Resident Editors:  Scott Goldberg, MD

Faculty Editor: Christopher Sha, MD

Bottom Line:

• MI is a brief, directive, patient-centered counseling style for eliciting behavior change by helping people to explore and resolve ambivalence
• The core to MI is a focus on OARS: open-ended questions, affirmations, reflections, and summaries

Overview of Motivational Interviewing

• Motivational Interviewing (MI)  is intended to increase the likelihood that a person may consider an attempt to change a behavior (often surrounding substance use disorders, chronic diseases, mental health, and lifestyle changes; though any behavior can be discussed using MI)
• MI avoids a confrontational style and seeks to build a patient’s self efficacy
• A Cochrane review (of 28 RCTs) published in 2015 found a statistically significant benefit of MI over brief advice or usual care in achieving tobacco cessation rates (RR 1.26, CI 1.16 – 1.36)
  • Subgroup analyses found that MI delivered by primary care physicians achieved greater quit rates than when delivered by counselors
  • Shorter sessions (<20 minutes) appeared more effective than longer sessions
• The concept of MI evolved from experiences in treating alcohol abuse, and was first described by Miller in 1983, whom described it as a “directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence”

Principles of Motivational Interviewing

• Road Map
  • OARS: the foundational core skills
  • Practical tools & strategies
  • The spirit of MI
• OARS – the core of MI
  • Open-Ended questions
    • Questions starting with “How,” “What,” or phrases like “Tell me more about”
    • Close-ended questions lead to a discrete or yes/no response, making it harder to explore complex concepts with patients
  • Affirmations
    • Avoid using the word “I” and try to use more “You” language
      • “You should be proud of yourself for ______” instead of “I’m proud of you”
    • Things to affirm: strengths, past success, future hopes, desires, current or past efforts to improve things, the humanity & character of a client
  • Reflections
    • Probably THE most important tool in MI (counterintuitive to many physicians)
    • Reflections are statements (not questions) that guess what the person means so that they can respond to their own words and ideas
      • Aim to have a reflection to question ratio of 2:1
    • Be ok with sitting with silence after you reflect
    • Reflection examples:
      • Suppose a patient says “I’m just wondering if I really need to exercise more, since I’ve been getting around just fine so far”
      • Simple reflections:
        • Repeat exactly what the speaker said – “you’re wondering if you really need to exercise more”
        • Re-phrase using your own language – “you’re thinking about whether you need to exercise more”
      • Complex reflections
        • Paraphrase and make an inference about the unspoken meaning of what was said – “you’re considering making some life changes to help you exercise more often.”
        • Reflection of feeling (paraphrase emphasizing the emotional dimension of the statement) – “exercising could make you feel more energized.”
        • Use metaphors & similes – “you’re considering turning a new leaf and trying to find time to be more active.”
        • Double-sided – “on one hand, you’ve been able to walk around just fine, and on the other hand, you’re thinking about how to be healthier and exercise more frequently.”
          • ***Pro Tip – always end with the Change Talk (see below) which will lead to the positive change 
  • Summaries
    • Ask the patient for permission to stop for a moment to summarize what you’ve heard
    • When summarizing, remind the patient of the salient points of the discussion, remembering to highlight the Change Talk (see below)
    • At the end of the summary ask:
      • “Did I get that all correct?  Anything you’d like to add or clarify?”
      • Then follow with “so where do you want to go from here?”
         
• Practical Tools in MI
  • Selectively reflect Change Talk –
    • People are more persuaded by what they hear themselves say than by what someone tells them (Self-perception theory: Bem, 1972).
    • Questions that tend to Evoke Change Talk
      • Reasons for change – “why would you want to make a change in this part of your life?”
      • Miracle question – “Suppose a miracle happened and you lost 20 pounds.  What would your life be like then?”
      • Ask for more details or an example whenever you hear change talk arising
      • Looking back – “what were things like before _____?”
      • Looking forward – “How would you like things to turn out for you?  How might your life be different if you ________?”
      • Querying Extremes – “what is the worst thing that could happen if ______?”
      • Explore Goals & Values – ask what a person’s guiding values are, “what do you want in life?”
  • Scaling Questions
    • Two scales that are very effective are the “Importance” and “Confidence” rulers
      • Importance: “How important do you think it is for you to change right now, on a scale of one to ten?”
      • Confidence: “How confident are you, on a scale of one to ten, of being able to change?
    • Can help establish where the patient currently is - after a patient replies with their scale (a 6 out of 10 for example), you can reply - “what made you say a 6?”
    • Can help focus on strengths - ask about why they are their number and not a number lower than what they said – “and why are you a 6 and not a 4?”
    • You can also consider asking “What would it take for you to be an 8 or 9 out of 10?”
  • Offering advice & information
    • Advice should be always given in a neutral, non-judgmental manner
    • Permission should be asked before giving advice
    • Process:
      • Ask permission: “Would you be open to some thoughts/information around ______?”
      • Offer advice: “Based on my professional experience,             might be a good option for you.”
      • Emphasize choice: “Of course, it’s up to you.”
      • Elicit response: “What do you think about this information?”
• The Spirit of MI
  • Asking Permission
    • Putting the power into your patient’s hands is incredibly empowering and can help the patient enter a conversation about a sensitive topic with greater openness 
    • When in doubt, ask for permission.  Patient’s really appreciate if we ask “would it be alright if we spent 5-10 minutes talking about ______”, “are you open to one thought around your alcohol use?”, “can I share one piece of information with you?”, etc.
  • Autonomy
    • People are more motivated to make change when it’s based on their own decisions and choices, rather than an authority figure telling them what to do
    • Often explicitly stating “this is your choice” or “I would never make you, nor could I force you to do ____” can help the patient be less on guard.
  • No Fixin’ No Fixin’ No Fixin'
    • As physicians, our natural response to resistance talk is to work harder to persuade the patient. We believe we are right and that we need to “fix” this behavior. In MI, we must resist the “righting reflex”at all costs. A common matra is “no fixin, no fixin, no fixin.”
    • Instead of trying to fix, we should encourage people to come up with their own solutions as they define them.
  • Supporting Self Efficacy
    • Even when someone is ready to make a change, they can be hindered by a lack of confidence. It is the practitioner’s responsibility to boost a person’s belief that they can achieve their goal. For those stuck in ambivalence about change, they view many experiences in a negative light. We can help reframe things in a more positive light. For instance:
      • “You were able to quit smoking for 1 week once before. It’s not a failure that you didn’t continue to stop. It shows that you could do it again if you choose to.”
      • “You’ve made real progress so far. How does that make you feel?”
      • “You showed up to clinic to talk about change. That shows you’re already taking action.”
  • Rolling with Resistance
    • Resistance is a normal reaction when people are considering change. It can take many forms including disagreement, discounting, interrupting, arguing, blaming, minimizing, excusing. 
  • Dancing Not Wrestling
    • If you find that you are going back and forth with your patient, you may be wrestling with them more than dancing and walking together.  If this is the case, consider reflecting more (remember the ratio of reflections to questions is 2:1) and check in with yourself if you are trying to “fix” your patient

Screening, Brief Intervention, Refer to Treatment (SBIRT)

• SBIRT is designed for use by providers who do not specialize in addiction treatment
• It is a short counseling tool that incorporates elements of MI and can be used for folks with substance use disorders
• Research has shown it to be effective in reducing alcohol use and alcohol-related adverse consequences
• Using alcohol as an example, let’s walk through how to employ SBIRT
• Asking Permission  
• Screening
  • There are many different alcohol screeners out there. A simple one-question screen for alcohol misuse or use disorder is:
    • In the last year, have you had…
      • For men: More than 4 drinks on one occasion or more than 14 drinks per week?
      • For women: More than 3 drinks on one occasion or more than 7 drinks per week?
    • If positive, then proceed to brief intervention.
• Brief Intervention:
  • In 5-15 minutes, the goals are to use the five principles of MI to engage a person in exploring their drinking behavior and the problems it causes by providing information, asking questions, expressing concerns, and providing encouragement
  • Step 1: Inform the patient what healthy drinking is.
  • Step 2: Assess readiness to change
    • If readiness is lowà Step 3a: Enhance motivation
    • If readiness is highàStep 3b: Action plan or treatment
  • Step 3a: Enhancing motivation with open-ended questions, affirmations, reflections and summaries that cover:
    • Pros/Cons: “Help me to understand what drinking/smoking does for you? What are some of the good things about drinking/smoking? Some not so good things?”
    • Rulers: “On a scale from 0 to 10, how important is it that you cut back or quit? Why that number and not a (lower number)?”
    • Goals/Values: “Tell me about what’s important to you? How does that fit in with your drinking/smoking? What would have to happen for you to consider cutting down?”
  • Step 3b: Setting a goal and developing an action plan
    • Making an action plan
      • ELICIT: “You seem ready to make a change. How can I help you to succeed?”
      • PROVIDE: “Here are some strategies that have helped others…”
      • ELICIT: “What might be the next step for you? How will you know if your plan is working?”
  • Step 4: Follow-up: summarize, emphasize patient’s strengths, highlight decisions made
    • “Thanks for taking the time today to talk about your alcohol use. I’d like to check in with you about this at our next appointment. Is that ok with you?”
    • Teach back: “If you told a friend about your plan, what would you say?”
• If patients meet criteria for a Substance Use Disorder: Manage medically and/or refer to treatment (RT). It can be helpful to include a social worker in this step as they may be more aware of available programs.
  • ELICIT: “What have you heard about treatments for alcohol or tobacco?”
  • PROVIDE: “There are a number of different medications or programs that can help…”
  • ELICIT: “What do you think about these options? What would you be willing to try?”

Supplementary Materials

• Alcohol Cessation Resources:
  • Groups: www.ncadi.samhsa.gov and www.aa.org
• Substance Abuse Facility Treatment Locator: http://findtreatment.samhsa.gov/
• Multilingual CA Smoker’s Helpline

(800) 7 NO-BUTTS English

(800) 556-5564 Korean

(800) 838-8917 Cantonese/Mandarin

(800) 45 NO FUME Spanish

(800) 778-8440 Vietnamese

(800) 933-4TDD Hearing Impaired

• You Can Quit Smoking: Information kit for consumers. US Public Health Service. http://www.surgeongeneral.gov/tobacco/

References

“AIPC Article Library | Principles and Techniques of Motivational Interviewing.”
Accessed March 30, 2018. https://www.aipc.net.au/articles/principles-and-techniquesof-motivational-interviewing.

American Public Health Association and Education Development Center, Inc. (2008). Alcohol screening and brief intervention: A guide for public health practitioners. Washington DC: National Highway Traffic Safety Administration, U.S. Department of Transportation.

Babor, TF, McRee BG, Kassebaum PA, Grimaldi, PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse 2007:28(3):7-30.

Berg-Smith, S.  (2016) Motivational Interviewing, An Introduction. 

Berg-Smith, S. (2016) Motivational Interviewing, Continuing the Journey.

Lindson-Hawley, Nicola, Tom P. Thompson, and Rachna Begh. “Motivational Interviewing for Smoking Cessation.” The Cochrane Database of Systematic Reviews, no. 3 (March 2, 2015): CD006936. https://doi.org/10.1002/14651858.CD006936.pub3.

Miller, W. (1983). Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy, 11(2), 147-172.

Top of FormMiller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: Guilford Press.