Brief Motivational Interviewing

Given the time constraints of your busy practice, you may wonder about quick and effective ways
to help children and teens adopt healthier behaviors. If it’s not already in your repertoire, consider
adding brief motivational interviewing, a patient-centered communication style designed to
enhance a patient’s own motivation to change. 

What is motivation?

Over the past few decades, advances in behavior research and theory propelled a major shift in
the concept of motivation (Tevyaw & Monti, 2004). It is no longer considered an all-or-nothing,
unchanging character trait in which an individual is either motivated or not. Instead, motivation
is viewed as a dynamic state of “readiness to change” that can be influenced by interpersonal
interactions, with confrontation leading to resistance, and with understanding and empathy
leading to change (Tevyaw & Monti, 2004; Levy et al., 2002).

How do people move forward in the change process? According to behavior researchers, they
become motivated when they “perceive a discrepancy between where they are and where they
want to be” (Miller et al., 1992). As a trusted health care provider, you are in a prime position to
help your patients recognize the disconnect between their behavior and their goals, values, and
beliefs, and to make a change for the better.

What is motivational interviewing?

Motivational interviewing is a directive, patient-centered style of counseling that helps
patients explore their natural ambivalence about changing. Its friendly, collaborative “spirit”
is considered more important than any particular set of techniques. The broad goal is to elicit
motivation from within the patient, not impose it from without. A core task is to help patients
examine their own reasons for and against making a change, and then guide them to a resolution
that triggers change in a healthy direction. Once patients commit to a change, they may or may
not need further assistance as to how to make the change—where there is a will, there are many
ways (Rollnick & Miller, 1995).

Although this counseling style grew out of the substance abuse field, motivational interviewing
is now used to address many other health behaviors, such as medication compliance and dietary
control (Erikson et al., 2005; Rubak et al., 2005). Thus, you may find that skills development in
this area will serve you well for any patient behavior change you would like to facilitate. 

How is it done?

There is no single prescribed way to do motivational interviewing; each interaction will be as
individual as the particular patient and his or her perspectives, goals, values, and beliefs. At its
core, however, four basic principles underlie the approach (Miller et al., 1992):

Express Empathy: Take a warm, nonjudgmental stance; listen actively and reflect back on what
is said to help the patient feel heard.

Develop Discrepancy: Raise awareness of the patient’s personal consequences of drinking; ask
how his or her goals, values, or beliefs could be hindered or compromised by drinking. 

Roll with Resistance: Acknowledge the patient’s beliefs and feelings; avoid lecturing
or debating; change gears and affirm autonomy if the patient shows resistance.

Support Self-efficacy: Express confidence in the patient’s ability to make a change; point to
patient’s strengths and other successes as examples.

As with most skills, proficiency in motivational interviewing increases with a combination of
training, practice, and feedback. For more background about motivational interviewing, along
with information about workshops and coaching, visit www.motivationalinterview.net. You may
also wish to refer to the book and journal articles referenced in this section.

Versatile and tailor-made for teens

You can apply motivational interviewing to address any level of alcohol use in your patients, from
a first, isolated experience to regular, heavy, problematic drinking (Narr-King & Suarez, 2011;
Tevyaw & Monti, 2004; Levy et al., 2002). It can be especially useful for adolescents in the early
stages of readiness to change, whether they are not yet interested in changing or they are thinking
about it, but are not yet ready to commit (Gold & Kokotailo, 2007). Patients who present with a
drinking-related injury or other negative consequence may be especially receptive in that painful
“teachable moment” (Macgowan & Engle, 2010). Even for patients with alcohol dependence,
motivational interviewing can encourage the patient to accept a referral to specialty treatment
(Levy et al., 2002) and engage more fully in care.

Though initially developed for adults, motivational interviewing is especially well suited for
adolescents. It avoids confrontation, which allows the adolescents their individuality. Its open and
respectful exchange of views supports teens’ desire to have their viewpoints heard and their quest for
autonomy. It can have benefits even when a patient does not admit to having a problem (Tevyaw &
Monti, 2004), which is often the case. When patients aren’t ready to commit to a behavior change,
motivational interviewing allows you to maintain rapport by “meeting them where they are” in their
change process and negotiating for some interim steps. In the process, as you elicit and show that
you value their opinions, teen patients get the opportunity to demonstrate their often remarkable
resourcefulness and to build decision-making skills that will serve them well into adulthood.

How effective is it?

In adults, the effectiveness of brief motivational interviewing has been well established. A
meta-analysis of 72 randomized controlled trials (RCTs) found that motivational enhancement
interventions outperformed traditional advice for a range of health behaviors in 8 out of 10 studies
(Rubak et al., 2005). Brief motivational interviewing can be effective in single visits as short as
15 minutes, and adding one or more followup visits nearly “ensures” effectiveness (Rubak et
al., 2005). Alcohol-focused studies have shown that motivational enhancement and other brief
interventions can reduce heavy drinking in nondependent adults, often as well as more intensive
treatment (Tevyaw & Monti, 2004).

In adolescents, studies of brief motivational interviewing for alcohol interventions thus far are
limited, but show promise (Macgowen & Engle, 2010). A 2010 review of 14 RCTs of brief alcohol
interventions for adolescents in clinical settings indicated that motivational interviewing appeared
more successful than other types of interventions and that even a single session can have positive
effects (Wachtel & Staniford, 2010). A 2011 meta-analysis also supported the effectiveness of
motivational interviewing interventions for adolescent substance use (Jensen et al., 2011).

Thus, the combination of solid evidence in adults and promising results in adolescents makes
motivational interviewing arguably the most reasonable, as well as the most feasible, approach
to recommend at this time for brief interventions with adolescents in clinical settings
(Clark et al., 2010). 

Setting Individual goals and action plans

With youth who drink alcohol, setting goals and action plans in the course of motivational
interviewing is trickier than it is with adults. Motivational interviewing involves encouraging
a patient’s autonomy in choosing his or her course of action, as well as acknowledging and
complimenting any change in a positive direction. People under age 21 who drink alcohol,
however, legally do not have complete freedom of choice when it comes to drinking decisions.
The goals you and your patient set need to be discussed in the context of both the patient’s safety
and restrictions imposed by the law, parents, school, or other sources (Tevyaw & Monti, 2004).

Your assessment (page 10) will help direct and shape the individual goals for your patient related
to drinking. Abstinence would, of course, be the ideal goal for youth who drink. In many cases,
however, cutting back and taking other steps to avoid harm are more realistic and achievable
goals. For dependent and other higher risk patients, the goal will be accepting a referral to
specialized treatment.

The following sample action plans for youth who drink but are not dependent can help you and
your patient chart constructive courses (adapted from Levy et al., 2002):

• Abstinence challenge: Ask permission from the adolescent to make a contract for 4–8 weeks of abstinence to help the two of you determine the severity of the problem. Discuss ways to successfully avoid drinking. At followup, reinforce success and discuss referral for more extensive assessment for those who failed the challenge or found it very stressful.
• Cut Back: For those who refuse to abstain, ask permission to negotiate and contract
  for drinking limits based on the patient’s history. In general, advise no substance use on
  weeknights, reducing quantity, and avoiding dangerous situations, such as drinking and
  driving. Elicit feedback from patients about your suggestions. At followup, continue to
  develop discrepancies and ask what additional steps they wish to take to reach their goals,
  building on prior successes. 
• Contingency: For more challenging or resistant patients who refuse even to cut back, see
  treatment as a process and accept any progress, such as discussing perspectives on their
  drinking, as partial success. Create a list of contingencies that indicate that a problem exists,
  and ask patients to agree to come see you if they occur. Avoid arguments, roll with resistance, and encourage them to continue thinking about their drinking and continue self-monitoring.

Followup

In general, followup is necessary. Negotiating a time frame for followup with the patient
may enhance the likelihood that the patient returns. As noted by the American Academy of
Pediatrics, sometimes a medical “hook” (e.g., a followup for acne or an immunization or to
discuss lab results) can bring the patient back to your office (AAP Adolescent Health Update
Editorial Board, 2007). Studies indicate that just one additional visit can significantly improve
the effectiveness of your intervention (Rubak et al., 2005).