motivational interviewing in social work essay

• DOI: 10.1177/1468017305051365
• Corpus ID: 143806288

Motivational Interviewing and Social Work Practice

• Published 1 April 2005
• Journal of Social Work

60 Citations

Resistance is futile exploring the potential of motivational interviewing, motivational interviewing: an approach to support youth aging out of foster care, the role of empathy in training social work students in motivational interviewing, motivational interviewing: creating a leadership role for social work in the era of healthcare reform, motivational interviewing: an evidence-based practice for improving student practice skills, motivational interviewing at the intersections of depression and intimate partner violence among african american women, impact of motivational interviewing by social workers on service users: a systematic review, the utility of motivational interviewing in domestic violence shelters: a qualitative exploration, applying motivational interviewing in a domestic violence shelter: a pilot study evaluating the training of shelter staff, problem gambling: a suitable case for social work, 58 references, motivational interviewing with problem drinkers, negotiating behaviour change in medical settings: the development of brief motivational interviewing, the use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review..

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Motivational consulting versus brief advice for smokers in general practice: a randomized trial

Motivational interviewing: an intervention tool for child welfare case workers working with substance-abusing parents., motivational interviewing: preparing people for change., motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients., motivational interviewing with problem drinkers: ii. the drinker's check-up as a preventive intervention, advanced generalist social work practice, a motivational interviewing intervention to increase fruit and vegetable intake through black churches: results of the eat for life trial., related papers.

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Motivational Interviewing in Social Work Practice

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Aisha Holloway, Motivational Interviewing in Social Work Practice, Alcohol and Alcoholism , Volume 47, Issue 3, May/June 2012, Page 362, https://doi.org/10.1093/alcalc/ags006

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This book is part of a series of volumes on Motivational Interviewing (MI) approaches. This volume relates to social work practice. William R. Miller and Stephen Rollnick edit this series, which—by virtue of their classic MI—means that this book has on the face of it a ‘good pedigree’. Melinda Hohman, Professor of Social Work, is the author tasked with bringing together a range of evidence-based presentations on the implementation and application of MI. These are brought to life through provision of case examples and step-by-step guidance, directing the reader accordingly. Hohman teaches social work practice, substance abuse treatment and MI at both undergraduate and graduate level. As a trainer in MI since the late 1990s, she clearly has a wealth of knowledge, expertise and experience to draw upon. Likewise, the 10 contributing authors all have related knowledge and experience.

The premise of the book is to bring to life information and examples of the skills that social workers use in their day-to-day work, crossing several facets of the social work environment. The foundations of MI are set out, which will be of use to newcomers. Interspersed throughout the book are dialogue examples that I personally find very useful when contemplating the idea of transferring theory into practice. All too often practitioners are faced with the evidence for a particular method/intervention but have nothing tangible in a clinical sense to take into their workplace. However, as a reader, one must not be lulled into thinking that by reading this book you are practised in MI, something the book is not trying to achieve. What the book does provide is a decent body of dialogue with enough guidance that the reader will be able to learn and reflect upon situations where MI may be appropriately implemented and integrated within practice. It has to be commended for this.

Traditionally, we are used to seeing MI used as an intervention for substance abuse; here however we see it applied to relatively novel situations such as mental health, school social work and intimate partner violence (IPV). The IPV vignette focuses on a 35-year-old mother of three survivor of IPV and how MI methods can be harnessed to support key components of self-efficacy, offering effective approaches to problem-solving in the future. This example provided an example of how MI can be implemented while building a therapeutic relationship with the client who can be empowered to make positive change.

Despite attempts to present an international flavour, the book is top heavy on contributions from across the pond with only two of the authors hailing from outside the USA. There is the acknowledgement of MI as a cross-cultural practice (although somewhat brief) and I would imagine that for those readers outside of the USA, the ‘Experiences from the Field’ would be particularly useful where Rhoda Emlyn-Jones and two other contributors describes the integration of MI in their day-to-day practice—in the case of Emlyn-Jones, this is in the UK. That aside, this small book appears to be a useful addition to the idea of the application of MI within a broader range of services or settings than one would traditionally think of.

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Impact of Motivational Interviewing by Social Workers on Service Users: A Systematic Review

• February 2019
• Research on Social Work Practice 29(8):104973151982737
• 29(8):104973151982737

• The Open University (UK)

• London South Bank University

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Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Health and Social Care, Edinburgh Napier University, Sighthill Court, Scotland, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Affiliation Nursing, Midwifery, Allied Health Professional Research Unit (NMAHP-RU), Glasgow Caledonian University, Glasgow, United Kingdom

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – review & editing

Affiliation Nursing, Midwifery, Allied Health Professional Research Unit (NMAHP-RU), School of Health Sciences, University of Stirling, Stirling, Scotland, United Kingdom

Roles Conceptualization, Supervision, Writing – review & editing

Affiliation School of Health Sciences, Division of Psychology, University of Stirling, Stirling, Scotland, United Kingdom

Roles Conceptualization, Methodology, Writing – review & editing

Current address: Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada.

Roles Conceptualization, Funding acquisition, Supervision, Writing – review & editing

Roles Data curation, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Writing – review & editing

• Helen Frost, 
• Pauline Campbell, 
• Margaret Maxwell, 
• Ronan E. O’Carroll, 
• Stephan U. Dombrowski, 
• Brian Williams, 
• Helen Cheyne, 
• Emma Coles, 
• Alex Pollock

• Published: October 18, 2018
• https://doi.org/10.1371/journal.pone.0204890
• Reader Comments

The challenge of addressing unhealthy lifestyle choice is of global concern. Motivational Interviewing has been widely implemented to help people change their behaviour, but it is unclear for whom it is most beneficial. This overview aims to appraise and synthesise the review evidence for the effectiveness of Motivational Interviewing on health behaviour of adults in health and social care settings.

A systematic review of reviews. Methods were pre-specified and documented in a protocol (PROSPERO–CRD42016049278). We systematically searched 7 electronic databases: CDSR; DARE; PROSPERO; MEDLINE; CINAHL; AMED and PsycINFO from 2000 to May 2018. Two reviewers applied pre-defined selection criteria, extracted data using TIDIER guidelines and assessed methodological quality using the ROBIS tool. We used GRADE criteria to rate the strength of the evidence for reviews including meta-analyses.

Searches identified 5222 records. One hundred and four reviews, including 39 meta-analyses met the inclusion criteria. Most meta-analysis evidence was graded as low or very low (128/155). Moderate quality evidence for mainly short term (<6 months) statistically significant small beneficial effects of Motivational Interviewing were found in 11 of 155 (7%) of meta-analysis comparisons. These outcomes include reducing binge drinking, frequency and quantity of alcohol consumption, substance abuse in people with dependency or addiction, and increasing physical activity participation.

Conclusions

We have created a comprehensive map of reviews relating to Motivational Interviewing to signpost stakeholders to the best available evidence. More high quality research is needed to be confident about the effectiveness of Motivational Interviewing. We identified a large volume of low quality evidence and many areas of overlapping research. To avoid research waste, it is vital for researchers to be aware of existing research, and the implications arising from that research. In the case of Motivational Interviewing issues relating to monitoring and reporting fidelity of interventions need to be addressed.

Citation: Frost H, Campbell P, Maxwell M, O’Carroll RE, Dombrowski SU, Williams B, et al. (2018) Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews. PLoS ONE 13(10): e0204890. https://doi.org/10.1371/journal.pone.0204890

Editor: Ethan Moitra, Brown University, UNITED STATES

Received: October 26, 2017; Accepted: September 17, 2018; Published: October 18, 2018

Copyright: © 2018 Frost et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This work was undertaken by and on behalf of The Scottish Improvement Science Collaborating Centre (SISCC). The Scottish Improvement Science Collaborating Centre (SISCC) is funded by the Scottish Funding Council, Chief Scientist’s Office, NHS Education for Scotland and The Health Foundation with substantial additional investment from partner organisations. Alex Pollock and Pauline Campbell are employed by the Nursing, Midwifery and Allied Health Professions Research Unit, which is funded by the Chief Scientist Office in Scotland. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

There is overwhelming epidemiological evidence that health behaviour such as smoking, substance abuse (drugs and alcohol), physical inactivity, and unhealthy eating are associated with increased morbidity and mortality. The cost to the UK NHS for diseases associated with poor diet, physical inactivity, smoking, alcohol and obesity are estimated to be in excess of £12 billion [ 1 ]. The challenge of addressing unhealthy lifestyle choice is complex and requires sustained behaviour change. The UK NICE (2014) guidelines [ 2 ] recommend a range of behaviour change approaches, guided by a taxonomy of interventions [ 3 ], aimed at changing health-related behaviour of individuals, communities or whole populations.

Motivation to change is a key component of the behaviour change process as it guides and maintains goal-related behaviour [ 4 ]. One approach to change motivation and subsequent behaviour is Motivational Interviewing, introduced by William Miller in 1983 to help people with alcohol problems change their drinking behaviour [ 5 ]. The approach was developed further in the 1990s into “A collaborative conversation style for strengthening a person’s own motivation and commitment to change” [ 5 ]. Motivational Interviewing aims to explore and resolve ambivalence that people might have about health behaviour in favour of change. It encourages people to say why and how they might change and pertains both to a style of relating to others and a set of skills to facilitate that process. The four overlapping processes involve: 1) engaging in a working relationship; 2) focusing on a problem to change; 3) evoking the person’s desire to change; 4) planning the change [ 5 ]. In 1997 an international organisation of trainers established ‘The Motivational Interviewing Network of Trainers (MINT)’ with an aim to improve the quality and effectiveness of counseling and consultations for professional delivering Motivational Interviewing. The organisation has grown to represent 35 countries and 26 languages, which demonstrates the global popularity of this intervention. Some reviews report positive outcomes for Motivational Interviewing and suggest it could be useful for a wide range of behavioural and health problems [ 6 – 9 ] whilst others are more cautious in their conclusions and recommendations [ 10 – 12 ].

Many different health care professionals and other groups are using behaviour change interventions including Motivational Interviewing to help people change or adapt their behaviour. However, it is unclear for which behavioural problems and populations Motivational Interviewing is most beneficial, or in some cases, where there is evidence of no effect or possible harm. This overview aims to identify, appraise and synthesise the review evidence for the effectiveness of Motivational Interviewing on health behaviour of adults in a wide range of health and social care settings to answer the following question;

What is the strength and quality of the current evidence to support the use of Motivational Interviewing to change adult behaviours in health and social care settings?

This question is important to guide health care professionals, researchers and other stakeholders to the most effective and worthwhile interventions for patients.

We conducted a systematic review of existing reviews (referred to as an overview [ 13 ]). An overview synthesises the evidence from more than one systematic review at a variety of different levels, including the combination of different interventions, different outcomes, or people from different populations with different conditions.

Search methods

We systematically searched the following electronic databases from January 2000 to 28th May 2018; Cochrane Database of Systematic Reviews (CDSR); Database of Reviews of Effects (DARE); PROSPERO (an international prospective register of systematic reviews); MEDLINE; CINAHL; AMED and PsycINFO. The search string was adapted for each database. (See Appendix 1 for Medline search). A comprehensive search combined key terms using Boolean operators (e.g. AND, OR) for: Intervention (e.g. "motivational interviewing," "motivational enhancement") and Review type (e.g. "systematic review," "meta-analysis, " "review literature, " "qualitative systematic review," "evidence synthesis" OR "realist synthesis", "qualitative AND synthesis", "meta-synthesis* OR meta synthesis* OR metasynthesis", "meta-ethnograph* OR metaethnograph* OR meta ethnograph*", "meta-study OR metastudy OR meta study"). Truncated forms of these terms and alternative spellings were included. To be eligible for inclusion, reviews met the following criteria:

Inclusion criteria.

• Reviews using structured, pre-planned methods to synthesise research studies addressing a clearly defined topic or research question (which could comprise either quantitative, qualitative or mixed methodology)
• Published from January 2000
• Interventions described as Motivational Interviewing or Motivational Enhancement Therapy (MET) delivered in any format (e.g. face to face, online, group, text or telephone)
• English language
• Interventions focused on adults.

Exclusion criteria.

• Letters, commentaries, expert opinion, theoretical and “non-systematic” or unstructured reviews e.g. reviews without an aim that did not clearly describe the search strategy, selection criteria and quality assessment employed.
• Reviews focused solely on children and adolescents under the age of 18 years
• Reviews focused on Motivational Interviewing intervention to change professional or organisational group behaviour.
• Reviews focused on combined psychological interventions e.g. Motivational Interviewing combined with Cognitive Behavioural Therapy.

Identification of studies

Members of the review team (PC / SM) ran the search strategy and then examined all titles to exclude clearly irrelevant papers. Two reviewers (PC and HF) independently reviewed the abstracts of all potential records identified from the electronic searches and excluded those not meeting the inclusion criteria. Inter-rater reliability was assessed for agreement of abstract screening.

Two reviewers (PC and HF) independently assessed full papers for all potentially relevant reviews. Full text papers ranked as irrelevant by both reviewers were excluded at this stage of the screening process. The final selection of full text papers (judged as relevant or unsure) were discussed at a consensus meeting, with a third reviewer (MM or AP) as required.

Data extraction

Three reviewers (PC, HF and EC) independently extracted the following information: review question or aims; types of studies included; characteristics of participants and numbers included; interventions details. The TIDieR framework[ 14 ] was used to guide reporting of interventions components and comparators. Two reviewers (HF and PC) checked all the extracted data and discussion between the two reviewers resolved any disagreement; with assistance from a third reviewer (AP) when necessary. A data extraction form (excel) specifically developed by the overview author team was used to collate the data.

Categorisation of reviews

Two reviewers (PC and HF) categorised each review into one of four of the following domains depending on the focus of the review.

Domain 1: Stopping or preventing an unhealthy behaviour

Domain 2: Promoting healthy behaviour for a specific problem

Domain 3: Behaviour change for multiple health related problems and /or multiple behaviour problems

Domain 4: Behaviour change in specific settings

Reviews in Domain 1 and 2 were then sub-grouped by HF and PC according to the main health behaviour or problem.

Assessment of quality of reviews

Two reviewers (HF and PC) independently assessed the methodological quality of included reviews using the ROBIS tool [ 15 ]. Any disagreement was resolved through discussion between the two reviewers. The tool covers four domains to detect bias in systematic reviews relating to study eligibility criteria; identification and selection of studies; data collection and study appraisal; synthesis and findings. The full result of assessment of bias aids transparency and aims to help researchers judge risk of bias in the review process, results and conclusions.

Meta-analyses data extraction

One reviewer (PC) extracted comparative data for individual and combined outcomes from any review that included meta-analyses. Data exploring effectiveness of Motivational Interviewing as the main intervention compared with any other intervention or control was extracted. One reviewer (HF) checked the data entry.

This included the following data: Number of trials and participants in the meta-analysis; Measure of effect (e.g. effect size, mean difference, standardised mean difference, relative risk); Measure of variability (95% confidence intervals) and Measure of heterogeneity (I-squared).

Three reviewers (AP, PC and HF) checked the quality assessment of individual studies reported in the reviews and considered the results when grading the evidence. We used the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) criteria to assess whether the quality of the evidence presented in the meta-analyses was high, moderate, low or very low [ 16 ] for all available comparator data within each review. This involved judgement of risk of bias relating to study design, imprecision, inconsistency, indirectness, and publication bias [ 17 ]. In addition, one reviewer (PC) extracted any data that included exploration of moderator variables and tabulated effect size for each comparator.

Meta-analysis synthesis

For reviews including a meta-analysis two reviewers (PC and HF) independently checked the overlap in studies within all the reviews and resolved any uncertainty through discussion. We excluded data superseded by a more up-to-date review (e.g. where a Cochrane review had been updated while we were conducting the overview), or in cases where an overlapping review was conducted with the same review question, we selected the higher quality review judged using the ROBIS quality assessment tool [ 15 ]. We tabulated the intervention, comparison, outcome, number of studies and participants’ data relating to effectiveness and the GRADE of evidence [ 18 ]. Using the data relating to effectiveness we noted whether there was statistically significant evidence of benefit or harm for each outcome reported in the meta-analyses, or if there was no evidence of benefit or harm (no statistically significant effect).

Narrative review synthesis

For all systematic reviews without meta-analysis data (defined as narrative reviews), we summarised key findings. We systematically documented and explored the conclusions reported by the authors of the reviews. Where these reviews included overlapping aims and outcomes, we compared conclusions; where there was a discrepancy in conclusions, we focused conclusions of the most up-to-date and highest quality reviews (judged using ROBIS) [ 15 ]. We considered whether these were in agreement with the results of any related meta-analyses reported in other reviews and focused our conclusions on the most up-to-date and high quality data.

The search identified 5222 records; we screened 2852 titles and removed 2363 obviously irrelevant records after removing duplications. Two reviewers screened 489 abstracts and 235 full text articles, excluded 131 reviews and extracted data from the remaining 104 reviews. The inter-rater reliability for abstract screening was 92%. The PRISMA flow diagram ( Fig 1 ) shows the flow of literature through the searching and screening process.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

MI = Motivational Interviewing; CBT = Cognitive Behavioural Therapy.

https://doi.org/10.1371/journal.pone.0204890.g001

Description of included reviews

Two reviewers categorised the reviews into four domains. The number of reviews in each domain are represented in Fig 2 .

https://doi.org/10.1371/journal.pone.0204890.g002

Domain 1. Stopping or preventing an unhealthy behaviour including smoking cessation (n = 11) [ 11 , 12 , 19 – 43 ], substance misuse for general population (alcohol and drugs) (n = 23) [ 28 , 29 , 38 – 58 ], substance misuse for people with mental health problems (n = 8) [ 31 , 33 , 35 – 37 , 59 – 61 ] and people with gambling addiction (n = 3)[ 7 , 62 , 63 ] (Total = 45).

Domain 2. Promoting healthy behaviour for a specific problem including; management of oral health (n = 5) [ 64 – 68 ], eating disorders (n = 3) [ 10 , 69 , 70 ], weight loss management (n = 4) [ 71 – 74 ], management of metabolic disease (Type 2 diabetes) (n = 6) [ 75 – 80 ], management of neurovascular (stroke) and cardiovascular disease (n = 3) [ 81 – 83 ], management of sexual health (n = 5) [ 84 – 88 ], adherence to medication (n = 9) [ 89 – 97 ] and engagement with interventions; cardiac care [ 98 ], health screening [ 99 ] and mental health interventions [ 100 ] (n = 3), cancer care (n = 1) [ 101 ], musculoskeletal problems [ 102 , 103 ] (n = 2), irritable bowel disorder[ 104 ] (n = 1).

Domain 3. Behaviour change for multiple health related problems and /or multiple behaviour problems (n = 9) including one recent review of Technology Delivered Motivational Interviewing (TDMI)[ 105 ] and eight reviews focused on various health problem such as excess drinking, smoking, and physical inactivity [ 8 , 9 , 106 – 111 ].

Domain 4. Behaviour change in specific settings (n = 8) including emergency care settings [ 112 , 113 ](n = 2), primary care [ 114 – 117 ](n = 4), medical care settings for multiple problems [ 6 , 118 ](n = 2).

Domain 1: Reviews focused on interventions aimed at preventing unhealthy behaviour

Smoking cessation..

Of the 11 reviews [ 11 , 12 , 19 – 27 ], two reviews focused on reducing exposure of smoke to children [ 11 , 20 ], one on smoking during pregnancy [ 19 ], three on general smoking cessation [ 22 – 24 ], two were carried out in emergency care settings [ 25 , 26 ], One review was updated from an earlier review of Motivational Interviewing to support smoking cessation [ 119 ] with the addition of 14 studies since 2010 [ 12 ]. One review focused on smokeless tobacco users although only one out of 34 trials included Motivational Interviewing [ 21 ].

Substance misuse.

Thirty-one reviews assessed substance misuse/abuse of which 13 focused primarily on alcohol related problems [ 28 , 39 , 40 , 43 – 46 , 49 , 50 , 52 , 53 , 55 , 58 ]. Reviews in this domain included different populations and problems [ 29 , 38 , 41 , 42 , 48 , 56 , 57 ] [ 53 , 54 ]; both alcohol and drug abuse users[ 56 ]; young adults [ 39 ]; pregnant women and drug use [ 38 ], two reviews focused on cannabis use [ 41 , 42 ]; one focused on offenders and treatment retention [ 29 ]. Eight reviews describe substance misuse in people with co-existing mental health disorders [ 31 – 37 ]. Jiang et al (2017) focused on brief non face-to- face interventions e.g. telephone.

Gambling behaviour.

Three reviews focused on Motivational Interviewing and psychological therapies for gambling addiction [ 7 , 30 , 63 ]. Yakovenko et al (2015) [ 7 ] identified eight trials including longer term follow up, Petry (2017) [ 63 ] reviewed trials of psychological interventions but identified only 2 trials that included Motivational Interviewing as a stand-alone intervention.

Domain 2: Reviews focused on interventions aimed at promoting healthy behaviour for a specific problem

Oral hygiene behaviour..

Five reviews focused on oral hygiene, 3 compared conventional oral hygiene advice with Motivational Interviewing interventions [ 64 , 65 , 68 ]. One compared periodontal therapy alone with Motivational Interviewing and periodontal therapy combined [ 66 ], and one included a meta-analysis of psychological treatment for people with poor oral health [ 67 ].

Eating disorders.

Three reviews focused on eating disorders of mainly female participants e.g. Anorexia nervosa and bulimia nervosa [ 10 , 69 , 70 ].

Weight management behaviour.

Three reviews focused on changing diet and physical activity for weight management in obese adults [ 71 , 72 , 74 ] and one investigated the management of weight gain during pregnancy [ 73 ].

Management of diabetes.

Six reviews focused on the management of people with diabetes. They include reviews focussed on evidence for; improving health behaviour in the management of diabetes [ 75 ], promoting glycaemic control [ 77 ] and lifestyle modifications programmes for- metabolic risk [ 78 ]. Four other reviews categorised in Domain 3 (multiple health problems / behaviours) and Domain 4 (Behaviour change in specific settings) assessed the effectiveness of Motivational Interviewing for diabetes management alongside obesity and other health related problems [ 71 , 91 , 114 , 118 ].

Management of neurovascular disorders and cardiovascular disease (CVD).

Three reviews focused on behavioural interventions for neurovascular disorders, but the reviews only included 11 trials in total evaluating the effectiveness of Motivational Interviewing. One review investigated Motivational Interviewing for the management of activities of daily living for stroke victims, identifying one study only [ 81 ]. Hildebrand (2015) reported one of 39 trials that incorporated Motivational Interviewing into interventions to support occupational therapy for stroke victims [ 82 ]. Lee et al (2016) [ 83 ] investigated lifestyle modification, physiological and psychological outcomes for people diagnosed with Cardiovascular disease. Overall there is insufficient evidence in this group to make firm conclusions about effectiveness of Motivational Interviewing.

Sexual health behaviour.

Five reviews focused on promoting safe sexual behaviours [ 84 – 88 ]. Two reviews focused specifically on sexual health in gay men [ 84 , 85 ]. One review focused on the effectiveness of Motivational Interviewing on contraceptive use in women [ 87 ].

Adherence to medication.

Adherence to medication was assessed for different populations and health problems. Hu et al (2014) assessed interventions including Motivational Interviewing to increase medication adherence in racial and ethnic minority groups [ 94 ]. Five reviews assessed medication adherence for patients with HIV [ 90 , 94 , 96 , 97 , 120 ]. Two recent reviews with meta-analyses assessed the effectiveness of Motivational Interviewing to enhance medication adherence for adults with chronic diseases and health problems [ 93 , 95 ].

Engagement with interventions.

Three reviews focused on engagement with a specific intervention [ 98 – 100 ]; one specifically on cardiac rehabilitation. Karmali et al (2014) assessed adherence to cardiac rehabilitation but only one trial of Motivational Interviewing was identified in this review [ 98 ]. A review with meta-analysis of outcomes relating to adherence by Lawrence et al (2017) [ 100 ] investigated individuals’ uptake of mental health interventions. Miller et al (2017) [ 99 ] assessed the efficacy of Motivational Interviewing to improve health screening for various problems e.g. breast screening, uptake of colonoscopy.

In addition, two other reviews grouped in Domain 1 and 2 assessed the effect of Motivational Interviewing on adherence to drug management programmes in offender populations [ 29 ] and adherence to treatment for chronic pain [ 102 ].

Management of musculoskeletal problems.

Two reviews focused on musculoskeletal problem [ 102 , 103 ] with some overlap of trial within the reviews. In the most recent review, Alperstein and Sharp (2016) identified 7 trials focused on pain outcomes and adherence to treatment in adults with various musculoskeletal problems e.g. low back pain, rheumatoid arthritis [ 102 ].

Management of irritable bowel disorders.

One review explored the use of Motivational Interviewing to improve outcomes for people with irritable bowel disorders including quality of life measures [ 104 ].

Cancer care.

One review focused on Motivational Interviewing to address various lifestyle behaviours and health problem associated with cancer such as fatigue, weight problems, and physical activity participation [ 101 ].

Domain 3: Reviews that focused on multiple health related problems and /or multiple behaviour problems

Nine reviews focused on behavioural interventions for people with multiple health problems [ 8 , 9 , 105 – 111 ]; These included multiple risk factors for cardiovascular disease[ 110 ]; diet, exercise, diabetes and oral health[ 109 ]; alcohol, drugs, diet and exercise[ 106 , 111 ]; substance abuse, smoking, HIV risk, diet and exercise[ 107 ] multiple behaviour problems[ 8 , 108 ] and multiple health outcomes [ 9 ]. Shingleton et al (2016) evaluated the efficacy of technology delivered Motivational Interviewing interventions in a mixed population from different socioeconomic backgrounds [ 105 ].

Domain 4: Reviews focused on behaviour change interventions in specific settings

Eight reviews reported behaviour change interventions delivered in specific settings [ 6 , 112 – 118 ]. One included a combination of healthcare settings [ 118 ]; one focused on medical care settings [ 6 ]; four were carried out in primary care[ 114 – 117 ]. Merz et al (2015)[ 113 ] and Kohler and Hofmann (2015)[ 112 ] focused on young adults in emergency care units. In addition, two reviews described in Domain 1 (preventing an unhealthy behaviour) also reported smoking cessation in emergency department settings [ 25 , 26 ].

Review characteristics and quality assessment

Tables 1 – 4 report details of the review characteristics and implications for clinical practice and research. Further details of the interventions using the ‘Template for Intervention Description and Replication (TIDieR) [ 14 ] are reported in S1 Table . Of the 104 reviews 40 were judged by two authors (PC and HF) as overall low risk of bias [ 7 , 11 , 12 , 20 , 21 , 25 – 27 , 30 , 35 , 38 , 41 , 44 , 47 – 49 , 51 , 53 , 54 , 56 , 57 , 59 , 65 , 71 , 81 , 83 , 84 , 89 , 91 – 94 , 97 , 98 , 100 , 102 , 111 , 113 – 115 ]. Fig 3 summaries the risk of bias across all reviews. S2 Table reports the assessment of bias for each review individually using the ROBIS tool [ 15 ].

https://doi.org/10.1371/journal.pone.0204890.g003

Abbreviations: MI = Motivational Interviewing, BMI Brief Motivational Interviewing, RCT = randomised controlled trial, MET = Motivational Enhancement Therapy.

https://doi.org/10.1371/journal.pone.0204890.t001

Abbreviations: MI = Motivational Interviewing, BMI Brief Motivational Interviewing, RCT = randomised controlled trial, MET = Motivational Enhancement Therapy, HAART = Highly Active Antiretroviral Therapies, ETS = Environmental Tobacco Smoke, SUMSM = Substance-using men who have sex with men, BCT = Behaviour change techniques, BZDs = Benzodiazepines, Blood alcohol concentration (BAC).

https://doi.org/10.1371/journal.pone.0204890.t002

Abbreviations: MI = Motivational Interviewing, BMI Brief Motivational Interviewing, RCT = randomised controlled trial, MET = Motivational Enhancement Therapy, HAART = Highly Active Antiretroviral Therapies, ETS = Environmental Tobacco Smoke, SUMSM = Substance-using men who have sex with men, T2D = Type 2 Diabetes, CVD = Cardiovascular disease, NVD = neurovascular disease, BMI = Body Mass Index, BCT = Behaviour change techniques.

https://doi.org/10.1371/journal.pone.0204890.t003

https://doi.org/10.1371/journal.pone.0204890.t004

Results of meta-analyses

Thirty-nine reviews reported meta-analyses but it was not possible to extract data from all. [ 6 – 9 , 12 , 21 – 23 , 26 , 27 , 30 , 38 , 39 , 41 , 45 , 46 , 48 , 49 , 56 – 58 , 67 , 71 , 73 , 74 , 77 , 81 , 84 , 87 , 91 , 93 , 95 , 100 , 102 , 106 , 108 , 111 , 112 , 116 ]. Table 5 provides a brief summary of results from the reviews with pooled data comparisons.

https://doi.org/10.1371/journal.pone.0204890.t005

Of the 155 meta-analysis comparisons that were extracted, we found no high quality evidence. Twenty seven comparisons provide moderate quality evidence according to the GRADE criteria. Most of this evidence was categorised in Domain 1 (Stopping an unhealthy behaviour). Further details of the outcomes for the moderate quality evidence are reported in Table 6 .

https://doi.org/10.1371/journal.pone.0204890.t006

Seventy one comparisons provided low quality evidence and 57 provide very low quality evidence judged by the GRADE criteria. S3 Table summarises the comparisons that were judged as providing low or very low quality evidence. The key reasons for downgrading the evidence to low or very low quality primarily relate to; risk of bias of the review was unclear; heterogeneity was judged to be moderate to high, or confidence intervals very large; volume of evidence was judged to be insufficient to support a definitive conclusion and concerns about the quality of the trials included within the comparison judged by review authors.

Moderate quality evidence for effectiveness of Motivational Interviewing

Table 6 summarises the 27 comparisons, which provide moderate quality evidence for Motivational Interviewing interventions judged from six reviews [ 12 , 49 , 56 , 58 , 84 , 111 ]. Eleven of these 27 comparisons (7% (11 of 155) of all meta-analyses’ comparisons) provide moderate quality evidence for mainly short term (<6 months) statistically significant beneficial effects of Motivational Interviewing. The remaining 16 comparisons demonstrate no benefit or harm, compared with a control of usual care or other active interventions. Moderate quality evidence of a beneficial effect of Motivational Interviewing was available for;

Alcohol use . 13 comparisons from two reviews [ 49 , 58 ] explored the effect of Motivational Interviewing on outcomes relating to alcohol use in mixed populations. Eight of the 13 comparisons provide consistent evidence that Motivational Interviewing has a beneficial effect on outcomes relating to the frequency and/or volume of alcohol consumption, for short term outcomes (< 4 months), but the evidence relating to sustained (>4 months) outcomes is less consistence. Comparisons relating to risky behaviour and drink driving demonstrated no benefit (or harm) of Motivational Interviewing. There is evidence of beneficial effects from one review of young adults (<25 years), for reducing binge drinking, frequency, quantity of alcohol consumption and peak blood alcohol concentration[ 58 ].

Smoking cessation . One comparison from a review on smoking cessation was judged to provide moderate quality evidence. This review comparing Motivational Interviewing with usual care or brief advice, provides evidence of beneficial effects on abstinence from smoking, particularly when attention was paid to treatment fidelity[ 12 ].

Substance abuse (drugs) . One comparison from a review of people with substance abuse dependency and addiction provides evidence of a benefit of Motivational Interviewing when compared with no intervention. The other four comparisons derived no benefit or harm when Motivational Interviewing was compared with usual care or any other treatment [ 56 ].

Physical activity . Four comparisons from a review of Motivational Interviewing for promoting physical activity participation were judged to provide moderate quality evidence when Motivational Interviewing was compared with a control or usual care. One out of the four comparisons provide evidence of benefits. No benefit was found for the other three comparisons, including outcomes for people with cardiovascular disease and obesity [ 111 ].

Sexual health . Four comparisons from one review provide moderate quality evidence of no benefit or harm of Motivational Interviewing relating to changing high risk sexual behaviours in men who have sex with men[ 84 ] when compared with a control.

Exploration of moderator variables

Of the six reviews that provide any evidence judged to be of moderate quality, three did not report the results of any subgroup analyses [ 56 , 84 , 111 ]. The three reviews that contain moderate quality evidence and report subgroup analyses are:

· Lindson-Hawley 2015 [ 12 ]–smoking cessation (Table A in S1 File )

· Foxcroft 2014 [ 49 ]–alcohol use in young people (Table B in S1 File )

· Vasilaki 2006 [ 58 ]–alcohol consumption (Table C in S1 File )

Exploration of the reported subgroup analyses provides consistent evidence which suggests that Motivational Interviewing is beneficial when compared to ‘weak’ comparison groups such as no treatment, assessment only or non-specified treatment as usual, but Motivational Interviewing is not beneficial when compared to other ‘strong’ interventions.

Generalisable conclusions relating to the most effective delivery of Motivational Interviewing (e.g. face-to-face or group), dose, or characteristics of provider or patient across behavioural domains are difficult to draw.

Results of narrative reviews

Of the 104 reviews included in this synthesis, 65 did not combine any data within meta-analysis. The main findings from the narrative reviews are summarised in Tables 1 to 4 . The majority focus on behaviour change in a general population, but also include people with specific mental and physical problems.

Narrative reviews of people with mental health problems include psychotic disorders[ 33 ], comorbid schizophrenia, combined mental health problems [ 31 , 32 , 35 ], general depression [ 10 , 33 – 35 , 69 ], post-stroke depression [ 36 ] and eating disorders [ 10 , 69 , 70 ]. One review in this category judged as low risk of bias suggests that Motivational Interviewing is important in psychiatric settings for reduction of substance use in the short term.

Narrative reviews of physical health problems include: cardiovascular problems (Motivational Interviewing for increasing physical activity) [ 83 , 110 ]; musculoskeletal health (adherence with intervention for back pain) [ 103 ]; diabetes self-management (effect of smoking, blood-glucose control, diet and weight management [ 62 , 75 , 76 , 78 – 80 ]; oral health hygiene[ 64 – 66 , 68 ] (use of dental fluoride, increasing dental utilization and reducing sugar consumption); obesity (adherence to weight loss programmes); management of neurovascular disorders [ 82 ]. The most recent reviews report outcomes for the effectiveness of Motivational Interviewing for cancer care [ 101 ] and outcomes related to the treatment of irritable bowel disorder [ 104 ].

Quality of narrative reviews

In total 20 narrative reviews were judged as low risk of bias graded using the ROBIS tool [ 15 ] [ 11 , 20 , 25 , 35 , 42 , 44 , 47 , 51 , 53 , 54 , 59 , 65 , 83 , 89 , 92 , 97 , 98 , 113 – 115 ]. Five of these reviews report positive effects of Motivational Interviewing. Rueda et al (2006) found beneficial effects of Motivational Interviewing for adherence to highly active antiretroviral therapy where there appears to be promising results for interventions delivered over 12 weeks or more [ 97 ]. Taggart et al (2012) found further support for benefits of Motivational Interviewing in achieving impacts around smoking cessation compared to other group education [ 115 ]. Cooper et al (2015) reported positive results for some but not all outcomes for reducing cannabis use [ 42 ]. Noordman et al (2012) conclude that Motivational Interviewing can be effectively delivered by physicians and nurses as a face-to-face communication-related behaviour change technique[ 114 ]. Reviews published since 2016 report mixed results. Kay et al (2016) suggest that Motivational Interviewing has potential for use in oral care [ 65 ]. Chatters et al (2016) report short term benefits for reducing cannabis use in younger adults [ 47 ]. However, most were unable to make firm conclusions about effectiveness of Motivational Interviewing [ 20 , 44 , 59 , 89 ]. In a review of brief non face-to-face Motivational Interviewing interventions Jiang et al (2017) found promising evidence for telephone delivery in the treatment of substance abuse, but the results were not consistent for other alternative modalities such as text messages in groups or internet-based interventions.

This overview is the first to integrate and systematically grade the quality of the evidence for the effectiveness of Motivational Interviewing interventions across a wide range of settings and populations for people with many different health problems and diseases. We have created a comprehensive map of all reviews relating to Motivational Interviewing to provide clarity relating to an intervention for which there have been multiple overlapping (and sometimes conflicting) reviews. Conflicting review evidence can create barriers and challenges to practitioners wanting to deliver evidence-based practice. This overview provides practitioners, policy makers and researchers with a summary of the quality and strength of the evidence for Motivational Interviewing. It signposts practitioners to the most up to date reviews, enabling them to efficiently access best review evidence to support clinical decisions. We found no high-quality evidence from the meta-analysis data within any review, mainly due to methodological flaws in the reviews and poor quality of the included studies.

Motivational Interviewing appears to be most effective for stopping or preventing unhealthy behaviours (categorised as Domain 1) such as binge drinking, reducing the quantity and frequency of drinking, smoking and substance abuse. For gambling behaviour, low quality evidence of short to long-term effectiveness suggests that further research on the effectiveness of Motivational Interviewing is warranted to address this significant public health problem [ 62 ]. For promoting healthy behaviour (categorised as Domain 2) where people may have little desire to change, most of the evidence is inconclusive or of low quality. For example, there is low quality evidence for the effectiveness of Motivational Interviewing for weight loss outcomes in obese and overweight adults. The exception in Domain 2 is physical activity promotion where there is moderate quality evidence of beneficial effects of Motivational Interviewing for increasing physical activity in people with chronic health conditions. However, the trials assessing adherence to physical activity participation were small and further high quality research in this field is justified to investigate the effectiveness of Motivational Interviewing in different populations, settings and context.

Mode of delivery

The exploration of moderator variables from meta-analysis data does not provide enough data to be confident about the effects of different modes of delivery for Motivational Interviewing. Reviews that focus on the mode of delivery report inconsistent results [ 45 , 51 , 95 , 105 ]. The TIDieR guidelines [ 14 ] capture some of the features that are relevant to intervention delivery but the mode of delivery is considered to be an important component of intervention and is not reported consistently in the literature [ 121 ]. Recent reviews have compared telephone [ 51 ] or technology-delivered Motivational Interviewing interventions (TAMIs) [ 105 ] and report inconsistent results or no beneficial effects. For example, Shingleton et al (2016) [ 105 ] found that TAMIs are feasible to deliver but there is limited evidence of effectiveness. For an intervention that relies on building and developing a relationship between client and provider it seems unlikely that this mode of delivery could be successfully adapted for Motivational Interviewing without considerable focus on training and fidelity measures.

Implication for clinicians and policy makers

The National Institute for Health and Care Excellence (NICE) guidelines [ 2 ] include Motivational Interviewing as a component associated with some effective interventions for behaviour change strategies. However, the NICE (2014) Programme Development Group (PH49) are cautious about making general recommendations due to lack of details of intervention components reported in this field of research [ 2 ].

This overview has identified clear gaps in the evidence in support of most of the interventions categorised in Domain 2 (e.g. weight loss programmes for obesity, oral health behaviour, management of diabetes and musculoskeletal disorders, adherence to medication and engagement with interventions). The high quality reviews on smoking cessation [ 12 ] and alcohol abuse [ 49 ] both recommend caution when interpreting results. However, the overall effect size reported by Lundahl et al [ 108 ] of 0.22 (95% CI 0.17 to 0.27) is similar to other complex behavioural intervention [ 122 , 123 ]. If applied to the 1 million smokers in the UK, or the millions of physically inactive people globally [ 124 ], it is plausible that the impact of Motivational Interviewing on health at a population level may be larger. Further rigorous research is required to support this assumption.

Training and fidelity

Many different health care professionals including nurses, counsellors, physicians, medical students, social workers, and physiotherapists deliver Motivational Interviewing interventions, but there is little information about their training. Reviews that compared different health care providers found either no difference between groups [ 114 ] or reported limited conclusions due to small sample size [ 12 ].

Details of the fidelity of training of professionals delivering the interventions were generally poor although this is not unique to reporting of Motivational Interviewing. Training issues are fundamental to the success of any complex intervention and Motivational Interviewing, like other surgical, therapy or other behavioural interventions, requires practice of skills and a basic level of competency. There is no formal requirement for training in Motivational Interviewing or evaluation therefore practitioners can claim to use the approach without assessment, and competency is likely to influence outcome. Hall et al (2016) suggest that investment in training would need to be large to impact on change in practice [ 125 ].

It is difficult to comment on the cost effectiveness of Motivational Interviewing as it was not the focus of this overview, however we identified very little health economic data. Where cost data was available from a trial of smoking cessation in the UK, no clear conclusions could be drawn as the sustained quit rates did not reach statistical significance[ 12 ].

Strengths and limitations of the overview

This overview is the first to synthesise systematic review evidence on the effectiveness of Motivational Interviewing from a wide range of populations and settings with an aim to provide information that informs practice and policy. It highlights the discrepancy between the widespread recommendations of Motivational Interviewing as a universal behaviour change strategy and the available evidence supporting this approach. We carried out a comprehensive search with an inclusive selection criteria and it is unlikely that we missed any reviews written in English prior to our initial search, but this overview is not exhaustive.

The conclusions of this overview are highly dependent on, not only the quality of the reviews but the studies within the reviews. We extracted data according to the TIDieR guidelines [ 14 ] but many intervention details were missing, making it difficult to draw conclusions with confidence. This problem needs to be addressed in future trials to facilitate data synthesis and provide clear recommendation to all stakeholders. Our assessment of review quality (ROBIS) [ 15 ] and evidence quality (GRADE) [ 17 ] are subjective judgements and we used these judgements to categorise the evidence, concentrating our conclusions on those judged to be moderate quality (or low bias for narrative reviews). Some may consider our methods overly critical, but authors of the higher quality reviews are equally cautious with their recommendations [ 11 , 12 , 49 ].

Recommendations and implication for future research

The established Network of Trainers (MINT) alone have delivered Motivational Interviewing around the world to millions of people [ 126 ] but many questions remain unanswered regarding effectiveness.

Recommendations for clinical practice.

Many different health professional groups are using Motivational Interviewing but the evidence for training reported in the literature is limited. The ‘Motivational Interviewing Treatment Integrity code’ (MITI) has evolved over the last 10 years [ 127 ] with an aim to standardise the delivery of Motivational Interviewing interventions. Guidelines for the minimum intervention content and training requirements for Motivational Interviewing are available and should be followed to standardise intervention delivery [ 127 , 128 ].

Recommendations for future reviews.

This overview has identified and brought together systematic reviews relating to Motivational Interviewing interventions; however further systematic reviews are warranted to inform clinical practice and future primary research in this field. Recommendations include, but are not limited to;

• Research should address the fact that in clinical practice Motivational Interviewing is often delivered in combination with another psychological intervention. Systematic reviews exploring combined interventions were excluded from this overview; consequently, it is important to identify and appraise any existing systematic reviews relevant to this, prior to planning new reviews or primary research.
• Future systematic reviews would benefit from the development of a taxonomy to ensure meaningful categorisation of the delivered intervention which considers the theoretical basis for Motivational Interviewing. Meaningful categorisation of Motivational Interviewing should be central to informing clinically relevant analyses and subgroup analyses.
• A systematic review to explore the cost-effectiveness of Motivational Interviewing as an intervention for those health conditions where there is moderate quality evidence of a beneficial effect of Motivational Interviewing on patient outcomes.
• A systematic review to explore the barriers and facilitators to delivery of Motivational Interviewing, focussed on those health conditions where there is moderate or high quality evidence of a beneficial effect.
• A systematic review of qualitative evidence to explore the acceptability and perceptions of this intervention to people who are offered Motivational Interviewing.
• Stakeholder involvement should be conducted in future reviews of the Motivational Interviewing literature particularly relating to categorising interventions and outcomes.
• The use of reporting templates, recognised guidance and best practice for the conduct of systematic reviews and primary research is essential. e.g. PRISMA [ 129 ] and TIDieR [ 14 ].

Recommendations for future primary research.

• Exploration of the effect of Motivational Interviewing should consider long-term outcomes and cost-effectiveness. Subgroup analyses should explore the length of intervention delivery and time since the end of the intervention.
• Investment in training would need to be large to impact on change in practice [ 130 ] and this along with other issues relating to sustainability of the intervention e.g. context, should be considered in future trials.
• To ensure avoidance of research waste [ 131 , 132 ] it is essential that researchers are fully aware of existing reviews before embarking on further reviews, and that critical systematic reviews of evidence are completed prior to further primary research.

For the health problems that Motivational Interviewing was originally developed to address such as smoking cessation and alcohol misuse, the evidence provides some support for implementation particularly if fidelity of the intervention is prioritised. However, Motivational Interviewing has been implemented already for a wide range of other health and social problems where a “one size fits all” approach has been adopted with inconsistent effects.

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pone.0204890.s001

S1 Table. Characteristics of interventions according to TIDIER checklist reporting guidelines.

https://doi.org/10.1371/journal.pone.0204890.s002

S2 Table. Quality assessment of included reviews based on ROBIS (risk of bias in systematic reviews) tools.

https://doi.org/10.1371/journal.pone.0204890.s003

S3 Table. Summary of comparisons judged to provide low or very low quality evidence.

https://doi.org/10.1371/journal.pone.0204890.s004

S1 File. Exploration of moderator variables.

https://doi.org/10.1371/journal.pone.0204890.s005

S1 Appendix. Medline search string.

https://doi.org/10.1371/journal.pone.0204890.s006

Acknowledgments

This work was undertaken by and on behalf of The Scottish Improvement Science Collaborating Centre (SISCC). We thank Sheena Moffat, Information Services Advisors at Edinburgh Napier University, for her assistance with the updated search.

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• v.118(7); 2021 Feb

Motivational Interviewing: An Evidence-Based Approach for Use in Medical Practice

Gallus Bischof

1 Lübeck University, Department of Psychiatry and Psychotherapy, Lübeck

Anja Bischof

Hans-jürgen rumpf.

Motivational factors in health-relevant modes of behavior are an important matter in medical practice. Motivational interviewing (MI) is a technique that has been specifically developed to help motivate ambivalent patients to change their behavior.

This review is based on pertinent publications retrieved by a selective search in the PubMed, Cochrane, and Web of Science databases. Special attention was paid to systematic reviews and meta-analyses concerning the efficacy of MI in the medical care of various target groups. The present review focuses on the relevance of MI for patients with highly prevalent disorders.

Meta-analyses reveal statistically significant mean intervention effects of MI in medical care with respect to a variety of health-relevant modes of behavior, in comparison to standard treatment and no treatment in the control groups (odds ratio [OR]: 1.55; 95% confidence interval: [1.40; 1.71]). Statistically significant effect sizes were reported for substance consumption, physical activity, dental hygiene, body weight, treatment adherence, willingness to change behavior, and mortality; effects on health-promoting behavior were mixed. Studies of the factors that contribute to the efficacy of MI suggest that it exerts its effects largely through the selective reinforcement of statements made by the patients themselves about potential changes in their behavior.

MI has been found useful for strengthening the motivation for behavioral change in patients with various behaviorally influenced health problems and for promoting treatment adherence. It can be used to optimize medical interventions. Further research is needed with respect to its specific mechanisms of action, its efficacy in reinforcing health-promoting modes of behavior, differential indications for different patient groups, and the cost-efficiency of the technique across the spectrum of disorders in which it is used.

This article has been certified by the North Rhine Academy for Continuing Medical Education. Participation in the CME certification program is possible only over the internet: cme.aerzteblatt.de. The deadline for submissions is 18 February 2022.

In highly developed industrialized countries, behavioral risk factors such as substance use (tobacco, alcohol), unhealthy diet, and insufficient physical activity are a key determinant of the burden of disease in the population as measured by disability-adjusted life years (DALYs) ( 1 ). These factors also have a crucial impact on the course of a variety of chronic diseases.

For example, according to the Global Burden of Disease study, the 23.9 million DALYs lost in the German population in 2010 can be attributed in percentage terms to the following causes ( 2 ):

• Unhealthy diet (men: 16.2%, women: 11.2%)
• Smoking (men: 14.2%, women: 6.7%)
• High blood pressure (men: 11.5%, women: 10.2%)
• Overweight (men: 11.5%, women: 10.3%).

Therefore, motivational aspects are a significant factor in patient treatment. Other important motivational factors for medical practice stem from the often insufficient adherence to medication, which, according to a number of studies, lies between 31.2% and 59.1% and also represents a significant factor in the chronification of health impairments ( 3 – 5 ).

Furthermore, societal changes in recent decades that challenge our understanding of the clinician’s role are reflected in the concept of “shared decision-making,” according to which treatment steps should be developed in consultation with the patient ( 6 ).

Motivational interviewing (MI) ( 7 ), which originated in the field of addiction treatment, is a promising concept for encouraging motivation to change in patients that are currently either unwilling or ambivalent to change, and can be deployed even with limited time resources. Since the first publications on the approach in the early 1980s, it has also been increasingly used, and successfully so, in other disciplines. This article presents the basic principles of the approach from the perspective of their applicability in medical practice. To assess the effectiveness of the method, systematic reviews and meta-analyses published in the PubMed, Cochrane, and Web of Science databases since 2005 on the effectiveness of MI across disorders in medical treatment settings, as well as on the effectiveness of MI on medication adherence, were selectively searched and summarized using the search terms (“Motivational Interviewing” AND (“primary care” OR “medical care”).

Basic tenets of motivational interviewing

Although MI is not a theory-guided approach, it nevertheless combines a variety of evidence-based approaches from cognitive psychology and social psychology. MI assumes that people with problematic behaviors (for example, smoking, high-risk alcohol consumption, unhealthy diet, lack of medication adherence, insufficient exercise) have different levels of readiness for behavior change.

According to Janis and Mann’s conflict-theory model of decision-making ( 8 ), the advantages of healthy behaviors (such as better health prognosis and improved fitness, among others) are always countered by disadvantages of behavior change (for example, loss of hedonistic reinforcers, significant effort, possible side effects of medication). The assumption in MI is that people with problematic behaviors are not fundamentally unmotivated to change their behavior, but are instead ambivalent, that is to say, their problem behavior conflicts at least to some extent with their self-concepts, values, or life goals, with those affected potentially having subjectively good reasons against a behavior change. If this ambivalence is not recognized, well-intentioned medical advice is perceived by patients as an assault on their freedom of choice, which, according to socio-psychological reactance theory ( 9 ), increases their motivation to restore their own subjective power to make decisions. This, in turn, often results in non-compliance either in the form of open disagreement or non-adherence to recommendations. A prerequisite of sustained encouragement of motivation to change is that patients become more aware of their behavioral discrepancies and actively confront their behavior. Therefore, MI is defined as “a person-centered, goal-oriented style of communication with particular focus on expressions of change. The goal is to increase personal motivation for and commitment to behavior change by eliciting and intensifying a person’s own reasons for change in an atmosphere of acceptance and empathy” ( 7 ). In line with self-determination theory (SDT; [10]), the approach recognizes the needs for autonomy, competence, and relatedness. As such, the atmosphere of acceptance and empathy represents a necessary condition for patients’ self-disclosure in interviews relating to difficult or stigmatized subjects such as substance use, overeating, or health problems. The authors of MI have repeatedly emphasized that MI is not a technique, but a fundamental therapeutic style that does not seek to make people change their behavior against their will. Roger’s person-centered therapy ( 11 ) forms an important basis of the approach, whereby MI is characterized by a goal-oriented approach and can essentially be combined with other therapeutic methods. The hallmark of MI is a differentiation into inner attitude (“human image”), methods and principles of implementation, as well as different processes of implementation ( box 1 ).

The spirit of motivational interviewing (MI)

The fundamental spirit of MI is to encourage and strengthen a trusting relationship, which is key to treatment success and can be characterized by the following components ( 7 ):

• A partnership-like, unpatronizing collaboration with the patient (“communication on equal terms”), in which the clinician does not assume the role of the expert (superior to the patient).
• A fundamental attitude of acceptance and empathy towards the patient’s needs, experiences, and points of view. In addition to unconditional regard for the patient, this includes ensuring their autonomy of choice and decision-making in relation to behavior change as well as the desired goals and methods of change (patient autonomy).
• Compassion for the patient’s life and experience, as characterized by the clinician not pursuing their own interests and giving highest priority to the patient’s needs.
• Evoking motivation to change by exploring and reinforcing the patient’s reasons for change. This also includes developing discrepancy between current problem behavior and the patient’s goals and values (for example, “You said that it’s important to you to do more exercise again. How does that tie in with your smoking?”).

Techniques of motivational interviewing

In addition to the basic principles of MI, the method includes altogether five intervention techniques, the importance of each of which may vary depending on the patient and the status of their treatment ( 7 ). The first four intervention techniques are methods that are also used in other schools of therapy, such as client-centered interviewing.

First intervention element

Open-ended questions are helpful for encouraging patients to confront their problem behavior, for example, “What worries you about your drinking?” MI is deemed to be good when at least 70% of the questions asked are open-ended ( 12 ).

Second intervention element

Active listening makes it possible to discover and focus on the patient’s concerns regarding their problem behavior. As part of this process, the clinician reflects back to the patient the essential content of their statements. Furthermore, active listening not only has the effect that the individual experiences understanding, it also enables the problem to be considered more deeply through increased self-exploration. At least 50% of reflections should be complex and go beyond simple repetition ( 12 ). Complex reflections refer either to non-explicit content that is inferred or to emotional elements (for example, patient: “I do think my cough comes from smoking.”; physician: “And that worries you.”). In good MI, at least two reflections should be used per question asked.

Third intervention element

Affirmation includes praise (“That’s great that you want to do something about your smoking!”), recognition (“You are going through a difficult time right now.”), and understanding (“I can well understand that you are concerned about the side effects your medication could have.”).

Fourth intervention element

Summarizing is an effective technique whereby the contents mentioned by the patient that are significant for motivation to change are reflected back to the patient (for example, “On the one hand, you don’t want to forbid yourself anything, but on the other, the amount of money you spend on smoking bothers you and your cough worries you”).

Fifth intervention element

MI is characterized in a narrower sense by the encouraging of self-motivational statements. This involves making a distinction between patient utterances that oppose change and suggest a stabilization of the status quo (“sustain talk”; for example, “I don‘t think those 10 cigarettes a day are so bad”) and utterances that make a behavior change more likely in that the patient names reasons and intentions for change (“change talk”; for example, “If I got sick again, I would probably lose my job—maybe I should try the medication after all”). “Change talk” is encouraged by asking specific questions (“How could the medication help you against your depression?”), by affirming (“It‘s impressive that you see a link between the medication and opportunities for your further career”), or by selective reflection (“The medication can help you to stay healthy”) and can be differentiated according to two objectives:

• Building motivation through concrete expressions characterized by the patient stating their desires, abilities, reasons for change, and perceived needs for change, as summarized by the acronym DARN (desire, ability, reasons, and need)
• Stating commitment, activation, and first steps (acronym [CAT] for “commitment,” “activation,” and “taking steps”).

For successful behavior change, it is important that the patient’s need for change translates in the next step into a commitment to change behavior.

Information, as well as the clinician’s own ideas, can be incorporated in MI, whereby it is important to ensure that the patient is prepared to be confronted with the information and that the clinician’s viewpoint is expressed merely as an option and not as the only truth. From a methodological perspective, this is achieved in a three-step process (elicit–provide–elicit) by first asking for consent (“Would you like to know more about…”), secondly, offering the information in a neutral way (for example, “Scientific studies have shown…”), and finally asking the patient for their view (for example, “What do you think about…”). Information that the patient does not want or that they perceive as threatening usually causes reactance.

Conflicts during an interviewing session typically occur when interventions are not suited to the patient’s current motivation to change, for example, when a patient with high-risk alcohol consumption is given recommendations for action, whereas the patient is not yet clear about whether their alcohol consumption constitutes problematic behavior. This can manifest interpersonal dissonance (discord; for example, “Are you trying to imply that I’m an alcoholic?”) or in a reversion to “sustain talk” (“In my case, exercise wouldn’t do any good anyway”). In situations such as these, in addition to treating the patient with empathy, it is particularly important to emphasize their autonomy (“Only you can decide whether you want to change something about that”) ( Box 2 , 3 ) .

Processes of motivational interviewing (MI)

The format of MI treatment can be divided into four distinct processes ( 7 ); however, these do not follow on from one another in a static manner, since processes that have already been gone through may become more important again at a later point in time:

• In this phase, which is indispensable for the development of a therapeutic working relationship, non-judgmental understanding of the patient’s views, values, and goals is of central importance. This can also be significant, for example, if the patient is not attending the interview voluntarily but due to external pressure.
• In most cases, patients have a number of problem areas, the subjective significance of which can vary greatly. Focusing is about identifying the areas that take priority for the patient.
• This process involves the transition to MI in the narrower sense; at this point, the interview becomes goal-oriented. Here, the motivation to change is encouraged relative to the patient’s priority areas of life, such that reasons for change and strategies for behavior change are incited by the patient themselves, that is to say, the patient “talks themselves into change,” so to speak. These change-related statements are reinforced and intensified.
• Whereas the first three phases are fundamental constituents of MI, achieving this fourth phase depends on whether the patient decides for behavior change. If this is the case, the focus is put on making the intention to change more concrete in terms of the goals of a change, the envisaged strategies for achieving these goals, and formulating a concrete (that is to say, near-term and implementable) change plan.

Effectiveness of MI in medical care

Since the approach was first developed, the number of MI-specific publications has increased exponentially, to the extent that there are now more than 1300 randomized trials and around 150 reviews on the effectiveness of MI in a variety of behaviors and target populations. The majority of studies address problematic substance use. By means of a systematic literature search limited to systematic reviews and meta-analyses in the PubMed, Cochrane, and Web of Science databases on the effectiveness of MI in medical care settings using the search terms (“Motivational Interviewing” AND [“primary care” OR “medical care”]), it was possible to identify a total of nine systematic reviews published since 2005, of which two were meta-analyses. Both meta-analyses found small to moderate effect sizes with regard to various health-related behaviors such as blood pressure, substance use, and medication adherence of d =0.18 (95% confidence interval [0.03; 0.33]; p =0.02) ( 13 ) and (odds ratio: [OR] = 1.55 [1.40; 1.71]; p <0.001) ( 14 ), for the effectiveness of the technique. The included MI interventions varied from single contacts lasting 15 min to long-term treatments lasting up to a total of 480 min, with the majority of studies including brief interventions of no more than three sessions ( 14 ). Selected results on individual outcome parameters from the more comprehensive meta-analysis by Lundahl et al. (2013), which covered 48 studies with a total of 9618 included subjects, are shown in the Table ( 14 ). Effect sizes represent the improvement in the outcome criterion relative to controls; odds ratios > 1 indicate superiority of the MI group. The practical effect of the intervention is expressed by the binomial effect size display (BESD), in which the probability of success in the treatment group is subtracted from the probability of success in the control group. Values of >50% indicate a greater effect for the condition in question. Particularly marked treatment effects were found for a reduction in substance use, physical inactivity, body weight, and mortality, as well as for improved dental hygiene, acceptance of further treatment, and self-monitoring of health behavior (for example, with regard to blood glucose monitoring and nutrition). No significant effects were seen for eating disorders, self-care behaviors, or individual medical parameters such as heart rate. Effect sizes were greater when the intervention was delivered by the treating clinicians (versus medical/technical assistants). The average treatment effects were significant across all outcome measures, but were most pronounced for patient self-reports (OR = 1.69; [1.55; 1.84]), followed by third-party assessments (OR = 1.48; [1.24; 1.78]), and lowest for biological outcome parameters (OR = 1.18; [1.09; 1.28]) ( 14 ). According to Lundahl et al. (2013), effect sizes decrease over time, but five studies with follow-up surveys after more than 13 months nevertheless demonstrate significant effects compared with controls (OR = 1.14; 95% CI [1.03; 1.28]). Treatment effects were significant in waiting lists, as well as in unspecified routine treatments and psychoeducational control conditions.

Reviews of the effects of MI on medication adherence across disorders not limited to medical care found positive, albeit small, effects with a pooled relative risk of 1.17 ([1.05; 1.31]; p < 0.001) ( 15 ) and a Cohen’s d of 0.23 ([0.08; 0.37], p > 0.001), with the included studies being of heterogeneous quality ( 16 ).

A systematic review of the overall effectiveness of MI across settings and based on 104 published reviews (of which 39 were meta-analyses) found good evidence for cessation or prevention of unhealthy behaviors, particularly with regard to problematic substance use (primarily alcohol, cannabis, and tobacco), whereas the evidence for health-promoting behaviors (except the promotion of physical activity) was more heterogeneous and, in terms of the methodological quality of the studies included, weaker ( 17 ). With regard to potential moderator variables, effects were found compared to control groups that had received either no treatment or unspecified routine treatment, but not compared to control conditions with other evidence-based interventions such as cognitive behavioral therapy ( 17 ). Although studies on the effectiveness of MI in substance-related disorders point to greater cost-effectiveness for MI compared to other evidence-based interventions ( 18 ), corresponding reviews on the cost-effectiveness of MI across disorders are lacking to date ( 17 ).

On the basis of the studies conducted to date, MI has proved to be an evidence-based, effective, and comparatively economical method of promoting behavior change in ambivalent patients, particularly in the case of problematic substance use. There are not yet enough studies of high methodological quality available for a variety of other medical fields of application, such as motivation to adopt health-promoting behavior, to be able to make detailed statements on the indication for and differential efficacy of MI.

Mechanisms of MI

With regard to the specific mechanisms of MI, three alternative hypotheses are purported. The technical hypothesis, according to which the effectiveness of MI is achieved through basic skills such as open-ended questions, active listening, affirming, and summarizing in the form of selective reinforcement of patients’ self-motivational utterances, is the hypothesis that has been the most extensively studied to date and, comparatively, has received the most empirical support ( 19 – 21 ). The relational hypothesis, in contrast, assumes that relationship quality and therapeutic empathy are the most significant factors for the effectiveness of MI. This hypothesis has been investigated to a lesser extent and is deemed to be insufficiently substantiated, with one critical review pointing out that, in the majority of studies considered, the MI clinicians studied differed insufficiently in these characteristics to be able to demonstrate effects on effectiveness ( 19 ). The conflict resolution hypothesis states that the effect of MI can be attributed to a large extent to exploration and resolution of conflict, although here again, the empirical evidence is heterogeneous. In their review, Magill and Hallgren ( 19 ) conclude that the various factors should be regarded more as necessary than as sufficient conditions for the effect of MI, whereby further research needed.

Conclusions for clinical practice

The MI approach has proved its value for the promotion of intentional readiness for behavior change in a number of behavioral health problems, as well as for the promotion of treatment adherence, and can be used in medical practice even with limited time resources. Continuing education courses on the basic principles of MI, which usually last 2 days, are regularly offered by German Medical Councils and various private sponsors, and specialist literature on different fields of application is available in German ( 7 ). A number of German-speaking trainers are members of the international Motivational Interviewing Network of Trainers ( www.motivationalinterviewing.org/trainer-listing ).

BESD, binomial effect size display: 2 × 2 table [group (MI, controls) × improvement (yes, no)]; * 1 p < 0.05; * 2 p < 0.01 MI, motivational interviewing

Example interview of motivational interviewing

Clinician: “We took a blood sample at your last appointment and I would like to discuss the findings with you. On the whole, your values are normal—only one liver enzyme value is elevated. You can see here, your gamma-GT is 220, a normal value would be 66 at the most. The gamma-GT level generally rises when, over a long period of time, one drinks more alcohol than the liver can break down. How does that sound to you?”

Patient: “I really can’t imagine that, I don’t actually drink that much. Well, okay, sometimes when I’m under a lot of stress at work, I’ll have a few more beers in the evening than usual, but otherwise I just have my after-work beer, and never any hard stuff.”

Clinician: “So this surprises you…”

Patient: “Yes, of course, I really don’t think I drink that much. I mean, I hardly ever get drunk.”

Clinician: “On the whole, you’ve got your drinking well under control; you only really drink a bit more when you’re under a lot of stress.”

Patient: “Of course, I’ll admit that now and again I need something in the evening to switch off. But I can’t imagine that my liver can’t cope with it; after all, I used to drink a lot more while I was training and never had any problems.”

Clinician: “You don’t see any problems with your alcohol consumption, and now the findings bother you, of course. Would you be interested in having a bit of information about the link between alcohol consumption and liver values?”

Patient: “Oh well, why not? Of course, I once read that too much alcohol is not good for the liver, but not in the case of one or two after-work beers….”

Clinician: “Recent studies have shown that alcohol consumption even in comparatively small amounts can cause a number of physical effects. Low-risk alcohol consumption is considered to be a daily amount of no more than two small alcoholic drinks in healthy men, which corresponds to about half a liter of beer. Higher alcohol consumption increases the risk of health consequences such as liver and cardiovascular diseases. Also, the recommendation is to not drink alcohol two days a week. What does hearing that make you think?”

Patient: “Well, to be honest, I’m already above that. I sometimes have four or five beers in the evening. But it never never seemed that much to me—it doesn’t make me drunk. But what you’ve told me about my liver values does of course sound quite worrying…”

Clinician: “On the one hand, you found your alcohol consumption quite normal, buth on the other, you’re worried now….”

Patient: “ Of course, and I don’t want it to get worse. But does that mean I can’t ever drink beer again?”

Clinician: “The idea that your liver values will continue to get worse scares you. From a medical perspective, it would be a good idea to abstain from alcohol completely for the time being so that your liver can regenerate, but only you can make that decision. So what do you think about what we’ve discussed so far?”

Patient: “Well, I suppose I should definitely cut down. To start with, no more alcohol until my liver is okay again. How long will that take?”

Clinician: “Not drinking anything for a while might actually be a good option. It generally takes 2–3 months for liver values to return to normal. How does that sound to you?”

Patient: “Well, 2–3 months sounds like an awfully long time—I mean, I can definitely manage it if I have to, but it’s probably okay to drink a beer once in a while when I’m with friends, isn’t it? The main thing is that I don’t drink as much as I have been drinking.”

Clinician: “You’re not sure whether you want to see this through for so long. On a scale of 0–10, how important is it to you at the moment not to drink alcohol for 2–3 months, if 0 means “not at all important” and 10 means “very important”?

Patient: “ Well, definitely a 6 or 7.”

Clinician: “Being able to sustain temporary abstinence is quite important to you. Why did you choose a 6 or 7 and not a 3 or 4?”

Patient: “If I’m honest, the thing with the liver values does make me think, and you did say that it takes that long for the values to normalize. And perhaps I could prove to myself at the same time that I’m still able to do that.”

Clinician: “In addition to the physical health aspect, you could also prove to yourself that you don’t need the alcohol. What would have to happen for your importance rating to increase from a 6 or 7 to an 8 or 9?”

Patient: “I’d need to have some sort of plan for what to do when I’m with my buddies. It would be weird to just have a water.”

Clinician: “It is actually normal to drink alcohol in your group of friends. How could you nevertheless abstain from drinking alcohol in those situations?”

Patient: “A good friend of mine once went on a diet and cut out beer, and actually everyone accepted it. Maybe I could try that too.”

Clinician: “That’s a really good idea! If you tell them that you’re not drinking at the moment for health reasons, that might help you feel less weird about the situation. So to recap: At the moment, you’re worried about your liver values, and you can imagine, in principle, giving up alcohol completely for a while. That way, you would also prove to yourself that you don’t need that after-work beer. It would feel strange at first when you meet up with friends, but if you tell them in advance, it shouldn’t be a problem. So what could you next step be?”

Patient: “ I think, to start with, I’ll try not to drink any alcohol for the next two months. Maybe that will already make a difference to my liver values, like you said.”

Clinician: “That’s a great idea! I suggest we make an appointment in six weeks and see how it went, and do another blood test at the same time.”

Questions on the article in issue 7/2021:

The submission deadline is 18 February 2022. Only one answer is possible per question. Please select the answer that is most appropriate.

What are the four processes of motivational interviewing?

• Engaging, evoking, planning, clinician discontinues contact
• Engaging, focusing, evoking, planning
• Focusing, evoking, evaluating success, praising/criticizing the patient
• Education, provocation, evaluation, distancing oneself from the patient
• Focusing, distancing oneself from the patient, evaluation, praising/criticizing the patient

What does the abbreviation DALYs, which is used as a measure of the disease burden in the population, stand for?

• Disease-adjusted life years
• Duration-adjusted life years
• Disease-affected life years
• Drug-affected life years
• Disability-adjusted life years

What is the patient’s basic attitude assumed to be in motivational interviewing (MI)?

• The patient is essentially unmotivated.
• The patient recognizes no abnormal behavior whatsoever in themselves.
• The patient is ambivalent about behavior change.
• The patient is highly motivated to change their behavior.
• The patient has no understanding of the fact that their behavior could harm their health.

In terms of the therapeutic style of motivational interviewing, what should be avoided?

• Evoking motivation to change
• Compassion for the the patient’s life and experience
• Being on eye level with the patient
• Achieving behavior change against to the patient’s will
• Developing discrepancy between problem behavior and the patient’s values

One of the techniques of motivational interviewing is to ask open-ended questions in order to address the problem behavior. How high should the minimum percentage of open-ended questions out of all the questions asked be in this type of interview?

• At least 70%
• At least 30%
• At least 10%
• At least 50%
• At least 90%

Patients’ statements about their problem can be roughly divided into two categories. What are these called?

• “Denial talk” and “progress talk”
• “Negative talk” and “positive talk”
• “Bad talk” and “good talk”
• “Sustain talk” and “change talk”
• “Ill talk” and “health talk”

No significant positive effects have been achieved as yet for which disease pattern according to Lundahl’s meta-analysis?

• Eating disorders
• Level of alcohol consumption
• Level of cannabis use
• Tobacco consumption

The chronification of health impairments is often promoted by inadequate medication adherence. How high is the percentage of patients with poor medication adherence according to a number of studies?

• Approximately 30–60%
• Approximately 20–40%
• Approximately 15–30%
• Approximately 5–10%
• Approximately 1–2%

Which mechanism of MI is able to best explain the effectiveness of the procedure?

• Exploration and conflict resolution
• Psychoeducation
• Reinforcement of self-motivational statements
• Positive relationship building
• Confrontation

Question 10

Motivation is built through the patient naming their desires, abilities, reasons for change, and needs for change. Which acronym summarizes these aspects?

Acknowledgments

Translated from the original German by Christine Rye.

Conflict of interest statement The authors are members of the international Motivational Interviewing Network of Trainers.

Motivational Interviewing in Social Work: An Evidence-Based Communication Approach

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We remain committed to active Kognito customers and will continue to serve these accounts through the term of existing agreements.

March is Social Work Month , a time to celebrate the social work profession and the immeasurable contributions social workers make to our society. Social workers are one of the largest groups of mental health care providers in the country, helping individuals and families overcome challenges so they can live to their fullest potential. Especially at a time of pandemic, racial unrest, economic uncertainty, and political divisiveness, social workers help the nation heal through the power of communication. And one of the most powerful communication methods they draw from is motivational interviewing.

Here’s a brief overview of what motivational interviewing is, the importance of motivational interviewing in social work, and how current and future social workers can gain valuable practice using motivational interviewing skills.

What is motivational interviewing?

Motivational interviewing (MI) is a communication technique originally developed by psychologists and educators Miller and Rollnick with the goal of helping people make behavior changes. Below is their most recent definition of motivational interviewing found in their book, Motivational Interviewing: Helping people to change (3rd edition):

“MI is 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.” – Miller and Rollnick (2013)

The four processes Miller and Rollnick outline in motivational interviewing include engaging, focusing, evoking, and planning. The approach uses skills and techniques to foster a partnership with clients, with elements including:

• Collaboration
• Promotion of autonomy
• Affirmation

Motivational interviewing skills are especially useful when working with people who are resistant to change, uncertain or doubtful about an issue, or struggle with low confidence. By helping these individuals discover their own intrinsic motivation to change, therapists, social workers, and other health professionals can help make a lasting impact in their clients’ lives.

The value of using motivational interviewing in social work

Motivational interviewing in social work is powerful because of the profession’s practice in behavioral health .

Social workers provide a wide spectrum of services to diverse populations and are focused on the overall wellbeing and health of their clients, with behavioral health being key. For every 10 people who visit a doctor, seven are there for reasons related to behavioral health . These prevalent issues can include:

• Diabetes management
• Weight loss
• Alcohol and other drug use problems

The social work practice in behavioral health involves the assessment, diagnosis, treatment, and prevention of mental illness, substance use, and other addictions.

Social workers are unique in that they not only help clients identify how they feel about situations, they also help create action plans for responding to them. Social work is complex and multi-faceted. Motivational interviewing is a powerful skill for social workers to master because it fits into the various roles they take on, particularly related to addiction.

Motivational Interviewing and SBIRT

An approach known as SBIRT — Screening, Brief Intervention, and Referral to Treatment — has gained popularity in recent years as an effective, evidence-based public health approach to the delivery of early intervention and treatment to these individuals, and uses motivational interviewing skills to increase awareness and motivate behavioral change.

SBIRT been bolstered by initiatives and formal recommendations from the National Institutes of Health (NIH), Substance Abuse and Mental Health Services Administration (SAMHSA) , Health Resources and Services Administration (HRSA) , Agency for Healthcare Research and Quality (AHRQ) , and several national and international public health agencies.

NORC at the University of Chicago, in collaboration with the Council on Social Work Education (CSWE), created a curricular resource on SBIRT. In this valuable resource for social work educators, motivational interviewing in social work is the sixth competency outlined.

“Through SBIRT, and consistent with the spirit of MI, social workers foster conversations that are centered on the strengths, priorities, and self-identified concerns of the individuals with whom they work. Social workers are mindful of the heavily contextualized nature of SBIRT practice and understand how individuals are affected by and affect families, other influential groups, organizations, and communities.” – NORC at the University of Chicago, Curricular Resource on Screening, Brief Intervention, and Referral to Treatment (SBIRT) , P. 16

Because social workers understand the importance and influence of external factors and contexts, they are uniquely positioned to effectively use motivational interviewing and SBIRT to effectively engage with their clients.

Learn and practice motivational interviewing techniques

Schools of social work are embracing technology to train their students . Using simulation technology to give students practice using motivational interviewing in social work can help give them valuable practice before they work with clients in-person or during telehealth sessions.

“It can be really scary for our students to walk out there and greet clients for the first time and remember all the things that we taught them about – confidentiality, how to engage, how to establish rapport, all of that,” says Dr. Noell Rowan, a professor and associate director at the University of North Carolina Wilmington (UNCW) School of Social Work. “The Kognito simulations can help students to feel more confident when they reach an actual client or client system or family or organization.”

Kognito’s behavioral health simulations use evidence-based role-play simulations to help equip social work professionals and students of social work with skills and knowledge to address clients’ behavioral health.

Two simulations are particularly impactful in social work:

SBI With Adolescents helps health professionals build and assess their skills in conducting substance use Screening & Brief Intervention (SBI) with adolescent patients and providing referrals to treatment when appropriate.

SBI Skills Assessment helps health professionals assess their skills in conducting substance use Screening & Brief Intervention (SBI) using evidence-based intervention and motivational interviewing techniques.

Motivational interviewing in social work is powerful, but takes practice to master. Through virtual simulation, learners can gain meaningful practice in a safe environment.

Learn more about Kognito’s behavioral health simulations and request a demo at kognito.com .

Privacy Overview

What Is Motivational Interviewing? A Theory of Change

They can be related to just about anything and can happen with friends and family or with a provider at a routine health visit.

During these conversations, people may voice various reasons for why they want and don’t want to change. In other words, they may be feeling ambivalent about change, which is entirely normal and a step included in the change process (DiClemente, 2003; Engle & Arkowitz, 2006).

What if we could navigate these conversations in a way to help others change for their benefit? What if we could do this in a way that wasn’t a gimmick or coerced, but completely supportive and encouraging?

Knowing that it is possible to have conversations that spark change and assist people to feel motivated and empowered, we look into the theory behind Motivational Interviewing and how we can use it for positive change.

Before you continue, we thought you might like to download our three Goal Achievement Exercises for free . These detailed, science-based exercises will help you or your clients create actionable goals and master techniques to create lasting behavior change.

This Article Contains:

What is motivational interviewing a scientific theory, the basics of mi: a model, eliciting change talk: 5 goals of mi, a look at the change cycle, positivepsychology.com mi resources, a take-home message.

Motivational Interviewing (MI) is an evidence-based treatment used by providers all around the world to explore clients’ ambivalence, enhance motivation and commitment for change, and support the client’s autonomy to change.

The approach allows clients to identify their reasons for change based on their own values and interests. Providers can decrease the client’s resistance or defensiveness by taking a seat alongside their clients, as both are considered experts in this approach.

A layperson’s definition of MI would be “ a collaborative conversation style for strengthening a person’s own motivation and commitment to change ” (Miller & Rollnick, 2013). This collaborative conversation includes the spirit of MI: partnership, acceptance, compassion, and evocation. The spirit of MI is based on the principles of Carl Rogers’s client-centered counseling (Rogers, 1965).

For change to occur in the conversation, unconditional positive regard is essential.

An acceptance of this other individual as a separate person, a respect for the other as having worth in his or her own right. It is a basic trust – a belief that this other person is somehow fundamentally trustworthy.

(Rogers, 1980)

The spirit of MI, combined with the four processes and core skills, has been used worldwide in various settings to assist with changing behavior.

Motivational Interviewing was developed in the 1980s for individuals struggling with addiction and is now generalized for use with a wide range of behaviors from managing chronic diseases, promoting oral health practices, preventing college dropout, and decreasing children’s TV time.

The development of MI includes the combination of Client-Centered Therapy , the Self-Determination Theory, and the Transtheoretical Model (TTM) of behavior change.

Motivational Interviewing provides an environment with respect for clients, worth in what they contribute to the discussion, consideration of their autonomy and volition to change (or not change), and an understanding of their readiness for change.

Client-Centered Therapy

Humanistic psychologist Carl Rogers developed the Client-Centered approach, which emphasizes having unconditional positive regard with clients. This concept is highlighted as Absolute Worth in the MI spirit of acceptance, which is explained more below.

Providers can hold an attitude of acceptance and have respect for their clients’ worth. This attitude of acceptance is without judgment and allows people to feel accepted for who they are, allowing them the space to naturally make changes that benefit them and align with their values.

Therapists can improve their skills and attitude of acceptance by reviewing the worksheets in our Unconditional Positive Regard article.

Self-Determination Theory

The Self-Determination Theory (SDT) emphasizes the distinction between types of motivation, intrinsic or extrinsic, and how that influences behavior. Additionally, the theory considers the client’s autonomy to choose, perceived competence to make a change, and the social context.

According to the SDT, when someone feels autonomous to control their own behavior and has the knowledge and skills to achieve the desired outcome, then they are more likely to put in the effort and persist in changing that behavior (Ryan & Deci, 2000).

The social context can further encourage or prevent behavior change. For example, suppose a client is speaking with their provider about decreasing their alcohol use, and the provider assists the client to explore why they want to change their behavior. The provider may ask how they can decrease their use and identify examples of making decreases in the past; then the client may be more inclined to try and decrease their use.

However, if the provider tells the client that they should decrease their use and how to do it, then the client may feel that this change is not their choice, unsure of how to start, and unsupported with making changes.

Transtheoretical Model

The Transtheoretical Model of behavior change (Prochaska & DiClemente, 1984) was developed to understand how ready people are to change. Here you can learn more about the specific stages of change .

The TTM relates to MI such that the client’s readiness, or what stage of change they’re in, can be considered throughout the four processes of MI. Different MI techniques can be used depending on the individual’s readiness for change. For example, if a client is in the pre-contemplation or contemplation stages, they may be voicing more preparatory change-talk statements, e.g., “ I want to be more active .”

Providers can proceed with the evocation process to strengthen the client’s amount of change talk. If a client is in the preparation or action stages, they may be voicing more mobilizing change-talk statements, e.g., “ I am going to take a walk this evening, ” and providers can assist with the planning process.

To understand the basics of motivational interviewing, we explain the MI spirit, share the four processes, and also mention the core skills.

The four aspects of the MI spirit

The MI spirit consists of partnership, acceptance, compassion, and evocation.

Figure 1. The spirit of MI

Partnership emphasizes how MI is used with and for someone to engage in an active conversation between two experts.

In MI, there is a collaboration between the provider and the client. Providers must sit with the reality that they don’t have all the answers and need their client’s expertise on how change would look in their lives.

The provider is not trying to convince, trick, or argue why a client should change. Instead, providers are guiding, listening, and trying to understand the client’s circumstances.

The four aspects of acceptance

Acceptance highlights the importance of respecting what a client contributes to the partnership.

There are four aspects of Acceptance:

• Absolute Worth
• Accurate Empathy
• Autonomy Support
• Affirmation

Collectively, these four client-centered conditions make up the MI spirit of acceptance.

“One honors each person’s absolute worth and potential as a human being, recognizes and supports the person’s irrevocable autonomy to choose his or her own way, seeks through accurate empathy to understand the other’s perspective, and affirms the person’s strengths and efforts.”

William Miller

Figure 2. The four aspects of acceptance

Absolute Worth and Accurate Empathy  highlight the work of Carl Rogers and the conditions critical for change.

Absolute Worth emphasizes Rogers’s concept of unconditional positive regard, such that when people are accepted without judgment, they are free to make changes.

Accurate Empathy  emphasizes efforts to understand a client’s perspective without feeling pity or identifying with them.

Autonomy Support  highlights the importance of respecting a client’s autonomy to choose, not to control, persuade, or coerce. This can facilitate change by decreasing a client’s defensiveness and emphasizes the client’s freedom of choice.

Affirmation emphasizes recognition of the client’s strengths and efforts.

Compassion was added to the underlying spirit of MI in the third edition of Miller and Rollnick’s book Motivational Interviewing: Helping People Change (2013) to highlight the importance of using MI to promote the wellbeing of others and not for our own self-interest or to exploit others.

Evocation is used to assist clients in identifying the wisdom and reasons for changing their behavior. The spirit of MI assumes that clients want and are capable of change. The provider can evoke from their clients why and how to change by paying attention to their current strengths and resources.

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The four processes of MI

The four processes of MI include engaging, focusing, evoking, and planning. They build on one another, overlap, and recur.

Miller and Rollnick (2013) describe these processes as stairs:

“Each later process builds upon those that were laid down before and continue to run beneath it as a foundation. In the course of a conversation or case, one may also dance up and down the staircase, returning to a prior step that requires renewed attention.”

Figure 3. The four MI processes

Engaging is the process where the working partnership is established and the focus is on building rapport with clients. It is more than being kind to clients.

Providers must be in tune with assisting their clients in feeling comfortable and engaged in establishing a mutually trusting and respectful relationship. When a good working partnership is established through the engaging process, clients are more likely to return and make changes.

Focusing is used to assist providers and their clients with clarifying an agreed-upon direction. Both the provider and client may have their own agendas. However, focusing allows the working partnership to collaborate on finding a common direction toward change. This can be done by presenting a clear set of possible topics to focus on during the conversation.

Evoking  is used by providers to help clients find and voice their own motivations for change. Providers can explore this with clients by asking open-ended evocative questions that elicit change talk, helping clients identify why they want or need to change, having clients voice what they can do to change, and developing discrepancy between the client’s goals and values and their current behavior.

Planning can begin when a client expresses readiness to change and the conversation becomes more about when and how to change. It involves identifying a plan of action and includes the spirit of MI and the other processes of engaging, focusing, and evoking.

The core skills used in MI include:

Change talk can be preparatory or mobilizing. Preparatory change talk can be elicited when providers explore clients’ desires, ability, reasons, and need to change. Mobilizing  change talk can be elicited when providers explore clients’ commitment, activation (willingness, readiness, and preparation), and steps to change.

Change talk can be elicited using the five techniques below.

1. Asking evocative questions

Preparatory evocative questions include exploring desire, ability, reasons, and need (DARN).

Desire questions explore what clients want or wish for life. Examples are provided below.

What do you want from therapy?

How much would you like to drink?

Tell me what you wish were different.

Ability questions explore what clients can and are able to do.

What do you think you could do to… ?

How likely are you to be able to… ?

What ideas do you have to change how much you’re… ?

How confident are you that you could… ?

Reason questions explore why clients want to change.

Why do you want to… ?

What’s the problem with continuing with how things are?

Tell me your top three reasons for… 

Need questions explore the client’s urgency for change.

What needs to occur for you to… ?

How urgently does… feel to you?

What do you think needs to change?

2. Using the importance ruler

An imaginary scale ranging from 0 to 10 can be used to explore the client’s level of perceived importance for change. It involves the use of two questions, and the second question is meant to elicit change talk and assist the client to identify why change is important.

“ On a scale from 0 to 10, where 0 indicates not at all important and 10 indicates the most important thing for me right now, how important is it for you to… ? ”

“ And why are you at a… and not a (lower number)? ”

Although someone may answer the initial question with 0, it is uncommon. In the event that a client reports an importance rating of 0, other evocative questions (desire, ability, or reasons) can be used to explore ambivalence.

3. Querying extremes

Exploring the client’s worst- and best-case scenarios can elicit change talk.

“ What can happen in the long run if you continue as you are? ”

“ What worries you the most about not changing your health habits? ”

“ What could happen if you were successful in… ? ”

“ What would be the best results if you did change? ”

4. Looking back and looking forward

Helping clients identify how their situation was before engaging in their problematic behaviors and comparing that with their lives currently can elicit change talk. Additionally, assisting clients in visualizing how life could be different can also elicit change talk.

Looking back:

“ What was your life like before you gained 30 pounds? ”

“ How has your weight changed you or prevented you from engaging with your family? ”

“ Tell me about when things were going well. What changed? ”

Looking forward:

“ How would you want things to be different in the future? ”

“ Tell me, if you didn’t have any physical pain, how would your interactions with your family change? ”

“ How would you like things to be in five years? ”

5. Exploring goals and values

Download 3 Free Goals Exercises (PDF)

These detailed, science-based exercises will help you or your clients create actionable goals and master techniques for lasting behavior change.

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It is completely normal for people to be ambivalent about making changes in their behavior. There are fluctuating reasons to change and not to change. It’s also important to consider someone’s belief that they’re capable of changing.

Motivational Interviewing can be used to explore someone’s ambivalence for change. With the spirit, processes, and techniques of MI, ambivalence can be resolved. Clients can identify and voice their own desires, ability, reasons, and need for change.

As ambivalence decreases and clients express more readiness and commitment to change, providers can assist clients through the planning process to engage in behavior change.

Figure 4. MI framework

Our site has numerous Motivational Interviewing resources, including specific MI questions, skills, and worksheets, to assist with your client’s readiness to change.

These three articles are particularly helpful:

• 17 Motivational Interviewing Questions and Skills
• The 6 Stages of Change: Worksheets for Helping Your Clients
• Motivation in Education: What It Takes to Motivate Our Kids

While these two worksheets can be equally apt:

• SCAMP – Goal Setting
• Basic Needs Satisfaction Through a General Scale

If you’re looking for more science-based ways to help others reach their goals, this collection contains 17 validated motivation & goals-achievement tools for practitioners . Use them to help others turn their dreams into reality by applying the latest science-based behavioral change techniques.

17 Tools To Increase Motivation and Goal Achievement

These 17 Motivation & Goal Achievement Exercises [PDF] contain all you need to help others set meaningful goals, increase self-drive, and experience greater accomplishment and life satisfaction.

Created by Experts. 100% Science-based.

As mentioned initially, conversations about change occur all the time. People inherently want to change and improve their life outlook , lifestyle, and habits. Yet they often fall into a pit of immobility and helplessness.

This is where Motivational Interviewing with its components, processes, and techniques can make a difference. This communication style is client centered, uses empathic listening , and evokes the client’s reasons for change; the conversation is focused on an identified target for change.

At the end of the day, whether or not clients engage in changing their behaviors is up to them. However, as providers, we can focus on understanding why (or why not) and then assist them in exploring why change may be in their best interest – and Motivational Interviewing is the best route to accomplish this.

We hope you enjoyed reading this article. Don’t forget to download our three Goal Achievement Exercises for free .

• DiClemente, C. C. (2003). Addiction and change: How addictions develop and addicted people recover . New York: Guilford Press.
• Engle, D. E., & Arkowitz, H. (2006). Ambivalence in psychotherapy: Facilitating readiness to change . New York: Guilford Press.
• Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change ( Applications of motivational interviewing) (3rd ed.). New York: Guilford Press.
• Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy . Homeward, IL: Dow/Jones Irwin.
• Rogers, C. R. (1965). Client-centered therapy . New York: Houghton Mifflin.
• Rogers, C. R. (Ed.). (1980). A way of being . Boston: Houghton Mifflin.
• Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist , 55 , 68–78.

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Motivational interviewing

Author: Karen Evans

Updated Date: 31 May 2024

Publication Date: 11 October 2013

Introduction

Learning points How the underlying principles and spirit of motivational interviewing integrate well with the social work role. The four tasks of motivational interviewing (engaging, focusing, evoking and planning) and traps to avoid when applying the approach in practice. Examples of using the core skills of motivational interviewing. Contents Introduction The principles and spirit of […]

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Title * Motivational interviewing

Date * 15-09-2024 (dd-mm-yyyy)

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Evans, K (2013) Motivational interviewing. Practice Guidance. Community Care Inform [online] https://adults.ccinform.co.uk/practice-guidance/guide-using-motivational-interviewing-social-work-practice/ [accessed: 15 September 2024]

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