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[Physio Explained] Motivational interviewing essentials: a guide for clinicians to inspire change with Dr Tim Anstiss

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In this episode, we break down motivational interviewing into bite sized useful skills that you can implement with your patients in the clinic. We discuss: 

  • Microskills of motivational interviewing
  • The different stages of change
  • How to facilitate a conversation with your patient
  • Unhelpful beliefs and the impact this can have on a patient’s pain

Dr Tim Anstiss is a medical doctor, educator, coach and coach trainer. After working various NHS jobs including in cardiology, orthopaedics, psychiatry and occupational health, Tim developed and led an MSc in Exercise and Behavioural Medicine at Thames Valley University. Tim has trained thousands of health professionals in motivational interviewing and health coaching, has been involved in several national and international behaviour change initiatives and has written several book chapters on different coaching approaches. 

See the active conversations course here - https://movingmedicine.ac.uk/activeconversations/

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Our host is @James_Armstrong_Physio

SPEAKER_02:

there are two important aspects of mi there's the technical aspects like eliciting and noticing and strengthening change talk etc doing a decisional balance to help a person explore their ambivalence or mixed feelings goal setting but the relational factors empathy warmth therapeutic alliance make as much a difference as the behavior change technique so if you're just offering behavior change techniques that may be helpful but it's combining that with good quality relational factors that can be that are known and strengthened makes a big difference

SPEAKER_01:

Facilitating change in patients can be a challenging and sometimes frustrating element of our practice. In today's episode, we're going to be talking to Dr. Tim Anstis about behaviour change, and he's going to tell us some of the really great ways that we can elicit change in our patients. Tim Anstis is a medical doctor, educator, coach and coach trainer. And after working various NHS jobs, including cardiology, orthopaedics, psychiatry and occupational health, Tim developed and led a and MSc in Exercise and Behavioural Medicine at Thames Valley University. And Tim has trained thousands of health professionals in motivational interviewing and health coaching, and has been involved in several national and international behaviour change initiatives, and has written several books and chapters on different coaching approaches. In today's episode, as I mentioned in the episode, you're bound to want to rewind and take note of some of the brilliant tips that Tim brings us in how you can help your patients make some big and long-lasting change Enjoy the episode. I'm James Armstrong and this is Physio Explained. Tim, welcome to the PhysioExplained podcast. It's great to have you on. I'm really looking forward to having a chat today all about how we can help patients make some of those big changes that we're looking to get them to do.

SPEAKER_02:

Well, thanks for having me on, James.

SPEAKER_01:

So as we said off air, we've got a limited time to talk about this, so we're going to get straight in. Tell me a little bit more about motivational interviewing, where it comes from and some of its core concepts.

SPEAKER_02:

It's essentially a conversational style that had its origins in the drug and alcohol field about 40 years ago. So the traditional approach in alcohol and drug field was to confront people and tell them, look, you've got a problem, et cetera. And then people would react defensively to that. And then they would be labeled as in denial. And what Bill Miller did, who developed their minds, realized that when you just adopt a nice person-centered, non-judgmental counseling approach with people without judging. And they would tend to come forward. And he recognized that when you just talk with people and you're curious and non-judgmental, they would say things like, well, I really ought to. You know what? I think I should. I used to be able to. What I want to do. And he labeled these statements self-motivating statements. Now, what's happened since with a lot of research is these statements which come out of someone's mouth are now called change talk, different aspects of change talk. And you can remember them by the acronym darn cat. So you may already hear some of your patients using D language, desire. I'd like to, I want to, I wish. A, ability. Well, I could do, I have done, I know how to. Reasons. Well, it would help me get back to work or I could help my wife out more with the shopping or I wouldn't come back in the hospital. Or need. That sounds like I've got to, I ought to, I should, I'm must. And then what you may hear towards the end of the conversation is commitment language, I will, I'm going to, activation, I'm kind of ready to, and TS is taking steps. Well, I've already Googled it. And so you can't see motivation, but you can pay attention to particular things patients say during the conversation. And there's evidence that the more change talk emerges as the conversation progresses, the more post-conversational change is likely. The book is in the fourth edition at the moment. The updated definition is really it's a conversational style. It's not a behavior change technique. It's compatible with or enables a clinician to offer, you know, decisional balance, goal setting, visualization, scheduling, relapse prevention. So you can use it as a style technique. to offer and use specific behaviour change techniques, but it's really a conversational style which emphasises partnership, acceptance, compassion and evoking, drawing out from the person rather than putting in. So it's a bit counterintuitive for many health professionals who have been trained as experts you are you we will have expert knowledge but we sometimes tend to jump in with unasked for advice and try and fix people which is fine for some things but when it comes to behavior change jumping in with unasked for advice and trying to fix people sometimes gets in the way of self-directed change. And that makes learning and practicing it a little bit more complex because for some of the conversation, you might need to be a bit instructional and telling. And for other parts of the conversation, you might need to make a transition to coaching, evoking, empowering, and building confidence. You might need to switch styles during a clinical conversation.

SPEAKER_01:

Which is really hard, isn't it? Because it's... As you say, a lot of physiotherapists, physical therapists out there, it's instilled in us to want to help and to want to give all the time. But sometimes actually we need to take a step back, talk less and facilitate a conversation.

SPEAKER_02:

You're exactly right, James. And so you're not helping less. You're still compassionate. You're still caring. You're still wanting what's best for the person. So some of the things, you know, in my training, I say, have you ever fallen into the yes, but trap where, you know, could you do this? Yes, but what about this? Yes, but have you thought about this? Yes, but. And so there were very, there were well-recognized traps. You know, I sometimes say, do you ever have the patient as they're about to leave, get to the door? They say, oh, just one more thing. And they'll nod. And I say, and how important is that? Oh, it's really important. And we call that the premature focus trap. So the good news is there's lots of good books and online training courses to help people get better at MI. But like anything, like much physiotherapy practice, psychotherapy practice, like sport or music, it's deliberate practice with feedback. which leads to skill acquisition. So I've done a lot of drive-by training, as it might be called, turn up, did a bit of workshop and left. And now I don't tend to do so much of that. I'm much more interested in blended and hybrid, bite-sized chunks. I want people to practice, get feedback from patients or others, because it is something which you can get better at over time. There are four micro skills we call open-ended questions, which you know, you know, how, why, rather than could you, have you, why don't you. Affirmations, which is commenting and noticing on what's right with the person. So often patients know what's wrong with them and you may be pointing out what's wrong with them. Affirmations are to do with, and you can remember the affirmations by the acronym VARS. Values, you know, your family is obviously really important to you. Achievements, you're walking further and easier than I saw you walk last time. Strengths, you're a very curious person, let's say. And effort. So even if they're not making much progress, you might comment on effort. R stands for reflections. Many of us listen in order to respond rather than listen in order to communicate empathy and understanding. And I'll digress slightly, but there are two important aspects of MI. There's the technical aspects, like eliciting and noticing and strengthening change talk, etc., doing a decisional balance to help a person explore their ambivalence or mixed feelings, goal setting. But the relational factors... Empathy, warmth, therapeutic alliance make as much a difference as the behavior change technique. So if you're just offering behavior change techniques, that may be helpful. But it's combining that with good quality relational factors that are known and strengthened makes a big difference. And empathic reflections, saying something back without a lot of meaning but using a different form of words can be really helpful. And then the final S is summarizing. where you offer the person a summary, you know, can I just check I've understood you correctly? So you've had the knee pain for a while. You're worried that the knee pain is going to get worse over time. You do appreciate that certain exercises might strengthen your knee in that way, might reduce the knee pain, which may enable you to walk more and lose some weight. But you're also concerned that it might actually make your knee pain worse. So again, you're not trying to fix it. But just summarizing back, some of the things that you've heard the patient say can be so important to the person because they, oh, this person understands me. This person gets me. So that's a bit of an overview of MI. And thank you because I love the approach. I trained in it a long time ago. And it might also improve the well-being of the practitioner because you stop struggling with people so much.

SPEAKER_00:

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SPEAKER_01:

So Tim, we now look at the stages of change model and how that might influence the way a physiotherapist might talk with a patient.

SPEAKER_02:

On the journey from not changing to changing a behaviour, people must pass through a phase of ambivalence or having mixed feelings, both wanting to eat better or move more and not wanting to eat better and move more, or whatever it might be. And people pass through certain recognised stages, and I'll come back to ambivalence very shortly afterwards, Pre-contemplation is you're not thinking about doing those balance exercises your physio said, or stopping smoking, or doing the breathing exercises. Contemplation is when you're thinking about it, but you're undecided. That's when you're ambivalent. You see the advantages, let's say, of doing some breathing exercises and some disadvantages. You see some advantages of not doing them and some concerns about not doing them. You then may pass into a planning or preparation phase where you're intending to change your behavior and your planning. And then there's the action phase where you're actually making attempts and seeking to change your behavior. And then after you've been doing that for a while, you're then in the maintenance phase. So an awful lot of what physiotherapists are trying to do, as well as deliver some treatment and education, et cetera, in a session, is speak to a person in such a way that they change their behavior after the conversation's over. Because they might spend half an hour, you might spend half an hour with a patient, but that's a huge amount of time each week they're spending on their own. So how do you activate and engage them? If there's something that you want to raise as a way of raising the topic, there might be an action phase for... regular walks and aerobic activity, but in pre-contemplation for strength training, or they might be in pre-contemplation for balance. There's a nice technique called ask, share, ask. Rather than jumping in with bits of unasked for advice, you might say, ask, what do you know about some of the benefits of strength training in women? Find out what they know. That also stops you patronizing people. And also, if they come out with nonsense or rubbish, that's important to know, because a lot of patients have unhelpful or nonsense beliefs about stuff and you'd like to find that out soon so i'll show what do you know about what do you know about strength training what do you know about the importance of flexibility in reducing back pain i know what they know then you ask permission can i share with you a couple of other things or can i share with you what we recommend here or can i share with you what a lot of my patients find really helpful and then you share two or three things so A couple of things. If your hamstrings are really tight, that influences, you know, I'm making it up. I'm not quite making it up, you know, et cetera. We find that by increasing flexibility of the hamstrings, that can also X, Y, and Z. What do you make of what I've just said? So the final ask is not saying, do you understand, but what do you make of what I've just said? So there are ways to surface a topic in a nonjudgmental way, which may move someone from pre-contemplation into contemplation. If they're in ambivalence, You might do a decisional balance. What would be the advantages to you of doing that balance exercise, standing on one leg with your hand on the back of the chair and closing your eyes? What would be the advantages of doing that twice a day for a week? Any other advantages? What are your concerns about doing these balance exercises? Or you might do importance and confidence scaling. On a scale of 0 to 10, how important is it for you to leave the house feeling at least once a day. 0 is not at all important, 10 is very important. Let's say they said 6. Why 6? You could have said 2 or 3. What are some of the reasons you have for leaving the house at least once a day? Okay, any other reasons? So you're evoking and eliciting from them their own arguments for change. Then you may move to the confidence scaling question. And if you did decide to leave the house at least once a day, how confident are you you could get started and keep this up for at least 10 days or 3? Okay, so you could have said nought or one. You said three. What are some of the reasons you think you could do it if you set your mind to it? So it's just a solution-focused approach. So even if they're not confident, as long as they don't say nought, they say three, you can still say, well, you could have said nought or one. And you're trying to evoke from them why they think they might be able to. That can strengthen their self-efficacy. Then you might say, what would build up your confidence to maybe a four or a five? So they haven't decided to change. They're in the contemplation phase. And you're using these importance and confidence scaling questions. And then you might say, can I share with you something other people find helpful? So then you can make a transition into our share hours. Then you might summarize it all back and say, so what's next for you? Where do you go from here? So you're using different coaching strategies according to where you think the person might be in the stage of change. If they've been doing the behavior, let's say they're in the action phase, you know, you might say, so what have you noticed since you've been doing this? What else have you noticed? You could do a bit of relapse prevention. What might get in the way of you keeping up this change? How could you find a way around that? So there's a nice series of open questions and there are particular questions and tools you may need, you may use according to where you think your patient is on their readiness to make and keep up one or more behaviour changes, which you and they feel could be helpful to their recovery, independence, etc.

SPEAKER_01:

Brilliant. It's a fascinating subject, isn't it? And one that, as you say earlier on, it does take practice, because as I'm sure the listeners are listening to you right now thinking, goodness me, there's so many things, there's so many facets to this that we could implore. What would your tips be to those listening, thinking, gosh, this is a little bit too much. This is quite overwhelming to be able to do all of this. Yeah. As a physiotherapist, also having to have that clinical knowledge and skills.

SPEAKER_02:

I would say, first of all, you're doing some of it already. You're already being empathic. I'm sure you're already asking some open questions. You're looking to be person-centered. Hopefully you're not rushing into goal setting prematurely. So it builds on what you're already doing, and it's certainly in line with your values. So let's take a strength-based approach. You're already doing a lot of this and it's in line with your values and what you want. The course which I've kind of helped develop with the Faculty of Sport and Exercise Medicine. So, you know, if you want to get better at it and get some CPD points and go at your own pace, there's a nice course called Active Conversations. So it's MI consistent, it's bite size, it's modular. And if you go to the Moving Medicine website, you'll see the active conversations course. And it can also help you with a one minute conversation. If all you've got is one minute at the end of whatever your clinical intervention, let's say, you've got a five minute conversation. And then there's a little bit of a structure for a more minutes conversation. And you'll get lots of tools and practice exercises and demos. But it's like any skill, like the first time you might have done a more traditional physiotherapy skill, whatever that might be. It's progression, you know, watch someone do it, have a little practice, bite-sized chunks, and then you progressively build your skills over time. And it is quite rewarding to learn. So what would be my tips? You know, just be curious, get started, have a practice, get some feedback, And hopefully you and I are chatting here, James, that's led to some people becoming more curious about developing this caring, evidence-based conversational style.

SPEAKER_01:

Absolutely. We know so much about the importance of building that relationship with a patient, building trust and trying to elicit some quite significant changes for some of our patients. And this is one way, an important way that we can potentially help improve our outcomes and patients' experiences.

SPEAKER_02:

What physios do can be transformational for people. People with chronic and persistent pain, people post-operative. There are so many things you could do, but if people don't make behavior changes after the physio intervention, then in a way you're reducing your impact. So yes, there's whatever you might be doing when you're face-to-face with someone, but talking with people in a way which increases the probability, they then engage in self-care or get better at self-management. you increase patient activation and confidence. That's just going to amplify your ability to offer first-class care to people and, as you say, get better outcomes.

SPEAKER_01:

There's so many more avenues I want to go down with this podcast. Unfortunately, we've pretty much run out of time. But I think certainly from this, I should imagine everyone listening is going to want to rewind this episode and listen back to some of the acronyms. Take some of them away and, as you say, practice. Get some feedback and see how it feels to use it.

SPEAKER_02:

Yeah. And then maybe local MI trainers and other people available. So happy to signpost people to helpful resources because I'm enthusiastic about it. And thanks for having me on the podcast, James. Not a problem. And, Tim, if people want to know more about you, where can they find you best? Connect on LinkedIn.com. I think it's at Tim Ansys, I'm not sure, but search Tim Ansys on LinkedIn and then ask to connect, etc.

SPEAKER_01:

So if you listen to this and you want some more information, do get in touch with Tim. I'm sure there'll be an opportunity for us to talk again on the podcast. maybe go into some more depth about some of the models of behaviour change that we haven't been able to today. I think we covered it really, really well. And there's loads that I'm sure listeners will be able to take away. You certainly got my head thinking about behaviour change and some of the things that I can improve and continue to look at and be inquisitive, as you say, in my practice.

SPEAKER_02:

Thanks. I enjoyed talking about it. And thanks for the questions.

SPEAKER_01:

Brilliant, Tim. All right. Well, enjoy the rest of your day. And we'll see. No doubt I'll have you on again. Thanks a lot, Tim.