I just participated in a two-day Motivational Interviewing training in order to better prepare me to design and deliver continuing medical education (CME) for healthcare professionals in the virtual world. Motivational Interviewing (MI) is a counseling approach originally developed by clinical psychologists William Miller and Stephen Rollnick. It is a client-centered method designed to maximize the patients’ intrinsic desire for behavior change. Physicians, nurses, and other clinicians are finding it effective for patients with diabetes, high blood pressure, obesity, or substance abuse – as a way to support and enhance their behavior change. My colleagues and I have a number of CME programs underway, to be delivered in the virtual world of Second Life, in which these MI techniques will be featured.
The methods are deceptively simple – in practice, however, it’s pretty darned hard to do. During the training, my fellow classmates found it particularly difficult since it flies in opposition to their traditional medical training. I found it difficult because, well, it’s just HARD. The difficulty only became apparent during the role-plays on our second day. The first day, when we listened, learned, and watched videos you found yourself saying, “of course! this makes total sense.” But then when you actually attempted it, with a “patient”, we all floundered.
Here are a few of the basic principles:
-First and foremost, separate yourself from the need to “fix” the patient and, in so doing, neutralize the language (take the charge out of it)
-Start by expressing genuine empathy (specifically and authentically) in order to develop rapport
-Reflect back (feeling + content + reasons) – by doing this you help to draw out their issue and make it clear that it is theirs (not yours)
-Establish the goal premise – set out the ideas which will be the foundation on which the rest will follow
-Engage/Explore patient’s line of reason, looking for weakness (in order to access the issue resistance) – but do so without them “loosing face”
-When you shift to exploration, make an explicit transition
-Throw a wrench into their line of reasoning so that they can shift to a new conclusion
-Remember that the most you can do is to invite them to a new conclusion (if you force the new conclusion you decrease rapport and take the burden of the work from them to you) “what are your thoughts about this?” or “where does this leave you?”
-Note the difference between issue resistance and relational resistant – do everything possible to avoid relational resistance (not blaming, patronizing, shaming)
-Support self-efficacy with every move
-Look for opportunities to blend self-efficacy with empathy “Because you’ve worked so hard to cut back on your smoking, you were shocked and disappointed to find out that your BP didn’t come down as much as you’d expected.”
-Ask for permission to give information (correct, add, create discrepancy)
-Share what other patients have done as a way to make suggestions
-If they aren’t ready to draw a new conclusion, back off – repeat it back, summarize where they are, let it go. “Alright, sounds like you’re not ready to do this now, but I would really like to help you. So when you’re ready, let’s talk again.”
-Reinforce any change talk, tying it back to the specific issue
-Close the deal: provide a summary of the patient’s line of reasoning, express a desire to help them achieve their goal, affirm the self-efficacy, look forward
-Be content with incremental changes
-With practice, the conversational flow will smooth out
Sounds simple, right? Yeah, well… With this training under my belt, my mind is snapping with ideas about how best to implement it in the virtual world. What special effects might we create in order to clarify the approach? How best to set up the role-playing (small groups? triads?)? How to reinforce the principles during the role-playing sessions? How to involve the other avatars who are watching the role-plays, awaiting their turn? This should be really interesting to figure out. If any of you have suggestions – I’d love to hear them!