a simple procedure that one
could learn in a few minutes over pizza. Instead, think of MI as a complex clinical
skill that is developed and refined over the course of one’s career, much like
learning to play chess or golf or the piano. A 1-hour lecture or even a full day of
training is unlikely to engender much proficiency in such skills. The guiding style
of MI is not a technique but a clinical method, a particular way of being with pa-
tients.
If MI is like chess, golf, or playing the piano, then one can expect at best
modest gains from reading or hearing about it or even from watching videotape
of the skilled practitioners. Practicing the fundamental shift to a guiding style
can be done in everyday practice, in which the patient’s reaction provides immediate
opportunity for improving skill. Supporting this kind of learning in everyday
practice is usually the best way to proceed.
It can be quite ambitious to expect practitioners to attend a workshop and
return proficient in MI. We’ve tried. In one study, we randomized practitioners
who wanted to learn MI to one of five training conditions. To one group we sent
our book (Miller & Rollnick, 2002) and a set of training videotapes (Miller,
Rollnick, & Moyers, 1998) and asked them to do their best to learn it on their
own. Four months later, there was no improvement in performance (Miller,
Yahne, Moyers, Martinez, & Pirritano, 2004). Skill improvement was also mini-
177
mal in another group, who were given these resources and also received a 2-day
clinical workshop with Dr. Miller (cf. Miller & Mount, 2001). Rather, proficiency
in MI occurred only when one or both of two training aids were added:
systematic feedback on performance and personal skill coaching. This makes
sense, because feedback and expert coaching are precisely how one typically
learns to master any complex skill. When we examined patient responses to the
practitioners, the only group showing substantial improvement was the one that
received both feedback and coaching, in addition to training (Miller et al.,
2004).
By implication, we do not expect you to become proficient in MI just by
reading this book nor even by going to an introductory lecture or workshop,
though it can be a good start. You learn this method by doing it in a situation in
which you can get feedback about how you’re doing. Practice without feedback
is not particularly helpful and can easily produce bad habits. It’s rather like playing
an electronic keyboard with the sound turned off. You can feel and imagine
yourself performing the operations without the satisfaction (or dissatisfaction) of
hearing the result.
AIDS TO LEARNING
One good aid to learning, then, is access to a clinician who is proficient in MI,
someone who is more skillful at it than you are. You will also need to practice on
your own, but short blocks of time with an expert coach can be very helpful. In
order to help you, the coach will need to listen to your practice (perhaps by audiotape),
much as a tennis coach needs to watch you and a piano teacher needs
to hear you play. Many health care systems have done this by hiring a supervisor
who is proficient in MI or bringing one of their current staff members up to such
expertise through training. This person then can function as an in-house coach,
helping other staff members to develop and strengthen their own clinical skills.
This is quite different from a one-time training event in that the learning continues
over time. Other systems and programs, lacking such an in-house expert,
have set up ongoing peer consultations and support groups that meet regularly
to discuss MI and listen to each other’s practice.
Another option is to bring in an expert trainer once or periodically to help
clinicians strengthen their practice. Repeated visits give clinicians the opportunity
to try out learned skills in between training sessions and to bring questions
and problems back to the trainer. One list of MI trainers is found at
www.motivationalinterview.org, along with a description of training exercises
often used to help practitioners learn this clinical method.
As discussed in many parts of this book, you also have at your disposal another
very reliable source of performance feedback: your patients. Every time
you practice MI, your patients give you clues as to how you are doing. Consider,
178 Appendix A
for example, the component skill of reflective listening. Your patient discloses
some personal information, and you do your best to respond with a reflective listening
statement (Chapter 7). You get two immediate forms of feedback. First,
the patient tells you whether or not the content of your reflection was correct:
PATIENT: I’ve been feeling kind of blue lately.
PRACTITIONER: You’re feeling a little sad.
PATIENT: Yes, I can’t really explain it, but I just break out crying over noth-
ing.
Or
PATIENT: No, not sad really. It’s more a lonely feeling.
Either way you get more information, and either way you’re receiving feedback
about the accuracy of your reflection. Second, if the patient keeps on talking
to you, exploring the topic, and revealing more information, chances are you
are doing it right.
Another important source of feedback is the patient’s change talk (Chapter
5). At first you are asking and listening for DARN talk—desire, ability, reasons,
and need for health behavior change. As you receive and collect these “flowers,”
you also reflect them and collect them in summary bouquets that you offer
back to the patient. When you do this well, you begin hearing commitment
language (Chapter 5), statements such as “I will” and “I am going to.” These
signal the kind of mental processing that leads, not always but usually, to behavior
change.
Thus from your patients’ own speech, what they say to you during consultations,
you can get feedback about how you are doing in learning MI. It can be
challenging at first to hear this in the midst of a consultation, and this is one reason
that it can be helpful to tape-record some visits (with patient permission, of
course) and review them later, either by yourself or with a consultant, trainer, or
peer group. Trainers also sometimes review tapes by using a structured coding
system that can yield a wealth of specific information. Several such systems have
been published (Lane et al., 2005; Madson, Campbell, Barrett, Brondino, &
Melchert, 2005; Miller & Mount, 2001; Moyers, Martin, Catley, Harris, &
Ahluwalia, 2003; Moyers, Martin, Manuel, Hendrickson, & Miller, 2005;
Rosengren, Baer, Hartzler, Dunn, & Wells, 2005).
The essential message here is that it takes time to develop skill in MI.
One does not master it from reading or watching or from a single training. It
can be slow going at first, as with any complex skill. Think of it as a learning
process that happens over time, supported as feasible by feedback and coaching.
It is a skill in which you can continue to improve for as long as you prac-
tice.
Appendix A 179
TRAINERS
For better or worse, we have made no attempt to restrict the practice or training
of MI. There is currently no formal, accredited route to becoming a trainer of
this clinical method. There is, however, an organization whose mission is to
promote quality in the training of MI: the international Motivational Interviewing
Network of Trainers (MINT). MINT operates an informational website
(www.motivationalinterview.org) with a cumulative bibliography, extensive information
about the clinical method, and a geographical listing of its members,
who as of 2007 provide training in at least 27 languages. It also publishes a
MINT Bulletin that is available online free of charge.
It is important to distinguish between teaching about MI (as one might do
in a survey course) and providing clinical training in the method itself. Our perspective
is that a competent trainer of MI should be quite proficient in delivering
it. The MINT website includes an overview titled “What Might You Expect Out
of Different Lengths and Types of Training?” that provides a good sense of the
range of skills required of a trainer. There is also a manual containing a menu of
exercises that MINT trainers use in various configurations.
If you are seeking a trainer, the MINT website is a good place to start.
MINT periodically offers a 3-day specialized training for trainers that its own
members have completed and that qualifies new trainers for membership in
MINT. This does not in itself guarantee competence as a trainer, of course. If you
are seeking a trainer or consultant, you might ask potential candidates about
how much experience they have had working with practitioners in your area of
expertise and for references from prior training events.
A BIBLIOGRAPHY ON TRAINING OF MI
Amrhein, P. C., Miller, W. R., Yahne, C., Knupsky, A., & Hochstein, D. (2004). Strength of
client commitment language improves with therapist training in motivational interviewing.
Alcoholism: Clinical and Experimental Research, 28(5), 74A.
Baer, J. S., Rosengren, D. B., Dunn, C. W., Wells, W. A., Ogle, R. L., & Hartzler, B. (2004). An
evaluation of workshop training in motivational interviewing for addiction and mental
health clinicians. Drug and Alcohol Dependence, 73(1), 99–106.
Bennett, G. A., Roberts, H. A., Vaughan, T. E., Gibbins, J. A., & Rouse, L. (2007). Evaluating
a method of assessing competence in motivational interviewing: A study using simulated
patients in the United Kingdom. Addictive Behaviors, 32, 69–79.
Broers, S., Smets, E. M. A., Bindels, P., Evertsz, F. B., Calff, M., & DeHaes, H. (2005).
Training general practitioners in behavior change counseling to improve asthma medication
adherence. Patient Education and Counseling, 58, 279–287.
Brug, J., Spikmans, F., Aarsen, C., Breedveld, B., Bes, R., & Ferreira, I. (2007). Training dietitians
in basic motivational interviewing skills results in changes in their counseling style
and in lower saturated fat intakes in their patients. Journal of Nutrition Education and
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Burke, P. J., DaSilva, J. D., Vaughan, B. L., & Knight, J. R. (2006). Training high school coun-
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Byrne, A., Watson, R., Butler, C., & Accoroni, A. (2006). Increasing the confidence of nursing
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182 Appendix A
Appendix BAppendix B
APPENDIX B
A Topical Bibliography of Research
on Motivational Interviewing
ALCOHOL/DRUG ABUSE
Adamson, S. J., & Sellman, J. D. (2001). Drinking goal selection and treatment outcome in
out-patients with mild–moderate alcohol dependence. Drug and Alcohol Review, 20,
351–359.
Agostinelli, G., Brown, J. M., & Miller, W. R. (1995). Effects of normative feedback on consumption
among heavy drinking college students. Journal of Drug Education, 25, 31–
40.
Allsop, S., Saunders, B., Phillips, M., & Carr, A. (1997). A trial of relapse prevention with severely
dependent male problem drinkers. Addiction, 92, 61–74.
Alwyn, T., John, B., Hodgson, R. J., & Phillips, C. J. (2004). The addition of a psychological
intervention to a home detoxification programme. Alcohol and Alcoholism, 39, 536–
541.
Anton, R. F., Moak, D. H., Latham, P., Waid, L. R., Myrick, H., Voronin, K., et al. (2005).
Naltrexone combined with either cognitive behavioral or motivational enhancement
therapy for alcohol dependence. Journal of Clinical Psychopharmacology, 25, 349–357.
Anton, R. F., O’Malley, S. S., Ciraulo, D. A., Couper, D., Donovan, D. M., Gastfriend, D. R.,
et al. (2006). Combined pharmacotherapies and behavioral interventions for alcohol dependence.
The COMBINE study: A randomized controlled trial. Journal of the American
Medical Association, 295, 2003–2017.
Aubrey, L. L. (1998). Motivational interviewing with adolescents presenting for outpatient
substance abuse treatment. Unpublished doctoral dissertation, University of New Mex-
ico.
Babor, T. F. (2004). Brief treatments for cannabis dependence: Findings from a randomized
multisite trial. Journal of Consulting and Clinical Psychology, 72, 455–466.
Baer, J. S., Garrett, S. B., Beadnell, B., Wells, E. A., & Peterson, P. L. (in press). Brief motivational
intervention with homeless adolescents: Evaluating effects on substance use and
service utilization. Psychology of Addictive Behaviors.
Baer, J. S., Kivlahan, D. R., Blume, A. W., McKnight, P., & Marlatt, G. A. (2001). Brief inter-
183
vention for heavy-drinking college students: 4-year follow-up and natural history. American
Journal of Public Health, 91, 1310–1316.
Baer, J. S., Marlatt, G. A., Kivlahan, D. R., Fromme, K., Larimer, M., & Williams, E. (1992).
An experimental test of three methods of alcohol risk-reduction with young adults. Journal
of Consulting and Clinical Psychology, 60, 974–979.
Bailey, K. A., Baker, A. L., Webster, R. A., & Lewin, T. J. (2004). Pilot randomized controlled
trial of a brief alcohol intervention group for adolescents. Drug and Alcohol Review,
23(2), 157–166.
Baker, A., Boggs, T. G., & Lewin, T. J. (2001). Randomized controlled trial of brief cognitive-
behaviouralinterventionsamongregularusersofamphetamine.Addiction,96,1279–1287.
Baker, A., Lee, N. K., Claire, M., Lewin, T. J., Grant, T., Pohlman, S., et al. (2005). Brief cognitive–behavioural
interventions for regular amphetamine users: A step in the right direction.
Addiction, 100, 367–378.
Ball, S. A., Todd, M., Tennen, H., Armeli, S., Mohr, C., Affleck, G., et al. (2007). Brief motivational
enhancement and coping skills interventions for heavy drinking. Addictive Behaviors,
32, 1105–1118.
Barnett, N. P., Tevyaw, T. O., Fromme, K., Borsari, B., Carey, K. B., Corbin, W. R., et al.
(2004). Brief alcohol interventions with mandated or adjudicated college students. Alcoholism:
Clinical and Experimental Research, 77, 49–59.
Battjes, R. J., Gordon, M. S., O’Grady, K. E., Kinlock, T. W., Katz, E. C., & Sears, E. A.
(2004). Evaluation of a group-based substance abuse treatment program for adolescents.
Journal of Substance Abuse Treatment, 27, 123–134.
Bellack, A. S., Bennett, M. E., Gearon, J. S., Brown, C. H., & Yang, T. (2006). A randomized
clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent
mental illness. Archives of General Psychiatry, 63, 426–432.
Bennett, G. A., Edwards, S., & Bailey, J. (2002). Helping methadone patients who drink excessively
to drink less: Short term outcomes of a pilot motivational intervention. Journal
of Substance Use, 7, 191–197.
Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S., & Hingson, R. (2005).
Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and
Alcohol Dependence, 77, 49–59.
Bien, T. H., Miller, W. R., & Boroughs, J. M. (1993). Motivational interviewing with alcohol
outpatients. Behavioural and Cognitive Psychotherapy, 21, 347–356.
Booth, R. E., Corsi, K. F., & Mikulich-Gilbertson, S. K. (2004). Factors associated with methadone
maintenance treatment retention among street-recruited injection drug users.
Drug and Alcohol Dependence, 74, 177–185.
Borsari, B., & Carey, K. B. (2000). Effects of a brief motivational intervention with college
student drinkers. Journal of Consulting and Clinical Psychology, 68, 728–733.
Breslin, C., Li, S., Sdao-Jarvie, K., Tupker, E., & Ittig-Deland, V. (2002). Brief treatment for
young substance abusers: A pilot study in an addiction treatment setting. Psychology of
Addictive Behaviors, 16, 10–16.
Brown, J. M., & Miller, W. R. (1993). Impact of motivational interviewing on participation
and outcome in residential alcoholism treatment. Psychology of Addictive Behaviors, 7,
211–218.
Brown, T. G., Dongier, M., Latimer, E., Legault, L., Seraganian, P., Kokin, M., et al. (2006).
Group-delivered brief intervention versus standard care for mixed alcohol/other drug
problems: A preliminary study. Alcoholism Treatment Quarterly, 24, 23–40.
Budney, A. J., Higgins, S. T., Radonovich, K. J., & Novy, P. L. (2000). Adding voucher-based
incentives to coping skills and motivational enhancement improves outcomes during
treatment for marijuana dependence. Journal of Consulting and Clinical Psychology, 68,
1051–1061.
184 Appendix B
Carroll, K. M., Ball, S. A., Nich, C., Martino, S., Frankforter, T. L., Farentinos, C., et al.
(2006). Motivational interviewing to improve treatment engagement and outcome in individuals
seeking treatment for substance abuse: A multisite effectiveness study. Drug
and Alcohol Dependence, 81, 301–312.
Carroll, K. M., Easton, C. J., Hunkele, K. A., Neavins, T. M., Sinha, R., Ford, H. L., et al.
(2006). The use of contingency management and motivational/skills-building therapy to
treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology,
74, 955–966.
Carroll, K. M., Libby, B., Sheehan, J., & Hyland, N. (2001). Motivational interviewing to enhance
treatment initiation in substance abusers: An effectiveness study. American Journal
on Addictions, 10, 335–339.
Cisler, R. A., Barrett, D. E., Zweben, A., & Berger, L. K. (2003). Integrating a brief motivational
treatment in a private outpatient clinic: Client characteristics, utilization of services
and preliminary outcomes. Alcoholism Treatment Quarterly, 21(3), 1–21.
Collins, S. E., & Carey, K. B. (2005). Lack of effect for decisional balance as a brief motivational
intervention for at-risk college drinkers. Addictive Behaviors, 30, 1425–1430.
Connors, G. J., Walitzer, K. S., & Dermen, K. H. (2002). Preparing clients for alcoholism
treatment: Effects on treatment participation and outcomes. Journal of Consulting and
Clinical Psychology, 70, 1161–1169.
Copello, A., Godfrey, C., Heather, N., Hodgson, R., Orford, J., Raistrick, D., et al. (2001).
United Kingdom Alcohol Treatment Trial (UKATT): Hypotheses, design and methods.
Alcohol and Alcoholism, 36, 11–21.
D’Angelo, M. (2006). A comparative study of motivational interviewing and traditional
treatment approach on movement along stages of change, treatment completion, compliance
with aftercare plan, and length of abstinence. Unpublished doctoral dissertation.
Davidson, D., Gulliver, S. B., Longabaugh, R., Wirtz, P. W., & Swift, R. (2007). Building
better cognitive-behavioral therapy: Is broad-spectrum treatment more effective than
motivational-enhancement therapy for alcohol-dependent patients treated with naltrexone?
Journal of Studies on Alcohol and Drugs, 68, 238–247.
Davis, T. M., Baer, J. S., Saxon, A. J., & Kivlahan, D. R. (2003). Brief motivational feedback
improves post-incarceration treatment contact among veterans with substance use disorders.
Drug and Alcohol Dependence, 69, 197–203.
Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., et al. (2004).
The Cannabis Youth Treatment (CYT) study: Main findings from two randomized trials.
Journal of Substance Abuse Treatment, 27, 197–213.
Dennis, M., Scott, C. K., & Funk, R. (2003). An experimental evaluation of recovery management
checkups (RMC) for people with chronic substance use disorders. Evaluation
and Program Planning, 26, 339–352.
DeWildt, W., Schippers, G. M., Van den Brink, W., Potgeiter, A. S., Deckers, F., & Bets, D.
(2002). Does psychosocial treatment enhance the efficacy of acamprosate in patients
with alcohol problems? Alcohol and Alcoholism, 37, 375–382.
Dunn, C. W., & Ries, R. (1997). Linking substance abuse services with general medical care:
Integrated, brief interventions with hospitalized patients. American Journal of Drug and
Alcohol Abuse, 23, 1–13.
Dzialdowski, A., & London, M. (1999). A cognitive behavioural intervention in the context
of methadone tapering treatment for opiate addiction: Two single cases. Clinical Psychology
and Psychotherapy, 6, 308–323.
Emmen, M. J., Schippers, G. M., Bleijenberg, G., & Wollersheim, H. (2005). Adding psychologist’s
intervention to physicians’ advice to problem drinkers in the outpatient clinic. Alcohol
and Alcoholism, 40, 219–226.
Feldstein, S. W. (2007). Motivational interviewing with late adolescent college underage
Appendix B 185
drinkers: An investigation of therapeutic alliance. Unpublished doctoral dissertation,
University of New Mexico.
Floyd, R. L., Sobell, M., Velasquez, M. M., Ingersoll, K., Nettleman, M., Sobell, L., et al.
(2007). Preventing alcohol-exposed pregnancies: A randomized controlled trial. American
Journal of Preventive Medicine, 32, 1–10.
Foote, J., Deluca, A., Magura, S., Warner, A., Grand, A., Rosenblum, A., et al. (1999). A
group motivational treatment for chemical dependency. Journal of Substance Abuse
Treatment, 17, 181–192.
Gil, A. G., Wagner, E. F., & Tubman, J. G. (2004). Culturally sensitive substance abuse intervention
for Hispanic and African American adolescents: Empirical examples from the
Alcohol Treatment Targeting Adolescents in Need (ATTAIN) project. Addiction, 99,
140–150.
Gray, E., McCambridge, J., & Strang, J. (2005). The effectiveness of motivational interviewing
delivered by youth workers in reducing drinking, cigarette and cannabis smoking
among young people: Quasi-experimental pilot study. Alcohol and Alcoholism, 40, 535–
539.
Grenard, J. L., Ames, S. L., Wiers, R. W., Thush, C., Stacy, A. W., & Sussman, S. (2007). Brief
intervention for substance use among at-risk adolescents: A pilot study. Journal of Adolescent
Health, 40(2), 188–191.
Handmaker, N. S., Hester, R. K., & Delaney, H. D. (1999). Videotaped training in alcohol
counseling for obstetric care practitioners: A randomized controlled trial. Obstetrics and
Gynecology, 93, 213–218.
Handmaker, N. S., Miller, W. R., & Manicke, M. (1999). Findings of a pilot study of motivational
interviewing with pregnant drinkers. Journal of Studies on Alcohol, 60, 285–287.
Heather, N., Rollnick, S., Bell, A., & Richmond, R. (1996). Effects of brief counselling
among heavy drinkers identified on general hospital wards. Drug and Alcohol Review,
15, 29–38.
Hester, R. K., Squires, D. D., & Delaney, H. D. (2005). The drinker’s check-up: 12-month
outcomes of a controlled clinical trial of a stand-alone software program for problem
drinkers. Journal of Substance Abuse, 28, 159–169.
Hickman, M. E. (1999). The effects of personal feedback on alcohol intake in dually diagnosed
clients: An empirical study of William R. Miller’s motivational enhancement therapy.
Unpublished doctoral dissertation.
Holder, H. D., Cisler, R. A., Longabaugh, R., Stout, R. L., Treno, A. J., & Zweben, A. (2000). Al-
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Ingersoll, K., Floyd, L., Sobell, M., Velasquez, M. M., Baio, J., Carbonari, J., et al. (2003). Reducing
the risk of alcohol-exposed pregnancies: A study of a motivational intervention in
community settings. Pediatrics, 111, 1131–1135.
Ingersoll, K. S., Ceperich, S. D., Nettleman, M. D., Karanda, K., Brocksen, S., & Johnson, B.
A. (2005). Reducing alcohol-exposed pregnancy risk in college women: Initial outcomes
of a clinical trial of a motivational intervention. Journal of Substance Abuse Treatment,
29, 173–180.
John, U., Veltrup, C., Driessen, M., Wetterling, T., & Dilling, H. (2003). Motivational intervention:
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in-patients. Alcohol and Alcoholism, 38(3), 263–269.
Juarez, P., Walters, S. T., Daugherty, M., & Radi, C. (2006). A randomized trial of motivational
interviewing and feedback with heavy drinking college students. Journal of Drug
Education, 36, 233–246.
Kadden, R. M., Litt, M. D., Kabela-Cormier, E., & Petry, N. M. (2007). Abstinence rates following
behavioral treatments for marijuana dependence. Addictive Behaviors, 32,
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Karno, M. P., & Longabaugh, R. (2004). What do we know? Process analysis and the search
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Kuchipudi, V., Hobein, K., Fleckinger, A., & Iber, F. L. (1990). Failure of a 2-hour motivational
intervention to alter recurrent drinking behavior in alcoholics with gastrointestinal
disease. Journal of Studies on Alcohol, 51, 356–360.
Labrie, J. W., Lamb, T. F., Pedersen, E. R., & Quinlan, T. (2006). A group motivational interviewing
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Lapham, S. C., Chang, I. Y., & Gregory, C. (2000). Substance abuse intervention for health
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Lincourt, P., Kuettel, T. J., & Bombardier, C. H. (2002). Motivational interviewing in a group
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Longshore, D., & Grills, C. (2000). Motivating illegal drug use recovery: Evidence for a culturally
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Martin, G., Copeland, J., & Swift, W. (2005). The adolescent cannabis check-up: Feasibility
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McCambridge, J., & Strang, J. (2005). Deterioration over time in effect of motivational interviewing
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Mullins, S. A., Suarez, M., Ondersma, S. J., & Page, M. C. (2004). The impact of motivational
interviewing on substance abuse treatment retention: A randomized controlled
trial of women involved with child welfare. Journal of Substance Abuse Treatment,
27(1), 521–558.
Murphy, J. G., Benson, T. A., Vuchinich, R. E., Deskins, M. M., Eakin, D., Flood, A. M., et al.
(2004). A comparison of personalized feedback for college student drinkers delivered
with and without a motivational interview. Journal of Studies on Alcohol, 65, 200–203.
Murphy, J. G., Duchnick, J. J., Vuchinich, R. E., Davison, J. W., Karg, R. S., Olson, A. M., et
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al. (2001). Relative efficacy of a brief motivational intervention for college student drinkers.
Psychology of Addictive Behaviors, 15(4), 373–379.
Noonan, W. C. (2001). Group motivational interviewing as an enhancement to outpatient alcohol
treatment. Unpublished doctoral dissertation, University of New Mexico.
Ondersma, S. J., Svikis, D. S., & Schuster, C. R. (2007). Computer-based motivational intervention
for post-partum drug use: A randomized trial. American Journal of Preventive
Medicine, 32, 231–238.
Peterson, P. L., Baer, J. S., Wells, E. A., Ginzler, J. A., & Garrett, S. B. (2006). Short-term
effects of a brief motivational intervention to reduce alcohol and drug use among homeless
adolescents. Psychology of Addictive Behaviors, 20, 254–264.
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Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol,
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Project MATCH Research Group. (1997). Project MATCH secondary a priori hypotheses.
Addiction, 92, 1671–1698.
Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity:
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Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity:
Treatment main effects and matching effects on drinking during treatment. Journal
of Studies on Alcohol, 59, 631–639.
Project MATCH Research Group. (1998). Matching patients with alcohol disorders to
treatments: Clinical implications from Project MATCH. Journal of Mental Health, 7,
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Project MATCH Research Group. (1998). Therapist effects in three treatments for alcohol
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Reid, S. C., Teesson, M., Sannibale, C., Matsuda, M., & Haber, P. S. (2005). The efficacy of
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trial. Journal of Studies on Alcohol, 66, 833–841.
Richmond, R., Heather, N., Kehoe, L, & Webster, I. (1995). Controlled evaluation of a general
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Rohsenow, D. J., Monti, P. M., Martin, R. A., Colby, S. M., Myers, M. G., Gulliver, S. B., et al.
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Rosenblum, A., Cleland, C., Magura, S., Mahmood, D., Kosanke, N., & Foote, J. (2005).
Moderators of effects of motivational enhancements to cognitive behavioral therapy.
American Journal of Drug and Alcohol Abuse, 31, 35–58.
Saitz, R., Palfai, T. P., Cheng, D. M., Horton, N. J., Freedner, N., Dukes, K., et al. (2007).
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Sanchez, F. P. (2001). A values-based intervention for alcohol abuse. Unpublished doctoral
dissertation, University of New Mexico.
Saunders, B., Wilkinson, C., & Phillips, M. (1995). The impact of a brief motivational intervention
with opiate users attending a methadone programme. Addiction, 90, 415–424.
Schneider, R. J., Casey, J., & Kohn, R. (2000). Motivational versus confrontational interviewing:
A comparison of substance abuse assessment practices at employee assistance
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Secades-Villa, R., Fernande-Hermida, J. R., & Arnaez-Montaraz, C. (2004). Motivational
interviewing and treatment retention among drug user patients: A pilot study. Substance
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B 189
ized controlled trial of motivational enhancement therapy (MET) for mild to moderate
alcohol dependence. Journal of Studies on Alcohol, 62, 389–396.
Senft, R. A., Polen, M. R., Freeborn, D. K., & Hollis, J. F. (1997). Brief intervention in a primary
care setting for hazardous drinkers. American Journal of Preventive Medicine, 13,
464–470.
Sinha, R., Easton, C., Renee-Aubin, L., & Carroll, K. M. (2003). Engaging young probationreferred
marijuana-abusing individuals in treatment: A pilot trial. American Journal on
Addictions, 12(4), 314–323.
Sobell, L. C., Sobell, M. B., Leo, G. I., Agrawal, S., Johnson-Young, L., & Cunningham, J. A.
(2002). Promoting self-change with alcohol abusers: A community-level mail intervention
based on natural recovery studies. Alcoholism: Clinical and Experimental Research,
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Spirito, A., Monti, P. M., Barnett, N. P., Colby, S. M., Sindelar, H., Rohsenow, D. J., et al.
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itive adolescents treated in an emergency department. Journal of Pediatrics, 145, 396–
402.
Stein, L. A. R., & Lebeau-Craven, R. (2002). Motivational interviewing and relapse prevention
for DWI: A pilot study. Journal of Drug Issues, 32(4), 1051–1069.
Stein, L. A. R., Colby, S. M., Barnett, N. M., Monti, P. M., Golembeske, C., & Lebeau-Craven,
R. (2006). Effects of motivational interviewing for incarcerated adolescents on driving
under the influence after release. American Journal of Addictions, 15(Suppl. 1), 50–57.
Stein, L. A. R., Colby, S. M., Barnett, N. P., Monti, P. M., Golembeske, C., Lebeau-Craven,
R., et al. (2006). Enhancing substance abuse treatment engagement in incarcerated adolescents.
Psychological Services, 3, 25–34.
Stein, M. D., Anderson, B., Charuvastra, A., Maksad, J., & Friedman, P. D. (2002). A brief
intervention for hazardous drinkers in a needle exchange program. Journal of Substance
Abuse Treatment, 22, 23–31.
Stephens, R. S., Roffman, R. A., & Curtin, L. (2000). Comparison of extended versus brief treatments
for marijuana use. Journal of Consulting and Clinical Psychology, 68, 898–908.
Stephens, R. S., Roffman, R. A., Fearer, S. A., Williams, C., & Burke, R. S. (2007). The marijuana
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957.
Stockwell, T., & Gregson, A. (1986). Motivational interviewing with problem drinkers: Impact
on attendance, drinking and outcome. British Journal of Addiction, 81(5), 713.
Supplee, P. D. (2005). The importance of providing smoking relapse counseling during the
postpartum hospitalization. Journal of Obstetric, Gynecologic and Neonatal Nursing,
34, 703–712.
Thevos, A. K., Roberts, J. S., Thomas, S. E., & Randall, C. L. (2000). Cognitive behavioral
therapy delays relapse in female socially phobic alcoholics. Addictive Behaviors, 25(3),
333–345.
Thevos, A. K., Thomas, S. E., & Randall, C. L. (2001). Social support in alcohol dependence
and social phobia: Treatment comparisons. Research on Social Work Practice, 11(4),
458–472.
Walker, D. D., Roffman, R. A., Stephens, R. S., Wakana, K., Berghuis, J. P., & Kim, W.
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randomized controlled trial. Journal of Consulting and Clinical Psychology, 74,
628–632.
Walters, S. T., Bennett, M. E., & Miller, J. H. (2000). Reducing alcohol use in college students:
A controlled trial of two brief interventions. Journal of Drug Education, 30, 361–
372.
White, H. R., Morgan, T. J., Pugh, L. A., Celinski, K., Labovie, E. W., & Pandina, R. J.
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Journal of Studies on Alcohol, 67, 309–317.
190 Appendix B
Zywiak, W. H., Longabaugh, R., & Wirtz, P. W. (2002). Decomposing the relationships between
pretreatment social network characteristics and alcohol treatment outcome. Journal
of Studies on Alcohol, 63(1), 114–121.
ASTHMA/COPD
Broers, S., Smets, E. M. A., Bindels, P., Evertsz, F. B., Calff, M., & DeHaes, H. (2005).
Training general practitioners in behavior change counseling to improve asthma medication
adherence. Patient Education and Counseling, 58, 279–287.
de Blok, B. M., de Greef, M. H., ten Hacken, N. H., Sprenger, S. R., Postema, K., & Wempe, J.
B. (2006). The effects of a lifestyle physical activity counseling program with feedback of
a pedometer during pulmonary rehabilitation in patients with COPD: A pilot study. Patient
Education and Counseling, 61(1), 48–55.
Schmaling, K. B., Blume, A. W., & Afari, N. (2001). A randomized controlled pilot study of
motivational interviewing to change attitudes about adherence to medications for
asthma. Journal of Clinical Psychology in Medical Settings, 8, 167–172.
BRAIN INJURY
Bell, K. R., Temkin, N. R., Esselman, P. C., Doctor, J. N., Bombardier, C. H., Fraser, R. T., et
al. (2005). The effect of a scheduled telephone intervention on outcome after moderate to
severe traumatic brain injury: A randomized trial. Archives of Physical Medicine and Rehabilitation,
86, 851–856.
Bombardier, C. H., & Rimmele, C. T. (1999). Motivational interviewing to prevent alcohol
abuse after traumatic brain injury: A case series. Rehabilitation Psychology, 44, 52–67.
CARDIOVASCULAR HEALTH/HYPERTENSION
Beckie, T. M. (2006). A behavior change intervention for women in cardiac rehabilitation.
Journal of Cardiovascular Nursing, 21, 146–153.
Brodie, D. A., & Inoue, A. (2005). Motivational interviewing to promote physical activity for
people with chronic heart failure. Journal of Advanced Nursing, 50, 518–527.
McHugh, F., Lindsay, G. M., Hanlon, P., Hutton, I., Brown, M. R., Morrison, C., et al.
(2001). Nurse-led shared care for patients on the waiting list for coronary artery bypass
surgery: A randomised controlled trial. Heart, 86(3), 317–323.
Ogedegbe, G., & Chaplin, W. (2005). Motivational interviewing improves systolic blood
pressure in hypertensive African Americans [Abstract]. American Journal of Hypertension,
18, A212.
Ogedegbe, G., Schoenthaler, A., Richardson, T., Lewis, L., Belue, R., Espinosa, E., et al.
(2007). An RCT of the effect of motivational interviewing on medication adherence in
hypertensive African Americans: Rationale and design. Contemporary Clinical Trials,
28, 169–181.
Riegel, B., Dickson, W., Hoke, L., McMahon, J. P., Reis, B. F., & Sayers, S. (2006). A motivational
counseling approach to improving heart failure self-care: Mechanisms of effectiveness.
Journal of Cardiovascular Nursing, 21, 232–241.
Scales, R. (1998). Motivational interviewing and skills-based counseling in cardiac rehabilitation:
The Cardiovascular Health Initiative and Lifestyle Education (CHILE) study.
Unpublished doctoral dissertation, University of New Mexico.
Appendix B 191
Scales, R., Lueker, R. D., Atterbom, H. A., Handmaker, N. S., & Jackson, K. A. (1997). Impact
of motivational interviewing and skills-based counseling on outcomes in cardiac rehabilitation.
Journal of Cardiopulmonary Rehabilitation, 17, 328.
Watkins, C. L., Anton, M. F., Deans, C. F., Dickinson, H. A., Jack, C. I., Lightbody, C. E., et
al. (2007). Motivational interviewing early after acute stroke: A randomized, controlled
trial. Stroke, 38, 1004–1009.
Woollard, J., Beilin, L., Lord, T., Puddey, I., MacAdam, D., & Rouse, I. (1995). A controlled
trial of nurse counselling on lifestyle change for hypertensives treated in general practice:
Preliminary results. Clinical and Experimental Pharmacology and Physiology, 22, 466–
468.
Woollard, J., Burke, V., & Beilin, L. J. (2003). Effects of general practice–based nurse-counselling
on ambulatory blood pressure and antihypertensive drug prescription in patients
at increased risk of cardiovascular disease. Journal of Human Hypertension, 17, 689–
695.
Woollard, J., Burke, V., Beilin, L. J., Verheijden, M., & Bulsara, M. K. (2003). Effects of a
general practice–based intervention on diet, body mass index and blood lipids in patients
at cardiovascular risk. Journal of Cardiovascular Risk, 10, 31–40.
DENTISTRY
Skaret, E., Weinstein, P., Kvale, G., & Raadal, M. (2003). An intervention program to reduce
dental avoidance behaviour among adolescents: A pilot study. European Journal of Paediatric
Dentistry, 4, 191–196.
Weinstein, P., Harrison, R., & Benton, T. (2004). Motivating parents to prevent caries in their
young children: One-year findings. Journal of the American Dental Association, 135(6),
731–738.
Weinstein, P., Harrison, R., & Benton, T. (2006). Motivating mothers to prevent caries: Confirming
the beneficial effect of counseling. Journal of the American Dental Association,
137, 789–793.
DIABETES
Channon, S., Smith, V. J., & Gregory, J. W. (2003). A pilot study of motivational interviewing
in adolescents with diabetes. Archives of Disease in Childhood, 88(8), 680–683.
Clark, M., & Hampson, S. E. (2001). Implementing a psychological intervention to improve
lifestyle self-management in patients with type 2 diabetes. Patient Education and Counseling,
42, 247–256.
Hokanson, J. M., Anderson, R. L., Hennrikus, D. J., Lando, H. A., & Kendall, D. M. (2006).
Integrated tobacco cessation counseling in a diabetes self-management training program:
A randomized trial of diabetes and reduction of tobacco. Diabetes Educator, 32, 562–570.
Rubak, S., Sandbaek, A., Lauritzen, T., Borch-Johnsen, K., & Christensen, B. (in press).
Effect of the motivational interview on measures of quality care in people with screen detected
type 2 diabetes: A one-year follow-up of a RCT. British Journal of General Prac-
tice.
Rubak, S., Sandbaek, A., Lauritzen, T., Borch-Johnsen, K., & Christensen, B. (in press). A
RCT study: Effect of “motivational interviewing” on beliefs and behaviour among patients
with type 2 diabetes detected by screening. Scandinavian Journal of Public
Health.
192 Appendix B
Smith, D. E., Heckemeyer, C. M., Kratt, P. P., & Mason, D. A. (1997). Motivational interviewing
to improve adherence to a behavioral weight-control program for older obese
women with NIDDM: A pilot study. Diabetes Care, 20, 52–54.
Trigwell, P., Grant, P. J., & House, A. (1997). Motivation and glycemic control in diabetes
mellitus. Journal of Psychosomatic Research, 43, 307–315.
Viner, R. M., Christie, D., Taylor, V., & Hey, S. (2003). Motivational/solution-focused intervention
improves HbA1c
in adolescents with type 1 diabetes: A pilot study. Diabetic Medicine,
20(9), 739–742.
West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing
improves weight loss with type 2 diabetes. Diabetes Care, 30, 1081–1087.
DIET/LIPIDS
Berg-Smith, S. M., Stevens, V. J., Brown, K. M., Van Horn, L., Gernhofer, N., Peters, E., et al.
(1999). A brief motivational intervention to improve dietary adherence in adolescents.
Health Education Research, 14, 399–410.
Bowen, D., Ehret, C., Pedersen, M., Snetselaar, L., Johnson, M., Tinker, L., et al. (2002). Results
of an adjunct dietary intervention program in the women’s health initiative. Journal
of the American Dietetic Association, 102(11), 1631–1637.
Bowen, D. J., Beresford, S. A. A., Vu, T., Fend, Z. D., Tinker, L., Hart, A., et al. (2004). Baseline
data and design for a randomized intervention study of dietary change in religious organizations.
Preventive Medicine, 39, 602–611.
Brug, J., Spikmans, F., Aartsen, C., Breedveld, B., Bes, R., & Fereira, I. (2007). Training dietitians
in basic motivational interviewing skills results in changes in their counseling style
and in lower saturated fat intakes in their patients. Journal of Nutrition Education and
Behavior, 39, 8–12.
Fuemmeler, B. F., Masse, L. C., Yaroch, A. L., Resnicow, K., Campbell, M. K., Carr, C., et al.
(2006). Psychosocial mediation of fruit and vegetable consumption in the Body and Soul
effectiveness trial. Health Psychology, 25, 474–483.
Mhurchu, C. N., Margetts, B. M., & Speller, V. (1998). Randomized clinical trial comparing
the effectiveness of two dietary interventions with hyperlipidaemia. Clinical Science, 95,
479–487.
Resnicow, K., Campbell, M. K., Carr, C., McCarty, F., Wang, T., Periasamy, S., et al. (2004).
Body and soul: A dietary intervention conducted through African-American churches.
American Journal of Preventive Medicine, 27, 97–105.
Resnicow, K., Coleman-Wallace, D., Jackson, A., Digirolamo, A., Odom, E., Wang, T., et al.
(2000). Dietary change through black churches: Baseline results and program description
of the Eat for Life trial. Journal of Cancer Education, 15, 156–163.
Resnicow, K., Jackson, A., Blissett, D., Wang, T., McCarty, F., Rahotep, S., et al. (2005). Results
of the Healthy Body Healthy Spirit trial. Health Psychology, 24, 339–348.
Resnicow, K., Jackson, A., Wang, T., De, A. K., McCarty, F., Dudley, W. N., et al. (2001). A
motivational interviewing intervention to increase fruit and vegetable intake through
Black churches: Results of the Eat for Life trial. American Journal of Public Health, 91,
1686–1693.
Resnicow, K., Taylor, R., Baskin, M., & McCarty, F. (2005). Results of Go Girls: A weight
control program for overweight African-American adolescent females. Obesity Research,
13, 1739–1748.
Richards, A., Kettelmann, K. K., & Ren, C. R. (2006). Motivating 18- to 24-year-olds to increase
their fruit and vegetable consumption. Journal of the American Dietetic Association,
106, 1405–1411.
Appendix B 193
Wen, D. B., Ehret, C., Pedersen, M., Snetselaar, L., Johnson, M., Tinker, L., et al. (2002). Abstract
results of an adjunct dietary intervention program in the Women’s Health Initiative.
Journal of the American Dietetic Association, 102(11), 1631–1637.
West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing
improves weight loss with type 2 diabetes. Diabetes Care, 30, 1081–1087.
Woollard, J., Burke, V., Beilin, L. J., Verheijden, M., & Bulsara, M. K. (2003). Effects of a
general practice–based intervention on diet, body mass index and blood lipids in patients
at cardiovascular risk. Journal of Cardiovascular Risk, 10, 31–40.
DOMESTIC VIOLENCE
Kennerley, R. J. (2000). The ability of a motivational pre-group session to enhance readiness
for change in men who have engaged in domestic violence. Unpublished doctoral disser-
tation.
Kistenmacher, B. R. (2000). Motivational interviewing as a mechanism for change in men
who batter: A randomized controlled trial. Unpublished doctoral dissertation, University
of Oregon.
DUAL DIAGNOSIS (SUBSTANCE USE
DISORDER AND MENTAL ILLNESS)
Baker, A., Bucci, S., Lewin, T., Kay-Lambkin, F., Constable, P. M., & Carr, V. J. (2006). Cognitive-behavioral
therapy for substance use disorders in people with psychotic disorders:
Randomized clinical trial. British Journal of Psychiatry, 188, 439–444.
Baker, A., Lewin, T., Reichler, H., Clancy, R., Carr, V., Garrett, R., et al. (2002). Evaluation of
a motivational interview for substance use within psychiatric in-patient services. Addiction,
97(10), 1329–1337.
Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S. W., Moring, J., O’Brien, R., et al.
(2001). Randomized controlled trial of motivational interviewing, cognitive behavior
therapy, and family intervention for patients with comorbid schizophrenia and substance
use disorders. American Journal of Psychiatry, 158, 1706–1713.
Brown, R. A., Ramsey, S. E., Strong, D. R., Myers, M. G., Kahler, C. W., Lejuez, C. W., et al.
(2003). Effects of motivational interviewing on smoking cessation in adolescents with
psychiatric disorders. Tobacco Control, 12(Suppl. 4), 3–10.
Carey, K. B., Carey, M. P., Maisto, S. A., & Purnine, D. M. (2002). The feasibility of enhancing
psychiatric outpatients’ readiness to change their substance use. Psychiatric Services,
53, 602–608.
Daley, D. C., Salloum, I. M., Zuckoff, A., Kirisci, L., & Thase, M. E. (1998). Increasing treatment
adherence among outpatients with depression and cocaine dependence: Results of a
pilot study. American Journal of Psychiatry, 155, 1611–1613.
Daley, D. C., & Zuckoff, A. (1998). Improving compliance with the initial outpatient session
among discharged inpatient dual diagnosis clients. Social Work, 43, 470–473.
Graeber, D. A., Moyers, T. B., Griffith, G., Guajardo, E., & Tonigan, J. S. (2003). A pilot
study comparing motivational interviewing and an educational intervention in patients
with schizophrenia and alcohol use disorders. Community Mental Health Journal, 39,
189–202.
Haddock, G., Barrowclough, C., Tarrier, N., Moring, J., O’Brien, R., Schofield, N., et al.
(2003). Cognitive-behavioural therapy and motivational intervention for schizophrenia
194 Appendix B
and substance misuse: 18-month outcomes of a randomized controlled trial. British Journal
of Psychiatry, 183, 377–378.
Hulse, G. K., & Tait, R. J. (2002). Six-month outcomes associated with a brief alcohol intervention
for adult in-patients with psychiatric disorders. Addiction, 21, 105–112.
Hulse, G. K., & Tait, R. J. (2003). Five-year outcomes of a brief alcohol intervention for adult
in-patients with psychiatric disorders. Addiction, 98, 1061–1068.
Kavanagh, D. J., Young, R., White, A., Saunders, J. B., Wallis, J., Shockley, N., et al. (2004). A
brief motivational intervention for substance misuse in recent-onset psychosis. Drug and
Alcohol Review, 23, 151–155.
Kreman, R., Yates, B. C., Agrawal, S., Fiandt, K., Briner, W., & Shurmur, S. (2006). The effects
of motivational interviewing on physiological outcomes. Applied Nursing Research,
19, 167–170.
Martino, S., Carroll, K. M., Nich, C., & Rounsaville, B. J. (2006). A randomized controlled
pilot study of motivational interviewing for patients with psychotic and drug use disorders.
Addiction, 101, 1479–1492.
Martino, S., Carroll, K. M., O’Malley, S. S., & Rounsaville, B. J. (2000). Motivational interviewing
with psychiatrically ill substance abusing patients. American Journal on Addictions,
9, 88–91.
Santa Ana, E. J. (2005). Efficacy of group motivational interviewing (GMI) for psychiatric
inpatients with chemical dependence. Unpublished doctoral dissertation.
Swanson, A. J., Pantalon, M. V., & Cohen, K. R. (1999). Motivational interviewing and
treatment adherence among psychiatric and dually-diagnosed patients. Journal of Nervous
and Mental Disease, 187, 630–635.
Tapert, S. F., Colby, S. M., Barnett, N. P., Spirito, A., Rohsenow, D. J., Myers, M. G., et al.
(2003). Depressed mood, gender, and problem drinking in youth. Journal of Child and
Adolescent Substance Abuse, 12(4), 55–68.
Zuckoff, A., Shear, K., Frank, E., Daley, D. C., Seligman, K., & Silowash, R. (2006). Treating
complicated grief and substance use disorders: A pilot study. Journal of Substance Abuse
Treatment, 30, 205–211.
EATING DISORDERS/OBESITY
Dunn, E. C., Neighbors, C., & Larimer, M. (2006). Motivational enhancement therapy and
self-help treatment for binge eaters. Psychology of Addictive Behaviors, 20, 44–52.
Feld, R., Woodside, D. B., Kaplan, A. S., Olmsted, M. P., & Carter, J. C. (2001). Pretreatment
motivational enhancement therapy for eating disorders: A pilot study. International
Journal of Eating Disorders, 29, 393–400.
Long, C. G., & Hollin, C. R. (1995). Assessment and management of eating disordered patients
who over-exercise: A four-year follow-up of six single case studies. Journal of Mental
Health, 4, 309–316.
Pung, M. A., Niemeier, H. M., Cirona, A. C., Barrera, A. Z., & Craighead, L. W. (2004). Motivational
interviewing in the reduction of risk factors for eating disorders: A pilot study.
International Journal of Eating Disorders, 35(4), 396–397.
Smith, D. E., Heckemeyer, C. M., Kratt, P. P., & Mason, D. A. (1997). Motivational interviewing
to improve adherence to a behavioral weight-control program for older obese
women with NIDDM: A pilot study. Diabetes Care, 20, 52–54.
Treasure, J. L., Katzman, M., Schmidt, U., Troop, N., Todd, G., & De Silva, P. (1999). Engagement
and outcome in the treatment of bulimia nervosa: First phase of a sequential
design comparing motivation enhancement therapy and cognitive behavioural therapy.
Behaviour Research and Therapy, 37, 405–418.
Appendix B 195
EMERGENCY DEPARTMENT/TRAUMA/INJURY PREVENTION
Dunn, C., Droesch, R. M., Johnston, B. D., & Rivara, F. P. (2004). Motivational interviewing
with injured adolescents in the emergency department: In-session predictors of change.
Behavioural and Cognitive Psychotherapy, 32(1), 113–116.
Johnston, B. D., Rivara, F. P., & Droesch, R. M. (2002). Behavior change counseling in the
emergency department to reduce injury risk: A randomized, controlled trial. Pediatrics,
110, 267–274.
Schermer, C. R., Moyers, T. B., Miller, W. R., & Bloomfield, L. A. (2006). Trauma center brief
interventions for alcohol disorders decrease subsequent driving under the influence arrests.
Journal of Trauma, 60, 29–34.
Zatzick, D., Roy-Byrne, P., Russo, J., Rivara, F., Droesch, R., Wagner, A., et al. (2004). A randomized
effectiveness trial of stepped collaborative care for acutely injured trauma survivors.
Archives of General Psychiatry, 61(5), 498–506.
FAMILY/RELATIONSHIPS
Cordova, J. V., Scott, R. G., Dorian, M., Mirgain, S., Yeager, D., & Groot, A. (2005). The
marriage check-up: An indicated preventive intervention for treatment-avoidant couples
at risk for marital deterioration. Behavior Therapy, 36, 301–309.
Kelly, A. B., Halford, W. K., & Young, R. M. (2000). Maritally distressed women with alcohol
problems: The impact of a short-term alcohol-focused intervention on drinking behaviour
and marital satisfaction. Addiction, 95, 1537–1549.
Naar-King, S., Wright, K., Parsons, J. T., Frey, M., Templin, T., Lam, P., et al. (2006). Healthy
choices: Motivational enhancement therapy for health risk behaviors in HIV-positive
youth. AIDS Education and Prevention, 18, 1–11.
O’Leary, C. C. (2001). The early childhood family check-up: A brief intervention for at-risk
families with preschool-aged children. Unpublished doctoral dissertation.
Rao, S. O. (1999). The short-term impact of the family check-up: A brief motivational intervention
for at-risk families. Unpublished doctoral dissertation.
Slavert, J. D., Stein, L. A. R., Klein, J. L., Colby, S. M., Barnett, N. P., & Monti, P. M. (2005).
Piloting the family check-up with incarcerated adolescents and their parents. Psychological
Services, 2, 123–132.
Uebelacker, L. A., Hecht, J., & Miller, I. W. (2006). The family check-up: A pilot study of a
brief intervention to improve family functioning in adults. Family Process, 45, 223–
236.
GAMBLING
Hodgins, D. C., Currie, S. R., & el-Guebaly, N. (2001). Motivational enhancement and selfhelp
treatments for problem gambling. Journal of Consulting and Clinical Psychology,
69, 50–57.
Hodgins, D. C., Currie, S., el-Guebaly, N., & Peden, N. (2004). Brief motivational treatment
for problem gambling: A 24-month follow-up. Psychology of Addictive Behaviors, 18,
293–296.
Kuentzel, J. G., Henderson, M. J., Zambo, J. J., Stine, S. M., & Schuster, C. R. (2003). Motivational
interviewing and fluoxetine for pathological gambling disorder: A single case
study. North American Journal of Psychology, 5(2), 229–248.
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Wulfert, E., Blanchard, E. B., Freidenberg, B. M., & Martell, R. S. (2006). Retaining pathological
gamblers in cognitive behavior therapy through motivational enhancement: A pilot
study. Behavior Modification, 30, 315–340.
HEALTH PROMOTION/EXERCISE/FITNESS
Bennett, J. A., Lyons, K. S., Winters-Stone, K., Nail, L. M., & Scherer, J. (2007). Motivational
interviewing to increase physical activity in long-term cancer survivors: A randomized
controlled trial. Nursing Research, 56, 18–27.
Brodie, D. A., & Inoue, A. (2005). Motivational interviewing to promote physical activity for
people with chronic heart failure. Journal of Advanced Nursing, 50, 518–527.
Butterworth, S., Linden, A., McClay, W., & Leo, M. C. (2006). Effect of motivational interviewing–based
health coaching on employees’ physical and mental health status. Journal
of Occupational Health Psychology, 11, 358–365.
Elliot, D. L., Goldberg, L., Duncan, T. E., Kuehl, K. S., & Moe, E. L. (2004). The PHLAME
firefighters’ study: Feasibility and findings. American Journal of Health Behavior, 28,
13–23.
Elliot, D. L., Goldberg, L., Kuehl, K. S., Moe, E. L., Breger, R. K., & Pickering, M. A. (2007).
The PHLAME (Promoting Healthy Lifestyles: Alternative Models’ Effects) firefighter
study: Outcomes of two models of behavior change. Journal of Occupational and Environmental
Medicine, 49, 204–213.
Harland, J., White, M., Drinkwater, C., Chinn, D., Farr, L., & Howel, D. (1999). The Newcastle
Exercise Project: A randomised controlled trial of methods, to promote physical
activity in primary care. British Medical Journal, 319, 828–832.
Hillsdon, M., Thorogood, N., White, I., & Foster, C. (2002). Advising people to take more
exercise is ineffective: A randomised controlled trial of physical activity promotion in primary
care. International Journal of Epidemiology, 31, 808–815.
Hudec, J. C. (2000). Individual counseling to promote physical activity. Unpublished doctoral
dissertation.
Kolt, G. S., Oliver, M., Schofield, G. M., Kerse, N., Garrett, N., & Latham, N. K. (2006). An
overview and process evaluation of Telewalk: A telephone-based counseling intervention
to encourage walking in older adults. Health Promotion International, 21, 201–208.
Ludman, E. J., Curry, S. J., Meyer, D., & Taplin, S. H. (1999). Implementation of outreach
telephone counseling to promote mammography participation. Health Education and
Behavior, 26, 689–702.
Moe, E. L., Elliot, D. L., Goldberg, L., Kuehl, K. S., Stevens, V. J., Breger, R. K. R., et al.
(2002). Promoting healthy lifestyles: Alternative models’ effects (PHLAME). Health Education
Research, 17(5), 586–596.
Thevos, A. K., Kaona, F. A. D., Siajunza, M. T., & Quick, R. E. (2000). Adoption of safe water
behaviors in Zambia: Comparing educational and motivational approaches. Education
for Health (joint issue with the Annual of Behavioral Sciences and Medical Education),
13, 366–376.
Thevos, A. K., Olsen, S. J., Rangel, J. M., Kaona, F. A. D., Tembo, M., & Quick, R. E. (2002–
2003). Social marketing and motivational interviewing as community interventions for
safe water behaviors: Follow-up surveys in Zambia. International Quarterly of Community
Health Education, 21, 51–65.
Thevos, A. K., Quick, R. E., & Yanjuli, V. (2000). Motivational interviewing enhances the
adoption of water disinfection practices in Zambia. Health Promotion International, 15,
207–214.
Valanis, B., Whitlock, E. E., Mullooly, J., Vogt, T., Smith, S., Chen, C. H., et al. (2003).
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Screening rarely screened women: Time-to-service and 24-month outcomes of tailored
interventions. Preventive Medicine, 37(5), 442–450.
Valanis, B. G., Glasgow, R. E., Mullooly, J., Vogt, T. M., Whitlock, E. P., Boles, S. M., et al.
(2002). Screening HMO women overdue for both mammograms and Pap tests. Preventive
Medicine, 34, 40–50.
van Vilsteren, M. C., de Greef, M. H. G., & Huisman, R. M. (2005). The effects of a low-tomoderate
intensity pre-conditioning exercise programme linked with exercise counselling
for sedentary haemodialysis patients in the Netherlands: A randomized clinical trial.
Nephrology Dialysis Transplantation, 20, 141–146.
Wilhelm, S. L., Stepans, M. B., Hertzog, M., Rodehorst, T. K., & Gardner, P. (2006). Motivational
interviewing to promote sustained breastfeeding. Journal of Obstetrical, Gynecological,
and Neonatal Nursing, 35, 340–348.
HIV/AIDS
Aharonovich, E., Hartzenbuehler, M. L., Johnston, B., O’Leary, A., Morgenstern, J.,
Wainberg, M. L., et al. (2006). A low-cost, sustainable intervention for drinking reduction
in the HIV primary care settings. AIDS Care: Psychological and Socio-Medical
Aspects of AIDS/HIV, 18, 561–568.
Baker, A., Heather, N., Wodak, A., Dixon, J., & Holt, P. (1993). Evaluation of a cognitive
behavioral intervention for HIV prevention among injecting drug users. AIDS, 7, 247–
256.
Carey, M. P., Braaten, L. S., Maisto, S. A., Gleason, J. R., Forsyth, A. D., Durant, L. E., et al.
(2000). Using information, motivational enhancement, and skills training to reduce the
risk of HIV infection for low-income urban women: A second randomized clinical trial.
Health Psychology, 19, 3–11.
Carey, M. P., Maisto, S. A., Kalichman, S. C., Forsyth, A. D., Wright, E. M., & Johnson, B. T.
(1997). Using information, motivational enhancement, and skill training to reduce the
risk of HIV infection for low-income urban women: A second randomized clinical trial.
Journal of Consulting and Clinical Psychology, 65, 531–541.
Dilorio, C., Resnicow, K., McDonnell, M., Soet, J., McCarty, F., & Yeager, K. (2003). Using
motivational interviewing to promote adherence to antiretroviral medications: A pilot
study. Journal of the Association of Nurses in AIDS Care, 14(2), 52–62.
Golin, C. E., Earp, J. L., Tien, H. C., Stewart, P., Porter, C., & Howie, L. (2006). A 2-arm,
randomized, controlled trial of a motivational interviewing–based intervention to improve
adherence to antiretroviral therapy (ART) among patients failing or initiating
ART. Journal of Acquired Immune Deficiency Syndrome, 42, 42–51.
Kalichman, S. C., Cherry, C., & Browne-Sperling, F. (1999). Effectiveness of a video-based
motivational skills–building HIV risk-reduction intervention for inner-city African
American men. Journal of Consulting and Clinical Psychology, 67, 959–966.
Knight, J. R., Sherritt, L., Van Hook, S., Gates, E. C., Levy, S., & Chang, G. (2005). Motivational
interviewing for adolescent substance use: A pilot study. Journal of Adolescent
Health, 37, 167–169.
Koblin, B., Chesney, M., Coates, T., & Team, E. S. (2004). Effects of a behavioural intervention
to reduce acquisition of HIV infection among men who have sex with men: The EXPLORE
randomised controlled study. Lancet, 364, 41–50.
Naar-King, S., Wright, K., Parsons, J. T., Frey, M., Templin, T., Lam, P., et al. (2006). Healthy
choices: Motivational enhancement therapy for health risk behaviors in HIV-positive
youth. AIDS Education and Prevention, 18, 1–11.
Parsons, J. T., Rosof, E., Punzalan, J. C., & DiMaria, I. (2005). Integration of motivational
198 Appendix B
interviewing and cognitive behavioral therapy to improve HIV medication adherence
and reduce substance use among HIV-positive men and women: Results of a pilot project.
AIDS Patient Care and STDs, 19, 31–39.
Patterson, T. L., Semple, S. J., Fraga, M., Bucardo, J., Davila-Fraga, W., & Strathdee, S. A.
(2005). An HIV-prevention intervention for sex workers in Tijuana, Mexico: A pilot
study. Hispanic Journal of Behavioral Sciences, 27, 82–100.
Picciano, J. F., Roffman, R. A., Kalichman, S. C., Rutledge, S. E., & Berghuis, J. P. (2001). A
telephone based brief intervention using motivational enhancement to facilitate HIV risk
reduction among MSM: A pilot study. AIDS and Behavior, 5, 251–262.
Robles, R. R., Reyes, J. C., Colon, H. M., Sahai, H., Marrero, C. A., Matos, T. D., et al.
(2004). Effects of combined counseling and case management to reduce HIV risk behaviors
among Hispanic drug injectors in Puerto Rico: A randomized controlled trial. Journal
of Substance Abuse Treatment, 27, 145–152.
Samet, J. H., Horton, N. J., Meli, S., Dukes, K., Tripps, T., Sullivan, L., et al. (2005). A randomized
controlled trial to enhance antiretroviral therapy adherence in patients with a
history of alcohol problems. Antiviral Therapy, 10, 83–93.
Stein, M. D., Anderson, B., Charuvastra, A., Maksad, J., & Friedman, P. D. (2002). A brief
intervention for hazardous drinkers in a needle exchange program. Journal of Substance
Abuse Treatment, 22, 23–31.
Thrasher, A. D., Golin, C. E., Earp, J. A. L., Tien, H., Porter, C., & Howie, L. (2006). Motivational
interviewing to support antiretroviral therapy adherence: The role of quality counseling.
Patient Education and Counseling, 62, 64–71.
MEDICAL ADHERENCE
Aliotta, S. L., Vlasnik, J. J., & Delor, B. (2004). Enhancing adherence to long-term medical
therapy: A new approach to assessing and treating patients. Advances in Therapy, 21,
214–231.
Bennett, J. A., Perrin, N. A., & Hanson, G. (2005). Healthy aging demonstration project:
Nurse coaching for behavior change in older adults. Research in Nursing and Health, 28,
187–197.
Berger, B. A., Liang, H., & Hudmon, K. S. (2005). Evaluation of software-based telephone
counseling to enhance medication persistency among patients with multiple sclerosis.
Journal of the American Pharmacists Association, 45, 466–472.
Broers, S., Smets, E. M. A., Bindels, P., Evertsz, F. B., Calff, M., & DeHaes, H. (2005).
Training general practitioners in behavior change counseling to improve asthma medication
adherence. Patient Education and Counseling, 58, 279–287.
Hayward, P., Chan, N., Kemp, R., & Youle, S. (1995). Medication self-management: A preliminary
report on an intervention to improve medication compliance. Journal of Mental
Health, 4, 511–518.
Kreman, R., Yates, B. C., Agrawal, S., Fiandt, K., Briner, W., & Shurmur, S. (2006). The effects
of motivational interviewing on physiological outcomes. Applied Nursing Research,
19, 167–170.
Robles, R. R., Reyes, J. C., Colon, H. M., Sahai, H., Marrero, C. A., Matos, T. D., et al.
(2004). Effects of combined counseling and case management to reduce HIV risk behaviors
among Hispanic drug injectors in Puerto Rico: A randomized controlled trial. Journal
of Substance Abuse Treatment, 27, 145–152.
Rose, J., & Walker, S. (2000). Working with a man who has Prader–Willi syndrome and his
support staff using motivational principles. Behavioural and Cognitive Psychotherapy,
28, 293–302.
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MENTAL HEALTH
Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds.). (2008). Motivational interviewing
in the treatment of psychological problems. New York: Guilford Press.
Humphress, H., Igel, V., Lamont, A., Tanner, M., Morgan, J., & Schmidt, U. (2002). The effect
of a brief motivational intervention on community psychiatric patients’ attitudes to
their care, motivation to change, compliance and outcome: A case control study. Journal
of Mental Health, 11, 155–166.
Kemp, R., Hayward, P., Applewhaite, G., Everitt, B., & David, A. (1996). Compliance
therapy in psychotic patients: Randomised controlled trial. British Medical Journal, 312,
345–349.
Kemp, R., Kirov, G., Everitt, B., Hayward, P., & David, A. (1998). Randomised controlled
trial of compliance therapy: 18-month follow-up. British Journal of Psychiatry, 172,
413–419.
Ludman, E., Simon, F., Tutty, S., & Von Korff, M. (2007). A randomized trial of telephone
psychotherapy and pharmacotherapy support for depression: Continuation and durability
of effects. Journal of Consulting and Clinical Psychology, 75, 257–266.
Murphy, R. T., & Cameron, R. P. (2002). Development of a group treatment for enhancing
motivation to change PTSD syndrome. Cognitive and Behavioral Practice, 9,
308–316.
Simon, G., Ludman, E. J., Tutty, S., Operskalski, B., & Von Korff, M. (2004). Telephone psychotherapy
and telephone care management for primary care patients starting antidepressant
treatment: A randomized controlled trial. Journal of the American Medical Association,
292, 935–942.
Westra, H. A., & Phoenix, E. (2003). Motivational enhancement therapy in two cases of anxiety
disorder: New responses to treatment refractoriness. Clinical Case Studies, 2(4),
306–322.
OFFENDERS
Harper, R., & Hardy, S. (2000). An evaluation of motivational interviewing as a method of
intervention with clients in a probation setting. British Journal of Social Work, 30, 393–
400.
Mann, R., & Rollnick, S. (1996). Motivational interviewing with a sex offender who believed
he was innocent. Behavioural and Cognitive Psychotherapy, 24, 127–134.
Marques, P. R., Voas, R. B., Tippetts, A. S., & Beirness, D. J. (1999). Behavioral monitoring
of DUI offenders with the alcohol ignition interlock recorder. Addiction, 94(12), 1861–
1870.
Sinha, R., Easton, C., Renee-Aubin, L., & Carroll, K. M. (2003). Engaging young probationreferred
marijuana-abusing individuals in treatment: A pilot trial. American Journal on
Addictions, 12(4), 314–323.
Slavert, J. D., Stein, L. A. R., Klein, J. L., Colby, S. M., Barnett, N. P., & Monti, P. M. (2005).
Piloting the family check-up with incarcerated adolescents and their parents. Psychological
Services, 2, 123–132.
Stein, L. A. R., Colby, S. M., Barnett, N. P., Monti, P. M., Golembeske, C., Lebeau-Craven,
R., et al. (2006). Enhancing substance abuse treatment engagement in incarcerated adolescents.
Psychological Services, 3, 25–34.
Stein, L. A. R., & Lebeau-Craven, R. (2002). Motivational interviewing and relapse prevention
for DWI: A pilot study. Journal of Drug Issues, 32(4), 1051–1069.
200 Appendix B
PAIN
Ang, D., Kesavalu, R., Lydon, J. R., Lane, K. A., & Bigatti, S. (in press). Exercise-based motivational
interviewing for female patients with fibromyalgia: A case series. Clinical
Rheumatology, 26.
SEXUAL BEHAVIOR
Kiene, S. M., & Barta, W. D. (2006). A brief individualized computer-delivered sexual risk reduction
intervention increases HIV/AIDS preventive behavior. Journal of Adolescent
Health, 39, 404–410.
Mann, R., & Rollnick, S. (1996). Motivational interviewing with a sex offender who believed
he was innocent. Behavioural and Cognitive Psychotherapy, 24, 127–134.
Orzack, M. H., Voluse, A. C., Wolf, D., & Hennen, J. (2006). An ongoing study of group
treatment for men involved in problematic Internet-enabled sexual behavior. Cyberpsychology
and Behavior, 9, 348–360.
Peterson, R., Albright, J., Garrett, J. M., & Curtis, K. M. (2007). Pregnancy and STD prevention
counseling using an adaptation of motivational interviewing: A randomized controlled
trial. Perspectives on Sexual Reproductive Health, 39(1), 21–28.
Yahne, C. E., Miller, W. R., Irvin-Vitela, L., & Tonigan, J. S. (2002). Magdalena pilot project:
Motivational outreach to substance abusing women street sex workers. Journal of Substance
Abuse Treatment, 23(1), 49–53.
SPEECH/VOCAL THERAPY
Behrman, A. (2006). Facilitating behavioral change in voice therapy: The relevance of motivational
interviewing. American Journal of Speech–Language Pathology, 15, 215–225.
TOBACCO
Ahluwalia, J. S., Nollen, N., Kaur, H., James, A. S., Mayo, M. S., & Resnicow, K. (2007).
Pathway to health: Cluster-randomized trial to increase fruit and vegetable consumption
among smokers in public housing. Health Psychology, 26, 214–221.
Ahluwalia, J. S., Okuyemi, K., Nollen, N., Choi, W. S., Kaur, H., Pulvers, K., et al. (2006).
The effects of nicotine gum and counseling among African American light smokers: A 2 ×
2 factorial design. Addiction, 101, 833–891.
Baker, A., Richmond, R., Haile, M., Lewin, T. J., Carr, V. J., Taylor, R. L., et al. (2006). A randomized
controlled trial of a smoking cessation intervention among people with a psychotic
disorder. American Journal of Psychiatry, 163, 1934–1942.
Boardman, T., Catley, D., Grobe, J. E., Little, T. D., & Ahluwalia, J. S. (2006). Using motivational
interviewing with smokers: Do therapist behaviors relate to engagement and therapeutic
alliance? Journal of Substance Abuse Treatment, 31, 329–339.
Borelli, B., Novak, S., Hecht, J., Emmons, K., Papandonatos, G., & Abrams, D. (2005).
Home health care nurses as a new channel for smoking cessation treatment: Outcomes
from Project CARES (Community-Nurse Assisted Research and Education on Smoking).
Preventive Medicine, 41, 815–821.
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Brown, R. A., Ramsey, S. E., Strong, D. R., Myers, M. G., Kahler, C. W., Lejuez, C. W., et al.
(2003). Effects of motivational interviewing on smoking cessation in adolescents with
psychiatric disorders. Tobacco Control, 12(Suppl. 4), 3–10.
Butler, C. C., Rollnick, S., Cohen, D., Bachmann, M., Russell, I., & Stott, N. (1999). Motivational
consulting versus brief advice for smokers in general practice: A randomized trial.
British Journal of General Practice, 49, 611–616.
Chan, S. S., Lam, T. H., Salili, F., Leung, G. M., Wong, D. C., Botelho, R. J., et al. (2005). A
randomized controlled trial of an individualized motivational intervention on smoking
cessation for parents of sick children: A pilot study. Applied Nursing Research, 18, 178–
181.
Cigrang, J. A., Severson, H. H., & Peterson, A. L. (2002). Pilot evaluation of a populationbased
health intervention for reducing use of smokeless tobacco. Nicotine and Tobacco
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Colby, S. M., Barnett, N. M., Monti, P. M., Rohsenow, D. J., Weissman, K., Spirito, A., et al.
(1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A
preliminary study. Journal of Consulting and Clinical Psychology, 66, 574–578.
Colby, S. M., Monti, P. M., & Tevyaw, T. O. (2005). Brief motivational intervention for adolescent
smokers in medical settings. Addictive Behaviors, 30, 865–874.
Curry, S. J., Ludman, E. J., Graham, E., Stout, J., Grothaus, L., & Lozano, P. (2003). Pediatric-based
smoking cessation intervention for low-income women: A randomized trial.
Archives of Pediatrics and Adolescent Medicine, 157, 295–302.
Emmons, K. M., Hammond, S. K., Fava, J. L., Velicer, W. F., Evans, J. L., & Monroe, A. D.
(2001). A randomized trial to reduce passive smoke exposure in low-income households
with young children. American Academy of Pediatrics, 108, 18–24.
Ershoff, D. H., Quinn, V. P., Boyd, N. R., Stern, J., Gregory, M., & Wirtschafter, D. (1999).
The Kaiser Permanente prenatal smoking-cessation trial: When more isn’t better, what is
enough? American Journal of Preventive Medicine, 17, 161–168.
Gariti, P., Alterman, A., Mulvaney, F., Mechanic, K., Dhopesh, V., Yu, E., et al. (2002). Nicotine
intervention during detoxification and treatment for other substance use. American
Journal of Drug and Alcohol Abuse, 28, 673–681.
George, T. P., Ziedonis, D. M., Feingold, A., Pepper, W. T., Satterburg, C. A., Winkel, J., et
al. (2000). Nicotine transdermal patch and atypical antipsychotic medications for
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Glasgow, R. E., Whitlock, E. E., Eakin, E. G., & Lichtenstein, E. (2000). A brief smoking cessation
intervention for women in low-income planned parenthood clinics. American
Journal of Public Health, 90, 786–789.
Haug, N. A., Svikis, D. S., & DiClemente, C. C. (2004). Motivational enhancement therapy
for nicotine dependence in methadone-maintained pregnant women. Psychology of Addictive
Behaviors, 18, 289–292.
Helstrom, A., Hutchinson, K., & Bryan, A. (2007). Motivational enhancement therapy for
high-risk adolescent smokers. Addictive Behaviors, 32, 2404–2410.
Hokanson, J. M., Anderson, R. L., Hennrikus, D. J., Lando, H. A., & Kendall, D. M. (2006).
Integrated tobacco cessation counseling in a diabetes self-management training program:
A randomized trial of diabetes and reduction of tobacco. Diabetes Educator, 32, 562–
570.
Hollis, J. F., Polen, M. R., Whitlock, E. P., Lichtenstein, E., Mullooly, J., Velicer, W. F., et al.
(2005). Teen Reach: Outcomes from a randomized controlled trial of a tobacco reduction
program for teens seen in primary medical care. Pediatrics, 115, 981–989.
Horn, K., Dino, G., Hamilton, C., & Noerachmanto, N. (2007). Efficacy of an emergency
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Kelley, A. B., & Lapworth, K. (2006). The HYP program: Targeted motivational interviewing
for adolescent violations of school tobacco policy. Preventive Medicine, 43, 466–
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Luna, L. (2005). The effectiveness of motivational enhancement therapy on smoking cessation
in college students. Unpublished doctoral dissertation.
Nollen, N. L., Mayo, M. S., Sanderson Cox, L., Okuyemi, K. S., Choi, W. S., Kaur, H., et al.
(2006). Predictors of quitting among African American light smokers enrolled in a randomized,
placebo-controlled trial. Journal of General Internal Medicine, 21, 590–595.
Okuyemi, K., Cox, L. S., Nollen, N. L., Snow, T. M., Kaur, H., Choi, W. S., et al. (2007). Baseline
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light smokers. American Journal of Health Promotion, 21, 183–189.
Okuyemi, K. S., James, A. S., Mayo, M. S., Nollen, N., Catley, D., Choi, W. S., et al. (2007).
Pathways to health: A cluster randomized trial of nicotine gum and motivational interviewing
for smoking cessation in low-income housing. Health Education and Behavior,
34, 43–54.
Okuyemi, K. S., Thomas, J. L., Hall, S., Nollen, N. L., Richter, K. P., Jeffries, S. K., et al.
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Pbert, L., Osganian, S. K., Gorak, D., Druker, S., Reed, G., O’Neill, K. M., et al. (2006). A
school nurse–delivered adolescent smoking cessation intervention: A randomized controlled
trial. Preventive Medicine, 43, 312–320.
Persson, L. G., & Hjalmarson, A. (2006). Smoking cessation in patients with diabetes
mellitus: Results from a controlled study of an intervention programme in primary
healthcare in Sweden. Scandinavian Journal of Primary Health Care, 24(2), 75–80.
Richter, K. P., McCool, R. M., Catley, D., Hall, M., & Ahluwalia, J. S. (2005). Dual
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Rigotti, N. A., Park, E. R., Regan, S., Chang, Y., Perry, K., Loudin, B., et al. (2006). Efficacy
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Rohsenow, D. J., Martin, R. A., Monti, P. M., Abrams, D. B., Colby, S. M., & Sirota, A. D.
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Smith, S. S., Jorenby, D. E., Fiore, M. C., Anderson, J. E., Mielke, M. M., Beach, K. E., et al.
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Steinberg, M. L., Ziedonis, D. M., Krejci, J. A., & Brandon, T. H. (2004). Motivational interviewing
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Stotts, A. L., DeLaune, K. A., Schmitz, J. M., & Grabowski, J. (2004). Impact of a motivational
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Stotts, A. L., DiClemente, C. C., & Dolan-Mullen, P. (2002). One-to-one: A motivational intervention
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Tappin, D. M., Lumsden, M. A., Gilmour, W. H., Crawford, F., McIntyre, D., Stone, D. H., et
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Thyrian, J. R., Freyer-Adam, J., Hannover, W., Roske, K., Mentzel, F., Kufeld, C., et al.
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204 Appendix B
IndexIndex
Index
Ability, 37
Adherence
MI outcome studies, 199
promoting, 98–107
Agendas, setting, 53–55, 151–152
Alcohol studies, 183–191
Ambivalence
discussion of, 34–35
resolving, 116–120
working through with reflective
listening, 83
Asking
closed questions, 44–45, 46–47
combining listening with, 75–76
as a communication skill, 19
may be a “roadblock” to listening,
69
in motivational interviewing, 51,
53–55
open questions, 45–46, 47–49
practical suggestions for, 56–64
the question–answer trap, 49–50
relationship to communication
styles, 21, 22
routine assessments and, 50–51
skillful practice in, 46–48
using with other communication
skills, 112–114, 115
Aspirations for patient behavior
change (ABC), 146–148
Assessments, 167–168
Asthma studies, 191
Attentiveness, 141–142
Autonomy. See Patient autonomy
Behavior change. See Health
behavior change
Behavior-change consultations. See
Consultations
Brain injury studies, 191
“Bubble sheet” strategy, 54–55
Cardiac rehabilitation services, 164–
170
Cardiovascular health studies, 191–
192
Case examples
cardiac rehabilitation services,
131–138, 164–170
general medicine, 121–125
HIV/AIDS services, 162–164
public health promotion, 170, 172
safe sex promotion, 126–130
Change talk
guiding patients through, 41–42
how the forms fit together, 40–41
205
Change talk (continued)
kinds of, 36–40
listening for, 35–41
practical suggestions for questions
to elicit, 56–64
reflecting, 80–82
Chunk–check–chunk strategy
examples, 99–100, 101–102
mindset in, 96–97
overview of, 94–95
Closed questions
excessive reliance on, 46–47
overview of, 44–45
Collaboration, 6
Commitment
language indicating, 37, 39
language to use when assessing,
118
listening for, 117–120
Communication skills
common use of, 20
overview of, 19–20
relationship to communication
styles, 21
used with communication styles,
21–28
using flexibly within consultations,
29–30
using in combinations, 112–116
See also individual skills
Communication styles
directing, 14–15, 17–18
following, 14
guiding, 15
learning to shift between, 173–174
mixing and matching, 15–17
overview of, 12–14
relationship of communication
skills to, 21
use of communication skills with,
21–28
using flexibly within consultations,
29–30
See also individual styles
Consultations
asking questions in, 46–48
case examples. See Case examples
general guideline for, 175–176
maintaining flexibility within, 29–
30
reviewing for self-improvement,
154–155
when agendas differ, 150–153
when to use listening in, 67
where directing seems essential,
152–153
Control, letting go of, 142
COPD studies, 191
DARN
eliciting change talk and, 40–41,
57–58
meaning of term, 38
Denial, 144
Dentistry studies, 192
Desire, 36, 37
Diabetes studies, 192–193
Diet studies, 193–194
Directing style
compared to other communication
styles, 12–14
dangers of falling into, 148
discussion of, 14–15
examples of, 22–25
overuse of, 17–18
relationship of communication
skills to, 21, 22–25
situations when necessary, 152–153
using with other communication
styles, 15–17
Domestic violence studies, 194
Drinking water safety, 170, 172
Drug abuse studies, 183–191
Dual-diagnosis studies, 194–195
Eating disorders studies, 195
Elicit–provide–elicit strategy (EPE)
discussion of, 95–98
example for promoting adherence,
100–101
example for sharing test results,
102–104
Empowerment, 10
Equipoise, 147–148
206 Index
Evocation, 6–7
Exercise studies, 197–198
Eye contact, 68
Family/relationships studies, 196
Feedback, 178–179
Fitness studies, 197–198
Following style
compared to other communication
styles, 12–14
discussion of, 14
relationship of communication
skills to, 21, 25–27
using with other communication
styles, 15–17
Gambling studies, 196–197
Groups
guidelines for guiding in, 171–172
for patient education, 168–169
Guided participation, 155
Guiding style
becoming skillful at, 174
compared to other communication
styles, 12–14
getting used to, 140–141
in groups, 171–172
integrating with directing, 153
and the issue of responsibility,
142–143
judging the effectiveness of, 119–120
looking ahead and letting go of
control, 142
motivational interviewing and, 18–
19, 33
overcoming obstacles, 143–153
and the patient’s struggles with
change, 144–145
practicing in everyday life, 155–
156
and the practitioner’s feelings,
145–150
relationship of communication
skills to, 21, 27–28
staying in the present, 141–142
using with other communication
styles, 15–17
watching the relationship and, 141
when agendas differ, 150–153
Health behavior change
asking about commitment to, 62–
63
asking about pros and cons of,
61–62
aspirations for, 146–148
current need for, 3–4
the myth of the unmotivated
patient, 5–6
the patient’s struggles with, 144–
145
removing service system barriers
to, 158–164
taking steps statements, 37, 39–40
See also Change talk; Readiness-to-
change
Health care information. See
Information
Health care providers. See
Practitioners
Health care systems
barriers to motivational
interviewing in, 157–158
removing barriers to change, 158–
164
Health promotion studies, 197–198
HIV/AIDS
MI outcome studies, 197–198
providing an innovation in
services, 162–164
safe sex promotion, 126–130
Hypertension studies, 191–192
Hypothetical questions/language, 63–
64
Information
delivering with care, 90
eliciting the patient to interpret,
104–105
including positive messages with,
89–90
overloading patients with, 149
understanding the patient’s needs
and wishes for, 90
Index 207
Information exchange
guidelines for improving, 88–90
using the directing style in, 90–91
See also Informing
Information gathering
with closed questions, 44–45
following style and, 25–26
with open questions, 45–46
Informing
asking permission for, 91–92
chunk–check–chunk strategy, 94–
95, 96–97
common difficulties experienced in,
86–88
as a communication skill, 19–20
directing with care, 90–91
eliciting the patient to interpret
information, 104–105
elicit–provide–elicit strategy, 95–98
examples, 98–107
offering options, 93
pitfalls of the righting reflex, 98
to promote adherence, 99–101
providing hope and, 105–107
relationship to communication
styles, 21, 22
sharing test results, 101–104
situations used in, 86
talking about what others do, 93–
94
using with other communication
skills, 112–113, 114–116
working within a relationship, 88–
90
See also Information exchange
Injury prevention studies, 196
Internal dilemmas, acting out of, 8
Key questions, 62–63
Lipid studies, 193–194
Listening
in combination with asking, 75–76
for commitment, 117–120
as a communication skill, 19
concerns about, 76–77
facilitative responses, 70
following style and, 14
in motivational interviewing, 77–
85, 111–112
opening steps in, 68–69
to patients, 9
practicing in everyday life, 155
questions may be “roadblocks” to,
69
by reflecting, 70–74
relationship to communication
styles, 21, 22
silence and, 69–70
summaries, 74–75
using with other communication
skills, 113–116
value of, 65–66
when to use, 66–67
See also Reflective listening
Making the Patient Your Partner
(Gordon & Edwards), 9
Medical adherence
outcome studies, 199
promoting, 99–101
Medical consultations. See
Consultations
Mental health studies, 200
MI. See Motivational interviewing
MI “spirit,” 6–7
Motivation
the myth of the unmotivated
patient, 5–6
understanding in patients, 9
Motivational interviewing (MI)
aids to learning, 178–179
can seem familiar, 11–12
case examples. See Case examples
guiding principles, 7–10
guiding style and, 18–19, 33
implementing, 164–172
the myth of the unmotivated
patient, 5–6
origin and development of, 4–5
overview of, 111–112
phases in learning, 173–175
refining one’s skills in, 174–175
service system barriers to, 157–158
208 Index
“spirit” of, 6–7
trainers in, 180
Motivational Interviewing Network
of Trainers (MINT), 180
Need, 37, 38–39
Nonverbal cues, good listeners and,
68
Obesity studies, 195
Offender studies, 200
Open questions
examples of, 48–49
features and advantages of, 45–46
in skillful asking, 47–48
Pain studies, 201
Parenting, communication styles and,
16
Patient education groups, 168–169
Patients
aspirations for behavior change,
146–148
autonomy, 7
communicating with when upset,
26–27
guiding through change talk, 41–
42
information and, 90, 104–105,
149
listening to, 9
motivation and, 5–6
obtaining permission from, 91–92
persuading too hard, 148–149
struggles with change, 144–145
Permission, obtaining from patients,
91–92
Persuasion–resistance trap, 148–149
Practitioners
aspirations for patient behavior
change, 146–148
descending into directing, 148
feedback and, 178–179
following the patients and getting
lost, 149
how feelings affect guiding, 145–
150
notions of rescuing patients, 149
overloading patients with
information, 149
overuse of the directing style, 17–
18
persuading patients too hard, 148–
149
protecting one’s health, 154
pursuing problems and weaknesses,
150
reviewing consultations for selfimprovement,
154–155
Premature focus, 53–54
Public health, 170, 172
Quantity–frequency investigation,
50
Question–answer trap, 49–50
Questions
closed, 44–45, 46–47
combining with listening, 75–76
may be “roadblocks” to listening,
69
open, 45–46, 47–49
See also Asking
Rating scales, 58–59, 60
Readiness-to-change, assessing, 60–
61
Reasons, 37–38
Referrals, encouraging, 27–28
Reflecting, 70–74
Reflective listening
choosing what to reflect, 78–79
overview of, 70–74
reflecting change talk, 80–82
reflecting resistance, 79–80
summaries, 83–85
and working through ambivalence,
83
Resistance
persuasion–resistance trap, 148–
149
reflecting, 79–80
Responsibility, 142–143
Righting reflex, 7–9, 98
Routine assessments, 50–51, 52
Index 209
RULE principles
overview of, 7–10
using, 56–57
Rulers, 58–59, 60
Safe sex promotion, 126–130
Scaffolding, 155
Sexual behavior studies, 201
Silence, in listening, 69–70
Speech/vocal therapy studies, 201
Substance abuse service, 158–162
Summaries, 74–75, 83–85
Teaching, communication styles and,
16
Team meetings, 166–167
Test results, sharing, 101–104
Tobacco studies, 201–204
Trainers, 180
Trauma studies, 196
Treatment requests, 26
Unmotivated patients, myth of, 5–6
Zambia, 170
210 Index