The principles of motivational interviewing
Using the principles of Motivational Interviewing (MI) allows physiotherapists to improve how they engage with their patients. This style of interviewing is an organised and evidence-based communication technique that is used across healthcare, including within physiotherapy (Miller & Rollnick, 2013; Rubak et al., 2005). This approach falls between ‘following’ (good listening and acting with empathy) and ‘directing’ (advising and instructing) (Miller & Rollnick, 2013). Utilising MI principles encourages patients to identify their personal motivations for change, allowing them to explore their own perspectives on why change is important for them and how they can achieve it. This requires a collaborative and respectful approach where the physiotherapist respects the patient’s autonomy and encourages the process of change (Miller & Rollnick, 2013). Patients can then “talk themselves into change” based on their own values and beliefs (Miller & Rollnick, 2013, p. 19).
Miller & Rollnick (2013) present four key principles to understand the spirit of MI:
- Partnership: Collaborating with the patient instead of deciding or imposing ideas.
- Acceptance: Respecting the values and beliefs of the patient and allowing autonomy.
- Compassion: Putting the patient’s best interests first and consistently considering the patient’s wellbeing.
- Evocation: Focussing questions to uncover the patient’s incentive to change rather than providing reasons to change from an outside perspective.
These key principles are used alongside core communication skills which are commonly referred to by the acronym OARS (Miller & Rollnick, 2013).
- Open-Ended Questions: To encourage the patient to explore their own thoughts and feelings. This ensures they are not using yes or no answers and enhances dialogue.
- Affirmations: To acknowledge the patient’s efforts, strengths and values. This enforces self-efficacy and strengthens positive behaviours.
- Reflections: The physiotherapist can use reflective listening where they repeat or rephrase the patient’s answers to highlight understanding and prompt further discussion. This can also be useful in comprehending the patient’s ambivalence.
- Summarising: The physiotherapist can bring together the main points from the conversation to outline the progress made and transition to discussing next steps.
When are the principles of MI beneficial in physiotherapy?
MI can be especially effective when a patient is unsure or ambivalent about change. This usually arises in physiotherapy when a patient is exposed to fear, pain or confusion regarding their treatment. Using the principles of MI can address a patient’s reluctance to change, improve motivation to adhere to treatment and increase engagement by constructing treatment goals from the patient’s values (Miller & Rollnick, 2013).
MI is increasingly useful for patients with chronic conditions, previous failed treatment or struggling with adherence (Rollnick et al., 2008).
Case example of a patient with chronic pain
Utilising the OARS technique will allow the physiotherapist to collaborate with Emily to uncover what motivates her to make change.
Open-ended question
“From what you’ve been saying Emily, I understand that this has been really difficult for you. Could you share what is stopping you from doing your exercises regularly?”
Emily could respond: “It’s so hard. Every time I attempt them, I feel like I am not improving at all. Even though I am doing them, I am still in pain and it’s really frustrating, so I don’t see the point in continuing them.”
Affirmation
“It’s a testament to you that you are continuing to do them, even when they’re not providing the results you’re looking for. It shows that you’re very determined and committed to feeling better which is a huge positive in working towards recovery.”
Emily could respond: “Thank you. I am just really wanting to feel better with my back so I can get back to seeing my friends and family. It’s hard to not let the pain discourage me.”
Reflection
“That is totally understandable. It sounds as though you’re discouraged by the ongoing pain and lack of progress, but you are also wanting to return to the things you enjoy, like seeing your family.”
Emily could respond: “That’s exactly right. I really want to get back to my past activities, but I don’t want to push too hard and make my back worse.”
Summarising
“We have discussed then that consistently exercising will help manage your pain more effectively long term. It’s common however to feel stuck initially when you don’t see those results immediately. What is one step you could make this week that you think is manageable so that we can start to build up a routine for you? This can help you feel more in charge of your progression.
Emily could respond: “Maybe if I started with an easy exercise like stretching in the morning before work for 10 minutes? I know that I can do 10 minutes of stretching comfortably and not aggravate my back.”
This example discussion highlights that MI can be used to draw out patient’s own strategies to managing their symptoms. This can build momentum in their recovery and their self-efficacy.
