La entrevista motivacional es una técnica de comunicación en consulta para mejorar la relación médico-paciente y favorecer el cambio de actitudes y conductas saludables. Desgraciadamente no es usada todo lo que sería necesario. En parte por desconocimiento, en parte por olvido, en parte porque en 6 minutos no es sencillo.
En el British Medical Journal (
en la tercera página) nos hacen un repaso, en una sección dirigida a médicos jóvenes. Me temo que en nuestro medio es aplicable también a los seniors, a enfermeras y a todos los profesionales sanitarios en general.
Aconsejar cambios saludables a pacientes suele ser poco efectivo y motivador.
La entrevista motivacional usa una guía de trabajo para comprometer al paciente, clarificar sus aspiraciones y fuerzas, rescatar sus propias motivaciones para el cambio y promover su autonomía y toma de decisiones.
Se puede aprender entrevista motivacional en tres sencillos pasos: usando un estilo de acompañamiento más que uno directivo, desarrollando estrategias que potencien la propia motivación del paciente al cambio, y mejorando las propias habilidades de escucha para potenciar el discurso de cambio del paciente.
La entrevista motivacional ha demostrado favorecer cambios saludables en distintos ámbitos y puede mejorar la relación médico paciente y la eficiencia de la consulta.
Step 1: practise the guiding style
Among the broad communication styles commonly used
to address patients’ problems are directing, guiding, and
following.
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Although each is appropriate to certain situa
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tions in everyday practice, a guiding style is best suited to
consultations about change. When this topic comes up,
shift your stance from that of a director to that of a well
informed guide, and follow three principles: engage with
and work in collaboration with patients, emphasise their
autonomy over decision making, and elicit their motivation
for change. You retain control over the direction and struc
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ture of the consultation and provide information as needed,
but you ensure that your patients retain responsibility for
change. Box 1 shows the contrast in styles between direct
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ing and guiding.
Use three core skills—asking, listening, and informing—
in the service of this guiding style to draw out your patients’
ideas and solutions.
2
This shows that you want to know
about and respect their ability to make sound decisions.
•
“Ask” open ended questions—invite the patient to
consider how and why they might change;
•
“Listen” to understand your patient’s experience—
“capture” their account with brief summaries or
reflective listening statements such as “quitting
smoking feels beyond you at the moment”; these
express empathy, encourage the patient to elaborate,
and are often the best way to respond to resistance;
•
“Inform”—by asking permission to provide
information, and then asking what the implications
might be for the patient.
Once you have practised these three skills, and once you
feel comfortable with the shift from director to guide, you
can add to your toolbox a set of strategies containing spe
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cific questions that are suited to different circumstances
Step 2: add useful strategies to your toolbox
Motivational interviewing aims to elicit the motivation to
change from the patient, rather than to try to instil this in
them; it also aims to work with their strengths rather than just
talk about problems and weaknesses. Different strategies are
available to achieve these aims in a guiding style, eliciting the
what, why, and how of change from the patient. This “menu
of strategies”
4
has been used successfully among college stu
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dents to reduce use of alcohol, tobacco, and cannabis.
5
Agenda setting (what to change?)
Patients often face more than one option for change.
In agenda setting, rather than impose your priority on
patients, you conduct an overview by inviting them to
select an issue or behaviour that they are most ready and
able to tackle, feeling free also to express your own views.
2
For example, to reach agreement about what to deal with
in the consultation you might say: “That’s very helpful. Are
you more ready to focus on eating or on increased activity?
Or is there some other topic that you would prefer to talk
about? I’d like to talk about those test results at some point,
but what makes sense to you right now?”
Pros and cons (why change?)
It is normal and common for patients to feel in two minds
about both the status quo and change. It can be helpful to
invite them to say how they see the pros and cons of a situ
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ation. Then your next step is to ask them to clarify whether
change is a possibility (box 2).
Assess importance (why) and confidence (how)
To be efficient you need to spend time where it is most
needed. Those who are not convinced of the importance
of change are unlikely to benefit from advice about how
to change, and a focus on the why of change is pointless if
the main issue is how to achieve it. This focused strategy
(box 3) has produced successful outcomes in the smoking
field,
6
where a recent review also provides support for the
efficacy of motivational interviewing.
7
Exchange information
One of the first successful studies of motivational interview
-
ing placed listening at the centre during feedback of test
results.
8
This gave rise to the “elicit-provide-elicit” strat
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egy (box 4), in which a guiding style is used to encourage
patients to clarify the personal implications of information
that you provide
Step 3: respond skilfully to patients’ language
You can refine your skills further by paying attention to
the language that patients use.
9
You will notice that they
talk about why or how they might change (this is called
change talk)—“I guess I should take my medicine more
regularly”; “I want to quit smoking”; “I am going to eat
less fried food”—or about the opposite: “I don’t like tab
-
lets”; “I enjoy my smoking”; “I’ve never succeed in losing
weight.” You can choose whether to elicit change talk or
not. The assumption is that if you do, motivation to change
will be enhanced, and subsequent change is more likely
take place.
9
Box 6 shows how a doctor elicits change talk
and responds to it with further listening. Many of the ques
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tions shown in step 2 are useful because they elicit change
talk—for example, “How important is it for you to take this
medicine?”
One line of research has been to examine whether moti
-
vational interviewing improves outcomes. A recent meta-
analysis of 119 studies concluded that it exerts a small but
positive effect across a wide range of problem domains,
but not in all.
10
Another line of research has been to study
language and change talk. For example, if people strug
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gling with alcohol and other drugs offer more change talk
in counselling, their outcomes in regard to substance use
are better
11
-
13
; moreover, practitioners who are competent
in motivational interviewing elicit more change talk, inde
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pendent of the motivation of the patient
.
