Motivational Interviewing - NurseCe4Less.com · 2016-03-17 · nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 Course Purpose To provide nurses and health team

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Motivational

Interviewing

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor

of academic medicine, and medical author. He

graduated from Ross University School of Medicine

and has completed his clinical clerkship training in

various teaching hospitals throughout New York, including King’s County Hospital Center

and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical

board exams, and has served as a test prep tutor and instructor for Kaplan. He has

developed several medical courses and curricula for a variety of educational institutions. Dr.

Jouria has also served on multiple levels in the academic field including faculty member and

Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several

continuing education organizations covering multiple basic medical sciences. He has also

developed several continuing medical education courses covering various topics in clinical

medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson

Memorial Hospital’s Department of Surgery to develop an e-module training series for

trauma patient management. Dr. Jouria is currently authoring an academic textbook on

Human Anatomy & Physiology.

ABSTRACT

The traditional methods of evoking change in the healthcare environment

involve educating patients and often dictating information to them that is

crucial to their health. This mentality and direction of information may or

may not be helpful to many people, who may end up feeling criticized or

judged for their decisions and who may have little motivation to change at

all. Motivational interviewing seeks to change the interaction between the

provider and the patient by assessing the patient’s desire and levels of

motivation and then working together to bring about change. It is a

collaborative process; and, successfully used with other forms of therapy to

support engagement between the provider and patient.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3.5 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this course

activity.

Statement of Learning Need

Motivational interviewing focuses on the patient and their desire to change

behavior to improve the state of their health. Nurses are integral in

supporting patients to recognize the need for change and to facilitate

improvements in their health outcomes.


Course Purpose

To provide nurses and health team associates knowledge about the use of

motivational interviewing to support health behavior change in patients.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC.

Release Date: 1/1/2016 Termination Date: 6/28/2017

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


1. The “R” in the DARN CAT acronym stands for:

a. realistic b. random

c. reason d. recognize

2. A client is talking with a nurse and telling her about how difficult

it was to accept the death of his father last year. While the client is talking, the nurse leans toward him, makes eye contact, and

nods her head periodically. These activities are best described as:

a. utilizing silence b. clarifying

c. active listening d. mirroring

3. According to Burke, et al., there are four states that contribute to self-efficacy in a person: mastery experience, vicarious

experience, physical and emotional states, and: a. personal success.

b. high self-esteem. c. generation of power.

d. social persuasion.

4. Which best describes an example of the self-efficacy step of the FRAMES method when used with a pregnant client?

a. The client receives a list of options to consider for changing her behavior

b. The provider helps the client to become more confident in herself by taking charge of her health

c. The client is made aware that she is responsible for herself and

the health of her baby d. The provider advises the client about what she can do to make

changes in her life

5. After going through an oral glucose tolerance test, a client has a blood glucose level of 160 mg/dL. This result would be

defined as: a. impaired glucose tolerance

b. type 2 diabetes c. impaired fasting glucose

d. altered glycogen synthesis


Introduction

Motivational interviewing (MI) is a method that promotes behavior change,

and can be used in a multitude of environments and situations to foster

growth and to help people to take on challenging situations. It uses the

principles of therapeutic communication and instead of providing advice, or

even just a listening ear, the interviewer acts as a coach for the client.

Motivational interviewing is a collaborative process that edifies the client and

makes him or her responsible for personal choices. It is not necessarily a

stand-alone type of therapy, but instead can be incorporated into treatments

and routine care for clients with various health issues, including those with

physical health problems, mental health issues, or substance abuse and

addiction. MI has also successfully been used along with other forms of

therapy to improve connection between the client and the provider and to

alter the process at which the client makes changes in his or her life.

Healthcare providers can use motivational interviewing in a number of

situations, yet it should always be recognized that no one could be forced to

change. Many nurses, physicians, and allied health professionals witness the

personal situations of clients and their families and grow frustrated by

feeling powerless to help. Although MI does not allow the healthcare

professional to change a person’s behavior, it does guide

the client toward making different choices that can foster change in his or

her life.1,2,3,4

The concept of motivational interviewing began in the early 1980s with the

publication of a book by William R. Miller, PhD, who focused his model of MI

on working with people suffering from substance abuse and addiction. The

book was titled Motivational Interviewing with Problem Drinkers and it was


initially used among psychiatrists and other professionals who provided

counseling services for people going through treatment for addiction.5

Almost twenty years later, Miller and a colleague, Stephen Rollnick,

published a second edition of the book. The second edition was geared, not

only toward addiction professionals working in the field of psychotherapy, to

any professional in the healthcare field who could utilize the principles and

put the techniques of MI into practice with their clients.5

Miller and Rollnick described motivational interviewing as a “directive, client-

centered counseling style for eliciting behavior change by helping clients to

restore and resolve ambivalence.”5 Ambivalence is a state in which a person

is uncertain about which direction to take, if any. A person who feels

ambivalent about his or her need for change or required treatments may

approach the situation with a lack of motivation. The person may have such

mixed feelings about the situation that making a decision can be paralyzing.

When a therapeutic relationship starts, the client may be in various stages of

ambivalence depending on the current situation. If he or she was recently

diagnosed with an illness or disease, ambivalence may be paired with

frustration or anger over the situation. Alternatively, the client may have

known for quite some time that change is necessary but has been unwilling

or unable to take steps to move forward.

Motivational interviewing is more than just a set of techniques that can be

implemented into conversations between healthcare providers and their

clients. It recognizes several theories as a basis for its approach, including

cognitive dissonance theory, which acknowledges that a person who acts

against his or her beliefs will be motivated to either change behaviors or

otherwise justify them; and self-perception theory, which is the idea that

people conclude certain traits or ideas about themselves based on observing


their own behaviors.33

A basic premise exists in motivational interviewing that talk can be helpful

for some situations, but without the motivation to change, talk, or simply

telling a person to do something, will not get very far. The provider who is

working with a client through motivational interviewing must recognize the

level of motivation the client holds and must be willing to work through

possible resistance to change in order to foster goal setting and to move

forward.33 Motivational interviewing can be used in many different types of

specialties for helping clients to change. Although it may be considered a

therapeutic approach that would traditionally be used in counseling or in

sessions with a psychologist, motivational interviewing can actually be a part

of some routine meetings or examinations for brief sessions.

Motivational interviewing has been used successfully in implementing change

in numerous situations, such as with drug or alcohol addiction, smoking

cessation, vocational rehabilitation, criminal justice, pregnancy, and as part

of treatment for many different medical conditions.29 Similarly, motivational

interviewing is not simply designated for counselors or psychologists. It can

be successfully implemented into appointments or interactions with various

healthcare providers, including nursing staff, primary care physicians, nurse

practitioners, or allied health professionals.

There is some formal training available in developing the techniques

associated with motivational interviewing, although learning the techniques

and the process of MI is typically either integrated into formal education

programs, such as social work or psychiatry, or through stand-alone training

opportunities, such as through workshops, conferences, or online

educational programs.


The Motivational Interviewing Network of Trainers (MINT) is a non-profit

organization that was started by a group of MI practitioners who were

originally trained by Miller and Rollnick in MI techniques. MINT promotes the

use of motivational interviewing, as well as continuing research and

appropriate training of practitioners. The organization is composed of

independent trainers and practitioners and can give details about specific

educational opportunities for those who want to learn more about

motivational interviewing and to put its methods into practice.30

Stages Of Readiness For Change

The ultimate goal of working through motivational interviewing is to move

the client through the various stages of change, from being ambivalent or

unmotivated to dealing with unhealthy behavior and making more positive

choices.21 The stages of readiness for change is actually a cycle of steps

identified by James Prochaska, and each step requires various interventions

to move the client on to the next step. The stages of change include:

precontemplation, contemplation, preparation, action, maintenance, and

termination.21,22

The precontemplation stage occurs before the client is even aware that a

change needs to happen. Family members, friends, and significant others

may easily recognize that the client has a problem or that change needs to

happen but the client is often unaware. During this phase, the client is

resistant to change because he or she does not understand its necessity. The

client may even be aware that life is difficult or there are several aspects of

life that demand attention that he or she cannot handle, but the concept of

change is still foreign.

The contemplation stage is when the client recognizes that a change needs


to happen. It is often at this stage where motivational interviewing begins.

Although the client may recognize the need for change, he or she may be so

ambivalent about making the change or what steps to take that no change

occurs at all. Many people remain in the contemplation stage for years,

always feeling that something needs to be done, but never taking steps to

do anything.

The preparation stage involves planning to make a change soon. People in

this stage may still be ambivalent about what to do, but they are planning to

try for a change. They may be uncertain that their plans are the best for

solving their situation and so may still be somewhat ambivalent about

making choices toward change. They often need to convince themselves that

change is necessary and that their plans are the best method of working

through the problem.

The action stage involves taking the steps to overcome the problem. It is

during this stage that the client does a lot of activity that demonstrates

working toward the change, such as quitting smoking or exercising more.

Others can see the client’s work toward the change as well, which can be

encouraging. This stage also requires the most energy to continue with

changes, even if they are uncomfortable.

The maintenance stage is the ongoing phase that may be life long for some

people. This stage occurs after a person has done the work of making

changes but then needs to continue to make efforts to maintain the results.

For example, a person who has lost 50 pounds needs to maintain the weight

loss by continuing with efforts that he or she implemented to lose the weight

in the first place. If the person does not maintain the work, he/she may gain

the weight back.


The termination phase is one in which the initial issue is no longer a

problem. Some people never reach this phase while working for change, as

the principles they developed and the work they completed must continue to

be maintained and reinforced for the rest of their lives. For others, the

termination phase results when the initial change or struggle is no longer a

problem and they can move forward into other activities without

continuously maintaining their previous efforts.22

Key Principles

Motivational interviewing can be broken down into key principles, followed

by significant processes that are used. Each process or principle is then

supported by various therapeutic techniques. Each technique may serve to

uphold or meet the goals of one or more principle or process throughout the

interview. To start, motivational interviewing consists of four key principles

that guide practice, which are empathy, discrepancy, rolling with resistance,

and supporting self-efficacy.5

Empathy

Motivational interviewing is characterized by empathy on the part of the

provider. Without empathy, no amount of discussion, sympathy, or

understanding will stir the client toward change. The client needs empathy

from the provider in order to feel as if he or she is not alone in the process

and to feel that someone truly understands. Knowing that someone else has

empathy can reduce feelings of isolation and can spur change.

The goal of being empathic is to help the patient to feel that he or she can

open up. The caregiver provides an open and non-judgmental attitude that

conveys warmth. The provider’s demeanor when engaging the client should

express unconditional acceptance whereby the patient senses the provider’s


response to them to be: “I know what you are going through; I care about

what happens to you”.

The provider during motivational interviewing does not try to change the

client’s ambivalence or condemn the situation. Rather, ambivalence should

be accepted as part of the process and the provider should expect that the

client would have those feelings. If not, then the motivational interview

would not otherwise be necessary. The provider should instead look at

ambivalence on the part of the client as the reason for their time together

and go forward from there.

Discrepancy

Discrepancy describes the state the client is currently in compared to the

point at which he or she wants to be. The clinician works through the

motivational interview to help the client see not only where he or she is

currently, but to remind the client of their goals. The client must understand

that these are two different states. The state where he or she currently is -

one of ambivalence about a situation requiring change - is not the same as

the state where he or she wants to be. If it were, the client would not be

working through the motivational interview.6

To best help the client develop discrepancy the clinician assists the client to

see how far he or she has come in other areas of success. The clinician may

point out other areas of change such as by saying to the client: “remember

when you used to struggle so much with this? Look where you are now and

how much you have achieved in that area.”

It can be helpful for the client to know that he or she has overcome


ambivalence or past challenges to reach goals in other areas and can know

that it can be done in this area as well. It is important for the clinician to

remember that the practice of developing discrepancy requires a non-

judgmental attitude. The clinician should also remember to ask before giving

advice, and to speak clearly and in a supportive tone. Clarifying those items

that do not make sense may also be necessary and is often an ongoing part

of the process to avoid misunderstanding. By utilizing these techniques, the

client will be better able to have a clear direction and understand where he

or she is at in a process of changing behavior versus where the client wants

to be at the conclusion of the motivational interviewing process.6

The provider incorporates these key principles throughout the process of the

motivational interview. Instead of being a straightforward path, MI is a

somewhat fluid method that uses these principles as a general direction. The

provider may also use other processes as part of motivational interviewing

that support the initial principles discussed. These processes are: engaging

the client, promoting change by supporting self-focus, determining the

client’s motivation for change, and formulating a plan.6

Roll with Resistance

While working with clients through the process of change, there are bound to

be times of resistance. When the provider discovers that the client is

resistant to ideas, suggestions, or change overall, it is important to take it in

stride and not create further tension; in other words, to roll with it. The

provider should avoid responding in a manner that is harsh or critical, even

if the client presents this type of demeanor.

Often, the idea of change can be threatening and some people may respond

negatively out of fear. Even if this is the response of the client, the provider


should work to remain calm and to continue with the relationship, providing

the most support and direction possible through conversation. When the

client starts to become upset or resistant to the MI process, it is a signal for

the provider to slow down, avoid being forceful in any way, take a deep

breath, and consider how their demeanor and delivery of information is

presented to the client.

The provider should consider his or her words, questions, and any types of

non-verbal communication that could be threatening to the client and make

adjustments as necessary. The provider should then determine how he or

she can best present an empathic presence and show more understanding

toward the client to prevent further resistance. It might be necessary for the

provider to use some specific phrases during the interview that can clarify

what the client is trying to say and to defuse the situation as necessary. For

example, the provider could say:

“I hear what you are saying and I just want to make sure that I am

understanding you correctly.”

“That must be very difficult for you; I can’t imagine how hard it is

for you.”

“It sounds as if you want to consider other options for dealing with

what we are talking about.”

By responding differently, and not mirroring negative attitudes or behaviors,

the provider prevents the conversation from unraveling and prevents the

client from turning away from making changes because of feeling threatened

or otherwise resisting the motivational interviewing process.6

Support Self-Efficacy

Self-efficacy defines how a person feels about his or her abilities. It differs


from self-esteem, which describes how a person feels about themself and

their value as part of society. Instead, self-efficacy is the personal self-

confidence to perform a task or to take on a situation. A person may have a

strong sense of self-efficacy in one area of life but be weak in another. For

example, a client may be strong and confident at his job and may be quite

successful as a leader at work; however, the client may also lack self-

efficacy when struggling with alcohol use and may be ambivalent about

change if they feel unable to overcome the struggle.11

Although high levels of self-efficacy feelings may help a person to feel more

confident in his or her pursuit of a goal or involvement with a certain

activity, having self-efficacy does not necessarily guarantee that the person

will succeed.11 A provider may work with a client to help them feel more

positive about personal abilities, but unless realistic goals and techniques for

achieving those goals are introduced into the equation, the client may still

not succeed when trying to change. Self-efficacy requires motivation and

effort to be successful.

A person’s belief that he or she can accomplish a goal works as a powerful

motivation toward change. Ultimately, it is the work of the client that

facilitates change, and not the provider. The client’s ability to make the

change, rather than requiring assistance or having a provider do the work

for them, further supports self-efficacy in the client because they know that

the accomplishment was achieved specifically by and for them. The

provider’s role is to be confident in the client’s ability to change and to

empower the client by asking questions and directing the discussion.

Engaging the Client

The goal of expressing empathy is to build a relationship of trust between


the provider and the client. Empathy involves accepting the client’s state of

ambivalence, even if the provider disagrees with the viewpoint. When the

provider takes on a non-judgmental stance toward the client, he or she

avoids being perceived as critical or otherwise condemning of the situation.

This stance engages the client and supports the development of a trusting

relationship.

A client who is going through a crisis or other situation that requires

motivational interviewing may already feel judged or criticized by others.

Many people who are in need of change are also aware of that need,

whether they can actually complete the change or not. For example, a client

who needs to lose a significant amount of weight in order to establish a

healthier lifestyle and to reduce the risk of developing certain health

conditions is most likely aware of the need for weight loss. Often, when

caregivers or the public judge or condemn others for their need for change,

it only serves to further diminish the motivation for change while

simultaneously causing negative feelings and disrupting self-esteem.

Therefore, a non-judgmental, accepting attitude must be in place on the part

of the caregiver before motivational interviewing even begins.

Expressing empathy involves considering the thoughts and feelings of the

other person by actually putting oneself into the place of the person. It

differs from sympathy, in which subjective information may allow a provider

to understand what a client is going through, but the provider can only

acknowledge the other person’s feelings as a method of providing comfort.7

Sympathy is not wrong in itself, but empathy can actually break down

potential barriers between the client and the provider by communicating

comfort and building trust through understanding. A client who receives an

empathic response from a provider during a motivational interview may be


willing to open up more if he or she perceives that some of the struggles

involved are shared.

Determining Self-Focus

The focusing component of motivational interviewing involves setting up the

direction in which the conversations will go. It often starts with an initial

meeting in which the client and the provider meet to discuss their purposes

for talking and to discuss initial thoughts, concerns, or priorities of the client.

Through focusing, the provider takes the information given during the initial

conversation and helps the client to find a direction for where the

conversations will go.6

It is important that the provider does not take complete direction with the

interview by telling the client what he or she should do. Part of the goal of

focusing is to allow the client to find his or her focus through the coaching

involved with motivational interviewing, not to be told what to do. The

provider should also avoid developing a premature focus in which he or she

decides the direction of the interviews early on.6 This can limit the potential

for where the conversations could go and also impact how well the client is

able to work toward change. If the provider decides on the focus for the

client early on in the relationship, the client may be less likely to stay

motivated or involved, particularly if he or she believes that the point of the

relationship is only to work toward the clinician’s goals, not the client’s.

To develop a focus for the interview process and the therapeutic

relationship, the provider and the client should work together to decide what

the goals of their time together should be. By collaborating on the focus,

both the client and the provider have a vested interest in the relationship

because they have worked together to set their goals.


Evoking Change

The heart of motivational interviewing, according to Community Care of

North Carolina, is evoking change through the relationship between the

provider and the client. Evoking change involves helping the client to

determine his or her own amount of ambivalence toward the subject at hand

and the amount of motivation that he or she has to make a change.6

Evoking change first requires understanding what the client wants to

change. This comes about through initial interviews, but may change

through the course of the relationship. If the provider and the client have

determined a focus for the MI, this will guide the provider toward where to

direct their discussions to evoke change. After the focus of the discussion

has been identified, the provider then helps the client to explore more

reasons for change, barriers to change, and what systems should be in place

to evoke change.6

Before change can begin, the provider must also bring up and discuss the

client’s level of ambivalence. If the client is uncertain about changing or

which direction to take in order to make the change, the ultimate goals and

focus of the relationship may not go far if ambivalence is not addressed. The

provider should ascertain the amount of uncertainty the client is

experiencing by guiding the discussion. For instance, the provider may ask

the client some questions to explore any ambivalent feelings and determine

what might be keeping the client from taking a step in one direction or

another.

Change may be more likely to occur if the discussion focuses on past

successes for the client. This focus can help to improve confidence and

feelings of self-esteem when a person knows that he or she has been


successful when attempting a previous activity.6

The provider might focus on the client’s strengths at his or her job or in

other relationships and use those strengths to apply to the current situation.

For example, when considering a client who needs to lose a significant

amount of weight, the provider might bring up that the client has been

successful with committing to their duties at work and can stay focused on

them. The client may bring up past success with completing projects or

enduring through situations when circumstances were difficult. The provider

can then use that information to empower the client toward his or her next

goal of losing excess weight. By remembering personal successes, the client

can bring that information to mind the next time he or she struggles with

working toward a current goal.

It should be noted that not all relationships developed through motivational

interviewing evoke a complete change or result in change occurring at all.

Some people, despite being willing to enter into the motivational

interviewing situation and the therapeutic relationship, will be resistant to

change. Making changes, regardless of the underlying need, can be scary

and overwhelming and some people may ultimately decide that changing is

not worth it. However, it is important for the provider that utilizes MI to

understand that resistance to change does not have to be end of the

relationship. Instead, it should be looked at as an opportunity for redirecting

the focus of the relationship. The provider does not determine the path that

the client takes. Rather, the provider helps the client along the path that he

or she has chosen.5

A final aspect of evoking change is preparing for the resources that will be

needed to support that change. Typically, a client does not make changes all


on his or her own, and even with the help of a provider, long-term and

permanent change is not carried out without the help and support of others.

The client must learn about what resources are available and where to turn

for continued support. As these ideas are mapped out, the motivational

interview moves into the planning stage for how tasks will be completed in

order to achieve the desired goals.

Planning

The planning phase of the interview comes after much of the discussion

surrounding change has occurred, including discussion of the client’s

motivation and levels of ambivalence, his or her desire for permanent

change, and level of commitment to the change. Additionally, the provider

and the client have set goals for where to direct the interview in order to

best plan for the final outcomes.

Planning involves structuring how the process of the interview will take

place. The client and the provider work together throughout the process and

continuously re-evaluate how well the client is working toward set goals and

ideas for change. This may involve setting smaller benchmarks during the

process and providing little rewards along the way as the client makes

changes.6

Planning also involves accountability between the client and the provider.

The client remains accountable toward the interviewer to keep him or her

updated about the work completed toward ultimate goals, the achievement

of smaller goals set along the way, and what resources have been utilized in

the process. This accountability allows for evaluation of what is working in

the process and what is not, and allows the provider and the client to work

together to make changes where necessary.


Accountability is also required from the provider toward the client. The

provider must follow through with his or her plans for coaching the client and

commitment to the relationship. This involves keeping contact with the

client, following up on unfinished business, and maintaining that side of the

relationship to ensure that it will continue.

Motivational Interviewing Techniques

Once the overall process of the motivational interview has been determined

and the healthcare provider is aware of the need for empathy, finding a

focus, evoking change in the client, and planning for resources, these

processes are facilitated through the conversation. The provider can use a

number of techniques to facilitate the interview, each with its own method of

supporting the processes that make up the therapeutic relationship.

Facilitating the Process

The motivational interview typically begins with a meeting between the client

and the provider, who could be a nurse, physician, medical student, allied

health professional, or someone in the field of counseling or psychotherapy.

Often, the first meeting is the first actual encounter with the client, and the

provider does not have much information into his or her background. The

provider may be aware of the need for the client’s change because of

circumstances understood in broad terms, but in order to understand the

client’s feelings of ambivalence as well as the greater details of the need for

change, the provider and client must have initial meetings to discuss the

client’s background and contributing factors for the relationship.

The initial encounter involves a getting to know you process in which the

client provides background information about him- or herself. Even at the


beginning of the interviewing process, the provider must use techniques of

therapeutic communication to gather information and to establish a basis for

trust in the relationship. This involves active listening, avoidance of

interruptions, and reflection on what the client has said.5

Once the background discussion has taken place, the provider can move

forward with the rest of the process of goal setting and evoking change by

utilizing various therapeutic techniques that are inherent parts of the

motivational interview. It is through these techniques that the client is able

to open up and provide more information, learn to trust the provider, and

work toward a mutual goal for the relationship. There are various techniques

that make up the motivational interview and can be utilized effectively to

support the different aspects of the relationship.

OARS

A technique that can be successfully used to engage the client, provide

empathy, and promote communication is known as OARS, which stands for

Open-Ended Questions – Affirmations – Reflection - Summaries. The process

of using OARS in communication can be looked at in the same way as a real-

life method of using oars in a rowboat. Wagner and Conners clarify the use

of OARS this way: “[OARS] give us power to move, yet it is not a powerboat.

We don't zip from one place to another, yet with sustained effort OARS can

take us a long way”.8

The provider uses open-ended questions to evoke more of a response than

simply “yes” or “no.” Although closed questions are sometimes necessary or

may be the only method of gaining some information, open-ended questions

should be utilized to get the client to share more information.8 Sometimes,

by starting to talk with answering an open-ended question, the client will


continue to share much more. Open-ended questions are probing but should

not be too intrusive for the client, which can result in an opposite effect.

They demonstrate that the caregiver is curious about the client’s situation

and wants to hear more.6

Examples of opening lines of open-ended questions that may be used in the

interview include:

“Tell me more about…”

“What did you do after…”

“Can you explain more about…”

“How did you feel when…”

Affirmations are the second section of the OARS mnemonic. Affirmations

look for successes from the client and point out those areas of

accomplishment. The provider must be genuine when providing affirmations,

as false praise is completely different than a genuine affirmation and a client

can usually understand when someone is not being authentic.5,8 If the client

does recognize that the provider is not genuine in his or her words, a

roadblock will quickly go up that is destructive to building trust and will keep

the client from sharing any more information.

Affirmations are words that are encouraging and optimistic; they are meant

to help the client see progress being made. Examples of affirmations that

could be included as parts of the interview are:

“I’m glad that you want to talk about this.”

“I think what you are doing would be very difficult, and you are

putting a lot of work into it.”

“You have made a lot of progress.”

“You controlled yourself well in that situation.”


The third component of OARS is reflective listening. This considers what the

patient has said and repeats it back to him or her in slightly different

language. The provider is reflecting on what the patient has said, while the

patient is listening to his or her own words said in a different way. This helps

both the provider and the patient. The provider uses reflection to fully

understand what the client is saying so that none of the information will be

misinterpreted. Reflection also helps the client to think about what he or she

is saying, consider its truth or inconsistencies, and clarify ideas that might

have been misunderstood.

Reflection should be a regular part of the motivational interview, as one

missed idea from one side or the other in the conversation can lead to a set

of false assumptions and misinformation that must be corrected before the

conversation can move on. Instead, regular reflection continues to provide

clarification for statements in a manner that is not threatening. Examples of

the openings of reflections that could be used in the interview include:

“What I hear you saying is…”

“It sounds as if you want to…”

“So, your concern is that…”

“You believe it is important to…”

“From your point of view, you…”

Summaries are the final component of the OARS mnemonic. Summarizing

takes the information the client has said and what has been discussed during

the interview and puts it into one or two concise statements. This process

has several purposes. It reinforces the idea that the provider is listening to

the client and has heard what he or she has been talking about; it serves as

a type of reflection to help the client hear again what he or she has been

saying and to think about it; it clarifies information from the part of the


provider, and it provides a transition into the next segment, which could be

closing the session or moving onto another topic.6

A summary of the discussion can motivate the client because it supports the

coaching provided by the provider. Summarizing also supports the focusing

aspect of MI in that the client is able to see a few distinct areas in which to

concentrate efforts, which can make the process seem less overwhelming

and may give him or her a better idea of how to focus tasks later on.

Examples of summarizing statements include:

“If we review what we have been discussing, I can see…”

“So, you believe that… Am I correct?”

“We have covered this information well by talking about…”

“Here are the points that I understand so far…”

“To summarize…”

Informing or Advice Giving

Providing information to the client and giving advice must be done very

carefully to avoid taking over the direction of the conversation and telling

the client what to do.

There will be many times when clients are impressionable: if they are

ambivalent about making a decision, they may want the provider to tell

them what to do. This is an important scenario to avoid, as the client needs

to process enough of the information in order to make his or her own

decisions. Additionally, if the client makes a decision based on what he or

she thinks the provider has said, there’s a risk the client may later regret the

choice or may not be willing to stay with the outcomes and then feel angry

or blame the provider for suggesting the “wrong thing to do.”


By allowing the client to take their own direction and supporting them in

decisions, the provider helps the client to feel empowered by their own

choices and alleviates them of the role of being ambivalent to being more

decisive and goal-oriented. Information and advice should be open and

guiding, allowing the client to be the best expert for their own situation. The

provider always asks permission before imparting advice or giving

information about a situation, using statements or questions such as:

“Would it be all right if I shared with you…”

“I have seen this experience in the past. Can I tell you about it?”

“Could I share with you what I have read about this?”

It may be helpful at the beginning of the relationship to determine what the

client’s best method of understanding information would be. Some people

are visual learners and respond best to pictures or reading materials. Others

are auditory learners, and can take in and better grasp the information that

they hear. When the provider understands the various different types of

learning methods, he/she can be better prepared to share information in a

manner that has meaning for the client, such as by bringing reading

materials that support the topic of the conversation.6

Giving advice, even when it is permissible, is not simply telling the client

what to do. Even if the client allows the advice, the provider should still

never direct statements to the client to say such things as, “if I were you, I

would…” or “you can fix this if you would…” Instead, the advice and the

information must be connected to the client’s concerns and address those

thoughts and feelings. A menu of options offers choices to the client so that

he or she does not feel as if the advice or information given by the provider

is the only choice for the client’s behavior. Instead, providing a menu of

options as part of the information still allows the client to choose the best


step for him- or herself.6

DARN CAT

A helpful mnemonic that can be used to elicit change is remembering DARN

CAT, which stands for Desire – Ability – Reason – Need – Commitment –

Activation - Taking steps. When a provider considers approaching the client

with talk about change, he or she can think of the DARN CAT acronym as a

reminder of how best to build motivation in the client.

Desire means a statement or words that the client uses that indicates

wanting to change. It is important to listen for desire statements, as the

provider can remember these and use them to remind the client at a later

time if he or she ever feels confused about their choices. Desire statements

are the beginning of resolving ambivalence: if a patient has a desire for a

change, he or she can at least understand the general direction in which to

go. Desire statements include anything that signifies the client’s wishes or

needs:

“I need to get my life in order.”

“I wish I could lose this weight to better care for my health.”

“I want my blood pressure levels to be normal.”

The A of DARN signifies the client’s ability to change, based on their beliefs

that change can happen by working with the tools and guidance available

from the provider. The provider can better direct the client toward thinking

about items and successes that will support his or her abilities. The provider

might say:

“You were able to accomplish this before, is there something

stopping you now?”

“Why do you want to do this?”


The client also may also make statements that will signify that they have a

growing belief in themselves. These might be positive phrases or comments

that indicate that the provider has noticed the client has been thinking about

the change made and has grown in believing in themself:

“I’ve done this before; there is no reason why I can’t do it again.”

“If I can just….I think I can do it.”

“I can make this change if I work at it.”

The R in DARN stands for reason and explores the reasons behind the

change. The discussion may center on why it is important to change or the

disadvantages of not making the change. Exploring the reasons behind the

change also help to reduce ambivalence in the client because it provides a

clearer direction of change for the client. The provider can ask questions to

help the client better determine his or her need for change:

“Why do you think this change is important?”

“What benefit do you see happening from this?”

The N in DARN CAT stands for need. This step is important for the client to

better understand the true need for the change. Again, this step helps

resolve some ambivalence when the client is able to see how the problem

affects his life and how making the change can improve the situation. Some

people become so involved with their situations that they fail to see how

destructive their lifestyles are. They may not be aware of the detrimental

effects of their choices or be able to see how change could make things

better.

For example, a provider might work with a client with a history of substance

abuse and who is working toward making changes in their behavior and

relationships with their family. The client may be so engrossed with


accessing and using drugs and alcohol that they do not understand the

impact that their behavior has had on their spouse and children. The client

may come to the situation feeling ambivalent about change or even unsure

whether the change is worth the time and effort. Over time, by discussing

the situation with the provider through motivational interviewing, setting

goals, and taking steps toward change, the client may be more likely to see

how much better life could be if he or she follows through with the changes.

The client better understands how truly important it is for them to change.

The client who starts to understand the need for change may make

statements that indicate his or her level of comprehension:

“I didn’t realize before how hurtful this all was.”

“I need to change so I can spend more time with my family.”

“I want to do things differently and try to mend my relationship

with my spouse.”

The first part of the acronym, DARN, is devoted to promoting change for the

client. Each of the letters in the word are focused on what the provider can

do to guide the client toward change, as well as how the client can recognize

the importance of change and determine to make a difference. This is what

is classified as change talk and is the focus of DARN. Alternatively, the CAT

portion of the acronym consists of the second phase of mobilizing someone

toward change.

The C in CAT stands for commitment and signifies that the client is taking

steps to commit to change. This step is important to acknowledge because

verbalizing the commitment is the first step toward following through. If the

client can speak his or her intent out loud, it may become clearer and may

be easier to focus attention in the right direction. Examples of statements

that indicate commitment on the part of the client include:


“I will quit, because...”

“I plan to start…”

“I will finish…”

The A of CAT stands for the activation of the stated commitment. Once a

client commits to making a change, the provider and the client must work

together to determine how to best go about making such a change. If the

client is not equipped with the right tools for change, his or her words of

commitment will be meaningless. Examples of phrases from the client that

signify a readiness to activate the change include:

“I am ready for this.”

“I am prepared to change by…”

“I will work at this through…”

Finally, the T in CAT stands for taking steps, which are statements by the

client that confirm the readiness to change. These statements demonstrate

the client’s commitment to change because they come from the client

instead of being directed by the practitioner. Because they are in the client’s

own words, the client has formed the suggestions for change into a

meaningful and realistic statement that he or she can now put into practice,

such as:

“I called my doctor to ask for a prescription for medication that will

help me quit smoking.”

“ I really had a craving for _____ earlier today, but I took a walk

instead.”

The implementation of the steps of DARN, followed by CAT, help the client to

understand the need for change and then take the important steps toward


completing interventions to reach his or her goal. Throughout the process of

working through the steps of the acronym, the provider should continually

evaluate the progress being made and make changes when something

doesn’t work. If the client resists one of the steps, the provider should take

a step back, clarify what is needed, and try to work through any gaps that

have presented as part of the process.

Elicit-Provide-Elicit

Another method of helping the client to take charge of his or her decisions is

the elicit-provide-elicit method. This idea serves to seek information from

the client, provide advice that can be helpful and empowering, and then

follow up with the success of the information. The elicit-provide-elicit method

is directed by the provider but is actually a collaborative process between

both the provider and the client.

The first elicit establishes the client’s expectations, beliefs, and goals of the

interaction or the change that is required. The provider approaches the topic

with sensitivity and asks permission before giving advice or otherwise

directing the client. The provider may open with a question or a statement,

such as:

“Do you mind if we talk about…”

“Can I clarify something that you said about…”

“Would you like to discuss the subject of…”

“Can I share some related information about…”

Each opening phrase is designed to ask or clarify what the client knows

about the situation; it also asks permission for the provider to provide more

direction on the topic. The second step is to provide information about the

topic or to clarify something the client has brought up that still might be


unclear. The provider may say:

“This could be why…”

“What we know is…”

“Others have worked through this by…”

During the provide step, it is important to avoid using statements that

include I or you; and, to remain neutral. This avoids coming across as

judgmental or condemning in any way.

After providing advice or direction, the provider once again elicits

information from the client to determine how well he or she understands the

information presented and to get a better feel for how the information will be

used. The second step of eliciting involves more about the patient’s feelings

for the situation and how the information is interpreted. The provider may

say:

“What do you think of what we have talked about?”

“Where can we go from here?”

“How can I help you at this point?”

As with other interactions, it is important that the provider not tell the client

what to do during the second elicit phase or give his or her opinion about the

situation. Instead, it should be looked at as another opportunity to

collaborate with the client by using known information to work toward

results.5,10

FRAMES

Another guide used to solicit change is termed FRAMES, which stands for

Feedback – Responsibility – Advice - Menu of options – Empathy - Self-

efficacy. Following the FRAMES model approach during the motivational


interview can help the provider to remember the most important aspects of

interaction to foster success for the client.

Feedback involves the exchange of information between the provider and

the client. The provider may ask for information from the client by asking

open-ended questions and helping him or her to open up more with sharing.

The provider may also give feedback as part of reflecting or summarizing the

discussions and clarifying points. Alternatively, the provider may also offer

feedback to the client in the form of thoughts or advice.

An essential component of motivational interviewing is to always ask for

permission before offering advice or feedback on the client’s perspective.

This practice respects the client’s point of view and helps to address some of

the client’s ambivalence about the topic.9

The R of FRAMES stands for responsibility, which outlines some of the

expectations for the interviews as well as the responsibilities for change.

Ultimately, it is the client’s role to take responsibility for making changes

within him- or herself, however, the provider serves as a coach or director

for assisting with changes. The provider and client work together to

collaborate on the change process but the provider should direct the client

as to his or her expectations for change that they have decided on together.

It is not appropriate, nor is it possible, for the provider to take responsibility

for the client’s change; that responsibility must belong to the client.

Many providers who work with clients during the motivational interview

process are skilled and have knowledge of various psychological concepts

and therapeutic techniques that would be helpful to share with others who

need guidance for making changes in their lives. Giving advice can be very


helpful for some clients, particularly when they have enough ambivalence

about a topic of change that they are unable to make a decision about where

to begin. Just as with offering feedback, it is essential that the provider ask

for permission from the client before giving advice. This is a crucial element

of communication, as unsolicited advice is often not helpful and could be

misconstrued as looking to provide an automatic response, rather than

searching together to find the right answers for the client’s situation.9

The menu of options refers to a list or group of choices given to the client for

making decisions. When a client is ambivalent about making a decision, it

can be easier when presented with more than one option of steps that could

be taken toward the goal. For example, if a client is trying to lower his or her

high blood pressure and is having difficulty adjusting to lifestyle changes,

the provider could offer a menu of options to choose from to change, any of

which would contribute positively toward lowering the blood pressure. The

client could choose to lower salt intake by 500 mg daily, choose to increase

exercise activity to two 30-minute sessions each week, or could contact their

physician about starting another form of blood pressure medication. The

menu of options requires that a choice be made, but regardless of which

choice the client decides, they would each help to take a step closer toward

the client’s goal of better health.

Empathy refers to the method of engaging with the client to foster a trusting

relationship and to impact the client’s ambivalence toward making a change.

By being empathic toward the client, the provider is better able to

understand where he or she is coming from, but is also able to make a

connection on a deeper level. When a person feels that a provider truly

cares, a better sense of the degree of the client’s ambivalence may be more

evident and the client able to more likely to find direction toward the choice


that should be made. The provider can express empathy through their

statements and responses to the client by supporting what he or she has to

say and expressing understanding of the situation.

Self-efficacy is the final component of FRAMES; it refers to helping the client

understand his or her own strengths in the situation of change. The provider

can promote self-efficacy by talking with the client about his or her strengths

and accomplishments. This may mean bringing up past successes to use as

reminders and to promote confidence in the client. When a person believes

in themselves, they are much more likely to continue moving in the direction

of change, thereby reducing feelings of ambivalence. The client may be less

likely to feel overwhelmed or incapable of change if they believe in their

abilities and capacity for change.

Pros and Cons

Exploring pros and cons of a situation can be helpful in assisting someone

with making a decision. When a client experiences ambivalence about a

situation, he or she may not have enough information to consider potential

choices. Determining pros and cons of the situation can help to provide clear

direction for deciding on the next step of change.

Determining pros and cons is a relatively simple process. The provider can

make a list or chart of the client’s options, followed by an area to list the

pros, or the good aspects of the choice, compared to the cons, which are the

negative aspects of the choice. Listing the pros and cons helps both

the provider and the client to explore and discuss each of the terms.

Some people use the information from a list of pros and cons to go on to

make their decisions. They may look at the number of pros versus the


number of cons and decide based on sheer numbers alone. Alternatively,

while one side may have more than the other, the client may make a

decision of the pros and cons based on one or two aspects on the lists that

really stand out as being more important.

Non-verbal Communication

Non-verbal communication makes up the posture, attitude, gestures, and

unspoken communication that both the client and the provider engage in.

The provider who is conducting the interview must be very cautious of his or

her non-verbal communication because it speaks volumes. Although the

provider’s words may be engaging and non-threatening, if the non-verbal

communication says otherwise, the provider will create the same impact as if

harsh or critical words had been spoken.

Non-verbal communication supports the spoken word and helps a person to

remember what has been said. Alternatively, non-verbal communication can

convey certain messages all on its own. Facial expressions, eye contact,

posture and gestures all make up types of non-verbal communication.

A healthcare provider who is conducting a motivational interview should

display active listening when the client is speaking. Active listening ties

listening to the client with the appropriate non-verbal signals that show the

client that the provider is attuned to what he or she is saying. By actively

listening to the client, the provider not only hears the words with their ears,

but demonstrates other measures that shows the client that he or she is

being listened to, such as by leaning forward, making eye contact, and

nodding the head periodically.5

Silence is another measure that may be implemented at the appropriate


time if the right non-verbal cues are paired with it. Often, people do not

necessarily like silence, believing that it makes conversations awkward.

However, if a client is sharing information that is valuable and personal, or if

he or she is experiencing emotions that can be overwhelming, the provider

can silently listen and wait while giving appropriate non-verbal cues. For

example, if a client begins to cry while talking about the death of their

father, the provider can sit silently with the client while they cry, allowing

them the opportunity to express grief. This silence can be much more

effective than trying to fill the space with words, interrupting the client while

they are emotional, or using automatic responses or clichés that are not

helpful.

Facial expressions involve non-verbal communication that could be

overlooked during the conversation. At times, it may be difficult to maintain

an appropriate or neutral facial expression when discussing distasteful or

shocking information. It is important to maintain a positive or at least

neutral facial expression when talking to a client, rather than a look that

shows anger, disgust, contempt, or boredom, which will most likely be

noticed by the client and could break down some of the lines of trust that

have been developing.

If the client is demonstrating strong feelings, it may be appropriate for the

provider to mirror those feelings through facial expression. For example, if a

client is angry about a situation involving a colleague at work, the provider

may show anger as well to demonstrate that he or she understands the

strong feelings. Eye contact is another area of non-verbal communication

that sends a strong message. It may be difficult to determine whether eye

contact is appropriate in some situations, as there are some cultures in

which it is considered to be disrespectful or rude. Alternatively, for many


people, eye contact shows interest in the conversation, it demonstrates a

sense of openness from the provider, and encourages the client to continue

talking.7 The amount of eye contact used is also important, as staring or

otherwise gaping at the client can put them off.

Posture can convey several messages, depending on how it is used. The

provider who wants to demonstrate openness and listening toward the client

should sit in a way that is leaning slightly forward with their hands in the lap

or at their sides. Alternatively, standing with the arms crossed in front of the

body demonstrates a closed appearance that is not easily approachable or

does not otherwise indicate a willingness to listen. Keeping the hands on the

hips may convey irritation or superiority, while tapping the foot or the

fingers demonstrates impatience or irritation.7

Many people display themselves through their posture with little thought to

how it appears to others. For example, a person who has self-confidence

may naturally walk upright with a straight back and look others in the eye.

Alternatively, someone who has low self-esteem or who is very shy may

have a slumped posture and may not make as much eye contact.7 The

healthcare provider who is conducting the motivational interview should be

very aware of his or her own posture and how they carry themselves, and to

think about how it may come across to others. It may help to study one’s

own posture in a mirror or to ask others to comment or give feedback about

one’s posture and gestures to see if changes should be made before

interacting with a client.

Lifespan And Cultural Perspectives

This section covers motivational interviewing in certain areas along the


lifespan and in varying cultural settings. Special focus is given in this section

to MI for children, adolescents and the older adult populations, and the

unique aspects of MI during the times of life where increased family support

is necessary and often crucial. A major development in the area of

motivational interviewing is in the area of child and adolescent care, where

youth require guidance in school and social settings. Its important for the

provider to realize that youth at all ages may have difficulties with change

because of the level of developmental changes they already undergo, and

the level and impact of their family support.

Interventions with children, in particular, during motivational interviewing

have been successful to some extent and are sometimes implemented by

teachers and counselors that work with them at school. Children are often

more dependent on their parents and caregivers for support than

adolescents and typically have little say in what goes on at home. Therefore,

working with children through MI may need the added component of family

therapy and discussion to ensure that the families involved are supporting

the changes their children are experiencing.15

Children and Adolescents

Motivational interviewing can be used with children and adolescents by

helping them to explore their needs for change and address their feelings of

ambivalence about change. A provider who works with a child can determine

his or her readiness to change based on statements made about problems or

the need for change. It can also help the provider to determine the level of

motivation that the child has for making a change. The provider working

with a child needs to recognize the importance to maintain and convey an

attitude of respect for the child’s situation and for his or her own decision

about making a change. The provider must be careful not to take on a


parental role by directing the child toward what he or she should decide,

and, instead, continue with the appropriate coaching method that will help to

guide the child toward the right decision.

Because parents and families are typically responsible for managing the care

of children and the fact that young children are often not developmentally

capable to make certain decisions on their own, motivational interviewing

techniques are best used for children and their families to facilitate change.

The age at which to transition to working solely with the child to make his or

her own decisions is based on several factors, including the developmental

ability to rationalize cause and effect situations, such as: the understanding

that certain behaviors can cause negative effects; the child’s language skills,

or ability to express feelings and address problematic behaviors; and,

understanding of the self, in which the child recognizes discrepancies

between their behavior and what they want to achieve. The age at which

these developmental concepts are achieved varies between children, but

often, working through MI exclusively with children without their parents

present does not occur until children have greater cognitive capacities for

change, which is closer to the age of adolescence.16

Adolescence can be particularly challenging for many families, as the time

between childhood and adulthood is fraught with confusion, hormone

changes, and outside pressures that can make many teens feel uncertain

about themselves and may lead them to engage in potentially destructive or

harmful behaviors. From the standpoint of MI, adolescence is an important

time to discuss change and to recognize its power, as the time of

adolescence often sets the stage for future habits and lifelong behaviors.

Those activities that an adolescent participates in during the teen years can


impact health and behavior well into adulthood. Using motivational

interviewing as a method to reach adolescents can then change some

behaviors and help them to make better choices, not only for their current

lifestyles but for their futures as well.

Working with adolescents can be challenging, because the provider is faced

with developmental factors as well as addressing ambivalence and the need

for change. In addition to developmental changes, most adolescents live

with others in families that have a strong influence because of their ages,

and providers may need to simultaneously work with the teen through MI

and handle the actions or viewpoints of the parents or caregivers. For

example, a teen client who is going through motivational interviewing as a

technique to lose weight may become motivated to change while working

through the MI process; however, the client may also have little to no

control over the types of food that is available at home because the client is

not responsible for grocery shopping, and may or may not be able to make it

to appointments consistently if dependent on others for a ride. If the parents

or major caregiver of teen clients that are undergoing MI are not on board

with the process, it can be much more challenging for the provider and the

client to work together to make changes that are consistent and lasting.12

Practitioners who work with teens may need to work around many changes

that are occurring in these young peoples’ lives. These include biological

changes, such as physical growth, hormone changes, and puberty; cognitive

changes, including the development of more mature thoughts, ideas, and

concepts; and, social changes, such as developing a personal identity,

having friends and social relationships that may include pressure to change,

to fit in, increasing levels of autonomy, and living with family members.12

Although all of these developmental changes greatly contribute to the


process and success of motivational interviewing, many practitioners also

find that working with adolescents is quite rewarding, despite its challenges.

Just as when using motivational interviewing while working with adults, the

provider and the teen client can start out in an individual session by building

rapport and investigating the levels of the client’s ambivalence. While

discussing the need for change and exploring ambivalence, the provider

must also look at discrepancies in the client’s behavior and desire for

change. Because teens can be impressionable and there are often greater

levels of confusion about the right way of behaving versus outside

influences, there could be larger discrepancies seen. For instance, a teen

who wants to have good grades at school and who states that this is

important to him or her may also struggle with avoiding social groups that

want to hang out all weekend, avoid studying, and otherwise engage in

problem behaviors. This is a discrepancy for the client, who must choose

between what he or she says is important and what is actually done.13

As with any interview, it is important for the provider to convey an attitude

of respect for the adolescent client. This may be difficult for some

practitioners who view adolescents in general as too malleable to be able to

make positive decisions for themselves. Before the interview even begins,

the practitioner must commit to respecting the adolescent client’s choices

and plan for change. The provider acts as a coach or guide during the MI

process and because many teens are impressionable, they may want

someone to make decisions for them or to assist them with deciding what to

do. There is a fine line to watch here to ensure that the provider does not

overstep their role to act as a parent or caregiver to the adolescent client

and make his or her decisions. Instead, the provider must always remember

to act as a coach and assist the teen client in decision-making, ultimately


allowing the decision to be the client’s choice.

The provider uses the principles of change talk with the teen client and

promotes self-efficacy for change in the situation. The other techniques

listed in this course can successfully be implemented with teen clients when

working through motivational interviewing.

One method that has been successful when working with teens in particular

is the use of group motivational interviewing, in which teens meet together

in a small group with a practitioner to go through the MI process together.

This may be challenging, as the provider must coordinate different opinions

and ideas from those involved to continue to coach and guide the group. The

various viewpoints and struggles that come from each of the teens involved

may also be difficult to coordinate for the provider. The practitioner who is

facilitating the group must be able to recognize the individual levels where

each participant in the group is at and determine each member’s willingness

to change.14

The RAND group has been working on an initiative to increase motivational

interviewing in teens and has shown that the program is beneficial. The

approach uses small groups for interventions and employs the therapeutic

principles of promoting self-efficacy and expressing empathy. The group-

centered approach has been a positive activity for those involved because it

engages them with others who may be struggling with similar issues. It is

also validating for those who participate when they see other adolescents

with similar issues overcome and make changes in their own lives.10,14

Older Adults

This section covers motivational interviewing in older adults and how it can


successfully be used as a means of facilitating change. The older adult

population should continue to be considered as a group worthy of continuing

change in life that leads to greater well being, despite the opinions of some

who deem older adulthood as a period of decline. Motivational interviewing

works well in the older adult population but typically must be reserved for

working with those who do not have cognitive disabilities.17

The basic practices associated with motivational interviewing are the same

for older adults and the geriatric population as they are for working with

younger adults; evoking change through the principles of coaching and

guidance by the facilitator who uses empathy and who promotes self-

efficacy. However, the provider must also recognize some challenges that

can go with working among older adults.

Life expectancy is shorter than when working among older adults and some

may experience a sense of hopelessness for the future as they age. Older

adults may also experience greater levels of grief from more frequent losses

in relationships or changes in circumstances; they also have more health

problems that develop because of the aging process and may be

concurrently involved with physical treatments or taking larger amounts of

medications.17

Because of these changes that occur with aging, some modifications must be

made through motivational interviewing when working with older adults. The

provider may need a greater amount of flexibility with planning and goal

setting with the ambivalent older adult. This can include reviewing goals

frequently and re-evaluating the course of the interview on a regular basis.

Many older adults are resistant to psychological treatment and therapy and

attach a stigma to it; therefore, the provider may need to approach the


process of MI from a slightly different standpoint, offering MI sessions in

different settings, such as over the phone.

Other strategies may include repetition of information on a regular basis to

reinforce concepts and consulting with other providers who may be working

with the older client to manage other physical conditions, such as another

medical specialist who manages the clients health plan and prescriptions or a

physical therapist who has been handling some of the client’s physical

limitations.17 Despite some of the added challenges associated with pursuing

motivational interviewing with older adults, working with this population can

be rewarding and satisfying for both the practitioner and the client.

Cultural Influences

Just as it is necessary to consider the unique aspects of each person when

conducting a motivational interview, whether it be due to age,

developmental status, or change required in each situation, it is also

essential that the interviewer recognize the impact of cultural influences on

the interview process. A growing and increasingly diverse society requires

that provider to recognize the varieties of people and cultural backgrounds

that they may work with.

Providers must initially place value on diversity in order to keep an open

mind right from the beginning of the motivational interviewing process.

Throughout the process of interviewing, the practitioner must maintain an

awareness of the cultural preferences of the client and seek to not override

those practices with their own. The provider must instead approach the

process of change from the cultural perspective and preferences of the

client.


It may be difficult for the provider to have empathy for the client,

particularly when such cultural differences exist between the client and the

provider that it is hard to imagine a connection. The provider must

symbolically put themselves into the shoes of the client in order to practice

empathy; this requires a greater understanding of the client’s cultural

preferences before understanding how to do that. For instance, consider a

situation in which a practitioner is working with a client who is religious and

engages in regular prayer as part of making changes. Alternatively, the

provider does not have the same beliefs as the client and does not consider

the impact of prayer in their own life when making personal changes. How

might the practitioner practice empathy in this situation if he or she does not

share the same beliefs as the client?

Although the provider cannot compare themselves in the exact same

situation as the clients because the provider does not have the same beliefs,

he or she should take a slightly broader perspective when trying to be

empathic in this situation. The provider may not believe in the power of

prayer in the same manner as the client, but may believe in something else

that is powerful to them and that worked to help them to make changes in

their own life. The provider can then consider the significance of these items

in their own life when showing empathy to the client. It is not that the

provider and client share the same exact beliefs, but they can both

understand the significance of certain practices that influence change. That

connection is where empathy is able to develop and where the provider can

genuinely find the link between him- or herself and the client.

In addition to being empathic toward the client, the provider must also

express empathy in a genuine manner so the client understands the

empathy and does not feel judged. A client who is seeking help through MI


for making changes may already feel condemned in some ways because of

the need for change. A client with a significantly different cultural

background from the practitioner may feel even more threatened if he or she

feels judged because of personal beliefs or cultural practices. It is imperative

that the practitioner be empathic toward the client in a manner that is

genuine and honest.18

Because promoting self-efficacy is a key component of motivational

interviewing, the process of reaching the point of confidence in making

changes for the client may differ between individuals with varying cultural

practices. Some people do not value self-efficacy as much as others, which

makes the concept a difficult one to teach. Additionally, factors such as

poverty, immigration, or gender roles can impact a person’s sense of self-

value or feelings of self-efficacy. For example, a person who has lived in a

refugee camp for years before eventually working through MI to make

personal changes may have little value for feelings of self-efficacy when he

has had to spend years simply trying to survive. There may be a range of

feelings about self-efficacy and its value within different cultures.

When a client places low value on self-efficacy because of cultural influences,

the provider may need to work more with the client to explore the reasons

behind this and to come up with solutions that will help the client to continue

to work toward change. According to Burke, et al., there are four states that

contribute to self-efficacy in a person: mastery experience, vicarious

experience and modeling, social persuasion, and physical and emotional

states. A person’s background through experiences and social influences

impacts their level of confidence and self-efficacy.19 If the provider

recognizes these influences, he or she can use some of their time with the

client to support the value of self-efficacy as a positive step toward change.


This may take longer and more in-depth study of the client’s background

and perceptions, but is worth the effort to connect with the client in a

manner that will support his or her self-confidence and provide direction

where ambivalence may exist.

In order to successfully work with clients of differing cultural backgrounds,

the provider must start by being aware of his or her own cultural beliefs and

how they may differ from those of others. If the provider is secure in their

own beliefs and preferences, they may be better able to work successfully

with others who are different, as they will be less likely to feel threatened or

challenged. Examining one’s own beliefs first before starting to work with

clients is foundational for the provider starting the motivational interviewing

process. The provider can then function in their practice with recognition of

the various differences in individuals and to value and respect the levels of

diversity that are present in the population.

Pregnancy And MI

Motivational interviewing has been used successfully among pregnant

clients who need to make lifestyle changes in order to improve their own

health and that of their baby. MI may be an option for soliciting change

among pregnant women in order to help them make healthy choices, such

as following a healthy diet and engaging in regular exercise. It can also be

used among some women who must make changes because they struggle

with substance abuse or are smokers, both of which can cause health

problems and increase the risk of complications during pregnancy.

Pregnant clients may engage with members of the healthcare team who can

provide motivational interviewing and who are often in the role of counseling


or educating patients about pregnancy support. A client may have several

visits with a healthcare provider during pregnancy as part of routine prenatal

care. Regardless of whether a pregnant client needs assistance with

changing negative or harmful habits, motivational interviewing can be part

of regular contact with the client.

When assessing a client who is seeking routine prenatal care, the provider

may open the conversation by first seeking rapport with the patient,

explaining their own role in the healthcare system, and identifying what type

of services are provided that the provider can help with. This presents an

open invitation without committing the client to any specific activity or

change.

If the client agrees to accept the services and participate in MI, the provider

can then move to ask about the best ways to help the client. For example,

the provider may say:

“How best can I help you at this time?”

“What services are you looking for?”

These are open-ended questions that elicit longer explanations from the

client, which can help the provider to better explore the direction of the

services needed. As the client is answering, the provider listens intently,

using body language that conveys an open and caring attitude. All of the

provider’s responses indicate empathy toward the client’s situation. If there

is a time when the client does not know what to do, the provider can help

her to narrow down possibilities to better guide her toward making a

decision. The provider should first ask permission, and then may say

something such as:


“Can I explain to you some of the services we offer here?”

“I can answer any questions you might have about your

pregnancy.”

“Are there any educational offerings you might be interested in

learning more about, such as breastfeeding or the childbirth

process?”

By offering a menu of options for the client, the provider gives suggestions

for areas of focus without actually making the decision. These offerings help

the client narrow down areas of content to focus on and ultimately, to make

the decision herself.

Once a client makes a decision about the focus of her care during

pregnancy, the practitioner and client then work together to successfully

incorporate the steps needed to accomplish the goals. Regular re-evaluation

of the client’s level of motivation, the need for services, and any issues or

problems that have developed should be done throughout the process with

the goal of getting the client through a healthy pregnancy by guiding her to

take care of herself.20

Unfortunately, some women who are pregnant make unhealthy choices or

engage in activities that can be detrimental to their health and can risk

harming the baby. Substance use, such as alcohol, drugs, or smoking

cigarettes can increase the risk of complications for the mother and fetus

and may cause problems during labor and delivery. The American College of

Obstetricians and Gynecologists (ACOG) supports the use of motivational

interviewing to affect change among women who are pregnant to promote

positive behavior choices.21


Motivational interviewing can be a part of regular routine prenatal visits for

pregnant clients or, if a problem has developed during pregnancy, such as

the identification of substance use, it can be a stand-alone objective in which

the provider and client sit down together to discuss the client’s choices and

their effects. When MI is incorporated into routine prenatal visits, the

provider could be someone such as the physician, the nurse, or the nurse

practitioner that is managing the client’s care. Adding MI to a regularly

scheduled appointment adds little time to the overall encounter, but the

results can be significant. According to ACOG, the process of active listening

and motivational interviewing during a visit only adds approximately three

minutes to the total time spent at the appointment.21

Motivational interviewing can be incorporated into many discussions and

topics that are covered through prenatal appointments for pregnant women.

Most pregnant patients go through a course of appointments in which the

mother’s and the baby’s health are evaluated during the time of pregnancy,

with prenatal visits coming more often as the estimated date of delivery

draws near. The physician or nurse practitioner caring for the patient

typically orders routine lab work, such as a test for gestational diabetes,

tests to check rubella status, or a complete blood count.

Other tests can rule out the presence of certain diseases during pregnancy,

such as tuberculosis, HIV, or other sexually transmitted diseases.

Additionally, the mother’s weight is monitored with each visit and other

areas that could potentially cause complications are checked routinely as

well, such as blood pressure readings. These aspects are monitored regularly

to assess for changes.

The results of many of these tests and procedures could point to an area in


which a pregnant client needs to change. For example, consider a client who

has just discovered that she is pregnant. She has her first prenatal visit,

where her provider orders routine labs and checks her weight and blood

pressure. Over the course of the next 3 to 4 months, the patient’s weight

increases at a rate that is much faster than what is normally expected during

pregnancy. The provider tries to discuss the appropriate amount of weight

gain during pregnancy and the patient starts to understand the necessity of

keeping her weight under control.

During many of the client’s next visits to see her provider, her healthcare

team, including the nurse or physician, can use motivational interviewing to

guide the patient toward change by eating a healthy diet, increasing her

activity levels, and monitoring her weight at home. Through this process of

MI at regular visits, the client may move out of ambivalence and toward a

better lifestyle that involves controlling her weight and taking care of herself.

ACOG has reported that motivational interviewing has been effective in a

number of areas among pregnant clients, including reducing fears related to

childbirth, reducing the amount of alcohol consumption, smoking cessation,

increasing education and promotion of breastfeeding after delivery, and

limiting risky behaviors that can lead to sexually transmitted infections.21

When clinicians specifically work with women who use alcohol during

pregnancy, intervention through motivational interviewing is extremely

important to prevent the development of fetal alcohol spectrum disorders

(FASD). FASD is a range of conditions that can develop with alcohol use

during pregnancy and can cause growth problems, central nervous system

abnormalities, behavioral issues, and problems with everyday functioning.

These problems are noted after birth and continue throughout the child’s

lifetime. FASD is preventable with eliminating exposure to alcohol, which is


why proper identification and intervention among pregnant women who use

alcohol is so important.23

A provider who works with pregnant clients can assess for those who are

high risk by using the FASD Clinician Toolkit developed by ACOG to identify

those at risk and to intervene using motivational interviewing techniques to

guide these clients toward change. According to ACOG, a multicenter study

conducted on pregnant women who were engaged in risky drinking

behaviors showed a 70 percent reduction of risk in having an alcohol-

affected infant six months after engaging in motivational interviewing to

educate them about the dangers of alcohol during pregnancy.23

After determining who would benefit from motivational interviewing for high-

risk behaviors during pregnancy, the provider can spend some time with the

client to discuss unsafe behaviors and the effects on the fetus. The interview

should not be long and could be incorporated into a routine prenatal visit.

ACOG uses the FRAMES approach to demonstrate how to proceed in the

discussion:23

Feedback

Provide information and data to the client about the effects of

alcohol use on the developing fetus. In some situations, the client

may not be aware of the dangers of alcohol consumption during

pregnancy.

Responsibility

The client needs to be made aware that she is responsible for

herself and the health of her baby and it is up to her to make a

choice about using alcohol while pregnant.


Advice

After asking permission, the provider advises the client about what

she can do to avoid alcohol and the positive effects that can happen

when she makes healthy choices.

Menu of options

The client receives a list of options to consider for changing her

risky behavior or for how to find other alternatives to using alcohol

when it is used as a coping strategy.

Empathy

Throughout the exchange, the provider conveys a sense of empathy

and understanding for the client, recognizing the difficulties in

making a change.

Self-efficacy

The provider helps the client to become more confident in herself

by taking charge of her health and knowing she is taking better

care of her unborn baby. By promoting self-efficacy, the client may

be more likely to commit to the change and maintain healthy

behaviors through the rest of her pregnancy.

After the MI process in which the provider addresses the problem behavior,

regular follow-up visits are necessary to ensure that the client maintains an

understanding of the importance of change. If the patient is demonstrating

changes at the next visit, the provider should be supportive of her progress

and encourage her to continue, regularly checking up with her to see if she

is following through. If the client is attempting to make changes but is

unable to carry out the work, the provider and the client should explore


these reasons together to determine if there are other methods of achieving

the same goal that the client could implement more easily. If the client is

unwilling to change, the provider should continue to work with her through

motivational interviewing to come up with solutions for change, making

referrals to other professionals as needed.

Smoking Cessation And MI

Smoking tobacco is a leading cause of chronic disease and death throughout

the world. People who start smoking cigarettes have a very difficult time

quitting the habit because of the addictive properties of nicotine, which is

found in tobacco. Nicotine has been shown to be as addictive as some illegal

drugs, such as heroine, and people who smoke on a regular basis or who

have smoked for many years become physically dependent on the nicotine,

resulting in symptoms of withdrawal when trying to quit.

Many people also become emotionally dependent on cigarettes, choosing to

smoke in certain situations, such as during social interactions or as a source

of comfort. They may have a difficult time quitting not just because of the

physical withdrawal from the nicotine, but also because of the psychological

impact that smoking has on their lives.25

Smoking impacts almost every part of the body, causing damage to cells and

resulting in acute or chronic diseases that can ultimately become life

threatening. It worsens respiratory illnesses and causes a chronic cough, it

can lead to other lung diseases, such as chronic obstructive pulmonary

disease; and, it can also cause changes in the circulatory system that can

increase the risk of heart disease, hypertension, and stroke. Additionally,

smoking tobacco increases a person’s risk of certain types of cancer and can


cause complications with pregnancy among women who are pregnant and

who smoke.25

Many people are aware of at least some of the dangers associated with

smoking, although not all people want to quit. Of the people who do want to

quit, many try to stop again and again without making a lifelong

commitment to stop.

There are many products and options on the market available to people who

smoke and who would like to quit. Studies have shown that both

pharmacological approaches and behavioral interventions have helped

people to stop smoking. Pharmacological interventions include some types of

medications that can reduce the craving for nicotine, while other

interventions include nicotine replacement that slowly decreases the amount

of nicotine taken in by the body over time until the dependence is minimal.

Alternatively, behavior mechanisms for quitting smoking range from

hypnosis to cognitive-behavioral therapy, to group therapy, to motivational

interviewing. MI has been used successfully with many patients to take steps

to change their lives and quit smoking permanently.

A study by The Cochrane Collaboration looked at the positive impact of

motivational interviewing to promote smoking cessation. The study

considered whether MI was successful in promoting smoking cessation when

compared to routine care or no advice. The study showed that the effects of

MI are long lasting when compared with other forms of therapy; intensive

sessions of MI that are longer in time or in number of sessions are more

effective than single sessions; that people who quit smoking while using MI

have similar long-term outcomes of relapse when compared with people who

quit smoking while using other therapies, and that there are no adverse


effects from using motivational interviewing.24

The study was a meta-analysis of work done by using motivational

interviewing for smoking cessation that examined randomized controlled

trials for results. The studies used the principles of motivational interviewing

as part of smoking cessation programs, including promoting change through

self-efficacy, exploring ambivalence, and assessing the clients’ motivation to

quit.24

The study results showed the positive impact of motivational interviewing by

using a non-judgmental and non-confrontational approach that improved

self-efficacy among patients who were trying to quit smoking. The sessions

that were at least 20 minutes long were more effective than short

interventions, and most clients needed at least two, if not more sessions, in

order to be successful in their attempts at quitting. The motivational

interviews were successfully held in various settings, including general

practice healthcare offices, outpatient settings of hospitals, through

telephone conversations, or in clients’ homes.24

A motivational interview session could develop in several different ways,

depending on the client’s initial desire to change and to quit smoking. The

interview evolves as the provider engages the client and each learns more

about the client’s level of ambivalence toward quitting, as well as other

factors that may be prominent, including resources available to help with the

change, level of resistance on the part of the client, and even the connection

and compatibility between the client and the provider. Because there are

various factors that can affect the motivational interview, no two interviews

will be alike. However, it is possible to anticipate varied directions that a

motivational interview could take with the goal to support smoking


cessation. The provider should begin with establishing rapport with the

client, making introductions, and orienting the client to the purposes of the

motivational interview:26

“Hello, my name is _____ and I am a registered nurse here at the

health clinic where we are meeting today. I thought we could talk

about healthy lifestyle practices to better help you know how to stay

healthy and feel good. Many people who smoke cigarettes eventually

develop health problems associated with their heart or their circulatory

systems. They can also become addicted to cigarette smoking because

of nicotine, a substance found in cigarettes. You may or may not have

these issues, and maybe you feel quite healthy. I would like to get

your opinion about cigarette smoking and its effects on health.”

The opening is friendly and it establishes the provider’s role and level of

education, which may be something that establishes even a greater level of

trust for the client. The provider also does not start out with telling the client

about the hazards of smoking and then recommending that he or she quit to

avoid having similar outcomes. Rather, the provider is non-judgmental and

open to the possibility that the client does not have current health problems

and instead would like to discuss his or her tobacco use.

After an initial discussion that involves the client’s opinions about cigarette

smoking, the provider can then move on to determine the client’s level of

ambivalence about quitting. The client may give many clues during the initial

sharing of opinions regarding smoking in the first place, but it is important to

determine what level the client is currently at when considering the

plausibility of quitting for good. The provider can give further feedback or

make requests for more information, or she may clarify what the client has

already said.


To provide feedback or request more information from the client, the

provider might start with:

“Tell me about your tobacco use.”

“What do you think of the effects of nicotine on a person’s body?”

“Do you think smoking could cause harmful effects to you?”

If the provider wants to clarify some information given by the client, she

might use some of the examples or phrases that the client has said:

“What I hear you saying is that you believe smoking is harmful to

your health.”

“So, your family member died as a result of smoking and you don’t

want the same thing to happen to you.”

As the provider continues to assess the client’s readiness for change and

level of ambivalence about quitting smoking, he or she should continue to

use words that reflect empathy, ask open-ended questions, and encourage

the client to do a lot of the talking. Frequent reflection or re-evaluation of

what the client has said is often necessary to continue to clarify important

points and to ensure that the conversation stays on track to avoid

misunderstandings.26 Finally, at the end of the initial discussions, the

provider should summarize what the client has said:

“To summarize, you have talked about how you know that smoking

cigarettes is harmful to your health and you would like to quit, but you

do not know how to get started. You are afraid that if you do no quit,

you will develop a disease similar to your family member’s condition

and you could die from that. You feel that you have been smoking for

so long that it would be impossible to quit now.”

The next step of the process moves the client toward change. The provider


has assessed the client’s level of ambivalence and now should emphasize his

or her talk on finding reasons for change, rather than maintaining the same

behaviors. After the initial discussion, the provider may determine that the

client is resistant to change, wants to change but doesn’t know how, or

wants to change and is ready to move forward. The following example might

be one in which the client wants to change but doesn’t know what to do

next.

“To go forward from here, you have told me that you have been a

smoker for fifteen years and you think it would be extremely difficult

to quit at this point. However, you have also said that you would like

to quit to benefit your health. What other reasons can you think of that

might be a benefit of quitting smoking?”

This conversation supports the concept of discrepancy, in which the client

sees the difference between where he or she is now and where she wants to

be. By listing other reasons for quitting smoking in addition to improved

health, the client verbalizes other measures that support his or her need for

change. The next step might be to ask the client about his or her level of

interest in quitting:

“Based on the reasons listed, do you think you should continue to

smoke?”

“You have discussed why you know smoking is harmful, what can

you think of to do about your smoking habit?”

“May I give you some more information? I think you know why it is

important not to smoke and you want to quit, but…”

This discussion places the responsibility for change in the client’s hands.

After starting with a foundational conversation about the importance of

quitting smoking, the provider comes to the point where he or she must


determine if the client will change or not. This determination then helps the

client to know if they should move forward to setting goals and finding

resources for quitting or if they need to revisit the discussion about the

detrimental effects of smoking. If the client has agreed that he or she should

play an active role and take responsibility for quitting smoking, the

discussion with the provider can continue.26

Once the client has committed to making a change, the next step is to

identify those steps that the client should take to work toward that change.

The provider and the client should work on identifying those steps together.

In some cases, the client who is trying to quit smoking may not be aware of

his or her options for taking steps to quit.

Education is a component of this step, and the provider

should give information that can be useful to the client, delivered in a

sincere and empathic method. An example would be:

“I think you recognize that it is important to quit smoking and you are

ready to take steps to quit. Let’s talk about some options that you

have for moving toward your goal of smoking cessation.”

A menu of options provides the client with alternatives for how best to

approach quitting smoking. For example, the provider might give the client a

list of methods, such as using nicotine replacement patches or undergoing

cognitive-behavioral therapy; contact numbers for support groups and

organizations that may be of assistance or may provide support and help, or

a referral to a healthcare provider to prescribe medication that can help with

reducing nicotine cravings. The provider could introduce options to the client

in the following way:


“I have a list of options that might be available for you to consider.

Let’s talk through each of these so you can better understand the pros

and cons of each and then you can decide if there are one or more

options that you could implement into your lifestyle to help you quit.

Once you decide, we can then see how to get started with putting

these into place.”

Once the provider has gone through the menu of options for the client, he or

she should ask the client which option works best for their situation. If the

provider encounters resistance, they should back up and talk through the

client’s decision to quit and then try to discuss the options again, acting as a

guide for the client instead of simply telling him or her what to do. Other

topics to explore might be obstacles or barriers that could develop that

would prohibit the client from making a permanent change or the return of

ambivalent feelings that would prompt the provider to revisit the client’s

level of motivation.26

The level of motivation could be explored with such statements as:

“Are there any issues you see that would stop you from putting

these interventions in place?”

“Do you feel that you can take the next step and [place a phone

call/contact a provider/ask for a prescription] to help you get

started?”

“Do you feel that if you implement these interventions, you will be

better able to meet your goal?”

Finally, as the meetings draw to a close, the provider should continue to

summarize and clarify in order to evaluate the effectiveness of the

discussions that have taken place. Regardless of whether the client plans to


change and quit smoking, the provider should thank the client for taking the

time to talk about the issue involved and for at least considering a change in

behavior. If the client decides to move forward with making a change toward

quitting smoking, the provider must affirm this and help the client know

what to do next:26

“We have talked about the importance of quitting smoking to you. You

have said that you have smoked for a number of years and you know

it will be difficult to quit. However, you also have had a family member

pass away due to illness caused by smoking and you do not want the

same thing to happen to you. Thank you for taking the time to discuss

your concerns about smoking with me. We discussed a number of

options that you can consider that can help you to quit and you have

decided to try nicotine replacement therapy through the patch system.

This sounds like an option that could work very well for you and you

could incorporate it into your lifestyle.”

At the end of the discussions the provider should follow up with the client to

determine how well the options are working and to see if the client needs

assistance with any other issues. The client may have tried the options

discussed but then found that they did not work out and may need further

direction. Alternatively, the client may report that the situation has improved

dramatically and he or she has been able to successfully quit smoking.

Whenever a client agrees to make a change in his or her lifestyle as a result

of motivational interviewing, someone should follow up to determine if other

needs have occurred or whether the MI sessions were successful in helping

to bring about and maintain change.26


Addictions And MI

Motivational interviewing has been successfully used with patients suffering

from substance abuse. The original work published by Miller in 1983 in the

early stages of MI was targeted toward working with patients who had

difficulties with alcohol addiction. Motivational interviewing continues to be a

successful intervention when used among some patients who want to stop

drinking alcohol.

A study by Lundahl and Burke, which included a meta-analysis of 119

studies that examined the effects of motivational interviewing when working

with patients with varying issues showed that motivational interviewing was

at least as successful as other forms of therapy when compared with other

types of interventions, and was significantly successful when compared to no

treatment for alcoholism.33

Substance abuse differs from addiction, although the two scenarios can

cause difficulties for the involved client and loss of relationships with others.

Substance abuse involves using a substance, often alcohol or some type of

drug, in an inappropriate manner, such that it becomes disruptive to normal

activities of daily living. Substance abuse interferes with responsibilities,

such as those of going to school or work, maintaining a home, or providing

childcare.

Despite the problems that the use of substance causes, people who struggle

with substance abuse continue to use, often with negative consequences.

For example, a person who is struggling with substance abuse may use

alcohol inappropriately to the point that it impacts his abilities to work or

take care of family. The person’s spouse and other family members are

aware of the problems caused by the alcohol use, but the person continues


to drink despite efforts to talk or convince him or her otherwise.56

Alternatively, substance addiction causes problems for the person abusing

the substances and also causes a dependence that typically requires using a

larger amount in order to achieve the same effects. The person also

experiences withdrawal when trying to stop using the substance, and may

have made efforts to cut back or stop entirely without success.56

Non-substance addictions, which may also be referred to as behavioral

addictions or impulse control disorders, are those situations in which a

person engages in an activity that produces some type of reward and

continues to do the activity despite adverse consequences.57 People who

struggle with non-substance addictions may have great difficulties resisting

the urge to perform an activity and may continue to do so on a repeated

basis, which is often similar to substance addiction. Also similar to substance

addictions, behavioral addictions cause a great amount of pleasure for the

person performing the activity, which then may be followed by feelings of

remorse, anger, or helplessness. Unlike substance addictions, behavioral

addictions do not cause symptoms of physical withdrawal when the addicted

person stops performing the activity.57

Examples of behavioral or non-substance addictions include pathological

gambling, excessive shopping, Internet addiction, or compulsive sexual

behavior. Patients who are addicted to these activities are at risk of

potentially severe consequences that can occur in addition to the alienation

and disruption to relationships that addiction causes. For instance, someone

who struggles with pathological gambling may be at risk of financial

difficulties through an inability to stop gambling, despite losing large

amounts of money at times.


Motivational interviewing has been used among professionals working with

clients who suffer from substance abuse and addiction. The process can be

implemented through counseling and alongside other treatments, such as

pharmacologic therapy, to help individuals with substance abuse disorders

make choices for their health and play an active role in managing their

diseases. Because the provider in the interview collaborates with the client

instead of taking on a paternalistic viewpoint, the partnership of working

together through MI can help the client focus on his underlying need for

substance use that resulted in addiction.58

Motivational interviewing also works in use with clients with both substance

addictions and behavioral addictions because the change is not forced and

the client is guided to come to their own conclusions about what or how he

or she wants to change, based on their level of motivation. This

empowerment puts the responsibility for change on the client and the

provider is not an authority figure, but, rather a coach or guide helping the

patient recognize this process.

The main principles of MI support this process. For instance, when a provider

is empathic toward the client who struggles with addiction, the client is less

likely to feel judged or cornered. A person with a substance abuse problem

who seeks treatment often already has a plethora of issues to face and

overcome and putting him or her with a provider who is critical of personal

choices will only derail the process of help and change. Instead, an attitude

of empathy by the provider helps the client feel that someone cares about

them despite their personal mistakes and background.58

When the provider acts as a guide, he or she helps the client to better see

the errors in some of their ways and the value of making changes. The client


may seek care coming from a situation full of hurt and regret, with feelings

of shame, hopelessness, or despair over an inability to stop whatever

activity is causing the addiction. The client may be angry that life is not

different or that the choices he or she has made have only led to confusion

and trouble. Regardless of the client’s feelings about their addiction, if they

are willing to work with the provider to consider change through motivational

therapy, then the client can see the discrepancy between where he or she is

now (heartache, pain, confusion) and where he or she wants to be (a life of

greater self-control, freedom from addiction).

12-Steps programs

Many people have found help from substance abuse and addiction by going

through 12-step programs such as Alcoholics Anonymous (AA). The idea

behind AA is to be a membership group where people who struggle with

alcohol use and addiction can meet with others for support and help for their

drinking. Alcoholics Anonymous meetings may have speakers or people may

share their experiences and challenges with using alcohol in order to

facilitate discussion.

The AA program is based on 12 steps that each person works through in the

process of handling alcohol addiction. Some of the 12 steps cover ideas that

the person is powerless over alcohol, believes in a power greater than

themself that he or she can turn their life over to for help with alcohol, has

made a moral inventory of themself, has admitted to themself and to others

the level of wrongs that they have committed, and has asked God or his

higher power to remove those wrongs and shortcomings.88

A benefit of going to AA and continuing involvement with it or any 12-step

program that is used for help with substance abuse and addiction is that if


the person is truly incorporating the 12 steps into his or her life, it is

understood that he or she wants to change. In this respect, motivational

interviewing can be incorporated into 12-step programs to facilitate change

and better help people struggling with substance abuse or addiction to set

goals for change and feel empowered to move forward.

In some situations, change is mandated, and the client may or may not want

to give up using drugs or alcohol. For instance, a situation in which a patient

is required to attend counseling for drug abuse as part of a sentence for a

criminal offense may only put the patient in a place where he grudgingly

goes along with therapy. In these types of situations, motivation will be

quite low and motivational interviewing may not be successful. Alternatively,

in situations where the client is willing to take steps to change and has a

sincere desire to give up the substance for the good of him- or herself and

others, MI can be incorporated into treatment.87

Diabetes And MI

Motivational interviewing has successfully been used in targeting patients

who are at risk of developing diabetes as well as those who have already

been diagnosed. There are modifiable risk factors for diabetes that, when

implemented, can significantly reduce the risk of developing the disease.

Motivational interviewing can help some patients to recognize their risks of

developing diabetes and to take steps to change their lifestyle habits

to minimize these risks.

Alternatively, people who have been diagnosed with diabetes can still

practice many activities that contribute to health and wellbeing and that

reduce the risk of complications associated with the disease. Motivational


interviewing can challenge these patients as well, to help them understand

the importance of healthy living through diet, exercise, and blood glucose

maintenance to control their disease.27

Diabetes is a condition in which glucose levels in the bloodstream are too

high. Normally, the blood glucose levels rise following a meal, as foods are

broken down and digested. The body responds to this rise in blood glucose

levels by secreting the hormone insulin from the pancreas, which acts to get

the excess glucose out of the bloodstream and into the cells where it can be

used for energy. This process provides energy to the cells and fuel for the

body, and it also regulates blood glucose levels, which can be damaging

when they remain consistently high over a period of time.28

Diabetes is further broken down into two main types: type 1 diabetes, which

used to be referred to as juvenile diabetes because it was consistently

diagnosed in childhood for many patients; and type 2 diabetes, formerly

known as adult onset diabetes, because it often developed during adulthood.

Today, type 1 and type 2 diabetes can develop in people of any age,

although type 2 is more common and has many more modifiable risk factors,

including being overweight and obese.

Type 1 diabetes often develops as a result of an autoimmune process in

which the body attacks the cells in the pancreas, affecting its ability to

produce insulin. The body then cannot keep up with insulin production

needed to regulate blood glucose levels and glucose remains consistently

high in the bloodstream. Type 2 diabetes develops when the cells become

resistant to the effects of insulin. The body may still secrete insulin through

the pancreas, but it is not as effective. The pancreas needs to secrete more

and more insulin to control blood glucose levels and it ultimately cannot


secrete enough to keep up with demands. This results in consistently

elevated levels of glucose in the bloodstream as well.28

Both type 1 and type 2 diabetes can cause significant complications that

impact a person’s ability to heal from certain diseases and can lead to

serious illness or even death. Diabetes is connected to heart disease,

metabolic syndrome, kidney disease, blindness, diabetic neuropathy, eye

disease, and problems with pregnancy.28 Being diagnosed with diabetes

requires lifelong maintenance of blood glucose levels, and often medications

and other lifestyle changes in order to reduce the risk of developing

complications. Clearly, it is important to manage diabetes as much as

possible upon diagnosis or to recognize risk factors in the lives of some

people to prevent its development in the first place to avoid considerable

loss later. Motivational interviewing can work with many patients at different

stages to recognize the various risk factors for diabetes or to better

understand the importance of managing the disease to maintain a healthy

lifestyle.

Motivational interviewing can work well as a form of lifestyle factor

intervention for clients who are at risk of diabetes. Pre-diabetes is defined as

impaired glucose tolerance (IGT), which is demonstrated by a glucose level

between 140 and 200 mg/dL upon undergoing an oral glucose tolerance

test; or impaired fasting glucose (IFG), which is demonstrated as a fasting

glucose between 100 and 125 mg/dL. People with IGT and IFG are at

significantly higher risk of developing type 2 diabetes and its associated

complications. However, studies have shown that instituting behavior

interventions among people with pre-diabetes, such as by using the

techniques applied through motivational interviewing, may reduce the risk of

pre-diabetes developing into type 2 diabetes.27


The Diabetes Prevention Program conducted a study that compared

therapeutic lifestyle changes with pharmacologic intervention in the

prevention of type 2 diabetes among patients diagnosed with pre-diabetes.

The study found that lifestyle interventions caused an overall reduction of

diabetes risk in 58 percent of clients when compared with a 31 percent

reduction in risk among clients who used metformin to control their risk of

diabetes.27 Motivational interviewing, when implemented into care visits or

as a stand-alone effort for reaching people at risk of developing type 2

diabetes, can educate clients about the effects of implementing therapeutic

lifestyle techniques and can promote change among clients who may know

they need to reduce their risk of diabetes but who are uncertain about where

to begin.

For patients who have been diagnosed with type 2 diabetes, management of

the disease can be difficult not only to understand the process, such as by

checking blood sugar levels on a regular basis or calculating appropriate

carbohydrate counts, but there may be other constraints that prevent some

patients from implementing strategies to care for their health when they

have type 2 diabetes. Some patients raise difficulties with paying for

supplies or medications, and there may be time issues that prevent some

people from being able to check their blood glucose levels or determine

appropriate amounts of insulin to administer. As well, some people may not

have access to regular appointments with healthcare providers to maintain

contact and updates about their care.32 Such factors can significantly affect

motivation for change among clients, which can be addressed through MI.

One of the reasons why MI can be successful when working with patients

who have type 2 diabetes is that it is an individualized approach that

considers the specific needs of each client’s situation. The method can


address issues that impact motivation in each client, rather than providing a

catch all method of giving generalized advice or using scare tactics.32

An example of how each client is different in their needs and responses for

MI can be understood in terms of the reasons why each client would seek

help to control diabetes in the first place. Two clients with diabetes may be

separately seeking help; and, while one client may not have been successful

with managing their health because they cannot afford to pay for glucose

monitor strips every day, the other client may not have made changes

because they are simply afraid of checking glucose levels. During

motivational interviewing, the provider can address each of these issues

individually with the separate clients, helping each client to come up with

solutions that are specific to their challenging situations.

According to the Journal of Diabetes Nursing, motivational interviewing

techniques were successfully implemented into educating and treating

patients with type 2 diabetes. The study was known as the Diabetes Nurse

Case Management and Motivational Interviewing for Change (DYNAMIC).

The study was a randomized, controlled trial that separated participants into

two different groups: a control group that received standard care for type 2

diabetes and a focus group that received care for their diabetes using the

DYNAMIC intervention, which used motivational interviewing as a method of

evoking change in health behaviors among participants. All of the

participants involved in the study had type 2 diabetes.

The researchers conducting the DYNAMIC study found that nearly all of the

participants involved had other psychological distress or issues connected to

their type 2 diabetes diagnoses. The concurrent psychological findings

ranged from depression related to a diabetes diagnosis and ongoing care to


feeling judged and policed about performing activities within a certain

timeframe, to lower levels of self-care behaviors related to anger or

frustration. The participants were all, therefore, at greater risk of poor

outcomes related to their diabetes control because of these additional

distressing circumstances. The study showed that participants who went

through MI as part of their treatment in the DYNAMIC group responded more

and had more beneficial health outcomes when compared with participants

who received standard diabetes care.32

The participants who received the DYNAMIC intervention stated that they felt

more positive about their role in taking charge of their health, they did not

feel judged or policed for their behaviors but instead were met with

empathic and consistently caring responses from their caregivers that made

them want to cooperate more. Even in situations when lab results did not

show changes or showed that participants had slipped in their accountability

for change, the nurses performing the motivational interviewing remained

non-judgmental and were accepting, which enhanced trust and a greater

desire to cooperate from the participants.32 Based on these outcomes, it can

be said that motivational interviewing certainly provides a positive and

healthy view of change that enhances in clients a motivation and desire to

take charge of their health.

Another study found in Diabetes Research and Clinical Practice also showed

that patients who participated in motivational interviewing as part of their

treatment for type 2 diabetes responded better to interventions when

compared to patients who received standard treatment alone. The study

divided groups into two areas: one that received standard treatments and

one that participated in motivational interviewing as part of treatment. All

patients involved had type 2 diabetes. Some of the patients were more


responsive to MI techniques as part of treatment and were more likely to

respond to making healthy changes.31

The patients who received standard care for their diabetes complained of

feeling judged and facing paternalistic and critical responses from their

providers. They often felt demeaned in their attempts to control their

diabetes. Alternatively, the participants who were in the MI group stated

that they had more positive feelings toward their treatment and received

care in a non-threatening and helpful manner. According to the study, five

themes emerged that participants commonly stated they felt was their

experience: nonjudgmental accountability, encouragement and

empowerment, being heard and responded to as a person, collaborative

action and goal setting, and coaching rather than critiquing.31

Effective communication is necessary when working with diabetic clients who

often need to understand the seriousness of their disease. In many cases,

healthcare providers are more aware of the complications and the

complexity of diabetes than the clients and must communicate the

information accordingly. Rather than directing clients about what they need

to do and checking in to see if they have been successful in following

directions, the provider through motivational interviewing can instead work

alongside clients to provide information about the seriousness of diabetes,

the need for self-care and management, and the importance of regular

healthcare follow-up.31

Through motivational interviewing the provider is able to provide the needed

follow-up to ensure that the client is making important changes and can

address those issues that are prohibiting change. Rather than taking a

paternalistic approach with diabetic clients, the provider through


motivational interviewing demonstrates a more collaborative and successful

approach to help prevent some very significant complications among this

population.

Heart Disease And MI

The American Heart Association (AHA) recognizes the importance of

behavior changes in improving heart health and has stated that behavior

changes are an important component of reaching the AHA’s 2020 goals,

which includes “improving cardiovascular health of all Americans by 20

percent while reducing deaths from cardiovascular disease and stroke by 20

percent”.40

Cardiovascular disease, also referred to simply as heart disease, is actually a

range of conditions that can affect and compromise the work of the heart. A

number of conditions that affect the heart and blood vessels can be classified

as heart disease, including coronary artery disease, heart attack,

cardiomegaly, heart arrhythmias, and heart valve disease.

Coronary artery disease is one of the most common forms of heart disease.

It occurs as the result of plaque buildup in the coronary arteries, or the main

arteries that provide blood to the heart. Plaque deposits build up inside the

coronary arteries because of cholesterol and other substances, which

eventually narrow the inside of the artery and decrease blood flow. When

coronary artery disease develops, the patient is at higher risk of other

complications, including stroke, heart attack, and peripheral vascular

disease.

A significant danger is the formation of blood clots. If a clot forms at the site

of the atherosclerotic plaque or a piece of the plaque breaks off into


circulation, it can become lodged in one of the vessels leading to the heart

or the brain, causing a heart attack or stroke. Decreased circulation to the

heart decreases its overall function and the function of major organs of the

body. Blood may not reach the distal extremities as quickly as it once did

and may result in pain in the legs when circulation cannot keep up with

activity.

If the atherosclerosis in the coronary arteries causes a complete blockage, a

portion of the heart can become deprived of blood. Without adequate blood

flow, the tissue in the area beyond the blockage becomes ischemic from lack

of oxygen and tissue death begins to occur. This is what happens with a

heart attack, which is a leading cause of death and disability among people

with heart disease.41

Other types of heart disease can also cause significant complications for

patients and must be managed accordingly to avoid developing further

problems or disabilities. Cardiomegaly occurs as enlargement of the heart

muscle that often develops after the muscle tissue has been damaged. This

damage can be caused by impaired circulation due to coronary artery

disease or hypertension. As the heart becomes larger in size, it is not able to

pump blood as effectively, which further impacts overall circulation and

decreases the amount of oxygen reaching the tissues and organs.41

A heart arrhythmia is an irregularity in the rate in which the heart beats.

Heart arrhythmia may occur as a result of coronary artery disease,

electrolyte imbalances, cardiomegaly, or injury that occurred from a heart

attack. When a heart arrhythmia develops, it can start in different areas of

the heart and may be erratic, fast, or slow. The condition can increase a

person’s risk of developing blood clots if blood does not flow properly


through the chambers of the heart and pools in certain areas within the

heart. A heart arrhythmia may also significantly disrupt circulation, which

affects other organs and can reduce how much oxygen and blood is reaching

parts of the body.

Finally, heart valve disease develops when the valves between the chambers

in the heart do not function properly. They may have become stiff and

stenotic, or they may not close completely when they are supposed to. As

with some other forms of heart disease, blood flow can be impaired with

valve disease as well. If blood backs up because it cannot flow through the

heart chambers properly, it can cause heart failure (formerly called

congestive heart failure), which leads to fluid accumulation in circulation,

respiratory difficulties, and tissue edema.41

Clearly, heart disease of any kind can be very significant, which is why so

many efforts are aimed at preventing, managing, and treating these

conditions. A number of lifestyle factors significantly contribute to the

development of heart disease, including being overweight/obesity, inactivity,

and smoking. Patients who are at risk of developing heart disease because

these lifestyle factors are a regular part of their lives or those who have

already been diagnosed with heart disease can all benefit from making

changes to incorporate healthier habits and either reduce the risk of

developing the disease or reduce the risk of developing complications

associated with heart disease.

Patients are at risk of heart disease when they are overweight or obese.

Overweight is classified as a body mass index (BMI) of 25.0-29.9, while

obesity is classified as a BMI over 30. It can be extremely difficult for some

people to lose weight and develop a healthy BMI, even with a diagnosis of


heart disease. Many people have become so accustomed to unhealthy eating

patterns, whether by choice of food because of taste, or due to other factors,

such as financial concerns or the availability of cheap and unhealthy foods.

Regardless of the reason behind unhealthy eating, it is important that the

patient understands the need for changing food intake to employ choosing

healthier foods in moderately sized portions in order to reduce the risk of

heart disease. Motivational interviewing can help the client to work with a

provider to come up with solutions for problems with eating. For instance, if

the client is having difficulties obtaining appropriate foods because junk food

is cheaper than healthy food and he does not have a lot of money, the

provider could work with the client to come up with options for obtaining and

preparing healthier foods.

Dietary intake impacts the work of the heart as well as circulation. Reducing

levels of saturated fat and cholesterol, as well as controlling salt intake all

impact the risk of coronary artery disease and hypertension. According to

Franklin, et al. in an issue of Circulation, people who follow a healthy diet

similar to those who live in Mediterranean areas and who consume greater

amounts of unsaturated fats have up to a 31 percent reduced incidence of

heart disease.40 Furthermore, changing dietary practices to include

decreased saturated fat intake and decreased cholesterol intake may reduce

plaque size in atherosclerosis, thereby potentially improving coronary artery

disease.40

Increasing physical activity has also been shown to improve heart health and

reduce the risk of cardiovascular disease and complications associated with

cardiovascular disease among those who have been diagnosed, with risk

reductions in up to 50 percent of cases of cardiovascular mortality.40


Increased physical activity regularly increases circulation and strengthens

the heart muscle. The heart must pump faster in order to keep up with the

demands of circulating blood to the tissues and the lungs when breathing is

increased due to exercise. Patients who increase their physical activity levels

may not only reduce the risk of heart disease and its complications, but may

also lose weight, have improved stamina, and may have greater feelings of

well being by participating in regular activities that are enjoyable.

Increasing exercise levels is also a change that could be taken on through

motivational interviewing. Patients who need to exercise more or who live

sedentary lifestyles may or may not be aware of the benefits of exercise and

the risks associated with a sedentary lifestyle. Motivational interviewing can

give a provider an opportunity to work with a patient to assess how he or

she feels about exercise and its benefits. After assessing the patient’s levels

of ambivalence toward exercise, the provider and the patient can work

together to set some goals for increasing exercise levels on a weekly basis, if

the patient is willing to make a change. For example, a patient with

hypertension is at risk of heart disease because of a high intake of saturated

fats and because of a very sedentary lifestyle. The patient may know that

exercise is important for some people but may not understand how it affects

the heart or why there is a need to add it to his or her life.

The provider can work with the patient to first help him or her better

understand the importance of exercise on heart function and to teach or

educate about how to incorporate more exercise into daily life. This

information is given in a nonjudgmental and non-threatening manner so that

the patient may be more likely to respond positively. If the provider and the

patient together determine that change is important and the client is willing

to work toward change, the provider can then direct him or her toward


programs or sources of support to help to increase the level of exercise.

Together, the provider and the heart patient may discuss which types of

exercise are most enjoyable or those that he or she could most easily begin.

They could talk about the minimum amounts of exercise needed to derive

benefits and then come up with ways to start slowly and increase to set

goals of regular activity. Motivational interviewing holds many benefits for

discussion and change talk to get a patient with a heart condition who needs

to exercise more for the sake of their health make positive changes.

Smoking cigarettes greatly contributes to heart disease and its

complications, and smoking kills 450,000 Americans every year. A study of

British physicians found that people who smoke shorten their lifespans by

approximately 10 years.40 Although smoking causes harm to almost every

organ in the body, it can significantly impact the work of the heart and the

blood vessels, contributing the heart disease. The chemicals that are found

in cigarette smoke cause damage to the blood vessels, which can impact

how well they function. The decreased functional capacity of the blood

vessels further contributes to atherosclerosis and coronary artery disease

when the blood vessels are more rigid and blood flow is less efficient.

Smoking, when combined with being overweight or obese and having a

sedentary lifestyle, can significantly increase the risk of heart disease and its

associated complications.42

As discussed in the section of this course related to motivational interviewing

and smoking cessation, motivational interviewing has helped some people to

quit smoking permanently. When a patient seeks help with their health

related to heart disease and the provider discovers that he or she is a

smoker, the provider can use the techniques of MI to discuss the situation


with the patient and address their level of motivation about quitting to

support their health. If the patient is willing to take steps to quit smoking to

reduce the risks of heart disease and improve their lifespan, the provider can

then help the patient to find more resources to successfully quit smoking

permanently.

5 A’s of Motivational Interviewing

Counseling professionals have recommended the use of the 5 A’s when

working with some clients to make lifestyle changes in general. Motivational

interviewing can be used alongside the 5 A’s when its essential techniques of

empathy, rolling with resistance, discrepancy, and supporting self-efficacy

are followed. The 5 A’s include:43

Ask

Advise

Assess

Assist

Arrange

Through motivational interviewing, the provider can first ask the client

questions about him- or herself as a method of building rapport and trust

between the client and the provider. When using MI to support smoking

cessation, the provider also asks questions about the client’s tobacco use,

such as length of time spent smoking and the amount smoked.

The advice and assessment methods could be paired together if they are

presented in a non-judgmental manner and if the clinician asks for

permission before giving advice. For instance, the provider might say, “do

you mind if I tell you…” and then share what he or she knows about the

negative impact smoking has on heart disease. The assess step of the 5 A’s


then determines the client’s level of motivation to quit smoking and make

better choices for his health. During the assessment phase, the clinician asks

the client outright if he or she wants to make a change and is willing to take

steps toward a permanent change.

If the client is willing to try to quit smoking, the provider then moves on to

the assist portion of the 5 A’s. It is at this point that the provider helps the

client to come up with reasonable goals toward quitting smoking, such as

using medication to reduce nicotine cravings or to attend support groups for

further encouragement. The provider can give the client resources to further

support what has been discussed during the motivational interview.

Finally, the arrange portion of the 5 A’s involves arranging follow-up

appointments to see if the client is continuing to take the steps that were

discussed. This might mean following up with a phone call to check in with

the client and determine how things are going, a follow-up appointment to

meet together again to talk more, or an appointment with another

professional who can continue to help the client in his or her work toward

the goal, such as a meeting with a medical specialist.

Whether or not patients with heart disease are willing to make these

changes in their lifestyle is governed by a number of factors, including

socioeconomic status, family or social support, and cultural factors. During

the discussion of the need to make changes to manage heart disease, the

provider must assess what factors are prohibiting the client from making

changes and then work with the client to address those issues.

For patients who have significant issues to overcome before starting to

change or for those who state that they have too many obstacles standing in


the way before they can get started might mean altering the goals

somewhat to fit what these patients can do. In some cases, it is better to

make some progress toward a lesser goal than to set a higher goal and then

fail when it is too difficult for the patient. For example, a patient who never

exercises and who leads a very sedentary life, including a desk job where he

sits for most of the day, followed by spending his evenings on the couch at

home watching television, is most likely not a candidate for setting a goal of

becoming actively involved in a running program and striving to run a 10K

by the end of the month. The patient may strive for this goal but might be

more likely to fail or give up because it is too much of a change to start out.

Although the patient may incorporate lifestyle changes and eventually reach

the point where he or she is an active runner, it may be best to start out

with smaller goals that can be achieved to improve self-efficacy. The patient

could instead begin with a walking program where he or she walks twice

around the block, two times a week. Although this goal would not meet the

exercise recommendations given by the American Heart Association for

moderate intensity exercise on five out of seven days a week, the patient is

still doing more exercise than before. If the patient achieves this goal and is

able to implement regular walking, then they may increase the time spent

walking, as well as the number of days each week. The patient may walk

further each time than previously done, and increase from two days a week

to four. Some patients need to slowly work toward their goals to improve

confidence and desire for change.

The American Heart Association has recommended motivational interviewing

as an effective method of promoting healthy outcomes by making lifestyle

changes in patients with heart disease.44 Use of MI can bring about changes

in some patients that continue long term. A study by Hardcastle, et al., in


the International Journal of Behavioral Nutrition and Physical Activity

compared patients who received five sessions of motivational interviewing,

combined with exercise and nutrition information with a group who only

received the information but no MI. The patients were measured for their

physical activity, dietary intake, BMI, blood pressure, and cholesterol

immediately following the completion of the study and then again a year

later.

The goal of the study was to show that the use of MI not only produces

changes in lifestyle factors for patients, but also to determine whether the

changes can be maintained long term. The study showed significant changes

in the patients who used motivational interviewing as part of their

interventions in the areas of weight loss and cholesterol management. The

MI intervention was particularly effective among those patients with the

highest risk factors for heart disease. The study found significant increases

in the amount of walking added among patients who used MI and as a

lifestyle change, 12 months after the interventions ended. Alternatively, the

group who did not use MI during the study had increased levels of

cholesterol and BMI in the 12 months following the interventions.44

Another study found in the Journal of Clinical Nursing performed a

systematic review of literature to analyze current research findings that used

motivational interviewing as part of practice in helping clients change to

improve their cardiovascular health. The review included four meta-

analyses, a systematic review, three literature reviews, and five primary

studies related to motivational interviewing and its use in promoting

cardiovascular health. The review found strong evidence that motivational

interviewing is useful and effective when focusing on and implementing

changes to promote cardiovascular health and, thereby, reducing the risk of


disease.45

Clearly, motivational interviewing has benefits in helping clients to make

changes that will improve their lives and that will reduce the risk or impact

of heart disease. Because so many patients with heart disease have multiple

factors that must be addressed, including weight management issues,

decreased activity levels; laboratory outcomes that can indicate severe risk

of cardiac problems, including elevated total cholesterol levels, elevated

levels of inflammation in the body that can lead to blood vessel changes, and

increased levels of triglycerides; as well as other common contributing

factors, such as smoking or high blood pressure, motivational interviewing

can work in each of these situations to come up with goals to make changes

as needed in the lives of many people. Whether the change is radical and

permanent, or whether the patient is able to achieve even smaller goals, MI

can be used successfully to help people live longer by reducing their risks of

heart disease.

Mental Health And MI

Severe and persistent mental illness, formerly referred to as chronic mental

illness, consists of a group of conditions that cause complex symptoms and

behaviors and that require ongoing treatment and management. People who

have persistent mental illness often have symptoms that worsen and then

abate over time, but do not necessarily go away permanently. Depending on

the severity of the diagnosis, patients with severe and persistent mental

illness may require assistance with activities of daily living, obtaining jobs,

finding housing, going to school, or making social contacts.45

Because severe and persistent mental illness is a long-term condition that

often results in periods of relapse and recovery, healthcare providers must


be aware of possible complications that can develop as part of maintaining

appropriate behavior and for living as productive and healthy of life as

possible. Ongoing case management and interventions may be necessary in

some situations, while in other situations, daily thoughts and behaviors are

under control but crisis situations may develop on an occasional basis. Some

examples of common severe and persistent mental illnesses include severe

depression, bipolar disorder, schizophrenia and delusional disorder.45

Persistent mental illness can cause difficulties with thoughts and behaviors

for those who have been diagnosed. The affected person may have difficulty

controlling his or her thoughts, which can lead to behavior that is sometimes

considered erratic, bizarre, confusing, or concerning. For many people who

struggle with mental illness, the disease takes over a considerable portion of

their lives, impacting their abilities to function on a daily basis, and putting

them at higher risk of complications that can develop as a coping

mechanism for the ongoing illness, such as substance abuse, violence, or

suicidal ideation.

According to the American Foundation for Suicide Prevention, 90 percent of

people who die by suicide had some form of mental disorder at the time of

their deaths.47 Suicide, which may also be classified as self-directed

violence, is the willful taking of one’s own life. People who commit suicide do

so for a variety of reasons, although as many as one-third do did not

communicate their suicidal intent prior to death.47

Even more concerning are the results of one study that showed

approximately 45 percent of people studied who had died by suicide had

seen a primary care provider within the past month before their deaths and

77 percent had seen a primary care provider within the past year.47 These


statistics place the role of primary care providers and other healthcare

providers in an important position to recognize situations that could

contribute to suicidal ideation and intervene as necessary.

The interventions provided through motivational interviewing can be helpful

for patients who are considering suicide. If a provider has recognized the

possibility of suicidal ideation in a patient, whether due to the presence of

mental illness or through exhibiting other concerning symptoms, the non-

judgmental and non-threatening approach used with motivational

interviewing could be a helpful intervention for the patient.

A 2012 preliminary trial published in The Journal of Clinical Psychology

worked with veterans who were hospitalized for psychiatric suicidal ideation

to determine if motivational interviewing was effective as part of treatment.

The participants completed two sessions of motivational interviewing after a

preliminary assessment, another session following treatment and

hospitalization and a final session 60 days after the intervention. The study

showed that the participants were open to motivational interviewing as part

of therapy and responded well to it as an intervention. The participants

showed significant reductions in suicidal ideation, both after treatment had

ended and at the 60-day follow-up appraisal. This study, because it is

preliminary, opens the doors for further research into use of motivational

interviewing as part of treatment and change for people who are

experiencing thoughts of suicide and who need intervention.46

Depression is another type of mental illness that can be classified according

to different terms, depending on the types of symptoms experienced, the

extent of the symptoms, and the length of time they have occurred.

Depression is one of the most common mental health disorders in the United


States. It is characterized by persistent feelings of sadness, emptiness,

hopelessness, or pessimism; a loss of interest in normal activities that used

to be pleasurable, suicidal ideation, fatigue, sleep problems, changes in

appetite, difficulties with memory and concentration; and some physical

discomfort, such as joint pain, or chronic back pain.48

Depending on patient circumstances and symptoms, the main categories of

depression are major depression and persistent depressive disorder. Major

depression occurs when symptoms considerably disrupt a person’s life and

ability to function on a daily basis, while persistent depressive disorder may

occur as underlying feelings of depression and its symptoms occur

continuously over the course of at least two years. A person with persistent

depressive disorder may have occasional exacerbation of depression

symptoms, causing a disruption of daily activities, as well as the ongoing

symptoms.48

Other types of depression can also cause significant problems for some

people but are classified slightly differently than major depression or

persistent depressive disorder. Postpartum depression is diagnosed when

depressive symptoms occur after delivering a baby. Seasonal affective

disorder results in depressive symptoms that more commonly develop

during certain times of the year, such as during the winter when there is less

environmental light; and, psychotic depression, which occurs when a person

has symptoms of depression as well as another type of mental illness, such

as delusional disorder.

Bipolar disorder is also classified as a form of depression, as the person

suffering from this condition has periods of depression followed by periods of

mania. When depression is apparent, the patient with bipolar disorder


experiences the symptoms associated with depression, including sadness,

fatigue, and hopelessness. The person may later shift to a time of mania in

which he or she experiences a very high mood and has increased energy and

tolerance for activities. The cycles back and forth between depression and

mania characterize bipolar disorder. The illness used to be called manic-

depression.48

People who suffer from depression are at higher risk of complications

because the symptoms are often overwhelming. They may be more likely to

consider suicide or other types of self-harm. People with depression may

also suffer from other health conditions that either contributes to the

depression or that have developed as a result of the depressive symptoms.48

For example, a person who suffers from chronic pain from arthritis may

develop symptoms of depression when he is unable to function in the same

way that they once did.

Treatment of depression through motivational interviewing can be

challenging because it can be difficult to actively engage patients who are

suffering from depressive symptoms to engage in a manner that leads to

change. Treatment of depression through pharmacologic intervention may

occur concurrently with motivational interviewing. In some situations,

motivational interviewing may play a role in getting a client to take his or

her medications to treat the depression. In other cases, MI can be adjunctive

to medication use.

Motivational interviewing can also be used in conjunction with other

traditional forms of treatment for depression that are related to counseling

or psychotherapy. One form of psychotherapy that is commonly used as part

of treatment for depression is cognitive-behavioral therapy (CBT). CBT


focuses on negative thoughts, views, and opinions that the client holds and

examines how those ideas affect his or her behavior. It may be used as a

type of therapy for a number of mental disorders and has been effectively

used as treatment for depression.49

Burke, in Cognitive and Behavioral Practice, looked at how well motivational

interviewing could be blended throughout the use of CBT to assess

motivation, encourage self-efficacy, and resolve ambivalence among patients

suffering from depression. Because motivational interviewing is not

necessarily a distinct therapy itself, it can be blended with other therapeutic

treatment approaches as a means of connecting with patients on a deeper

level.

Cognitive behavioral therapy and motivational interviewing have a number

of elements in common. Both types of interventions work collaboratively

with clients to set goals and both involve checking in or following up with

clients to evaluate how they are progressing toward their goals.49 Although

cognitive behavioral therapy has been beneficial in treating many patients

with depression, studies have shown that many patients who have

undergone CBT for depression have successful remission rates of depressive

symptoms at approximately 50 percent of those who undergo pharmacologic

treatment for depression.

Despite large numbers of patients undergoing CBT for depression, there are

still many of these patients who continue to suffer from depressive

symptoms, even after this therapy.49 Alternatively, there have been studies

that have shown that patients with depression who went through therapy,

focused on motivation and behavior activation, responded better to the

treatment than those who went through therapy that was focused on


cognitive interventions and used pharmacologic treatment. Because

motivational interviewing focuses on behavior activation and motivation as

studied, it is a viable intervention to add as part of traditional therapy and

may show more promising results with depressed patients than when it is

not used.49

Patients with mental illness are at higher risk of developing concurrent

disorders, most commonly substance abuse. This is often referred to as dual

diagnosis or co-morbidity and occurs when one or more illnesses occur in a

person, whether at the same time or one after the other. For instance,

people who struggle with drug addiction are almost twice as likely to suffer

from anxiety or mood disorders when compared to the general population.50

Rates of mental illness are surging among adolescent clients, which are also

often concurrent with substance abuse issues. A study by The Center for

Substance Abuse Treatment found that 62 percent of male clients and 83

percent of female clients entering treatment facilities for substance abuse

also had concurrent mental health diagnoses.13

The co-morbidity of mental illness combined with substance abuse puts MI

practitioners in the position of addressing more than one problem behavior.

When discussing options with the client and assessing levels of motivation,

providers and clients may need to determine the highest area of priority for

change or whether to tackle both issues at the same time. The change talk

that occurs as part of motivational therapy encourages individuals to share

more of their thoughts and feelings about their behavior in a method that is

open-ended, non-judgmental, and promotes self-efficacy. When the client

opens up and expands on certain subjects because of the change talk that

happens during MI, he or she may be more likely to see the discrepancies

between their current behavior and the lifestyle or behavior that they would


like to have, which also may promote change.

Another important aspect of motivational interviewing that is essential to

remember when working with clients who have co-morbidities of mental

health issues is that eliciting change in the client who is not ready for change

is counterproductive, a waste of time, and can even be damaging to the

therapeutic relationship. Thus, the provider needs to approach each

individual with his or her diagnoses as individuals and at the levels of

motivation in which they present.51 Additionally, clients who are cognitively

impaired at times because of their mental illnesses may also benefit from

the elicit-provide-elicit technique of motivational therapy. This technique

asks the client permission before offering or generating information or

advice. When the client approves, the provider then gives the information

and asks the client to respond. Using this process in a client who may be

cognitively impaired because of mental illness can help to better keep the

client on track with the conversation and what decisions are being made.

The client often must repeat back the important information to the provider

as part of this method, which further conveys his or her understanding of

the topic and keeps the client on track.51

According to the book, Intervention in Mental Health-Substance Abuse, this

method is similar to the PAPA technique. The PAPA method starts with:

Permission: the client seeking permission to give advice or information

and when allowed;

Asks: the provider then asks the client what he or she knows about

the topic they are discussing;

Provided: further information is provided to the client to clarify about

the topic or to summarize his or her understanding of the topic;


Asked: finally, the client is asked about what he or she thinks of the

topic and the idea of change.

The PAPA method may elicit more information from the client and help him

or her to stay on track with the conversation.51

Personality disorders are a prevalent form of persistent mental illness and

are classified into three groups, according to the American Academy of

Family Physicians:52

Cluster A: schizoid and paranoid personality disorders

Cluster B: borderline, histrionic, narcissistic, and antisocial

personality disorders

Cluster C: avoidant, dependent, and obsessive-compulsive

personality disorders

Cluster A personality disorders are classified according to bizarre or odd

characteristics among patients, and may involve an inability to maintain

close relationships as well as misguided thoughts and feelings related to

others. For example, some people who suffer from cluster A personality

disorder may have a lot of paranoid feelings from others and feel judged or

threatened.

Cluster B personality disorders are more related to dramatic, self-involved

behavior. They may include feelings of grandiosity, attention seeking, or lack

of impulse control. People with cluster B types of illnesses can also cause

difficulties with relationships when excessively emotional behavior or the

near-constant need for validation gets in the way of the normal give and

take of relationships.


Cluster C illness is marked by anxious or fearful behaviors, which often

impact relationships with others. Cluster C disorders may cause social

phobia, overdependence on others, perfectionism and control, or clingy

behaviors, which are often challenging to healthcare providers as well as the

families and friends of these patients.52

An important aspect of working with patients who have personality disorders

is to avoid succumbing to or otherwise being drawn into their situations. A

provider who is working with a patient who has a personality disorder must

maintain a line of professionalism and a working relationship to avoid

becoming too involved in the situation. For example, a provider working with

a patient who has histrionic personality disorder may need to have a number

of discussions that involve the patient’s emotions and feelings. The patient

may consistently talk about a number of situations that have caused her

pain or that have been difficult for her, in an effort to get the provider to feel

sorry for her and comfort her. In order to provide effective care for the

patient, the provider must be aware of the challenges presented with this

situation before even starting the therapeutic relationship, or she could

easily get too involved. It can be difficult to know how to provide comfort

and help to a patient without being drawn too far into the personal lives of

some patients with personality disorders.52

Personality disorders are treated in psychiatric practice through counseling

and intervention but many patients with these types of mental illness are

also seen for primary care in a number of other community settings,

including by general health practitioners. As noted by their title, personality

disorders cause changes in personality, which may be characterized in a

number of methods, from bizarre or confusing words and attitudes to

outright anger, aggression, and violence. Often, providers who work with


people with personality disorders are challenged with providing quality care

while simultaneously managing feelings of frustration, helplessness, or even

anger when trying to help these patients because of their personalities and

attitudes.52

Personality disorders may be prevalent in almost 15 percent of the

population in the United States. It is not uncommon for some people to have

more than one type of personality disorder or concurrent mental illness,

including substance abuse that is connected with the condition.52

Motivational interviewing has been shown to be helpful when working with

some patients who have personality disorders. While the MI techniques will

not change the disorder, it can help patients suffering from these illnesses to

make positive choices that impact themselves and their behavior as well as

their relationships with others. Motivational interviewing can be used as part

of other therapeutic interventions or even during primary care evaluations to

help clients with personality disorders with decision-making and through

setting goals that will create positive outcomes.

In the example of the patient with histrionic personality disorder, the

provider may use motivational interviewing techniques during an

appointment to discuss the clients’ need for taking care of their children. The

client may recognize that he or she has trouble taking care of their children

and getting home in time to help their spouse by being involved in the

family. Through MI techniques, the provider could work with the client to

come up with goals that will support this desire for change in one area of

their life. The client might set a goal to start picking their children up from

daycare at the same time each day, or spending 30 minutes every evening

playing games with them in a focused manner. The focus of motivational


interviewing in this situation does not cure the personality disorder or even

reduce demonstration of symptoms to a large degree, but rather helps the

client with the disorder to better manage his or her life around the condition.

One condition that providers may need to manage and that may coincide

with personality disorders is crisis intervention. A crisis occurs when a

person is overwhelmed by events and is unable to cope with the situation. If

the person cannot handle what is happening, he or she may develop

maladaptive behaviors in a further attempt to cope, such as through

substance use or violence, or the person may succumb to the situation and

exhibit behaviors that demonstrate an unwillingness or inability to function,

such as having panic attacks or psychotic events.54

Crisis intervention aims to work with clients in acute distress to help them

manage the current situation. It may then go on to help affected clients with

problem solving or assist them with changing their situations so that they

are less likely to have another crisis. Therapy for crises involves counseling

and working with family members and friends of the affected person to

provide support and to educate those involved about appropriate coping

mechanisms that are available.54 It is important, however, that some

techniques be used for a short time instead of a long therapeutic

relationship. In many situations of working with people who are in crisis or

who have personality disorders, motivational interviewing may need to be

delivered in short but intense sessions in order to prevent the client from

becoming dependent on the therapist.54

Studies have shown that motivational interviewing can be helpful when

working with clients as part of crisis intervention. Motivational interviewing

may be used concurrently with other forms of behavioral therapy and crisis


intervention methods. It shows the client that the provider is a trusted

partner in therapy and intervention and is someone who is willing to help

bring about change. It also helps the client to better visualize the

discrepancies in his or her behavior and the ultimate goals or outcomes.53

For example, if a client is seeking help for excessive drinking and has

concurrent narcissistic personality disorder, he may meet with a therapist for

crisis intervention for help with stopping the harmful behaviors. During the

course of the intervention, the practitioner may utilize motivational

interviewing to discuss the client’s current situation and assess his or her

goals and objectives.

During the interview, the client may become more aware that their current

situation of drinking to excess and taking advantage of their personal

relationships is far from where they want to be. The provider can then use

techniques of MI to promote self-efficacy in the client. The techniques leave

the decision ultimately up to the client, although the provider will act as a

guide along the way.

Some personality disorders also leave patients more prone to violence and

aggressive behavior, which could lead to a need for crisis intervention.

Motivational interviewing is also beneficial in these situations because the

core of the MI sessions is to have the client take responsibility for his or her

own behavior. If the client is willing to change or sees the need for it, the

provider works with the client to help him or her make the changes but

ultimately it is the client’s responsibility to take charge of angry or

aggressive behavior.

Anger is a normal feeling that may occur in response to feeling judged,

slighted, insulted, or ignored. It can develop based on real or perceived


situations. It is important that clients understand that anger is a normal

emotion that almost everyone feels at one time or another, however,

aggression and violence as a result of anger are not normal.

Peter Prisgrove of the Western Australian Department of Corrective Services

states that providers can work with clients on anger control issues through

such interventions as cognitive-behavioral skills training, in which the focus

is on recognizing the impact of thoughts related to behavior and working

through negative or angry thoughts to recognize them and deal with them

before they lead to problem behaviors. Behavioral skills training also

consider those situations that might lead to aggressive or negative reactions

and teaches the client how to behave and handle him- or herself when the

urge to lose control happens.55

When using motivational interviewing as part of cognitive or behavioral skills

training, the client may have mixed responses for being motivated to

change, depending on his or her background and the situation at hand.

Some clients feel true remorse and are motivated to change because they

have hurt someone they care for or they are facing legal consequences of

their actions. Alternatively, other clients may have little motivation to

change and may feel justified in their actions or continue to feel angry about

the situation. Just as with any other situation that requires motivational

interviewing, the provider must first assess the level of motivation from the

client and his or her amount of ambivalence toward change before

progressing into change talk.

Prisgrove also states that there are two main types of aggression often seen

among individuals who are in treatment for this kind of behavior:

instrumental aggression and reactive aggression. Instrumental aggression


often occurs because of a cause that the offender deemed necessary or

justified at the time, or to achieve some sort of objective. An example might

be when a client attacks their employer because they have been angry about

unfair treatment at work and believes that through force the employer can

be made to change. Alternatively, reactive aggression is the result of loss of

control over a situation in which the client acts out. An example might be

when a client comes home and becomes angry and violent toward their

spouse because he or she forgot to run an errand for them.55

In the treatment sense, different clients obviously will arrive for help and

treatment of different needs. The provider using motivational interviewing

will need to understand the background of the aggression, or whether it was

instrumental or reactive aggression, in order to better understand the

client’s level of motivation for change. Finally, when working with aggressive

clients, whether or not due to underlying personality disorders, the

probability for repeat offenses is high.55

A client may be seen for therapy or treatment of an aggressive outburst, go

through the steps of change, and then return for treatment again at a later

date. The change invoked through motivational interviewing may or may not

be permanent because the anger and aggression takes on an almost

addictive framework in which the client is drawn to repeating the same

offenses over and over. A client in this situation may need repeated sessions

or ongoing, long-term treatment and therapy in order to handle aggressive

feelings and avoid acting out. Studies have shown that the most difficult

area of treating clients with anger-control issues is the long-term

maintenance of behavior change.55

The goal, therefore, of treatment along with motivational therapy is not to


cure the client of their anger, but rather to help them change behavior so

that he or she makes better choices when frustrating situations arise. This

involves learning new skills, and the motivational interviewing process is

there to help the client acquire these skills to implement them into daily life.

If a lapse in behavior occurs, the client may have learned the skills needed

to cope with the situation before he or she completely loses control. The

provider, however, can use this lapse in behavior in a positive way to

reinforce the need for change and to elicit further growth in the client.55

Disease Management And MI

Motivational interviewing may often be implemented into specialty settings,

particularly when working with clients with specific needs, such as drug or

alcohol abuse, pregnancy, or certain medical conditions that require

specialty training for treatment. However, motivational interviewing can also

be included as part of primary practice and the interventions need not take

much more time that a routine meeting with a specialist. There are both

advantages and disadvantages to using MI in the primary care setting.

Despite motivational interviewing being used primarily in specialty

situations, it can be implemented into community and primary health care

settings with some modifications. In order to facilitate the process of MI into

these settings, changes may be necessary in terms of time available to

participate. Most encounters in the primary care or public health setting are

very brief and may only allow a few minutes for discussion of issues.

Depending on the situation, some primary care providers may have very

limited time to see their patients, discuss the plan of care, and then

document interactions before moving on to the next client because of time

issues or the larger numbers of clients waiting to be seen. Taking the time to


work with the client, as a guide toward change and implementing healthcare

goals, may be a low priority for these providers. It may seem impossible to

integrate MI into the primary care setting in these situations; however, with

some adaptations it can be done.39

When first incorporating motivational interviewing into the primary care

setting, the provider must begin by changing some assumptions or thoughts

that he or she already has about delivery of ideas.39 For example, a

physician in a primary care office may have many clients to see in one day

and most of them may need advice or instructions about how to better

manage their health. The provider may have a prepared speech about the

importance of weight loss, quitting smoking, or increasing exercise and may

be prepared to give it as part of the routine appointment. However, the

provider must first consider that instead of delivering the information in a

paternalistic method and then moving on to the next client, he or she may

need to change this idea and focus on first assessing the client’s level of

ambivalence or motivation toward change.

As with other situations that incorporate motivational interviewing, the

provider should ask open-ended questions and show empathy toward the

client in order to draw him or her out more to talk about the situation. If the

client’s issue is clear, the provider may be able to quickly assess for a level

of how much the problem is impacting the client’s life by using a brief

assessment scale or interview that have been specifically developed for this

purpose. For example, Rollnick, et al, have develop a questionnaire about

smoking cessation that addresses the importance of quitting for health

benefits and assesses the client’s level of motivation and willingness to

change. The assessment takes only about 5 to 10 minutes and gives the

provider quick answers about where the client is coming from at the start of


the interview.39

The provider may take available information that he or she has about the

client, such as data from the medical record, to use as points of discussion

with the client to collaborate toward change. Using this information also

supports the need for the appointment and increases the client’s awareness

of the need for intervention. If the client is not willing to change or is

unsure, the provider may ask the client for permission to give more

information about the topic and then follow up at a later time to see if he or

she has considered the change further. Alternatively, if the client has

decided that he or she is ready to change, the provider then gives the client

a menu of options to consider that could successfully help to implement the

change. The provider may also provide contact information for referrals if

necessary.39

Motivational interviewing has also been used successfully as an adjunct to

other methods of working with clients to promote change. There are a

number of different resources in the community that are available to help

people see the need for change and to implement certain interventions into

their way of life, whether through therapy, hypnosis, meditation, or other

methods. In some practices, motivational interviewing is incorporated into

techniques to improve outcomes for patients already seeking care through

other alternative measures.

Mindfulness is a concept that involves choosing to live in the present

moment and accepting it, whatever is happening. Mindfulness originally

started as a Buddhist practice but it is being incorporated into many different

medical and psychological therapies today after researchers have discovered

some of its many health benefits. Mindfulness has been shown to have a


positive impact on mental health, including depression, substance abuse,

anxiety, and obsessive-compulsive disorder. It can also benefit physical

health and has been shown to lower blood pressure, relieve stress, and

reduce chronic pain.35

Mindfulness involves a form of meditation in which the person practicing it

uses techniques to focus on what is happening within him- or herself in the

present moment. It may involve focusing on body sensations, emotions, or

sensory input that is happening, recognizing them for what they are, and

accepting them without judgment.35 People who use mindfulness regularly

can learn the techniques and use them on their own or they may

continuously practice them within groups or with others.

Mindfulness may also be incorporated into motivational interviewing and

pairing these two methods together has shown promise for healing in some

areas. The Center for Mindfulness in Corrections uses mindfulness to

promote research, evidence-based practices, improved environments, and

staff wellbeing in the field of corrections. The center has used mindfulness

techniques among police officers and prison guards to help them manage

the stress of their jobs and to better handle the strain and difficulties

sometimes associated with working in corrections. The mindfulness

techniques have helped workers to relieve some of the stress of their daily

jobs and to cultivate a more positive response to certain situations instead of

acting out in anger or reacting in a stressful manner.36

The Center for Mindfulness in Corrections also uses motivational interviewing

as part of the mindfulness techniques when working with officers and

corrections agents. By pairing motivational interviewing with mindful

behavior and utilizing mindful meditation when considering choices, the


center has seen changes in their clients. In general, the clients have been

able to more readily address concerns in their lives, focus on future-oriented

situations that may require change so that they can readily accept them

rather than react poorly when they occur, and feel affirmed at the

completion of positive goals. Motivational interviewing is a routine part of

some of the techniques used at the Mindfulness Center because the

organization recognizes the benefits of connecting the two methods.36

Cognitive-behavioral therapy (CBT) is another treatment method that can be

successfully integrated with motivational interviewing techniques. According

to the National Alliance on Mental Illness (NAMI), CBT is “a form of

treatment that focuses on examining the relationships between thoughts,

feelings, and behaviors”.37 The process recognizes that a person’s thoughts

impact his or her behavior and then works to disrupt the potential cycle that

can develop when someone has consistently negative thoughts that

contribute to negative behavior. For example, if a person feels that he or she

is not qualified for a certain job, they may avoid applying or trying to change

from their current job. Instead, by not trying, the client remains in their job

that is not liked and does not give themself the opportunity for a better

situation.

As the client continues in their job, they may feel worse about themself,

further thinking that they are not capable, undeserving, or will never do

better. The negative thoughts and emotions impact the client’s behavior into

a continuous cycle of despair. Cognitive behavioral therapy seeks to break

that cycle by intervening to help a client to understand how their thoughts

impact behavior.

The process of CBT may be similar to motivational interviewing, in that the


client seeking help and the therapist work together to formulate goals and to

come up with solutions to current problems. The process is active and

involves both client and therapist involvement.37

Using this approach, MI can be incorporated into CBT techniques to promote

change and address motivation in the client. If the client is ambivalent about

change and has negative thoughts about themself and an ability to change

for the better, it may come out through their behavior. However, by using

CBT and MI together, the provider may be able to guide the client toward

change, to redirect their thoughts and feelings for the better.

Barrowclough, et al., published a study that looked at the success of

integrating cognitive behavioral therapy with motivational interviewing to

improve success of change among clients with mental illness and underlying

substance abuse disorders. The randomized, controlled trial integrated MI

with CBT over the course of one year, using two phases. Phase one of the

study focused on recognizing levels of motivation among the participants

and potential ambivalence regarding substance abuse.

Phase two was the action phase that then implemented cognitive-behavior

approaches to help facilitate a change in behaviors among those involved.

The study found that integrating MI with CBT among this group improved

substance abuse patterns by reducing the overall amount of substance use

among participants for at least a year following the study, including a

reduction in alcohol consumption and drug abuse.38


Summary

Motivational interviewing can be effective in a number of situations in which

clients require help for making changes in their lives. The concepts of

motivational interviewing can be incorporated into routine physical exams or

through specialist interventions, and they may be used as part of

conversations or therapy sessions within the acute healthcare setting or in

primary health or community care. Regardless of the exact situation in which

motivational interviewing is used, its techniques and practices can bring

hope and help to many people by teaching them how to make decisions and

providing a coaching method to guide them toward change.

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1. Which best describes what occurs during the contemplation

phase of the change process? a. Family members and friends may recognize that the client has a

problem but the client is often unaware b. The client recognizes the need for change but he or she may be

so ambivalent that no change occurs at all c. The client may still be ambivalent about what to do, but he is

planning to try for a change d. The client does a lot of activity that demonstrates working

toward the change

2. The “R” in the DARN CAT acronym stands for:

a. realistic b. random

c. reason

d. recognize

3. A client is talking with a nurse and telling her about how

difficult it was to accept the death of his father last year. While the client is talking, the nurse leans toward him, makes eye

contact, and nods her head periodically. These activities are best described as:

a. utilizing silence b. clarifying

c. active listening d. mirroring

4. Which of the following is a consideration that must be

recognized when working through motivational interviewing with an adolescent client?

a. The provider must avoid taking on the role of a parent toward the client

b. The client typically only responds in group situations c. The provider must alter most techniques used in motivational

interviewing to fit the developmental needs of the client d. The client cannot be expected to make much progress until he or

she has completed puberty


5. According to Burke, et al., there are four states that contribute

to self-efficacy in a person: mastery experience, vicarious experience, physical and emotional states, and:

a. personal success b. high self-esteem

c. generation of power d. social persuasion

6. A nurse has contacted a pregnant client to talk with her about the services available to her from the healthcare center. After

the nurse asks the client if there are any services she would be interested in receiving, the client states she does not know.

The most appropriate response of the nurse is: a. “Can I give you some information about educational offerings

available?”

b. “Are you feeling ambivalent about making a decision?” c. “There is a lot of information to digest. We do not need to

discuss this anymore.” d. “I think that you should consider one of our parenting courses.”

7. Which best describes an example of the self-efficacy step of the FRAMES method when used with a pregnant client?

a. The client receives a list of options to consider for changing her behavior

b. The provider helps the client to become more confident in herself by taking charge of her health

c. The client is made aware that she is responsible for herself and the health of her baby

d. The provider advises the client about what she can do to make

changes in her life

8. A nurse is using the techniques of motivational interviewing to

work with a client who is trying to quit smoking. The nurse starts the conversation by introducing herself and explaining

her job title and role at the clinic. Which best describes the purpose of this introduction?

a. To provide an empathic approach to the client’s care b. To give the client a menu of options for making decisions

c. To establish rapport and begin to build trust with the client d. To promote confidence in the client for making decisions


9. Which of the following describes a difference between

substance abuse and addiction? a. Substance addiction is disruptive to daily living while abuse

causes physical dependence on the substance b. Substance abuse causes symptoms of withdrawal when trying to

quit while addiction does not c. Substance abuse is disruptive to daily living while addiction

causes physical dependence on the substance d. Substance abuse and addiction are used interchangeably; they

have the same definition

10. After going through an oral glucose tolerance test, a client has

a blood glucose level of 160 mg/dL. This result would be defined as:

a. impaired glucose tolerance

b. type 2 diabetes c. impaired fasting glucose

d. altered glycogen synthesis

11. A patient has developed cardiomegaly as a form of heart

disease. This is best described as: a. decreased circulation in the coronary arteries due to plaque

development b. areas of tissue ischemia that cause pain and decreased cardiac

function c. pain in the legs with exercise and increased activity

d. enlargement of the heart muscle that has developed because of tissue damage

12. While working with a client who has heart disease, the

healthcare provider is reviewing some medical information from the client’s chart. Which of the following BMI results

indicates that the client is classified as overweight? a. 23.9 b. 24.9 c. 26.9 d. 31.9


13. A nurse is discussing the benefits of exercise with a client who

has been diagnosed with coronary artery disease. The client states, “I know I need to exercise more to improve my health,

I just don’t know how to get started.” What is the most appropriate response of the nurse?

a. “For your condition, you should start with walking twice a week.” b. “What do you think you should do to exercise?”

c. “It is important that you think about the types of food you eat as well.”

d. “Can we talk about some of the different types of exercise that you might enjoy?”

14. People who commit suicide do so for a variety of reasons, although as many as _____ who do did not communicate their

suicidal intent prior to death.

a. 15 percent b. 33 percent c. 50 percent d. 90 percent

15. An important aspect of motivational interviewing that is essential to remember when working with clients who have co-

morbidities of mental health issues is: a. giving unsolicited advice is usually necessary

b. self-efficacy is an ultimate goal but is rarely achieved c. empathy is offered on a case-by-case basis

d. eliciting change in someone who is not ready will be counterproductive

16. The first P of the PAPA technique, as stated by the book,

Intervention in Mental Health-Substance Abuse stands for: a. provider

b. provoke c. permission

d. prepare


17. Which thoughts or feelings are most commonly associated with

cluster B personality disorders? a. paranoia, feeling threatened

b. anxious, fearful, helpless c. anger, hatred, feeling criticized

d. dramatic, emotional, theatrical

18. Which of the following is a consideration when using

motivational interviewing among patients with personality disorders?

a. Motivational interviewing does not cure the underlying disorder but instead helps the client to make better behavioral choices

b. Motivational interviewing is more effective when used with personality disorders and concurrent substance abuse issues

c. Motivational interviewing resolves anger issues but cannot treat

other clusters of personality disorders d. Motivational interviewing is usually ineffective in personality

disorders and should not be attempted

19. Which of the following must be considered when using

motivational interviewing to work with an angry and aggressive client?

a. The provider should always have a form of protection available during each session

b. Client sessions must be broken down into intervals of 20 minutes or less in order to be effective

c. The probability for repeat offending in this population is high d. Despite large numbers of patients undergoing MI for aggression,

there are still many who continue to suffer

20. Which of the following is a true statement about mindfulness? a. Mindfulness is a state of hypnosis in which the person is given

suggestions for changing behavior b. Mindfulness is more effective when used in group settings than

when used alone c. Mindfulness involves the belief in and connection with a higher

power for facilitating change d. Mindfulness involves a form of meditation in which the person

focuses on what is happening within herself in the present moment


Correct Answers:

1. B

2. C 3. C

4. A 5. D

6. A 7. B

8. C 9. C

10. A 11. D

12. C 13. D

14. B

15. D 16. C

17. D 18. A

19. C 20. D

References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. Dart, M. (2011). Motivational interviewing in nursing practice:

Empowering the patient. Sudbury, MA: Jones and Bartlett Publishers

2. Community Care of North Carolina. (2013). CCNC Motivational

interviewing resource guide. Retrieved from

https://www.communitycarenc.org/population-

management/behavioral-health-page/motivational-interviewing/

https://www.communitycarenc.org/population-management/behavioral-health-page/motivational-interviewing/

https://www.communitycarenc.org/population-management/behavioral-health-page/motivational-interviewing/


3. O’Brien, P., Kennedy, W. Z., Ballard, K. A. (2012). Psychiatric mental

health nursing: An introduction to theory and practice (2nd ed.).

Burlington, MA: Jones & Bartlett Learning

4. Wagner, C., Conners, W. (2003, Jan.). Interaction techniques.

Retrieved from

http://motivationalinterview.net/clinical/interaction.html

5. Kamya, H. (2012). Motivational interviewing and field instruction: The

FRAMES model. The Field Educator (2.1). Retrieved from

http://fieldeducator.simmons.edu/article/motivational-interviewing-

and-field-instruction-the-frames-model/

6. American Society on Aging, American Society of Consultant

Pharmacists Foundation. (2006). Facilitating behavior change.

Retrieved from

http://www.adultmeducation.com/FacilitatingBehaviorChange_2.html

7. Siegle, D. (2000). An introduction to self-efficacy. Retrieved from

http://www.gifted.uconn.edu/siegle/selfefficacy/section1.html

8. Naar-King, S., Suarez, M. (2011). Motivational interviewing with

adolescents and young adults. New York, NY: The Guildord Press

9. Slack, K. (2010). Motivational interviewing: A potential framework for

co-occurring disorders treatment for adolescents. Sacramento, CA: On

Track Resources

10. The RAND Corporation. (2014). Group MI for teens. Retrieved from

http://groupmiforteens.org/

11. McNamara, E. (Ed.). Motivational interviewing: Theory, practice and

applications with children and young people. Merseyside, UK: Positive

Behaviour Management (PBM)

12. Erickson, S. J., Gerstle, M., Feldstein, S, W. (2005, Dec.). Brief

interventions and motivational interviewing with children, adolescents,

and their parents in pediatric health care settings. Archives of

http://motivationalinterview.net/clinical/interaction.html

http://fieldeducator.simmons.edu/article/motivational-interviewing-and-field-instruction-the-frames-model/

http://fieldeducator.simmons.edu/article/motivational-interviewing-and-field-instruction-the-frames-model/

http://www.adultmeducation.com/FacilitatingBehaviorChange_2.html

http://www.gifted.uconn.edu/siegle/selfefficacy/section1.html

http://groupmiforteens.org/


Pediatrics & Adolescent Medicine 159(12), 1173-1180. Retrieved from

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13. Crowther, T. R. (2008). Motivational interviewing and the older

population in psychiatry. Psychiatric Bulletin 32: 23-25. Retrieved from

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14. Chi-Ying Chung, R., Bemak, F. (2002). The relationship of culture and

empathy in cross-cultural counseling. Journal of Counseling and

Development 80, 154-159.

15. Burke, N. J., Bird, J. A., Pasick, R. J. (2009, Oct.). Social and cultural

meanings of self-efficacy. Health Education & Behavior 36(5 Suppl),

111S-128S. Retrieved from

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management patient engagement scripting using motivational

interviewing. [Program Manual]. Retrieved from

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17. ACOG Committee Opinion No.423. (2009, Jan.). Motivational

interviewing: A tool for behavior change. Obstetrics & Gynecology 113:

243-246. Retrieved from

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/Committee_on_Health_Care_for_Underserved_Women/Motivational_I

nterviewing_A_Tool_for_Behavior_Change

18. University of Minnesota. (2014). Stages of readiness for change.

Retrieved from

http://www.takingcharge.csh.umn.edu/activities/stages-readiness-

change

19. American College of Obstetricians and Gynecologists (ACOG). (n.d.).

Drinking and reproductive health: A fetal alcohol spectrum disorders

prevention tool kit. Retrieved from

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http://pb.rcpsych.org/content/32/1/23


http://whb.ncpublichealth.com/provPart/

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http://www.takingcharge.csh.umn.edu/activities/stages-readiness-change

http://www.takingcharge.csh.umn.edu/activities/stages-readiness-change


http://www.acog.org/About_ACOG/ACOG_Departments/Tobacco__Alco

hol__and_Substance_Abuse/Drinking_and_Reproductive_Health_Tool_

Kit_for_Clinicians

20. Lai, D. T. C., Cahill, K., Qin, Y., Tang, J. L. (2010). Motivational

interviewing for smoking cessation (Review). Cochrane Database of

Systematic Reviews. doi: 10.1002/14651858.CD006936.pub2

21. American Cancer Society. (2014, Feb.). Why is it so hard to quit

smoking? Retrieved from

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moking/guide-to-quitting-smoking-why-so-hard-to-quit

22. Martino, S., Ondersma, S., Howell, H., Yonkers, K. (n.d.). A nurse-

delivered brief motivational intervention for women who screen positive

for tobacco, alcohol, or drug use [Intervention Manual]. Retrieved from

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N_Manual.pdf

23. Carino, J. L., Coke, L., Gulanick, M. (2007). Using motivational

interviewing to reduce diabetes risk. Retrieved from

http://www.medscape.com/viewarticle/496829

24. International Diabetes Federation. (2014). About diabetes. Retrieved

from http://www.idf.org/about-diabetes

25. Case Western Reserve University. (2011). Motivational interviewing.

Retrieved from http://www.centerforebp.case.edu/practices/mi

26. Motivational Interviewing Network of Trainers (MINT). (2013). What is

motivational interviewing? Retrieved from

http://www.motivationalinterviewing.org/

27. Dellasega, C., Añel-Tiangco, R. M., Gabbay, R. A. (2012, Jan). How

patients with type 2 diabetes mellitus respond to motivational

interviewing. Diabetes Research and Clinical Practice 95(1), 37-41.

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http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-why-so-hard-to-quit

http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-why-so-hard-to-quit

http://www.mirecc.va.gov/visn1/docs/products/Project_START_MI-N_Manual.pdf

http://www.mirecc.va.gov/visn1/docs/products/Project_START_MI-N_Manual.pdf

http://www.medscape.com/viewarticle/496829

http://www.idf.org/about-diabetes

http://www.centerforebp.case.edu/practices/mi

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Retrieved from


28. Dellasega, C., Gabbay, R., Durdock, K., Martinez-King, N. (2010).

Motivational interviewing to change type 2 diabetes self-care

behaviours. Journal of Diabetes Nursing 14(3), 112-118.

29. Lundahl, B., Burke, B. L. (2009). The effectiveness and applicability of

motivational interviewing: A practice-friendly review of four meta-

analyses. Journal of Clinical Psychology 65(11), 1232-1245.

30. Harvard Medical School. (n.d.). Benefits of mindfulness. Retrieved from

http://www.helpguide.org/harvard/mindfulness.htm

31. Center for Mindfulness in Corrections. (n.d.). Motivational interviewing.

Retrieved from http://mindfulcorrections.org/

32. National Alliance on Mental Illness (NAMI). (2012, Jul.). Cognitive

behavioral therapy (CBT). Retrieved from

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Mental_Illness/About_Treatments_and_Supports/Cognitive_Behavioral

_Therapy1.htm

33. Barrowclough, C., et al. (2010). Integrated motivational interviewing

and cognitive behavioural therapy for people with psychosis and

comorbid substance misuse: a randomised controlled trial. BMJ 341.

doi: 10.1136/bmj.c632

34. Emmons, K. M., Rollnick, S. (2001). Motivational interviewing in health

care settings: Opportunities and limitations. American Journal of

Preventive Medicine 20(1), 68-74.

35. Franklin, B. A., Brinks, J., Friedman, H. (2013). Foundational factors for

cardiovascular disease: Behavior change as a first-line preventive

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36. National Heart, Lung, and Blood Institute. (2011, Dec.). How does

smoking affect the heart and blood vessels? Retrieved from

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37. Agency for Healthcare Research and Quality. (2012, Dec.). Five major

steps to intervention (The “5 A’s”). Retrieved from

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recommendations/tobacco/5steps.html

38. Hardcastle, S. J., Taylor, A. H., Bailey, M. P., Harley, R. A., Hagger, M.

S. (2013). Effectiveness of a motivational interviewing intervention on

weight loss, physical activity and cardiovascular disease risk factors: A

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motivational interviewing to address suicidal ideation with hospitalized

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