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Empowering Patients for Change

Motivational interviewing (MI) has recently become a topic of great interest in the diabetes behavioral field. It has been applied to the management of a wide range of target behaviors, including addictive behaviors, HIV risk reduction, eating disorders, criminal justice case management, fruit and vegetable intake, exercise, and major psychiatric disorders. Also, several authors have identified its potential role in the management of diabetes.

What is MI?
Motivational interviewing is a coherent, teachable, evidence-based approach drawn from several existing models of psychotherapy and health behavior change theory. It is a person-centered counseling style for addressing the common problem of ambivalence about change. In a successful MI session, the patient is doing most of the talking. The patient discusses a specific behavioral target, and the practitioner focuses on problem recognition, a teasing out of ambivalence regarding change, and the “what, when, and how” of any change that the patient might be ready for. It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

MI focuses on providing opportunities to help patients assess for themselves what might be important or possible and how change might be achieved. This is a clear shift away from the current physician’s professional position of feeling responsible for fixing “broken” patients. Instead, this empowers the patient to be determined to change, a change that will eventually lead to the achievement of his desired goal.

One practical value of MI for health care professionals working in today’s busy clinical settings is that the basic elements of MI can be learned and successfully applied in brief, practical medical interventions to reduce clinician frustration with “noncompliant” patients. Direct questioning, persuasion, education, and advice-giving which have been the workhorse techniques of our health care providers have proven to be of limited effectiveness in the management of chronic illnesses and sources of frustration for patients and clinicians alike.

This is where the role of MI comes into play. Since it is patient-centered, the patients are empowered. There is an open communication between the physician and the patient. The physician listens to what the patients have to say and the physician does not assume an authoritative role. Instead, he provides an open ear and a compassionate heart to know the patient more including their sentiments and obstacles in achieving the desired goal.

Some techniques of MI
The principles of MI allow the physician to employ a simple but effective empathy technique by asking permission before giving advice or information if a patient hasn’t asked for it. (“Do you mind if I ask you a few personal questions?” or “With your permission, I’d like to propose a plan,” or “If you don’t mind, may I share a bit of information?”) Asking permission is similar to the ubiquitous knock on the door of health care practitioners just before entering the examination room; it is a very simple, inexpensive tool for communicating respect and empowerment.

It certainly can be overdone as a technique and can then become awkward for patients. But MI practitioners have found that the simple asking of permission frequently allows them to provide expert information and advice without falling into the “expert trap,” wherein patients stop listening not out of disinterest but rather because of the experience of being lectured or talked down to.

“Rolling with resistance” is a specific type of empathy, wherein arguing is avoided and attempts are made to thoroughly understand a patient’s reluctance to change. The key MI element, “developing discrepancy” (between a patient’s current behavior and his or her own goals, interests, and values) through effective listening, is considered the main driver of patient behavior change.

In MI, the goal is to increase intrinsic motivation for change (“I will change because I want to”) by helping patients become aware of the discrepancies between their current behaviors and their highly cherished personal values and goals.

Finally, “supporting self-efficacy” acknowledges that wanting to change is only half of the behavior change battle. Patients need to also believe (have the confidence) that change is possible, that there is a way to succeed and persist with health behavior change when roadblocks arise. Empowerment and offering choice are critical to the development of patient self-efficacy. Potential solutions are elicited from patients rather than prescribed by clinicians. There is a working assumption in MI that patients, with good medical and educational expertise and support, are in the best position to figure out the focus of change and the best way to proceed.

Diabetes patients and their physicians can benefit from the principles of MI. Most of the time, the physicians are frustrated whenever they see the results of their patients’ laboratory tests. Nothing is more frustrating for a physician than seeing his patient succumb to the complications of diabetes: retinopathy and eventual blindness, cardiovascular disease, stroke, leg amputation and death. But why does this happen? In a patient who regularly sees his physician and whose medications are adjusted regularly, it seems that this is not fair.

Benefits of MI
The application of MI principles allows a physician to understand his patient better. There is indeed more to patients’ not being compliant. The physician has to motivate the patient to open to him the pandora’s box of becauses and ifs, that the patient has been hiding. The physician must be able to encourage the patient to tell him the reason why his sugars have been high, why the patient has not been dieting or exercising. The physician should make his patient speak up and not just freeze because of fear. The physician can successfully do this by not asking questions only answerable by yes or no. Better questions are those that start with why, how and even when. In this manner, the physician can empathize with his patient and possibly be able to provide realistic options in bringing about change.

MI is also an effective modality in educating our patients. By asking patients certain questions like “What do you need to know about diabetes? What ideas do you have so far of the complications of diabetes?”, the physician can elicit interest and enthusiasm from the patient to learn. This is very much different from just lecturing or simulating a teacher-student relationship in a classroom setting.

Motivational interviewing then, is an approach to health behavior change consultation that employs high-quality listening to discuss the whys and hows of change, with the goal of increasing patients’ readiness for and commitment to adopting a healthier lifestyle. This is one approach that each physician treating diabetes should try to adopt, in order to bring about success in wholistic treatment of patients. This only takes a few minutes but is enough to change the lives of patients.

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