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Keep your hands off that monkey! How Motivational Interviewing supports diabetes care

It’s a blustery day in Birmingham and Motivational Interviewing course facilitator Jan Procter-King makes a joke about her windswept appearance, “I apologise if my hair becomes a barrier to learning”.  A practice nurse with a long career, including; facilitating diabetes care across 100 GP practices in Bradford, heading up the Cardiac and Stroke Network in West Yorkshire and a national cardiovascular adviser for the Department for Health and Social Care, Jan and her fellow trainer and physiotherapist Cath Robertson are the NHS version of Wood and Walters.

This dynamic duo, working under the name Et Al Training, use humour to explain complex concepts. Jan is a familiar face on Channel 5’s GPs Behind Closed Doors; appearing in one episode dressed as a cholesterol plaque to explain to a patient how statins work. The jokes are funny but the topic is serious; staff and patient leaders from across the health and social care system are here to learn how to help people with diabetes to help themselves.

Secretary of State for Health and Social Care Matt Hancock’s recently unveiled ‘prevention vision’ is focused on empowering people to take responsibility for their own health in order to make the NHS sustainable in the long term. With treatment and complications of diabetes alone constituting 10 per cent of the NHS budget, and a prediction the disease will contribute to 39,000 heart attacks, 50,000 strokes and a variety of cancers by 2035, NHS England is doubling the size of its diabetes prevention programme. In diabetes, self-care is essential and Motivational Interviewing can be a very useful tool in encouraging behaviour change.

A counselling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick, Motivational Interviewing aims to elicit behaviour change by helping people to explore and resolve ‘ambivalence’ (i.e., conflicting feelings about making changes). Jan and Cath’s approach tailors Motivational Interviewing to fit the health and social care system. They start the session by encouraging participants to explore their own psychology as well as the people they will be working with. Traditionally, the health profession has taken a paternalistic approach to behaviour change, reminding people of the harmful impact their unhealthy habits will have on themselves and on other people, i.e., ‘if you carry on smoking, you won’t be around to see your grandchildren grow up’. The theory is that if you feel bad enough about yourself you will change.

Jan offers an explanation of why people’s brains are hard wired to resist being dominated, or told what they SHOULD be doing, “when we give advice, even when well meaning, what you’re doing is, you’re saying, I know what’s best for you. We’re hard wired to reject advice. This NO response is subconscious and not within our control. It makes people blank out the message. The ‘fight or flight’ instinct kicks in and we have to think about how to defend ourselves from that advice”.

With health and social care professionals super keen to give that advice, after all that is what they are trained and committed to doing, a clash is inevitable. While patients and service users can appear to be compliant, often the message is being instantly disregarded. Some patients will start arguing and justifying their negative behaviour. Some simply won’t engage with services at all and miss all their appointments. It can be very frustrating for health professionals when they want the patient to be well but struggle to understand why the person with a health condition continues with harmful behaviour such as poor diet, inactive lifestyle and smoking.

Motivational Interviewing instead focusses on creating an exchange between equals, with the professional eliciting ‘change talk’, whereby the patient or service user talks themselves into making positive changes. As an example, Cath shares her own experience of struggling to resist eating a tempting pastry while on a diet and justifying the pros and cons of eating it. “It’s like having a committee in your head – which side do you listen to? Ambivalence is a step on the way to change”, explains Cath, “if you’re leading an unhealthy lifestyle that doesn’t fit in with your values, how you see yourself, how you interact with your family, etc., you’ll consider change. We all ricochet between making choices that are healthy and unhealthy.”

Professionals desperately want to help but this ‘righting reflex’ actually takes responsibility away from the person who needs to take control of their own medical condition. Jan and Cath use a powerful visual metaphor to explain this concept, as Jan exits and enters again covered in dozens of cuddly monkeys. The monkeys represent responsibility and taking on too many responsibilities literally weighs staff down, exacerbates ‘burn-out’ and drains them of their love of the job. “We’ve trained people to hand responsibility to clinicians. Let people think and talk themselves towards change”, says Cath, “some people have been trained all their lives to be passive. If you don’t lecture people, then they can’t assume the passive role.”

Each participant is given their own cuddly monkey and are then encouraged to keep their hands off other people’s, as people are teamed in pairs to practice eliciting ‘change talk’ from the other. “In Motivational Interviewing, you go slowly but you cover a lot of distance. It makes staff more effective and less burnt out.” says Jan, encouraging people to let their partner talk without interruption for just two minutes.

Participants work in pairs and are asked to listen without interrupting one another – most struggle with not jumping in to comment or question. They are encouraged to practice ‘active listening’, notice what matters to the person speaking and don’t judge them. “We want to help so much we ‘monkey grab’; it makes us feel good to take on the responsibility. Sometimes, the urge to show we care about people can be overpowering and unhelpful”, says Cath.

The issue of judging somebody while trying to encourage behaviour change is key. Jan enacts a negative conversation with a patient who is struggling with their care, “Now, let’s go through all your shameful behaviour”.

Jan dons a pair of pink love heart sunglasses to demonstrate the need for professionals to always view people using their ‘kind eyes’. “People come to us when they’re out of control and they don’t want to be judged. When you’re ashamed or feeling judged, you can’t think straight, so you lie about your behaviour; people do it all the time”.

Motivational Interviewing encourages professionals to offer information, not advice, and to use reflection, making statements back to the person based on what they’ve said and to see them as full of potential, not lost causes. Jan and Kath advocate establishing what people know about their condition and asking permission to give information.  Words to avoid include ‘must’ and ‘should’, and professionals might make statements such as “what is recommended…” or “people who keep their blood sugar between certain levels have better outcomes…” instead.

“I spend more time listening. People have usually got the facts”, Jan says, “note the language – you are obese. Judgement comes in. Change is uncomfortable; it is not an easy thing to do. People need support in the right way. We are privileged to be in a position with people as they share something they’re not proud of. We have hope for them. “Don’t think you have the solution – believe the patient has the solution as they’re an expert in them. Sit there with your ‘kind eyes’ and listen.”

Motivational Interviewing has added complexity when working with interpreters. Jan suggests asking the person translating to repeat exactly what is being said and not to negatively interpret the message, i.e., “She says you’re too fat”. “A smile works in any language; ‘kind eyes’ work in any language. If you care about the person in front of you, it oozes out of you.” says Jan.

Having ‘kind eyes’ also keeps professionals motivated when faced with ‘revolving door’ patients who repeatedly present with the same issues and don’t appear to make any progress. Jan and Kath whizz through a number of stereotypes the audience clearly recognise, from the ‘living leaflet’ barking out advice to the ‘sewage worker’ who thinks everything about the job is terrible and can’t wait for retirement. “We don’t have to be like that. Always be the ‘superhero’, that’s why you joined the profession”, says Jan.

Jan was prompted to start delivering the training as she was disappointed by the quality of education training available. “People relate to stories. Motivational Interviewing makes a difference to patients and professionals. It encourages people to think about their own behaviour and to empathise with patients”, she says.

It seems to be working; the trainers get a lot of positive feedback and repeated requests to deliver training. GP Kate King attended the training in Birmingham and was impressed with the course: “The huge demands of the job means it can be easy to lose empathy with patients. The good thing about these techniques is they reinforce your own motivation to help and encourage people”, she says. Fellow GP Jodie Blackadder agrees: “GPs need to be aware of their own vulnerability to burn out. Motivational Interviewing not only reignites your belief in people’s ability to change but also your curiosity about them and what’s going on in their lives”.

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