Family Medicine

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World Book of Family Medicine – European Edition 2015 patient's ambivalence, we need to avoid a directional and “expert” driven style. Instead, we should adopt an empathetic, reflective, listening style in order to communicate understanding of the patient’s inner world of conflicts. Reflective listening involves the following skills: Using Open Questions. Making reflections aloud to show empathy and to test whether we have understood what the patient meant. Affirming the strengths and qualities of the patient. Summarising to check that both doctor and patient have the same understanding of what has been said and/or agreed. Studies show that these skills are easy to understand, but difficult to use in a fluid and easy manner during a consultation. Like the game of tennis - easy to understand, but not so easy to master well! A lot of training and supervision is necessary (3). The Spirit of MI, is defined essentially by our will to collaborate with the patient and activate his/her own expertise. It means Unconditional Acceptance, Empathetic Reflection and support for the patient's Autonomy and this can be summed up as: “I’m here to help but it’s up to you to decide where to go and what to do”. An important element of Acceptance is affirming the qualities and strengths we can observe in our patient. This is linked to Compassion which is another important element of the spirit of MI and implies “I want the best for my patient”. MI usually starts with Engaging: “Do I understand this person’s perspective and concerns? “How comfortable is this person in talking to me?” This is followed by Focusing which is to look for the “goals for change” and questions “Are we working together with a common purpose?” “Does this feel more like dancing or wrestling?” Next comes Evocation which means: “What are this person’s own reasons for change? Is his/her reluctance more about confidence or the importance of change? What change talk am I hearing? Am I steering too far or too fast in a particular direction? Is the reflex “to be right” making me the one to be arguing for change?” The last element is Planning which takes in: “What would be a reasonable next step toward change? What would help this person to move forward? Am I retaining a sense of quiet curiosity about what will work best for this person?” (1 - p.311). MI is described as a style of being with people, an integration of particular skills to foster motivation for change. It is essentially a collaborative partnership that honours the other’s autonomy, seeking to understand the patient’s internal frame of reference. Compassion is added to the spirit of MI precisely to emphasise that MI is to be used to promote the patient’s welfare and best interests, not one’s own. There are currently a lot of studies showing the efficacy of MI (4, 5, 6,7,8). The most powerful change catalysts operating in MI include empathic listening, the capacity to strengthen change talk, and the therapists ability to refrain from counter therapeutic responses (1 - p.386). One last word: there is a benefit for the family doctor himself in MI. My experience in adopting this style of interaction with my patients is that, not only is there a greater degree of satisfaction in the doctor/patient relationship, but it is also an effective preventative measure for ‘burnout’. Take Home Messages When patients resist the doctor’s advice, it’s time for MI MI gets much better results than blaming or criticizing When patients hesitate to consider behaviour change, it’s time for MI. Original abstract http://www.woncaeurope.org/content/ws216-applications-motivational-interviewing-hypertension-treatment References 1. Motivational Interviewing. William R. Miller, Stephen Rollnick, Third edition 2013 New York Guilford Press 38
World Book of Family Medicine – European Edition 2015 2. Health Behavior Change. S. Rollnick, P.G.Mason, C.C.Butler Churchill Livingstone 1999 3. Building Motivational Interviewing Skills. D.B. Rosengren New York Guilford Press 2009 4. see the ref. in (1) p.435 - 470 especially: Bien,Miller 1993; Brown, Miller 1993; Bohart, Tellman 1999; Hubble &al 1999, Miller & al 1993, Project MATCH research group 1998 Hettema & al 2005, Hubble, Duncan, Miller 1999, Sanders L.2011, White, Miller 2007) 5. D’Amico EJ et al, Group Motivational Interviewing for Adolescents. Change Talk and Alcohol and Marijuana Outcomes J Consult Clin Psychol 2014 Nov 3 6. Vesely JM et al.: Obesity: Dietary and Lifestyle Management FP Essent. 2014 Oct; 425: 11-5 7. Vasilaki EI et al: The Efficacy of Motivational Interviewing as a Brief Intervention for Excessive Drinking: a Meta-analytic Review Alcool Alcool 2006 May-Jun; 41 (3) ; 328-35 8. Keeley R.D. et al Training to Use Motivational Interviewing Techniques for Depression. J Am Board of Family Med 2014; 27: 621-636 39
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