Pearls

Motivational interviewing: The RULES, PACE, and OARS

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CASE

Mr. C, a veteran in his 60s who has posttraumatic stress disorder (PTSD), presents to your clinic for a 45-minute follow-up visit. He has a remote history of depression and a 20-year history of substance use disorder (SUD); he uses heroin, at least 3 bags a day by insufflation. You review his response to his currently prescribed PTSD treatment regimen, ask if he is experiencing any adverse effects, and perform a mental status exam and a review of systems. You offer Mr. C detoxification and rehabilitation treatment for his heroin use, but he refuses. With 15 minutes left in the appointment, you consider conducting motivational interviewing (MI) to help him reconsider getting treatment for his SUD.

Even when delivered as a brief, one-time intervention, MI can be effective in getting patients to change their behavior.1 First created in part by psychologists William Miller, PhD, and Stephen Rollnick, PhD,2 MI is based on the premise that a patient’s ambivalence to change is normal and that all patients vary in their readiness to change. MI can be brief, and can be more helpful than providing only proscriptive advice, which sometimes can be counterproductitive.3

To effectively implement MI during a brief visit, it is helpful to keep in mind 3 mnemonics: RULE, PACE, and OARS.

RULE

RULE can be used to remember the core principles of MI.4 First, Resist the righting reflex, which means we should resist giving suggestions to our patients for their problems. While we may mean well, offering suggestions might actually make the patient less likely to make a positive change. Understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the patient. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.4,5 Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the physician is a clinical expert, the patient is an expert in prior efforts at trying to change his or her circumstances for the better. Make the therapeutic environment as positive as possible so that your patient will find it comfortable to discuss change. The patient should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.5 While as physicians we must continue to educate our patients about the harms of behaviors such as excessive drinking or substance use, we recognize that ultimately the decision is the patient’s. Make every effort to draw from the patients’ goals and values, so that the patient, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that we are on the patient’s side and that his past choices in life do not negatively affect our perception of him. The patient should be accepted for who he is, and not met with disapproval over any personal decisions that he made.5 Exercise Compassion towards the patient’s struggles and experiences,5 and never be punitive. Make every attempt to have discussions that can be Evocative for the patient. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

OARS

OARS can be used to help remember core skills of MI.5 These include asking Open-ended questions to get the patient to think before responding, providing frequent Affirmations of the patient’s positive traits, using Reflective listening techniques while your patient talks about his disorder, and providing succinct Summaries of the experiences expressed by your patient throughout the encounter to invite continued exploration of his behaviors.

Getting patients to talk about change

Use RULE, PACE, and OARS to elicit “change talk,”4 so that your patient makes his own arguments for change. Here ambivalence is good, in that an ambivalent patient may be open to discuss reasons for making changes. It is important to remember not to use the righting reflex to give suggestions to change.

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