In this episode of the Move to Value Podcast, we have a conversation about Motivational Interviewing with Sebastian Kaplan, PhD, a clinical psychologist at Atrium Health Wake Forest Baptist and Associate Professor of Psychiatry and Behavioral Medicine at the Wake Forest School of Medicine.

Dr Kaplan has additional Motivational Interviewing resources available here: https://www.guilford.com/author/Sebastian-G-Kaplan

Can you give a broad overview on motivational interviewing and its role in healthcare?

Sure, well, motivational interviewing in its most simplest way of defining it, is it’s a conversation about change. Now there’s all kinds of ways to have conversations about change honestly. So, what makes MI unique? So, one of the things that separates it is the interpersonal style that we strive for in every MI conversation. And it’s a style that is predicated on collaboration, on a lack of judgment or minimal judgment, one of acceptance of a person’s choices and whether they are choices that seem to be consistent with health or not, we’re accepting of their autonomous decision-making. And it’s a style that’s rooted in compassion as well. So that’s the like style of the conversation.

There’s also an intentional, strategic part of the conversation, which really does separate MI. The interpersonal style, that’s pretty consistent, at least in theory, on what other approaches would be about. But the specific strategy about MI is one that listens for and explicitly invites the patient to talk about change. And so again, that might seem like, well ok, that’s what all conversations are about. But there’s a really set of specific strategies and techniques that are used on top of that style that serve to build a conversation about change. But, most importantly though, it’s the patient’s own reasons for change. Their own desires and motivations for change. Not our imposition of what they should or they shouldn’t do. It’s designed to kind of draw that out from the other person.

What is the benefit of MI versus traditional health behavior change methods?

So, I guess we could start with what would traditional behavior change methods be. Broadly speaking in healthcare, right? We’re not only talking about psychotherapy, you know, because MI is something that’s broadly applicable. I would say a traditional conversation follows a, and this is a generalization of course, but follows a path where the healthcare provider, who is viewed as the expert on whatever the topic at hand is, gathers information. With that information they develop the, they arrive at a diagnosis, and they develop a plan for the patient. And then informs the patient what the plan is, and, you know, go along on your way to implement this plan. And again, this is a gross generalization. But in general, it’s a very, it’s fairly hierarchical where there’s one expert, and that’s the provider, and then the patient is there to, you know, tell the provider information about themselves but the provider is the one who has the answers, you know.

And, you know, so what are the advantages? Well, I guess, we know both from empirical research but even just our own experience, human beings aren’t great at following through with things when they’re told what to do. Right? And not just, you know, lectured or you know if it’s done in a harsh way, not even that. It’s, you know, we’re more likely to follow through with behavior change, particularly really challenging behavior changes that are discussed all the time in health care. We’re more likely to follow through if the plan, and if the drive and reasons for change come from within us.

It’s obvious that there are major benefits of using MI, so why do you think it hasn’t been adopted by the entire health care industry?

Well, yeah, so it’s a good question. I think a few things. One, and I think a lot in the work that I do and a lot of the trainings that I’ve done, have been for professionals that are involved in pretty high stress or with problems of fairly high urgency. You know, so for instance, in psychiatry we talk a lot, and in my particular work, you know, at least part of my work, I work with teenagers that are suicidal, that harm themselves for various reasons. Who may use drugs and alcohol. And, you know, that and other, you know, kind of urgent, you know, health problems, I think elicit a lot of, you know, stress and concern on the part of the healthcare provider. And I think it’s just really, I think that higher level of urgency, kind of, evokes more of a you have to change kind of approach from the provider and it’s a lot harder to kind of settle into a more relaxed, collaborative, conversational style when someone is in that kind of high stress, high urgency kind of situation. So, I think that’s one.

But, you know, I think it’s just been, it’s also a method that’s just been passed down over the years. Where the healthcare provider is viewed as the expert, and that, the expertise of the healthcare provider is what will ultimately lead the patient towards health. And it just takes a while in healthcare for things to change. You know, healthcare, the literature certainly doesn’t support a lecturing, paternalistic style of communication. But, because that’s what has been, you know, in place for, you know, decades and centuries perhaps. You know, those that teach the younger generations continue to do that and I think we’re seeing shifts, we’re seeing changes. There’s certainly a lot of like patient-centered language that’s in our medical education curriculum here. I think it feels a lot more natural for Med students now than maybe fifteen years ago when I first started in this position to really get and understand why lecturing somebody to change is probably not going to be all that helpful.

What would a conversation using MI techniques look like?

Well, it would, I think a key element to an MI conversation that would lead one to sniff it out pretty quickly is the use of a particular counselling skill or conversational skill called a reflection, or broader than that, reflective listening. And so, what reflective listening is is a, it’s sort of, I guess a way to start describing it is to contrast it with what’s typically seen and that is a series of questions followed by answers. A reflection isn’t a question. You can think of it as a brief summary about or of what somebody just said.

Now, the reflection though has a couple of purposes. One is it is an invitation to say more, to speak more. And in particular to say more about the thing that the provider has reflected. So, in that sense, it functions kind of like a question because people kind of know if you ask me a question, I’m going to answer your question. Well, most people kind of get, if you hear a reflection, they’re going to likely say more about that thing. The other thing though about a reflection is that it does something that a question doesn’t, which is it has, in an unspoken way, it delivers the message I’m listening and what you say matters, I’m accepting of what you say. And, you know, of course, the tone and intonation matters too in how you deliver a reflection.

But, so what is an MI conversation sound like? Well, you’re likely to hear way more reflections than questions. That’s the most obvious difference. And then, I guess another one is you’ll hear questions that are, you know, probably, I guess less frequent than you might find in other settings or in other kinds of styles. You might hear questions like, “What are your top three reasons to quit smoking?”, for instance. Right? That is a question that, again, if you’re going on the traditional role where the provider’s job is to tell the patient why they should quit smoking, there’s no need to ask the patient what their three reasons are because we have the reasons. We know and we’re going to tell the patient. So, it’s questions like that that serve to draw out from the patient their own ideas about change, the reasons why they would change, their impressions for any advice and feedback that the provider does have is really explicitly drawn out. So, I guess that would be another thing. You’d probably hear the patient talking a lot more than they otherwise would.

If I’m a provider and I want to start using motivational interviewing in my practice, where do I start?

Yep. So, one strategy for those that are, you know, a lot more comfortable with questions. We try to rely more on open questions versus closed questions. So, open questions are ones that typically start with the words what, or how, or why, or even the invitation of tell me more about, you know, x, y, or z. And not that we can’t ask closed questions or shouldn’t, but if we, if our default setting is ask closed questions, you are likely going to get really abbreviated answers. You are likely to get kind of narrow experiences from the patient. Whereas, if you ask open questions or at least start with open questions, it both invites more from the patient but also, you know, it, in terms of leveling the playing field and enhancing the patient’s active role in the healthcare encounter, open questions just invite that more so than closed questions. So, that would be one thing.

The use of reflections, obviously. That’s something that’s really critical in terms of a skill. And, you know, I also wouldn’t want to express the belief that unless you’re, you know, doing 2-3 times more reflections to questions, then don’t bother. Actually, there was a study that I cite sometimes, although I don’t have it, the exact citation in my mind, but it demonstrated that in primary care settings, any use of reflections, any use, by the physician, was a significant contributor to that healthcare experience on the part of the patient. I believe it was a study looking at, you know, obesity and weight management. And so, it facilitated a more open dialogue and more comfort on the part of the patient to convert. So, you know, even if you just sprinkle in a reflection or two in there, that’s a great place to start.

What would be another thing? I would, you know, kind of get comfortable with the question that is so often overlooked when talking about change. And that is, before you start delivering the message of how a person could change, stop, and find out what’s in it for them. Why would they change at all in the first place? And I would go even so far as to say it is perhaps even more important to ask that question for the higher urgency conversations. You know, so I, one of the things that I teach a lot of the psychiatry residents and Med students I work with is, you know, working with kids that are harming themselves, I mean that’s as high urgency as you might get. I always ask those kids, so what’s in it for you. What, how would, if you decided not to harm yourself, how would that make life better for you? And we so often skip that. And again, out of good intentions trying to get to the strategies that we know, or we think we know that will help, we miss that whole part of it, which is so important because they’re not going to change if they don’t have reasons to change. So, it can be really important to ask that kind of a question.