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Putting prevention into practice (Green Book)

Motivational interviewing strategies

  • Regard the person’s behaviour as their personal choice. Acknowledge that:
    • ambivalence is normal
    • patient decisions may be well researched
    • there are both benefits and costs associated with the behaviour, and highlight these to the patient
  • Let the patient decide how much of a problem they have
    • explore both the benefits and costs associated with the problem as perceived by the patient
    • use the patient’s own language and examples when exploring their concerns
    • encourage the patient to rate their motivation to change out of 10 and explore how to increase this score. If the score is already high, ask them what is contributing to this high score
    • repeat the process (score how confident the patient is in being able to change, where 10 = very confident) when looking at the patient’s confidence to change
  • Avoid arguments and confrontation
    • confrontation, making judgments or moving ahead of the patient generates resistance and tends to entrench attitudes and behaviour
    • externalising the problem minimises resistance (eg. come alongside the patient, focuson the discrepant beliefs/values of the patient)
    • accept that patients may be contrary to suggestion
    • avoiding direct patient confrontation doesn’t mean that you accept the patient’s beliefs and values
  • Encourage discrepancy
    • change is likely when a person’s behaviour conflicts with their values and what they want
    • – the aim of motivational interviewing is to encourage this confrontation to occur within the patient, not between the doctor and patient
    • highlighting any discrepancy encourages a sense of internal discomfort (cognitive dissonance) and helps to shift the patient’s motivation
    • when highlighting the discrepancy, in the first instance, let the patient make the connection.

A decision balance is a useful tool to summarise the above information and identify areas of discrepancy. It can be used to systematically explore a patient’s motivation and their beliefs about a particular behaviour. Write down what the patient likes and dislikes about this behaviour, and document the good and bad aspects of changing this habit or adhering with treatment. Alternatively, get the patient to do this as an exercise. They could present it at the follow up visit (Table 2).

 

Like

Dislike

Stay the same

Relaxes, helps to unwind, tastes nice,social activity

Increasing anxiety and forgetfulness, putting off making decisions and not being able to think clearly, restless sleep, often waking up worrying, gaining weight (s/he used to be trim and fit), fear of being out of control, increased marital friction and arguments

Change (eg. cut down on drinking)

Possible better control of anxiety, able to remember things and cope with the business more, less arguments with spouse, less stomach upsets

Uncertainty about how to cope when stressed, loss of social contact with mates, loss of enjoyment associated with having a few drinks

Table 2. Decision balance: patient drinking at a hazardous level

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