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The motivational interview

Family physicians regularly see patients for whom they suggest changes in lifestyle or medications. While physicians are perfectly capable of explaining the relevance of recommended changes (the illness, its prognosis, the possible scenarios depending on what, if any, action is taken, etc), they have relatively few resources when it comes to actually supporting patients in making changes. Until recently, the physician’s "toolbox" was fairly limited in this regard. Too often, physicians resorted to standard statements. ("You have to change." "You have to quit smoking." "You have to lose weight." "You will take this medication twice a day to control your hypertension.") Studies performed during the past 3 decades indicated that 30% to 70% of patients followed their doctors’ recommendations only partially or not at all. Such behaviour means that patients did not derive the intended benefits from the interventions.¹ We can, therefore, question the strategies used by physicians.

The motivational interview—an approach developed by psychologists Miller and Rollnick^2,3 to treat alcoholism and substance abuse—can help physicians structure the interventions designed to effect change in patients’ behaviour. Their systematic approach is intended to motivate patients to change. They define the motivational interview as "a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence."²

Both this article and the one that follows in an upcoming issue will examine this approach. The intent of the first article is to situate the motivational interview in the more general context of the influence physicians can exercise over their patients.⁴ The second article will describe the approach in more detail and attempt to illustrate its use in the clinical setting.

	Definition

TOP Definition Influencing motivation Understanding is a factor Footnotes Acknowledgement References

 
In the scientific literature, motivation is often associated with emotions, as they are closely related. Motivation is what drives us to act. It can be intrinsic or extrinsic. It can be described in terms of cause, need, prime mover, drive, reason, principle, source, or interest. Motivation can also refer to the stimulus to act. In this case, we would speak of call, challenge, overcoming, emulation, excitement, impulse, or even of outdoing oneself. It is also associated with willingness and tenacity. In addition, one can be motivated to avoid unpleasant sensations or feelings, such as hunger or pain. Conversely, the quest for pleasure and enjoyable situations can provide motivation to act. By its very nature, motivation is closely associated with change and learning.

	Influencing motivation

TOP Definition Influencing motivation Understanding is a factor Footnotes Acknowledgement References

 
Any physician interventions to support efforts patients make to benefit their health falls within the purview of the professional relationship, which is largely what determines the attitudes and actions of physicians. Since the 1950s, the "dominant" model of the physician-patient relationship has evolved from paternalism (remember Dr Welby?) to a relationship model that promotes patient autonomy and participation, where the physician becomes more of a counselor. In this context, it becomes difficult to talk about motivation or, even worse, persuasion.⁴

We suggest that this narrow view of patient autonomy and the currently fashionable "relativism"—which puts various approaches to health care on the same level, reducing them to a simple matter of belief—is harmful. We submit that the scientific approach to health is a more valid approach and believe that it has been demonstrated to be the best way to help patients. The scientific tradition, which is what the physician represents, provides the best assurance available regarding the effectiveness of treatment. In this context, physicians can legitimately be confident that the solutions they suggest are evidence-based and that they can actively promote them.

It is interesting to note that in a psychotherapeutic relationship, it is not necessary to justify the fact that the therapist is intervening to modify, influence, or change the patient’s behaviour. Perhaps this is so because the individual is voluntarily undergoing psychotherapy for the express purpose of changing; that is, it is an explicit objective. Patients’ willingness to change behaviour is not necessarily as explicit during medical consultations. Patients are often not ready to change the way they are or how they behave. Information-giving alone, although a well-intended communication strategy, is not sufficient to effect change in most of these patients. Information-giving can, in fact, be seen as a way of transferring to patients the responsibility for choosing between alternative treatments and adhering to them.

Inasmuch as physicians see themselves as members of the scientific community, and as patients come to see them voluntarily, physicians are morally justified to try to convince patients to choose the best treatments, based on the scientific knowledge available and the professional assessment of their conditions. This, in our opinion, justifies talking about a motivational interview. Depriving patients of what physicians consider most appropriate (on the pretext of not influencing) and simply providing a list of options is, in our opinion, a way of avoiding physician responsibility to suggest and defend a treatment or course of action.

	Understanding is a factor

TOP Definition Influencing motivation Understanding is a factor Footnotes Acknowledgement References

 
Understanding is, in itself, a motivational factor for patients. Basically, the greater the understanding, the greater the need will be to change the situation. Having an understanding of one’s condition might appear simple; however, it is somewhat more complicated than it seems. The human mind usually works through successive approximations, which gradually help build understanding and the knowledge of consequences. Thus, for example, the reality of what it means "to have diabetes" sets in gradually, as the discomforts, consequences, implications, and repercussions become clear to patients. Understanding takes time, and a degree of experimentation is required to grasp the true meaning of an explanation; receiving the information is not enough.

In conjunction with developing patients’ understanding of their conditions and the attendant consequences, physicians must suggest solutions. It’s important that the solution be in keeping with the perceived problem—only then will a solution be of value. It must correct the problem perceived—ideally, without creating a new one.

The motivational interview technique is closely linked to patients developing understanding of their conditions. We will more fully examine how to motivate patients, particularly with respect to matters of adherence to treatment, in the next article of this doctor-patient communication series.

	Acknowledgement

TOP Definition Influencing motivation Understanding is a factor Footnotes Acknowledgement References

 
This article in the series "Communication Tips" has been adapted from an article that originally appeared in the French-language journal MedActuel FMC. We thank AstraZeneca for covering the costs of adaptation and translation.

	Footnotes

TOP Definition Influencing motivation Understanding is a factor Footnotes Acknowledgement References

 
Competing interests

The authors initially received funding from Rogers Communications, the publisher of MedActuel FMC, where the French version of this article was published.

	References

TOP Definition Influencing motivation Understanding is a factor Footnotes Acknowledgement References

 

1. Haynes RB, McDonald HP, Carg AX. Helping patients follow prescribed treatments: clinical applications. JAMA 2002;288(22):2880-3.[Abstract/Free Full Text]
2. Miller RW, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York, NY: The Guilford Press; 1991.
3. Rollnick S, Mason P, Butler C. Health behavior change: a guide for practitioners. New York, NY: Churchill Livingstone; 2000.
4. Cohen S, Bird J. The medical interview: the three-function approach. 2 ed. St Louis, MO: Mosby Year Book; 2000.

This article has been cited by other articles:

				M.-T. Lussier and C. Richard The motivational interview: In practice Can Fam Physician, December 1, 2007; 53(12): 2117 - 2118. [Full Text] [PDF]

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