4 take-home tips for motivational interviewing

At my house, I have one key rule: Do what I say now. We'll talk about why later.

The five- and six-year-old don't always follow it, of course, but the point is that our home is not a democracy. I am Mom and I am in charge. Nonetheless, a huge proportion of my daily energy is spent trying to get two other free-willed individuals to comply with what I'm telling them to do. I get pushback, even though I clearly know better what will happen if they don't listen to me than they do.

So on a basic level, I empathize with the frustration of physicians whose own patients' actions (or lack thereof) impede them from doing their jobs as caregivers. And you don't even have the luxury, like I do, of stating, "Do it, or I'm going to count to three; you'll go in the corner; and then you'll do it anyway."

However, it wasn't that long ago that physicians did take a mostly paternalistic (or maternalistic) approach to encouraging patients to follow their advice. Today, thankfully, attitudes are changing. One approach in particular, known as motivational interviewing, was discussed in a recent article in The Wall Street Journal.

The article provides a great overview of what motivational interviewing is all about, but in a nutshell, this is how it works: "Instead of telling patients what to do and scolding them when they don't do it, clinicians ask the individual what changes he or she is willing and able to make, and then promote patients' desire, confidence and commitment to following through."

To gain a more personal perspective of what it's like as a clinician to employ this technique, I ventured outside of the physician practice world into the arena of home health, in which operations are vastly different but patient-relations issues, especially in terms of managing chronic disease, are very relevant.

Jennifer Holmgren is a registered nurse with the Home Health VNA in Massachusetts. From our conversation about her experience using the motivational interviewing technique, there are four main points I'd like to share with you, all of which can be adapted to the way physicians interact with patients in the office setting.

1. Patients want to be validated. "In home care we see a lot of people with chronic issues. A lot of time it has to do with lifestyle choices, and the knee-jerk reaction is to walk in with an agenda to give them a list of things that they need to do and that's it. Certainly dealing with ongoing issues is every patient's responsibility, but a lot of the times people have a lot of anxiety and guilt around dealing with what they've been handed," Holmgren said. "I just try to work toward validating people's feelings and validating their experiences. People have a lot of mistrust of the medical system. They've had a lot of negative experiences."

Rather than dictating to patients what they need to do, she said, it can be far more effective to open a dialogue about what the patient has already tried and why they think it did or didn't work. Then the clinician can work with the patient to develop a solution around the root cause of noncompliance.

2. Time is a challenge, but you don't need to accomplish all of your goals at once. "I find myself to be inhibited by what I perceive as time constraints. This particular training focused on eating the elephant one bite at a time, as my grandfather used to say. It's important to be positive and to validate people's feelings, but it's also important to remember none of these problems are going to be solved in one day. Rather, just planting a couple of ideas or coaxing people to think about a couple of things will hopefully create a domino effect; and they'll hopefully present you with their progress at your next visit."

3. Displaying disappointment can work against you. Practicing good boundaries is important, Holmgren said, which she described as being nonjudgmental and not overly attached to the patient's outcome. "Practicing good boundaries helps a lot, too. People, I think, inherently want to do well. They really want to succeed, but if you find yourself being disappointed by their mistakes or their failures, they're not going to want to try as hard because they don't want to disappoint you."

4. Listening speaks volumes. Very often, Holmgren encounters patients or family members who understand the medical information and instructions she provides fairly well, but desperately want to be listened to. "And if you do take the time to listen to somebody, they're going to work with you much, much better. There is a limit. You do have to set limits with certain people," she said.

"It's surprising, but people really all want the same thing, and it's just to be acknowledged. Yes, there's some technical things they need to learn about medications and blood pressure and how to operate and IV and what's going to happen with my wound and how long recovery will take," she said. "But if you just remember that we're all in the same boat and we all have kind of the same agenda, which is to be healthy and to be functioning to the best of our ability, as a healthcare practitioner, that goes a long way toward helping people."

- Deb (@PracticeMgt)

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