Presented at Plenary Session at 6th Medical Update Trengganu 2017. 5-6 May 2017.

1. POWERFUL SECRETS TO MOTIVATE YOUR
PATIENTS
Dr. Umi Adzlin Silim I Consultation-Liaison Psychiatrist, Hospital Kuala Lumpur I 5 May 2017

2. A bigger
picture
Understand stages of motivation &
changes
Understand the powerful secrets to
motivate patients: using motivational
interviewing technique
Understand the theoretical explanations
of motivational interviewing
Appreciate how brief motivational
interviewing can work in practice

3. REFLECTIVE PRACTICE
Think about a time when someone try to make a
plan or set a goal with you and you are not ready
yet.
• How do you react?
• Have you ever made a plan with someone who
you thought was ready but wasn’t. How did this
go?
• Talk about this with the person next to you.

4. STAGE OF
MOTIVATION
(Stage of
Changes)
Prochaska, J.O. & DiClemente, C.C. (1983)

5. STAGE OF MOTIVATION (Stage of Chnages)

7. Stages of Change Model: Use Different
Strategies and Activities for Different Stages
• What works at one stage often does not work well at another stage.
• Most behavior change programs are targeted at people in the
Preparation and Action stages – people who are ready to make a
change.
• Only a fraction of people are actually in these two stages of change.
Motivating Health Behaviour Change

8. Stages of change model & strategies
STAGE OF MOTIVATION PATIENT HEALTH PROVIDER
PRECONTEMPLATION Unaware of problem, no interest in
change
Provide information about health
risks and benefits
CONTEMPLATION Aware of problem, beginning to
think of changing
Help resolve ambivalence; discuss
barriers
PREPARATION Realizes benefits of making
changes and thinking about how to
change
Teach behavior modification;
provide education
ACTION Actively taking steps toward change Provide support and guidance, with
a focus on the long term
MAINTENANCE Initial treatment goals reached Relapse control
RELAPSE
Motivating Health Behaviour Change (AMA, 2003)

10. MOTIVATIONAL
INTERVIEWING
(MI)
Method that works on facilitating and
engaging intrinsic motivation within
the client in order to change behavior.

11. Introduction
•Client-centred counselling
•Modern Method: emerged in the 1980s
•Traditional Method: directing or giving
advice may cause resistance and
defensiveness in ambivalent patient

12. ‘Helping conversation’
strategies
• Directing
• Following
• Guiding

13. Directing styles (Traditional Method)
•The clinician tells a patient what to
do, and how to go about doing it.
•Can be constructive in some situations
•But if a clinician uses a directing style
with a patient who is ambivalent
about making a change, this may
inadvertently elicit the patient’s
arguments in favour of staying the
same.

14. Following style
• More passive and involves listening to what a patient has to
say, supporting them while they work the situation out for
themselves.
• May be constructive in few situation eg grief
• If a clinician uses a following style with a patient who is
ambivalent about making a change, this can simply
encourage the patient to go around in circles with their
ambivalence.

15. Guiding styles (Modern Method)
• MI involves a guiding style, sitting in the middle of the spectrum.
• The role of the guide is to listen supportively, but also to offer
expertise when necessary.
• If a clinician uses a guiding style with a patient who is ambivalent
about making a change, they can structure the consultation in
such a way that the arguments for change become stronger and
more persuasive to the patient; this occurs when the patient
hears themselves making these arguments.

16. Hagar © King Features Syndicate. April 6, 1999.
Traditional Medical Visit

17. Definition
Motivational interviewing (MI) is a
directive, client-centered counseling style
for eliciting behavior change by helping
clients to explore and resolve
ambivalence.

18. Ambivalence

19. Analogy: The Angle & The Devil

20. Motivational Interview (MI): Modern Method
• Accepts that ambivalence about change is a normal human
experience, and often a necessary step in the process of change.
• Encourages clinicians to work with patients’ ambivalence rather than
viewing it as a problem.
• Aims to encourage the patient’s autonomy in decision making.
• Guiding: The clinician acts as a guide, clarifying the patient’s strengths
and aspirations, listening to their concerns, boosting their confidence
in their own ability to change, and eventually collaborating with them
on a plan for change.

22. THE SECRET
CODES
The Spirit (ACE)
The Secret Principles (READS)
The Secret RULE
The Secret Skills (OARS)
The 4 Process (EVOKE – IS TE HEART OF
MOTIVATIONAL INTERVIEW)

23. THE SPIRIT
OF MI (ACE)

24. THE SECRET
PRINCIPLES OF
MI (READS)

25. ROLL WITH RESISTANCE
• Resistance is normal
• Getting away from it and do not engage it
• Do not confront
• Let the patient express and roll on it to
defuse/decrease it
• REFLECTIVE LISTENING: “Jadi nampaknya
anda belum lagi bersedia untuk berhenti
merokok kerana begitu banyak cabarannya.
Apa yang encik akan lakukan seterusnya?”

26. AVOID ARGUMENTS
• Dancing not wrestling ;)
VS

27. EXPRESS EMPATHY
• The Key to Empathy is Reflective Listening
(in later slides on THE SKILLS OF MI)

28. DEAL WITH DISCREPANCY (AMBIVALENCE)
• The Heart Of
Motivational Interview
(in later slides on THE
PROCESS OF MI)

29. THE SECRET
RULE OF MI

30. RESIST ‘Righting reflex’
• Happens quite commonly during traditional
advice-giving.
• It is the tendency to identify another person’s
problem, and immediately try to fix it, and
involves a directing style.
• A common belief may be that if only you can
convince a patient of the rational reasons to
change, and provide them with all of the correct
information, then they will change.
• At the heart of the righting reflex is usually simply
the desire to help, but paradoxically it often has
the opposite effect.

31. THE SECRET
SKILLS OF MI
(OARS)

32. OARS: CLOSE-ENDED VS OPEN-ENDED
CLOSE-ENDED OPEN-ENDED
Encik ada jaga pemakanan?
Encik ada ambil makanan manis-manis?
Bagaimana dengan penjagaan pemakanan encik?
Saya dengar encik rasa susah nak jaga pemakanan,
boleh encik ceritakan lebih lanjut?
Encik ambil ke ubat yang saya bagi bulan
lepas?
Saya ada beri ubat pada bulan lepas, apa pendapat
encik tentang ubat baru tersebut?
Encik ada usaha berhenti merokok? Apa yang encik rasa mengenai tabiat merokok
encik?
Encik ada bersenam tak? Cuba encik terangkan apa yang encik tahu dan
faham tentang bersenam?
Encik ada cuba tak turunkan berat badan? Boleh encik ceritakan kesukaran dan cabaran encik
mengenai isu berat badan?

33. OARS: AFFIRMATION
Strategies Example
Emphasize A Strength Puan dah lalui macam-macam dugaan dan tetap tabah.
Notice & acknowledge
positive behaviour
Terima kasih datang pada hari ini.
Saya hargai sebab puan memberitahu dengan berterus-terang dan
jujur tentang perkata yang sebenar…..
Bagus kerana puan ada cuba berusaha untuk kawal pemakanan
walaupun belum begitu nampak hasilnya
Express caring Semoga semuanya dipermudahkan untuk puan..
Genuine
Different from Praise!! BUKAN
Puan nampak berseri-seri hari ni!
Puan ni baik!

34. OARS: REFLECTIVE LISTENING
• Convey that you listen & understand
• Express your empathy
• Important in therapeutic relationship
• Help to prevent ‘righting reflex’ eg giving advice too quickly
• KEY TO ACCURATE EMPATHY
• KEY SKILL OF MOTIVATIONAL INTERVIEWING

35. OARS: REFLECTIVE LISTENING
STRATEGIES PESAKIT:
Saya paling tak suka bila semua orang membebel suruh saya jaga makan,
lagi orang buat macam tu lagi saya makan semua benda..
REPEAT Saya dengar encik kata … (ulang semua)
REPHRASE Encik pantang kalau orang berleter menyuruh-nyuruh encik jaga makan,
menyebabkan encik lagi makan semua benda
PARAPHRASE Encik pantang kalau orang berleter menyuruh-nyuruh encik makan, dan
kerana itu encik bertindakbalas dengan buat sebaliknya walaupun perkara
itu berbahaya untuk encik sendiri…
REFLECT THE EMOTIONS Encik rasa marah dan benci kalau…..

36. OARS: SUMMARIZING
• Special application of reflective listening
• Links together what have been discussed & prepare patient to move
on
• Examples: “Apa yang saya faham setakat ini ialah……………………………
…………………………………………… ada apa-apa yang saya tertinggal? Ada
apa-apa lagi yang penting yang perlu saya tahu?”

37. Key communication skills: OARS
• Open questions
• Affirming (recognising and commenting on the patient’s
strengths and abilities)
• Reflective listening (summarising what the patient has told
you in your own words, in the form of a statement rather
than a question that encourages them to continue talking)
• Summarising (giving a collection of reflections, allowing
you to indicate what you think were the most important
headlines of what the patient has said)
• Informing and advising (giving information and advice
where appropriate only, for example when the patient
asks, or more spontaneously, when there is good
engagement).

39. THE PROCESS OF MI

40. THE PROCESS OF MI
4. PLANNING – provide guidance, advice, education,
support.
3. EVOKE – the heart of motivational interview
2. FOCUS – focus one behaviour at a time
1. ENGAGE – apply OARS, READS (rolls with resistance,
empathy, avoid argument, deal with discrepancy, support
self efficiency) with RULE (resist ‘righting reflex’,
understand, listen, empower)

41. EVOKING: THE HEART OF MOTIVATONAL THERAPY
• Evoking involves eliciting the patient’s own motivations for a particular change,
and can only take place with adequate focus – we have clarified a goal for
change.
• Aims to encourage the patient to talk about why and how they might change
(also known as change talk).
• Designed to strengthen personal motivation and commitment to a specific goal.
• Ambivalence (feeing two ways about making a change) is viewed as a normal part
of the change process.
• Central to MI, and is often the stage at which it becomes most obviously different
from traditional advice-giving.

42. EVOKING: TECHNIQUES
• LOOK BACK
Semasa berat badan encik normal dulu, macamana kehidupan encik?
• LOOK FORWARD
Pernah encik bayangkan hidup yang berbeza kalau berat badan encik
normal?
Apa kesannya kalau masalah terlebih berat badan dibiarkan begini untuk diri
encik?
• EXPLORE EXTREMES
Apa perkara paling buruk boleh terjadi?
Apa perkara paling baik boleh terjadi?

43. Importance & Confidence Ruler

45. • “Jadi sebahagian diri encik memang mahu
turunkan berat badan dan encik nampak
pentingnya untuk imej, kesihatan dan ingin
kembali aktif seperti dulu tapi sebahagian
dari diri encik rasa sukar mencari masa untuk
bersenam dan sukar menjaga makan kerana
makan di luar…..”

46. Change Talk

47. PLANNING (example: giving advice)
• GIVING ADVICE: Elicit-Permission & Provide-Elicit (EPE)
• Elicit: Apa yang encik dah tahu mengenai strategi turunkan berat badan?
• Permission & Provide: Boleh saya beritahu encik lebih lanjut…
• Elicit: Apa pendapat encik tentang cara ini?
Saya nampak encik kelihatan keliru.
Boleh encik ulang semula mengikut pemahaman encik?

48. TAKE HOME
MESSAGE

49. Thank You for Your Interest, All The Best
umiadzlin@gmail.com