Health Coaching Skills for Clinicians: Motivational Interviewing Basics

Most patients who need to change their diet, activity, sleep, alcohol or smoking already know that change would help. What holds them back is rarely lack of information. It is ambivalence: they want to change and they also do not, for reasons that make sense to them. Telling people what to do, however expertly, often strengthens the part of them that resists. Motivational interviewing offers a different approach, developed from addiction treatment and now used across healthcare, in which the practitioner helps the patient articulate and strengthen their own reasons for change.

The spirit of motivational interviewing

Its developers emphasise that motivational interviewing is not a set of tricks but a way of being with patients, built on 4 elements.

The righting reflex

Practitioners often feel a strong urge to fix problems, persuade and warn. This righting reflex is well intentioned but frequently counterproductive. When a practitioner argues for change, an ambivalent patient naturally voices the other side, and people tend to believe what they hear themselves say. Recognising and resisting this reflex is the first skill of motivational interviewing.

4 processes

1. Engaging: building a working relationship.
2. Focusing: agreeing a direction, a behaviour or goal to discuss.
3. Evoking: drawing out the patient’s own reasons for change.
4. Planning: developing commitment and a concrete plan, when the patient is ready.

These processes overlap and can be revisited. A common mistake is to jump to planning before engaging and evoking.

Core skills: OARS

Open questions

Questions that invite reflection rather than yes or no answers. “What would you like to be different about your health?” rather than “Do you want to lose weight?”

Affirmations

Genuine recognition of the patient’s strengths, efforts and values. “You’ve managed to cut down on sugary drinks despite a hectic job. That took real determination.”

Reflections

Statements that reflect back what the patient has said or meant. Simple reflections repeat or rephrase; complex reflections add meaning or emotion. “You’re worried about your blood sugar, and at the same time the evening wine is one of the few ways you get to relax.” Reflections should outnumber questions.

Summaries

Collecting and linking what the patient has said, often highlighting their reasons for change, and checking accuracy.

Change talk and sustain talk

Change talk is anything the patient says in favour of change. It is commonly described in categories:

Sustain talk is the opposite: reasons not to change. The practitioner’s task is to notice change talk, reflect it and ask about it, while responding to sustain talk with understanding rather than argument.

Useful techniques

Importance and confidence rulers

“On a scale of 0 to 10, how important is it for you to change this?” followed by “Why a 6 and not a 3?”, which invites the patient to explain their reasons for change. The same approach for confidence reveals barriers and resources: “What would it take to move from a 5 to a 7?”

Elicit, provide, elicit

A way of sharing information respectfully: ask what the patient already knows or would like to know, provide information briefly and neutrally, then ask what they make of it.

Exploring values

Asking what matters most to the patient, and how their current behaviour fits with those values, can surface powerful motivation.

Asking permission

“Would it be all right if I shared some ideas that have helped others?” respects autonomy and increases receptiveness.

A brief example

Practitioner: “You mentioned your blood sugar results. What do you make of them?”

Patient: “I know I should do something. But with work and the kids, I just don’t have time to exercise.”

Practitioner: “You’d like to do something about it, and your days are already full.”

Patient: “Exactly. My dad had diabetes and ended up losing a toe. I don’t want that.”

Practitioner: “Seeing what happened to your dad makes this really important to you.”

Patient: “Yes. Maybe I could walk the kids to school instead of driving.”

Practitioner: “That would fit into a day you’re already having. How confident do you feel about that, from 0 to 10?”

The practitioner has not given advice, yet the patient has voiced a reason for change and proposed a plan.

What the evidence shows

Systematic reviews and meta analyses of motivational interviewing have found modest but meaningful effects across a range of health behaviours, including alcohol use, smoking, physical activity, diet and treatment adherence, with effects seen even in brief encounters. Effects vary with practitioner skill, and training with feedback improves proficiency.

Using it in a busy consultation

Motivational interviewing does not require long appointments. A few minutes can include one open question about the patient’s goals, 1 or 2 reflections, an importance or confidence ruler and a summary with a small agreed step. Over several visits, these brief conversations accumulate.

Common mistakes

• Asking a series of closed questions and calling it motivational interviewing.
• Arguing with sustain talk.
• Moving to planning before the patient is ready.
• Using techniques without the underlying spirit.
• Giving unsolicited advice without asking permission.

Helping people find their own reasons

Motivational interviewing shifts the practitioner’s role from persuader to guide. It helps patients discover their own reasons for change and their own ways to achieve it, which makes change more likely to last.