Motivational interviewing in health settings: a review
Introduction
Many health problems are related to lifestyle factors such as diet, exercise, and smoking. Changing such behaviours is difficult, requiring time, considerable effort and motivation. Furthermore, ambivalence about behaviour change is a common problem in health care consultations [1].
Traditionally, health practitioners have encouraged patients to make such changes through the provision of advice (i.e. information giving with direct persuasion) about behaviour change [2]. While this works with some patients [3], the evidence of the effectiveness of advice giving about lifestyle change is not strong [4], with success rates of only 5–10% [5], [6].
Furthermore, there is evidence that patients do not necessarily want advice if it is provided in a style that is perceived as being “told what to do” [7]. Additionally, advice giving can develop into non-constructive disagreement, with the health practitioner placing emphasis on the benefits of change while undervaluing the personal costs, and the patient looking closely at the personal implications of change and the immediate costs while minimising future benefits [2]. The risk of such an encounter is that the patient becomes resistant to change or resistance, if already present, is increased [8].
In contrast, there is evidence that more patient-centred approaches produce better outcomes [9], [10], [11]. The essential features of these patient-centred approaches are that the patient does most of the talking, and that there is a ‘meeting between experts’ [2], with the concept of reciprocity in the consultation [12]. However, patient-centred counselling has not been developed into a replicable method specifically geared towards negotiating behaviour change in health consultations [13].
Motivational interviewing (MI), which evolved from Miller’s experience with the treatment of problem drinkers [14], and was later elaborated by Miller and Rollnick [8], is a patient-centred approach that has been gathering increased interest in health settings [13]. Miller conceptualises motivation as a state of readiness for change, rather than a personality trait [14]. As a state, motivation may fluctuate over time or from one situation to another, and can be influenced to change in a particular direction [15]. Thus, lack of motivation (or resistance to change) is not seen as inherent within the patient but rather something that is open to change. The main focus of MI is facilitating behaviour change by helping patients to explore and resolve their ambivalence about the behaviour change [16].
This conceptualisation of motivation as a state which is open to change is a sharp contrast to traditional approaches which view motivation as an attribute of personality, and denial or resistance as something to be dealt with through aggressive confrontation [17], [18], [19], [20]. In fact, Miller and Rollnick suggest that adopting an aggressive and/or confrontational style (as in traditional approaches) is likely to produce responses from the patient (such as arguing) which may then be interpreted by the practitioner as denial or resistance [8], thus creating a “self-fulfilling prophecy” (p. 10).
While MI is patient-centred in that it focuses on the patients wants, thinks and feels, and it is the patient that does most of the talking, MI differs from other patient-centred approaches in that it is directive. That is, in MI there is the clear goal of exploring the patient’s ambivalence in such a way that the patient is more likely to choose to change his or her behaviour in the desired direction, and systematic strategies are used in order achieve this [8].
Section snippets
MI principles and techniques
Rollnick and Miller distinguish between the “spirit” (p. 326) of MI and specific MI techniques [16]. Within the spirit of MI, readiness to change is not seen as a patient trait, but a “fluctuating product of interpersonal interaction” (p. 327), and motivation to change is viewed as something which is evoked in the patient, rather than imposed [16]. It is the patient’s task (not the practitioner’s) to articulate and resolve his or her own ambivalence. It is the practitioner’s task to expect and
Theoretical basis
MI was not based on any specific theory. Rather, Miller drew from social psychology [14], applying processes such as attribution [24], cognitive dissonance [25], and self-efficacy [26], [27], and empathic processes from the methods of Rogers [21], [22].
Despite the lack of empirical data, considerable interest in MI was shown, mostly within the addictions field, after Miller’s initial article [14]. Because of this interest, Miller began to research the processes and outcomes of MI, and as
Specific interventions
The principles of MI have been incorporated into a brief intervention (called the Drinker’s Check-up or DCU) for problem drinkers [44], [45]. This is an assessment based strategy, involving a comprehensive assessment of the patient’s drinking and related behaviours, followed by systematic feedback to the patient of findings using a MI communication style.
Motivational Enhancement Therapy or MET [46] is a four session adaptation of the Drinker’s Check-up, which was developed as one of three
Efficacy of MI
Many studies reporting on the outcome of MI do not provide adequate information on what the intervention involved, or how it may have been modified for the particular target problem or client population, which makes it difficult to draw conclusions or make comparisons. However, there have been studies, particularly within the alcohol abuse field, which have utilised a specific MI intervention, such as the DCU or MET, and which have made attempts to ensure that the therapists adhere to the
Conclusions
MI appears to hold substantial promise for health behaviour change. It is consistent with the call (from patients, and health researchers and practitioners) for more patient-centred approaches in health care in which the health practitioner–patient relationship is seen as a partnership, rather than an expert–recipient one. MI also provides health practitioners with a means of tailoring their interventions to suit the patient’s degree of readiness for change. In particular, it provides
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