Motivational Interviewing in the Virtual World

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!



Filed under Teaching with Technology, Virtual Worlds

7 responses to “Motivational Interviewing in the Virtual World

  1. Kate

    No ideas (sorry), just general intrigue at the concept. Many of the steps you listed run counter to my experiences with health professionals, who perhaps need to be In Charge, to be Authoritative, to be The Source (of information, particularly), to be Right, to have the upper hand… all of which can lead to brisk, judgmental, one-sided interactions.

    All of which, also, of course, is tremendously reassuring to many patients (though few like the bum’s rush through the doctor’s office that can ensue).

    Great topic, Robin!

    • rheyden

      Yes, it is very interesting, isn’t it, Kate? And, you’re right, completely counter to the standard medical model. This MI approach really turns the whole patient-doctor relationship on its head.

  2. We shall have to talk. You are now in my backyard.
    Dolphins, dogs, husbands.
    Reinforce the desired behavior.
    Unreinforced behavior is self extinguishing.


  3. Lest I appear flip, I found the MI work to be brilliant and very powerful, as did the participating doctors during our recent project. Finding a way to frame material so that it is accessible is a huge accomplishment and I credit Stephan for his approach.

    But I understand the brain gymnastics you are engaged in as well. There’s great literature out there regarding the power of specific, focused reinforcement yet it can be difficult to believe until you employ it. Practice is very helpful to build your confidence in the very simple approaches which can inspire “change behavior.” I’ll collect some articles for you.


  4. This technique is very useful in addiction treatment. The hardest part of it is to avoid tripping over your own ego. You know they should go to treatment. You know better than they do, after all they are high on drugs. They should just do what you say, after all you have their best interests in mind.
    It is hard for a person to realize this is not about you, it is about the client.
    It takes practice but is worth it in my opinion.
    It would be nice to have a place for people to practice online and get feedback on how they are doing.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s