Motivational interviewing is interviewing to help people to change.
It is different from a typical clinical interview in a health setting.
Here are two examples. You can spot the differences.
They are taken from:
Motivational Interviewing, Helping People Change, Third Edition, William R Miller and Stephen Rollnick The Guilford Pres 2013
Spot the Difference
(page 306 – 308 Miller & Rollnick)
What differences can you spot between the following two interviews?
Both conversations start in the same place, but there are many differences in technique as well as style. Here's the situation: A doctor is concerned about whether a man in his early 80s might be depressed following a mild right hemisphere stroke 2 weeks earlier. A nurse on the ward offers to speak with the patient about his future before he is discharged, keeping in mind the possibility of a referral to the psychiatric liaison service.
Ask yourself: Is this nurse doing MI? How do you know?
CLIENT/PATIENT: I feel worried about going home now. I hardly know where to begin.
INTERVIEWER: Oh, that's very understandable for someone with your condition. I'm sure you will get much better, you'll see. It's only been 2 weeks, and you could get back a lot of functioning in the year ahead. Have you been working with the physical therapist here?
CLIENT: Yes I have, but I live alone, you see, and now I can't even walk properly. I don't know how I am going to cope.
INTERVIEWER: Well, we've scheduled a physical therapist to come to your home for a while, and we have also arranged for you to see the social worker so you can talk about how things will go at home. From our point of view here on the ward you're recovering very well, and we think you will keep regaining some of your functioning over the next few months. This is quite likely, and so you'll gradually find it easier to cope than you can imagine right now.
CLIENT: I miss my friends.
INTERVIEWER: We also have outpatient recovery group meetings where you can meet new friends and talk together about coping with a stroke. I know other stroke patients who have gone there and they have found it very helpful. Do you think you might be interested in that?
CLIENT: I don't know. I used to go golfing a few times a week and then for a drink at the clubhouse afterward, but now I can't even walk properly.
INTERVIEWER: Don't worry, you will get to feeling better bit by bit. The drinking probably wasn't good for you anyway. The social worker will work with you, and if you need it we'll also get the occupational therapist to come around to your house and help you cope with all the changes. It's important that you make yourself try a little harder each day to move around and do the normal things like washing and walking and that sort of thing. That will help you feel better, too.
CLIENT: Well thanks, but that's the problem, because I can't imagine myself doing all this. It all feels like too much.
INTERVIEWER: You just take it a day at a time. If you like, we can ask the hospital psychologist to come around and talk to you, because I can see you are feeling pretty down about this all.
CLIENT: Wouldn't you? How could a psychologist help with my situation? I don't understand.
INTERVIEWER: Well, the psychologist can help you to adapt to these changes better and to make the best of your situation. They have a lot of experience in helping people like you. I'm sure you'll do fine.
CLIENT: I just don't know.
INTERVIEWER: Well, wait until you've had some time to work with the physical therapist, the social worker, and the psychologist. You're just getting started, and it takes time to recover from a stroke like you had. You just need to be patient.
CLIENT: I just don't see how it's possible for me to get my life back.
CLIENT/PATIENT: I feel worried about going home now. I hardly know where to begin.
INTERVIEWER: It all seems rather overwhelming for you. CLIENT: That's right. I live alone, you see.
INTERVIEWER: And you're wondering how life will turn out now that you've had this stroke.
CLIENT: Yes, I like to play a round of golf and have a drink with friends, and now I can't see how it's possible to get that life back again when I can't even walk properly.
INTERVIEWER: It seems like a real uphill struggle.
CLIENT: Yes, exactly. More like a mountain! The doctor told me I might get a bit better but we'll have to wait and see.
INTERVIEWER: There's still a lot of time and room for improvement.
308 MOTIVATIONAL INTERVIEWING IN EVERYDAY PRACTICE Experiencing Motivational Interviewing 309
CLIENT: That's what the doctor says. It's only been 2 weeks.
INTERVIEWER: And you've already made good progress. What do you think would help you the most right now?
CLIENT: I don't know, but thank you. I need to figure out how to get my life back and carry on, even if it's for my grandchildren. They were here this morning and that was good.
INTERVIEWER: You really enjoy being with them.
CLIENT: I was in tears after they left and I decided that I have to get better, but then the reality hit me that I can't even get to the toilet on my Own!
INTERVIEWER: Your independence is a very precious thing.
CLIENT: Well, I want to go out with my golfing group. It was me who started that foursome 40 years ago.
INTERVIEWER: Wow! You've been together for a long time with those friends.
CLIENT: Yes, and they came to see me yesterday. It was good to see them, you know.
INTERVIEWER: I'll bet they want you back with them one way or another.
CLIENT: I can't see how it's possible and that's what makes me just, well, really upset.
INTERVIEWER: I wonder how you could keep in touch with them while you're recovering.
CLIENT: They'll come around to see me, I know, and maybe we can do some other things together.
INTERVIEWER: Like what?
CLIENT: Well, I'll probably be able to have a drink and play cards with them even if I can't play 18 holes.
INTERVIEWER: So it feels like you have a mountain climb ahead of you. It looks so difficult that you can't quite imagine it yet, since this is all so new. And you also have some good friends to go on this journey with you. Is that about right?
CLIENT: Yes, that's how I feel.
INTERVIEWER: I'll tell you what. How about if I come back tomorrow morning—I'm on duty then—and I'll bring us a cup of tea and we can talk again, see how you're feeling, and think together a bit about getting up that mountain. Would that be all right?
CLIENT: Yes, thank you, that will be good. It helps to talk about this.
Was Is Motivational Interviewing?
Clearly both Nurse A and Nurse B were concerned and trying to be helpful, and both conversations took about the same amount of time. It is possible that both nurses thought of what they were doing as MI. But was it? How can you tell? Here are some questions to consider related to the four processes of MI.
1. What was engagement like?
To what extent did the nurse seem to be interested in understanding the patient's perspective? What was the quality of reflective listening? How engaged do you think the patient felt in the conversation? Was a foundation laid for further conversation?
In terms of technique, Nurse A asked two closed questions and offered no reflections.
Nurse B offered nine reflections and asked three open questions before closing: a 3-to-1 ratio of reflections to questions. Quality listening didn't take any longer, and it might be argued that it saved time, allowing Nurse B to get closer to the heart of the challenge. Sometimes not listening can prolong the process.
2. Was there a clear focus?
Both conversations did focus on issues related to recovery from stroke. Nurse B homed in on the patient's relationship with his golfing friends, a somewhat more specific topic that is of obvious importance to him.
3. Was the interviewer evoking change talk?
With Nurse A the patient offers only sustain talk, no change talk. Through reflective listening and open questions Nurse B is already evoking change talk (did you spot it?), with the patient seeming more activated and engaged in the conversation. Specifically, Nurse B asked three open questions, the expected answer to which would be change talk:
- "What do you think would help you the most right now?"
- "I wonder how you could keep in touch with them while you're recovering."
- "Like what?" [Asking for elaboration or an example]
4. Was there collaborative planning?
Perhaps the biggest difference between these two conversations was the extent and style of planning.
Nurse A jumps right in with advice and solutions (never with permission, by the way). The righting reflex is flagrant, and the patient seems unimpressed with the ideas being provided. No advice was asked for, and none was given by Nurse B. Instead, all three of the open questions listed above were such as to elicit the patient's own ideas for what to do.
With these four considerations in mind, the latter conversation was clearly MI whereas the former was not.
Nurse A's obvious concern is channelled into a directing style and unilateral problem solving. The well-intentioned reassurance peppered across Nurse A's conversation clearly falls within Thomas Gordon's description of a roadblock to listening, to understanding the client's predicament (Chapter 5).
Nurse B's conversation is much closer to a guiding style. As a dance it has a firm sense of direction, with a gentle and fluid approach to movement. Even in this short exchange the elements of the underlying spirit of MI (Chapter 2) are apparent.
Spot the Difference
(page 306 – 308 Miller & Rollnick)
This consultation occurs in a busy prenatal clinic where a pregnant woman with HIV-AIDS is facing the need to maintain a healthy diet, adhere to an antiretroviral medication regimen, and practice safe sex. Her first language is not English.1 In this example we use a very brief segment to illustrate the directing style and then an example of a guiding style.
Ask yourself: Is this counselor doing MI? How do you know?
INTERVIEWER: Good morning. We are talking today because we don't want you to have an HIV-positive baby.
CLIENT: Uh-huh. It's difficult because what about if my husband wants to have sex with me?
'Thanks to Bob Mash and colleagues for this practical example.
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INTERVIEWER: You need to use a condom.
CLIENT: But he doesn't want to use a condom.
INTERVIEWER: The problem is that you can get reinfected. For the sake of your baby you need to discuss this with your husband if you want this baby.
CLIENT: Yes, I want the baby.
INTERVIEWER: Well, if you want a healthy baby you need to discuss this and work it Out with your husband to use condoms as responsible parents.
CLIENT: But he gets mad and hits me sometimes.
INTERVIEWER: You have to protect your baby. Are you taking your medications?
CLIENT: Yes, when I can. Sometimes I miss doses.
INTERVIEWER: You really need to take all your medications faithfully. That's very important. If you miss doses the medicines don't work as well.
CLIENT: I do take them most of the time.
INTERVIEWER: I'm afraid most of the time isn't good enough. You need to take them all as we discussed.
CLIENT: I'll try.
INTERVIEWER: And how about your diet? Are you eating good food for you and your baby?
INTERVIEWER: Because you are eating for two people now, so watch the
beer also. It's not good for the baby. Do you have any questions?
INTERVIEWER: All right, I'll see you again in 3 weeks.
INTERVIEWER: Good morning. I'm glad you came back to see me today. CLIENT: I must do this for my baby.
INTERVIEWER: This baby is very important to you and you want it to be healthy.
CLIENT: Yes, I told my husband and he is supportive but there are some issues he is not helping me with. He doesn't want to use the condoms.
Experiencing Motivational Interviewing 317
INTERVIEWER: The condoms are an issue. We can talk about that, about
your medication, your diet, or anything that's important to you.
CLIENT: I want to talk about the medicine.
INTERVIEWER: Yes, fine, we can come back to other things. The medication feels important to you.
CLIENT: I know it's very important. If I miss some doses, is that bad?
INTERVIEWER: Tell me what difficulty you're having.
CLIENT: I don't want my mother to know about this. I hide the medicines from her, but she can see what I am doing all the time.
INTERVIEWER: So sometimes it's a challenge for you to take the medicine on time.
CLIENT: Yes, I want to do this for myself and my baby, and sometimes she looks at me strangely.
INTERVIEWER: How might you be able to take them without her seeing? CLIENT: When I go to the toilet.
INTERVIEWER: That's good. When else could you take them? CLIENT: After she's gone to bed.
INTERVIEWER: It sounds like that could work. With just those two options I think you could take them when you need to, and maybe there are even more possibilities. What do you think?
CLIENT: I don't want to miss doses. I'll see how that works.
INTERVIEWER: Good! You're right that it's important to take them regularly, and that sounds like a good plan. Now, could we talk a bit about how it's going with your husband and using condoms?
CLIENT: All right.
MI at its best is both simple and skillful, though not necessarily easy.
These two brief conversations are the same in length: 10 exchanges in each.
Consider these questions:
- How engaged was the patient in each conversation?
- How well was the interviewer listening to the woman's own perspective?
- How is she likely to be feeling at the end of each exchange?
- In each conversation about change how was the focus established, and by whom?
- Is there change talk? If so, what did the counselor do to evoke it and how did the counselor respond when it occurred?
- How willing would the woman be to continue the discussion if the clinician has time to do so?