Supplement Article  |   April 2010
Adding MI principles to your communication skills
Article Information
Evidence-Based Medicine / Preventive Medicine / Professional Issues / Psychiatry
Supplement Article   |   April 2010
Adding MI principles to your communication skills
The Journal of the American Osteopathic Association, April 2010, Vol. 110, eS15-eS16. doi:
The Journal of the American Osteopathic Association, April 2010, Vol. 110, eS15-eS16. doi:
This issue's DO Corner features an interview with Susan Butterworth, PhD, about the application of Motivational Interviewing (MI), a behavior change approach found to be effective in the addictions realm to the primary care setting. She discusses how the underlying principles of MI can be adapted for brief interventions and the importance of embracing this skill as a core competency in medicine today. 
Dr. Butterworth is an associate professor at Oregon Health & Science University, Portland, where she was awarded a grant from the National Institutes of Health to implement a clinical trial studying the impact of health management interventions and a follow-up grant to further evaluate the outcomes. She founded Health Management Services, which won multiple awards under her leadership for its evidence-based health-coaching practice, which consistently demonstrated improved health outcomes. 
Dr. Butterworth has published numerous articles on the theory and outcomes of Motivational Interviewing-based health coaching and currently provides consulting and training activities for her practice, Q-Consult. Dr. Butterworth is a member of the Motivational Interviewing Network of Trainers, which includes more than 1,000 trainers all over the world who share their experiences and successful training activities across a listserv and at annual forums. 
Tell us about Motivational Interviewing and why you saw the application to the primary care setting?  
Dr. Butterworth: Motivational Interviewing (or MI) was developed by William R. Miller, PhD, and Stephen Rollnick, PhD, in the 1980s as a counseling approach for people with addictions. Thirty years later, there have been over 300 clinical trials demonstrating its effectiveness in facilitating behavior change in clients and engendering an effective clinical outcome. And not just in addictions—practice and outcomes have been used across diverse populations around the world with participants in smoking cessation, HIV prevention, corrections, public health, wellness, disease management and, more recently, primary care. 
Since the majority of health care today deals with the treatment and management of chronic care conditions, it makes sense that an evidence-based and standardized health-coaching approach is needed to address the lifestyle management and treatment adherence issues that dominate clinic practice. 
Aren't there a lot of people out there today in public health, disease management and wellness who claim that they are using a health-coaching model? What makes an approach like MI better than others?  
Dr. Butterworth: Yes, you are right. Health coaching is a popular approach that is being widely used today—as well as in the medical home model—but, after a thorough review of the health-coaching literature, I found that MI is the only health-coaching approach to be fully described and consistently demonstrated as causally and independently associated with positive behavioral outcomes. 
Question: What exactly is MI and how does it work?  
Dr. Butterworth: Miller and Rollnick describe MI as a directive (goal-oriented), client-centered style for helping people to explore and resolve ambivalence about behavior change. It works by activating a patient's own motivation for change and adherence to treatment. After working in the health care field for over 25 years and having used this approach for the last 10, I can say that this approach is very different from the traditional health education approach typically used in the primary care setting. 
How so?  
Dr. Butterworth: Without proper guidance, a physician is most likely to assume a directive approach, which is used very effectively in the acute medical setting. Unfortunately, when this same approach is used in situations where the discussion is about lifestyle change or treatment adherence, the physician comes across in a way that appears authoritarian, confrontational, forceful, or guilt inducing. 
There is some fascinating evidence now indicating that this directive approach results in defensiveness in the patient—a resistance to being told what to do and/or defending the reasons why change is difficult. As you can imagine, this causes well-intending physicians to push back and argue why their advice is sound. This type of defensiveness and resistance from the patient has been called `counter-change talk' and is correlated with negative clinical outcome. It's not the physician's intent at all, but he or she is actually doing harm when this happens. 
Well, what differs when they use MI? Dr. Butterworth: If the physician can put on a `guiding' hat during these discussions about behavior change or treatment recommendations, the whole nature of the interaction shifts. The physician explores and listens to the patient's motivations and barriers, and selectively uses different communication skills to assist the patient in working through their ambivalence, build their confidence for the change, and evoke change talk (desire, ability, reasons and need to change). All of this helps to strengthen the patient's commitment to the treatment plan or lifestyle change and leads to a positive correlation in positive clinical outcome. 
The four principles of MI are: (1) Resist the righting reflex (that's the pushing or arguing I talked about above); (2) Understand and explore the patient's motivations for change; (3) Listen with empathy (or showing that you understand the situation and challenges through the patient's eyes); and (4) Empower the patient (by evoking the change talk, building self-efficacy, and leveraging their activation for self-management). 
That sounds great but I can hear the physician now saying “First of all, I'm not a counselor,” and secondly “I don't have time for this in my practice.”  
Dr. Butterworth: You've raised two excellent points. This would not be a very effective skill set for physicians to learn if it wasn't practical in their setting and if they had to be a psychologist in order to use it. The good news is that these techniques can be applied in very brief interactions and can actually save time by getting to the core issues or barriers more quickly. Plus, in the long run, if their patients were making better choices and managing their chronic conditions better, physicians would have more time to devote to the acute medical issues. Finally, we have trained lay people and health care providers all over the world with this approach and they have been very successful using it without being a counselor or psychologist. 
How can physicians learn MI?  
Dr. Butterworth: If there is one downside to this approach, it is that while the principles are pretty straightforward, it's not easy to learn. Miller compares it to learning how to play a complex sport (like golf) or a musical instrument (like the piano). You can listen to it or watch it and gain an appreciation for it; however the only way to build the skill set is to learn it from an expert and practice it. Over time, it becomes easier and easier, an almost reflective part of your practice. Generally, we recommend that a physician attend a workshop, but the practice and subsequent feedback is how they will actually get better. 
By feedback, you mean...?  
Dr. Butterworth: It's kind of like piano or golf lessons. You have an initial period of being exposed to the basics. Then, on a regular basis, you work with your instructor to get feedback on how you are doing. This can happen by listening to a recording with a colleague or a friend in a mock health-coaching session or by doing a role play. It's also helpful for medical staff to incorporate discussions during their case reviews about how this patient-centered approach was used or not used effectively. 
Lastly, I don't think that physicians and other clinical staff necessarily have to be experts in MI. In fact, that would be impractical. Instead, I advocate that it would be great to get all clinical staff up to a beginning level of competency—a `do no harm' level—and refer their most challenging patients to an MI expert in their clinic. This model is gaining a lot of momentum in the medical care home model. 
Any final thoughts?  
Dr. Butterworth: With the ever-increasing emphasis on adherence to practice guidelines, an evidence-based approach to positively affect chronic care management and treatment adherence will be required. This means that physicians need to: 
  • be knowledgeable about the principles of behavior change science
  • adopt the attitudes and beliefs that support a role as a change agent in their patients' self-management
  • master a new skill set that includes a patient-centered approach or MI
  • learn how to be a quarterback in the clinic to coordinate a team approach that successfully addresses lifestyle change and treatment adherence.
Lastly, I can tell you that a side-benefit of learning this approach is that physicians have better job satisfaction and less frustration. They are working more with patients who are more motivated and have better success in making those difficult choices.