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Motivational Interviewing as Case Management Intervention • Part II of II
By Brendali F. Reis, PhD, Victoria Vaughan Dickson, PhD, CRNP; Barbara Riegel, DNSc, RN, CS, FAAN
EDITOR’S NOTE: Part I of this article was featured in the previous issue, and examined Motivational Interviewing (MI) as a case management
intervention. Part I discussed the foundational philosophies and elements of MI, and how this clinical tool developed by psychologists in the fields
of substance abuse counseling and health psychology is now being utilized in health care to improve patient self-management of chronic conditions.
The second part of this article presents a MI Primer – including the specific elements included in an MI intervention and an example dialogue.
A MOTIVATIONAL INTERVENTION PRIMER
In addition to using empathic listening, non-confrontational
communication, and helping patients perceive the discrepancies
between their larger goals and their current behaviors, a case manager
using MI will resort to other conditions of brief counseling that have
also been empirically demonstrated to lead to change1. These include:
• feedback regarding risk and impairment,
• emphasis on personal responsibility for change,
• clear advice,
• a menu of options for change, and
• enhancement of self-efficacy or optimism about change.
Although Figure A may imply linearity, the process is actually iterative;
all elements are present throughout the exchange.
Feedback
Feedback presented to patients is often factual in nature, such as
lab or screening test results, blood pressure readings, or blood glucose
levels. The clinician can help a patient see the connection between
behavior and symptoms or lab results. Feedback, however, is not
presented as a rationale for the need to change, which would be
prescriptive and authoritative. Rather, it is used as another way to invite
discussion and reflection. Many times, patients are surprised by the
results of tests, as they do not seem to reflect patients’ lived experience
of the problem. That perceived difference – and the feelings
accompanying it – make fertile ground for a conversation that may
start showing, for example, the patient’s discomfort with his or her
health status. Once that is acknowledged, the patient may produce his
or her own self-motivational statements. Other times, feedback
provides an opportunity for re-evaluating a change plan that is already
being implemented.
An example of an interview with a diabetic patient might begin
with Hemoglobin A1C lab results. Rather than rhetorically asking the
patient why he/she thinks the results are at their current levels, the
interviewer might invite the patient to “tell [me] about your diet over
the past few weeks.” Probing will uncover whether “there were any
unusual events;” for example, the patient could have been on a trip,
eating out more often, sick, or otherwise thrown off an exercise regime.
Often, these discussions will lead to a statement by the patient that is
self-motivational:
“I had to eat out more than usual; I wish I could manage to do that and
control my sugars.”
Responsibility
As mentioned above, case managers practicing MI acknowledge
that patients are autonomous partners in collaboration with them. As
such, their choice is preserved and honored throughout the process,
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and with choice comes responsibility. While the provider offers support
in the process, the responsibility for making change ultimately rests
with the patient. Sometimes a patient needs support in learning to
articulate whether changes are necessary, and in committing to them.
Establishing for himself/herself the importance of change is the first
step in accepting responsibility. It is important to encourage the patient
to give voice to his/her own ideas about implementing change, and to
underscore connections between these ideas and the patient’s own
self-motivational statements whenever possible. Some examples of
language that can accomplish this are:
“Should you decide to do anything different, what kinds of things
come to mind?”
(After summarizing the patient’s perception of the problem and
his or her self-motivational statements) “Now what? Where do we
go from here?”
“You are right. No one could decide this for you; I certainly could not,
even if I tried. The choice about changing your diet or not is certainly
yours to make.”
Advice
Prescriptive advice is an area that nurses, in particular, are well
skilled in providing. They are called to do this frequently – either
passing along their own or a physician’s expertise. While the element of
patient autonomy is crucial in MI, it would be a gross misinterpretation
of the approach to assume that it does not allow for any direct advice
on the part of the provider. At times practitioners may become “too
patient focused,” and refuse to provide any guidance lest the patient
feel imposed upon. What is critical is that advice be offered at the
solicitation of the patient, after he/she has articulated for himself/
herself the reasons why change should take place, and how he/she
needs help to begin the change process. When the provider can sense
that the patient is envisioning change but truly needs a hand in getting
there, that window of opportunity should not be missed and clear
advice should then be given. For instance, once a patient expresses a
desire to change and perhaps even sets a goal, he may ask for guidance
about how he can best achieve the goal. If patients do not explicitly ask
for any advice but there is enough “envisioning”2 on the part of the
patient that advice seems to be in order, providers should offer it after
asking the patient’s permission to do so. For example:
“Is it alright if I share with you some ideas that have helped other
patients in this kind of situation?”
Menu of Options
Case managers are often solution-oriented, and identifying
potential solutions comes naturally. However, it is even better if
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alternative solutions can be offered as a “menu of options.” Option and
choice are important elements in this process. Offering a patient a menu
of potential solutions or resources to aid in reaching a goal provides the
patient an opportunity to “own” his/her chosen course of action.
This element of choice should be preserved even when trying
to establish the agenda for the meeting. Often patients with
chronic diseases will have a variety of symptoms or a variety of
behavior modification goals. It is helpful when the patient is offered
the opportunity to address those that are most important to him/her
on a given day, discussing that which is most compelling at the
moment. This can be as simple as opening the session with a
statement such as:
“It sounds like you have concerns related to your weight, your diet, your
blood pressure, and managing your medication. Where would you like to
start? How would you like to spend the time we have today?”
Naturalistic Decision Making
Person Environment
PROBLEM
Decision Influences
Knowledge
Experience
Skill
Compatibility with Values
Decision Making About Self-Care
FIGURE A
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C A S E M A N A G E M E N T
Self-efficacy and Change Plan
In no moment of the motivational process is it more important to
enhance the client’s self-efficacy than during the negotiation of a
change plan. As mentioned before, a person’s ability to take action is
directly related to how confident he/she feels about being successful at
it. Identification of past successes, identification and removal of
barriers, and provision of new resources are all helpful in enhancing
self-efficacy. In addition, it is crucial to elicit self-motivational
statements related to confidence. When discussing possible courses of
action and confidence becomes an issue, a case manager could use, for
example, the “confidence ruler,” a technique aimed at generating
self-motivational statements.1 It goes as follows:
“On a scale from 0 to 10, where 0 is not confident at all and 10 is as
confident as you could possibly be, how confident do you feel about …
(e.g., managing your sugars when eating out)?”
The answer is followed up with another question:
“How come not a (e.g., 3, a value one or two numbers lower than what
the patient gave)?”
The clinician essentially wants to understand how it is that the
client is not even less confident about implementing the change. The
most likely answer to that question will be “change talk” – statements
“reflecting desire, perceived ability, need, readiness, reasons, or
commitment to change.” These can then be amplified by the counselor
in order to further enhance self-efficacy.3
Providers negotiating a change plan with patients should always
remain cognizant of the importance of not setting the patient up for
failure. To the extent possible, obstacles should be anticipated and
coping mechanisms should be discussed, barriers should be removed
and, above all, plans should be realistic.
Lastly, it is essential to elicit commitment to the plan. Usually,
a summary about what was discussed in informal, “you” language.
For example,
“You said you are not happy with your weight, so you will inquire about
a gym membership, so that you can decide exercising regularly is an
option for you.…”
At the end of the summary, the provider can then ask:
“Is that what you want to do?”
These relatively simple techniques help patients fine tune the plan
to a further level of comfort, if they feel the need, and to commit to the
self care plan. Writing the plan, even getting the patient to sign it and
take a copy home, may also enhance commitment.
MOTIVATIONAL INTERVIEWING IS NOT A “QUICK FIX”
Different patients present with different levels of readiness for
change. Some are already taking steps toward change, but perhaps
stumbling on the details; others are not even acknowledging the
importance of any change; still others may present with every
variation in between. Accepting this reality and talking to patients
according to their motivation level is a fundamental principle of MI.
This provides a foundation for counselor empathy and effective
continued on page 12
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Motivational Interviewing as Case Management Intervention (continued from page 7)
communication, and it creates acceptability for the process to take
longer for some patients than for others. One study has found that an
average of three hour-long sessions are required to see a patient
commit to making a change in heart failure self-care.4 Motivational
sessions designed to enhance self-care may also be more productive
when conducted in a patient’s home, as this affords the opportunity to
absorb all of the contextual information available in addition to that
provided directly by the patient. Patients may also be more relaxed
and receptive in their own environment.
A FINAL WORD
Learning and using motivational interviewing is not for everyone.
Practitioners must be, above all, comfortable with the philosophical
principles of change discussed earlier in order to feel genuine empathy
and be truly curious about the patient’s experience. It is from such a
general stance that effective listening skills can be learned. Reflective
listening seems, on the surface, simple to apply, but it is not. Some are
more natural at this skill, while others need more time and practice to
learn it. Ironically, this is especially true for practitioners in the helping
professions, for whom the impulse to make things right is deeply
ingrained through long years of training. The greatest challenge for many
in practicing MI is to remain in charge of their expertise while at the same
time putting it aside in order to fully take in the patient’s own expertise in
himself/herself and his/her experience. This ability to wear the “expert
hat” strategically, based on the provider’s understanding of each
patient’s unique world, is where the provider’s greatest strength resides.
Brendali F. Reis, PhD, is Associate Faculty at the Institute for Graduate
Clinical Psychology at Widener University in Chester, PA. She earned her
NICM & ACMA ANNOUNCE FOR 2009
16th Annual NICM Case Management Conference
and the 10th Annual ACMA Meeting
APRIL 18 –22, 2009 • WESTIN BOSTON WATERFRONT
VISIT WWW.ACMAWEB.ORG/BOSTON FOR MORE INFORMATION
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BA and Master’s in Psychology at the Federal University of Rio Grande do
Sul, Brazil, and her PhD at the California School of Professional
Psychology in Fresno, CA. Before joining the faculty at Widener University,
she was on the research faculty of the University of Pennsylvania and was
part of the Motivational Interviewing Network of Trainers (MINT).
Victoria Vaughan Dickson, PhD, CRNP, is Adjunct Assistant Professor at
the University of Pennsylvania School of Nursing in Philadelphia, PA.
She earned her BSN in Nursing at Temple University in Philadelphia, PA,
and her MSN and PhD in Nursing at University of Pennsylvania. Dr.
Dickson is an adult nurse practitioner with more than 20 years in
primary care and employee health experience.
Barbara Riegel, DNSc, RN, FAAN, FAHA is Professor at University
of Pennsylvania School of Nursing. She has been on the faculty
at the University of Pennsylvania for six years. She earned her BS in Nursing
from San Diego State University and her MN and DNSc from the University
of California, Los Angeles. During her 30-year nursing career, she has had
experience as a cardiovascular clinical nurse specialist, case managing
many cardiac patients with both stable and acute cardiac illnesses.
ENDNOTES
1 Miller, W., & Rollnick, S. (2002). Motivational Interviewing: Preparing People
for Change. (2nd ed.). New York: Guilford.
2 Rollnick, S., Miller, W. R., & Buttler, C. C. (2008) “Motivational Interviewing in
Health Care: Helping Patients Change Behavior.” London: Guilford Press.
3 Arkowitz, Westra, Miller, & Rollnick (Eds.) (2008) Motivational Interviewing in
the Treatment of Psychological Problems. London: Guilford Press.
4 Riegel, B., Dickson, V., Hoke, L., McMahon, J., Reis, B., & Sayers, S. (2006). “A
Motivational Counseling Approach to Improving Heart Failure Self-care:
Mechanisms of Effectiveness.” Journal of Cardiovascular Nursing, 21(3), 232-241.