Overview
This lecture introduces Motivational Interviewing (MI) as a collaborative, patient-centred communication style for health behaviour change. It covers the definition and rationale for MI, its underlying “spirit” (three linked components), its general/core skills (OARS) and specific skills (READS) plus change talk, and two related but distinct stage-of-change frameworks: a six-stage “Stages of Change: Primary Tasks” cyclical model and a separate five-stage Transtheoretical Model. These are then applied to a worked case study (AB, a 69-year-old man with type 2 diabetes) and a sample exam question.
What Motivational Interviewing Is
- Definition (Miller & Rollnick, 2012): “Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”
- Founded by Dr William R. Miller.
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- Further characterisation (Rollnick & Miller):
- A collaborative, person-centred form of guiding to elicit and strengthen motivation for change.
- A style of communicating constructively about reducing health risks and changing behaviour.
- Designed to enhance the patient’s own motivation to change using empathic, non-confrontational strategies.
- Facilitates behaviour change by helping patients explore and resolve their ambivalence about change.
- Increases the patient’s self-efficacy.
- A directive approach: uses systematic strategies/statements to make it more likely a patient chooses to change in the desired direction.
- Uses “change talk” (see below).
- Can use a stages of change model.
The Spirit of MI
Three interlinked components (shown as overlapping circles):
- Collaborative: working together to understand the patient’s perspective (beliefs and concerns).
- Honouring autonomy: recognising that although the doctor may inform/advise, ultimately the patient decides what to do, and this decision may not result in the desired health outcome.
- Evocative: evoking the patient’s own arguments and reasons for change.
Core Skills: OARS
General/core MI skills (the same skills taught in Clinical Skills interviewing):
- Open questions
- Affirmation
- Reflective listening
- Summarizing
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Specific Skills: READS and Change Talk
Specific MI skills, with the acronym READS:
- Roll with resistance: resistance often stems from fear of change; rolling with it (rather than opposing it) reduces the likelihood the patient stays resistant. Used when patients express resistance to an issue. Examples: “You are not ready to start making dietary changes at this time”; “You don’t like this idea of joining a gym. It’s your choice”; “Okay, so you are not up for trying to quit smoking with the patch. What other options have you heard of?”
- Express empathy: behaviour change is only possible when the patient feels personally accepted and valued. Demonstrate understanding with phrases like “You seem…”, “You feel…”, “I gather that…”, “You sound…” rather than “I understand.” Example: “You sound frustrated. You have been asked to make a lot of changes to control your diabetes and blood pressure and people don’t seem to appreciate how overwhelming and difficult all of this has been and continues to be for you…”
- Avoid argumentation: demonstrates understanding and prevents creating extra resistance to change. Examples: “You do not see yourself quitting smoking this time. What types of things are you willing to do to get your cholesterol down?”; “On a scale of 0-10 how ready are you to start working on increasing your physical activity?”
- Develop discrepancy: increases the patient’s awareness of the gap between where they are and where they want to be, using change talk that doesn’t increase resistance. Aims to identify the patient’s core beliefs/values and highlight where their behaviour is inconsistent with those beliefs/values. Examples: “On the one hand you have an important goal of lowering your blood pressure to prevent stroke and heart attack. On the other hand, your smoking raises your blood pressure and your risks. What are your thoughts on that?”; “You want to see your children grow up, but you simultaneously recognize that smoking can have numerous serious health consequences for you and shorten your life.”
- Support self-efficacy: doctors help patients believe in themselves and become confident they can carry out chosen changes, reinforcing both thoughts and actions. Even a motivated patient will not change unless they believe they have the resources and capability to overcome barriers. Examples: “I am really pleased to hear that you are thinking of increasing your physical activity. What has you thinking more about that?”; “…you’ve tried before. That’s great!”
Change talk: patient statements reflecting desire, perceived ability, need, readiness, reasons, or commitment to change. Examples: “I would like to stick to my medication regime, but…”; “I really want to lose weight”; “I could quit drinking”; “If I stick to my medication then I would have better control over my diabetes”; “If I stop smoking, I will stop putting my children’s health at risk”; “I need to have more energy to play with my kids.”
Stages of Change: Primary Tasks (six-stage cyclical model)
Presented twice in the lecture (slides 25 and 37) as a circular diagram with six stages, each with a definition and a primary task for the clinician. Progression runs Precontemplation → Contemplation → Determination → Action → Maintenance → Recurrence, with dotted arrows also showing possible relapse back to earlier stages:
- Precontemplation — not yet considering change, or unwilling/unable to change. Primary task: raising awareness.
- Contemplation — sees the possibility of change but is ambivalent and uncertain. Primary task: resolving ambivalence, helping the patient choose change.
- Determination — committed to changing but still considering what to do. Primary task: help identify appropriate change strategies.
- Action — taking steps toward change but hasn’t yet stabilised in the change process. Primary task: help implement change strategies and learn to eliminate potential relapses.
- Maintenance — has achieved the goals and is working to maintain change. Primary task: develop new skills for maintaining recovery.
- Recurrence — has experienced a recurrence of the problem. Primary task: cope with consequences and determine what to do next.
In this model, a recurrence of the problem is itself a numbered sixth stage in the cycle, not just an arrow.
A separate video exercise (slides 29-30) asked students to identify which stage of change a person shown in a clip was in, and to justify the answer.
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The Transtheoretical Model (five-stage model)
A separate framework, named explicitly on slide 35 as the Transtheoretical Model, also called “Stages of change.” It has five formal stages, each given a plain-language equivalent:
| Formal stage | Plain-language label |
|---|---|
| Precontemplation | NO |
| Contemplation | MAYBE |
| Preparation | PREPARE/PLAN |
| Action | DO |
| Maintenance | KEEP GOING |
Relapse is shown as a two-directional arrow linking the two stacks of stages, not as a numbered sixth stage. This model was used to ask students to identify AB’s current stage of change (slide 35) and, using the six-stage “Primary Tasks” model, to ask “Where is AB now?” (slide 37) — the two questions are posed with the two different models, but neither slide marks the correct answer.
Note the two frameworks are distinct as taught: the six-stage “Stages of Change: Primary Tasks” model (Precontemplation, Contemplation, Determination, Action, Maintenance, Recurrence, with primary tasks for each and recurrence as a full sixth stage) versus the five-stage Transtheoretical Model (Precontemplation, Contemplation, Preparation, Action, Maintenance, with plain-language labels and relapse as a two-directional arrow rather than a stage).
Outcomes and Evidence
A grid of behaviour-change-related outcomes was shown (slide 31): increased physical activity, improving diet and weight management, decreased depression, improved quality of life, increasing self-efficacy, clinical outcomes/self-monitoring, medication adherence, decreasing health resource use, managing blood pressure. Some cells carried a checkmark, an equals sign, or a question mark icon, and some had no icon.
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The same list of behaviours/outcomes was reused (slide 34) to identify behaviours relevant to the AB case study specifically.
Case Study: AB
- AB: retired 69-year-old male with a 5-year history of type 2 diabetes.
- At diagnosis he was advised to lose weight but had limited GP follow-up.
- Over the past 6 months he tried to lose weight and increase physical activity, without success.
- Does not test his blood glucose at home, doubting this would help him improve control.
- Does not understand why he has diabetes, as he rarely eats sugar.
- Feels he has been fairly healthy most of his life.
- His partner is encouraging him to treat diabetes with herbal remedies and weight-loss supplements.
- His health beliefs are possibly interfering with his behaviour change.
Case outcome, after MI-informed consultation:
- AB and his partner agreed that referral to a dietitian was their first priority.
- AB stated his weight was unhealthy and “embarrassing,” and recognised his glucose control was affected by consuming large portions of bread and pasta.
- AB and his partner agreed on an exercise plan starting with short walks three times per week.
- AB stated: “Medications would make a sick man out of me.”
Exam-Style Application (sample question)
Sample scenario: Alex, a 58-year-old female with heart disease, has tried dieting and exercise but repeatedly stops soon after starting and falls back into no exercise and unhealthy eating; she feels demotivated and remains obese. Describe how MI might help her change her health behaviour.
Sample answer approach given: check where she is at in a non-judgmental way; ask why her attempts have failed in the past; emphasise where she has succeeded, to increase self-efficacy; note that she is preparing for change and present options; take her side using statements like “I know this is hard,” avoiding telling her what to do. The lecture notes there are many acceptable ways to answer this type of question.
Summary
- Doctors play a crucial role in helping people make health behaviour changes.
- This role involves more than just telling patients what to do.
- Doctors need to understand why a person is not making optimal health behaviour changes in order to help motivate them; without this understanding, patients often will not make recommended lifestyle changes.
- The Stages of Change models and Motivational Interviewing are important tools doctors can use, first to gain an accurate understanding of where a patient’s barriers to change lie, and then to engage in effective change talk that encourages realistic health behaviour changes.
Self-test
- Define Motivational Interviewing, using the Miller & Rollnick definition.
- Describe the three components of the “spirit” of MI and how they relate to each other.
- List the four OARS core MI skills.
- Describe the five READS specific MI skills and what each is intended to achieve.
- What is “change talk,” and what six things can it reflect? Give an example statement.
- Describe the six stages of the “Stages of Change: Primary Tasks” model, in order, with the primary task for each.
- List the five stages of the Transtheoretical Model with their plain-language equivalents, and explain how relapse is represented in this model.
- Distinguish the six-stage “Stages of Change: Primary Tasks” model from the five-stage Transtheoretical Model as taught in this lecture.
- A patient says: “I could quit drinking, but I don’t think I could handle the stress without it.” Identify which MI skill (from READS) would be most appropriate to respond with if you wanted to avoid increasing the patient’s resistance, and give an example of what you might say.
- Using the case of AB, describe two health beliefs that may be interfering with his behaviour change, and one outcome from his consultation that reflects successful use of MI.
Answers
Reveal answers
- Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change, designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
- Collaborative: working together to understand the patient’s perspective (beliefs and concerns). Honouring autonomy: the doctor may inform/advise, but ultimately the patient decides what to do, and the decision may not achieve the desired health outcome. Evocative: evoking the patient’s own arguments and reasons for change. The three are shown as overlapping, interlinked components of MI.
- Open questions, Affirmation, Reflective listening, Summarizing.
- Roll with resistance (work with, not against, patient resistance, which often stems from fear of change); Express empathy (show the patient feels accepted and valued, e.g. “You seem…”, “You sound…”, not “I understand”); Avoid argumentation (demonstrate understanding without creating extra resistance); Develop discrepancy (increase awareness of the gap between the patient’s current behaviour and their goals/values, without increasing resistance); Support self-efficacy (help the patient believe they can carry out the changes they’ve chosen, reinforcing both thoughts and actions).
- Change talk is patient statements reflecting desire, perceived ability, need, readiness, reasons, or commitment to change, e.g. “I really want to lose weight.”
- Precontemplation (not yet considering change, or unwilling/unable — raise awareness); Contemplation (sees possibility of change but ambivalent — resolve ambivalence, help choose change); Determination (committed but still deciding what to do — help identify appropriate change strategies); Action (taking steps but not yet stabilised — help implement strategies and learn to eliminate relapses); Maintenance (goals achieved, working to maintain — develop new skills for maintaining recovery); Recurrence (problem has recurred — cope with consequences and determine what to do next).
- Precontemplation (NO), Contemplation (MAYBE), Preparation (PREPARE/PLAN), Action (DO), Maintenance (KEEP GOING). Relapse is shown as a two-directional arrow linking the stages, not as a separate numbered stage.
- The six-stage “Primary Tasks” model (Precontemplation, Contemplation, Determination, Action, Maintenance, Recurrence) gives a definition and a specific clinical primary task for each stage, and treats a recurrence of the problem as a full sixth stage in the cycle. The five-stage Transtheoretical Model (Precontemplation, Contemplation, Preparation, Action, Maintenance) instead pairs each formal stage with a plain-language label (NO/MAYBE/PREPARE-PLAN/DO/KEEP GOING) and represents relapse as a two-directional arrow between stages rather than as a stage of its own.
- Roll with resistance, since the patient is expressing ambivalence/resistance about the difficulty of quitting. An appropriate response reflects back their position without arguing, e.g. “Okay, so you are worried about handling the stress without drinking. What other options have you heard of?”
- Health beliefs interfering with change: he does not understand why he has diabetes since he rarely eats sugar, and he doubts that home blood glucose testing would help him improve control (also feels he has been fairly healthy most his life, and his partner favours herbal remedies/supplements over medication). Successful outcome: he and his partner agreed to a dietitian referral and to an exercise plan of short walks three times a week, and he recognised that his glucose control was affected by his portions of bread and pasta.