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Dan I Lubman Background One of the biggest challenges that primary care practitioners face is helping people change longstanding behaviours that pose significant health risks.

Discussion Research into health related behaviour change highlights the importance of motivation, ambivalence and resistance.

Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in others areas of health including smoking cessation, reducing sexual risk behaviours, improving adherence to treatment and medication and diabetes management. One of the motivational option challenges that primary care practitioners face is helping people change longstanding behaviours that pose significant health risks.

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When patients receive compelling advice to adopt a healthier lifestyle by cutting back or ceasing harmful behaviours eg. Importantly, an authoritative or paternalistic therapeutic style may in fact deter change by increasing resistance. Their transtheoretical model of behaviour change the 'Stages of Change' describes readiness to change as a dynamic process, in which the pros and cons of changing generates ambivalence.

Ambivalence is a conflicted state where opposing attitudes or feelings coexist in an individual; they are stuck between simultaneously wanting to change and not wanting to change.

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Ambivalence motivational option particularly evident motivational option situations where there is conflict between an immediate reward and longer term adverse consequences eg. For example, the patient who presents with serious health problems as a result of heavy drinking, who shows genuine concern about the impact of alcohol on his health, and in spite of advice from his practitioner to cut back his drinking, continues to drink at harmful levels, embodies this phenomenon.

The Prochaska and DiClemente Stages of Change model2 offers a conceptual framework for understanding the incremental processes that people pass through as they change a particular behaviour.

Goal setting

This change process is modelled in five parts as a motivational option from an initial precontemplative stage, where the individual motivational option not considering change; to a contemplative stage, where the individual is actively ambivalent about change; to preparation, where the individual begins to plan and commit to change.

Successful progression motivational option these stages leads to action, where the necessary steps to achieve change are undertaken.

If successful, action leads to the final stage, maintenance, where the person works to maintain and sustain long term change. Motivational interviewing MI is an effective counselling method that enhances motivation through the resolution of ambivalence.

Motivation and Goal Setting

It grew out of the Prochaska and DiClemente model described above2 and Miller and Rollnick's1 work in the field of addiction medicine, which drew on the phrase 'ready, binary options strategies iq option and able' to outline three critical components of motivation.

These were:1 the importance of change for the patient willingness the confidence to change ability whether change is an immediate priority readiness.

Research has implicated two factors in potentially mediating these contradictory effects: the personal control conferred by a choice and the costs associated with a choice.

Using MI techniques, the practitioner can tailor motivational strategies to the individual's stage of change according to the Prochaska and DiClemente model Table 1. The spirit of motivational interviewing Motivational interviewing is underpinned by a series of principles that emphasise a collaborative therapeutic relationship in which the autonomy of the patient is respected and the patient's intrinsic resources for change are elicited by the therapist.

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Within MI, the therapist is viewed as a facilitator rather than expert, motivational option adopts a nonconfrontational approach to guide the patient toward change.

The overall spirit of MI has been described as collaborative, evocative and honouring of patient autonomy.

Although paradoxical, the MI approach is effective at engaging apparently 'unmotivated' individuals and when considered in the context of standard practice can be a powerful engagement strategy Case study, Table 2. Case study — using the spirit of motivational interviewing A male patient, 52 years of age, who drinks heavily and has expressed the desire to reduce drinking, but continues to drink heavily.

It is easy to conclude that this patient lacks motivation, his judgment is impaired or he simply does not understand the effects of alcohol on his health. These conclusions motivational option naturally lead the practitioner to adopt a paternalistic therapeutic style and warn the patient of the risks to his health.

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In subsequent consultations, when these strategies don't work, it is easy to give up hope that he will change his drinking, characterise him as 'unmotivated' and drop the subject altogether. In MI, the opposite approach is taken, where the patient's motivation is targeted by the practitioner.

Control and Effort Costs Influence the Motivational Consequences of Choice

Using the spirit of MI, the practitioner avoids an authoritarian stance, and respects the autonomy of the patient by accepting he has the responsibility to change his drinking — or not. Motivational interviewing emphasises eliciting reasons for change from the patient, rather than advising them of the reasons why they should change their drinking.

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What concerns does he have about the effects of his drinking? What future goals or personal values are impacted by his drinking? The apparent 'lack of motivation' evident in the patient would be constructed as 'unresolved ambivalence' within an MI framework.

Motivational interviewing techniques

The practitioner would therefore work on understanding this ambivalence, by exploring the pros and cons of continuing to drink alcohol. They would then work on resolving this ambivalence, by connecting the things the patient cares about with motivation for change. For example, drinking may impact the patient's values about being a loving partner and father or being healthy and strong. A discussion of how continuing to drink maintaining the status quo will impact his future goals to travel in retirement or have a good relationship with his children may be the focus.

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The practitioner would emphasise that the decision to change is 'up to him', however they would work with the patient to increase his confidence that he can change self efficacy.