Dan I Lubman Background One of the biggest challenges that primary care practitioners face is motivational option people change longstanding behaviours that pose significant health risks. Discussion Research into health related behaviour change highlights the importance of motivation, motivational option and resistance. Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in others areas of health including smoking cessation, reducing sexual risk behaviours, improving adherence to treatment and medication and diabetes management.
One of the biggest challenges that primary care practitioners face is helping people change longstanding behaviours that pose significant health risks. When patients receive compelling advice to adopt a healthier lifestyle by cutting back or ceasing harmful behaviours eg. Importantly, an authoritative or paternalistic therapeutic style may in fact deter change by increasing resistance.
Their transtheoretical model of behaviour change the 'Stages of Change' describes readiness to change as a dynamic process, in which the pros and cons of changing generates ambivalence. Ambivalence is a conflicted state where opposing attitudes or feelings coexist in an individual; they are stuck between simultaneously wanting to change and not wanting to change.
Ambivalence is particularly evident in situations where there is conflict between an immediate reward and longer term adverse consequences eg. For example, the patient who presents with serious health problems as a result of heavy drinking, who shows genuine concern about the impact of alcohol on his health, and in spite of advice from his practitioner to cut back his drinking, continues to drink mi token motivational option levels, embodies this phenomenon.
The Prochaska and Motivational option Stages of Change model2 offers a conceptual framework for understanding the incremental processes that people pass through as they change a particular behaviour. This change process is modelled in five parts as a progression from an initial precontemplative stage, where the individual is not considering change; to a contemplative stage, where the individual is actively ambivalent about change; to preparation, where the individual begins to plan and commit to change.
Successful progression through these stages leads to action, where the necessary steps to achieve change are undertaken. If successful, action leads to the final stage, maintenance, where the person works to maintain and sustain long term change.
Motivational interviewing MI motivational option an effective counselling method that enhances motivation through the resolution of white label binary options. It grew out of the Prochaska and DiClemente model described above2 and Miller and Rollnick's1 work in the field of addiction medicine, which drew on the phrase 'ready, willing and able' to outline three critical components of motivation.
These were:1 the importance motivational option change for the patient willingness the confidence to change ability whether change is an immediate priority readiness. Using MI techniques, the practitioner can tailor motivational strategies to the individual's stage of motivational option according to the Prochaska and DiClemente model Table 1.
The spirit of motivational interviewing Motivational interviewing is underpinned by a series of principles that emphasise a collaborative therapeutic relationship in which the autonomy of the patient is respected and the patient's intrinsic resources for change are elicited by the therapist. Within MI, the therapist is viewed as motivational option facilitator rather than expert, who adopts a nonconfrontational you can make money on a truck to guide the patient toward change.
The overall spirit of MI has been described as collaborative, evocative and honouring of patient autonomy.
Although paradoxical, the MI approach is effective at engaging apparently 'unmotivated' individuals and when considered in the context of standard practice can be a powerful engagement strategy Case study, Table 2.
Case motivational option — using the spirit of motivational interviewing A motivational option patient, 52 years of motivational option, who drinks heavily and has expressed the desire to reduce drinking, but continues to drink heavily. It is easy to conclude that this patient lacks motivation, his judgment is motivational option or he simply does not understand the effects of alcohol on his health.
These conclusions may naturally lead the practitioner to adopt a paternalistic therapeutic style and warn the patient of the risks to his health. In subsequent consultations, when these strategies don't work, it is easy to give up hope that he will change his drinking, characterise him as 'unmotivated' and drop the subject altogether. In MI, the opposite approach is taken, where the patient's motivation is targeted by the practitioner. Using motivational option spirit of MI, the practitioner avoids an authoritarian stance, and respects the autonomy of the patient by accepting he has the responsibility to change his drinking — or not.
Motivational interviewing emphasises eliciting reasons for change from the patient, rather than advising them of the reasons why they should change their drinking. What concerns does he have about the effects of his drinking?
Motivational option future goals or personal values are impacted by his drinking?
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The apparent 'lack of motivation' evident in the patient would be constructed as 'unresolved ambivalence' within an MI framework. The practitioner would therefore work on understanding this ambivalence, by exploring the pros and cons of continuing to drink alcohol.
They would then work on resolving this ambivalence, by connecting the things the patient cares about with motivation for change.
For example, drinking may impact the patient's values about being a loving partner and father or being healthy and strong. A discussion of how continuing to drink maintaining the status quo will impact his future goals to travel in retirement or have a good relationship with his children may be the focus.
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The practitioner would emphasise motivational option the decision to change is 'up to him', however they would work with the patient to increase his confidence that he can change self efficacy. Table 2.
The spirit of motivational interviewing vs an authoritative or paternalistic therapeutic style The spirit of motivational interviewing Authoritative or paternalistic therapeutic style Collaboration: a partnership between the patient and practitioner is formed. Joint decision making occurs.
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The practitioner connects health behaviour change to the things the patient cares about Education: the patient is presumed to lack the insight, knowledge or skills required to change. These basic counselling techniques assist in building rapport and establishing a therapeutic relationship that is consistent with the spirit of MI.
Table 3. Can you tell me about them? Versus Are you concerned about your drinking? But you motivational option beginning to worry about the impact drinking is having on your health. How am I doing?
Research has implicated two factors motivational option potentially mediating these contradictory effects: the personal control conferred by a choice and the costs associated with a choice. Across four experiments, utilizing a physical effort task disguised as a simple video game, we systematically varied costs across two levels of physical effort requirements Low-Requirement, High-Requirement and control over effort costs across three levels of choice Free-Choice, Restricted-Choice, and No-Choice to disambiguate how these factors affect the motivational consequences of choosing within an effortful task. Together, our results indicated that, in the face of effort requirements, illusory control alone may not sufficiently enhance perceptions of personal control to boost intrinsic motivation; rather, the experience of actual control may be motivational option to overcome effort costs and elevate performance. Additionally, we demonstrated that conditions of illusory control, while otherwise unmotivating, can through association with the experience of free-choice, be transformed to have a positive effect on motivation.
In the absence of a goal directed approach, the application motivational option the strategies or spirit of MI can result in the maintenance of ambivalence, where patients and practitioners remain stuck. This trap can be avoided by employing strategies to elicit 'change talk'. Alternatively, if a practitioner is time poor, a quick method of drawing out 'change talk' is to use an 'importance ruler'.
Example: 'If you can think of a scale from zero to 10 of how important it is for you to lose weight. On this scale, zero is not important at all and 10 is extremely important. Where would you be on this scale?
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Highlighting this discrepancy is at the core of motivating people to change. This can be followed by asking the patient to elaborate further on this discrepancy and then succinctly summarising this discrepancy and reflecting it back motivational option the patient. Next, it is important to build the patient's confidence in their ability to change. This involves focusing on the patient's strengths and past experiences of success. Again, a 'confidence ruler' could be employed if a practitioner is time poor.
Example: 'If you can think of a scale from zero to 10 of how confident you are that you can cut back the amount you are drinking. On this scale, zero is not confident at all and 10 is motivational option confident. This involves standard goal setting techniques, using the spirit of MI as the guiding principle and eliciting from the patient what they plan to do rather than instructing or advising. If a practitioner feels that the patient needs health advice at this point in order to set appropriate goals, it is customary to ask permission before giving advice as this honours the patient's autonomy.
Examples of key questions to build a 'change plan' include: It sounds like things can't stay the same as they are.
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What do you think you might do? What changes were you thinking about making? Where do we go from here? What do you want to do at this point?
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How would you like things to turn out? After reviewing all of this, what's the next step motivational option you? It is common for patients to ask for answers or 'quick fixes' during Phase II. In keeping with the spirit of MI, a simple phrase reminding the patient of their autonomy is useful, 'You are the expert on you, so I'm not sure I am the best person to judge what will work for you.
But I can give you an idea of what the evidence shows us and what other people have done in your situation'. Table 4. What difficulties have resulted from your drinking? In what way does your weight concern you? What are the advantages of reducing your drinking? What would be different in your life if you lost weight? How did you do it? What strengths do you have that would help you make a change? Forget how you would get there for a moment.
If motivational option could do anything, what would you change? Miller and Rollnick17have attempted to simplify the practice of MI for health care settings by developing four guiding principles, represented by the acronym RULE: Resist the righting reflex Understand the patient's own motivations Listen with empathy Empower the patient.
Resist the righting reflex The righting reflex describes the tendency of health professionals to advise patients about the right path for good health. This can often have a paradoxical effect in practice, inadvertently reinforcing the argument to maintain motivational option status quo. Essentially, most people resist persuasion when they are ambivalent about change and will respond by recalling their reasons for maintaining the behaviour.
Motivational interviewing in motivational option requires clinicians to suppress the initial righting reflex so that they can explore the patient's motivations for change. Understand your patient's motivations It is the patient's own reasons for change, rather than the practitioner's, that will ultimately result in behaviour change. By approaching a patient's interests, concerns and values with curiosity and openly exploring the patient's motivations for change, the practitioner will begin to get a better understanding of the patient's motivations and potential barriers to change.
Listen with empathy Effective listening skills are essential to understand what will motivate the patient, as well as the pros and cons of their situation. A general rule-of-thumb in MI is that equal amounts of time in a consultation should be spent listening and talking. Empower your patient Patient outcomes improve when they are an active collaborator in their treatment.
A truly collaborative therapeutic relationship is a powerful motivator. Patients benefit from this relationship the most when the practitioner also embodies hope that change is possible. If a practitioner has more time, four additional principles Table 5 can be applied within a longer therapeutic intervention.
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Table 5. Building empathy and understanding does not motivational option the practitioner condones the problematic behaviour. Exploring the pros and cons of change can help a patient develop discrepancy. If the patient is ambivalent about change, this approach will commonly be met with resistance from the patient.
In MI, rolling with this resistance involves approaching resistance without judgement and interpreting these responses as a sign that the patient holds a different perspective to the practitioner.
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They may have attempted to cease smoking and only lasted a week, or tried to lose weight but been unable to sustain a diet. They may have attempted to comply with their medication several times in the past but found it difficult because of side effects or a complicated dosing regimen.
By promoting self efficacy, the practitioner can help the individual develop the confidence that they are capable of change Barriers to implementing motivational interviewing in general practice Barriers to implementing MI in general practice include time pressures, the professional development required in order to master MI, difficulty in adopting the motivational option of MI when practitioners embody pensioners additional income expert role, patients' overwhelming desire for 'quick fix' options to health issues and the brevity of consultation times.
These barriers to implementing MI in primary care represent significant cons on a decisional balance. On the other hand, the pros for adopting an MI approach with patients who are resistant to change are compelling. While we are not advocating MI for all patient interactions in general practice, we invite practitioners to explore their own ambivalence toward adopting MI within their practice, and consider whether they are 'willing, ready and able'.
Practitioners who undertake MI training will have an additional therapeutic tool to draw upon when encountering patient resistance to change and a proven method for dealing with a number of common presentations within general practice. Resource For further information and motivational option motivational interviewing training opportunities visit www.
Conflict of interest: none declared. Motivational Interviewing. Preparing people for change. New York: The Guilford Press, Prochaska J, DiClemente C.
Towards a comprehensive model of change. Treating addictive behaviours: processes of change. New York: Pergamon, Motivational interviewing and the stages of change. Motivational interviewing, second edition: Preparing people for change.
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The efficacy of motivational interviewing: a meta-analysis of controlled trials. J Consult Clin Psychol ;— Motivational interviewing. Ann Rev Clin Psychol ;— A meta-analysis of motivational interviewing: twenty-five years of empirical studies. Res Soc Work Pract ;— Effectiveness motivational option motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. The effectiveness of motivational interviewing delivered by youth workers in reducing drinking, cigarette and cannabis smoking among young people: quasi-experimental pilot study.
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Clinician-delivered intervention during routine motivational option care reduces unprotected sexual behaviour among HIV-infected patients. J Acquir Immune Defic Syndr ;— Influencing risk behavior of sexually transmitted infection clinic visitors: Efficacy of a new methodology of motivational preventive counseling. Healthy choices: Motivational enhancement therapy for health risk behaviours in HIV-positive youth.
Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients. J Nerv Ment Dis ;—5. Motivational interviewing improves weight loss in women with type 2 diabetes.