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Motivating Behavior Change

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Motivating behavior change (Harvard Mental Health Letter, February 2011)

Motivational interviewing helps patients identify reasons to change.

If change were easy, people wouldn’t have to make resolutions every New Year. Anyone who wanted to give up smoking, become sober, or lose weight would do so.

The reality is that changing behavior — especially overcoming an addiction — is difficult. Motivational interviewing is a therapeutic technique many clinicians use to help a patient identify personal reasons for undertaking the hard work of behavior change. Although originally developed for the treatment of alcohol dependence, motivational interviewing is now used to help patients overcome other types of substance abuse, stop smoking, lose weight, increase physical activity, and improve adherence to medical treatment.

Motivational interviewing shares much in common with the transtheoretical or “stages of change” model of behavior change. Although not universally endorsed, the transtheoretical model holds that at any given time, a person is at a particular stage in relation to behavior change: precontemplation, contemplation, preparation, action, or maintenance.

At the precontemplation stage, people do not acknowledge how serious the problem is, or even refuse to admit that they have a problem. At the contemplation stage, they are aware of the problem but have not yet decided to act. Especially for people addicted to alcohol or drugs, the first steps are often the most difficult, and many of them languish too long in the precontemplation and contemplation stages. Motivational interviewing is often best suited for these early stages of change.

A collaborative approach:

The word “interviewing” suggests inquiry rather than advice or instruction. Interviewers ask questions because they don’t know all the answers. In motivational interviewing, clinicians function as partners in dialogue rather than experts. They avoid warnings, confrontations, and direct attempts to argue, persuade, or educate. They do not use diagnostic labels.

A variety of health care clinicians can use motivational interviewing in their practice, including primary care physicians, psychiatrists, psychologists, nurses, and dietitians. Details of how to conduct this therapy are published in manuals and described in a number of papers. Typical sessions involve several components.

Expressing empathy. Clinicians who practice motivational interviewing often employ reflective listening during a session. This is a technique in which clinicians repeat back or paraphrase a patient’s answer, to make sure they understand what the patient is saying.

Developing discrepancies. The clinician draws attention to the discrepancy between the patient’s present behavior and broader interests and values. The clinician may ask a patient to identify personal goals or values. The two will then discuss how the patient could change present behavior in order to reach those goals or live according to those values.

Rolling with resistance. The therapist avoids directly confronting a patient’s resistance to change. One way to roll with resistance is to state arguments for and against change in the same response. Another approach is to be a devil’s advocate, stating reasons not to change so that the patient will be inclined to review points in favor of change. Hearing oneself state those reasons explicitly may foster a commitment to change, along with a fear of disappointing oneself, the therapist, and others who have a stake in one’s life.

Promoting self-efficacy. People are ready to change when they have confidence that they can make the change. Believing that they are in control helps them set high goals, sustain commitments, overcome obstacles, and recover from setbacks. To encourage self-efficacy, clinicians may ask patients to rate, on a scale of 0 to 10, how strongly they are motivated for change, how important change is to them, and how confident they are that they can make the change. If patients rate themselves low on the scale, clinicians ask what it would take to increase motivation or confidence.

Multiple Uses:

Most of the research on motivational interviewing has evaluated its use in treating alcohol and other substance use disorders, but a smaller body of evidence suggests that this technique may also help promote other types of healthy behavior change.

Researchers in Denmark who conducted a meta-analysis of 72 randomized controlled studies found that motivational interviewing proved significantly more effective than traditional clinical advicegiving in about 75% of trials, involving a variety of medical problems. Motivational interviewing produced a large enough change to be clinically (as well as statistically) meaningful in helping people reduce alcohol consumption, lose weight, and lower their blood pressure. What follows are a few examples of the findings of studies focused on particular behaviors.

Substance use. One of the first large clinical trials that evaluated motivational interviewing, Project MATCH, compared four sessions of motivational enhancement therapy (a modified form of motivational interviewing) with two different 12-session treatments for alcohol dependence — cognitive behavioral therapy and a 12-step facilitation (preparation for Alcoholics Anonymous). All three treatments were equally effective, but motivational enhancement therapy took less time than the others, so that patients more quickly reduced their alcohol consumption.

Six other federally funded, multisite studies concluded that motivational interviewing was significantly better than standard community treatment for drug problems and dependence on several measures, including reduction of drug use and increased patient adherence to treatment.

Smoking cessation. The Cochrane Collaboration, an international group of experts, reviewed 14 randomized controlled studies in which motivational interviewing was compared with standard interventions to help people stop smoking. They found that motivational interviewing was significantly more effective than standard care, although quit rates remained low. Motivational interviewing was most likely to help people quit smoking when sessions with a clinician lasted at least 20 minutes, and when the patient saw a clinician multiple times rather than for only a single office visit.

Weight loss. Studies of motivational interviewing to promote weight loss have produced mixed results. A work group convened by the American Dietetic Association reviewed the literature and concluded that motivational interviewing alone was no more effective than traditional diet advice. However, when clinicians combined motivational interviewing with cognitive behavioral therapy, patients were more likely to eat more fruits and vegetables, consume less fatty food, and lose weight than those who received only traditional advice.

Although motivational interviewing does not work for every patient, it is a flexible approach to therapy that enlists the most powerful instigator of change: the patient’s own desire to make it happen.

References:

Lai DT, et al. “Motivational Interviewing for Smoking Cessation,” Cochrane Database of Systematic Reviews (Jan. 20, 2010): Doc. No. CD006936.

Miller WR, et al. “Toward a Theory of Motivational Interviewing,” American Psychologist (Sept. 2009): Vol. 64, No. 6, pp. 527–37.

Pollak KI, et al. “Physician Communication Techniques and Weight Loss in Adults: Project CHAT,” American Journal of Preventive Medicine (Oct. 2010): Vol. 39, No. 4, pp. 321–28.

Rollnick S, et al. “Motivational Interviewing,” BMJ (April 27, 2010): Electronic publication.

For more references, please see www.health.harvard.edu/mentalextra.

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