It’s a lament heard frequently from health care providers – patients just do not listen to their advice. Appointment after appointment, providers carefully repeat the risks posed by obesity or high blood pressure or not taking important medications, assuming that a rational patient will do as they advise. And when, appointment after appointment, the patient doesn’t follow their advice, providers may well conclude, based on the evidence, that the patient’s behavior is pathological because, after all, a rational person would not chose to suffer the consequences of ill health.[1]
But what if the patient’s response was not pathological, that he or she actually did understand the risks and was not simply being irrational?
And what if the provider acknowledged that changing human behavior is not the automatic output of a rational cost-benefit analysis but is, rather, a deeply complex process, especially for people whose chronic illness makes them vulnerable to some of the same strong emotions as people who have experienced loss and grief – anger, denial, sadness and fear?[2]
What would that provider-patient interaction look like?
And, most importantly, what impact would that patient-provider interaction have on health outcomes?
Listen & Ask
Being highly trained in a fact-based profession, many providers assume that simply knowing the potentially devastating consequences of chronic ill health should be sufficient motivation for anyone to make changes that could either forestall or obviate suffering. Providers, acting with the best of intentions, focus on explaining the facts to their patients – why and what they should change and what will likely happen if they do not. When patients do not respond to what, in the provider’s eyes, is a clear set of simple directives, providers may become frustrated and annoyed and communicate those sentiments, either verbally or through their demeanor, to their patient – leading to tense, rather than productive, office visits.
But what if providers could elicit the desired changes by asking more and telling less?
A style of clinician-patient communication called Motivational Interviewing (MI) takes just that approach – asking, not telling.[3] First described by the psychologist William R. Miller in 1983 and then expanded in collaboration with the psychologist Stephen Rollnick in their 1991 seminal book, Motivational Interviewing: Preparing People to Change, MI is defined as a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”[3] The approach is intentionally focused on helping people move past their ambivalence about change by carefully examining what it is that is keeping them stuck in the status quo.[1] MI helps the patient to see the discrepancy between their behavior and their goals and values; change will come when closing this gap is sufficiently important to the patient.[1]
But MI is more than simply a framework for understanding one’s patients – it is also a practical strategy that can be incorporated into a clinical setting. As a strategy, MI asks the provider to step out of the traditional role of “expert advisor” or “educator” to become a persuader, a collaborator with their patient, in order to support their patient’s efforts to examine why they are ambivalent about changing and identify the thoughts and feelings that are holding them back.[4] [5] MI re-orients the traditional provider-patient dynamic away from one where the “expert” clinician talks at the “ill-informed” patient, dispensing advice and expecting it to be followed, to one where the provider and the patient work together on a level playing field, engaging in a mutually respectful conversation to find the patient’s own reasons for change.[6] In MI, the provider will not save the patient — the patient will save himself.[7]
Central to MI as a clinical strategy is the provider’s ability to listen and respond to the patient’s concerns in a way that clarifies and amplifies the patient’s own experience; this reflective listening will allow the patient to recognize where there is a problem with the status quo.[1] In order to do this, the provider must resist his or her own tendency to dictate, to argue, and to judge. Rather, the provider must focus on the patient’s verbalized willingness to change, acknowledge that their concerns have validity, if only from the patient’s perspective, and let the patient find for himself those areas where change is possible, however incremental.[1] And when the patient has found a path forward, the provider must be confident that change will occur because the provider’s obvious confidence in the patient’s ability to change can function as a self-fulfilling prophecy.[1]
MI: Efficient and Effective in a Medical Health Setting
MI has been shown to be an effective model for treating behavioral and addiction disorders; it has been evaluated in outcome studies, in comparative effectiveness research trials, and in meta-analyses published in hundreds of peer-reviewed journals.[8] Its effectiveness has been evaluated in randomized clinical trials across a range of clinical settings and disease states including diabetes, cardiovascular disease and at-risk pregnancies, and found, to varying degrees, to be more effective than traditional advice giving.[5] [9] MI has been shown to be effective regardless of the severity of the illness or the gender, age or ethnicity of the patient.[4]
A 2005 review of 72 randomized clinical trials found that MI had a clinically relevant positive impact on changing behavior in 75% of the studies with approximately equal impact on patients with psychological and physiological conditions.[10] The underlying clinical trials included smoking cessation, weight loss, alcohol consumption, and cholesterol levels.[10] More than one MI counseling session showed greater effectiveness.[10]
A 2009 review of four meta-analyses found that MI was consistently and significantly (10%-20%) more effective in reducing risky behaviors and increasing healthy ones than were weak intervention alternatives such as no treatment, and equal to or, in some cases better than, strong treatment interventions such as cognitive behavioral therapy or 12-step programs.[4] MI was found to be effective up to six months post-counseling; at the one-year mark and beyond, its effectiveness was found to be mixed with some studies showing diminished impact and others showing positive impact up to two years later.[4] This 2009 analysis echoed the earlier, 2005, review with regard to the question of how optimal is MI. Both found that the more time spent counseling patients within the MI framework, the greater is its impact.[4] The meta-analysis did, however, find that MI was not especially effective in a group setting.[4]
Implications for Providers – A Cost Effective Tool for Moving Toward the Triple Aim
For practices striving to achieve the Triple Aim, MI offers a cost effective means to move patients toward healthy lifestyles. It is demonstrably effective and does not consume a lot of a practitioner’s time, especially when compared to other counseling paradigms.
Counseling done within the MI framework typically takes up far less time than do alternative, and comparably effective, interventions; the 2009 meta-analysis noted that the typical MI session was between 101 and 180 minutes shorter than were the alternative strategies studied in the underlying research.[4] On average, MI sessions involved 100 minutes less face-time when compared with alternative interventions.[4] In randomized clinical trials of MI, more than half of the patients showed positive results after counseling sessions that were as short as 15 minutes.[10] Given the relatively short duration of any given counseling session, providers can readily incorporate MI into their patients’ routine office visits; by continually working with patients over time, providers can increase the likelihood that their patients will be ready and able to change their risky behaviors.[11] [10]
An increasing number of medical schools are offering MI training to their students or as CME courses. Training can be quite short; typically, an effective MI training session ranges in length from 9 to 16 hours.[4] Even shorter training sessions can effectively train providers in the strategy; a clinical trial involving obstetric care clinicians showed that they were able to counsel patients within the MI framework after viewing one, 20-minute training video.[5]
Starting Rowing
The MI communication skills that training programs teach to counselors can be summarized by Miller and Rollnick’s acronym, “OARS”: Open-ended questions that prompt the patient to verbalize the concerns and goals that are important to him or her; Affirmations of the patient’s strengths and ability to change; Reflective listening that calls attention to those aspects of the patient’s circumstances or experiences that can enable change, and; Summarizing to help the patient focus on their own statements and experiences that could help facilitate change.[8]
An increasing number of providers are adopting the MI framework when counseling patients about the need to change the lifestyle and behaviors that increase their risk for a range of disease states. For these providers, and their patients, it’s time to start rowing together with those OARS.
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[1] Miller WR, Rollnick S. Motivational Interviewing: Preparing People For Change. 2nd ed. New York: Guilford Press; 2002.
[2] Schoo A, Motivational interviewing in the prevention and management of chronic disease: improving physical activity and exercise in line with choice theory. Int J Real Therapy, Spring 2008; 27(2): 26-29. https://www.choixdecarriere.com/pdf/5671/28.pdf.
[3] Miller WR, Rollnick S. Motivational Interviewing. New York: Guilford Press; 1991.
[4] Lundahl B, Burke BL. The effectiveness and Applicability of Motivational Interviewing: a practice-friendly review of four meta-analyses. J Clin Psych in Session 65: 1232-1245. 2009. https://faculty.fortlewis.edu/burke_b/criticalthinking/readings/mi-burke.pdf
[5] Motivational interviewing: a tool for behavior change. American Congress of Obstetricians and Gynecologists. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/co423.pdf?dmc=1&ts=20141123T1733164215.
[6] https://www.motivationalinterviewing.org/. Accessed November 11, 2014.
[7] Possidente CJ, Bucci KK, McClain WJ. Motivational interviewing: a tool to improve medication adherence? Am J Health Syst Pharm. 2005 Jun 15;62:1311-4. https://www.ncbi.nlm.nih.gov/pubmed/15947131.
[8] Substance Abuse and Mental Health Services Administration (SAMHSA). Comparative effectiveness research series: motivational interviewing an informational resource. 2012. SAMHSA, Rockville, MD. https://nrepp.samhsa.gov/pdfs/MI_Booklet_Final.pdf.
[9] Floyd RL, Sobell M, Velasquez MM, et al. Preventing alcohol-exposed pregnancies: a randomized controlled trial. Am J Prev Med. 2007 Jan;32(1):1-10. https://www.ncbi.nlm.nih.gov/pubmed/17218187.
[10] Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. Apr 1, 2005; 55(513): 305-312. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463134/.
[11] Lussier MT, Richard C. The motivational interview in practice. Can Fam Physician, Dec 2007;53(12):2117-2118. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231547/.