Reviewed by Sean McGowan, Psy.D., ABPP
As rehabilitation therapists, we are all too familiar with the unmotivated patient. These often-labeled difficult patients routinely forget to do their exercises, are too busy to integrate trained strategies into their daily routine, frequently cancel scheduled treatments, or just don’t buy-in to the swallowing therapy at all. They sometimes come to speech therapy without any stated goals or they are forced to come to speech therapy by a loved one. Perhaps from our perspective, these patients seemingly have no desire to improve their impairments or quality of life. This patient is content with the status quo and isn’t a good candidate for rehab, we may think to ourselves. Yet, how often do we consider what we do as therapists to contribute to the status quo or our patient’s lack of motivation?
A Little Background on MI
Motivational interviewing, otherwise known as MI, is the brainchild of Dr. William R. Miller and Dr. Stephen Rollnick, two psychologists who were searching for a way to change the behavior of alcoholics. Developed in 1983, MI has evolved into an empathetic, collaborative, and evidence-based counseling approach centered on helping people resolve their ambivalence about change by eliciting their own motivations for making a change in their lives. MI has been applied and tested in an array of settings with a long list of diagnoses, including cancer, diabetes, heart disease, and substance use disorders.
Why MI in Dysphagia Therapy?
In 2018, a systematic review on patient adherence to dysphagia recommendations was published in Dysphagia. Recommendations included in the systematic review were mostly based on strength-based swallowing exercises, but a few studies focused on compensatory strategies and diet modifications. The results of the review clearly indicated SLPs have more work to do in this area. “The average adherence rate to dysphagia recommendations from studies that reported an overall level of average patient adherence ranged between 21.9% for those patients considered to be “fully adherent” to 52% for those with “average adherence” (Krekeler et al). Is it possible that so many of our patients are just difficult patients? Or are SLPs lacking the patient-centered counseling training required to do effective therapy?
The Spirit of MI
MI is not just a counseling technique, nor is it meant to be coercive. Clinicians who use MI are not using it with the intention of tricking or directing patients to adhering to their exercises or a certain diet consistency. Any use of MI with another person must be used with the ‘spirit of MI.” To use the spirit of MI, the clinician not only has to understand how to apply the counseling approach, but he or she also has to put into practice the 4 principles of MI, which are partnership, acceptance, compassion, and evocation. These principles are embedded into every aspect of MI training.
Without the spirit of MI, “MI becomes a cynical trick, a way to manipulate people into doing what they do not want to do” (Miller and Rollnick, 2013). Therefore, MI is not used “on” a person, but rather “with” a person. SLPs bring their knowledge, experience, and training related to the patient’s swallowing disorder, but the patient is the expert on himself. Only the patient can say why and how he can make changes for himself. Miller and Rollnick utilize this helpful metaphor: “MI is like dancing rather than wrestling. One moves with rather than against the person. […] Without partnership, there is no dance”. After all, the services we provide as SLPs exist to benefit the people we serve, not force them into a certain diet or to use a certain exercise regimen.
Stop Using Goal Banks
French philosopher, Blaise Pascal, once said, “People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others.” Tailoring treatment plans to individual patients can be difficult if the SLP is tied to using templates or goal banks. Instead of copying and pasting general goals into a patient’s treatment plan, the patient would benefit from the clinician who takes the time to understand why he or she has come for swallowing therapy and what the patient wants to change. To this end, the person-centered approach of MI uses a process of 4 core communication skills shown in the illustration below (Miller and Rollnick, 2013) to evoke reasons for change and then uses those reasons as stepping stones for planning the path to change with the patient.
Engage the Patient via Rapport
The MI clinician engages the patient by building a working, respectful relationship through rapport with the patient and his or her caregivers. This first step is the pre-requisite for effective therapy, and without it, the patient and caregivers may struggle to work collaboratively with the clinician. Be careful not to underestimate how easy it is to establish rapport, especially with patients who are mistrusting of the medical system, have bad experiences with SLPs, or who are not interested in our services. To build rapport with the patient from the onset of care:
- Demonstrate that you appreciate the patient’s situation and feelings by showing empathy while interviewing the patient.
- Engage in active listening. The patient should be doing most of the talking during your interview.
- Utilize the BATHE technique (background, affect, trouble, handling, empathy):
- 1) Ask the patient to describe his or her situation.
- 2) Ask the patient how the problems affect his or her life.
- 3) Ask the patient about his or her current complaints.
- 4) Ask how the patient copes with his or her problems.
- 5) Offer an empathetic statement like, “This must be difficult for you.”
Once a caring relationship has been established, the real work can commence. The clinician can begin by homing in on the specific focus of therapy.
Focus on Priorities
One of the keys to effective therapy is knowing what is important to the patient. A patient may state that returning to a PO diet is important to her, but perhaps she has higher priorities that prevent her from focusing on that goal (i.e. pain management, inadequate nutrition, etc.), which may be the reason why she does not adhere to the exercise program you created for her. Asking patients what is most important to them and prioritizing that list will direct the patient and SLP to collaboratively find a focus for therapy. How could a clinician narrow down the goals with the patient?
- Using a 10-point scale, 0 being not at all important and 10 being extremely important, the patient can narrow down what is important for her to achieve in therapy. A goals card sort can be another way to achieve exploring priorities and setting goals.
- Using the goal cards, the patient selects the top 1-3 goals most important to her and rank them in order of importance. From there, the patient and SLP can collaboratively develop a list of treatment goals.
Sean McGowan, Psy.D., board certified clinical psychologist and a VA national MI/MET consultant and trainer, cautions therapists not to create a long list of goals. “Identifying more than 3 goals can sometimes be overwhelming for individuals, and it can make it more difficult to identify what goal one wants to really focus on.”
Evoke Reasons for Therapy
“A simple rhythm in MI is to ask an open question and then to reflect what the person says, perhaps two reflections per question, like the waltz” (Miller and Rollnick, 2013). Through open-ended questions and reflective listening statements, the patient will be able to hear her own motivations for changing her current swallowing situation and the SLP can use the patient’s own words to highlight the aspects that require further attention from the patient. “As opposed to simply stating a need or desire to change, hearing themselves express a commitment out loud has been shown to help improve a client’s ability to actually make those changes” (Hettema et al., 2005). Focus on the patient’s words that relate to what he or she wants to change. A reflective statement from the SLP might be, “You miss eating and drinking the things you love.” Notice this is not a question, which may require perhaps less elaboration from the patient. A reflective statement of change talk makes a guess at what the patient may mean when she says she wants to have her PEG removed and return to a PO diet. Consequently, reflective statements will encourage the patient to further confirm or deny your guess. If the SLP is doing all the talking, he or she is in the wrong chair. It is not the role of the MI clinician to inform, educate, and advise the patient unless the patient asks for it first. Instead, the clinician using MI understands the patient’s perspective and their needs, without judgement, and acts as the guide throughout the change-making process.
Plan the Path
As soon as a clinician hears change talk from the patient, the MI clinician uses a technique known as OARS (open question, affirmation, reflection, summary).
- Ask an open question to learn more about it. The SLP could say, “How did you fit the exercises into your schedule?” Curiosity about how the patient took a step forward will likely lead to elaboration and more change talk.
- Affirm the patient’s step towards change by saying, “I see your swallowing is very important to you,” or “Once you set a goal for yourself, you act on it.” Specific affirmations are more impactful than general affirmations like, “Good job!”
- Reflect the patient’s change talk to strengthen and hopefully lead to more change talk by saying, “Even though you are busy, you made time for your swallowing exercises.”
- Summarize what the patient has said during this session, highlighting the change talk in particular and end it with a question probing the patient to think about and verbalize his or her next step as specific as possible.
Now that the patient has identified her priorities and confirmed them with her stated motives, how does the clinician know when the patient is ready to act and how exactly does the patient start down that path? Assessing readiness is the crucial step before creating an action plan. “When people’s motivation reaches a threshold of readiness, the balance tips and they begin thinking and talking more about when and how to change and less about whether or why” (Miller and Rollnick, 2013). Hints of readiness or lack thereof can be heard in the patient’s words.
- Patients whose priorities are elsewhere may say, “I’m sorry, I’d like to do the exercises, but I’m really busy” or “I’ll try to get to it this week.” These statements are called sustain talk, and they indicate that the patient has a low level of readiness or the goals selected are not truly high on her priority list.
- On the other hand, patients who are ready to move forward with their goals may say, “I thought about how I can fit my exercises into my daily schedule” or “I did my exercises last night.” These statements demonstrate steps toward change. Miller and Rollnick refer to these statements as change talk.
Key Message from MI
It is human nature to grapple with change. When a patient seeks the services of a SLP, he or she (or the caregiver) hopes that therapy will produce positive changes, such as improved swallowing function and quality of life. However, not every patient comes to therapy prepared and motivated to do the required work. Yet, take a moment to think about what SLPs ask patients to do on a daily basis. They often prescribe multiple exercises, multiple times a day. Frequently, these patients have a lot on their plate already; they often have to do PT and OT exercise programs as they recover from a major medical illness and cope with the financial and emotional stress of life after a CVA, TBI, or head and neck cancer, for example. It is understandable if patients come to the therapy room overwhelmed about what they have to do in order to reach their goals. Ultimately, MI is not about telling the patient what he or she needs to do to get better. MI is about empowering the patient to make changes based on what is truly important to them. Now that is patient-centered therapy!
Reading about MI will help clinicians reflect on their counseling approaches, but to effectively use MI with patients, clinicians need training and feedback from MI experts. After 200 randomized controlled studies and 1200 publications on MI, Miller and Rollnick state that the research has made 3 things clear to them about the efficacy of MI: empathy matters, the clinician’s use of the language of MI matters, and proficiency in MI leads to increased change talk. For more information about MI training, visit the MI network of trainer (MINT) website at https://motivationalinterviewing.org. Also, seek out discussions with MI-trained psychologists in your area. Having a MI-trained expert offer you feedback on how you talk with patients will change your clinical practices forevermore. I should know; it was a game changer for me.
Special thanks to Sean McGowan, Psy.D., my MI role model and mentor, who opened up my SLP world to a more collaborative, empathetic counseling style. Thanks to him, I am trying to keep my righting reflex in check, personally and professionally. Dr. McGowan, I appreciate your input on this article.
If you would like to learn more about how to incorporate specific Motivational Interviewing approaches into your dysphagia therapy to improve patient participation and treatment outcomes, consider taking Megan’s “Applying Motivational Interviewing in Dysphagia Therapy” live webinar this September! For more information about the webinar, CLICK HERE!
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1(1), 91–111. doi: 10.1146/annurev.clinpsy.1.102803.143833
Krekeler, B. N., Broadfoot, C. K., Johnson, S., Connor, N. P., & Rogus-Pulia, N. (2017). Patient Adherence to Dysphagia Recommendations: A Systematic Review. Dysphagia, 33(2), 173–184. doi: 10.1007/s00455-017-9852-9
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: helping people change. New York: Guilford Press.