Motivational Interviewing for Long-Term Conditions

Introduction

Motivational interviewing is a style of communication designed to strengthen motivation towards change, and is widely used by professionals working in behaviour change fields, including medical doctors, nurses, dietitians and nutritionists, exercise and fitness coaches, criminal justice professionals, and business leaders and managers. Classified as a person-centred style of communicating with people, the technique as been particularly effective in helping individuals overcome issues that cause them to be stuck in an endless cycle of destructive and habitual behaviour (e.g., overeating, sedentary lifestyle, poor food choices, drug, and alcohol abuse).

Motivation, Behaviour and Health

While human behaviour is somewhat selective and people do have the freedom (and responsibility) to choose their own actions, the reality is much more complex and nuanced – especially where health habits are concerned. Habits, which we all know to be those behaviours we instinctively perform without much conscious control, are influenced by a complex interaction of personal, social, economic, and environmental factors, which significantly and often individually, determine the extent to which individuals perceive that they have control over their behaviour. Many people consciously and subconsciously engage in daily behaviours (e.g., smoking vaping, consuming fast food), but report that they have little control over their urges and compulsions to perform these.

In the context of weight management, society and interventions oversimplify the problem, often choosing to focus only on the individual and their choices around food, exercise, and lifestyle. In this regard, they present the obesity crisis that much of the developed world is facing as a simple energy balance crisis, where too many people are simply ‘choosing’ to over eat and/or under exercise, and in doing so determine their own fate. There is of course some truth to this, but the reality is much more complex because people’s ‘choices’ are influenced and affected by a number of indicators which affect their socioeconomic status (e.g., education, employment status, including income, food insecurity, and housing insecurity).

To provide a simple analogy to support the previous paragraph, consider an individual who grows up in relatively deprived area where there is limited access to money within the household, schools are overwhelmed with behaviour management issues suppressing average educational attainment. Locally, there are more fast-food outlets selling highly processed and hyper-palatable foods cheaper than the cost of fresh produce at the nearest supermarket. Just how much individual choice do people in these circumstances have? Sadly, this is the reality for many people – they simply feel overwhelmed and out of control!

Motivational interviewing won’t fix the socioeconomic challenges that many people face today, but it can help them to muster up the courage, confidence (self-efficacy) and motivation to seek help. In these circumstances, motivational interviewing can be used as a both an intervention, but also a prevention strategy for many of those people with, or facing chronic diseases and long-term health conditions).

Research with MI and Long-Term Conditions

As previously stated, MI has evolved from, and is widely used in, the field of behaviour change and addiction, especially with alcohol, drugs, smoking, and eating (Miller and Tonigan 1996; Burke et al 2003; Saunders et al 1995). While the nature of addiction-based therapy is clinical, there is a substantial body of evidence to suggest that MI may also be effective in non-clinical settings. In fact, in recent years, MI has been widely adopted by health, fitness and wellbeing practitioners, especially those working in the field of managing chronic diseases (Bundy 2004), like exercise referral schemes for example.

A small sample of this research is listed below:

• A review of 26 separate MI studies concluded that research supported the efficacy of MI for hypertension and diabetes, although precise links between processes and successful outcomes were not established (Burke et al., 2002).
• A study of hypertensive patients randomised into one of three groups, found that the MI group produced significantly lower weight and blood pressure measures over an 18-week programme of physical activity and dietary change (Woollard et al., 1995).
• A study of 22 obese women with type 2 diabetes found enhancing a standard behavioural treatment programme with MI significantly improved adherence to the programme (Smith et al., 1997).
• Older fibromyalgia sufferers were found to have more positive outcomes when MI was used to encourage increased levels of physical activity (Stewart et al., 2001).
• An investigation of 30 of the best controlled clinical trials concluded that MI required significantly less time and professional interaction to produce behaviour change than comparable strategies (Miller & Rollnick, 2002).

Exercise referral-style programmes represent an important intervention for supporting clients who have long-term health conditions. MI is an essential style of communication that exercise referral professionals can use with their clients to achieve better health outcomes. To provide further support to this statement, in a qualitative study conducted by Moore et al., (2012), it was found that providing introductory MI training to exercise referral professionals was beneficial when they were working with clients that had complex long-term health conditions. MI was also found to elicit more change talk (i.e. the clients’ motivation for change) and thus supported the creation of more client-centred exercise programmes.

Quality of MI Between Practitioners

A common observation, and indeed criticism of MI is practitioner variability, which significantly affects the quality of the intervention and any subsequent results that it yields. To some extent, every MI interaction a practitioner has with a client will be different from the next, depending on the individual in front of them, their circumstances, experiences, emotions, and thoughts around change. This is to be expected…

Practitioners will also be different in style and how they deliver MI, including how they approach conversations around change. This to some extent will be influenced by the motivational interviewing training that they have received and the qualifications that they hold. Practitioners’ personal experiences will also vary, which will again influence how they use the technique. In fact, in one study exploring the variability and integrity of MI three years following the practitioner’s initial training, it was found that in many cases, the variability within practitioners exceeded the variability between different practitioners (Dunn et al., 2016).

MI does not have a rigid structure or framework that practitioners follow, there are just guiding principles and values which inform how the practice is implemented. This represents another complexity when trying to standardise, or indeed measure the quality of MI interventions. Standardisation is clearly a challenge, but one has to question whether creating a universal approach to MI would yield better results, or whether it’s potency and effectiveness lie in it’s ability to be tailored to individuals and circumstances?

MI is a relatively simple concept and when the principles and values of Mi are presented on paper, it feels somewhat obvious and intuitive to those working in behaviour change roles. However, becoming a competent MI practitioner is far from easy – it’s certainly not a skill that can be developed overnight. Additionally, to become a proficient, practitioners need access to a good quality foundational motivational interviewing training course, which is supported with ongoing observations from a suitably experienced MI practitioner/trainer, and extensive reflective practice.

Depending on the circumstances, MI is delivered in a variety of formats, including in-person, telephone, virtual meetings, and also group situations (usually in-person or virtually). While quality may differ between delivery methods, as it will between practitioners, research supports the stance that MI can be effective regardless of how it is delivered (Nuss, Moore, Nelson and Li, 2021)

Summary

Motivational interviewing is person-centred style of communication that strengthens motivation to change behaviour. It has consistently demonstrated its effectiveness in supporting habitual behaviour change programmes for individuals with long-term health conditions, and addiction, whether alcohol, drugs, food, or smoking. MI is a universal tool which can be used and adapted to meet the specific needs of the practitioners using it, and clients receiving it. MI can be used in clinical settings, or in more informal situations, like exercise counselling or nutrition coaching for example. In the active leisure sector, MI is widely used in health and wellbeing coaching, and also by exercise referral instructors working with clients that have long-term medical conditions.

To find out more about our motivational interviewing courses, get in touch with our Careers Team on 0800 612 4067.

References

Chris Dunn, Doyanne Darnell, David C. Atkins, Kevin A. Hallgren, Zac E. Imel, Kristin Bumgardner, Mandy Owens, Peter Roy-Byrne,(2016). Within-Provider Variability in Motivational Interviewing Integrity for Three Years after MI Training: Does Time Heal?, Journal of Substance Abuse Treatment, Volume 65.

Miller, W.R. and J.S. Tonigan, Assessing drinkers’ motivation for change: The stages of change readiness and treatment eagerness scale (SOCRATES). Psychology of Addictive Behaviors, 1996. 10(2). 81-89.

Moore, G, F., Moore, L., Murphy, S. (2012) Integration of Motvational Interviewing into Practice in the National Exercise Referral Scheme in Wales. A Mixed Methods Study. Behavioural and Cognitive Psychotherapy.

Nuss K, Moore K, Nelson T, Li K. Effects of Motivational Interviewing and Wearable Fitness Trackers on Motivation and Physical Activity: A Systematic Review. Am J Health Promot. 2021 Feb;35(2):226-235. doi: 10.1177/0890117120939030. Epub 2020 Jul 14. PMID: 32662277.

Smith, D.E., et al., Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM. A pilot study. Diabetes Care, 1997. 20. 52-54.

Stewart, A.L., et al., Physical activity outcomes of CHAMPS II: a physical activity promotion programme for older adults. J. Gerontol. A. Biol. Sci. Med Sci, 2001. 56. 465-470.

Woollard, J., et al., A controlled trial of nurse counselling on lifestyle change for hypertensives treatment in general practice: preliminary results. Clin Exp Pharmocol Phisiol, 1995. 22. 466-468.