means open discussion and listening to allow patients to identify needs for change themselves and to provide motivation for making such changes
helps particularly to start and to maintain lifestyle changes (e.g. increase physical activity, lose weight, quit smoking or decrease alcohol consumption)
helps to implement self-care
makes the patient responsible.
Instruction or discussion?
Instruction and counselling are often experienced as authoritarian, given from 'above', and this easily arouses opposition. In most cases concerning change in lifestyles, the problem is not lack of information but the difficulty of changing one's habits.
Many people know that their habits are detrimental to health. There is some motivation but the change appears so difficult that they are not prepared or do not have the strength to implement it.
The discussion aims at
creating trust and cooperation
helping patients to see the conflict between their values or aims and the current state of affairs
facilitating change
supporting and bringing out the patients' own will and ability to change.
People are the best experts in their own lives. Patients should choose the issues they wish to change and think up the aims and the means.
The level of preparedness for change often appears in the patient's reply.
“I know I should stop smoking, but I don't want to.”
“My weight has gone up. I suppose I should start jogging again.”
In an ambivalent situation, patients are not yet ready or willing, or do not really believe in their ability. Lead them to consider the pros and cons and then draw a short conclusion using their words. Patients often carry on thinking about this, and the next time they may be prepared for change.
When patients wish to change, ask in more detail, what is involved and how they think they would go about it. At this stage, you can suggest various alternatives. Nevertheless, the patient will choose what to change and how.
Practical implementation
Ask open questions (what, how?).
“What do you think about your health?” or “What are your dietary habits?”
Avoid questions that can be answered in one word (yes/no).
Show empathy.
When patients feel they are being heard and approved of, it will be easier for them to start working for their health.
“Sounds difficult, how are you coping?”
“You are right, weight loss is not easy...”
Show interest when listening.
Look, gestures and facial expressions, such as nodding slightly or a short acknowledgement, such as “yes”
Eye contact is important; do not look at the computer screen.
Make reflective statements, repeating the patient's words.
This will lead the patient to reflect further or to tell you more.
“Did I get it right that you have already started to walk more? … ”
“You said that you had previously quit smoking for three years.”
“You said your wife urged you to see me. What do you think yourself?”
Recognize change talk, and react to it.
Take up the patient's words and ask further.
Help patients to consider the conflict between the current state of affairs and what they wish for. It is the patient who should suggest grounds for a change, not the doctor.
“It sounds as if you have considered starting physical exercise? Can you tell me more about this?”
“You said you are worried about your overweight. What do you mean?”
Take a neutral position and “roll with resistance”.
In the beginning of the discussion, medical argumentation may raise opposition.
Stay in tune with the patient's story, avoiding argumentation and direct instructions.
You can summarize the patient's thoughts, arguments and hesitations.
“You said that smoking relaxes you and gives you a break and chance to talk to your colleagues. Working life is indeed quite tough, and breaks are needed. You also said that sometimes you are in a hurry to get things done...”
Try to make patients think themselves, find new views and wake up to the situation.
Emphasize the positive and the successful.
Emphasize the good things patients bring up. Grasp even the slightest positive things. Compliment them on their success.
“So you walk 10 minutes every day. That's great! How did you accomplish that?”
Reinforce the possibility for change and the patient's own ability and strength (empowerment).
Find out the patient's strengths and enforce their belief in their abilities
These may include, for example, determination, consideration of others, responsibility, caring, reflection.
“You appear to be very decisive...”
The patient will choose what to change and how.
Consideration of pros and cons is particularly appropriate if they are ambivalent about the change.
Let patients consider the pros and cons themselves.
“Why would you like to quit smoking?”
“What positive aspects does smoking involve?”
“What benefit would you get from quitting?”
Here you can provide neutral reinforcement, such as “You're right, smoking...”
Make short summaries and repeat.
Use the patient's own words and sentences.
These reinforce the experience of being heard and the possibility of change.
The doctor is a medical expert.
You should not withhold information but wait for the appropriate moment in the discussion.
A conversational approach will make patients think.
They themselves should state the need. “Yes, I suppose antihypertensive medication should be started. Can it be stopped if I manage to lose some weight?”.
Proceed in small steps.
Individual small changes are easier to make.
Help the patient to think of a reasonable goal and change at the beginning.
Success reinforces the patient's ability and belief in the possibility of further changes.
Relapses
Relapses do not mean permanent failure. It is possible to learn from relapse.
Discuss everything that went well and what led to the relapse.
For example, patients who manage to lose weight permanently usually succeed only after 2 to 4 attempts. When quitting smoking, it is often only the 3rd or 4th attempt that is successful. “You managed to quit a year ago, how did you do it then?”
References
Miller WR, Rollnick S. Motivational interviewing. Preparing people for change. Second edition. The Guilford Press. New York 2002.
Easthall C, Song F, Bhattacharya D. A meta-analysis of cognitive-based behaviour change techniques as interventions to improve medication adherence. BMJ Open 2013;3(8):. [PubMed]
Keeley R, Engel M, Reed A, et al. Toward an Emerging Role for Motivational Interviewing in Primary Care. Curr Psychiatry Rep 2018;20(6):41. [PubMed]