Motivation and emotion/Book/2021/Brief motivational interviewing as a health intervention

=Overview = Motivational interviewing (MI) is a psychological technique introduced by Miller and Rollnick in 1983 to treat problem drinking by focusing on a client's belief about autonomy in their own problems (Hettima et al., 2005). Motivation is the driving force in human action, exploration into its origins provides insight into why we make choices and partake in behaviours. This force is generated through complex interaction of wants and needs, or 'motive', being the blanket terminology, where motives arise from are split into three categories: biological, social, and personal. Biological are considered primary, held similarly by everyone across the population. Psychosocial needs are secondary and consist of diversified and situation dependent motives stemming from interactions with others. The final category, personal, interacts with the others via cognitive processing, influencing perceived importance of motives and changing our planned actions (Sheldon et al., 2004). There is differentiation in ease of motives being recognised by individuals. For example, hunger is highly distinguishable through external cues such as stomach rumbling or pain. However, when asked why we eat, answers for motives are rarely due to the primary motive in isolation. Other reasons given for eating can range from pleasure to wanting to belong in social events. While eating full-fills primary hunger in the moment, unrecognised motives can cause maladaptive behaviour. Binge-eating, a leading cause in obesity, is an example of this phenomenon where eating is no longer due to hunger but is purely due to social or personal desires. Reflective therapies which help individuals recognise motives have been shown to help redirect behaviours in healthier ways (Boggiano et al., 2014).

MI highlights that individuals all have different types of motives for the same action and is aimed at teaching this and fostering confidence. MI calls for avoidance of suggesting ways individuals can change behaviour, the aim is calm, empathetic, discussion that encourages individuals to internally debate with themselves benefits and costs of change, then, with the practitioner self-efficacy about implementation of new goals is fostered (Treasure, 2004). MI originated to tackle unhealthy behaviour that is driven by subconscious motives such as substance abuse disorders and has risen to be currently one of the most frequently used techniques in this area (Madson et al., 2019). This has encouraged exploration into expanding the concept into other areas of health to be used as preventatively as a health intervention to encourage behaviours to put individuals on the 'right path', rather than reactively having to revert ingrained habits (Pas, 2021).

A health intervention refers to any action taken to minimise likelihood of illness occurring or a current illness deteriorating. Factors that are likely to predict wellness are known as determinants of health and consist mainly of self-regulated behaviours like smoking, nutrition and lack of physical activity (NSW Health, 2010). Interventions can be on broad such as smoking danger campaigns or more targeted such as a fitness plan from a general practitioner (GP). There are two current focusses in health interventions for behavioural modification, education and fear appeals, both techniques have been used for decades, however, recent evidence is amassing that neither are sufficient when used in isolation (Morrow, 2015); (Tannenbaum et al., 2015). MI potentially provides an opportunity for intervention across all determinants by adjusting an individual's motivation for self-care and allowing education to be put into action through motivation.

Focus questions:


 * Where can it be used best in the health care system?
 * Do motivation theories provide evidence this method will have significant impact?
 * Would health practitioners need to change the current status quo to implement brief MI, if so, how?

= Brief Motivational Interviewing = Brief MI is a collaboration between practitioner and client that provides foundation for longer therapy sessions. During MI the practitioner focuses on judging an individual's willingness, ability and readiness for change; these stages are, pre-contemplation (not ready), contemplation (getting ready), preparation (ready) and maintenance (sticking to it). During initial stages the practitioner encourages the client to verbalise personal perception of their problems and help them identify potential positive reasons for change. Then, through support from the practitioner confidence in ability to control behaviour and set new goals is fostered (Gibbie et al., 2012).

This quote embodies the idea that if a practitioner relies purely on authority for advice giving, the only people who will listen are those who lack confidence in their own life approach, so, ironically, will not be able to put recommendations into action. Studies have shown that practitioners who advocate for change in the traditional method of giving advice and education are also likely to encounter confrontation and actually foster resistance to change due to clients becoming defensive of the unconscious nature of their own actions (Hettema et al., 2005). Brief MI also includes consideration of relapse however it is not viewed negatively, and instead as an opportunity to review what happened to avoid it in the future.

The Australian Department of Health (2004) lists the core principles below for this method.



Empathy
Expressing empathy with a client is vital to foster trust in all types of therapeutic interactions. Listening to a patient express their experiences without imparting judgement increases desire for continued explanation and, therefore, a deeper understanding of the situation.

Awareness of Past Behaviour and Future Goals
Encouraging the client to be cognisant of behaviour that has occurred in the past allows for a foundation of how they approach situations and how this can be adjusted to build better future goals. This approach also helps disconfirm a patient's uncertainty bias where they fear future events will be less manageable than all those encountered in the past (Grupe et al., 2013).

Avoid Defensiveness
Defence mechanisms are activated when a client is put under pressure to avoid anxiety, therefore it is vital that practitioners implement empathy and avoid forcing thought. Those with anxiety or traumatic experiences often avoid emotionally laden conversations and individuals with high social approval motives may even seek to terminate treatment if they feel judged (Bonnie, 1963).

Rolling with Resistance
If a client is concerned about change they will often display resistance in defensive body language or comments that undermine their own involvement in problems, such as 'Drugs have not affected me and all my friends do it', rolling means practitioners should not try to deny the thought or attribute judgement but instead focus on emphasising that there is no pressure to change quickly and it is instead their choice to decide if it benefits them (Gibbie, 2012).

Support Self-efficacy
If a client is confident in their ability to cope with adversities they will be more likely to act in ways that reflects trust in themselves. A meta analysis of 38 self-efficacy in therapy as a predictor showed self-efficacy has been supported as more influential when elicited through reflection on success in past behaviour rather than telling the client that they have the resources to deal with future experiences (Sitzmann & Yeo, 2013).

Limitations
The original creators of MI have raised concern with modern day studies stating that over analysis of MI in therapeutic settings goes against their original aim of the theory as a 'spirit' of interaction as opposed to a clinical method (Emmons, 2001). The main issue this presents is a very abstract concept to study 'success' of implementation. Analysing if principles are being held similarly by all practitioners also becomes difficult.

See Also: Interactive Q & A With William Miller and Stephen Rollnick about MI

Application to Health Interventions
Brief MI has already begun to be implemented into health interventions and there is an upward trend of the terms being used together in research since the 2000's. While studies still show the strongest support is for the original area of substance abuse the strongest trend that is appearing is usage in primary health care settings by GP's in initial and also later stage consultations, especially for continuous management of CI progression (Emmons, 2001); (Stor, 2011). Through revision of research there are five core areas that brief MI would have impact in:


 * 1) Adherence to Medication
 * 2) Healthy Behaviours and Avoidance of Risk Taking
 * 3) Self-Management of CI
 * 4) Bolstering Immunity by Decreasing Stress
 * 5) Identifying Psychological Illness

A meta-analysis by Rubak (2005) suggests that using brief MI of 15 mins at the start of a GP consultation had a significant impact on body mass index, cholesterol, blood pressure and average blood alcohol content. These are all determinants of health which also minimise disease progression in the already ill. Coping mechanisms fostered by brief MI can help bolster the immune system by lowering stress which also exacerbates CI (Ski & Thompson, 2013) ; (O'Leary, 1990). Fostering of health behaviours also influences adherence to taking medication, which is difficult to encourage in advanced disease progression (Palacio, 2016). GP's are already trained in basic identification of mental illness so implementing brief MI discussion would help correct minor erroneous thinking that leads to severe cases, but also allow GP's an opportunity to identify necessity of referral to mental health professionals (Lawrence, 2017). Implementation timing is most effective when used in earliest phase of treatment, however retention can be bolstered with follow-ups a maximum of one year apart (Carrol et al.,2006). Studies show that the demographic that would benefit most is adults and elderly and not youth (Emmons, 2001).

Co-Morbidity
There has been rise in psychological illnesses simultaneously to a decrease in general population health. A lot of psychological illnesses can cause feelings of loss of control and inability to sustain goals, this means many patients may have underlying mental illnesses that are effecting coping with physical illness, the inverse is also true (Lipowski, 1970). Brief MI can help both with an almost equal effect on physiological (72%) and psychological (75%) illness (Rubak, 2015).

The Rise of Chronic Illnesses
Self-management of illness is becoming vital with the rise of chronic illness (CI) whose progress rely on self-regulated health behaviours (Morgen et al., 2011). Dealing with a worsening illness presents a unique psychological challenge for goal setting as goals do not involve increasing wellbeing, rather, achieving the best during decline stages. Brief MI by medical specialists supports self-management through asking questions that reveal appraisals of what works then encouraging focus on that optimistic belief (Coleman, 2005).

Individual Motivational Reasoning
Exploration into theories of motivation provide potential ability of medical practitioners to interpret explanations given by patients in a functional light by not only being able to define an individual's core motives, but, how they use these in relation to cognitive and worldview. This can then be used to align treatment to an individual's unique style of motivation.

Intrinsic vs Extrinsic Motivation


This dualistic model states motivation can be divided into two categories, extrinsic and intrinsic. Extrinsic motives arise externally to the individual and can be directly gained or lost by completing a specific behaviour, for example, competing in sports because your goal is to win a trophy. Intrinsic motives are internal in nature, for example, competing in sports because you feel more belonging or improvement a skillset. The creators of this theory state individuals hold both types simultaneously, but what defines ability to self-regulate behaviour is how much reliance there is on extrinsic motives for guidance (Deci & Ryan, 2000). In health interventions, intrinsic motivation is directly related to long term behaviour change and can be fostered by implementing programs with extrinsic rewards and then encouraging individuals to focus on intrinsic rewards; this process is called 'internalisation'. If health practitioners can identify the primary source of a motivation they will then be able to foster this type change (Seifert, 2012).

Attribution Theory of Motivation


Attribution theory explains individual difference in psychological outcomes from the same event of failure or success. This theory by Heider (1958), is used largely in academics to explore why some individuals hold higher levels of confidence in achievement. Heider (1958) outlines that an individual's perceived control over a situation relies on locus of control, this refers to reasoning behind an event, whether it occurred because of them, if the outcome is changeable and if this outcome will continue. A student who fails a test may cope better if they see the event outcome as being an uncontrollable element such as illness, in comparison, a student who contributes failure to ability will foster lower perceived control (Gedeon, 1999). In the health environment, this theory explains non-adherence to medical programs as, if a patient views illness as always being uncontrollable, they are unlikely to find motivation to change (Skinner, 2012).

Theory of Planned Behaviour


This theory presents explanation of why original health intervention methods need adjustment. Created by Ajzen in 1985 the theory of planned behaviour sees individuals as rational actors that if we know their personal beliefs, norms and perceived control over a situation likelihood of behaviour can be predicted. This theory was a rework from the theory of reasoned action which did not include control beliefs. Ajzen published a review of the use of his theory in 2011 observing successful adoption had been mostly in the field of health. The adaption of theory suppports that patient perception of control is the missing link in motivating health behaviour. Education campaigns as health interventions are designed to change individual's behavioural beliefs about an event while changing perception of the group norm, yet, they contain no information to encourage an individual's belief in their own control. Using this knowledge when interacting with patients medical practitioners can, additionally to fostering sense of control can also analyse if individuals are lacking knowledge on a certain behaviour or check what social barriers may be holding them back (Conner, 2021).

Quiz {A patient states 'No matter what I'm going to get sick anyway, its my genetics' What type of motivational reasoning is this?} + Viewing wellness from an external locus - Have minimal intrinsic motivation - Needing money as an external motivator

{If you ask a patient to focus on how they feel directly before and after exercise could you condition an intrinsic desire for it?} - No + Yes

= Patient/Medical Practitioner Roles = Historical dynamics between patients and medical practitioners consist of imbalanced power dispersion where the medical practitioner holds knowledge and the patient holding no education is expected to listen without question. In recent years the role of the patient is becoming stronger and resistant with resources like the internet allowing access to previously unobtainable health research (Nimmon, 2016).

Parson's Sick Role
This a sociological theory of note that outlines that when individuals are labelled as sick they adopt a socially accepted role that includes loss of motivation and non participation as normal societal expectations. Individuals adopt new societal expectations, those are to get better, and to seek help from professionals. This theory gives explanation to the power inherent in the role of being a medical professional and the overwhelming loss of motivation and powerlessness felt by sick individuals (Cole & Lejeune 1973).



Teaching Areas for Medical Practitioners
The conditions for empathy model in medicine outlines 5 key areas to train medical practitioners in to help ability to participate in brief MI, These can all be taught by incorporating role play into medical courses (Bayne & Hays, 2017).
 * 1) Physician Medical Knowledge
 * 2) Emotional Internal barriers to care
 * 3) External barriers to care
 * 4) Displaying initial empathy
 * 5) Embracing patient role

Meg is an obese middle-aged lady with who presents with joint pain, onset of flu like symptoms and a feeling of tiredness. She states she's been finding it hard to get out of bed but 'That's ok because I'm a bit slow at the moment due to the infection, my friends worry, but I know it's temporary'. When asked about what she believes is going to happen in the next few weeks she states 'Oh, I'll eventually get better but my joint pain will be much worse so I'm quite afraid I won't be able to move, but I really want to see my son's soccer match'.


 * Meg appears motivated by close connections, by encouraging her to think about why her friends are concerned about her, (has she shown this behaviour before?) see where the resistance arises.

Conclusion
Brief MI has great potential to be used as a health intervention by teaching general medical practitioners to adjust their own role in patient/practitioner relationships to foster empathy and coping mechanisms in patients. Through using motivational theories they would be able to identify thought patterns and use these to foster a sense of control that research shows has been a missing critical element in health interventions over the past decades. Motivation is also at the core of general health behaviours and coping behaviours that arise from bad diagnosis so implementation of brief MI is critical to being able to minimise, across the scale, determinants of ill health. This could greatly lower occurrence of CI and help patients cope much better with the self-management behaviours required for life outlooks that are filled with uncertainty.