When I introduced the clinical method of motivational interviewing (MI) in 1983,1 I was thinking primarily about patients who drink too much. It turns out, however, that the motivational and adherence issues in problem drinking are quite similar to those of people facing the need to change other health behaviors. Indeed, these same dynamics of ambivalence are part of normal human experience: to want something, and simultaneously not want it. Ambivalence is a state where people get stuck, sometimes for a long time.
A first step, then, is to realize that it is perfectly (albeit maddeningly) normal for patients to be reticent to make lifestyle changes, even ones that could significantly prolong and improve the quality of life. One would think that having had a heart attack would be enough to persuade a smoker to quit, and sometimes it is, but often it is not. Habit is tough enough to break. Add to that the incentive of immediate brain reinforcement after every puff, and the motivational barriers to change can be robust.
In this context, it is surprising that MI works at all. How could relatively brief counseling possibly derail a behavioral habit that has persisted for a decade or two? Yet, that is precisely what has been found with problem drinkers in several randomized clinical trials.2 Furthermore, when a single session of MI was added at the beginning of substance abuse treatment, abstinence rates were doubled in 3 randomized trials.3-5 These findings indicate that (1) MI alone can enhance health behavior change,6 and (2) MI can also increase the efficacy of a treatment, most likely by increasing patient adherence.
Would MI also work with other health behaviors? As of our most recent meta-analysis,7 there were 72 clinical trials of MI, with the number of trials doubling every 3 years. On average, clinically meaningful effects (mean effect size of d > .40) were observed with alcohol and illicit drug use, treatment adherence, diet and exercise change, HIV-risk reduction, and other health-promoting behaviors. Most of the MI interventions tested in these trials consisted of relatively brief counseling.
It appears, therefore, that enhancing patient motivation is (or at least can be) an important part of medical practice. Rather than waiting for patients to acquire motivation or bemoaning its absence, there is something that healthcare professionals can do to enhance it.
Ironically, what seems to work well in motivating patients runs somewhat counter to many clinicians' natural inclinations. Wanting to help, we naturally want to step in and fix the problem, to set it right. Furthermore, this is precisely what many patients expect from their doctor: to ask important questions, formulate a diagnosis, and offer expert advice and intervention. This model usually works well in treating acute illnesses such as infections, breaks, and sprains. Many of the challenges in modern medicine, though, involve chronic conditions that are substantially influenced by lifestyle behavior: diet, exercise, smoking, drinking, and such.
In changing health behavior, the expert model (ask questions and give advice) works sometimes, just often enough to keep us using it. A small percentage of patients will stop smoking when advised to do so by their doctor, more than would do so without such advice. Giving advice, however, can also undermine change. An ambivalent patient feels at least 2 ways about making the needed changes. By taking the expert role, a practitioner sides with and verbalizes the pro-change side of the patient's dilemma. The natural response of an ambivalent person is to express the other side of the internal dialogue: "Yes, but[horizontal ellipsis]" Inadvertently, the provider causes the patient to verbalize the arguments against change, the reasons why it would be inconvenient, difficult, or unnecessary. That might be harmless enough, except that like the rest of humanity, patients tend to hear and believe what they themselves say. They can literally talk themselves into not changing.
As ably described by Hancock and colleagues in the accompanying article,8 MI represents an opposite approach. In MI, it is the patient who expresses the arguments for change.9 MI is not a cute "reverse psychology" trick, but rather a clinical method through which the clinician-counselor helps the patient to explore ambivalence and express the reasons for change. We liken it to dancing rather than wrestling with patients, and indeed MI is considerably more enjoyable than trying to pin down patients to change. Motivational interviewing involves listening more than telling, evoking the patient's perspectives rather than installing your own. When done well, MI helps patients talk themselves into health behavior change.
If you are just starting out, give this a try with your next 3 patients who present with problems that suggest a need for lifestyle behavior change. This little exercise is meant to give you a sense of the spirit of MI, the basic approach. In it, you ask 4 questions, listen to what the patient has to say, and then give a brief summary of what the patient has said to you.
1. Ask your patient, "On a scale from 0 to 10, where 0 is not at all important, and 10 is extremely important, how important would you say it is for you to _____?" In the blank space, fill in the behavior change that would be health-promoting: to exercise a bit more, to eat more fruits and vegetables, to stop smoking, etc.
2. Then ask, "And why are you at a _____ (the number the patient gave) and not 0?" The answer to this question is the patient's reasons for change. (If, as rarely happens, the patient says "zero" to number 1, then just move on to number 3 instead of asking this question.) Do not ask what feels like the natural question: "Why are you at _____ and not 10?" The answer to that question is the patient's resistance to change.
3. Next ask, "And on a scale from 0 to 10, where 0 is not at all confident and 10 is certain, how confident are you that you could _____ if you decided to?"
4. Then follow up in the same way: "And why are you at a _____ and not 0?" The answer to this question is the patient's "self-efficacy," the positive reasons why change seems possible.
5. Finally, in just a few short sentences, give the patient a short summary of what you just heard.
That is it. You do not have to have brilliant answers or expert advice. You are just consulting the patient about why and how he or she might change. The whole thing should take just a few minutes.
This is not in itself MI, but it gives you a taste. Motivational interviewing is a learnable clinical skill,10 and practitioners vary widely in their effectiveness in using it. Once you learn what to look for, your patients will teach you how to do it. That is how I learned it. If your patient is expressing the arguments for change, you are doing it right. Motivational interviewing is a consulting style that you can use in the context of normal practice without getting caught up in long counseling sessions.6 The purpose is to increase a patient's motivation for and commitment to make a change in behavior in the interest of his or her own health. Once patients really make up their mind and commit to change, often they find the way to do it.
Motivational interviewing is no miracle method or panacea. It does not work all the time, but clinical experience and randomized trials indicate that it does often trigger health behavior change. It is an artful clinical skill that, like chess or dancing, you can keep doing better over a lifetime of practice.
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