Motivational Interviewing

Motivational interviewing is a method for helping someone resolve ambivalence in the direction of their own goals. It matters in genetic counseling because so much of the work involves a patient who knows what is recommended and has not done it: the surveillance colonoscopy not scheduled, the relatives not told, the risk-reducing decision deferred indefinitely. Arguing for the recommended action reliably produces resistance, and motivational interviewing is the structured alternative.

• Ambivalence is normal, not obstruction. A patient who both wants and does not want a test is in the ordinary human state before a hard decision. Treating it as a deficit to be corrected creates the resistance the counselor then has to manage.
• The righting reflex is the counselor's urge to fix by arguing. When the counselor voices the arguments for change, the patient predictably voices the arguments against, and having said them aloud becomes more committed to them. Resisting this reflex is the central discipline.
• OARS are the core skills: Open questions, Affirmations, Reflective listening, and Summaries. Reflection does the heavy lifting, and complex reflections that name the feeling underneath the statement move a conversation further than simple restatement.
• Change talk is the patient's own language about wanting, needing, or being able to change. The method aims to evoke and reinforce it, on the principle that people are persuaded by what they hear themselves say. Sustain talk is the language for staying put, and it is met with reflection rather than argument.
• The spirit matters more than the techniques: partnership, acceptance, compassion, and evocation. Techniques deployed to steer a patient toward a predetermined answer are not motivational interviewing, they are persuasion wearing its clothes.
• Rolling with resistance. When a patient pushes back, the move is to reflect and shift rather than press. Resistance is treated as a signal about the interaction rather than a trait of the patient.
• Elicit, provide, elicit is how information is given within the method: ask what the patient already knows and wants to know, provide the information, then ask what they make of it. This keeps information-giving from becoming a lecture.
• Fit with nondirectiveness. Motivational interviewing is directional toward a health behavior, which sits uneasily with a strictly nondirective stance. The usual resolution is that it fits well where a clear health recommendation exists, such as surveillance for a known pathogenic variant, and fits poorly where the profession takes no position, such as reproductive decisions. Recognizing which situation you are in is the judgment.
• Importance and confidence are separate. A patient may believe an action matters greatly but doubt they can do it. Scaling questions on each surface which one is actually blocking.

• A woman with Lynch syndrome has deferred colonoscopy for two years. Rather than restating the guidelines, the counselor asks what has made it hard, reflects the fear underneath the practical reasons, asks what she already knows about surveillance, and then asks what would need to be different. She names a scheduling barrier and a fear of sedation, neither of which more guideline information would have addressed.
• A man carrying a pathogenic variant has not told his brother. The counselor asks what stops him, reflects the guilt without reassuring it away, and asks what he imagines the conversation being like. The plan that emerges is his rather than the counselor's, and it happens.
• A patient says, "I know I should do the screening, I just do not want to." The counselor reflects both halves of the ambivalence rather than answering the second, and the patient continues into the reasons, which is change talk that would not have appeared if the counselor had argued.
• A couple is deciding about prenatal diagnostic testing. Here the counselor deliberately does not use motivational interviewing to move them toward a choice, because there is no recommended direction. The skills of reflection and summary still apply; the directionality does not.

• Do not use the techniques to win an argument. Without the underlying spirit it becomes manipulation, and patients notice.
• Do not answer sustain talk with counterargument. Reflecting it moves the conversation; arguing entrenches it.
• Do not apply directional methods to value-laden reproductive decisions where the profession does not endorse an outcome.
• Do not confuse importance with confidence. A patient who fully accepts the recommendation may still be blocked by believing they cannot do it.
• Do not give information without asking first. Elicit, provide, elicit exists because unrequested explanation is what triggers the resistance in the first place.