Motivational Interviewing
Robert Rhode PhD, in Integrative Medicine (Fourth Edition), 2018
Foundation or Spirit of Motivational Interviewing
A motivational interviewing approach is built upon four foundational values. Most health care providers, particularly integrative medicine ones, find that these are already part of their consultations or interactions:
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Accepting the client. This includes empathizing with the client and recognizing that the client is valuable and competent regardless of his or her circumstances. It also involves recognizing that it is the client who has to adopt the health-promoting behavior; the health care provider cannot do it to the client or for the client. This also includes demonstrating support for the client’s ability to decide to change now, later, or not at all.
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Compassion. Dedication to others’ welfare and well-being has often been present in the health care provider’s life and values long before formal training and working with clients.
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Collaboration. Involves coming along side, joining up, or looking at the client’s life or situation with the client; partnering with the client to consider a difficult situation.
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Curiosity. Instead of trying to instill knowledge or motivation, the health care provider helps the client access his desire and reasons for doing the health-promoting behavior. The health care provider does not lead with his or her expertise but rather solicits and learns what the client knows first.
A directive helping style does not involve a lot of collaboration with the client because the health care provider is adopting an expert role and “driving the bus.” Similarly, it is not so important to be curious about the client’s experience because the clinician is deciding what needs to be done. An example of this is when the clinician tells the client that he or she is drinking too much, meets the criteria for alcoholism, needs to attend Alcoholics Anonymous meetings, and should abstain from drinking. The client’s objection to the diagnosis and treatment recommendation does not change the clinician’s directions and is often labeled, very logically, by the clinician as an example of the client’s denying reality or the truth (“The patient is in denial.”).
Noncompliance is often used to blame the patient that does not follow a directive helping style. In fact, noncompliance is two people working towards different goals.
When a motivational interviewing style is used, the clinician respects the client as capable and competent, and therefore it makes sense to collaborate with him or her. If the clinician intends to collaborate with the client, it makes sense to respect and support his or her autonomy. The client will literally be the one to implement (or not) the health-promoting behavior. During a stay in the hospital, health care providers may have more control over the patient’s diet, activity, and medication. When the client is out of the hospital, he or she decides what to eat, what to do, and what medication to take. Respecting this reality and explicitly recognizing that the client will make these decisions relieves the clinician of the frustrating task of trying to control the client. The clinician is no longer driving the bus but is “on the bus” with the client, looking at health behaviors and decisions with the client. If the client is capable, competent, and believed to be the key person to implement any treatment, then it makes perfect sense to be curious about the client’s experience and his or her reasons for embracing or rejecting the health-promoting behaviors.
The client who is drinking too much is approached differently with this mindset. The clinician still maintains a focus on the destination of less drinking or abstaining, but instead of telling the client what the problem is, he or she now asks what the client thinks about the drinking and how it fits with other goals or values. Instead of pushing a treatment, the clinician explores what makes sense to the client. The client’s objections to abstaining are not heard as denial but rather as the client’s natural ambivalence to giving up something that he or she enjoys or to which he or she is attached. The clinician may help the client find his or her motivation to change this drinking by exploring which of the client’s goals or experiences are diminished by the current drinking.
This collaboration with a client who is recognized as capable seems consistent with integrative medicine as described by Andrew Weil:7 “There is this tremendous innate healing capacity that we all have. When I sit with a person who is sick, always at the back of my mind is the question, What is blocking healing here? What is preventing it? What can I do from outside that can facilitate that process?”
Table 101.1 describes some ways to experiment with a helping style that is consistent with motivational interviewing. This can be summarized as, “Don’t tell, ask.”
A similar way to generate a motivational interviewing consistent approach is for the health care provider to suspend the expert role. He or she will very likely join the client who is facing the challenge of improving well-being or managing a chronic condition. Although “care” today has the connotation of intervening in a beneficial way, another meaning is “to be with.” Collaborating includes looking together at the situation. While looking in the same direction, being curious about the client’s motivation for the health-promoting behaviors is easier. Table 101.2 outlines four questions that have been used in this manner.