Version May 2024
| Non-motivational interview (MI) approach: Focusing |
| In the first vignette, a doctor uses a standard checklist approach to review issues with a cardiac rehabilitation patient. MI-inconsistent techniques are identified following the physician's statements. |
| Doctor: Hi Mr. Y, I'm Doctor A. It's nice to meet you. I have your chart here. I see you've had a rough time of it lately. |
| Patient: Yes, I never thought I'd have a heart attack. Now the nurses have me half scared to death that I'll have another one if I don't change my life completely. |
| Doctor: Well, it's their job to give you the information you need. (Ignoring patient emotions) So my job is to review how you're doing in a number of areas, and to set some goals for you to keep your heart as healthy as possible. (Providing information) |
| Patient: Okay. |
| Doctor: So for most people, the big areas are, first, cholesterol and lipids, which are related to diet, exercise, genetics, and medicines, and second, personal habits like smoking, drinking, being too sedentary or too stressed. (Providing information) Let's go through the list and see what you might do to improve your heart health. (Non-collaborative agenda setting) |
| Patient: Okay. |
| Doctor: I see you're a non-smoker, so that's great - one less thing to worry about! (Providing information) |
| Patient: Yes, and I don't drink much either. But I do have a lot of stress. |
| Doctor: So, how much are you drinking, typically? (Ignoring opportunity to reflect on drinking or stress) |
| Patient: Oh, a few beers a week. Maybe wine with dinner out once a week. |
| Doctor: So when you say a few, how many per night do you mean? (Closed question) |
| Patient: Well, probably three or four beers a night on work nights to relax. I have put on weight - now I have this beer gut - as I've gotten older and work at a desk job all day. |
| Doctor: So, are you thinking about cutting down on your beer, and getting rid of that beer gut with some exercise? (Closed question) You're drinking more than the limit for a healthy man. (Providing information) And one of the best things for your heart is brisk walking 45 to 60 minutes a day, four to five times a week. (Providing information) You probably should substitute walking for drinking those beers! (Providing advice without permission) |
| Patient: Well, I could walk my dog each afternoon, but I really like the beer to unwind after work. |
| Doctor: That sounds great - healthy for you and your dog! I have some brochures here about steps to take to cut down your drinking. (Providing information) Take these home, read them over, and then when you come back you can tell me how you did! (Providing advice without permission) |
| Patient: Well, okay... |
| This conversation, rather than helping the patient focus on a realistic, achievable, and meaningful change, is likely to result in him leaving less internally motivated, and more helpless to make a long list of changes. The doctor overlooks the opportunity to reflect the patient's perspective, and misses the life context that can serve as a facilitator of, or a barrier to, healthy change. |
| Motivational interviewing (MI) approach: Focusing |
| In contrast, let's review an MI-consistent conversation during the process of focusing. |
| Doctor: Hi Mr. Y, I'm Doctor A. It's nice to meet you. I have your chart here. I see you've had a rough time of it lately. |
| Patient: Yes, I never thought I'd have a heart attack. Now the nurses have me half scared to death that I'll have another one if I don't change my life completely. |
| Doctor: It's been a frightening experience in many ways. (Reflection) It seems like you have to change your whole life immediately, or risk another attack. (Complex reflection) I'm really glad you're here today. (Affirmation) While I know a lot about the heart, your rehabilitation after a heart attack isn't just up to me. It's a team effort. You are the expert on you, and what's realistic for you. (Providing information, inviting collaboration) I see my job right now as guiding you through a number of areas, to select one or two you are most ready to adjust, not to push you to make changes all at once. (Providing information, agenda setting) We'll figure out together where you're likely to get the most gain, and which other areas can be set aside for now. (Providing information, agenda setting) Together, we can figure out some small, achievable changes that will help you to keep your heart as healthy as possible. (Providing information) |
| Patient: Okay - wow, that's a relief. It sounds like I might be able to make some small adjustments that will help, rather than overhauling everything right away. |
| Doctor: That's right. (Affirmation) Changes you can make, that you can live with, are more likely to stick. (Providing information) What areas are you thinking about changing? (Open question) |
| Patient: Well, clearly I need to lose some weight, and get rid of my beer gut. |
| Doctor: Tell me about your exercise and drinking habits up until now. (Open question) |
| Patient: Well, I don't get much exercise. I'm penned up in an office most of the time, and when I'm stressed, I like to unwind with a few beers. |
| Doctor: It's been hard for you to be active. (Reflection) Your job makes you feel a bit penned in. (Reflection) And when you're stressed, it's relaxes you to have a few beers. (Reflection) |
| Patient: Right. But I have been thinking about what the nurses told me, to walk more, and even across the day. So I'm considering how to walk more frequently, but I'm not really wanting to cut out my beer completely. |
| Doctor: You really have been giving this a lot of thought. (Affirmation) You're right, some exercise changes could get you a lot of benefit, heart-wise. (Providing information) You're thinking about how to incorporate more walking, and also considering whether to do anything about your beer intake, but you're not sure about that one yet. (Reflection) Tell me a little more about how beer fits in your day. (Open question) |
| Patient: Well, when I get home, I'm pretty tense. I like to have a beer or two before dinner. Then we usually have wine with dinner, but just a glass of red wine, good for the heart, you know? Maybe later I'll have one or two more beers, but not every day. |
| Doctor: So beer before dinner, one or two to relax, then a glass of red wine with dinner, and sometimes a couple of beers later on. So maybe between three and five drinks each day. |
| Patient: Well, and on the weekends, sometimes more, if I go fishing or to the races. Maybe two six-packs on those weekend days. |
| Doctor: Beer is a part of your routine for relaxing and also for your social and recreational time. |
| Patient: Yeah, I guess so, and thinking about it now, I must be drinking about 36 beers a week. That seems like a lot, now that we are talking about it. No wonder I got this beer gut. |
| Doctor: You're adding it up, and it's more than you realized. It might account for putting on that weight in the middle. (Complex reflection) What do you make of this, now that we're talking about it? (Open question) |
| Patient: Well, I think I should cut back. I'd like to lose this extra weight, and find some other way to deal with my stress. I'm not sure what to do though, instead of enjoying a beer. |
| Doctor: You're making a commitment to get healthy, and now you're considering how to get there. (Reflection) |
| Patient: Yeah. So I'm interested in your thoughts about how to get started. |
| Doctor: Okay, so we'll work together to create a plan that can work for you. (Collaborative spirit, conveying optimism, providing information) |
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
