Introduction
According to recent research, the worst case scenario in health coaching is when the practitioner argues for the change while the patient argues against it. This typical scenario in healthcare when a patient is "non-adherent" actually predicts negative clinical outcome - yet it’s the norm now in the traditional medical model. However, there is an evidence-based approach that flips the typical scenario on its head, while predicting more positive clinical outcomes. Motivational Interviewing (MI) is an evidence-based approach, with over 900 clinical trials, either completed or in progress, demonstrating its effectiveness.¹ First we’ll quickly introduce the MI approach and provide an overview of the research that supports its efficacy. We’ll explore the underlying dynamics of MI. Lastly, we’ll make the case for why MI is an important approach to integrate into healthcare interventions.

Origins of Motivational Interviewing
First described by Dr. William Miller in 1983, MI began as a behavior therapy for problem drinkers, and has since evolved into a much broader patient-centered communication approach.² More specifically, MI is “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation of and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion."³ Currently considered the gold standard in addiction counseling, MI has expanded as a popular approach for a spectrum of lifestyle management, treatment adherence, and engagement interventions in a variety of settings, including corrections, healthcare, social work, and vocational rehabilitation.

Key Characteristics and Causal Chain
An important factor that influenced the development of MI’s causal chain is the client-counselor relationship with an emphasis on therapeutic understanding as described by Carl Rogers.⁴ According to Miller and Rollnick, this foundation of the approach is known as the MI Spirit and can be pared down to the following characteristics: (1) Partnership, (2) Acceptance, (3) Compassion, and (4) Evocation, with each component being experienced by the practitioner as well as displayed.³

However important the MI Spirit is to the foundation of the approach, the glue that ties the approach together, captures its essence, and separates it from Rogerian client-centered therapy is the emphasis on the language of change. The original hypothesis for the causal chain of MI- influenced behavior change has been borne out:

1. Encouraging the client to verbalize arguments for change (“change talk”) promotes change; and
2. Evoking and/or pushing back against client barriers or challenges to change (sustain talk) promotes the status quo and/or resistance

In other words, the use of MI techniques that increase change talk and decrease sustain talk result in behavior change and improved clinical outcomes.⁵

The evocation and reflection of change talk by the practitioner has been shown by recent research to be particularly influential in health coaching sessions.⁷ Findings suggest that increases in change talk and commitment language are positively correlated with progression in stages of change and improved health outcomes .^7-9 There is even research using neuroimaging to demonstrate that change talk processing occurs in the same parts of the brain consistent with self-perception and intentions. This suggests that in treatment sessions where clinicians evoke change talk, they are “tapping into neural circuitry that may be essential to behavior change.”¹⁰ In summary, numerous studies have supported the hypothesis that patient language about change (i.e. change talk) does in fact effect the causal chain of MI.

Research has also shown that clinician behavior can have a significant effect on patient language; demonstrating that change talk is not just an indicator of a patient’s intrinsic motivation, but can be influenced by the technique of the provider in an MI intervention.^10-12  In addition, Moyers clearly demonstrated that practitioners can be trained how to strategically evoke and respond to client change talk, as well as reduce client sustain talk.^11,13

Advantages of MI Approach Over Traditional Approach
Although MI was founded in the addictions and counseling domain, there is sufficient literature now regarding the application of the approach in the healthcare setting; indeed, there are now numerous meta-analyses in the healthcare setting that provide significant evidence of its efficacy. In one meta-analysis of MI limited to clinical trials, results showed a statistically relevant positive correlation between the use of MI and measurable health outcomes.¹⁴ In another systematic review and meta-analysis of the application of MI in the primary care setting, results demonstrated positive results in clinical outcomes, with as few as one MI session being effective in increasing change-related behavior on certain outcomes.¹⁵

The literature also indicates that MI can be used with diverse and challenging populations. A meta-analysis observed that effect sizes of MI were larger with ethnic minority populations and, additionally, “MI is particularly useful with clients who are less motivation or ready for change, and who are more angry or oppositional”.¹⁶

Specific components of MI have been directly associated with improved health outcomes. For instance, in a study that focused on empathy levels of primary care physicians with their diabetic patients, results showed that physicians with high
empathy scores, compared with patients of physicians with moderate and low empathy scores, had a significantly lower rate of acute metabolic complications. They concluded that physician empathy is significantly associated with clinical outcome for patients with diabetes mellitus and should be considered an important component of clinical competence.¹⁷

Apart from increased efficacy, a more patient-centered approach holds other advantages, such as improved patient engagement and satisfaction. In the traditionally directive approach commonly used in healthcare interventions, the provider’s agenda is prioritized, while MI allows for more collaboration. In other words, MI allows the provider and the patient the opportunity to partner together in an egalitarian manner which improves engagement. In one review of MI, the authors evaluated empirical studies testing the effectiveness and clinical utility of MI in three health areas: diet and exercise, diabetes, and oral health. In all three areas, providers were prone to give advice and use confrontational tactics with their patients, but “MI provides a ‘kinder and gentler’, respectful, and more efficacious approach that is less likely to produce resistance among patients.”¹⁸ And, as we have reported in previous blog articles, numerous studies have found that the strongest impact on patient satisfaction is the care provider’s interaction and engagement with the patient.^19,20

Moreover, the MI approach also promotes a more efficient use of resources. The traditional approach fosters passivity and dependence on the part of the patient on the provider; whereas the MI approach engenders activation and empowerment of the patient become the driver of her own health care. Thus, patients who have been coached using the MI approach do not utilize healthcare resources as heavily. Lastly, a review of four meta-analyses indicated that the MI approach demanded 100 minutes less face-to-face time overall with patients compared to the traditional patient education approach.²¹

MI in Practice
There are two main components in MI, each of which rests on a patient-centered perspective and genuine sense of collaboration. Together they compose a comprehensive patient-centered communication skillset that is genuine, organic, and tactical. First, the relational component is focused on empathy and the interpersonal spirit of MI.⁵ This component emphasizes an approach that: (1) is collaborative, rather than authoritarian; (2) evokes the client’s own motivation rather than trying to install it; and (3) honors the client’s autonomy.⁵

The technical component involves the skills to demonstrate intention; evoke and reinforce change talk; minimize, but validate, sustain talk; and other methods to facilitate movement towards positive behavior change. Strategies such as “Elicit-Provide-Elicit”, assessing importance and confidence, or using a “menu of options” are examples of  technical components of MI.²²

Note some differences between the traditional approach and an MI-based approach:

MI as a Healthcare Intervention Standard
​Much of healthcare practice today addresses the treatment and management of chronic care conditions, so it makes sense to incorporate an evidence-based health coaching approach. MI is the only health coaching approach to be fully described, standardized, and consistently associated with positive clinical outcomes.^22-25

MI is a complex skill set that does not lend itself to the typical “one-and-done” style of training; it takes commitment, planning, and dedicated resources to train medical staff. Like learning a foreign language, it takes practice, feedback and continuous support after the initial training over time to develop proficiency. In addition, policies and procedures in the organization may need to be modified to support the new approach. There are several learning modalities and options available to your team or for individual practitioners interested in pursuing MI as a clinical communication approach. Stay tuned for more on the criteria that should be met for a successful workforce training initiative plus a sustainability plan for integrating MI into your practice or setting.

References

¹ National Center for Biotechnology Information, U.S. National Library of Medicine. Key word: motivational interviewing; Article type: Clinical Trial. Accessed on October 23, 2016 at https://www.ncbi.nlm.nih.gov/pubmed

² Miller WR. Motivational interviewing with problem drinkers. Behav Psychother 1983; 11: 147–172.

³ Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Third Edition. New York: Guilford Publ.: 2013.

⁴ Rogers CR. The necessary and sufficient conditions of therapeutic personality change. J Consult Psychol 1957;21(2):95-103.

⁵ Miller WR, Rose GS. Toward a Theory of Motivational Interviewing. Am Psychol 2009;64(6):527-537.

^​6 Moyers TB. The relationship in motivational interviewing. Psychother 2014;51(3):358–63.

⁷ Barnett E, Moyers TB, Sussman S, et al. From counselor skill to decreased marijuana use: Does change talk matter? J Subst Abuse Treat 2014;46(4):498-505.

⁸ Perry CK, Butterworth SW. Commitment strength in motivational interviewing and movement in exercise stage of change in women. J Amer Acad Nurse Pract 2011;23(9):509-514.

^​9 Moyers TB, Martin T, Christopher PJ, Houck JM, Tonigan JS, Amrhein PC. Client Language as a Mediator of Motivational Interviewing Efficacy: Where Is the Evidence? Alcohol Clin Exp Res 2007;31(s3).

^​10 Houck JM, Moyers TB, Tesche CD. Through a glass darkly: Some insights on change talk via magnetoencephalography. Psychol Addict Behav 2013;27(2):489-500.

^​11 Glynn LH, Moyers TB. Chasing change talk: The clinician's role in evoking client language about change. J Subst Abuse Treat 2010;39(1):65-70.

^​12 Apodaca TR, Jackson KM, Borsari B, et al. Which Individual Therapist Behaviors Elicit Client Change Talk and Sustain Talk in Motivational Interviewing? J Subst Abuse Treat 2016;61:60-65.

^​13 Moyers TB, Houck J, Glynn LH, Hallgren KA, Manuel JK. A randomized controlled trial to influence client language in substance use disorder treatment. Drug Alcohol Depen 2017;172:43-50.

^​14 Rubak S, Sandbæk A, Lauritzen T, et al. Motivational interviewing: a systematic review and meta-analysis. Brit J Gen Pract 2005; 55:305-312.

^​15 VanBuskirk KA, Wetherell JL. Motivational Interviewing Used in Primary Care: A Systematic Review and Meta-analysis. J Behav Med 2014;37(4):768-80.

^​16 Hettema J, Steele J, Miller WR. Motivational Interviewing. Annu Rev Clin Psychol 2005;1:91-111. 

^​17 Canale SD, Louis DZ, Maio V, et al. The Relationship Between Physician Empathy and Disease Complications. Acad Med 2012;87(9):1243-1249.

¹⁸ Martins RK, Mcneil DW. Review of Motivational Interviewing in promoting health behaviors. Clin Psychol Rev 2009;29(4):283-293.

¹⁹ Weinacker A. Press Ganey Again? Strategies for Improving the Patient Experience. Stanford Health Care. Accessed on February 26, 2017. Available at:https://stanfordhealthcare.org/health-care-professionals/medical-staff/m...

²⁰ Johnson DM, Russell RS. SEM of Service Quality to Predict Overall Patient Satisfaction in Medical Clinics: A Case Study. Qual Manage J 2015;22(4):18–36.

^​21 Lundahl B, Burke BL. The Effectiveness and Applicability of Motivational Interviewing: A Practice-Friendly Review of Four Meta-Analyses. J Clin Psych 2009;65(11):1232-45.

²² Butterworth SW, Linden A, McClay W. Health Coaching as an Intervention in Health Management Programs. Dis Manage Health Out 2007;15(5):299-307.

^​23 Noordman J, van der Weijden T, van Dulmen S. Communication–related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature. Patient Educ Couns 2012;89(2):227-44.

^​24 Wolever RQ, Simmons LA, Sforzo GA, et al. A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral intervention in Healthcare. Globl Adv Health Med 2013;2(4):38-57.

²⁵ Olsen JM, Nesbitt BJ. Health Coaching to Improve Healthy Lifestyle Behaviors: An Integrative Review. Am J Health Promot 2010;25(1):e1-e12.