Motivational Interviewing: Definition, Techniques, and Target Populations
Motivational interviewing is a patient-centered counseling method that increases intrinsic motivation for behavior change by helping patients explore and resolve their ambivalence through strategic questioning, reflective listening, and emphasizing patient autonomy rather than direct persuasion. 1
What is Motivational Interviewing?
Motivational interviewing (MI) is a directive yet collaborative therapeutic approach that elicits patients' own motivations for change rather than imposing external reasons. 1 The fundamental goal is to strengthen personal motivation and self-efficacy for engaging in health-promoting behaviors through patient-centered communication techniques. 1
The approach works by helping patients identify discrepancies between their current behaviors and their personal values or life goals, then supporting them in resolving this ambivalence. 1 For example, a counselor might help an adolescent recognize the inconsistency between wanting to graduate college while engaging in unprotected sex that risks pregnancy. 1
Core Techniques and Principles
The "MI Spirit" Foundation
MI requires an empathetic, collaborative, and nonjudgmental demeanor that respects patient autonomy—this is called "MI spirit." 1 The approach fundamentally resists the "righting reflex" where clinicians naturally want to tell patients what to do, which typically generates resistance. 1
Key Communication Strategies
The OARS framework provides the structural foundation for MI conversations: 2
- Open-ended questions that invite exploration rather than yes/no answers
- Affirmations of character strengths and past successes
- Reflections that identify and mirror back statements supporting change
- Summaries that periodically recap to reinforce commitment
Specific Techniques
"Elicit-provide-elicit" is a nonconfrontational approach to giving advice that allows patients to express their feelings about change while helping clinicians assess readiness. 1 Rather than lecturing, the clinician first elicits what the patient already knows, provides targeted information, then elicits the patient's response to that information.
The "5 R's" model (recommended by the US Preventive Services Task Force) structures motivational conversations around: 1
- Relevance: Making information personally meaningful
- Risks: Identifying personalized risks of current behavior
- Rewards: Exploring potential benefits of change
- Roadblocks: Having patients identify barriers so tailored solutions can be offered
- Repetition: Repeating MI at each visit with reminders that multiple attempts may be needed
"Rolling with resistance" means avoiding direct confrontation when patients resist, instead waiting for them to find their own answers rather than pointing them out. 1
Eliciting "change talk" is central to MI—these are patient statements expressing their own desires, abilities, reasons, needs, and commitments to change behavior. 1 Research shows that increased change talk mediates the effects of MI on behavior change. 3
Decision Analysis
The "pros and cons" technique helps patients articulate advantages and disadvantages of changing, facilitating their own decision-making process. 1
Most Effective Populations and Diagnoses
Substance Use Disorders (Primary Evidence Base)
MI is most strongly supported for substance abuse and dependence disorders, where it manages resistance and increases readiness to change in patients experiencing defensiveness, ambivalence, guilt, and shame. 1 A Cochrane review of 93 studies with 22,776 participants found MI produces small to moderate effects on substance use reduction compared to no intervention, with effects persisting at medium-term follow-up. 4
For substance dependence specifically, brief MI counseling helps ambivalent patients enter treatment programs, engage with mutual help meetings, or agree to pharmacotherapy trials. 1 The approach is particularly valuable because substance dependence patients often lack concern about their use and resist direct advice. 1
Smoking Cessation
MI demonstrates modest but significant effectiveness for smoking cessation, with a 2015 Cochrane review of 28 studies showing increased quit rates versus brief advice or usual care. 1 Notably, one-time short MI sessions of less than 20 minutes have demonstrated efficacy. 1
For cancer patients attempting to quit smoking, MI is beneficial for all patients, including those currently ambivalent or unwilling to quit, addressing the high rates of anxiety, depression, and stress that serve as relapse triggers. 1
Adolescent Populations
Increasing evidence shows MI is most effective for adolescent counseling about contraception and sexual health when using patient-centered approaches. 1 MI addresses ambivalence and discrepancies between adolescents' behaviors, relationship values, and future life goals. 1
The approach is particularly suited to adolescents because it aligns with youth development principles through its focus on goals, future orientation, and belief in adolescents' capacity to change. 1
Dual Diagnosis (Comorbid Mental Illness and Substance Use)
For patients with dual diagnosis, MI shows improvement in functioning, psychiatric symptoms, medication compliance, and substance use, with significant reductions in relapse occurrence and alcohol abuse days. 5 This population has particularly low treatment engagement, making MI's non-confrontational approach especially valuable. 5
Dental/Oral Health Behaviors
The American Academy of Pediatrics recommends MI for improving oral health behaviors in children, with evidence showing reduction in severe caries in some populations and increased parent/caregiver knowledge. 2 Implementation is most effective when initiated at key moments, such as at eruption of a child's first tooth. 2
Chronic Disease Management
MI has been effective in promoting health behavior change for individuals with and without chronic diseases, though its reach may be limited by the expense of trained counselors. 1 Technology-delivered adaptations are being developed to increase accessibility. 1
Important Clinical Considerations
Brief MI sessions are effective—even single sessions under 20 minutes show benefit, making this feasible for busy clinical settings. 1
MI by primary care physicians appears somewhat more successful than by counselors, though both are effective. 1
Effect sizes are larger with ethnic minority populations, suggesting particular value for addressing health disparities. 6
The effectiveness of MI varies highly across providers, indicating that proper training and fidelity to MI principles is critical—simply calling an intervention "motivational interviewing" without adhering to core techniques will not produce results. 4, 6
Common pitfall: Giving complex messages (like encouraging abstinence while offering contraception counseling) can be managed through MI by maintaining the empathetic, nonjudgmental stance while helping patients explore their own values and goals. 1