In the majority of the medical illnesses, establishing a relationship of trust with the patient is key in facilitating treatment adherence. In this sense, 70% of specialists are aware of the fact that good communication with patients encourages adherence. Therapeutic communication with the patient who is holding an unhealthy behaviour can be the way to arouse motivation to change in the individual. The most used method in Healthcare assistance when a habit change is needed (i.e. smoking, dietary habits, alcoholism, among others) is Motivational Interviewing (MI).
What is motivational interviewing?
MI is an easy-to-learn method and its use is associated with a better adherence as well as an increased probability of unhealthy habits change among patients. MI is a technique that can help the professional who attends patients with maladaptive behaviors to improve the therapeutic relationship while addressing emotional aspects without being a psychologist, guiding the patient towards change and facilitating adherence to a healthier lifestyle. MI is a model of care consistent with the current trend in medicine to address chronic disorders where the traditional paternalistic role of the physician is replaced by a guiding role that takes into account the patient’s preferences and concerns, and where learning communication techniques is a logical necessity when most of the time the interaction between physician and patient is through dialogue. This patient-centred and collaborative style of care, aims to reinforce motivation for change by helping the patient to resolve ambivalence towards change through the patient’s own reasons for change (1). In MI, the clinician accepts that ambivalence to change is a normal universal experience that arises before the resolution of a dilemma that is weighed by both pro and cons factors. The clinician acts as a guide, clarifying the patient’s aspirations and strengths, listening to their concerns, increasing their confidence and collaborating in developing a plan for change (2).
MI currently has spread and it is used in different medical settings but it started in the field of addiction treatment. Traditionally, the addicted patient was considered a denier and resistant to submerging his problem, and the most commonly used treatment was the external confrontation in which the therapist pointed out unequivocally the problems of the patients with the substance. However, it was observed that a free of prejudice listening revealed that the patient was neither so denial nor so reluctant to change and that, on the contrary, the confrontational attitudes of the therapist generated both relapse and an early abandonment of treatment (3).
Evidence of the effectiveness of motivational interviewing in treatment adherence
MI, in contrast to the traditional model of care, promotes a collaborative doctor-patient relationship, where information is provided according to the needs of the patient (4). This is vitally important for improving the adherence of the patient with a chronic disorder. Furthermore, since educational interventions have been shown to play a role in improving accidental adherence (that is, due to forgetfulness or lack of understanding of the guidelines), they have no effect on the voluntary commitment to accept the treatment, which is influenced by emotional variables such as concern about the medication side effects or lack of perception of the need for it. The latter can only be avoided in the context of a collaborative and empathic therapeutic relationship (5).
In recent decades MI has spread to various medical disciplines and there are currently more than 200 randomized controlled trials of the use of MI in different clinical settings. A 2005 systematic review found a significant clinical effect in 3 out of 4 studies and it worked better than the traditional standard method in 80% of the studies. In brief sessions of less than 15 minutes, MI was effective in 64% of the studies (6). Similarly, recent meta-analyses have demonstrated the efficacy of MI in achieving behavioural change such as reducing sedentary behaviours, improving diet or increasing physical activity, as well as in improving adherence to therapeutic recommendations in non-addictive settings compared to traditional interventions (7). Furthermore, MI has widely been applied in a number of other health conditions, such as smoking cessation, reporting positive outcomes, to reduce sexual risk behaviours, to improve diabetes management and the engagement in prevention or treatment programs for diabetes or cardiovascular health (8, 9).
There are also studies in the literature in which MI is combined with other strategies such as Cognitive-Behaviour Therapy (CBT) to increase the adherence to the treatment. In the obesity treatment, research shows that it is feasible to integrate MI techniques with behavioural interventions for weight loss, including CBT. In fact, interventions that combine both MI and CBT have the potential to improve health-related outcomes among people with obesity, especially in the long-term (10). Finally, a meta-analysis of Randomized Controlled Trials (RCT) using MI techniques for the treatment of overweight and obesity found an enhanced effectiveness when using MI in combination with a behavioural weight management program (11).
How can Motivational Interviewing be helpful?
Miller and Rollnick’s work (12) in the field of Addiction Medicine, used the phrase “ready, willing and able” to outline three critical components of motivation: the importance of change for the patient (willingness), the confidence to change (ability) and whether change is an immediate priority (readiness). The practitioner, using a non-judgmental style in which ambivalence to change is accepted as normal, helps the individual enter into, continue, and adhere to a specific change strategy, in the context of his/her own desired outcomes, and following the Prochaska and Di Clemente model (12, 13). In contrast to the traditional directive style, MI encourages the physician to develop empathy and assume the role of guiding the patient, which consists in listening while giving support and offering expertise information only if necessary. “Microskills” of MI that will allow the clinician to improve some aspects related to the lack of motivation are known by the acronym OARS (Open Question, Affirmations, Reflective listening and Summarizing) and to which another skill called EPE (Elicit-Provide-Elicit) is added to provide information and advice (14). MI skills are used with the aim of a) improving communication and strengthen the therapeutic relationship, b) identifying the patient’s readiness to change or predisposition to follow the treatment, c) facilitating patient education about his/her disease and increasing collaboration, d) promoting shared decision making and e) improving patient motivation and confidence. These objectives described above, are integrated to help the patient change, and achieve his or her goals in 4 consecutive phases: Engaging, Focusing, Evoking and Planning.
References
1. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: The Guilford Press; 2008.
2. Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. Motivational interviewing. BMJ. 2010;340:c1900.
3. Moyers T, Miller W. Is low therapist empathy toxic? Psychol. Addict Behav. 2013;27:878—84.
4. Stavropoulou C. Non-adherence to medication and doctor-patient relationship: Evidence from a European survey. Patient Educ. Couns. 2011;83:7—13.20.
5. Emmons KM, Rollnick S. Motivational interviewing in healthcare settings opportunities and limitations. Am J Prev. Med.2001;20:68-74.
6. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: A systematic review and meta-analysis. Br J GenPract. 2005;55:305-12.
7. Lundahl B, Moleni T, Burke BL, Butters R, Tollefson D, ButlerC, et al. Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlledtrials. Patient Educ. Couns. 2013;93:157-68.
8. Hall K, Gibbie T, Lubman D. Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Aust Fam Physician. 2012;41(9):660–7.
9. Gowan J, Roller L. Disease state management: Hypercholesterolaemia, diet, statins and risk factors. Aust J Pharm. 2012;93(1106):73–7.
10. Barrett S, Begg S, O’Halloran P, Kingsley M. Integrated motivational interviewing and cognitive behaviour therapy for lifestyle mediators of overweight and obesity in community-dwelling adults: a systematic review and meta-analyses. BMC Public Health [Internet]. 2018 Dec 5;18(1):1160. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6062-9
11. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ, Campbell TS, Hemmelgarn BR. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev [Internet]. 2011 Jul; Available from: http://doi.wiley.com/10.1111/j.1467-789X.2011.00892.x
12. Miller W, Rollnick S. Motivational interviewing: Preparing people for change. 2nd editio. New York: The Guilford Press; 2002.
13. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. J Consult Clin Psychol [Internet]. 1983;51(3):390–5. Available from:
http://doi.apa.org/getdoi.cfm?doi=10.1037/0022-006X.51.3.390
14. Miller W, Rollnick S. La entrevista motivacional: ayudar a las personas a cambiar. Barcelona: Paidós; 2015.
About the author
Julia Vázquez is a clinical and research neuropsychologist working as pre-doc at Vall d’Hebrón Research Institute (VHIR) in different research projects focused on psychological factors and cognition in metabolic disorders. She has expertise in the neuropsychological assessment and treatment of neurodegenerative disease, brain injury and epilepsy patients at Neurology Services at different Hospitals in the city of Barcelona. She had dedicated part of her clinical and research practice to the diagnosis and treatment of learning and language disorders in childhood neurorehabilitation centres. Also, she had collaborated as a teacher of the Neuropsychology master’s degree of the Universitat Autònoma de Barcelona and she is author of contents about Language pathology of the Master of Neuropsychology of the Universitat Oberta de Catalunya.