Motivational interviewing empowers engagement in diabetes management
Behavioral change is a basic requirement for improving diabetes outcomes, but making those changes can be difficult for people with diabetes and for practitioners charged with helping them. Traditional counseling strategies can leave the person with diabetes feeling a loss of autonomy and leave the educator frustrated with less than optimal patient outcomes. In this issue, Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with National Diabetes Prevention Program lifestyle coach Jan Kavookjian, MBA, PhD, FAPhA, about using motivational interviewing techniques to empower people with diabetes to take control of their disease management.
What is motivational interviewing and how can its techniques help to spur behavior change?
Kavookjian : Motivational interviewing is a person-centered communication skills set and intentional approach that is caring and nonjudgmental, supports autonomy and self-efficacy, and guides the person with diabetes through the process of getting to their own internal motivations. The practitioner first elicits the person’s perspective, preferences and ideas before giving information or advice. This lets the person express their own ideas out loud, which can bring a powerful pivot in decision-making about behavior change. The process of hearing oneself express reasons for making a health behavior change, describe what things they might be able to do to achieve it, and set their own goals — instead of feeling a lack of autonomy when a practitioner tells them what to do — is empowering.
The motivational interviewing approach also recognizes that many people experiencing detrimental outcomes are discouraged and may not engage in self-management behaviors that could improve those outcomes. They may exhibit resistance or ambivalence to making big changes, so a second-line approach with focus on setting goals for small, incremental changes may be more effective. Small successes can bring encouragement and confidence for bigger changes.
Examples of questions to elicit patient input for small changes include “What are your thoughts about making one or two small changes in the foods you eat?” “What are some things you can think of to do to get more activity into your routine?”
What are some of the challenges involved in using motivational interviewing?
Kavookjian : I’ve trained about 3,000 providers across health professions in motivational interviewing and have learned a lot about what the challenges are. Most clinically trained professionals have been highly trained and rewarded as problem solvers. This focus shouldn’t change in motivational interviewing, but should intentionally support autonomy rather than violate autonomy as in the traditional approach that leaves people defensive and less likely to change.
Autonomy-supporting motivational interviewing strategies — like using open-ended questions and asking permission to give information or advice — are critical components to making successful person-centered connections. One key open-ended question is “What questions do you have for me?” instead of “Do you have any questions for me?” This implies that you expect the person to have questions, so they are more likely to feel safe in asking.
The permission-asking strategy simply gives the person a choice to receive your advice or information. For example, “I’d like to share with you some strategies others have said worked for them for remembering to take their medications, if that’s OK with you.” “May I share some additional information about what HbA1c means in terms of risks for complications?”
For most practitioners, these and other motivational interviewing strategies represent a change in ways of listening and communicating. Change can be as hard for a practitioner as it is for a person attempting health behavior change. Finding evidence-based training is a key to becoming skilled at using motivational interviewing. Evidence-based training goes beyond just awareness-raising and information-giving; according to motivational interviewing originators, it requires an initial 1- to 2-day workshop that builds from conceptual-based to applications-based exercises, culminating in at least two rounds of expert-facilitated role-play and feedback or coaching, and ideally also includes follow-up exposures. These are keys to changing established provider-centered communication habits formed and reinforced during health professions school, residency and beyond to practice.
Can you give some examples of motivational interviewing skills, tools or strategies that a practitioner could use in approaching a person with diabetes who struggles to engage in self-management behaviors?
Kavookjian : In brief, motivational interviewing includes communication principles, such as expressing empathy, developing discrepancy, rolling with resistance/avoiding argumentation and supporting self-efficacy; approaches, such as following, informing and guiding; and micro skills that support autonomy, including using open-ended questions, asking permission to give information or advice, and agenda-setting to give discussion topic choices in the order that is salient to the person: “Today we can talk about insulin use, healthy eating and getting more activity. Which would you like to talk about first?”
Among these strategies, expressing empathy with a person exhibiting resistance or strong emotion has been shown to be a stand-alone, person-centered skill that has a longstanding evidence base for impact on outcomes. Examples are: “You sound frustrated or discouraged.” “It does seem unfair that you now have another diagnosis to take care of.” “You sound overwhelmed by all the self-management tasks we’re asking you to do for your diabetes.”
Another key motivational interviewing strategy is eliciting change talk vs. sustain talk — the person talking about making the change vs. defending why not to change. Recent studies have shown that the change talk-eliciting skill is one of the most powerful in predicting that a person will make change. More change talk vs. sustain talk has demonstrated statistically significantly greater probability that a person engaged in the target behavior. This strategy asks questions about the change. Examples are: “What are the reasons you might start monitoring as instructed?” “What can you do toward reducing late-night snacking?” “How much do you want to start getting activity into your routine?” “What have you been told about the benefits of insulin use for diabetes control?” “What will you like about your life if your HbA1c and risks are reduced?”
Using the motivational interviewing readiness ruler also elicits change talk. “On a scale from 1 to 10, with 10 being most, how ready are you to start getting 1,000 more steps per day to help reduce risks?” The first follow-up question for the person who responded with “6” would be “Why a 6 and not a 1?” The person’s responses to this are change talk. A second follow-up question would be “What would have to happen for that 6 to become a 7?” This question elicits change talk and also expresses an incremental change expectation.
For more information:
Jan Kavookjian, MBA, PhD, FAPhA, is associate professor of health outcomes research and policy at Auburn University in Alabama and a National Diabetes Prevention Program lifestyle coach. She can be reached at firstname.lastname@example.org.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is the 2015 AADE Diabetes Educator of the Year and co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at email@example.com ; Twitter: @susangweiner.
Disclosures: Kavookjian reports she is a consultant for MediMergent LLC, for motivational interviewing training on a funded longitudinal study training practitioners to talk with persons with diabetes about medication adherence; a consultant for Merck as motivational interviewing content expert in person-centered communication education materials; and a member of the speakers bureau for Merck for nonproduct education for topics of motivational interviewing, shared decision-making and health literacy communication. Weiner reports she is a clinical adviser to Livongo Health.