The previous issue of Diabetes Spectrum included an overview of motivational interviewing (MI) in diabetes care.1 As a sequel, this article explores skills in MI, approaches to challenging clinical areas (equipoise and resistance), and resources for learning MI. The content presented here would be enhanced by reading the previous article.
Clinicians often work with people whose self-management of diabetes is compromised. People usually express interest in the tasks of self-management but often become overwhelmed by the challenges of considering and initiating the work involved in healthful change. Unfortunately, the consequences of this ambivalence are not without risks. When ambivalence about change is not effectively addressed, self-management becomes compromised, leaving people at risk for avoidable complications that shorten life expectancy or diminish in some way their quality of life.
The collaborative approach of MI respects people's autonomy in making treatment choices for their diabetes and affirms their capacity for initiating change. After all, most people regularly institute significant changes in their lives successfully without professional guidance.2
Open-Ended Questions, Affirmations, Reflections, and Summaries
Listening is the most difficult task in clinical health care. The difficulties arise from distraction. As we listen to someone speaking, a variety of thoughts may be evoked, diminishing the quality of our listening. MI relies on careful listening. Curiosity and the ability to “hear between the lines” of what is said—reflective listening—facilitate the quality of interviews.
The good ideas clinicians have for treating chronic illness often are not adopted by people with those illnesses.3 MI is a process of strengthening commitment and guiding conversation toward initiating change. This involves an interview process that evokes from patients change talk (utterances that refer to change) and commitment language (statements evidencing the intent to begin working on changes). As the strength and frequency of these statements increase, change becomes more likely.4
Specific skills are involved in the guiding process. Let's examine an interview with a man using intensive insulin therapy. He tells you, “I am only checking my glucose levels twice a day now.” He had been testing four times daily. One option is to tell him directly the problems of this approach, especially given that he has hypoglycemia unawareness. In contrast, MI relies on specific skills—open-ended questions, reflections, affirmations, and summaries—to facilitate understanding the patient's circumstances and to guide him to identify solutions.
The interview continues: “So how is this working for you?” “I am saving money on my test strips; I was cut back at work. I might even lose my health insurance,” he replies.
Reflective statements stimulate comments from people, things they want us to know. As in most of life, people seeking health care have a basic human need to be accurately understood, especially when they feel more vulnerable about treatment or their perceived incapacity to be successful with it. So you offer a simple reflection (rephrasing what the person said): “You're saving money buying half the number of strips.”
Reflections are statements, not questions. When we speak in statements, the inflection of our voice goes down at the end of the statement. In asking questions, the inflection goes up. This is an important language nuance. The question, “You're saving money buying half the number of strips?” is answered by a simple “yes” or “no.” Reflective statements are often answered with more detail. He tells you: “I have saved money, but I am not sure how well this plan is working for me.”
Another reflection is offered, a complex reflection adding emotion or feeling to his statement: “The cost of saving money in your diabetes treatment is something important for you now. You like doing that.” Reflections do not have to be accurate. If they contain errors, people readily correct any misunderstandings. He replies, “Saving money was important until I was very low at work last week and passed out. They called an ambulance for me, and I ended up in the ER.”
Another reflective statement, a compound one that reflects the patient's ambivalence about testing, is offered. “You want to test less frequently, but you don't want to experience complications in the dayto-day care of your diabetes.” He replies, “Yeah, this was embarrassing for me. I hope I don't get fired or cut back more.”
Compound reflections emphasize an aspect of what the patient said. They can be used to guide the conversation toward change or commitment language. Linguistically, using the conjunction “but,” rather than “and,” creates the emphasis. In the construction of this reflection, the word “but” places emphasis on the phrase that follows it. This is more evident when considering four different constructions of this reflection:
“You want to test less frequently, but you don't want to experience complications in the day-to-day care of your diabetes.”
“You don't want to experience complications in the day-to-day care of your diabetes, but you want to test less frequently.”
“You want to test less frequently, and you don't want to experience complications in the day-to-day care of your diabetes.”
“You don't want to experience complications in the day-to-day care of your diabetes, and you want to test less frequently.”
Notwithstanding the importance of people's financial concerns, one of the four possible ways to make this statement—the first one—emphasizes a critically important health issue requiring attention: an episode of hypoglycemia requiring hospital assistance for a person with hypoglycemia unawareness.
The next statements are an affirmation, something that recognizes his self-efficacy (capability to institute changes in his life), and a request for permission to guide the conversation. “Three years ago, you worked hard building a successful treatment program using insulin. Would it be helpful now to work together on some options for treatment?”
He replies, “Yes, but there are more restraints today than there were then.” Then you summarize, “You're under financial strain and responded with a plan you thought would work. But a new concern now is that diabetes problems on the job could cause you even more hardship. I have some thoughts that might be helpful here, but first I'd like to know something else: what would a good solution to this look like for you?”
This brief interview, lasting only a few minutes, is adapted from a practice conversation that took place last year. During the interview, the provider began and ended with open-ended questions and asked only one other question—permission to discuss options that will focus on evoking the patient's commitment to a plan that could ameliorate this problem. There were four reflective statements and one affirmation preceding the last two questions leading to a collaborative exploration of action plans. And the patient, although not very talkative, provided a great deal of clinical information.
Affirmations are not congratulations or cheerleading; they are statements of fact. Summaries create a transition point in the discussion providing the patient an opportunity to confirm or correct the clinician's understanding. The process is important; it is an opportunity for patients' active participation in the creation of their treatment plan.
Neutrality or Equipoise
There are many times in health care where the guiding process toward certain changes is justifiably important. For example, a 24-year-old woman with type 1 diabetes who is pregnant and desirous of a healthy outcome for her baby and herself. The options here involve evidence-based interventions for optimizing maternal and infant outcomes. At other times, the treatment options are not as clear and need to be individualized for specific circumstances. In this area, the guiding process is neutral. The other name for this approach is equipoise. Instead of guiding toward a specific change, the guiding process focuses on unbiased discussions in which the patient and/or family are supported and encouraged to decide what would work for them. An interesting discussion of the challenging treatment issues in equipoise was recently published.5
In neutrality/equipoise situations, clinicians replace guiding toward certain choices or options with skillful conversation that instead evokes patients' choices from among the options that exist. For example, consider the treatment options for two people with type 2 diabetes, one a 14-year-old boy the other an 88-year-old man with severe Alzheimer's disease living in a nursing home. For the boy, the MI guiding process would be based on treatment research, expert opinion, and the boy's life experiences. It would result in a number of appropriate options for care.
For the elderly man, who has a pervasive neurodegenerative disease globally affecting brain function, treatment goals are not as clear. Treatment depends more on the resources of the facility where the man resides and the choices the man, to the extent he is able, and his family make in this difficult stage of life. The MI conversation focuses on evoking a discussion of their desires among the options for care. The clinician maintains neutrality and supports the decisions they make about diabetes and other care modalities.
Skills for Resistance
MI has two perspectives concerning resistance. The first perspective deals with discord that is evoked by clinicians' behaviors. Features of this can be seen when patients argue with the clinician, interrupt discussions, or remain detached and unengaged with the discussion. There is no justification for this feud over aspects of care. Encounters characterized by these behaviors place patients in the role of defending inadequate health care or ignoring what is being said and actually increasing patients' resistance to change.6 The mantra in MI is to “roll with resistance.” When clinicians change their behaviors during these circumstances, discord can be avoided.
The other type of resistance is often viewed as “intrapersonal resistance,” coming from patients themselves. Strong emotion may be linked with it, fueling opposition to certain treatments such as injection therapy, physical activity, and dietary changes; but it may occur in all areas of diabetes self-management. MI has another way of viewing this situation. It can be viewed as a manifestation of the negative side of ambivalence.
One useful tool for discussions with people exhibiting strong resistance is to ask permission to discuss the particular area of care in ques tion. For example, a 61-year-old man with well-controlled type 2 diabetes suffers a near myocardial infarction, avoided by prompt cardiac intervention. He has a 25 pack-year history of cigarette smoking, something that he has been unwilling to work on in the past. At his visit with you, he speaks of his gratitude for being alive and continuing to have an opportunity to share life with his family, especially his grandchildren.
In the guiding process of rolling with resistance, the avoidance of arguments makes it less likely he will close his mind to change. So, you ask his permission. “I am not going to force you to change anything. I want to speak with you about smoking. Would you be willing to discuss that?” The question respects his autonomy, something people greatly value. He consents.
Reflective statements and open-ended questions offer tools for the conversation. “I would like to ask you a speculative question. How will smoking affect your desire to be with your family in the coming years?” If he says, “I need to quit,” you can make a complex reflection: “It feels important to stop smoking. You want to have all the time possible for what you value in life.” If he says he will continue to smoke, another speculative question could be used to evoke change talk. “I understand you are not planning to stop smoking, but I want to ask a speculative question: “Would there be any benefits at all if you did stop?”
Both scenarios avoid conflict, increasing the likelihood that he will allow future discussions on this topic. And in the second example, you created a chasm for him to ponder—the gap between his values (family and life) and his habit (smoking). This might produce a creative conflict within him that stimulates change. The goal is to facilitate engagement and ultimately guide toward change by eliciting change talk (evidenced in the brief discussion above) and commitment language as change talk becomes stronger over time.
Learning MI
Time and training are necessary to build competency using MI clini cally. This usually begins with an introductory program lasting 2–3 days. Coaching, especially in a small group, helps to advance learning. In some cases, coaching provides opportunities to reviewing recordings of interviews to hone skills. Coaching also provides opportunities to discuss the difficulties encountered when translating new learning into skills.
A good resource for MI information, trainers, and books is the Web site of the Motivational Interviewing Network of Trainers, an international group that promotes both research in and the clinical use of MI. The Web site (www.motivationalinterview.org) lists members, many of whom provide training and coaching.
Acknowledgments
The author thanks Michael Fulop, Psy D, and Steve Zellmer, MS, LCD, MCAC, for their help in reviewing and editing this article.
