Review and special articleMotivational interviewing in health care settings: Opportunities and limitations
Introduction
M uch of the research literature on chronic disease prevention has focused on behavioral outcomes (e.g., smoking cessation, weight loss, increase in physical activity). Because such health behaviors are predictors of decreased risk, behavior change is an important outcome in prevention efforts. A number of theories of health-behavior change provide important perspectives on the factors that promote behavior change and maintenance, including Social Learning Theory,1 the Health Belief Model,2 the Theory of Reasoned Action,3 the Transtheoretical Model,4, 5 and the Precaution Adoption Model.6 All of these theories recognize the importance of motivation to change behavior, and highlight the importance of strengthening the factors or processes that prompt behavior change. Although different theoretical perspectives posit different precursors to change, self-efficacy, social support, decisional processes, and perceived relevance or vulnerability have been identified as important.
Behavior change research in the 1970s and 1980s focused on the application of these theoretical models for the development of the skills needed to change behavior. In the past decade, the importance of motivation for health-behavior change, in addition to skills, has been recognized, and efforts to enhance motivation have received increased research attention. An important contribution to the literature about health-related behavior change has been made by Miller et al.7, 8, 9, 10, 11 Miller’s programmatic research has investigated the impact of therapist behaviors on clients’ motivation for and participation in behavior change. Of particular note has been the development of motivational interviewing (MI), a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.9, 11 Because of its focus on preparing people for behavior change, MI has an important role in health behavior interventions (Dunn C, DeRoo L, Rivara F, University of Washington, Seattle, unpublished observations, 2000).
Given the challenge of achieving and sustaining health-behavior change, it is not surprising that there has been considerable interest in the application of MI to a wide variety of behaviors (e.g., smoking, medication compliance, diabetes management, AIDS risk reduction), and to health care settings. The purpose of this paper is to: (1) provide a brief background on MI; and (2) identify and discuss the key issues likely to arise when adapting MI for use in health care/public health settings. This article is intended as an overview and conceptual discussion that provides one perspective to be considered in the use of MI in health care settings.
Section snippets
MI: a brief overview
MI was developed by specialists in the addictions field who were focusing on problem drinking. In traditional alcoholism treatment, it was common for counselors and clients to fall into disagreement over the nature and extent of the client’s problems, as well as their treatment. A persuasive statement from the counselor such as, “Can’t you see that your drinking is seriously damaging your marriage?”, was typically met by a response like, “Yes, but it’s not my drinking that’s the problem, it’s
Adaptation of MI to health care settings
Health care practitioners have begun to show an interest in MI, in part because of successes reported with this technique in specialist settings (Dunn C, DeRoo L, Rivara F, University of Washington, unpublished observations, 2000). This interest may also stem from the significant challenges posed by behavior change efforts in health care settings, such as neighborhood health clinics, where resources are minimal and client motivation for health-behavior change may be low. Although MI has great
Challenges in the design and evaluation of MI for community health care settings
Experience of conducting trials with MI in public health settings has given rise to new challenges for those wishing to evaluate such methods. On the one hand, MI is an individually tailored, client-centered method. By tailoring an intervention to the individual, the effectiveness may be enhanced, compared to intervention approaches that target specific characteristics of a population, but do not tailor the intervention to the specific individual.40 On the other hand, researchers are required
Conclusions
The aim of this paper has been to discuss the key issues that will arise in the translation of MI from specialist method to public health application. Common to all of these applications is the fact that MI is based on the often delicate task of encouraging change within a constructive working relationship.
There will clearly be variations in the adaptation of MI for health care settings. While such developments are generally healthy, refinement and adaptation can lead to confusion.
Acknowledgements
Mary Eileen Twomley provided invaluable assistance in the preparation of this manuscript. Robin Mermelstein provided conceptual input to the development of this paper. This research was supported in part by grants from the National Cancer Institute (CA73242-04, CCSS), the National Heart Lung and Blood Institute (KISS), NYNEX, Liberty Mutual Insurance Company, Aetna, and the Boston Company.
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