Motivational interviewing (MI) is a form of counseling developed by William R. Miller, PhD and Professor Steven Rollinick in 1983. First devised to help in the treatment of alcoholics, MI can serve as a framework for evoking any motivation to change and has been used for many conditions including substance abuse, smoking, obesity and diabetes. The goal of MI is to ignite and engage motivation within a patient. It acknowledges the fact that those patients who need to make changes come at a different stage of readiness to change. However, it poses a very special problem in diabetics because you are trying to change several things.
What is the spirit of Motivational Interviewing?
- There needs to be collaboration, not confrontation, between the patient and the healthcare provider. This facilitates trust which is a very important component of encouraging intrinsic motivation.
- Evocation, drawing out, rather than imposing thoughts is the keystone of the interview. The motivation to change is most powerful when it comes from the patient rather than being suggested by the provider. A provider may use countless factors to convince a person to change, but that means nothing until the patient themselves is convinced to change. The patient should be allowed to come up with their own motivations and skills to change.
- The patient should be allowed autonomy rather than listening to the provider as an authority figure. Ultimately, the patient must take on the responsibility to change.
Motivational interviewing follows four core principles: empathy, self-efficacy, rolling with resistance, and developing discrepancy. Empathy involves trying to see things through the patient’s eyes and trying to understand how they feel and think about things. When we have empathy, patients feel that we understand them and are more likely to be open with us. As doctors, we need to help patients believe that they can change. But any change comes from within them and we are there to support them. When a patient expresses resistance to change, we need to roll with it and not become confrontational. Using this approach actually seems to decrease the resistance. The motivation to change usually happens when a patient feels the discrepancy of where they are and where they want to be. The doctor needs to help the patient understand how current behaviors are not leading them to their goals.
Most often diabetics need to change their eating habits. Those who are sedentary need to start exercising. Some diabetics may need to learn to start injecting insulin or take other medications. They may suffer side effects of these medications. They may need to learn to test their blood sugars at home. So, where does one start in helping diabetics adapt change?
The most important first step is patient safety. Dangerous blood glucose levels need to be curbed. Whether this is done through medication or lifestyle changes depend on the type of diabetes and the level of glucose. And despite our best wishes, it is still the patient that must decide and accept the treatment program.
A patient must understand their own disease. They must be aware of the immediate danger as well as the long-term complications. The doctor should present all the options available for treatment. If a patient is not self-motivated to take medication, there is a good chance that they won’t or not as prescribed. It is anxiety-producing for a patient to be starting on a new medication. We must listen to their concerns and address any side-effects. A medication that makes someone sick is not going to be one they continue taking. We are trying to help them but not at the point of sacrificing their quality of life.
Many choices of medications for treating diabetes
In diabetes, there are now many choices of medications to start. Sure, the doctor is the one who knows these medications best. But, a patient may just not be ready to start injecting themselves with medication every day. It is important to sometimes make compromises. A less than optimal treatment regimen is better than none at all. While we may think that a newly type 2 diabetic needs to start right away on injectables, maybe they will be resistant to that idea. It might work to be flexible and start on oral medication first. It may not bring the glucose control desired, but it may be the first step in helping the patient find the motivation to go on the injectable for life-long control. Be flexible, but not at the point of creating a dangerous clinical situation. Also, when a patient sees that you are willing to accommodate their requests, they will trust you more and listen when you suggest best treatment recommendations. As mentioned above, empathy is critical and we should try to see things through the patient’s eyes.
Every diabetic remedy will involve making some lifestyle changes. Whether or not a patient takes medication, eating healthy and exercise remain cornerstones to treatment. But, if a patient is not ready to make those changes, it is not going to happen despite how much we try to convince them of the importance. It is necessary to ask open ended questions and assess the barriers to implementing change. If we are able to help remove these barriers, we should. For example, if a patient just doesn’t know how to eat to control their diabetes, we can refer them to a nutritionist. If someone else cooks for them (such as a spouse), ask them to bring that person along to the next visit. Until the barriers are torn down, no motivation can even begin to form. I have seen doctors continually lecture their diabetic patients about the importance of eating right. But, this is not going to work until the patient is motivated. Stop lecturing and find out what is the problem. Help patients find their inner motivation. Continually humiliating them for being unable to do so is going to push that motivation far away.
When the patient is motivated, that is when they will start asking questions. Be prepared to answer them and have resources ready to provide them so they can find out more when they are not in the exam room. Sometimes, life events will spur motivation. The patient should have the tools necessary to undertake their new found goals at any time, not just when they return to you for their three month follow up.
The incidence of diabetes is soaring in the US and in other counties around the world. Often, patients are diagnosed before they even exhibit any symptoms. The ability to help find motivation to adapt healthy lifestyle is imperative in the treatment and prevention of this disease. Nothing will change if we continue to reach for the prescription pad and hope our patients take our advice.
Linda Girgis MD, FAAFP is a family physician practicing in South River, New Jersey. She was voted one of the top 5 healthcare bloggers in 2016. Follow her on twitter @DrLindaMD.