Motivational Counsel

Authors: Kate Hall, Tania Gibbie, Dan I Lubman
Objectives: To explore the understanding of behaviour change, and the role of motivational interviewing (MI) in facilitating this change in primary care settings.
- Background: Primary care practitioners face the challenge of assisting individuals in changing persistent harmful behaviours impacting health.
- Motivation, Ambivalence, and Resistance: Research shows motivation is crucial for behaviour change and that ambivalence and resistance are common responses to change efforts.

Definition: A counselling method designed to enhance a patient's motivation to change by applying four guiding principles encapsulated in the acronym RULE:
- Resist the righting reflex: Avoid correcting patients or imposing advice, which can lead to increased resistance.
- Understand the patient’s own motivations: Recognize and explore the individual's reasons for change.
- Listen with empathy: Engage in active listening to foster understanding and trust.
- Empower the patient: Acknowledge the patient's autonomy and potential for self-directed change.
Effectiveness: Recent meta-analyses indicate MI's efficacy in treating addiction (alcohol and drug use), adhering to treatment, managing diabetes, and other health issues such as smoking cessation.

Common Issues: Patients may ignore or contest health advice, leading to frustration for practitioners. Initial responses to a patient's resistance often include more authoritative advice, which may exacerbate resistance.
Dynamic Nature of Motivation: Motivation fluctuates and can be influenced by the therapeutic approach. Authoritarian styles typically increase patient resistance.

Developed by Prochaska and DiClemente, this model identifies readiness for change as a vital mediator of behavioural change.
The Five Stages of Change:
1. Precontemplation: No intention to change.
2. Contemplation: Ambivalence towards change.
3. Preparation: Planning and committing to change.
4. Action: Taking steps to change.
5. Maintenance: Sustaining the change over time.
Relapse: Recognized as a normal part of the change process, providing insights for future maintenance efforts.

Core Principles:
- MI emphasizes a collaborative relationship, respecting patient autonomy and eliciting their intrinsic motivation to change.
- The practitioner assumes a facilitating role rather than an authoritarian one.
Comparison Against Authoritative Styles:
- MI promotes partnership and joint decision making while authoritative styles impose insights and coercively compel change.

Two Phases:
1. Building Motivation to Change:
- Basic skills represented by OARS:
  - Open-ended questions
  - Affirmations
  - Reflections
  - Summarizing
1. Strengthening Commitment to Change:
- Involves goal setting and creating a "change plan of action". Avoid maintaining ambivalence through direct goal-oriented questions.
Key Strategies for Eliciting Change Talk:
- Target specific areas:
  - Disadvantages of Status Quo: What worries you about your condition?
  - Advantages of Change: How would your life improve with changes?
  - Optimism for Change: Reflect on previous successful changes.
  - Intention to Change: What steps do you want to take for improvement?
- Use tools like the importance ruler to quantify motivation levels and encourage reflective thinking.

Scenario: A 52-year-old male with heavy drinking habits who expresses a desire to reduce consumption but continues drinking heavily.
Approach:
- Explore the patient’s personal motivations rather than providing authoritative advice.
- Discuss the impact of drinking on values such as health, relationships, and personal goals, highlighting the individual’s autonomy in deciding to change.
Conclusion of Interaction: In MI, apparent lack of motivation is treated as unresolved ambivalence rather than a deficiency in the patient.

Common Challenges:
- Time pressures during consultations.
- Need for professional development to master MI techniques.
- Patient requests for quick-fix solutions may hinder deeper engagement.

Empathic Understanding: Use reflective listening to build an open dialogue.
Develop Discrepancy: Assist patients in recognizing discrepancies between current behaviours and future goals.
Roll with Resistance: Approach resistance non-judgmentally as differing perspectives.
Support Self-Efficacy: Encourage patients by recognizing their strengths and past successes in change efforts.

Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. 2nd edn. New York: The Guilford Press.
Prochaska, J., & DiClemente, C. (1986). Towards a comprehensive model of change. In: Treating Addictive Behaviours: Processes of Change. New York: Pergamon.
Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: a meta-analysis of controlled trials. J Consult Clin Psychol, 71(5), 843-861.
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Ann Rev Clin Psychol, 1, 91-111.
Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: twenty-five years of empirical studies. Res Soc Work Pract, 20(137), 137-160.
Jensen, C. D. et al. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. J Consult Clin Psychol, 79(3), 433-440.

Kate Hall: Senior Lecturer, Deakin University, Department of Psychology, senior clinical psychologist, Turning Point Alcohol and Drug Centre, Eastern Health, Melbourne, Victoria. Email: kateh@turningpoint.org.au
Tania Gibbie: Health Psychologist, Barwon Health, Geelong, Victoria.
Dan I Lubman: Director and Professor of Addiction Studies, Turning Point Alcohol and Drug Centre, Eastern Health and Monash University, Melbourne, Victoria.

MI is identified as a crucial tool for promoting behaviour change in a variety of health-related contexts, supporting practitioners in navigating patient resistance and fostering optimal health outcomes.