Motivational Interviewing in the Classroom

What is motivational interviewing (MI)? It was originally developed back in the 1980s as a method to treat addiction. A counselor named Bill Miller discovered that patients’ openness to behavior change depended on how they were spoken to by a counselor. Counselors using a less confrontational approach were less likely to elicit counterarguments and defensiveness from their patients. This was largely because the patient, and not the counselor, was providing the reasons for change. The counselor also played the role of “guide” in this approach by using their expertise to give the patient options, but allowed the patient to ultimately decide the next course of action. This approach has been adapted to many different situations where the goal has been to help someone modify their behavior. For example, it has been used successfully to help people with medication adherence, smoking cessation and weight loss.

How could this help in the classroom? The approach could be considered for students who routinely miss class or are resistant to participating in activities. It has mostly been used in one-on-one situations, but it has also been used in some group situations in limited circumstances, even in higher education settings. Motivational interviewing requires some skill and practice, but there are many tools out there to help educators learn the techniques.

Whether those using MI encounter defensiveness and counterarguments in part depends on the relationship between the person using MI and the person receiving the information. This is the “spirit” of MI. To build this relationship, there are a variety of verbal techniques which are utilized. For example, one technique is called READS. The MI practitioner rolls with resistance (R), expresses empathy (E), avoids argumentation (A), develops discrepancy (D), and supports self-efficacy (S). Other verbal strategies including using open-ended questions to better understand the person’s perspective, listening and reflecting back with the appropriate level of emotion, affirming behaviors or ideas which are positive, and encouraging dialog about positive reasons for change.

Here’s an example of a student-based case scenario using this technique.  The details of the scenario have been fabricated but the case overall was inspired by real events.

Administrator: I was asked to speak to group 25 because one of our faculty members notified me that the team did not participate in the activity assigned to the class on Thursday. What was happening that day?

The administrator approached the issue by describing the facts. Facts vs. opinions are very important with this process, as opinions can easily be disregarded as “opinion.”  The administrator then asked an open-ended question, which can be helpful in getting to the reason for the perceived lack of motivation.

Students: We started the activity, but then it became confusing, so we gave up.

Administrator: So you had trouble completing the activity. That sounds frustrating. Anything else happen?

Instead of jumping in with advice or criticism of the students for giving up, the administrator empathizes with the students. This helps build trust with the students so they can feel open to being honest about their experiences. This comment is more than just empathetic, it is reflective, so the students know that their response was heard by the administrator.

Students: Well, to be honest, a classmate texted a funny video, so we were also watching that and discussing it.

Administrator: There are so many funny videos out there. It’s nice to get a break with something light-hearted from time to time. Everyone made the decision to come to class today, presumably to learn and to be prepared for the next assessment, but the video interfered with that by distracting you from your work. Can I offer some advice about that?

Students: Sure.

The administrator again empathized. They then identified a fact-based discrepancy. There’s a small assumption being made about the reason for coming to class, but it’s unlikely the students would disagree with this. The administrator also asked for permission to offer advice. By asking permission to share information, the administrator is respecting the students’ autonomy. This reminds the students that they are in a position to decide, which helps the students see the administrator as a partner or ally in this situation. Could the students have said “no”? Absolutely, and in that case, the administrator would need to decide the risk of not sharing the information.

Administrator: We all have to deal with distractions while we are trying to do our work, and there’s no way to avoid them.

The administrator has used language like “we” and “us” intentionally. They are telling the students that they too have experienced the problem. They are not singling out the students, which further shows their nonjudgmental approach.

Administrator: When I really need to focus on my work or I need to do something which requires a lot of listening and concentration, I close my laptop and put my phone away, so I’m not tempted to check it and so I don’t hear it when it gives me an alert. What are your thoughts about this approach?

The information shared is like a key and how the students make sense of the information is a lock. There must be a match for the information to be sufficiently persuasive. This is why the information shared was only about how to minimize distractions.

Notice that the administrator didn’t use the word “should” and instead kept the information neutral. By asking the students what they think about the approach, the administrator lets the students know they are interested in their opinion while learning about the impact of the information shared. In many cases, that’s the only way to know if they agree with the solution. The administrator should be prepared for resistance, but hopefully the student will share the reasoning (ex. need to be notified by a caregiver at home), because the question was asked in an open-ended way.

Students: We could try that. We do tend to lose focus when someone gets distracted with a notification, and that can cause us to not finish the activity.

Administrator: Ok, great, it sounds like losing focus can be a serious problem. What about the activity being confusing? How did you approach that?

The administrator is affirming their reason for change, which is that they don’t perform well with distractions.

Students: The faculty member was wandering between breakout rooms but never made it to our room; we therefore couldn’t easily ask for help. We also didn’t feel like tracking the faculty member down because the activity didn’t seem important.

Administrator: So there was a problem with a lack of faculty availability. Out of curiosity, why did the group feel the activity wasn’t important?

It might have been very tempting here for the administrator to come to the defense of the faculty member here about their perceived lack of availability or the perceived lack of importance of the activity. The administrator was probably concerned, but by using the word “curious” they kept things neutral to help the students continue to share information.

Students: We were told to do the activity as a group but we weren’t clear how the activity pertained to the assessment. It just seemed much more complicated than something we would be expected to do, and we figured we could wait on the answers and use those to study from if the activity was important for the assessment.

Administrator: That makes sense. I can see how it would be less motivating to work on an activity or ask for help if you aren’t sure how it will be beneficial. How do you think the group could approach this concern if it comes up again?

The administrator again reflected what the students shared without agreeing with their reasoning. An important thing happened next, which was that the administrator created an opportunity for the students to find their own solution.

Students: We could take a more active approach to finding out the purpose of the activity by asking the professor to explain the purpose to us.

Administrator: It sounds like you’ve got yourselves a solution to try. Are you willing to put this into action the next time there’s an activity which doesn’t seem to have a clear purpose?

The administrator has affirmed that the students have created a plan. Phrasing it this way reminds the students that they own their decisions and actions. This can help make behavior change more motivating. The administrator is also asking for a commitment to try the new solution.

Students: We are willing to try that.

Administrator: So, if I understand you correctly, the issue seems to be a combination of distractions and confusion regarding the value of the class activities. To address these two problems, the group will try to minimize distractions from phones, etc. during class activities, and the group will also reach out to the faculty member about the purpose of the in-class activity if it is unclear. Is there anything I left out or misunderstood?

Students: No, we are good for now. Thanks for your help!

Now that you see how MI is used, it is also important to be aware of what can make it difficult to implement.

  • In order for MI to work, the practitioner has to genuinely care for the person or people with which the technique is being used, vs. trying to fix or control their behavior. This can be especially challenging when encountering anger, resistance and defensiveness.
  • You can’t be empathetic or helpful if you objectify the person or people. It may not seem obvious how we can turn a person into an object, but one clue might be the language we use in conversation (ex. “those unmotivated students”). The risk increases in situations of high stress.
  • We are taught in our training that we are the experts and that we are expected to convey information in a one-way fashion. To make sense of individual concerns and needs and to potentially influence behavior, we have to be willing to listen.
  • We feel responsible for our students’ and patients’ outcomes. This can create pressure to persuade or direct someone who isn’t ready. We never had this level of control to begin with and the outcomes should not be tied to our professional identities.

Even when situations don’t work out perfectly, MI can help individuals at least feel like they did the right thing, and that is still valuable. If the result is improved rapport with the patients or students and increased change talk from them, positive behavior change may still be possible down the road.

Resources

www.stephenrollnick.com – a co-founder of Motivational Interviewing. He’s written several books for a variety of audiences

https://motivationalinterviewing.org – an organization which maintains a database of local trainers and a calendar of MI training events.

Berger BA, Villaume WA. Motivational interviewing for health care professionals: A sensible approach. Washington, DC: American Pharmacists Association; 2013. https://pharmacylibrary-com.roseman.idm.oclc.org/doi/full/10.21019/9781582121802.fm    Accessed October 23, 2019. – Dr. Berger is a retired faculty member from Auburn University who consults and speaks nationally to healthcare and academic audiences on motivational interviewing.

Sheldon, LA. Using motivational interviewing to help your students. Thought & Action: The NEA Higher Education Journal. 2010. 153-158. http://www.nea.org/assets/img/PubThoughtAndAction/Sheldon.pdf    Accessed October 23, 2019.

Author
Katherine Smith, PharmD, FCCP, BCPS
Associate Professor of Pharmacy Practice
Roseman University of Health Sciences, College of Pharmacy

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