One of the challenging things about learning Motivational Interviewing can be using the spirit and techniques when you have a limited amount of time with a client. I often hear how MI “won’t work in my setting because our visits are short. We have to just tell them what to do.” Examples are an emergency room clinician talking to an accident victim whose breath smells of alcohol or a dietitian asked to teach a diet to a hospital patient in the midst of being discharged. In both cases, not only is time limited, but the patient is distracted by other things.
The truth is that it takes more skill rather than less to use this method in a brief intervention. The clinician must know intuitively what to say next and how to navigate the conversation. Remember that our goal is to guide the other person to make their own decision about changing behavior. It can seem simple to just tell them what to do, be very directive and, we think, clear in our instructions. It is simple but not very effective.
People make decisions about changing their behavior when their own goals and values align with the change proposed. They respond better when they feel they are being heard and seen for exactly who they are (we all feel that way!). The clinician’s job is to help the patient clarify what is important to them, so they can decide about changing behavior.
An example is the woman with congestive heart failure being seen in a primary care practice for an increase in symptoms. The clinician has just a few minutes with this patient and knows that a lower sodium diet would help. They have talked about this before, but there has been no change. During this visit the clinician and patient have talked about grandkids, and attending sports activities with them, but now the problem is that she can’t walk far enough. Here’s some dialogue that might happen:
Clinician: I know we’ve talked in the past about eating less salt. I think that would help with the shortness of breath.
Patient: Maybe, but food just doesn’t taste good without salt and food is very important to me!
Clinician: I know that’s a problem. You’ve said that the grandkids sports events are important to you, but you can’t go anymore because you can’t walk to the fields. So, on one hand the grandkids’ activities are important to you, but on the other hand you don’t want to change what you eat to make attending more possible. Did I get that right?
Patient: Well, when you put it that way….I guess I’ll have to think about it. I have the diet booklet on this that you gave me. I’ll have to take a look at it again.
Clinician: Sounds good. If you decide you’d like to see our dietitian, just let me know and I’ll arrange it.
In this case, the clinician has made the connection between shortness of breath that interferes with something important to the patient. She then leaves it to the patient to decide if the value of going to her grandkids’ events is important enough to change what she eats. That’s the key, guiding the patient to make their own decisions. Note this is a very short interaction, but it leaves the patient with some ambivalence, which is a good thing!
