This article is more than 5 years old. Information may no longer be current.

Motivational interviewing guides informed contraceptive choice

Motivational interviewing is a valuable counseling style designed to help patients gain the impetus to make positive health behavior changes. The approach uses open-ended questions, discussion of the patient’s long-term goals and information about different available options to guide decision-making. By elucidating their objectives and understanding what behaviors would promote or hinder those goals, the patient is in a better position to find motivation and make a decision.

Contraception decisions are very personal, and some women might not be comfortable discussing them. Given the many stigmas around reproductive choices, women may sometimes even have difficulty recognizing and articulating their own wishes. For this and many other reasons, motivational interviewing can be very useful in guiding women toward an informed decision.

“It’s used for all contraceptives, and it’s used for all patients, because all patients have a right to make the decision about which contraceptive method they want, unless there is a medical contraindication,” Melanie A. Gold, DO, professor of pediatrics at Columbia University Medical Center and professor of population and family health at the Mailman School of Public Health, told Healio Internal Medicine. “Barring that, it’s actually very consistent with motivational interviewing to offer women what they are most interested in and support them in that choice, whatever it may be.”

Gold discussed the process of motivational interviewing, the types of questions that are used and the various populations who can benefit from this counseling. – by Jennifer Byrne

Question: How do you approach motivational interviewing when trying to help patients make contraceptive decisions?

Answer: We always talk about what the patient’s goals are — I don’t just mean her contraception goals, I mean her life goals, her education goals, her career goals and her relationship goals. What she wants to achieve in her life, and how a pregnancy fits in with that and the timing of that. Then we talk about how STD protection and prevention fits in as well, because most of the methods don’t prevent STDs, although some provide some decrease in risk for pelvic inflammatory disease. We talk about how STD protection is separate from pregnancy prevention, although it’s wonderful to use them together. Staying with a monogamous single partner, where you’ve both been tested and are confident with that monogamy, may make STD protection a lower priority. But if you’re in a new relationship, or switching relationships, maybe it has a regular role.

I think some of it is about understanding, for each woman, what is unique to her circumstances, and to help her by offering, with her permission, information and advice. You do this using one of the micro-skill of motivational interviewing called open-ended questions.

Q: What are the other micro-skills, besides the open-ended questions?

A: We use reflections that are either simple or complex, called reflective listening. A simple reflection is a statement that paraphrases or repeats back what the other person just said. A complex reflection is a statement that includes the meaning or emotion behind what the other person meant or felt but was not actually said but is a reasonable guess as to what they might mean or feel. We use also use affirmation which are statements of appreciation for the other person’s actions, behaviors, attempts at change, strengths or positive traits.  I commonly affirm efforts that a young woman makes made to plan her life, to plan her pregnancies, to protect herself against unwanted pregnancies or unintended pregnancies. Then I use autonomy statements, which are statements that tell the other person that she is the one in the control seat, to support her sense of control over what she wants, and what she values, and then I would use summaries to summarize what I’ve heard her say.

What you’re looking for when you’re using motivational interviewing are discrepancies between what she says she wants to accomplish and whether what she’s currently doing is likely to get her there. You look at what she values, and figure out whether what she’s doing is consistent with her values or not.
Lack of consistency, that discrepancy, is the active ingredient of motivational interviewing. That’s what makes it an effective intervention, because people don’t like to be internally inconsistent. If I just told you I wanted to be a doctor and finish high school, college, medical school and residency, and a pregnancy doesn’t fit that plan, or if a pregnancy isn’t consistent with my values, it’s unlikely I’m going to change my goals and values. I’m probably going to change my behavior.

They need to be her goals, not mine. That’s why I don’t tell people which method to use. I ask for permission to make suggestions, and before I give a suggestion, I tell the patient that it’s my job to offer information or suggestions, and their job is to think about it and decide what they think of those ideas.

Q: You work with teenagers at school-based health centers at New York Presbyterian. What kinds of questions would be specifically targeted to teenagers?

A: Well, I frequently ask them, after they’re done telling me what they want to achieve in life in terms of education and career, or life goals, “So where does having a baby fit in with this, and at what age, if ever, are you thinking you would want to get pregnant?” If that age is not the age they are now, which it usually isn’t, I say, “Well, why did you say 28, instead of now when you’re 16? What makes 28 the right time?” Then they start talking about all the reasons why they want to wait.

Q: Do you initiate conversations about contraception to teens, or do you wait for them to bring it up?

A: We ask every patient, no matter what they’re coming in for, about their gender identity, their sexual orientation, their preferred name and gender pronoun, who they’re attracted to, if they ever been sexually active, and what their experience is with contraception. What are their needs related to contraception? We have all of the contraceptive methods on site.

Q: How well does the motivational interviewing work for contraceptive choice? Are there data on outcomes, such as pregnancy prevention or reduction of STDs?

A: There is literature on that. In one of our studies we did when I was at University of Pittsburgh School of Medicine, we used computer-assisted motivational interviewing to help young women initiate and maintain contraception use, and we actually included everyone who wanted to be in the study, including girls who were not sexually active, thinking that it might become an issue for them later. Unfortunately, in doing that, we lost some of our statistical power to see change, because we looked at every contraceptive method.

What we found was that for condom use, the girls who got the computer-assisted motivational interviewing had higher condom use than those who got just information and advice about birth control, STD prevention and abstinence.

There have been some other studies that colleagues of mine have done, like Beth Barnet, MD, of the University of Maryland School of Medicine, who did a study using motivational interviewing to prevent repeat pregnancy in teen moms.

Then there is another researcher named Jennifer Clarke, MD, MPH, at Brown University, who worked with me and who actually took my intervention and adapted it for women in jail.

Lynda A.R. Stein, PhD, at the University of Rhode Island  has been using an adaptation of the computer-assisted motivational intervention, or the CAMI, with teenaged girls in detention.

Q: What is the difference between motivational interviewing and computer-assisted motivational interviewing?

A: When you do regular motivational interviewing, you don’t necessarily have any feedback to give to the person. With computer-assisted, we had girls come in — this was before we had apps — and they would enter their information about their sexual history, and their contraceptive history, and their behaviors into the computer, and then the computer would calculate their risk for pregnancy and STDs. It would give us a printout with their history, everything they had said. So rather than having the interviewer, coach or counselor having to ask them their history, it was all right there. It assisted in the sense that I didn’t have to waste any time asking them their age, when they first had sex, how many sexual partners, were they ever pregnant, etc. These are all closed-ended questions, and they put the patient or the young person in a very passive role, where they just answer what you ask. That’s not motivational interviewing - that’s data collection. I can let a computer do that, and the girls really liked it.

I should mention that we’ve gotten a bit more sophisticated these days, and so we’re working on a similar study with young men using this computer-assisted motivational interviewing, but we’re not using computers. We’re using an app, and the guys download the app onto their phone, enter the information, and all of the coaching is done on the cell phone. It’s not even done in person.

Q: How well has that worked?

A: We’ve just started. In the first year, we took the intervention we had developed for girls, adapted it for young men, then solicited feedback from a group of young men. At the same time, we were developing and building the app to collect all the behavioral data, as well as a neat value card game that allows them to choose the values that are most important to them. There’s a whole section on their career goals, their educational goals, their relationship goals, and their parenting goals. Everything is on the app. The information is fed back to the coaches. We will be collecting data through the end of September with, hopefully, between 200 and 300 young men in a pilot study. The control group is getting a motivational interviewing intervention aimed at fitness, and then the other group is getting a motivational interviewing intervention aimed at preventing teen pregnancies.

Q: What are some important things for primary care providers to keep in mind when using motivational interviewing?

A: I would say that motivational interviewing is a learned skill. You have to be collaborative; you have to respect the autonomy of the person you’re working with. People might look at adolescents and think “Oh, they’re just kids,” but they are amazingly resourceful and smart. They’re just sometimes misinformed.

I think when you’re respectful of them and when you collaborate and partner with them and support their autonomy, and use motivational interviewing skills to really elicit or evoke from them their goals and values, what they want to achieve, I think you will discover that they’re much more willing to embrace behavior change. Then you can work on small steps toward continual, ongoing change, which is a much more realistic approach than expecting to change someone’s behavior in 10 minutes.

I’ve found that since I learned to do motivational interviewing, I enjoy, appreciate and respect my patients so much more. My interactions with them are so much more gratifying from having learned how to do this, because I don’t feel like I have to wrestle them onto the floor and make them see my way of understanding something and make them change. It’s also changed that sense of responsibility I once felt to make patients change. It’s improved the quality of my experience being someone’s healthcare provider, and that’s important.

For more information:

Melanie Gold, DO can be reached at Center for Community Health and Education, 60 Haven Avenue, Level B-3 Room 308, New York, NY 10032; email: mag2295@cumc.columbia.edu

Disclosure: Gold reports the following financial disclosures: Consultant for Bayer, Lecturer for Genocea, Clinical Advisory Board member for Afaxys, Inc.