WD03 Motivational Interviewing: How to Improve your Success in Promoting

Kristin Bell, M.D
Tomoko Tanabe, M.D.
Motivational Interviewing:
How to Improve your Success in Promoting
Health Behavior Change
A. Background
B. Definition of Motivational Interviewing
C. Spirit of Motivational Interviewing
D. Efficacy data review
Key Techniques of Motivational Interviewing
A. Basic skills (OARS)
B. Advanced skills (EDARS)
C. Useful Techniques for Creating Change Talk
Traps to Avoid
Sample Questions
I. Introduction
A. Background
ƒ Nearly all top causes of mortality have behavioral components important for
etiology and treatment
Medical providers are ideally suited to be key agents in promoting health behavior
Motivational interviewing provides important tools to promote health behavior
Implementing these skills is realistic but requires shift in attitudes and culture
B. Definition
Motivational interviewing (MI) is a directive, client-centered counseling style for
eliciting behavior change by helping clients to explore and resolve ambivalence
C. Spirit of Motivational Interviewing
MI is a method of interacting with patients to assess their readiness for change
and to facilitate movement from one stage to the next. This is done by addressing
a patient's ambivalence about change, examining their personal pros and cons of
change, and facilitating exploration of their personal barriers to change.
The tone and demeanor adopted when using MI is nonjudgmental, empathic, and
MI is used to selectively illuminate the discrepancy between the patient's desired
goal and their current health behavior.
Understanding change from the patient's point of view is an important aspect of
the spirit of MI. Two particularly relevant points are (1) readiness to change is a
not a client trait but a fluctuating product of interpersonal interactions, and (2) the
desire to change should be "elicited," not "imposed".
MI has been used in many health settings to promote smoking cessation, weight
loss, increased exercise, and reduced alcohol and drug use. Originating in the
addiction field, MI has now been successfully adapted for brief medical
Employing an MI-oriented approach is in keeping with the recommendations for
patient-centered communication and is an effective tool used to promote health
behavioral change.
D. Efficacy Data Review: Two high quality meta-analysis identified
Burke BL, Arkowitz H, Menchola M.
The Efficacy of Motivational Interviewing: A Meta-Analysis of
Controlled Clinical Trials. J Consult Clin Psychol. 2003;71(5):841-861.
(*The first meta-analysis of the motivational interviewing)
Table 1. Included Studies
Numbers of Studies
Problem Area
Smoking Cessation
Drug Addiction
HIV-risk Behaviors
Diet and Exercise
Treatment Adherence
Eating Disorders
Sample Size:
Ranged from 22 to 952, median of 206 participants
Follow-up Length:
Ranged from 4 weeks to 4 years, with a mean of 18 weeks
ƒ Comparative efficacy of “Adaptations of Motivational Interviewing” (AMIs):
o Of the 30 studies examined, 11 produced at least one statistically
significant effect size in favor of the AMIs.
AMIs compared with no-treatment, placebo groups or other active treatments:
o AMIs were equivalent to other active treatments and superior to notreatment or placebo controls for problems involving alcohol, drugs, diet
and exercise.
o The efficacy of AMIs for alcohol, drug, diet and exercise problems was in
the median range overall (ds around 0.50)
o AMI interventions were shorter that the alternative active treatments
(eg.cognitive behavioral therapy) by average of 180 minutes, yet produced
similar results.
Sustained efficacy of AMIs:
o Effects of AMI were sustained at follow-up as long as 4 years posttreatment
Clinical impact of AMIs:
o Overall, the percentage of people who improved following AMI
treatments (51%) was significantly greater that the percentage who
improved with either no treatment or treatment as usual (37%).
o The combined effect size of 11 studies using AMI as stand-alone
intervention was large (0.82), with patients reducing their drinking by 56%
from about 36 SEC drinks/week to 16 SEC drinks/week after AMI
treatment at follow-ups of up to 1 year.
o 38% AMI participants reported abstinence vs. 18% in the no-treatment or
treatment as usual group.
o Research suggests AMI is efficacious both as a stand-alone treatment and
as an adjuvant to enhance other treatments.
o AMIs have not shown any significant effects in the areas of smoking
cessation or HIV-risk behaviors based on the two studies conducted in
each area.
ƒ Benchmarks for comparison:
o Other meta-analyses for alcohol treatments: brief interventions (4 sessions
of treatment) reduced drinking by 4-5 drinks/week vs. AMI reduced
average 20 drinks/week.
o 50% patients improved in 8 sessions of psychotherapy vs
50% patients improved in only 2 sessions of AMI
Table 2.
Basic Characteristics of Controlled Clinical Trials Involving Adaptations of Motivational
Interviewing (AMIs)
Problem Area
Dose of AMI
Interval (%
3 months (49)
Bien et al.
6 months (72)
Bosari et al.
6 weeks (98)
Brown et
3 months (89)
Gentiello et
3 years
Handmaker et
2 monthsn (81)
Heather et
6 months (70)
4 years (83)
Marlett et
12 months (83)
Miller et
18 months (76)
Miller et
6 months (98)
Monti et
3 years (85)
Sellman et
Butler et
Colby et
Booth et
Martino et
Sauders et
Schneider et
Stephens et
Baker et
Baker et
Swanson et al.
Harland et
Mhurchu et
Smith et
Woodlard et
Treasure et
6 months (89)
3 years (85)
6 momths (98)
1 month (52)
6 months (78)
Drug Addiction
3 month (95)
Drug Addiction
3 months
Drug Addiction
12 weeks (26)
Drug Addiction
6 months (60)
Drug Addiction
9 months (71)
16 months (89)
6 months (84)
6 months (44)
Diet & Exercise
1 year (85)
Diet & Exercise
3 months (80)
Diet & Exercise
4 months (73)
Diet & Exercise
18 weeks (80)
Eating disorder
4 weeks (54)
Table 3. Combined Effect Sizes of Adaptations of Motivational Interviewing (AMIs) by
Problem Area
AMIs compared with no-treatment/
AMIs compared
placebo control
with active
Problem Area
d (95% CI)
d (95% CI)
Alcohol (SEC)
0.25 (0.13-0.37)
0.21 (0.09-0.33)
0.09 (-0.04-0.23)
Alcohol (BAC)
----0.53 (0.20-0.86)
Smoking Cessation
0.11 (-0.11-0.27)
0.11 (-0.66-0.27)
--Drug Addiction
---0.01 (-0.25-0.25)
0.56 (0.31-0.82)
0.01 (-0.29-0.31)
-0.11 (-0.30-0.29)
Diet & Exercise
0.57 (0.33-0.81)
--0.53 (0.32-0.74)
Effect sizes (d) in bold are significant at p<.05. CI=Confidence Interval; TA=total attrition; SEC=standard
ethanol content (a measure of drinking frequency); BAC= (peak) blood alcohol concentrations (a measure
of degree of intoxication); dashes indicates the data were not available.
*The effect size is the difference in outcomes between the intervention and control groups divided
by the standard deviation. The effect size summarizes the results of each study in terms of the
number of standard deviations of difference between the intervention and control groups. (Guyatt
D, Rennie D. User’s Guide to the Medical Literature. AMA Press. P167)
**In this review, effect size means that a person receiving the AMI treatment improved by an
average of d standard deviations on that measure relative to someone in the control group.
***The conventional values of effect size are:
d = .20
d = .50
d = .80
Hettema J, Steele J, Miller WR.
A Meta-Analysis of Research on Motivational Interviewing Treatment
Effectiveness (MARMITE). Annual Review of Clinical Psychology.
Table 1. Included Studies
Numbers of Studies
Problem Area
Substance Abuse
HIV Risk Behavior
Treatment Compliance
Water Purification
Diet and Exercise
Eating Disorders
Sample Size:
Ranged from 21 to 952, mean of 198 participants
Table 2. Sample Characteristics
Male 54.8% (0-100%)
Mean Age 34 (16-62)
Minorities 43%
ƒ Effects of MI across studies, within problem areas, appear early.
Effects of MI diminish over time, except in additive studies.
Table 3. Effect Size of MI over time
4-6 months
6-12 months
Effective Size (d)
Table 4. Mean Combined Effects Size by Problem Area (N=72 Clinical Trials)
Effect Size
Problem Area
HIV Risk Behavior
3 Months
Drug Abuse
Public Health
Treatment Adherence
HIV Risk Behavior
Drug Abuse
Public Health
Treatment Adherence
ƒ Robust and enduring effects when MI is added at the beginning of treatment
o MI increases treatment retention
o MI increases treatment adherence
o MI increases staff-perceived motivation
The effects of motivational interviewing emerge relatively quickly
The between-group effects of motivational interviewing tend to diminish over
12 months.
o This is also true for other treatments.
o This may not be true of MI’s additive effects with other treatment.
Effects of MI are highly variable across sites and providers.
o This is also true of other treatments, but may be more true with MI.
o Provider baseline characteristics do not predict effectiveness with MI
II. Key techniques of Motivational Interviewing:
A. Basic Skills: Keys to patient-centered counseling: “Use your OARS”
Open ended questions: What concerns you about your current situation?
Tell me about your drinking.
Affirm; I admire you sharing your fears with me today, it takes a lot to share
something so personal
Reflect: I. Simple (restate/paraphrase): You are worried about your drinking.
II. Strategic
A. Amplified: You can’t see ANY possible benefits to cutting back
on your drinking.
B. Double Sided: On the one hand you like the fact a cigarette
helps you relax, but on the other hand, you are
worried about the health risk of smoking for so
many years.
C. Reframing: “Nagging wife” reframed as “caring wife”
D. Agree w/ a twist: You don’t see any reasons to quit smoking
yourself, since you are currently healthy, despite the
fact you know that cigarettes led to your father
having a heart attack at an early age.
Summarize: “You are not quite sure you are ready to make a change. On the one
hand, alcohol helps you relax and you enjoy going out drinking
with your friends, however on the other hand, you are aware that
your drinking has raised concerns from your wife and your boss,
and you are worried it might even lead to problems with your liver
if you keep on this path.”
B. Advanced Skills: The ABCs of MI
Express Empathy: Express acceptance, affirmation in genuine, respectful way
Develop Discrepancy: Explore patients’ concerns and perspectives, help pt see
discrepancy b/w current behavior & future goals
Analyze Ambivalence: Explore and help resolve patients’ ambivalence
Use of decision balance (The good, the not-so-good)
Roll with Resistance: Avoid arguing with patient
Instead, try these tools:
Use reflections in response to resistance talk
Emphasize personal control
Ex.“Only you can decide what is best for you.”
Shift focus using a summarization
Give paradoxical challenge (arguing against
Ex. “You’re not even sure if you could quit, even if
you wanted to.”
“This may not be for you”
“No matter what happens in life, your smoking will
always be a part of it.”
Support Self-Efficacy: Emphasize personal choice and control
C. Useful Techniques for Creating Change Talk
ƒ Exploring personal goals/values
What are your goals for your life? What do you value most?
ƒ Decision balance (the good, the not-so-good)
“There are always 2 sides to change, the good things, and the not-so-good
things. Maybe we could spend a bit of time thinking about how you feel
about your drinking. What are some of this good things about drinking?
What are some of the not-so-good things?”
C. Useful Techniques for Creating Change Talk (continued)
Imagine extremes
If you continue drinking, what do you think is the worst thing that could
happen? If you tried to reduce your drinking, what do you think is the best
thing that could happen?
Hypothetical change
Suppose you did make this change, what do you think it was that made it
work? How did it happen?
Review a typical day (present)
Tell me a little bit about what life is like for you, describe your typical day.
Looking back (past)
“Tell me a little bit about what life was like for you before you started
“What’s different now?”
Looking forward (future)
“Looking ahead 5 years, what would you like your life to be?”
“How does what you’re doing right now fit into that?”
“What would your life be like in 10yrs if you kept on the same track?”
“What would if look like if you did make the change to quit drinking?”
Imagining extremes
“What’s the worst thing you could imagine would happen if you continued
the way you’re going now?
Assess importance, readiness, confidence (0-10 scale)
“How important is it for you, on a scale from 1-10, to change any aspect
of your drinking?”
“How ready are you to make that change right now, on a 1-10 scale?”
“How confident are you that you can make that change, on a 1-10 scale?”
“What made you say a ‘4’ and not a ‘1’?”
Review past successes, reframe past failures
What has worked for you in the past, when you made up your mind to
make a change?
Review personal strengths/supports
What strong points do you have that could help you make this change?
III. Traps to Avoid:
“Expert” stance (goal is collaborative partnership, empower patient)
Arguing for change (remember, let the patient be the one to argue for change
when he/she is ready)
Question-answer (leads to a passive role in the patient)
Premature focus (a set up for failure, need to lay foundation first)
Assigning blame, labeling (not conducive to lasting change)
Advice without permission (avoid authoritative relationship)
Doing most of the talking (the patients words have greatest impact)
IV. Additional Sample Questions
ƒ Would you mind spending a few moments talking about your drinking and how
you see it affecting your health?
ƒ How do you feel about your drinking?
ƒ What concerns you about your current situation?
ƒ How does alcohol affect your life?
Open ended:
ƒ Tell me about…
ƒ I’d like to know more about…
ƒ What else?
ƒ How do you think your drinking fits in with those goals?
ƒ What do you think your wife would say are the not-so-good things about your
ƒ What would have to happen for you to know that this is a problem?
ƒ What would be some advantages of not drinking?
ƒ How might you go about a change? What would be a good first step? What
obstacles do you see? How might you deal with them?
ƒ What barriers are keeping you from changing now?
ƒ What things have helped you in the past?
ƒ What would get in your way of stopping smoking?
ƒ What would it be like for you to not drink?
ƒ What is your plan? How are you going to do this?
ƒ What would it take for you to consider thinking about a change?
ƒ You’ve obviously thought a lot about this issue.
ƒ You really express yourself well and you have a lot of insight into this matter.
ƒ Thank you for sharing this with me today.
ƒ I admire you sharing your fears with me today, it takes a lot of courage to share
something so personal.
Raise client awareness:
Give feedback with permission, non confrontational, use objective data if possible
ƒ What do you make of these results?
ƒ Is this right for you? What do you think about it?
ƒ Is there anything else you would like to know about the topic?
ƒ Here are some options for change, what do you think would work best for you?
Give advice w/ permission:
o “I have some ideas, would you like to hear them?”
o “Here’s something that’s worked for others, it may not be a fit for you,
what do you think?”
V. Bibliography
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Further Recommended Reading in MI:
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Deterioration over time in effect of Motivational Interviewing in reducing drug consumption and related
risk among young people. Addiction. 2005 Apr;100(4):470-8.
Miller WR.
Motivational interviewing and the incredible shrinking treatment effect. Addiction. 2005 Apr;100(4):421.
Lange N, Tigges BB.
Influence positive change with motivational interviewing. Nurse Pract. 2005 Mar;30(3):44-53.
Samet JH, Horton NJ, Meli S, Dukes K, Tripps T, Sullivan L, Freedberg KA.
A randomized controlled trial to enhance antiretroviral therapy adherence in patients with a history of alcohol
problems. Antivir Ther. 2005;10(1):83-93.
Kanouse DE, Bluthenthal RN, Bogart L, Iguchi MY, Perry S, Sand K,
Shoptaw S.
Recruiting drug-using men who have sex with men into behavioral interventions: a two-stage approach. J
Urban Health. 2005 Mar;82(1 Suppl 1):i109-i119. Epub 2005 Feb 28.
Baker A, Lee NK, Claire M, Lewin TJ, Grant T, et al.
Brief cognitive behavioural interventions for regular amphetamine users: a step in the right direction. Addiction.
2005 Mar;100(3):367-78.
Moyers TB, Martin T, Manuel JK, Hendrickson SM, Miller WR.
Assessing competence in the use of motivational interviewing. J Subst Abuse Treat. 2005 Jan;28(1):1926.
Channon S, Huws-Thomas MV, Rollnick S, Gregory JW.
The potential of motivational interviewing. Diabet Med. 2005 Mar;22(3):353.
Stewart SH, Conrod PJ, Marlatt GA, Comeau MN, Thush C, Krank M.
New developments in prevention and early intervention for alcohol abuse in youths. Alcohol Clin Exp
Res. 2005 Feb;29(2):278-86.
Parsons JT, Rosof E, Punzalan JC, Di Maria L.
Integration of motivational interviewing and cognitive behavioral therapy to improve HIV medication adherence
and reduce substance use among HIV-positive men and women: results of a pilot project. AIDS Patient Care
STDS. 2005 Jan;19(1):31-9.
Lane C, Huws-Thomas M, Hood K, Rollnick S, Edwards K, Robling M.
Measuring adaptations of motivational interviewing: the development and validation of the behavior change
counseling index (BECCI). Patient Educ Couns. 2005 Feb;56(2):166-73.
Rakel D, Rindfleisch A.
Optimal healers: igniting the spark and fanning the flame. Training academic medical faculty in optimal
healing. J Altern Complement Med. 2004;10 Suppl 1:S113-20.
Westra HA.
Managing resistance in cognitive behavioural therapy: the application of motivational interviewing in mixed
anxiety and depression. Cogn Behav Ther. 2004;33(4):161-75.
Marrero CA, Robles RR, Colon HM, Reyes JC, Matos TD, Sahai H, Calderon JM, Shepard EW.
Factors associated with drug treatment dropout among injection drug users in Puerto Rico. Addict Behav. 2005
Feinstein RE, Feinstein MS.
Psychotherapy for health and lifestyle change. J Clin Psychol. 2004 Dec 21;57(11):1263-1275.
Moyers TB, Rollnick S.
A motivational interviewing perspective on resistance in psychotherapy. J Clin Psychol. 2004 Dec
Miller WR, Yahne CE, Moyers TB, Martinez J, Pirritano M.
A randomized trial of methods to help clinicians learn motivational interviewing. J Consult Clin Psychol. 2004
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Innovative techniques to address retention in a behavioral weight-loss trial. Health Educ Res. 2004 Dec 14;
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trial. Nurs Res. 2004 Nov-Dec;53(6):396-405.
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sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial. Nephrol Dial
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2004 Sep;27(2):123-34.
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