Motivational Interviewing: The Four Key Stages

 

Authors: Stephen Rollnick and Nina Gobat

Getting patients to change their lifestyle behaviour can often be a struggle but by using a technique called’ motivational interviewing’, clinicians can help patients progress on their change journeys.

 

Patient-centred counselling 

Motivational interviewing is a patient-centred counselling style, designed to strengthen personal motivation for — and commitment to — a specific goal. 

The technique emerged in the 1980s within the setting of alcohol addiction treatment, where it was noted that encouraging patients to think and talk about their own reasons to change minimised their resistance and increased their motivation.

Evidence suggests this technique is more effective than traditional advice-giving within a number of different clinical situations.

 

4 key stages

The role of the clinician in motivational interviewing is to act as a guide, to clarify the patient’s strengths and aspirations, listen to their concerns, boost their confidence in their own ability to change, and eventually collaborate with them on a plan for change.

These break down into four key stages: engaging, focusing, evoking, and planning. 

 

1. Engaging

Engagement is the process of establishing a constructive working relationship with a patient, and so aims to address any doubts or concerns they may have about the consultation, for example whether the patient trusts you, whether the consultation is likely to be useful, and whether they plan to come back.

Initially the patient may be unsure about whether the consultation will be useful, and about whether they plan to come back. Engagement should address these unspoken questions and act as a foundation for the rest of the consultation.

Use open questions to build and strengthen a collaborative relationship, as well as to find out more about the patient’s perspective and ideas about change.  

 

2. Focusing

Focusing is the process of concentrating on a specific agenda or direction for change. This may be obvious, but many patients may have a number of options to consider, or may be unclear of the direction in which they would like to change.

Focusing may therefore involve encouraging them to concentrate on an agenda which makes the most sense for them, and also one that is achievable, at the present time.

Within the context of motivational interviewing, the decision about what to focus on should ultimately lie with the patient. This should not stop you offering your own advice if this is appropriate however, for example if the patient asks for your opinion.

 

3. Evoking

Evoking involves the clinician eliciting the patient’s own motivations for a particular change. The aim is to encourage the patient to talk about why and how they might change (also known as change talk). 

This stage is fundamental to motivational interviewing, and a defining characteristic of it. It is perfectly acceptable to listen while the patient talks about their reasons for not changing. What you should avoid is either offering your own opposing arguments, or failing to evoke their reasons for changing (change talk). 

Motivational interviewing works on the assumption that most people will be ambivalent about making a change; it can be helpful to encourage the patient to look at both sides of the argument before making a decision.

After this you can summarise both sides, and then invite the patient to consider the next step. Throughout, you should keep a keen focus on their strengths and reasons for changing.

 

4. Planning

This is about agreeing a plan for action. When you are confident that the patient is sufficiently engaged and motivated, and when there is a clear focus in place, it is often a good idea to steer the conversation towards planning.

There will not necessarily be an obvious cue for when the time is right but, often in practice, you will know when patients are ready for the planning stage when they begin talking about when and how to make a change, and less about whether and why. They may also start to talk about what it would feel like to have made the change. 

Planning should be a collaborative process between patient and clinician. Where possible, you should elicit the patient’s own solutions, although this should not stop you from offering your own information and advice where appropriate.

You may need to revisit planning from time to time, for example if the patient comes across obstacles or setbacks (sometimes referred to as ‘relapses’). It is not uncommon for patients’ motivation to fluctuate, and if this happens you may need to revisit earlier stages of the process (for example planning, evoking, or engaging). 

 

Learn more

Click here to learn the five key communication skills for motivational interviewing by completing a course on the technique. It includes video role-plays, information on how to apply technique principles in practice and questions to check your knowledge, based on real-life scenarios.

Stephen Rollnick and Nina Gobat are based at Cardiff University. Stephen Rollnick is an honorary distinguished professor in the department of primary care and public health, and Nina Gobat is a post-doctoral research fellow at the Wales School of Primary Care Research.