by Llaen Coston-Clark

According to the founders of motivational interviewing, a communication style “refers to an attitude and approach to helping patients, a way of talking with them that characterizes your relationship with them.”  They identify three communication styles which can be imagined as points on a continuum: Following at one end, Directing at the other end, and Guiding in the middle.  During a BNI (brief negotiated interview) with a patient, different communication styles might be used during different parts of the intervention.

Following is used when we allow the patient to lead the conversation; we follow the story and work at understanding it.

• This would be Step 1 of the BNI: Build Rapport, where we ask the patient to describe a day in their life and how the health behavior we are discussing fits in to it.  By sitting back and listening, we get a lot of useful information about the patient (such as family, housing, employment, access/resource barriers, other/related health concerns) in a short amount of time.

Directing is used when we lead the conversation by telling or prescribing something (information, instructions) to the patient.

• This would be Step 3 of the BNI: Information/Feedback, where we get permission from the patient to share facts, knowledge, guidelines about the health issue.  Here we might be sharing information that is critical to the patient’s well-being (such as long and short term health effects, medication warnings, recommendations for preventing disease).

Guiding is used when we are exploring the health behavior alongside the patient and we are there to support, encourage, and assist.  We are not just passively listening, nor are we taking control of the conversation. As a good guide, we know “what is possible and can offer alternatives” from which the patient can choose.

• In Step 2 of the BNI, Pros and Cons, we explore with the patient what they like and like less about a behavior (ex: drinking alcohol).
• In Step 4, Readiness Ruler, we ask the patient about their readiness to make any changes to the behavior (ex: reduce drinking).
• In Step 5, Action Plan, we elicit steps they would like to take to be safer or healthier.

We are providing some guidance during these steps; we are not Following so much that we lose the focus and goal of the intervention, nor are we Directing so much that we impose our ideas and suggestions onto the patient.

Ultimately, the guiding style communicates, “I can help you to solve this for yourself,” and this is the predominant style of the brief negotiated interview.

Source: Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York, NY: The Guildford Press.