Motivation and emotion/Book/2023/Brief motivational interviewing as a health intervention

Overview
Over the past year, Carly gained about 20 kg in weight and is self-conscious about it. Carly made an appointment to discuss the matter with her doctor. She was nervous to talk about her excess weight, but when she did, her doctor’s response was discouraging and left her feeling ashamed. The doctor took Carly’s weight and height, calculated her body mass index (BMI) and informed her that she was obese (BMI of 31). The doctor's advice to Carly was to lose about 15 to 20 kg because of the risk factors associated with being overweight or obese. The doctor concluded by encouraging Carly to "eat less junk food, introduce more fruit and vegetables in her diet, and move more". Carly left the doctor’s office feeling demotivated, not heard, and not better equipped to manage her weight.
 * Case study

In 2017-18, 67 percent of Australians were classified as overweight or obese (Australian Institute of Health and Welfare, 2023). Excess weight exposes individuals to an increased risk of developing preventable chronic conditions such as heart disease, type 2 diabetes and many cancers (Australian Institute of Health and Welfare, 2023). These preventable but chronic conditions bring many people to their doctors.

Carly's story is a made up example of what happens when some people visit their doctor. Patients reported that conversations about their weight are not a frequent topic during medical consultations (Ananthakumar et al., 2020). When weight-related conversations did take place, patients noted that doctors often offered generic advice, assumed patients had poor diets, and lacked interested in addressing their weight (Ananthakumar et al., 2020). But what if Carly's doctor approached the consultation differently? Would Carly have responded differently? Could Carly have left the doctor's consultation thinking about how changes could be introduced in her life?

Brief motivational interviewing (MI) may offer a more constructive approach to doctor-patient consultations. Brief MI is a person-centred, both directive and nondirective, interviewing style that hinges on appropriate use of empathy while engaging with a person (Rollnick et al., 1992). There are four key characteristics of brief MI: it is usable in time-limited (5-30 min) consultations, training of practitioners takes between 12 to 15 hours, the notion of behaviour change is raised in a respectful and sensitive manner, and it is adaptable to patients' readiness to change (Rollnick et al., 1992). The integration of brief MI into medical practices could help nurture intrinsic motivation for behaviour change, especially in people who have mixed feelings or uncertainty about making those changes - ambivalence.


 * What is the theoretical foundation of brief MI?
 * How effective is brief MI in weight management and physical activity?
 * What training is needed to practice brief MI?
 * How can brief MI be used in primary healthcare settings?

Theoretical framework
Motivational interviewing is a 'bottom up' model that developed from practical experience in the treatment of alcohol addiction (Miller & Rollnick, 2012). Brief MI developed out of the need for behaviour change conversations in primary health care settings that moved away from overt persuasion for a behaviour change (Rollnick et al., 1992). Direct persuasion was seen as an unhelpful method that led to patients’ defensiveness (Rollnick et al., 1992). In addition, giving advice about behaviour change to patients who are not ready for change is untimely and misdirected (Rollnick et al., 1992).

Brief MI has the same underlying assumptions as MI, however, the interventions aim to achieve slightly different goals. For instance, brief MI aims to initiate thinking and/or building motivation for a behaviour change, while MI evokes a commitment to behaviour change (Rollnick et al., 2002). Figure 1 illustrates the main parts of brief motivational interviewing: technical and relational. The fidelity of technical and relational components lead to different levels of change and sustain talk (Miller & Rose, 2009; Frey et al., 2021).

Technical part
The technical part consists of microskills such as open-ended questions, reflective listening, summarising, and affirmations (Rollnick et al., 1992). The purpose of the technical component is to draw out a new perspective from individuals that are open to, and favour, change while minimising the focus on expressed thoughts that are maintaining the status quo (i.e. sustain talk). The proficient use of the microskills will increase a patient's talk about change while decreasing any sustain talk (Miller & Rose, 2009). When change talk dominates sustain talk, behaviour change is predicted (Miller & Rose, 2009).

Change and sustain talk
Change talk is an expression of desires, wants, reasons, or needs that moves people towards making a change (Rollnick et al., 2023). It can also present itself when a person is deciding to take or preparing to make a change through statements characterised by their willingness, commitment, or necessary steps towards a change (Rollnick et al., 2023). Sustain talk is the opposite of change talk. As such, sustain talk moves people away from making a behaviour change by arguing for not making the change (Rollnick et al., 2023). As people talk about change, they may express both change and sustain talk at the same time (Frey et al., 2021).

Relational part
The relational part reflects the importance of communication between a patient and a doctor. Miller and Rollnick (1991) note that a therapist or a doctor is not just an observer of a patient’s motivational state but an important influence on a patient’s motivation. The authors further go on to say that ‘lack of motivation’ is a challenge to doctor’s skills and not a fault assigned to patients. Therefore, establishing a strong relationship between a patient and a doctor is achieved by the doctor showing accurate empathy, respecting patients’ autonomy, and approaching the relationship as one of equal collaboration (Frey et al., 2021).

The concept of fidelity recognises that brief and/or MI proficiency or skill requires training and ongoing learning. Frey et al. (2021) suggests that intervention fidelity, at a minimum, requires participation in role plays or workshops, individualised feedback, and ongoing support to encourage reflection (i.e. coaching or supervision). Implementation fidelity would be maximised by addressing both technical and relational parts as well as avoiding MI inconsistent practices (Frey et al., 2021).

Knowledge review {Two key elements of brief motivational interviewing are:} - Indirect and conversational style + Relational and technical components - Doctor and their patient

{Which one of the following statements best describes ambivalence:} - I'll start tomorrow + I want to and I don't want to - I really don't want to this right now

Effectiveness
Systematic reviews and meta-analysis of randomised controlled trials demonstrated that MIing outperformed traditional advice giving in the treatment of many behavioural problems and diseases (Rubak et al., 2005). Research on behaviour changes in reducing weight loss and increasing physical activity acknowledges the benefits of MI. However, the reviews highlight many limitations related to intervention design, follow up periods, outcome measures, professional background of people using brief/MI, delivery mode, and lack of information on fidelity assessments (Armstrong et al., 2011; Barnes & Ivezaj, 2015; Frost et al., 2018; Bischof et al., 2021).

Weight loss
The effectiveness of MI in achieving weight loss in overweight or obese adults was tested in a review of 12 randomised control studies (Armstrong et al., 2011) Weight loss and body mass index were used as measurements and the interventions ranged from 50 to 320 minutes. The review's meta-analysis showed a medium effect size (0.51 SD) for MI interventions compared to the control group. MI interventions contributed to a greater weight loss (1.47kg) than the control group in overweight and obese adults. However, the analysis also reported that both groups lost significant weight.

Another review focused on MI interventions for weight loss in primary care settings. 24 randomised controlled studies were included with the majority comparing MI to usual care or standard diet advice (Barnes & Ivezaj, 2015). A quarter of the studies used MI in regular primary care appointments. A few studies provided information on MI training length which ranged from 3 hours to 170 hours. Only one study provided satisfactory fidelity scores (Barnes & Ivezaj, 2015). In terms of outcomes, Barnes and Ivezaj (2015) found a third of the studies reported significant weight loss in patients who were in the MI group compared to the usual care or control group. It is important to note more than a half of the studies also showed no significant weight loss (Barnes & Ivezaj, 2015).

More recently, Frost et al. (2018) concluded that evidence base for the effectiveness of MI in weight loss outcomes in obese or overweight adults is of low quality. A more recent review confirms this view too. It reported small effect sizes of MI on weight loss (0.19) and reduction in body mass index (0.35) (Suir et al., 2021). The same review found that consultation frequency was identified as a factor predicting the success of weight management programs. More frequent interventions that span over several months are important in achieving desirable weight and BMI outcomes (Suir et al., 2021). Patients who visited their healthcare provider every 6 to 7 weeks successfully maintained more than 10 percent weight loss over 12 months (Lenoir et al., 2015). Those who did not maintain the weight loss visited every 9 weeks and those that did not reach the same percentage weight loss only visited their healthcare providers every 11 to 12 weeks (Lenoir et al., 2015). This observation may have implications for how brief MI interventions could be integrated into primary care settings.

Reviewed literature suggests lack of support for MI interventions on their own in promoting weight loss. More promising results are found when MI is used in combination with other effective interventions. For instance, Bean et al. (2013) found that brief MI (2 x 30 min sessions that were 10 weeks apart) improved treatment effects among adolescents with obesity undergoing multidisciplinary treatment. Brief MI participants had greater adherence to treatments such as dietician and behaviour support visits at 3 and 6 month marks than the control group that received information. Evidence does not support brief MI as a standalone intervention in weight loss. However, if combined with other weight loss aspects (i.e. healthy eating, nutrition, physical activity, peer groups), it has the potential for fruitful outcomes in healthcare settings.

Physical activity
The MI evidence base for increasing physical activity in adults is also mixed. Some report medium effect sizes (0.53) of MIing leading to increase in diet and exercise for overweight adults with an effect size of 0.53 (Burke et al., 2003). Moderate quality evidence related to physical activity points to beneficial effects of MI for increasing physical activity in people with chronic health conditions (Frost et al., 2018). While others note that it is difficult to determine the effectiveness MI based approaches for physical activity behaviour change as most studies targeting physical activity used many parts (Morton et al., 2015). Only a quarter of the studies used MI with no or minimal additional components and out of 20 studies examined about half showed positive effects of MI on physical activity (Morton et al., 2015).

Training
Competence in brief MI can be achieved through 12 to 16 hours of intense training with role play opportunities and reinforced with 4 to 5 hours of coaching and supervision from an expert trainer (Rollnick et al., 1992; Fifefield et al., 2019; Dockerty et al., 2016). Another study showed that 6 hours of training improved healthcare providers' confidence and skills in guiding patients through eating and exercise behaviour change (Edwards et al., 2015). The results also showed that knowledge and confidence were retained at a six months after the training (Edwards et al., 2015). The training included a two-hour lecture and four hours of role play spread out over two sessions, as suggested by Rollnick et al (1992).

Use of brief MI in healthcare settings


Medical practices are in a unique position to provide brief MI interventions. Brief MI is suitable for medical practices because it is an opportunistic, time efficient, potentially preventative way to facilitate patients in identifying existing or emerging habits (Docherty et al., 2016). Patients can choose if and when they begin their behaviour change, how they continue, and when they end it.

Resnicow et al. (2002) identified a few differences between brief MIing and MIing in healthcare settings. Firstly, the nature and extent of ambivalence in behaviour change may differ between addictive and non-addictive behaviours. For non-addictive behaviours, behavioural approaches and less interviewing may be suitable ingredients to resolve ambivalence. Secondly, a person who engages with a primary healthcare provider may not necessarily seek help for being overweight or obese but rather for another condition of concern (Resnicow et al., 2002). In addiction counselling, people are referred to or have sought treatment for their condition. This suggests that some clients may be less willing to address behaviour change in primary healthcare settings.

Doctors can initiate patients' thinking about behaviour change during conversations about medical results or concerns that patients raise. If concerns are not raised by patients, these can be drawn out by establishing rapport and using the opening questions provide in Table 1. It is also important to seek patient's agreement to discuss weight and physical activity concerns. Table 1 provides an overview of strategies and questions that could be asked during consultations. These questions and strategies integrate the technical and relational parts of the brief MI. Patient readiness will determine which questions are most appropriate to ask. Understanding patient's readiness to change can be assessed through the set of questions provided in Table 1. Figure 3 shows that a patient can start (depicted by dark purple and black figures) from anywhere on the readiness to change, move forward and backwards on the continuum.


 * Understanding client's concerns and circumstances by establishing rapport
 * Raise the subject of weight management or physical activity by getting client's agreement to discuss it
 * Understand readiness to change behaviour and accept treatment or referral
 * Provide feedback by raising client awareness of consequences of behaviour and share concerns
 * Assure that ongoing support is available and target questions to the person's level of readiness to change

Table 1.

Brief MI strategies for use in primary care settings (Rollnick et al., 1992; Emmons & Rollnick 2001)


 * It is your turn to help Carly!

{A few weeks have passed and Carly has come to see you about her blood test results. You read Carly's medical records and note that your colleague gave Carly general advice about weight loss. How might you initiate a conversation with Carly about her weight?} {Two key elements of brief motivational interviewing are:} - My colleague gave you advice about weight loss last time. How are you going with that? - I would not initiate the conversation but leave it up to Carly to bring it up. + My colleague gave you advice about weight loss last time. How do you feel about talking about your weight today?

{During your consultation, you observe that Carly wants to lose weight and walk more. However, she also says that she's really busy with her work and just can't find the time to cook during the week. What question might you ask Carly next?} - Would you be interested in knowing more about how weight/eating patterns affect our bodies? + How would you like things to be different in the future? - What are you going to do about weight loss?

Conclusion
Brief MI is a person-centred approach that aims to initiate thinking about a change or build motivation for a behaviour change. Its theoretical beginnings stem from MI which has two critical parts: relational and technical. The integration of technical and relation aspects along with adequate training and ongoing coaching ensures proficient and skillful use of the communication style. The magnitude of change and sustain talk guides the practitioner in applying appropriate strategies or questions to initiate thinking about behaviour change. Brief MI could be used in healthcare settings to motivate patients to improve levels of physical activity and weigh less when supplemented with other strategies. Brief MI offers an open, judgement free and supportive way of interacting with patients in primary care.