Motivational Interviewing: A Practical Learning Lab

Kelly N. Gable, PharmD, BCPP
Associate Professor
SIUE School of Pharmacy

The learning labs were a hit at CPNP 2014, offering attendees an opportunity to participate in one-hour active learning sessions. Each of the five sessions included practical discussions on topics such as hepatic and renal dosing dilemmas, motivational interviewing, passing the BCPP, pharmacy provider status, and systematic reviews and meta-analyses. The learning labs were a new edition to the CPNP annual meeting and were member-led discussions intended to offer quick, useful information for the psychiatric and neurologic pharmacist, while also allowing for time to practice specific skills surrounding the topic. The Motivational Interviewing (MI) lab offered an overview of the spirit of MI and updates from the latest 2013 text edition on MI by William Miller and Stephen Rollnick.¹ In addition, participants were given an opportunity to practice core communication skills through the review of clinically challenging patient scenarios.     

Summary: Motivational Interviewing (MI), first described by psychologist William Miller in 1983 in the context of addiction treatment, has developed into a communication style widely accepted by therapists. More recently, the healthcare field has recognized it as valuable in the context of patient-centered care and nurses, pharmacists, and physicians have begun to receive training to build upon their skills.^2,3 MI is best described as a collaborative, person-centered communication style intended to elicit behavior change by helping people to explore and resolve ambivalence.¹ Ambivalence is natural and common among patients with addictions, nicotine dependence, and serious mental illnesses. Despite the increase in recognition of MI as an evidence-based practice, most medical providers do not receive training on MI.

What Type of Communicator are You?

Director: often tells, leads, provides advice and instruction to others on how to fix a problem
Follower: listens and refrains from inserting own ideas
Guide: listens and offers expertise when elicited – most consistent with MI

Take-Home Points From the Learning Lab:

• The Spirit of Motivational Interviewing: The spirit of motivational interviewing is just as important to understand as the skills themselves. Without the spirit, MI becomes a form of behavioral manipulation. The spirit of MI reminds us that communication is a collaborative effort (partnership) among two experts. The pharmacist may be the expert on medication therapy; however, the patient is the expert on themselves.  The spirit of MI also embodies acceptance and compassion. We must respect that another person has worth, autonomy, and self-direction. Compassion is to value the well-being of the patient. To see the world as they see it.  It is an expression of empathy, not sympathy or identification. Finally, evocation is to suspend an authoritarian role and recognize that if change does occur, it is the patient’s choice. The MI provider’s goal is to evoke and strengthen change that is already present from within the patient.

Questions/Comments NOT consistent with MI:

• “We are talking today because we don’t want you to end up in the hospital again.”
• “Don’t worry; you will start to feel better once you start this medicine.”
• “Are you taking your medications?”
• “You have a serious problem and you need to quit.”

Questions/Comments consistent with MI:

• “How do you hope I might be able to help you today?”
• “Would it be alright if I tell you a few things that have worked for other people?”
• “Tell me about how you take your medications.”
• “Tell me what you already know about alcohol and how it affects your body.”

• Processes and Skills: There are four overlapping processes of MI that consist of engaging, focusing, evoking, and planning.¹ Throughout the process of MI, five communication skills can be utilized that include: asking open ended questions, affirming and respecting a patient’s strengths, using reflective statements, summarizing key points said during the interaction, and informing and advising when the patient asks for it.¹

• Reflections are interviewer statements (NOT questions) intended to mirror meaning of preceding patient speech (e.g.- a hypothesis). They ensure an understanding or clarify uncertainty. Reflective listening also allows a patient to hear their statement again and think about its accuracy.
• Simple reflections repeat or slightly rephrase what the patient has said.
• Complex reflections often involve the provider making inferences about what the patient has said. Complex reflections add meaning to what the patient has said and often facilitate communication and move the conversation forward.

So Why Learn MI?

Change is difficult and does not happen overnight. Adults with serious mental illnesses have been reported to die 25 years earlier than the general population, often due to preventable conditions and modifiable risk factors. Simply telling a patient to stop smoking, take their medication, or eat healthier, does not produce or promote sustainable change. 

Clinicians may feel an overwhelming desire to persuade a patient into doing the right thing to improve their health. When we take a more directive role in patient care, this is known as the “righting reflex.” This form of communication often leaves the patient feeling frustrated, defensive, and even powerless in their own care. Motivational interviewing is intended to elicit behavior change by exploring the patient’s own internal motivation for change. As a clinician, if you argue for one side of ambivalence, the patient is likely to defend the opposite.¹ Use of MI will increase a patient’s change talk or the patient’s own motivation for change. 

There are over 1,200 publications and 200 randomized controlled trails highlighting the effectiveness of MI in promoting behavior change.¹ I am hopeful that the learning lab and this article piqued your interest to learn more about MI. It is important to recognize that attending workshops and lectures can enhance your knowledge of the core concepts of MI, but to become proficient is an ongoing process.  Seek out ongoing trainings in your area, as well as feedback from a Motivational Interviewing Network of Trainers (MINT) member.       

“The great thing in the world is not so much where we stand, as in what direction we are moving.” - Oliver Wendell Holmes

Cardinal References

1. Miller, W.R., Rollnick, S. (2013). Motivational interviewing: helping people change, 3rd edition. Guilford Press.
2. Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational interviewing in health care: Helping patients change behavior.  New York: Guilford Press.
3. Emmons KM, Rollnick S.  Motivational Interviewing in Health Care Settings: Opportunities and Limitations.  Am J Prev Med 2001; 20(1).