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Motivational Interviewing A Guide for Medical Trainees
Second Edition
Edited by
Antoine Douaihy
University of Pittsburgh School of Medicine
Thomas M. Kelly
University of Pittsburgh School of Medicine
Melanie A. Gold
Columbia University Irving Medical Center
Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.
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CIP data is on file at the Library of Congress
ISBN 978–0–19–758387–6
DOI: 10.1093/med/9780197583876.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.
Printed by Sheridan Books, Inc., United States of America
Sarah Minney and Julie Childers
2. The Style and Spirit of Motivational Interviewing
Antoine Douaihy, Melanie A. Gold, Gail Gutman, and Dina Romo
3.
Amelie Meltzer, Morgan Faeder, and Thomas M. Kelly
Mark D’Alesio, Thomas M. Kelly, and Antoine Douaihy
Miriam Rosen and Julie Kmiec
Areej Ali and Erin Smith
7.
Janice Pringle and Mara Rice-Stubbs
8. Motivational
Carolyn Windler and Brianna Rossiter
12.
Daniel Salahuddin and Esa Matius Davis
Antoine Douaihy, Thomas M. Kelly, Augusto Bermudez, and David Bell
Lindsay Leikam, Dana Rofey, and Melanie A. Gold
Lauren Auster, Judy Chang, and Elizabeth Miller
Joshua T. Morra, Daniel Cohen, Melinda Armstead, and Antoine Douaihy
Vivianne Oyefusi and Jeanette South-Paul
Jessica J. Stephens and Melanie A.
Jordon Post and Jessica Gannon
Elizabeth
23. Integration of Motivational Interviewing in Medical Training
Laura Marengo and Neeta Shenai
24. The Ethical Practice of Motivational Interviewing in Healthcare Settings
Lisa Forsberg, Isra Black, and Mariel Piechowicz
Epilogue
Patrick H. Driscoll
Foreword
It is hard to think of a request to write a foreword for a book as captivating as this one. The case for using Motivational Interviewing (MI) in routine practice is well-made. It is one thing to locate and describe research evidence and another to bring it to life. MI is illustrated in so many ways in this book that it is hard to put it down. Clinical scenarios, calls from the hearts of experienced clinicians, illustrative dialogue, quizzes, literature reviews, hot topics like health disparities and ethical practice, specialist applications in different medical settings, and the list goes on. In the end, the book is a call to consider what kind of person and doctor you would like to be. Showing that MI directly helps medical trainees to answer this question is a considerable achievement by this diverse group of authors. The skills for improving your well-being and practice are here for the taking. The more experienced clinicians will also find this one of the most useful handbooks to keep close to one’s desk.
Stephen Rollnick, PhD Cardiff University
William R. Miller, PhD
The University of New Mexico
Preface
Building on the pioneering work of Drs. William R. Miller and Stephen Rollnick, Motivational Interviewing: A Guide for Medical Trainees, Second Edition is a 24-chapter volume that guides medical trainees which is used interchangeably with practitioners on the practice and applications of Motivational Interviewing (MI) in a variety of healthcare settings. Much has happened in the MI field since the first edition of this book. The number of clinical research trials and studies of MI-based interventions has exploded exponentially, and those studies now clearly demonstrate the effectiveness of MI for a wide range of medical practices, including the treatment of psychological disorders, and patient populations. The current edition of this guide attempts to distill the extensive research findings to what is most meaningful and important in real-life clinical encounters for practicing medical trainees. The contributors of this book are medical trainees, mentors, and specialists who offer their unique collaborative perspective as they implement MI in their daily practice of patient care. This is essentially a guide by trainees for trainees. This guide is arranged into two parts. To lay the groundwork for incorporating MI into clinical encounters, Part I provides an overview of its foundations, skills, and strategies of MI, and the role of ambivalence and processes of change in MI. Part II focuses on the clinical applications of MI in diverse healthcare settings and patient populations. The fundamentals of MI are presented as they relate to a particular medical setting and specialty, such as using MI in pediatric populations or psychiatric care. The guide also includes a couple of chapters addressing challenges related to integrating MI in the context of the latest technological advances in medicine, such as telemedicine and electronic medical record utilization. Chapter 16 is devoted to the intersection of MI and social justice and particularly the role of MI in addressing healthcare access and disparities. A new chapter covers the issues related to the ethical practice of MI in healthcare settings.
This clearly written book is augmented by clinical vignettes of patienttrainee interactions, which are followed by detailed explanations of the clinical rationale for using MI, with a specific emphasis on its spirit and method, in each vignette, which provides a dynamic guidance to trainees on how to implement MI-adherent practices with the ultimate goal of improving patients’ health-related outcomes. This volume also incorporates video clips of clinical
encounters conducted by two medical trainees, illustrating the mindset and “heartset” of practicing MI. A coding sheet for every video the trainees watch is included to help with assessing adherence to MI spirit and skills.
Each chapter offers the trainees’ personal reflections on their experiences with doing and being MI as well as how they came to realize its value in the healing process for their patients. A question-and-answer section at the end of each chapter allows the readers to assess their knowledge of the concepts and strategies presented.
A challenge in the writing and editing of this guide has been about maintaining a consistent vision as we offer a wide range of experiences and perspectives from many contributors. With humility, we have made every effort to give a pragmatic and unified voice to the spirit of MI.
This guide has been conceptualized and designed for medical trainees. At the same time, it will serve as an invaluable resource for all healthcare professionals who wish to learn about the foundations and applications of MI across healthcare settings and its impact on patient outcomes.
Prologue
Jared Kopelman
I used to think I was a good listener. After all, I could talk to patients, hear the words they said, and write them down to present later or use to formulate a differential diagnosis. What else is there to listening? When I started to learn and practice Motivational Interviewing (MI) this month, I realized the answer to that question: a lot. MI requires more than just silence and eye contact while a patient is speaking; it requires you to formulate active reflections of what the patient is saying. These reflections require a type of listening I had rarely practiced before, and I was initially frustrated at how difficult I found it. When you are practicing this type of listening, there is no hiding. You cannot “zone out” for even the briefest period. To be able to accurately reflect what patients have said back to them, you have to truly understand the meaning behind the patients’ words.
An example of both the difficulty and strength of this approach arose when I was working with one of my first patients on the dual diagnosis service, KS, a 34-year-old woman with alcohol use disorder. Our discussion revolved around a particular medication, aripiprazole (antipsychotic medication used to treat psychotic and bipolar disorders), which she had taken in the past. In this conversation, I was tasked with informing her that we would not be prescribing her this medication when she left the hospital, as there was no indication for her to be on it. She had demonstrated no signs of bipolar disorder, and her history of symptoms was not consistent with this disorder. Rather, we believed she carried the diagnosis of severe alcohol use disorder, which included periods of binge drinking lasting days, where she would sometimes only sleep for an hour or two a night. I recognized this conversation as potentially perilous. I was telling her that I did not believe she carried a diagnosis that she believed she did, a direct challenge to a longstanding part of how she identified herself and explained her behavior. Further, I was telling her that we would not be prescribing her a medication that she endorsed as helpful in the past, which could be seen as undermining her experience and, therefore, disempowering.
Previously, I would have approached this conversation nervous about the potential for conflict, but confident that I was armed with the facts—facts that she would accept if I could just make my case persuasively enough. I could
rattle off the diagnostic criteria for bipolar disorder, which she did not meet; I could explain that there was no evidence aripiprazole would treat people with her diagnosis; I could even explain away her belief that this drug had helped her because her taking aripiprazole coincided with her period of abstinence from alcohol, which was likely the larger contributor to her improved mood. I had approached a prior discussion with her (about the duration of her hospitalization) just this way, and the conversation ended with her saying, “we have nothing more to discuss,” and walking out angrily. Determined not to replicate this conversation and equipped with some rudimentary and recently acquired MI skills, I approached the conversation differently. The issue of her diagnosis and the possibility of us discontinuing her aripiprazole had been touched on briefly in a prior session. I started by simply asking her what she thought of that previous discussion. She said she was surprised when she first heard this and then described some of her previous symptoms and behaviors, including an inability to regulate her emotions (which led to her drinking), as well as rapid shifts in her mood. I reflected to her the difficulty of these mood swings and how they affected her life and then related them to some of the skills she had developed during her hospitalization. Coping strategies that we had discussed in our sessions, that she had worked on in group sessions, and that she had worked through in workbooks could all be applied to these situations. As we discussed different strategies for how she could deal with her emotions when she left the hospital, the label of her illness became less important. Rather, what was important was her experience of the symptoms of her illness, the recognition of the distress it caused her by her practitioner, and our shared goal of giving her the skills she would need to better deal with these emotions in the future. By reflecting her distress and her difficulty coping with the stressors that led to her alcohol use, I was able to help her understand her disorder and empower her to use the tools that she had been working on to mitigate those stressors.
What my experiences with KS, and my experiences with MI more broadly, have taught me is that there can be no true listening without empathy. Reflective listening allows you to support patients by acknowledging their feelings and experiences, and it allows you to develop a nonjudgmental, collaborative patient-practitioner relationship. Further, empathy, when thought of like this, is not simply something you have. It is not a finite resource that can be used up at the end of a stressful day (or week or month or career). Rather, it is something that we can cultivate and use to empower our patients and collaborate with them to reach their goals.
Acknowledgments
First of all, I want to express my gratitude and appreciation to my coeditors and collaborators, Tom and Melanie, and all contributors for their work, encouragement, guidance, and wisdom in helping shape and refine this project. I have been privileged to learn and contribute to the learning experience of medical trainees who have provided me intellectual engagement and inspiration. I am also deeply indebted to my patients of diverse backgrounds, who trusted me with their minds and hearts, and who have taught me the true meaning of empathy and compassion. A special word of appreciation goes to Dennis Daley. As a mentor, collaborator, and friend, Dennis has played a major role in the development of my personal and professional identity. This book was made possible because of the work, inspiration, generosity, and influence of many pioneers of Motivational Interviewing (MI) who developed and researched the practical approaches in this guide, including Bill Miller, Steve Rollnick, Terri Moyers, and many others. In the preparation of this work, the members of the Motivational Interviewing Network of Trainers (MINT) have contributed tremendously to systematically consolidating my perspectives and publishing them. Finally, I am especially grateful to Senior Editor Andrea Knoblock and Project Editor Katie Lakina at Oxford University Press for guiding us through another enriching editorial experience and production process.
Antoine Douaihy
First, I acknowledge my coeditors, Antoine and Melanie. This work was created because of Antoine’s vision of its significance for the field, and I thank him for persuading me of its importance. Melanie’s breadth and depth of experience brought an enlightened perspective to every chapter. Second, the group of practitioners involved in writing this volume provided most of the inspiration for its content. Their experiences as specialists brings a truly unique perspective to learning how MI is effective with patients in all healthcare fields. A subgroup of these young practitioners provided exceptional creativity and technical expertise in creating the illustrations and videos. I want to thank Dennis Daley for mentoring me and for the ongoing support he has provided me as a faculty member, clinician, and as a specialist in applied addiction research. John E. Donovan was also instrumental in my postdoctoral training as
a clinician-researcher. My early training in individual and family therapy was critical because I was taught by an outstanding group of clinicians, especially Tom Saunders. Later, at Western Psychiatric Hospital, the late Carol Anderson helped me to recognize the overarching influence of the family system as a model for diagnosing and addressing problems in family therapy. Similarly, William Cohen widened my knowledge of psychotherapy. Under his tutelage I came to recognize that each patient, or family, requires both a treatment plan and an individualized therapeutic strategy. Paul Soloff helped me to understand the critical integration of intrapsychic and interpersonal dynamics that exist in the treatment of all patients. These are the influences that I try to combine with the relational style that is the core of MI. I have learned that a strong therapeutic alliance provides the best opportunity for treating psychological and behavioral maladies, and that MI is the best way to establish such an alliance. My hope is that the perspectives expressed in this volume will stimulate medical trainees to integrate the content of their medical training with Bill Miller’s and Steve Rollnick’s invaluable process for establishing truly therapeutic relationships.
Thomas M. Kelly
Editing a book is never a solitary effort. This guide would have been impossible without the hard work, support, and collaboration of my two amazing coeditors and colleagues, Antoine and Tom. Antoine’s vision and perseverance initiated and kept the ball moving on completing this second edition. Tom’s clinical insights and wealth of experience improved every chapter. This guide was inspired by and written by medical trainees, including medical students, residents, and fellows in various fields of medicine. Their collaboration on this guide makes it a true reflection of the “MI spirit.” First and foremost, thanks go to my mother, Rona Beth Fisher, who taught me from the time I could speak, the importance of listening to language, of communication skills, of respect for people and their different perspectives, and of all the other key aspects of MI. It was not until my early years as a faculty person in 1998, when I realized that what my mother had taught me was called MI. I also must thank my friend, colleague, co-investigator, and teacher, Allan Zuckoff, who introduced me to MI and provided me with numerous hours of one-on-one supervision when I was first learning. There is no one who has taught me more about MI than Allan. I would also like to express my appreciation to Bill Miller and Terri Moyers for many years of support in learning and doing research on MI, and especially to Bill Miller and Steve Rollnick for reviewing our second edition of the guide and for agreeing to write the foreword for it. Others I wish to acknowledge, who played critical roles in my
learning to use, teach, and study MI include Carlo DiClemente, Christopher Ryan, and Bill Cohen. Each one played a unique and important role in my development. Finally, I wish to thank the patients, medical students, residents, and fellows at the University of Pittsburgh and at Columbia University; the student-patients, nurse practitioners, health educators, and mental health providers at the NY Presbyterian School Based Health Centers; and all the research staff and research participants from whom I always learn new ways to listen and reflect. You have all enhanced the quality of my MI skills and more importantly brought me great joy and gratitude from our interpersonal relationships.
Melanie A. Gold
About the Editors
Antoine Douaihy, MD, is a professor of Psychiatry and Medicine at the University of Pittsburgh School of Medicine. He serves as the senior academic director of Addiction Medicine Services and director of the Addiction Psychiatry Fellowship at Western Psychiatric Hospital of the University of Pittsburgh Medical Center. Dr. Douaihy has been a member of the Motivational Interviewing Network of Trainers (MINT) since 2002. He has focused his career on patient care, education, mentoring of medical trainees, and research in the areas of psychology of behavior change, Motivational Interviewing (MI), substance use disorders, and HIV Psychiatry. Dr. Douaihy has been a champion in the implementation and dissemination of MI across healthcare settings and has been the recipient of multiple teaching and mentoring awards, including the Leonard Tow Humanism in Medicine Award and The Charles Watson Teaching Award, recognizing him for the qualities of a masterful clinician, academician, caretaker of his patients, educator, mentor, and contributor to the medical school community and community at large.
Thomas M. Kelly, PhD, began his career as a licensed clinical social worker at the Western Psychiatric Hospital of the University of Pittsburgh Medical Center in 1982. Dr. Kelly received his doctoral degree in social work in 1996 from the University of Pittsburgh and served as the director of the Adolescent Substance Abuse Treatment Service until 2014. Dr. Kelly’s other work focused on teaching, consultation, and research. He was a coinvestigator with the National Institute on Drug Abuse Clinical Trials Network and has published over 50 peer-reviewed publications. Dr. Kelly has been a MINT member since 2005, and has conducted training workshops, lectures, and seminars, locally and nationally. Dr. Kelly retired from full-time practice as an associate professor of Psychiatry in 2014. He continues to publish on psychiatric treatment.
Melanie A. Gold, DO, is a former Professor and current Special Lecturer in the Department of Pediatrics in the Division of Child and Adolescent Health, Section of Adolescent Medicine at Columbia University Irving Medical Center. She is a former Professor and current Special Lecturer in the
Department of Population & Family Health at the Mailman School of Public Health at Columbia University. She served as medical director of New York Presbyterian’s School Based Health Centers (SBHCs). Dr. Gold is an osteopathic pediatrician who is board certified in Adolescent Medicine. She trained in MI in 1998 and became a MINT member in 2000. MI has become an integral and critical component of her work as a clinician, researcher, educator, and administrator.
Contributors
Areej Ali, UT Southwestern Medical Center
Melinda Armstead, Erie County Medical Center, Buffalo, New York
Lauren Auster, University of California at San Francisco
David Bell, NY Presbyterian Hospital-Columbia
Augusto Bermudez, NY Presbyterian Hospital-Columbia
Isra Black, University College London
Katelin Blackburn, Boston Children’s Hospital
Cassandra Boness, University of New Mexico
Pamela Burke, Boston Children’s Hospital
Judy Chang, University of Pittsburgh Medical Center
Julie Childers, University of Pittsburgh Medical Center
Daniel Cohen, University of Pittsburgh Medical Center
Elliot Collins, University of Washington Affiliated Hospitals
Amelia Cuevas, University of Pittsburgh School of Medicine
Mark D’Alesio, University of Pittsburgh School of Medicine
Esa Matius Davis, University of Pittsburgh Medical Center
Antoine Douaihy, University of Pittsburgh Medical Center
Patrick H. Driscoll, University of Pittsburgh Medical Center
Morgan Faeder, University of Pittsburgh Medical Center
Lisa Forsberg, University of Oxford
Jessica Gannon, University of Pittsburgh Medical Center
Jody Glance, University of Pittsburgh Medical Center
Melanie A. Gold, Columbia University Irving Medical Center
Tina Goldstein, University of Pittsburgh Medical Center
Gail Gutman, Columbia University Irving Medical Center
Estelle Hirsh, University of Pittsburgh Medical Center
Elizabeth Hovis, Medical College of Wisconsin
Meghan Keil, University of Pittsburgh Medical Center
Thomas M. Kelly, University of Pittsburgh Medical Center
Julie Kmiec, University of Pittsburgh Medical Center
Jared Kopelman, University of California at San Diego
James Latronica, University of Pittsburgh Medical Center
Lindsay Leikam, University of Pittsburgh Medical Center
Laura Marengo, MGH McLean
Amelie Meltzer, University of Pittsburgh School of Medicine
Elizabeth Miller, University of Pittsburgh Medical Center
Sarah Minney, University of Rochester
Joshua T. Morra, Horizon Health
Vivianne Oyefusi, UT Southwestern Medical Center
Mariel Piechowicz, University of Pittsburgh Medical Center
Jordon Post, University of Illinois Chicago
Janice Pringle, University of Pittsburgh School of Pharmacy
Mara Rice-Stubbs, University of Pittsburgh Medical Center
Dana Rofey, University of Pittsburgh Medical Center
Dina Romo, Columbia University Irving Medical Center
Miriam Rosen, University of Pittsburgh Medical Center
Brianna Rossiter, University of Pittsburgh Medical Center
Daniel Salahuddin, University of Pittsburgh Medical Center
Neeta Shenai, University of Wisconsin
Erin Smith, The University of British Columbia
Jeanette South-Paul, University of Pittsburgh Medical Center
Jessica J. Stephens, University of Pittsburgh Medical Center
Carolyn Windler, Tacoma Family Medicine, MultiCare Health System
PART I
FOUNDATIONS OF MOTIVATIONAL INTERVIEWING
1
Motivational Interviewing in Medical Training
Sarah Minney and Julie Childers
We think we listen, but very rarely do we listen with real understanding, true empathy. Yet listening, of this very special kind, is one of the most potent forces for change that I know.
—Carl Rogers, Empathic: An Unappreciated Way of Being, 1975.
PERSONAL REFLECTION (Sarah Minney) (PART I)
Already sweating through my freshly ironed short white coat, I held my breath while I raised my hand to knock twice on the “standardized” patient’s door as instructed. “Come in” said the patient gruffly. All I knew about the patient was the short blurb which was posted on the door. She was here to follow up on some routine liver testing her primary care doctor had ordered. Did I already do or say something wrong? I thought, as I entered the room and registered a look of frustration and a flash of anger in the patient’s eyes. “I’m not really even sure why I’m here, the doctor said they were just routine lab tests and now for some reason they’re not?” she inquired. We just finished our GastroIntestinal (GI) module in school, I thought to myself, so it must be a GI problem I am supposed to diagnose. I ran through a litany of yes-or-no questions about symptoms, the patient’s medical history, social history and medication history, and the patient just grew more and more irritated. “I do not understand why you’re asking me all these questions the doctor already asked me last time. Why can’t you just tell me what is wrong with my liver? This is a waste of time.” Why am I getting nowhere? I thought, and I wished the overhead bell would just ring already and tell me it was time to leave the room. What do you do when there is a communication breakdown between you and your patient? I wrapped up the visit and stepped out of the exam room feeling frustrated and defeated. On reviewing our interactions in our feedback session, I came
to realize that with my urge to correctly diagnose the patient, I had missed the crucial step of listening to the patient. She had been struggling with increased alcohol use and was worried it was the cause of her abnormal liver function. Yet, she was too ashamed to discuss her concern with her doctors. Behind what I had viewed as defensiveness and impatience was really the patient’s fear. As you will come to learn as you continue to read this book, active listening is essential to Motivational Interviewing (MI), and it can transform your interactions with patients.
THE ORIGINS OF MOTIVATIONAL INTERVIEWING: FILLING A NEED
Despite the innumerable biomedical and technological advancements over the past century, the County Health Rankings and Roadmaps model demonstrates that clinical care contributes only 14.9% to 32.5% of health outcomes, and health behaviors contribute 26.5% to 31.6%; this makes health behaviors just as significant, if not more so, compared to medical care in terms of overall health (Park, Roubal, Jovaag, Gennuso, & Catlin, 2015). And as a trainee I spent the majority of my first two years of medical school learning the pathophysiology of disease states rather than how to address the health behaviors that can trigger them. Therefore, it is essential that medical trainees not only learn how to communicate with their patients about health behaviors, but also how to do so efficiently and effectively. We cannot improve the health of our patients without ensuring their success in modifying their desired health behaviors, and thanks to the work of Drs. William “Bill” R. Miller and Stephen “Steve” Rollnick and their development of MI, we have an approach to do that.
Miller stated that developing MI was completely unplanned and unanticipated. It originated initially from an inspiration which came from his own data, whereby he noted that accurate empathy is the therapist skill that best predicts patient reductions in alcohol use (Miller, Benefield, & Tonigan, 1993). Leaving on a sabbatical from the University of New Mexico, Miller started working in an “alcoholism” clinic in Bergen, Norway, in 1982, lecturing on cognitive-behavioral treatment and teaching a group of Norwegian psychologists about reflective listening through role playing with patients and discussing challenging clinical situations. These experiences helped Miller conceptualize some clinical principles and decision rules. This is how MI emerged. Miller reasoned that direct argumentation was an ineffective way to change someone else’s behavior. Instead, he focused on the principle that any person is more likely to be committed to a position that he or she
defends verbally. He pointed out that the patient, not the counselor, argues for change. The MI approach is designed to evoke these arguments. Miller’s first description of MI was published in 1983, in the British journal Behavioural Psychotherapy. In the period after, Miller began doing research and evaluating the approach through working with individuals with alcohol use disorder, who were then referred to as “problem drinkers.” He proposed an approach rooted in the tenets of social psychology, namely cognitive dissonance, and internal attribution (Miller, 1983). Seven years later, he met Rollnick in Australia, who had been teaching MI in addiction treatment programs in the United Kingdom. In collaboration with Rollnick, Miller wrote a more detailed description of MI and its associated clinical processes in the book Motivational Interviewing: Preparing People to Change Addictive Behavior (Miller & Rollnick, 1991).
THEORETICAL UNDERPINNINGS AND ASSOCIATED MODELS
When an individual did not engage in treatment or change a particular behavior, it was attributed to a lack of motivation or a “denial” of their condition. Confrontation is, therefore, the natural therapeutic response, rather than empathy and collaboration. A central tenet of Miller’s approach is the psychological principle that individuals commit more strongly to opinions and arguments when they voice them. Miller proposed that therapists should work to elicit statements from individuals regarding their concerns about their negative behaviors and reasons why they believe they should change their behaviors. This allows the creation of statements that reflect dissonance. These statements, then called “self-motivational statements” and now better known as “change talk,” are then reinforced by the therapist along with an atmosphere that promotes reflection on behavior change. The use of these statements comprise the four “key principles of motivation” that Miller outlines in his 1983 article:
1. De-emphasis on labeling, meaning the focus is not on labeling an individual with a problem but rather having the individual describe their own problems.
2. Individual responsibility, meaning a person can define for themselves if their behavior is a problem and why.
3. Internal attribution, meaning the responsibility to change is placed on the individual rather than the external environment.
4. Cognitive dissonance, reflecting that in order for a behavior change to occur, individuals must recognize the discordance between their thoughts and beliefs versus their behaviors.
As opposed to being fundamentally grounded in psychological theory, the concept of MI arose from intuitive clinical experience. Nevertheless, Miller drew upon several prevailing theories in his descriptions of MI, including the following (Miller & Rose, 2009):
• Leon Festinger’s formulation of cognitive dissonance: that when faced with an internal contradiction, we tend to change our thoughts and beliefs in order to resolve the conflict (Festinger, 1962).
• Daryl Bem’s reformulation of self-perception theory: that just as we are influenced by our observations of our own behaviors, so too are we influenced by what we ourselves say aloud (Bem, 1972).
• Albert Bandura’s self-efficacy theory: that the stronger individuals believe they will succeed in performing a given task, the more likely they will attempt to finish that task (Bandura, 1997).
MI follows Carl Rogers person-centered approach to therapy that is based upon building empathy, congruence, and the positive regard “necessary and sufficient [to establish] interpersonal conditions [which foster] discussion about behavior change.” (Rogers, 1975). However, unlike classic Rogerian therapy, MI is more goal-driven and directional, meaning that there is a clear, positive behavioral outcome.
More recently, self-determination theory (SDT) has been identified as a de facto model for understanding why and how MI works (Deci & Ryan, 2012). SDT postulates that all behaviors may be understood as occurring along a continuum ranging from external regulation to true autonomy, or self-regulation. Both SDT and MI view the concept of motivation as theoretically central to each model and emphasize the importance of patients developing “intrinsic” motives, in addition to assuming responsibility for change. Another similarity is that both models are person-centered and endorse engaging with patients in a safe atmosphere of genuine empathy and unconditional positive regard as a prerequisite for the success of behavioral interventions. SDT emphasizes the core needs of autonomy, competence, and relatedness as relevant to motivating behavior change. Likewise, autonomy support is central to MI and is promoted though reflective listening, eliciting the patient’s perspectives and values, providing a menu of choices, and the marked lack of persuasion
throughout a clinical encounter. Clearly, many of the tenets of SDT provide a theoretical framework to guide an MI approach, and in many ways, MI may be considered as “the interventional method of SDT” (Deci & Ryan, 2012; Resnicow & McMaster, 2012).
THE SPIRIT OF MOTIVATIONAL INTERVIEWING
It is the spirit of MI that allows it to transcend from a counseling style to a tool of equity and social justice. While MI can be characterized by conversational strategies and techniques, it is more accurately defined as a way of being with others. At its core is empathy (as alluded to in this chapter’s epigraph), as the creation of MI largely drew on Miller’s training in Carl Rogers personcentered therapy. With the central tenet of empathy comes a natural positive regard for all-comers, regardless of race, ethnicity, gender identity, sexual orientation, origin of birth, religion, educational level, socioeconomic status, or physical ability. Miller wrote about the relationship between MI and social justice in a plenary published in 2013, which outlined the values inherent to both: compassion, respect, fairness, human potential, prizing of differences, and collaboration. MI allows for these values to be placed into action on an individual level with a natural extension to the family unit, community level, and national level. The spirit of MI will be discussed in detail in Chapter 2.
DEFINITIONS OF MOTIVATIONAL INTERVIEWING
The book Motivational Interviewing: Helping People Change (3rd ed.) (Miller & Rollnick, 2013) offers the following definitions of MI for laypersons and practitioners, along with a more technical definition. MI is:
1. “A collaborative conversation style for strengthening a person’s own motivation and commitment to change” (p.12).
2. “A person-centered counseling style for addressing the common problems of ambivalence about change” (p.24).
3. “A collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for, and commitment to, a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” (p.29).
Figure 1.1 Guarding against burnout.
GUARDING AGAINST COMPASSION FATIGUE
The spirit of MI allows practitioners to navigate emotionally taxing conversations with patients and may even reduce the risk of compassion fatigue (Figure 1.1) (Douaihy, Kelly, & Gold, 2014). As compassion and a belief in human potential and autonomy drive MI, practicing it allows practitioners to let go of the common belief that they have control over or total responsibility for patients’ behaviors and outcomes. This “righting reflex,” which is the desire to “fix,” meaning telling patients what to do, is counter to the MI spirit of supporting patient autonomy and is a known internal risk factor for compassion fatigue and moral injury. By being with patients instead of confronting them, we support their own journeys without judgment, and their own choices without criticism. MI’s unconditional positive regard for others is also a balm to the compassion fatigue many practitioners face and is another high-risk factor for burnout. When we approach patients with curiosity and empathy, the urge to label or categorize patients is diminished. Labels like drug-seeker, vasculopath, sickler, alcoholic, diabetic, poor historian, demented . . . . the list goes on, result in automatic negative thoughts by practitioners as well: they just want drugs, they’ll never stop smoking, they’ll just go home and drink anyway, I can’t determine how to treat them. The conversation changes from how am I going to fix you? to what is your story and how can we work together on what you would like to change? Rollnick and Miller note that the essence of MI can free us from the burden of failure and defeat that often accompanies the unpleasant realization that we cannot make our patients change. By fully embracing the spirit of MI, we become intentional in our perceptions of patients and conscious of our role in our relationships with them.
THE EVIDENCE: APPLICATIONS OF MOTIVATIONAL INTERVIEWING
From its origins as a therapeutic style and treatment modality for addiction, MI has grown and expanded and is put to use for a wide variety of health
behaviors across treatment settings and practitioner types. Because MI is a clinical style with communication skills as its foundation (as will be discussed in subsequent chapters), it can be taught to practitioners across disciplines and requires little in the way of materials. Further, the success of MI in modifying a variety of health behaviors is well-established. Miller and Rose review the dissemination of MI across healthcare settings in a journal article published in 2009; this review is a comprehensive outline of Rollnick’s work in MI in health care as well as that of other practitioners. The success of MI has been proven in numerous health challenges including cardiovascular rehabilitation, diabetes management, hypertension, gambling, smoking, and many others (Douaihy, Kelly, & Gold, 2014; Rubak, 2005). Even brief encounters of 5 to 15 minutes, especially multiple encounters over time, are effective in creating behavior changes (Westra, Aviram, & Doel, 2011). Lastly, as a style rooted in verbal communication, MI can be implemented in telemedicine, which became a necessary component of healthcare in the era of COVID-19 (Chapter 21).
PERSONAL REFLECTION (Sarah Minney) (PART II)
A few months ago, I had a follow-up with a clinic patient of mine who had recently started a beta-blocker for treatment of an essential tremor. Our conversation meandered from its original start to the health effects of alcohol; my patient seemingly out of the blue asked if alcohol use could be contributing to a new hip pain she was having. I thought back to the case I shared with you at the beginning of this chapter; back then, without a working knowledge of MI skills and practice, I struggled to walk alongside my patients rather than in front of my patients and had missed the opportunity to truly listen. This time, I instead approached her questions with openness, curiosity, empathy, and reflective listening, and I came to learn she was struggling with increasing alcohol use but had not known how to ask me for help. I elicited her ambivalence about her drinking pattern—she did not think abstinence made sense because, “I don’t want to lose the fun part of me,” but also stated that “I had a fall so now I know it’s getting dangerous.” This led to change talk regarding her desire to modify her drinking, “I could start with not drinking during the week and going to more of my Jehovah’s meetings,” and her confidence in her ability to change her patterns, “I’ve cut back before and can do it again”— all of these strategies you will learn about through the course of this guide. Rather than leaving the encounter frustrated and defeated, I left feeling fulfilled, and the patient left stating she felt “relieved” and “hopeful.” Clearly, MI strengthens our ability to withstand the very real threat of disillusionment and
emotional exhaustion during medical training. While the process of learning MI requires a meaningful commitment of time and energy, it is an investment with great potential to bring about better outcomes for our patients, and to improve our effectiveness, our time management skills, and the satisfaction we experience in our work as medical trainees.
SELF-ASSESSMENT QUIZ
True or False
1. MI is an evidence-based framework that addresses unhealthy behaviors.
2. MI is a trainee-directed conversation in which trainees assume the role of experts who provide guidance toward a desired behavior change within a patient.
3. Dr. Miller incorporated elements of contemporary psychological theories and adapted them into a goal-driven therapy based on collaboration and respect for patient autonomy.
4. Directly confronting patients regarding their unhealthy behaviors is a cornerstone of MI.
5. Long-term therapy is essential to MI’s success as a clinical intervention.
6. An essential element of the spirit of MI is that trainees must relinquish a sense of having the power to change or control patient behavior.
Answers
1. True. There is an expanding body of scientific literature validating the effectiveness and efficacy of MI for numerous health-related behaviors. Research continues on the use of MI among patients with substance use, anxiety, depression, eating disorders, and chronic medical conditions such as diabetes, heart disease, HIV, and obesity.
2. False. MI is a collaborative conversation between trainees and patients, rooted in the principles of egalitarianism and empathy. It is patientcentered and oriented toward strengthening a patient’s motivation and commitment to targeted behavior change.
3. True. In the 1980s, Dr. Miller was inspired by Festinger’s formulation of cognitive dissonance, Bem’s reformation of self-perception theory, Bandura’s self-efficacy theory, and Rogers person-centered approach.
4. False. MI is based on the observation that argumentative and confrontational approaches compromise trainee–patient relationships and lead to poor outcomes. MI-based interactions are defined by a patient-centered focus, empathy, and support, which have been demonstrated to improve outcomes.
5. False. While MI is effective over the course of long-term practitioner–patient relationships, 64% of studies investigating the use of MI in brief encounters demonstrate positive patient outcomes.
6. True. The false sense of power that some trainees believe they possess to change a patient’s behavior is contrary to the principles of MI. MI focuses on patient-centered care and affirms patient autonomy. Unfortunately, trainees are subject to feelings of failure and defeat when they realize they are unable to force patients to change. Consequently, some trainees are at risk for profound cynicism, burnout, and a pervasive sense of therapeutic nihilism. MI reminds trainees that the responsibility for behavior change rests with patients.
REFERENCES
Bandura, A. (1997). Self-efficacy: The exercise of control. W H Freeman/Times Books/ Henry Holt & Co.
Bem, D. J. (1972). Self-perception theory. In L. Berkowitz, (Ed.), Advances in experimental social psychology (Vol. 6, pp. 1–62). Academic Press.
Deci, E. L., & Ryan, R. M. (2012). Self-determination theory in health care and its relations to motivational interviewing: a few comments. International Journal of Behavioral Nutrition and Physical Activity, 9(24), 24.
Douaihy, A., Kelly, T. M., & Gold, M. A. (2014). Motivational interviewing: A guide for medical trainees. Oxford University Press.
Festinger, L. (1962). Cognitive dissonance. Scientific American, 207(4), 93–106.
Miller, W. R. (1983). Motivational Interviewing with problem drinkers. Behavioural Psychotherapy, 11(2), 147–172.
Miller, W. R. (2013). Motivational Interviewing and social justice. Motivational Interviewing: Training, Research, Implementation, Practice, 1(2), 15–18.
Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455–461.
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. Guilford Press.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
Miller, W. R., & Rose, G. S. (2009). Toward a theory of Motivational Interviewing. American Psychologist, 64(6), 527–537.
Park, H., Roubal, A. M., Jovaag, A., Gennuso, K. P., & Catlin, B. B. (2015). Relative contributions of a set of health factors to selected health outcomes. American Journal of Preventive Medicine, 49(6), 961–969.
Resnicow, K., & McMaster, F. (2012). Motivational Interviewing: moving from why to how with autonomy support. International Journal of Behavioral Nutrition and Physical Activity, 9, 19. Rogers, C. R. (1975). Empathic: An unappreciated way of being. The Counseling Psychologist, 5(2), 2–10.
Rubak, S. (2005). Motivational Interviewing: A systemic review and meta-analysis. British Journal of General Practice, 55(513), 305–312.
Westra, H. A., Aviram, A., & Doell, F. K. (2011). Extending Motivational Interviewing to the treatment of major mental health problems: Current directions and evidence. Canadian Journal of Psychiatry, 56(11), 643–650.
