Three health behaviors (poor diet, physical inactivity and tobacco use) contribute to the four major chronic conditions (type 2 diabetes, cardiovascular disease, chronic lung disease and cancer) that account for 50% of all deaths worldwide (James et al., 2018). When these chronic conditions are present and an individual is consuming harmful levels of alcohol, the risk of associated mortality significantly increases (World Health Organization, 2018). 

Underlying a patient’s perceived lack of motivation to change these and other health behaviors is often ambivalence, or feeling two ways about a particular change. Motivational interviewing (MI) is an evidence-based clinical approach to exploring and resolving ambivalence (Rollnick and Miller, 1995). In contrast to persuasion or confrontation, MI focuses on empowering individuals to identify their own goals and reasons for change. 

Benefits of Using MI

The Quadruple Aim framework emphasizes improved patient outcomes, enhanced patient experience, reduced healthcare costs and provider well-being (Berwick et al., 2008). MI aligns with these values, enhancing the effectiveness and sustainability of healthcare delivery in a number of ways. 

MI’s focus on patient-centered communication and enhanced patient engagement improves both patient satisfaction and outcomes (Lundahl et al., 2013; Pollak et al., 2016). Further, by honoring and enhancing patient autonomy, MI promotes efficient use of resources and reduces unnecessary interventions (Pantalon et al., 2013). MI has also been proposed to enhance provider well-being through strengthened patient-provider relationships, more effective patient interactions and reduced stress (Pollak et al., 2016; Rollnick at al., 2008). 

How MI Can Help 

MI is effective in promoting behavior change across various health domains (Martins and McNeil, 2009; Lundahl et al., 2013). MI can enhance treatment adherence and self-management for chronic health conditions such as diabetes, hypertension, obesity and asthma. Individuals experiencing mental health concerns may also experience ambivalence regarding treatment engagement or taking medications, which can be explored via MI. 

With regard to substance use, MI has been utilized with substances like tobacco, alcohol and marijuana. Compared to treatment as usual, interventions including MI strategies demonstrate reductions in target behaviors such as unprotected sex and needle sharing. 

Providers addressing chronic pain and opioid use may also find MI useful in exploring patient ambivalence to consider alternative treatments (Borsari et al., 2021). MI strategies have been applied to vaccine hesitancy (Bones et al., 2022) and increasing uptake of cancer screening (Chan and So, 2021). During any routine healthcare visit, MI can be utilized to support lifestyle modifications that may enhance health promotion and disease prevention. 

The Core Four

Within a non-judgmental framework focusing on developing a partnership and fostering patient autonomy, MI is guided by four core principles. Upon this relational foundation, the provider selectively utilizes four key communication techniques to engage the patient in four processes that elicit and strengthen motivation for change (Rollnick and Miller, 1995; Miller and Rose, 2009).

4 Core Principles of MI

1. Expressing empathy: Understanding the patient’s perspective without judgment

2. Developing discrepancy: Highlighting incongruence between current behavior and goals

3. Resisting the “righting reflex”: Avoiding confrontation by meeting the individual’s ambivalence with understanding 

4. Supporting self-efficacy: Fostering the individual’s belief in their ability to change

4 Key MI Techniques

1. Open-ended questions: Understanding the patient’s perspective 

2. Reflective listening: Sharing and deepening understanding

3. Affirmations: Recognizing patient efforts and strengths

4. Summarizing: Sharing understanding, reinforcing change talk, shifting toward planning

4 MI Processes

1. Engaging: Listening to understand, affirming strengths  

2. Focusing: Agenda setting, exploring ambivalence, use of information

3. Evoking: Selective eliciting, responding and summarizing toward change talk

4. Planning: Moving to a change plan 

Application of MI 

MI encompasses both relational and technical skills, utilizing both empathy and selective reinforcement of language that favors change (Miller and Rose, 2009; Miller and Rollnick, 2013). Psychologists are uniquely trained to adapt MI strategies to specific populations and clinical concerns. 

Psychologists often support the use of MI in healthcare by offering training workshops, participating in shared medical visits, and offering ongoing coaching and case consultation. Providers and treatment team members can begin by adopting the spirit of MI and incorporating core MI communication skills into medical visits to support patient change.

1. Ask permission to discuss the topic. 

2. Explore patient understanding, beliefs, experience and readiness.

3. Support and affirm interest, benefits and past success.

4. Share information (with permission) and check for understanding.

5. Confirm next steps and plans, including follow-up.

Sample Scripting of MI Applied to Alcohol Use

1. Ask permission to discuss alcohol use

• May I talk with you about alcohol use?

2. Explore readiness and experience (ask ANY of the following questions):

• What do you know about the health risks associated with alcohol consumption? 

• What steps have you taken to avoid these risks?

• On a scale of 0 to 10, how important is reducing your alcohol use? Why did you pick X and not a lower number? (Asks patient to speak to reasons for change.)

3. Support and affirm ANY interest, benefits, current/past success

• I’m glad to hear that you are aware of the risks.

• It sounds like you have had some success in the past limiting yourself to two drinks per sitting.

• Thank you for your honesty. Many people aren’t sure about the impact of alcohol. 

4. Share information (with permission)

• May I share some information with you about how limiting alcohol would improve your health? What you do with this information is totally up to you. (Provider tailors information based on patient health history, values and goals.)

• May I share some information about strategies people often find helpful in reducing alcohol use?

5. Confirm next steps

• So, what do you think about this? (Elicit understanding, interpretation and reaction.)

• Would you like to set a specific goal today regarding your alcohol use?

• If a goal is set, ask:

• “On a scale of 0 to 10, how confident are you about achieving this goal? Why did you pick X and not a lower number?” (Asks patient to identify strengths.) 

• “What would it take to move you from X to [insert next highest number]? (Asks patient to identify support needed.)

• If patient declines:

• Ask if there is any other information they would like to receive.

• Assure them support is available later if now is not the right time. “We are ready to help you when you are ready.”

By incorporating MI into your medical visits, you can address the patient’s ambivalence and empower them to identify their own goals and reasons for change. 

References

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and cost. Health affairs, 27(3), 759-769.covid-19 vaccine hesitancy. The Journal of the American Board of Family Medicine, 35(2), 420-426.

Boness, C. L., Nelson, M., & Douaihy, A. B. (2022). Motivational interviewing strategies for addressing covid-19 vaccine hesitancy. The Journal of the American Board of Family Medicine, 35(2), 420-426.

Borsari, B., Li, Y., Tighe, J., Manuel, J. K., Gökbayrak, N. S., Delucchi, K., … & Seal, K. H. (2021). A pilot trial of collaborative care with motivational interviewing to reduce opioid risk and improve chronic pain management. Addiction, 116(9), 2387-2397.

Chan, D. N., & So, W. K. (2021). Effectiveness of motivational interviewing in enhancing cancer screening uptake amongst average-risk individuals: a systematic review. International Journal of Nursing Studies, 113, 103786.

Cucciare, M. A., Ketroser, N., Wilbourne, P., Midboe, A. M., Cronkite, R., Berg-Smith, S. M., & Chardos, J. (2012). Teaching motivational interviewing to primary care staff in the Veterans Health Administration. Journal of general internal medicine, 27, 953-961.

James, S. L., Abate, D., Abate, K. H., Abay, S. M., Abbafati, C., Abbasi, N., … & Briggs, A. M. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet, 392(10159), 1789-1858.

Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of clinical psychology, 65(11), 1232-1245.

Martins, R. K., & McNeil, D. W. (2009). Review of motivational interviewing in promoting health behaviors. Clinical psychology review, 29(4), 283-293.

Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American psychologist, 64(6), 527.

Pantalon, M. V., Sledge, W. H., Bauer, S. F., Brodsky, B., Giannandrea, S., Kay, J., … & Rockland, L. H. (2013). Important medical decisions: Using brief motivational interviewing to enhance patients’ autonomous decision-making. Journal of Psychiatric Practice^®, 19(2), 98-108. 

Pollak, K. I., Nagy, P., Bigger, J., Bilheimer, A., Lyna, P., Gao, X., … & Armstrong, S. (2016). Effect of teaching motivational interviewing via communication coaching on clinician and patient satisfaction in primary care and pediatric obesity-focused offices. Patient education and counseling, 99(2), 300-303.

Rollnick, S. and Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325–334

Rollnick, S., Miller, W. R., Butler, C. C., & Aloia, M. S. (2008). Motivational interviewing in health care: helping patients change behavior.

VA National Center for Health Promotion and Disease Prevention (NCP). Motivational Interviewing for PACT Clinicians.

World Health Organization (2018). Global status on alcohol and health. WHO.