Motivational interviewing: hype or hope?

Lifestyle behaviour (sedentariness, unhealthy diet, smoking and alcohol consumption) not only plays a big part in the incidence of heart disease, stroke, cancer, chronic respiratory conditions and diabetes, but also affects the outcomes of chronic illnesses. Other patient behaviours, such as adequate disease selfmanagement are also related with improved health outcomes. For example, improved asthma self-management has been shown to enhance lung function and decrease morbidity and healthcare use. Healthcare providers can significantly influence healthful patient behaviour because of their access to chronic patients. To encourage positive patient behaviour, practitioners need adequate interpersonal communication skills. To this end, many counselling books and DVDs have become available over the years. Several received good critiques from experts in the field. But have they contributed to better patient education and counselling? My most recent doctor’s visit suggests that this seems not to be the case. Of course, I may not be an average patient and one experience is not enough. But international literature also indicates that patients lack adequate guidance and skills when confronted with chronic disease and its subsequent long-term management. For decades, patients have consistently indicated that the interpersonal counselling skills of practitioners are of particular value to them. Each time it is suggested that such techniques should receive wider acknowledgement as a basic element of the health practitioner’s technical repertoire. Still, this aspect remains relatively under-discussed in current education. It seems that the onus is on the practitioners themselves to become and remain effective counsellors to guide patients through the numerous changes they are confronted with. Therefore, there is a need to help practitioners acquire skilfulness in helping patients to change. Luckily, help seems to be on its way. A new method has emerged in healthcare called motivational interviewing (MI). Developed in 1983, it aims to help increase patients’ motivation to change, and enhance behavioural change. I must admit, I welcomed the hype with some scepticism. Why? My experience is that failure to achieve positive change in patients may not be the result of not having the counselling methods to do so, but rather of practitioners’ non-adoption, partial implementation (low completeness and low fidelity) and/or failure to maintain acquired counselling skilfulness to change patients’ motivation and behaviour. To illustrate this point, I present a study on urinary incontinence, a major health problem affecting 25–30% of communitydwelling, mostly female, adults, which can be improved by pelvic floor muscle exercise (PFME). As we felt that practitioners required counselling skilfulness, all intervention physiotherapists received a counselling refresher course. After the course, they indicated that they had not learned new skills and that in practice they performed all these skills already. To evaluate the counselling process, the level of skill implementation was assessed among all therapists. It appeared that filling out this evaluation tool made all therapists (including those in the control group) aware of the fact that they only minimally employed the required counselling steps. Due to the improved implementation of