Abstract
Alcohol use disorders are related to many negative health, emotional, societal, and economic consequences. These disorders are often difficult to treat because individuals suffering from them tend to be ambivalent about and resistant to change. Motivational interviewing provides health care providers with the appropriate tools to treat individuals who are resistant to change and can help with long-term lifestyle and behavioral changes. Motivational interviewing has also been shown to be helpful when a lifestyle approach to treatment is used.
‘Overall, MI [motivational interviewing] is intended to facilitate behavior change by allowing patients to internalize the change process and make the decision to change for themselves.’
Alcohol use disorders, abuse, and dependence are a large and growing issue not only in this country but throughout the world. In the United States alone, 17.4% of men and 8% of women meet the criteria for alcohol dependence during some point in their lives, and the incidence of alcohol use disorders and abuse are even higher. 1 As discussed in this issue by Huang et al, 2 alcohol abuse can result in detrimental consequences on a personal, societal, and economic level.3-17 Alcohol’s serious, negative health effects and increased levels of morbidity and mortality are of especial importance, as alcohol can be attributed to 3.8% of global deaths annually.13,18
Multiple interventions have been developed to treat alcohol abuse and dependence. These interventions are based on a wide range of theoretical frameworks and have demonstrated varying outcomes for success and patient adherence at 1-year follow up.19-21 One of the main barriers to treating alcohol abuse and dependence is that many people engaged in treatment are ambivalent about and resistant to change.22-24 Additionally, treatment often requires considerable time, effort, and motivation from the patient. 20 A significant goal of the health care provider in these cases is to address ambivalence and resistance.25-27
Motivational interviewing (MI), developed by William R. Miller 28 and later elaborated by Miller and Stephen Rollnick, 29 was created to specifically treat alcohol abuse. Although MI is consistent with a patient-centered approach, it also focuses on techniques to help patients address their intrinsic motivation (or lack thereof) to change behavior. MI has been incorporated into health care settings to treat a variety of conditions in which a lifestyle approach is used.30-32 The role of the health care provider in MI is not to give advice or provide information because these actions may be viewed by the patient as insensitive to their personal needs and lead to a breakdown of communication. Rather, the goal of treatment is to encourage the patient to do most of the talking with the health care provider guiding the process. Overall, MI is intended to facilitate behavior change by allowing patients to internalize the change process and make the decision to change for themselves. 26 As the treatment of many lifestyle issues could benefit from increased motivation by the patient, health care providers may find the use of this technique to be beneficial in their general practice.
Principles of Motivational Interviewing in a Health Care Setting
Express Empathy
At the core of MI is a sense of empathy and understanding. 33 Demonstrated empathy by the health care provider facilitates responsiveness and encourages cooperation. As a feeling of acceptance is established, patients feel comfortable in discussing issues such as ambivalence to change. Through this type of relationship, practitioners can better communicate to patients that their ambivalence is normal.27,34 To create this atmosphere, health care providers should avoid the standard practice of advice giving in an authoritative manner, as this is not entirely what the patient needs or wants to hear. 35 Rather, it is the patient who should be primarily in charge of their treatment, and the health care provider should simply guide and facilitate the change process helping patients to explore and resolve ambivalence and resistance.26,36-38
Develop Discrepancy
Although the patient is in charge of determining the course of treatment, the health care provider guides this process by exploring discrepancies.26,29 Basically, health care providers help patients to see that their current behavior is not in line with their health goals.29,34,39 To assist this, patients may be asked to determine the positive and negative aspects of their current behaviors. 40 Because patients determine the negative aspects of their behavior, they are more likely to consider change than when the health care provider indicates behaviors that are a health risk. Exploring behaviors that have negative consequences is intended to create a state of cognitive dissonance, which, in turn, promotes motivation. 39 This method allows patients to determine the need for change rather than being told what to do from a health care provider. 41 The key to developing discrepancy is to ensure that the patient presents the argument for change within themselves. 27
Avoid Argumentation
In the health care provider–patient relationship, argumentation or direct persuasion should be avoided. 29 For resistant-to-change behaviors, arguing is counterproductive to treatment and often results in defensiveness and further increases resistance.29,42 By avoiding giving advice or telling a patient which changes are needed, the likelihood of argumentation is decreased. 35 Additionally, placing emphasis only on benefits for behavioral change, while ignoring or underplaying the personal costs to the patient, may promote defensiveness in patients and ultimately undermine treatment. Recognizing that behavior change comes at a cost promotes long-term change. When health care providers take this approach, treatment is more like a partnership with both parties working toward a mutual goal, rather than a typical “doctor–patient” relationship.43,44
Roll With Resistance
The aforementioned techniques encourage a cooperative exchange between health care providers and patients; however, resistance to change may still occur.45,46 When resistance is experienced by the patient, health care providers should avoid trying to persuade the patient to work harder.41,45,46 Instead, resistance should be seen as a sign to change or alter the treatment and discussion strategy. 46 Resistance should not be ignored but acknowledged and explored. The goal of this exploration is to determine barriers that the patient is facing. Allowing resistance to be openly discussed further facilitates patients’ abilities of finding new ways to address the problem.27,45
Support Self-Efficacy
The overarching goal of MI is to create and support self-efficacy. 26 This is accomplished by allowing the patient to find and develop solutions to their problems. Because the patient is implicitly and explicitly viewed as being in control of and making decisions to change his or her behavior, successes are the result of the patient’s hard work. The role of the health care provider is one of support. 34 This further promotes the belief in the patient’s own ability to change his or her behavior. Allowing patients to freely make choices in changing their behavior at their own pace supports long-term skills in problem solving. As the patient gains confidence in their ability to make behavioral life changes, the health care provider assists them by being supportive. 46 As treatment progresses, health care providers may find that they begin to suggest, rather than impose, various solutions and methods for behavioral change. 27
Conclusion
Although MI was originally developed to treat alcohol abuse, it has since been incorporated in the treatment of a range of other clinical issues such as obesity, schizophrenia, asthma, and diabetes.47-52 Motivational Interviewing is a promising method to enhance outcomes in patients in need of lifestyle treatment. This is especially true for individuals who are resistant to change. In terms of issues that require a lifestyle approach, resistance to change may be one of the greatest barriers to treatment. Because of this, health care providers are encouraged to develop these skills in order to be better prepared for these difficulties. Although each of the techniques used in MI may not be used in each session, the overall concept or “spirit” may greatly assist health care providers in supporting long-term lifestyle and behavioral changes.