The Concept of
Motivational Practice

Evidence-based, primary care guidelines for addressing risk behaviors predominantly address surface change. Practitioners give information and advice to patients, with the goals of eliciting their good intentions and setting goals for change. The guidelines quantify the mean impact of behavioral interventions (absolute risk reduction and/or Number Needed to Treat) on specific populations: or more simply, what is the intervention benefit to the average person from a specific population.

Practitioners still face the challenge of working out whether the "proven" interventions from these guidelines are relevant to their individual patients. Regrettably, these interventions work in modifying their risk behaviors for only a minority of patients. These interventions predominantly address surface change: imparting information, giving advice, eliciting good intentions and setting goals. Most patients do not change their risk behaviors in response to these interventions.

Why do the guidelines fail for the vast majority of individuals? These guidelines underestimate the complexity of changing from unhealthy to healthy habits. Practitioners assume a health adviser role and deliver simplistic interventions that take only minutes. Such interventions are unlikely to change unhealthy habits that most patients have taken years to develop. Furthermore, patients spend most of their lives on autopilot: doing what they have to do, without going beyond surface change.

The challenging question is: what can work, in particular, for an individual patient when the "proven" interventions are ineffective? Do you keep hammering away with ineffective interventions as though patients were nails? Hammering away at patients may only make some patients more resistant that they avoid coming to see you. An alternative approach is needed. The development of motivational approaches to behavior change should promise in addressing the shortcomings of the current guidelines.

Most patients know (and even think) that they should change, but they do not feel like it. They not only lack motivation, but they also emotionally resist change. Emotional resistance to change is the hidden force in clinical encounters, and practitioners are often unaware of how its presence defeats their efforts to effect change.

Practitioners need go beyond surface change to deep change: helping patients explore their feelings, perceptions, motives and values.

This intra-personal process can help patients learn how to lower their emotional resistance and increase their motivation to change. In other words, what does it mean for individuals to work through their ambivalence about changing their risk behavior?

This paradigm shift from the outside-in (objective) to inside-out (subjective) approach moves beyond the limits of scientific evidence and guideline to personal evidence and practical wisdom that arises from reflecting on structured learning experiences. This shift transfers the "principal investigator" role for behavior change from the scientist to the individual patient. Practitioners assist individual patients in taking charge of generating their own personal evidence, based on their reflective learning experiences.

With this role transition, the practitioner assumes the "co-investigator" role and works as a motivational guide to the "principal investigator". Or alternatively, the patient is the driver's seat with the practitioner in the passenger seat using a map to guide their journey. Both of these analogies put patients in charge of working on behavior change: in other words, supporting patients in taking the one-up position.

Anytime that practitioners consistently put more effort into the change process than the patients is a signal that they need to change their relational process. For example, with the health adviser role, practitioners often fall in the trap of taking the one-up, fix-it role. The role is dysfunctional when using ineffective interventions over and over with patients: a frustrating experience.

Motivational practice involves practitioners engaging patients in ongoing opportunities that evoke reflective learning experiences about behavior change. Patients can use this introspective process to generate their own personal evidence about making deep change, and re-program their automatic behaviors to develop healthier habits.

This intra-personal process may use blended learning methods with any combination of the following activities (listed below). Health care settings can develop a comprehensive program by adopting an organizational culture based on the concept and principles of motivational practice. To extend beyond their setting, they develop outreach activities to community organizations who are willing to become trained in the Motivate Healthy Habits learning process.

• Reading the MHH, mutual aid and self-help guidebooks
• Working with, and getting support from family and friends
• Journaling experiences in using learning exercises
• Participating in online learning programs (individual and group)
• Using supportive groups to address contextual issues, such social deprivation, poverty, and complex psychosocial issues.
• Counseling with practitioners and/or lay health guides (in-person or telephonically)
• Working with community programs

These learning methods are an epiphenomenon to the inner, core experience of the individual who is willing to explore deep change. The primary focus of motivational practice is on helping individuals participate in meaningful, learning experiences that facilitate deep change. This sense-making process can activate patients to optimize their health habits and/or self-care of chronic diseases. The intra-personal process can involve patients in any combination of the following activities:

Understand the challenge of change

• Clarify their issues about change
• Assess their resistance based on what they think and how they feel
• Assess their motivation based on what they think and how they feel
• Explore perceptions about risks, benefits and harms
• Assess energy levels to change and competing priorities
• Examine their values and motives

Master the process of change

• Alter their perceptions about risks, benefits and harms
• Lower their emotional resistance
• Increase their motivation
• Change their values

Rise to the challenge to change

• Enhance confidence and ability to change
• Implement an action plan
• Prevent lapses and relapses

How Practitioners Interact with Patients

In the health advisor role, practitioners wait for "teaching moments" in clinical encounters to promote healthy behaviors. In effect, they impose their perceptions and values on patients. They may act in behavioral controlling ways that are antithetical to the motivational principle of being autonomy-supportive. To interact more effectively with patients, practitioners first need to unlearn this professional role in order to go beyond the rational and linear interventions described in the guidelines.

To develop motivational skills as a lifelong learning process, practitioners need to learn how to adopt the motivational role. In this role, they help patients decide for themselves if they want to change their perceptions and values about behavior change. Instead of conducting a question and answer, information-giving interview, they engage patients in dialogues about change that help them develop individualized interventions to meet their changing needs over time. They also engage patients in ongoing learning opportunities inside and outside of the clinical encounter. Practitioners can use the concept of motivational practice to benefit patients and their own professional development.

Motivational practice integrates the following theories, models and concepts (table 1) into a cohesive framework of six steps (table 2) that practitioners can use with patients to facilitate behavior change. Practitioners work best when they use theories, models, methods and concepts to meet patients' changing needs over time, rather than making patients fit a particular mould. This orientation represents a shift from the practitioner's loyalty and fidelity to a particular theory, model, method or concept to the changing needs of the individual patient over time.

Practitioners use motivational principles (Table 3) to engage patients in change dialogues during clinical encounters that can guide the patients' ongoing learning process. These dialogues can help patients develop individualized interventions for motivating behavior change and select additional learning methods. The concept of motivational practice can enhance the capabilities of practitioners to work in more patient-centered ways, using a variety of learning methods that accommodate their preferences.

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