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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

Motivating Behavior Change

March 23, 2012

By Michael Craig Miller M.D.

Harvard Medical School

If change were easy, people wouldn't have to make New Year's resolutions. And anyone who wanted to give up smoking, become sober, or lose weight would "just do it." The reality is that changing behavior — especially overcoming an addiction — is difficult.

Motivational interviewing is a technique many therapists use to help people identify their reasons for undertaking the hard work of behavior change. It was originally developed for the treatment of alcohol dependence. Motivational interviewing is now used to help people quit drugs, stop smoking, lose weight, increase physical activity and stick with medical treatment.

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What is Motivational Interviewing?

Motivational interviewing leans on a theory called the "stages of change" model. Proponents of the theory believe that people seeking behavior change need to go through several stages. Although not universally accepted, this model holds that at any given time, a person has a particular attitude toward changing. The stages are:

  • Pre-contemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance

Motivational interviewing is often best suited for the early stages of change. At the pre-contemplation stage, people do not know that the problem is serious. They may refuse to admit that they have a problem. At the contemplation stage, they are aware of the problem but have not yet decided to act. Especially for people addicted to alcohol or drugs, the first steps are often the most difficult, and many get stuck too long in the pre-contemplation and contemplation stages.

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Partners in a Conversation

The word "interviewing" suggests the idea of asking questions and getting answers, rather than giving advice or instruction. Interviewers ask questions because they don't know all the answers. In motivational interviewing, clinicians are partners in a conversation. They avoid warnings, confrontations and direct attempts to argue, persuade or educate. They do not use diagnostic labels.

A variety of clinicians can use motivational interviewing, including primary care physicians, psychiatrists, psychologists, nurses and dietitians. Details of how to conduct this therapy are published in manuals and described in a number of papers. Typical sessions involve:

  • Expressing empathy. Clinicians who practice motivational interviewing repeat back or paraphrase answers, to make sure they understand what the person is saying.
  • Developing discrepancies. The clinician points out the differences between what the person is doing and their broader interests and values. This can help the person identify goals or values. Then they can discuss how to make changes or how to achieve the stated goals or values.
  • Rolling with resistance. Therapists avoid directly confronting a person's resistance to change. One way to roll with resistance is to state arguments for and against change in the same response. Another approach is to be a devil's advocate, stating reasons the person should not change; in response, the person may be inclined to review points in favor of change. Hearing oneself say those reasons explicitly may foster a commitment to change, along with a fear of disappointing oneself, the therapist, and others who have a stake in one's life.
  • Promoting self-efficacy. People are ready to change when they have confidence that they can make the change. Believing that they are in control helps them set high goals, sustain commitments, overcome obstacles and recover from setbacks. To encourage self-efficacy, clinicians may ask patients to rate, on a scale of 0 to 10, how strongly they are motivated for change, how important change is to them and how confident they are that they can make the change. A low rating would lead the clinician to ask what it would take to increase motivation or confidence.

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Motivational Interviewing Has Many Uses

Most of the research on motivational interviewing has evaluated its use in treating alcohol and other substance use disorders, but a smaller body of evidence suggests that this technique may also help promote other types of healthy behavior change.

Researchers in Denmark who conducted a meta-analysis of 72 randomized controlled studies found that motivational interviewing proved significantly more effective than traditional clinical advice giving in about 75% of trials, involving a variety of medical problems. Motivational interviewing produced clinically (and statistically) significant changes when it came to reducing alcohol consumption, losing weight, and lowering blood pressure.

Here are a few examples of research focused on particular behaviors:

Substance use. One of the first large clinical trials to evaluate motivational interviewing, Project MATCH, compared four sessions of motivational interviewing with two different 12-session treatments for alcohol dependence. All three treatments were equally effective, but motivational enhancement therapy took less time than the others. As a result, patients more quickly reduced their alcohol consumption. Other studies have found that motivational interviewing was better than standard community treatment for drug problems.

Smoking cessation. The Cochrane Collaboration, an international group of experts, reviewed 14 randomized controlled studies in which motivational interviewing was compared with standard interventions to help people stop smoking. They found that motivational interviewing was significantly more effective than standard care, although quit rates remained low.

Weight loss. Studies of motivational interviewing to promote weight loss have had mixed results. A work group convened by the American Dietetic Association reviewed the literature and concluded that motivational interviewing alone was no more effective than traditional diet advice. "However, when clinicians combined motivational interviewing with cognitive behavioral therapy, patients were more likely to eat more fruits and vegetables, consume less fatty food and lose weight, compared with those who received only traditional advice.

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Finding a Motivator

Motivation is a prerequisite to behavior change. It's helpful to find a person to push you along, but the wrong kind of pushing can often backfire. Finding a clinician who uses motivational interviewing techniques may be a good way to avoid the impulse to run away from change.

Many clinicians bring these techniques into their work without calling them motivational interviewing. A person seeking help, though, can pay attention to how the clinician is working. If you feel less motivated rather than more, you may want to seek someone specifically trained in this method.

Although motivational interviewing does not work for everyone, it is a flexible approach to therapy that enlists the most powerful instigator of change: a person's own desire to make it happen.

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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.

Rubak S., A. Sandbaek, et al. "Motivational interviewing: a systematic review and meta-analysis." The British Journal of General Practice. 2005; 55(513): 305-312.

Project MATCH Research Group. "Project MATCH (Matching alcoholism treatment to client heterogeneity): rationale and methods for a multisite clinical trial matching patients to alcoholism treatment." Alcoholism: Clinical and Experimental Research. 1993; 17(6): 1130-1145.

Project MATCH Research Group. "Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes." Alcoholism: Clinical and Experimental Research. 1998; 22(6): 1300-1311.

Lai DT, et al. "Motivational interviewing for smoking cessation," Cochrane Database of Systematic Reviews. Jan. 20, 2010; Doc. No. CD006936.

Spahn JM, et al. "State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change," Journal of the American Dietetic Association. June 2010; Vol. 110 (6): 879–91.

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