Motivational interviewing: How patients motivate themselves

Career Manager By Steph Luon, PharmD, BCACP, BCPS

It is another typical day in the family medicine clinic. Your first patient of the day is a gentleman with an A1C of 12%. He has been coming to appointments in the clinic regularly with you for the past 6 months, but his A1C remains elevated. He reports missing several doses of medications each week because he forgets. He refuses to try any injectable medications because he reports that he does not want to inject himself “like a recreational drug user.” Each time you see him in clinic it saddens you that this patient, with two young sons, is not willing to make the changes that are necessary to live a longer, healthier life.

After learning about motivational interviewing techniques at a continuing education event, you decide to take a different approach with his appointment today.

Steps to get started
William Miller and Stephen Rollnick, two well-published authors of literature on motivational interviewing, define motivational interviewing as: “A collaborative conversation style for strengthening a person’s own motivation and commitment to change.” 
Here are some simple steps to help you implement motivational interviewing with patients.

Step 1: Build rapport and set the agenda. If the patient had a recent loss in the family, lowering his A1C is likely the farthest thing from his mind today. Build rapport by letting the patient know that you care for them. Allowing the patient to help set the agenda acknowledges that sometimes, people decide now is not the right time for them to change, and the patient will be the best judge of when they are ready to change.

If the patient is not ready to discuss smoking cessation, for instance, ask politely, “Would it be okay if we revisit this at a future visit?”

Step 2: Assess readiness and explore importance. One of my favorite techniques for helping my patients to help themselves is the “readiness ruler.” Readiness is a combination of importance and confidence. I ask patients to rate their readiness to change on a scale from 1 to 10, 1 being not ready to change and 10 being really ready. If the number is high, ask the patient, “Why is it so high?” or “What is motivating you to want to change?” If the number is low, ask the patient, “What would make this number go from a 4 to a 7?” There are often barriers that we do not foresee that get in the way of a patient’s readiness and ability to change their lifestyle. 

Ask what would need to happen for it to be more important for them to change their habits. When you learn what patients care about, you can help them to prioritize and set realistic goals.

Step 3: Build confidence and address questions. Again, using a scale from 1 to 10, ask the patient, “If you decided to make a change now, how confident are you that you would succeed?” Follow up by asking, “What could make that number higher?” Ensure the patient has all the tools and information needed to be successful with their lifestyle change.

Step 4: Summarize discussion and plan for follow-up. It is important to always remain non-judgmental and to listen and elicit information from the patient, rather than try to figure out why they have not made changes on their own. 

As a New Practitioner, you can use the techniques above to advance the care of your patients, in addition to the care of your families, friends, and colleagues. It is never too late to help others discover their own inner motivation and change their lives for the better.