Elder Care Interprofessional Provider Sheets

Motivational Interviewing with Older Adults

Denise A. Beagley, M.Sc, Center for Applied Behavioral Health Policy, College of Public Service & Community Solutions, 
Robin P. Bonifas, Ph.D., MSW, LICSW, School of Social Work, Arizona State University

October 2016

TIPS FOR USING MOTIVATIONAL INTERVIEWING (MI) WITH OLDER ADULTS
  • MI can be particularly useful in older adults because they often have multiple medical problems and treatment regimens that can be difficult to cope with. Consider using MI when a patient is having difficulty making the necessary changes or is ambivalent about the changes needed to deal with those medical problems and treatments.
  • When using MI, use the approaches outlined in the PACE and OARS mnemonics (Table 1 and Table 2).
  • Be flexible and work with the patient in ways that meet the patient's specific needs.

Motivational interviewing (MI) is an approach to counseling that aims to strengthen a person's motivation and commitment to behavior change by helping them resolve their ambivalence about the change. MI fosters a partnership between clinicians and patients, allowing the clinician to demonstrate empathy, build rapport with the patient, learn about the patient's world, and help the patient achieve change.

MI was developed in the early 1980s by psychologist William Miller. Miller's experience working with individuals with alcohol problems convinced him that motivation to change was a frequent obstacle to reducing problem drinking. Miller described a way of talking with people to evoke and strengthen their motivation. Since then, the principles of MI have matured, and it has become an evidence-based practice used world-wide as an approach to resolving an individual's ambivalence about changing behavior.

MI Communication Style

There are three commonly used communication styles in behavioral counseling. "Following" is used when the patient is allowed to lead the conversation, and the clinician follows the patient's story and strives to understand it. "Directing" is used when the clinician leads the conversation by providing patients with instructions or directing them to do something. "Guiding" is used when the patient and clinician work together and the clinician provides support, encouragement, and assistance. When guiding, clinicians are not just passively listening, nor are they taking control of the conversation. Rather, clinicians guide the patient by discussing what is possible and helping patients develop alternatives from which the patient can choose. The clinician then provides support and encouragement to assist patients in acting on their choices.

Each of these communication styles is used in everyday life, as well as in health care practice. Each style has a context in which it works best. It is useful to think of these three styles as forming a continuum, with following at one end, directing at the other, and guiding in the middle. Guiding is best suited to help people solve behavior-change problems, and it is the key communication style used in MI.

The principles of guiding in MI are exemplified by the PACE mnemonic - Partnership - Acceptance - Compassion - Evocation. These principles, often called the "MI spirit," are outlined in Table 1.

Table 1.  The MI Spirit: PACE
Partnership
  • Work with the patient as equals
  • Stay outside of the "expert" role
  • Avoid giving advice
  • Treat patients as the experts on their behavior
Acceptance
  • Accept the patient without judgment (though without condoning behavior you do not approve)
  • Avoid confrontation
Compassion
  • Be empathetic (demonstrate compassion) rather than sympathetic (feeling compassion)
  • Advocate for the patient
Evocation
  • Evoke talk of change
  • Elicit the patient's reasons for changing
  • Do these things by expressing genuine curiosity

When interacting with patients to develop a partnership and implement the MI spirit, it is often useful to use the OARS approach: Open-ended questions, Affirmation of the patient's point of view, Reflecting on what the patient has said, and Summarizing (Table 2).

Table 2. OARS Approach to Motivational Interviewing
  • Open-ended questions: These are questions that cannot be answered with a simple yes or no.  For example: "Why do you think it might be a good time for a change?" Asking open-ended questions allows the patient to set the path for the discussion.
  • Affirmation: Affirm the patient's strengths and goals. For example,"You handled yourself really well in that situation." But also be honest and genuine, as being insincere can interfere with the clinician-patient relationship. For example,"I know you don't really want to be here, but it's good that you want to follow through on your obligations."
  • Reflective listening: Listen to, and reflect on, what the patient has said. If you are not sure what the patient means, ask for clarification. Patient says, "I have been smoking since I was 13, and now I am 73." Clinician says, "Being a smoker is a part of who you are for all these years, but you don't want it to be."
  • Summarize: This is an extension of reflective listening in which you summarize what the patient has said and ask for corrections if you have misunderstood. For example: "Here is what I have heard from you. You want to take your medication, but you don't like the side-effects, especially the weight gain and stomach pains. Tell me if I've missed anything."

Why Use MI With Older Adults?

Although there are few randomized-controlled trials of MI in older adults, most published studies indicate that MI is effective for influencing change in health behaviors including weight loss, medication management, and even increased walking to improve function in patients with peripheral vascular disease. MI is cost-efficient treatment and can be used in primary care and geriatric settings.

MI may be particularly useful for older patients because they often have multiple and interacting medical problems with treatment regimens that involve multiple medications, medication side-effects, and changes in activity - all of which can be difficult to cope with unless patients are motivated to make changes in their daily lives. 

Furthermore, older patients may be coping with other issues, such as grief over losses, physical illness, or disability. Again, this makes behavior change difficult.

How to Use MI with Older Adults

Clinicians working with older adults may need to provide MI at a slower pace and use repetition, as well as other strategies, that aid in retention of information. However, because MI is inherently patient-centered, it should require minimal substantive adjustments for use with older adults. More work is needed to identify adaptations of MI that might be beneficial for older patients who have distinctive needs (e.g., dysthymia, mild cognitive impairment, speech difficulties, etc.) and in different settings (e.g., primary and specialty care, long-term care).

A particular challenge occurs if a patient is experiencing more significant cognitive impairment. In such patients, MI is less likely to work because of limitations in understanding, interpreting, and remembering what was discussed in counseling sessions. If MI is attempted with older adults with cognitive impairment, it is important to remember that when such individuals are spoken to in "elder speak" (a sing-song voice that might also be used to encourage children), they are more resistant to counseling than when they are spoken to with respect.

Using MI Successfully

The communication style described in this Elder Care is a tool that MI uses to facilitate behavior change. Change occurs by highlighting discrepancies between patients' core values and their current behavior, helping them understand the ambivalence about their current behavior, and facilitating a readiness to change. For optimal success, MI requires appropriate training and cannot be provided in a rigid or formulaic manner. Clinicians need to be flexible and sensitive to the specific needs and goals of the patients they are treating and constantly adjust MI to fit their needs and goals. With this requirement for flexibility, MI becomes a therapeutic style, rather than a restrictive, "manualized" psychotherapeutic treatment, and it lends itself to adaptation across different settings, disciplines, and populations. MI techniques are taught in universities and training programs, and can be used by a range of clinicians, including physicians, nurses, psychologists, pharmacists, and social workers.

References and Resources

  • Bugelli T, Crowther TR. Motivational interviewing and the older population in psychiatry. Psychiatric Bulletin. 2008;32:23-25.
  • Cunningham, MA, Swanson V, Holdsworth, RJ, O'Carroll RE. Late effects of a brief psychological intervention in patients with intermittent claudication in a randomized clinical trial. Br J Surg. 2013;100:756-760.
  • Rollnick, S, Miller W R, Butler CC. Motivational interviewing in health care. New York: Guilford Press, 2008.
  • Serdarevic M, Lemke SA. Motivational interviewing with the older adult. Int J Ment Health Promot. 2013;15:240-249.
  • Video: Using Motivational Interviewing-based Skills and Strategies with Older Adults at Risk for Falls.