Motivational Interviewing in Primary Care
? Springer Science+Business Media, LLC 2009
reforming themselves to better meet the needs of people
with, or at risk of developing, chronic diseases and long
term conditions. One goal of these efforts is the coproduc-
tion of activated, informed, engaged and motivated patients
and citizens. The clinical, public health and financial ben-
efits of achieving such a goal may be dramatic. Motivational
Interviewing (MI) is a proven and practical front-line
approach which can help deliver this goal whilst also
helping to deliver such policy objectives and intermediate
outcomes as increased levels of patient centered care, par-
ticipatory or shared decision making, evidence-based
healthcare and improved clinician-patient relationships.
Until now, MI has been passively diffusing through the
system as a result of the innovation and early uptake by
insightful individuals and organizations. If healthcare sys-
tems want to breakthrough to higher levels of performance,
investment in the conscious and deliberate implementation
of MI into front-line settings may prove helpful.
Healthcare systems are in the process of
Brief interventions ? Primary care ?
Chronic disease management ? Healthcare reform ?
Patient centered care ? Shared decision making
Motivational interviewing ?
Motivational Interviewing (MI) is an evidence-based clin-
ical approach delivering a wide range of benefits to
patients, clinicians and healthcare organizations alike.
However, its full potential to improve both individual and
population health and wellbeing outcomes is a long way
from being realized. This article provides a description of
MI, where it comes from, evidence of its effectiveness and
how its potential might be better realized.
Chronic or long term conditions are common, costly and
result in a huge burden of ill-health and disability in many
nations (Pomerleau, Knai, & Nolte, 2008; Mokdad, Marks,
Stroup, & Gerberding, 2004). In developed nations a
combination of population ageing and advancing medical
technology means the prevalence of long term conditions is
increasing (Yach, Hawkes, Gould, & Hofman, 2004). Data
from the Centers for Disease Control and Prevention
indicate that just four modifiable behavior risk factors––
tobacco use, unhealthy diet, physical inactivity and excess
alcohol consumption––cause up to 40% of mortality in the
US (Mokdad et al., 2004).
Faced with this growing burden of partially preventable
and modifiable ill-health (World Health Organization
[WHO], 1998; Sabate, 2003; Ashenden, Silagy, & Weller,
1997), healthcare systems are experimenting with a range of
policies and strategies (Rosen, Asaria, & Dixon, 2007) to
improve the way they respond to, engage with, activate and
support patients with long term conditions, with the goal of
helping them change their behavior, engage in more self
care (Lorig et al., 1999) and live longer, more independent,
higher quality lives (UK Department of Health, 2008).
A recent review (Singh, 2005) of interventions targeting
the way care for people with long term conditions is
organized and delivered found evidence to support the
beneficial impact of a range of initiatives on patient and
system outcomes including: the use of broad chronic care
management models; involving people with long term
conditions in decision making; greater reliance on primary
care; providing accessible structured information; self-
management education and the use of nurse led strategies.
T. Anstiss (&)
Thames Valley University, London, UK
J Clin Psychol Med Settings
An Evidence-Based Model to Inform System Reform
Perhaps the most empirically informed and extensively
tested model relevant to the redesign of primary care sys-
tems to improve care and outcomes for people with long
term conditions is the Chronic Care Model (Bodenheimer,
Wagner, & Grumbach, 2002) developed by Ed Wagner and
the MacColl Institute (Wagner, Davis, Schaefer, Von Korff,
& Austin, 1999; Wagner et al., 2001). Please see Fig. 1.
Implementation of the model has led to favourable
outcomes in a range of conditions (Asch et al., 2005;
Mangione-Smith et al., 2005; Schonlau et al., 2005; Vargas
et al., 2007). According to the developers of the model, the
essential element of good chronic illness care is a ‘‘pro-
ductive interaction’’ in which the work of evidence-based
chronic disease care gets done in a systematic way, and
patient needs are met––including the delivery of behav-
ioural support to help patients become better self-
managers. To deliver superior outcomes (clinical, func-
tional, financial and satisfaction) the model suggests
healthcare systems must get better at creating ‘‘informed,
activated patients’’––patients who have goals and a plan to
improve their health, along with the motivation, informa-
tion, skills, and confidence required to manage their illness
How Might this Best be Done? Motivational
Interviewing (MI) as One Useful Approach
MI is an empirically supported (Rubak, Sandbæk, Laurit-
zen, & Christensen, 2005; Burke, Arkowitz, & Mechola,
2003), theoretically consistent (Markland, Ryan, Tobin, &
Rollnick, 2005; Vansteenkiste & Sheldon, 2006) and rap-
idly diffusing approach which improves the quality of the
Defined as ‘‘a client centered, directive method for
enhancing intrinsic motivation to change by exploring and
resolving ambivalence’’ (Miller & Rollnick, 2002) and
more recently as ‘‘a person-centered method of guiding to
elicit and strengthen personal motivation for change’’
(Miller & Rollnick, 2009) MI originated as a clinical
method in the addiction field which was subsequently
supported by empirical research and theoretical explana-
tions. It is currently being used by clinicians and other
professionals to deliver improved outcomes in a wide range
of different fields and settings including public health and
the workplace (Hersey et al., 2008), sexual health (Peter-
sen, Albright, Garrett, & Curtis, 2007), dietary change
(Vanwormer & Boucher, 2004), weight loss (Carels et al.,
2007), voice therapy (Behrman, 2006), gambling (Wulfert,
Blanchard, Freidenberg, & Martell, 2006), physical activity
promotion (Bennett, Lyons, Winters-Stone, Nail, &
Scherer, 2007), medication adherence (Cooperman, Par-
sons, Chabon, Berg, & Arnsten, 2007), diabetes (Channon
et al., 2007), mental health (Arkowitz, Henny, Westra,
Miller, & Rollnick, 2008)––including depression, anxiety,
OCD, eating disorders and dual diagnosis––fibromyalgia
(Ang, Kesavalu, Lydon, Lane, & Bigatti, 2007), chronic
leg ulceration (Morris & White, 2007), criminal justice
(Woodall, Delaney, Kunitz, Westerberg, & Zhao, 2007),
vascular risk (West, DiLillo, Bursac, Gore, & Greene,
2007), stroke rehabilitation (Watkins et al., 2007), chronic
pain (Rau, Ehlebracht-Konig, & Peterman, 2008), self-care
(Riegel et al., 2006), domestic violence (Wahab, 2006) and
child health (Schwartz et al., 2007). The approach is rela-
tively systematic and has been (and continues to be) well
evaluated from both an outcome and process perspective.
Publications evaluating the effectiveness of MI have been
doubling every 3 years (http://motivationalinterview.org/
The approach has a goal, a spirit and several principles.
It requires competency in several core communication
skills, and is commonly delivered with the aid of several
tools or strategies. Key aspects of client speech guide the
skilful practitioner in their efforts to be as helpful as pos-
sible to their patients.
The goal of MI is health behavior change––which might
be medication taking, physical activity, smoking cessation,
reduced illicit drug use, attending an appointment or
practicing safe sex. The spirit of the approach is charac-
terized as being collaborative, autonomy supporting and
evocative. ‘Collaborative’ in that the clinician works with
and alongside the patient, addressing their concerns and
helping them make progress towards their goals rather than
entering into a confrontation due to a mismatch of agendas
and needs. ‘Autonomy supporting’ in that the practitioner
never forgets that the patient is the active decision maker,
and that making decisions may be good for people from a
Fig. 1 The Chronic Care Model
J Clin Psychol Med Settings
personal development perspective even if the choice they
make may not have been ‘‘technically’’ best. (This is
consistent with Self-Determination Theory’s emphasis on
autonomy as a ‘‘psychological nutriment’’ essential for
healthy human development and thriving (Ryan & Deci,
2000)). ‘Evocative’ in that the practitioner seeks to draw
concerns and solutions out of the patient, underpinned by a
belief that the patient is the expert in their own lives and
that, to quote a French mathematician: ‘‘People are gen-
erally better persuaded by the reasons which they
themselves discovered, than by those which have come into
the minds of others’’ (Blaise Pascal, 1669). And this is not
just theoretical––a clinician’s ability to manifest the spirit
of the approach can be reliably measured (Moyers, Martin,
Catley, Harris, & Ahluwalia, 2003; Madsen & Campbell,
2006) and seems to be a predictor of both increased client
responsiveness and treatment outcome (Gaume, Gmel, &
Daeppen, 2008; Moyers, Martin, Houck, Christopher, &
The principles of the MI approach (Miller & Rollnick,
2002; Rollnick, Miller, & Butler, 2007) are summarized by
the alliterative: Express Empathy; Develop Discrepancy;
Roll with Resistance and Support Self-Efficacy and the
acronym R.U.L.E.: Resist the righting reflex; Understand
your patient’s dilemma and motivations; Listen to and
Empower your patients.
The core communication skills which MI practitioners
strive to master are: asking skilful open-ended questions;
making well-timed affirmations; making frequent and
skilful reflective listening statements and using summaries
to communicate understanding. Significant progress can be
made in helping patients explore and resolve their ambiv-
alence about behavior change using just these four skills,
remembered by the acronym O.A.R.S.
MI practitioners make use of several tools and strategies
to develop empathy and help their patients explore and
resolve their ambivalence about behavior change, but these
tools and strategies are not unique to MI nor do they define
it. Furthermore, unthinking, mechanical or inflexible use of
these tools and strategies can get in the way of the spirit of
the approach and the deployment of the principles, possibly
interfering with the maintenance of empathy and rapport
and reducing the chances of good outcomes. That being
said, commonly used tools and strategies include: setting
the scene; agreeing on the agenda; exploring a typical day;
assessing importance and confidence; exploring two pos-
sible futures; looking back and looking forwards; exploring
options; agreeing goals and agreeing to a plan.
In MI, two key aspects of client speech guide the
practitioner in their efforts to help clients enjoy higher
levels of future health and wellbeing: ‘‘change talk’’ and
‘‘resistance’’. Change talk comprises client verbalizations
that signal desire, ability, reasons, need, or commitment to
change (D.A.R.N––C) (Amrhein, Miller, Yahne, Palmer, &
Fulcher, 2003) and MI practitioners are trained to recog-
nize change talk, elicit it and develop it once it has
occurred. Studies by Amrhein et al. (2003) using psycho-
linguistic analysis have shown that abstinence from illicit
drugs can be predicted by the strength of client commit-
ment language during MI sessions, a finding in line with
other research indicating that client verbalization of spe-
behavior change (Chiasson, Park, & Schwarz, 2001; Gol-
lwitzer, 1999). Resistance, in contrast, can be considered a
state of oppositional, angry, irritable or suspicious patient
behavior which bodes poorly for treatment effectiveness
(Beutler, Moleiro, & Talebi, 2002). MI practitioners use a
range of strategies to avoid triggering resistance in the first
place and ‘‘roll’’ with resistance as and when it is observed
(Moyers & Rollnick, 2002). Recent process research sug-
gests that attending to client language may help mediate
client outcome and that MI may substantially increase
change talk and reduce resistance relative to other
approaches (Miller, Benefield, & Tonigan, 1993).
Motivational Interviewing and its Relationship to Other
Areas of Psychology
Whilst MI is sometimes spoken of as a form of cognitive
behaviour therapy (CBT) and has its origins in behavioral
approaches to the treatment of people with alcohol prob-
lems, there are important differences between MI and CBT
approaches. Perhaps the most important is that the focus of
MI is on helping the person resolve their ambivalence
about behavior change––rather than helping them to
acquire the cognitive, emotional, coping and behavioral
skills required to live more healthily. Many people fail to
change not because they can not, but because they have not
yet decided that they want to. Once they have decided to
change no further help may be needed. Of course many
people do need help in changing and clinicians are well
placed to support them, but in helping people acquire new
skills they would be switching between MI and another
approach––considered stage 8 in a recent paper exploring
how people become more skilful in MI over time (Madson,
Loignon, & Lane, 2009).
MI can be viewed through a ‘‘negative psychology’’ lens
as an attempt to ‘‘fix’’ ‘‘repair’’ or ‘‘treat’’ someone who is
somehow dysfunctional, or through a positive psychology
(Seligman, Steen, & Peterson, 2005) lens as a way of
helping a person reconnect with their values and experi-
ence positive emotions on their journey towards improved
physical and psychological health. A recent paper by
Wagner and Ingersoll (2008) explores how motivation
involves a desire to experience positive emotions, and how
J Clin Psychol Med Settings
MI has the potential to elicit such positive emotions as
interest, hope, contentment and inspiration as the practi-
tioner helps clients imagine a better future for themselves,
recall past successes and develop confidence in their ability
to change and improve their lives. If MI does indeed help
patients experience more frequent, intense or longer lasting
positive emotional states, then this may be one of the
mechanisms explaining the approach’s effectiveness (Ly-
ubomirsky, King, & Diener, 2005).
MI is complementary to and may even be synergistic
with other treatment approaches (Hettema, Steele, & Miller,
2005). Clinicians can use the approach before, during or
after other treatments, and the additional benefit may well
be due to increased levels of patient engagement with and
exposure to the effective elements of the other treatment.
In setting out their vision for a 21st century healthcare
system the Institute of Medicine (2001) promotes patient
centered care, defined as: ‘‘care that is respectful of and
responsive to individual patient preferences, needs, and
values and ensuring that patient values guide all clinical
decisions’’. By explicitly asking patients about their con-
cerns, hopes, aspirations and goals, by providing them with
information on an as-needed basis to help them reach
informed decisions, by helping them explore the advanta-
ges and disadvantages of different courses of action (not
just in terms of clinical outcomes but in terms of other
things which patients value) and by building their confi-
dence in making successful health behaviour changes, MI
can help clinicians deliver patient centered care.
Training in MI can also contribute towards improved
clinician empathy. A systematic review of research into the
verbal and non-verbal behaviors of primary care physicians
(Beck, Daughtridge, & Sloane, 2002) identified 22 physi-
cian verbal behaviors and 16 specific non-verbal behaviors
associated with favourable patient outcomes or patient
characteristics, including: empathy; statements of reassur-
ance or support; encouragement; explanations; addressing
the feelings and emotions of patients; increased time on
health education; friendliness; listening behavior; summa-
rization; expression of positive reinforcement or good
feelings in regard to certain patient’s actions; receptivity to
patient questions and statements; and allowing the patient’s
point of view to guide the conversation in the concluding
part of the visit. Physician behaviors shown to be negatively
associated with patient outcomes included: passive accep-
tance; formal behavior; antagonism and passive rejection;
high rates of biomedical questioning; interruptions; a one
way flow of information from patient to physician (infor-
dominance. Whilst MI is not the only way to improve cli-
nician communication skills in line with this evidence, its
incorporation into a physician training program (Bonvicini
et al., 2008) has been shown to improve physician global
empathy scores by 37% from baseline compared to a con-
trol group of physicians not receiving the training.
How Motivational Interviewing can Help Health
Systems Deliver Integrated Care
MI can help healthcare systems with the task of integration
in several ways:
(1) MI can help implement the CIC model of integrated
chronic disease management care––not least the key
model element of activated, informed patients.
MI can contribute towards the building of more
groups work together towards a common purpose.
MI skills are equally relevant to a wide range of
primary care professions, and can help ensure a
consistency of approach when members of the team
work with the same patient––e.g. on weight loss or
medication adherence issues. Shared training in the
approach works well and can help break down inter-
professional barriers, building increased trust and
understanding between different parts of the system.
It can help build consensus around the preferred
models, pathways and skills required to make high
quality health behaviour change a reality in front line
settings, whilst providing a common framework and
language to talk about this key aspect of patient care
and primary care improvement.
MI can help clinicians integrate evidence-based
medicine with patient centered care and shared
decision making. One of the key challenges in
becoming an evidence-based practitioner is incorpo-
rating patient preferences into the decision making
process during the clinical encounter (Barratt, 2008).
Once the clinician has determined the best course of
action for a patient from a technical and future health
risk perspective, MI can help the clinician share the
individualized evidence with the patient in a neutral,
non-judgemental way––eliciting their views and
preferences and incorporating this into the agreed
way to move forward.
MI can help integrate physical and mental healthcare.
Clinicians whose focus is physical healthcare can
sometimes feel uncomfortable asking patients about
mental health issues. By increasing clinician confi-
dence with a guiding style of consultation, MI may
serve to increase some clinicians’ readiness to ask
their patients about any associated mental health
problems, and then to collaboratively explore options
and ways forwards, supporting their patients in their
efforts to recover lost mental and emotional health.
J Clin Psychol Med Settings
(5) MI can help clinicians integrate treatment with
prevention. By increasing clinician skill and confi-
dence about surfacing and talking about lifestyle
issues, MI can contribute to the delivery of at least ‘‘1
minute for prevention’’ (Stange, Woolf, & Gjeltema,
2002), helping primary care reduce the future burden
of disease in individuals and communities.
MI can help integrate treatment with wellness and
wellbeing approaches. By helping clinicians raise
awareness about the behaviours, activities and skills
likely to be associated with increased happiness,
wellbeing, and quality of life (Lyubomirsky, 2007),
MI has the potential to integrate the emerging insights
from positive psychology into traditional disease
models of care provision. This may not only help
primary care clinicians get better clinical results with
their patients, but may also help their patients flourish
as human beings, enjoying improved satisfaction with
life, enjoyment, resilience, and possibly longevity,
productivity and disease resistance.
MI can help integrate clinical care and self-care.
Skilled MI practitioners can make the transition
between MI and other approaches during the course
of a consultation, providing confident diagnostic and
clinical services when required but also placing
responsibility for making changes to lifestyle and
health behaviour with the patient, whilst increasing
their patients confidence about making such changes
and improvement to their self care.
And finally MI can help more fully integrate models
for detecting and treating substance abuse into
primary care settings. This may be by improving
the frequency and quality of screening for drug and
alcohol problems, improving the quality of the follow
up questions asked after the screening questions,
improving the delivery of brief interventions, improv-
ing the quality of the referral to specialist services
and/or by encouraging the deployment of behavioural
health specialists delivering MI informed behaviour
change services in primary care settings. In view of
the burden of disease related to alcohol usage, and the
better outcomes associated with earlier interventions
(Ernst, Miller, & Rollnick, 2007) more fully integrat-
ing substance misuse services into primary care has
the potential to significantly improve the health
output of primary care systems.
Summary and Conclusion
Healthcare systems the world over are reforming and
redesigning themselves to better meet the current and
future health and wellbeing of people with, or at risk of
developing, chronic diseases and long term conditions. A
major goal of these efforts is increased healthcare system
effectiveness and efficiency at co-producing activated,
informed, engaged and motivated patients and citizens. The
clinical, public health and financial benefits of achieving
such a goal may be dramatic. MI is a proven and practical
front-line approach which can help deliver this overarching
goal as well as several other policy objectives and inter-
mediate outcomes including increased levels of patient
centered care, participatory or shared decision making,
evidence-based healthcare and improved clinician-patient
relationships. Up until now, MI has been passively dif-
fusing through the system as a result of the innovation and
early uptake by insightful individuals and organizations. If
healthcare systems want to breakthrough to higher levels of
performance, investment in the conscious and deliberate
implementation of MI into front-line settings may prove
ments during the writing of this paper.
With thanks to Bill Miller for his helpful com-
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