Key Points:

• Motivational Interviewing (MI) is an approach to behavioural change which provides General Practitioners with a broader range of communication skills that are tailored to the individual patient’s readiness to change.
• MI is based on an underlying model of the stages that people go through in deciding whether to change.

Diabetes is a chronic, manageable condition which requires major changes in lifestyle to optimise that management. Motivating behavioural change in diabetic patients is one of the most important but also more frustrating experiences for General Practitioners (GPs). There is great diversity in patients’ acceptance and understanding of diabetes. One’s own diabetes is often perceived as less serious than that of others and short-term comfort may be prioritised over long-term consequences.

Although effective treatments are available for diabetes, the rate of adherence to medication, dietary changes, physical activity, blood monitoring, or attendance to regular medical screenings is reported to be approximately only 50% or lower. The role of professional support in effective self-management of chronic illness has been recently acknowledged. Furthermore, numerous studies on professional support for self-management of chronic illness have focused on the health professional as a ‘coach’. Coaching has been defined as an interactive role undertaken by a peer or professional individual to support a patient to be an active participant in the self-management of a chronic illness.

Motivational interviewing (MI) is an approach to behavioural change which provides GPs with a broader range of communication skills that are tailored to the individual patient’s readiness to change. There are many possible lifestyle or behavioural issues in diabetic patients that can be addressed through motivational interviewing: diabetic diet, obesity, hyperlipidemia, exercise, smoking cessation, adherence to medication, use of alcohol etc.

MI is intended to elicit behavioural change by helping patients explore and resolve their own ambivalence about change. It is based on an underlying patient-centric consultation style. Resistance from the patient is interpreted as a sign that the GP is being too confrontational or is incongruent with the patient’s readiness to change. The goal is to facilitate patients’ self-evaluation and decision making about change rather than to confront patients with the doctor’s evaluation and ideas about what they ‘must do’. These kind of interviews can be performed in single sessions as brief as 5 minutes.

MI is based on an underlying model of the stages that people go through in deciding whether to change. This model identifies at least five different stages: pre-contemplation, contemplation, readiness to change, maintenance and relapse

 

It is important to choose the right time to discuss behavioural change. If a patient is acutely distressed or preoccupied with some other issue it may be inappropriate. Patient-centric consultations may identify important psychosocial issues that may be influencing diabetic control.

Patients with pre-contemplation: Pre-contemplative patients are often seen as difficult patients and may be labeled as ‘non-compliant’ because they are not even considering the idea of change. They have virtually no motivation to change. The aim of MI in pre-contemplative patients is to help them shift in their readiness to change without undermining the doctor-patient relationship. Part of helping the patient to shift is exchanging information carefully in a way that does not increase resistance through prescribing solutions.

Patients with contemplation: Contemplative patients are pulled in two directions — on the one hand they enjoy or benefit in some way from their behaviour, but on the other hand, they have some concerns about the negative consequences of not changing. They have mixed motivation to change. In MI, the aim is to help patients examine and evaluate their own ambivalence and for them to make a more conscious decision about change. The purpose of these skills is to enhance patients’ self-efficacy and not to manipulate patients into agreement with the doctor’s agenda.

Patients with ‘Ready to Change’ nature: These patients have a high motivation and are ready to plan and implement change. Readiness to change can be seen as having two key dimensions of importance and confidence. Some patients may feel that stopping smoking is very important, but may lack confidence in their ability to do so. Alternatively some patients feel confident that they could change, but are not convinced it is important. Some of the MI skills attempt to ascertain where the patient is in terms of these dimensions as this will guide the kind of interaction that the GP should make with the patient. The MI aim here is to help the patient set concrete and specific goals or targets for change. The focus is on the practical aspects of how to change and discussion of difficult situations which may tempt the patient to slip backwards. Motivational interviewing expands the range of skills available to the general practitioner and allows more realistic goals in the consultation. A more holistic, respectful and deeper understanding of the patient’s dilemma may also result. Communication skills aim to build confidence. Brainstorming with the patient is a collaborative process of deciding on a few specific actions that are realistic and feasible.

General principles of motivational interviewing:

• The doctor-patient relationship is a partnership more than an expert-recipient relationship.
• Readiness to change is not a patient trait, but a fluctuating product of interpersonal interaction.
• It is the patient’s task, and not the doctor’s, to articulate and resolve ambivalence.
• The doctor is directive in helping the patient respond constructively to ambivalence.
• Direct persuasion and argument from the doctor is not an effective method to resolve ambivalence.
• The counseling style should be generally a quiet and eliciting one.
• Phase-wise patient counselling should transform ‘resistance to change’ to ‘readiness to change’ attitude.