Brief Interventions and Motivational Interviewing

In order to understand brief interventions and motivational interviewing, we need to understand the stages of change model.

Stages of Change Model

The Stages of Change Model, also known as the Transtheoretical Model, is a framework for understanding the process of intentional behaviour change. Developed by Prochaska and DiClemente in the 1980s, it outlines a series of stages that individuals typically go through when changing behaviour. Here’s a summary of each stage:

  1. Precontemplation
    • In this stage, individuals are not yet considering change.
    • They may be unaware of the need to change or may be resistant to acknowledging it.
    • People in this stage often underestimate the pros of changing behaviour while emphasizing the cons.
  2. Contemplation
    • Here, individuals are aware that a change is needed and begin to think seriously about it.
    • They recognize the benefits of change but also understand the costs and effort involved.
    • This stage is characterized by ambivalence about change.
  3. Preparation
    • Individuals in this stage are planning to take action soon.
    • They start to take small steps towards change or may experiment with small changes.
    • The preparation stage is about setting realistic goals and developing a plan of action.
  4. Action
    • This is the stage where individuals actively implement their change strategies and modify their behaviour.
    • It requires commitment and effort.
    • Support from others can be crucial in this stage to maintain motivation and overcome challenges.
  5. Maintenance
    • After the behaviour change has been consistently implemented, the focus shifts to maintaining the new behaviour.
    • This stage involves integrating the change into one’s life and avoiding relapse into old behaviours.
  6. Termination
    • In some versions of the model, this final stage is where the individual no longer feels tempted to revert to the old behaviour and has complete confidence in their ability to maintain the new behaviour.
    • However, not all models include this stage, as ongoing maintenance can be a lifelong process for many behaviours.
  7. Relapse
    • Although not a formal stage, relapse is recognized as a common part of the change process.
    • It involves returning to older behaviours and is often considered an opportunity for learning and growth, helping to inform future efforts at change.

The Stages of Change Model is widely used in various fields, including psychology, health promotion, and addiction treatment. It emphasizes that change is a personal and non-linear journey, often requiring multiple attempts, and provides a framework for understanding and supporting this process.

The 5As approach

The 5As approach is a structured framework to guide brief interventions for behaviour change. It is used in areas like tobacco cessation, promoting physical activity, and improving diet. The 5As stand for:

  1. Ask
    • Initiate the conversation by asking about the specific behaviour
      • “Do you smoke?”
  2. Advise
    • Provide clear and personalized advice about the benefits of change and the risks of continuing the behaviour.
      • “Quitting smoking is one of the most important things you can do for your health. It will reduce your risk of heart disease, cancer, and respiratory problems.”
  3. Assess
    • Determine the patient’s willingness to change, the frequency of the behaviour, and any previous attempts to modify the behaviour.
      • “Have you ever tried to quit smoking?”
      • “What have you tried before?”
      • “How ready are you to quit smoking?”
  4. Assist
    • Offer tools, resources, or strategies to help the patient make the desired change.
    • This is where motivational interviewing techniques can be particularly helpful in exploring and resolving ambivalence.
      • “Would you like some resources or strategies to help you quit?”
  5. Arrange
    • Schedule follow-up appointments or referrals to provide ongoing support and to track progress.
      • “I’d like to see you in two weeks to see how things are going. Would that work for you?”

The 5As approach is evidence-based and has been found to be effective, especially for behaviours like tobacco use. Motivational interviewing complements the 5As by providing a patient-centred counselling approach, which can be especially useful during the “Assist” phase to help patients explore and resolve ambivalence about behaviour change.

FLAGS

FLAGS is a mnemonic to remember how to action a brief intervention. Using alcohol use as an example:

  • Feedback  
    • Provide individualised feedback about the risks associated with continued drinking, based on current drinking patterns, problem indicators, and health status.
    • Discuss the potential health problems that can arise from risky alcohol use.
  • Listen
    • Listen to the patient’s response.
    • This should spark a discussion of the patient’s consumption level and how it relates to general population consumption and any false beliefs held by the patient.
  • Advise
    • Give clear advice about the importance of changing current drinking patterns and a recommended level of consumption.
    • A typical five to 10 minute brief intervention should involve advice on reducing consumption in a persuasive but non-judgemental way.
    • Advice can be supported by self-help materials, which provide information about the potential harms of risky alcohol consumption and can provide additional motivation to change.
  • Goals
    • Discuss the safe drinking limits and assist the patient to set specific goals for changing patterns of consumption.
    • Instil optimism in the patient that their chosen goals can be achieved.
    • In this step, motivation-enhancing techniques are used to encourage patients to develop, implement, and commit to plans to stop drinking.
  • Strategies
    • Ask the patient to suggest some strategies for achieving these goals.
    • This approach emphasises the patient’s choice to reduce drinking patterns and allows them to choose the best approach to their own situation.
    • The patient might consider setting a specific limit on alcohol consumption, learning to recognise the antecedents of drinking, developing skills to avoid drinking in high-risk situations, pacing one’s drinking and learning to cope with everyday problems that lead to drinking.

FRAMES

FRAMES is an alternative mnemonic to remember how to action a brief intervention. Using alcohol use as an example:

  • Feedback
    • Provide feedback about the patient’s alcohol use and related problems and the risks associated with them, as well as general information about alcohol-related harm.
    • Feedback can include a comparison between the patient’s alcohol use and population norms.
  • Responsibility
    • Acknowledge the patient is responsible for their own behaviour and that they can make choices about their alcohol use.
  • Advise
    • Provide clear advice about the current and future potential harms associated with continued alcohol use.
  • Menu for Change
    • Provide the patient with a range of alternative strategies to choose from to help them cut down or cease alcohol use.
    • Examples include:
      • alcohol use monitoring,
      • engaging in alternative activities instead of alcohol use,
      • identifying high-risk situations and strategies to avoid them,
      • providing other self-help resources.
  • Empathy
    • Deliver the brief interventions using a warm, empathic and understanding approach.
  • Self-efficacy
    • Build the patient’s confidence in their ability to make a positive change in their alcohol use.

RULE and OARS

The RULE approach is a fundamental concept in motivational interviewing, a patient-centred counselling technique designed to enhance an individual’s motivation to change. RULE is an acronym that stands for:

  1. Resist the Righting Reflex
    • Clinicians often feel a natural inclination to “fix” problems or provide immediate solutions when patients present issues.
    • Resisting this reflex means not immediately jumping in with advice or solutions, but rather allowing the client to explore their feelings, beliefs, and desires related to change.
  2. Understand the Patient’s Motivation
    • Instead of imposing reasons for change, it’s essential to understand the patient’s own motivations and reasons.
    • By listening actively and asking open-ended questions, the clinician can help the client voice their personal motivations for change.
  3. Listen to the Patient
    • Active listening is at the heart of motivational interviewing.
    • The clinician should listen more than they speak, providing the client with space to express their thoughts, feelings, and ambivalence about change.
  4. Empower the Patient
    • This is about fostering the client’s belief in their ability to change.
    • Providing positive reinforcement, emphasizing their autonomy in decision-making, and building their confidence are all crucial components of empowerment.

Using the RULE approach in motivational interviewing helps create a collaborative and non-confrontational environment where patients feel understood, respected, and empowered to drive their own change.

While RULE is a foundational aspect of MI, it is also complemented by other key concepts and skills, often summarized by other acronyms. One of the primary extensions to the RULE approach is the OARS technique:

OARS stands for:

  1. Open-ended questions
    • These types of questions are designed to encourage a full, meaningful answer using the subject’s own knowledge and feelings. It helps to engage the client and elicit their perspective and understanding of the situation.
    • E.g., “How do you feel about your current situation?”
  2. Affirmations
    • These are positive statements that recognize the client’s strengths, efforts, and accomplishments.
    • Affirmations are important for building rapport, boosting the client’s confidence, and reinforcing their capacity for change.
    • E.g., “You showed a lot of courage by sharing that with me.”
  3. Reflective listening
    • This skill involves actively and empathetically listening to the client and then reflecting back to them what they’ve expressed, often by paraphrasing or summarizing their words.
    • Reflective listening demonstrates understanding and can help clients process their feelings and thoughts. E.g.,
      • Client: “I’ve tried to quit smoking many times, but I always go back.”
      • Clinician: “It sounds like quitting has been a real challenge for you, and you’re frustrated by the repeated attempts.”
  4. Summaries
    • These are condensed, reflective responses that capture the essence of what the client has shared over a longer conversation.
    • Summaries can help highlight themes, confirm understanding, and transition to new topics.
    • E.g., “From what you’ve shared, it sounds like you value your health and want to make a change, but you’re feeling stuck due to past experiences.”

The combination of RULE and OARS provides a comprehensive framework for clinicians to effectively use motivational interviewing to support clients in their journey towards positive behavioural change.