Encouraging change with motivational interviewing

For busy primary care physicians seeking to help patients change their behavior, be it to exercise more, take their medications, eat a healthier diet, stop smoking, or other examples, motivational interviewing (MI) can be a helpful communication tool.

“MI is a structured way to guide the conversation using a series of skills to actually pull out the reason for change from the individual, rather than tell them what to do,” said Damara Gutnick, MD, an associate professor in the departments of family and social medicine, psychiatry and behavioral sciences and epidemiology, and population health at the Albert Einstein College of Medicine in New York, and a member of the Motivational Interviewing Network of Trainers (MINT).

“The goal with MI is to really listen to the individual deeply for what we call ‘change talk’, which is any language that favors movement towards change,” she added. “The opposite of change talk is sustain talk, which by definition is any language that favors the status quo.”

According to Dr. Gutnick, four underlying tenets (Partnership, Acceptance, Compassion, and Evocation), together called “The Spirit of MI,” form the foundation of all MI conversations. Partnership is about coming alongside the patient and meeting them where they are, Acceptance is about respecting the other person's autonomy or their right to change or not change a behavior, Practicing with compassion ensures that a physician is doing everything in the best interest of the other person, and Evocation is about pulling the ideas for change from the patient themselves, she said.

The skills of MI, meanwhile, are defined by the acronym OARS: Open-ended questions, Affirmations, Reflective listening, and Summaries, Dr. Gutnick said.

While most physicians are taught to ask open-ended questions during their training, they aren't often taught true MI. “A lot of these principles have now been integrated in standard communication and counseling,” said Melanie Jay, MD, MS, an associate professor in the departments of medicine and population health at NYU Langone Health in New York, adding that this can complicate research on the use and effectiveness of motivational interviewing. “It's getting incorporated a lot in standard practice, but none of us do it well enough. We can all do better.”

Anecdotes versus data

Many clinicians will traditionally jump into action planning when they are faced with a patient who needs to make a change, but this could be a waste of time if the patient is not yet ready. This is where motivational interviewing can be particularly helpful, experts said.

Before he was trained in motivational interviewing, David P. Miller Jr., MD, MS, FACP, an internal medicine physician at Atrium Health Wake Forest Baptist in Winston-Salem, N.C., said he would frequently counsel patients to quit smoking. “I had a common speech that most doctors give, which is, ‘Well, as your doctor, I should tell you that quitting smoking would be one of the best things you can do for your health because if you continue to smoke, you're much more likely to get COPD or potentially lung cancer and die,’” he recalled.

However, motivational interviewing taught him to ask questions like “What do you like about smoking?” and, based on the answers, “What concerns you about your smoking?” Dr. Miller said these questions help elicit the specific reasons patients have for wanting to quit—one example he gave was of a mother not wanting to be a hypocrite by telling her 14-year-old daughter not to smoke—as well as the relevant barriers.

Dr. Gutnick said extensive literature has demonstrated the effectiveness of motivational interviewing for controlling chronic diseases like diabetes and hypertension, eating healthy, or “anything that requires self-management or a behavior change goal like losing weight or exercising more.”

That said, not all of the research has been positive. For example, a 2019 Cochrane review found insufficient evidence to show whether motivational interviewing helps people with smoking cessation, and a systematic review published in the June 2022 Annals of Internal Medicine found no evidence that motivational interviewing increased the effectiveness of behavioral weight management programs in controlling weight. In an editorial accompanying the Annals study, Dr. Jay and her coauthor wrote, “Strengthening motivation through MI is insufficient for weight management because obesity is a disease with a complex etiology, including multilevel factors that are outside the patient's control.”

Dr. Gutnick, meanwhile, pointed out that the studies with the best evidence to support MI are those that pay close attention to the fidelity of its methods. And Dr. Miller said he is “confident that in my conversations with patients, [MI] results in improved trust in our relationship and in a more honest exchange of information. And to me, that's just as valuable as the end result.”

MI is also a very time-efficient strategy for him, he added. “Insufficient evidence just means we don't necessarily have high-quality trials that are rigorous that show this works, but it doesn't mean that there's evidence that shows it's harmful,” he said.

Dr. Jay estimated that about 60% to 75% of the research in the field of MI shows positive outcomes. One of her favorites was published in 2015 in Patient Education and Counseling and looked at the potential mechanisms at play. “It's very messy to try to look at mechanisms, but there is some data that suggests that one reason why motivational interviewing would work is because it does indeed, as intended, help patients move along the stage-of-change model,” she said.

Notably, Dr. Jay said MI shouldn't be used for “every single behavior, because usually in a medical visit we're asking a patient to do multiple things. We're asking them to take their medicine, come to another visit, get a screening mammogram, and go to this specialist. … You can't do motivational interviewing for every behavior, but if there's an important one, you can focus on that.”

There are also situations when it might backfire, she said. “MI could be a tool for encouraging someone who's ambivalent about a vaccine, but I find that if I did that with everybody, that would just take up so much of my time.” For most of her patients, she simply states that it's time for a vaccine. “Sometimes that works better than asking, ‘How do you feel about the shingles vaccine?’ Doing that sometimes could introduce ambivalence or time when it didn't need to,” she said.

‘Listen for change talk’

As for how clinicians might incorporate these skills into their already crammed appointments, Dr. Gutnick said that MI tools can actually end up saving time in the long run.

“Listen for change talk,” she said. “When you hear it, the person's ready for action planning or goal setting. And then you can use that; that's a great use of time. If instead you're hearing no change talk, then you ask yourself how much time you have to invest in the conversation today and what's the urgency of the behavior change.”

She said physicians often tend to tell patients what to do, something called the righting reflex, rather than evoke from patients why they feel a certain way and then address that. A better scenario is to use the ask-tell-ask method of finding out what information patients already know, offering a small bit of advice, and then asking how patients feel about that new information, she said.

“Another key thing is not to jump to planning when the person's not ready because that's not going to save you time,” Dr. Gutnick said. “That's just checking a box, and it's not going to have an impact.”

Dr. Jay also recommended a technique called brief action planning, developed by Dr. Gutnick and others, as an algorithmic approach to motivational interviewing. Focusing on a single behavior change, she said, the physician can ask, “What do you think is one healthy change you can make in the next couple weeks?” They then follow up by asking how the patient intends to make the change, have them come up with a plan, elicit a commitment, “and then ask them how confident they are about it.”

Dr. Miller uses MI techniques and strategies as several tools in the toolkit, he said. “I can just pull out one of those tools and use it briefly in my visit, depending on what the situation is.” One of his favorites is to ask, “On a 1-to-10 scale, where 10 is the most important thing in the world [and] 1 is this isn't important at all, how important is it for you to, say, quit smoking?” This will quickly reveal a patient's readiness for change. By following up with a question about the patient's confidence that they can make the change, he can learn about any specific barriers standing in the way.

Reflective listening, “the simple act of reflecting back to people what they tell you,” is another tool he loves, although he said it is probably one of the trickier skills to learn in motivational interviewing. The hard part about doing this, Dr. Miller explained, is learning how to reflect upon something and be comfortable with letting a statement rest instead of asking another question.

Often, however, the result of this reflection is having the patient come up with a solution that works for them. “The goal is to have the patient doing work to come up with the reason to change and saying it out loud,” Dr. Gutnick said. “When you use MI, it's like you're dancing with a patient rather than pushing them and wrestling with them, so it's a much more enjoyable encounter. And the patients do most of the work, so it's more relaxing.”

Learning new skills

It takes time and practice to become confident with MI skills. Short workshops are offered annually at ACP's Internal Medicine Meeting, and the experts also recommend attending a multiday course to really become fluent in the skills and practice them.

“Learning MI brought me so much joy to my work, and it changed my entire practice of medicine,” Dr. Gutnick said. “Initially, you're going to make mistakes and you're going to be consciously incompetent at it. And as you practice, you're going to become consciously competent slowly, and eventually it will become the way you are with your patients, and then you become unconsciously competent.”

She recommends trying one skill a day. “Say, ‘I'm going to try a reflective statement or affirmation on one patient in the next clinical session. One patient.’ And you pay attention to the impact. Does it elicit change talk? Does it emerge that the change talk is getting stronger?”

Dr. Miller said MI has made him a better listener and he doesn't consciously think about using the tools anymore now that he's had more than 15 years of practice. “I would say a one- to two-day workshop is sufficient to get you comfortable to the point where you will feel comfortable trying some of these tools out with your patients,” he said. “And then the more you practice using them, the more comfortable you're going to get with it over time.”

While it's difficult to measure the effects of motivational interviewing, “a victory would be to get to have patients start thinking about a change if they weren't thinking about it before, or, if they were thinking about it, to actually make some steps to prepare or take action,” Dr. Jay said. She recommended that physicians try it in several circumstances and see what works. “I think you develop your own style with it,” she said.