Question 1

Can motivational interviewing be used in brief consultations in health care where time pressure is an issue?

Stephen Rollnick · Accepted Answer

Motivational Interviewing has been adapted and used in brief healthcare consultations from the late 1980’s.  It has been supported in many randomized trials among patients in a range of settings, with a range of presenting problems.  The enduring common thread running through this work is the use of a guiding style in which the patient is encouraged to say why and how they might change, supported not dominated by information and advice. This might take a little longer than simply telling patients what to do, but then time might be wasted using unskilful advice-giving, and outcomes seem like they are poorer. There is also the argument that skilful listening takes very little time.

Question 2

What advice would you give an overwhelmed primary care physician on how to start putting Motivational Interviewing into practice?

Stephen Rollnick · Accepted Answer

Start with yourself would be my first suggestion.  Your wellbeing is the fuel that drives good or practice. There is no one way to start putting Motivational Interviewing into practice. Many practitioners find it useful to practice the switch from telling to guiding.  This takes pressure off you to solve the change problem for the patient. That can be a source of stress for you (“banging your head against a brick wall”). It also minimises that feeling of boredom, because guiding helps you to see every patient as unique, so you start to enjoy the consultations more. Other practitioners choose to get on top of using the Elicit-Provide-Elicit framework for giving information and advice; others prefer to practice improving their listening skills. Trust your own instinct about where to start, with your wellbeing centre stage.

Question 3

How does motivational interviewing improve the quality of communication with patients in a health care setting?

Stephen Rollnick · Accepted Answer

Patients generally like to feel understood, respected, be able to say what they think and feel and be given a sense of choice about what to do to improve their health.  MI provides the style and skills for doing this efficiently. But it does take practice.

Question 4

How can motivational interviewing help with "resistant" and "non-compliant" patients?

Stephen Rollnick · Accepted Answer

When patients react against things you say or ask them to do there is a tendency to argue back, or try to “put sense into them”. This often makes it worse. Motivational Interviewing provides an alternative, where by using listening skills they feel more understood and more ready to consider why and how they might change.

Question 5

Can burnout in health care be prevented?

Stephen Rollnick · Accepted Answer

There is no single solution to burnout prevention, rather a set of conditions and actions that can help.  The more practitioners feel in charge of a balanced workload that they enjoy, the less burnout will be experienced. Systems of care can be designed with this in mind. Practitioners also need to feel heard and supported - given the chance to talk about what will help them feel as balanced as possible. Then, inside the consultation, they can reflect about what is putting them under strain. Some find that they can empathise too much, others that they are too rushed and don’t really do a good job. Put simply – an environment in which their wellbeing is a top priority will generate happier and more successful practitioners.

Question 6

Why do people often have ambivalence about their health?

Stephen Rollnick · Accepted Answer

Ambivalence means feeling two ways about something. In healthcare this often focuses on a change that the person, someone close to them or a practitioner feels is a good idea. As people get older, problems arise, and old habits no longer serve them well, like excessive eating, heavy drinking, smoking and so on. But this often involves the person having make adjustments that have both benefits and costs.  It is really normal and very common to feel two ways about a change in health behaviour.

Question 7

What is ambivalence and how can motivational interviewing help?

Stephen Rollnick · Accepted Answer

Ambivalence means feeling two ways about something. It is common and normal to experience doubt and uncertainty, and when it comes to a change in behaviour, people often feel ambivalent. A common response from a helper or practitioner is to make the case for change, and this usually elicits reactance from the other.  Persuasion often leads to kickback. Motivational interviewing is helpful because it allows you to bypass this problem by asking the person to say for themselves why and how change might come about. They rather than you present the case for change.

Question 8

What are the goals of Motivational Interviewing in health care?

Stephen Rollnick · Accepted Answer

The goals of motivational interviewing in healthcare are to connect with patients, and to encourage them to say for themselves why and how they might change, supported not dominated by your advice and information.

Question 9

When do we use Motivational Interviewing in health care?

Stephen Rollnick · Accepted Answer

Motivational interviewing (MI) is used in healthcare for those scenarios where you want to talk about change with a patient that is in the best interest of their health and wellbeing. This can arise with almost any patient, in any setting, either right from the start of the consultation or perhaps midway through it. The idea is that instead of the practitioner presenting the arguments for change, the patient is guided to do this for themselves.

Question 10

What are the limitations of motivational interviewing in health care?

Stephen Rollnick · Accepted Answer

Not every practitioner will enjoy learning motivational interviewing. It requires a willingness to hold back from providing solutions for patients, and some practitioners find this not to their liking. It is not yet clear whether some patients might be unsuited to MI, and this is a possibility. Lack of time is often cited as a limitation, but ways have been found of using Mi in very brief consultations.  A challenge however is that to do MI well requires skill and practice, and not every service and practitioner will want to give priority to this.

Question 11

Why don't people change?

Stephen Rollnick · Accepted Answer

Put very simply this is probably because their social environment and financial circumstances leave them feeling disempowered, or because they themselves either do not feel it is important or lack the confidence and support needed to make the change.

Question 12

What are the basic principles of Motivational Interviewing in a health care setting?

Stephen Rollnick · Accepted Answer

The basic principles of MI in healthcare are the same as those for any other setting. They are to establish good engagement, clarify the focus, and then guide the patient to say why and how they might change. One important guiding principle concerns what you don’t do: interrupt, cut across, leap in with premature advice and generally block the patient’s opportunity to speak for themselves.

Question 13

What do you see as the greatest benefit of Motivational Interviewing in a healthcare setting?

Stephen Rollnick · Accepted Answer

The wellbeing of practitioners and their patients.

Question 14

I train medical staff in motivational interviewing. It is generally very well received, especially in experienced practitioners who can see the value of this approach. Any tips for motivating young, trainee doctors to be interested in this approach? What skill/s would you prioritize teaching them?

Stephen Rollnick · Accepted Answer

In training practitioners we find it helpful to start with them, not their patients and their problems, and to ask questions like, “What are your strengths in the consultation”; “How would you like to improve?”; “What challenges do you face?”. This not only helps to engage them but allows you to fit your material on Motivational Interviewing into their everyday challenges.

Question 15

How do I sell training our staff in motivational interviewing to my organization as a staff well-being initiative?

Stephen Rollnick · Accepted Answer

If you start having conversations with managers/leaders about wellbeing, Motivational Interviewing can be presented as one way of doing something positive. It can be useful to be prepared to answer the “why” and “how” questions likely to arise. Have these clear in your mind, and make sure you don’t present MI as the solution to wellbeing, because it can only be part of a wider effort to recognise wellbeing as an issue, and consider how the culture can change to foster it. Another approach is from the bottom up: form a small group of practitioners who learn MI together and who are clear in their own minds how this helps with their wellbeing. Then approach leadership for a conversation.

Question 16

Is there evidence linking the use of Motivational Interviewing in health care to a reduction in complaints to regulation bodies and litigation against health practitioners?

Stephen Rollnick · Accepted Answer

There is good evidence that complaints are linked to poor communication. Motivational interviewing (MI) is based on principles and skills designed to improve communication (as are any of a number of other approaches to the healthcare consultation). Research is yet to be conducted that looks at the question posed here, whether the use of Mi actually reduces complaints.

Question 17

What do you wish frontline healthcare practitioners knew about MI?

Stephen Rollnick · Accepted Answer

Frontline practitioners can add a wide range of Motivational Interviewing skills, strategies and the underlying style to enrich their everyday practice. What is often not appreciated is that adopting a guiding style relieves pressure on them to solve problems for patients. The most radical transformation of practice might not come from adopting MI wholesale, but in learning and using the “Eicit-Provide-Elicit” strategy for giving information and advice. It is very simple, and with practice is easier.

Question 18

We are now seeing patients via telemed, many by phone only encounters. Some of these patients are already well known to our team but others much less so. Meaningful encounters by phone are proving challenging; do you have any guidance for MI by phone?  Thank you.

Stephen Rollnick · Accepted Answer

It's such an important question. New media, new challenges. Listening and engaging from the outset will be more important than ever.  I would dig around on the internet for guidelines for telemed consultations because they are out there, packed with wisdom. A selection of open questions to start with seems essential. Using MI as such in these consultations is possible, but this is at another level so to speak.  The challenge you are probably facing sound like more basic engagement ones. Practitioners do well to discuss among themselves how to improve their skills.  Above all they want to avoid blaming the patients for communication struggles and not leap in too quickly without engaging.

Question 19

I do only group therapy with revolving dual diagnosis patient groups, and rarely have an opportunity to do any prolonged one-on-one counseling. Can MI be applied in this type of situation? Thanks!

Stephen Rollnick · Accepted Answer

MI can be used in this situation, but on a foundation of good general group facilitation skills. There is a textbook on this subject by Chris Wagner and Karen Ingersoll. Establishing clear and shared ground rules is one fundamental foundation.  Then if you are using MI, it is like tossing a balloon into the group and inviting them to toss its around among themselves, stealing for themselves not others, with you asking open questions and making listening statements that encourage them to say why and how they might change. That’s the essence of it, and it takes skill for sure.

MI in Health Care