Commentary by Gretchen Ames, PhD; Janelle Coughlin, PhD; and Kerrie Warne
Motivational interviewing originated in the 1980s for treating addictions, but since has been adopted to help patients who are obese and overweight to manage weight either before undergoing bariatric surgery or in a nonsurgical program.
Concepts of Motivational Interviewing
The motivational interviewing framework takes a different approach than the standard "lose weight for your health," said Gretchen Ames, PhD, Assistant Professor of Psychology at Mayo Clinic College of Medicine in Jacksonville, Florida. “A health care provider who does motivational interviewing also has to abandon the traditional role of expert,” she said. Rather, the health care provider is a partner in the effort; inspiring patients to look at the ambivalence that is associated with any change, then address that ambivalence to figure out how to change.
"Most of us have been trained to give information, as advice giving," said Janelle Coughlin, PhD, Assistant Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University (Baltimore, Maryland) and a consultant for Healthways, Inc. "We are the experts, and we set the agenda and persuade the patient to change. [However] advice giving isn't really going to be what helps people change."
The techniques include goals of working together, focusing on what needs to change (with the patient coming up with suggestions, based on information) and planning how to change.
How Motivational Interviewing Works
Dr. Ames gave a case history to illustrate how the technique works. Miss Jones, a college senior with a body mass index (BMI) of 44.6 and obstructive sleep apnea, is trying to lose some weight before having bariatric surgery. Instead of giving the patient a diet to follow at the first meeting and telling her it's important to follow it, Dr. Ames indicated she will give Miss Jones diet information but then ask: "What do you think is going well with your eating?" Given that question, she said, patients will tell you the good part and then are likely to mention things they need to work on.
Dr. Ames then focuses on the efforts that are going well, giving the patient positive feedback. Affirmation is a crucial part of motivational interviewing, she said. For instance, if Miss Jones told her she keeps track with a food log, she affirms the value of that.
If Miss Jones mentions problematic areas, Dr. Ames won't say, "You need to do x, y, z." Instead, she asks her to think about why they are problems and what could be done. The technique inspires patients to come up with the solutions. For instance, Miss Jones discovers by calorie tracking that alcohol calories add up, and told Dr. Ames she plans to go out to eat less with friends—as that means she eats and drinks too much. Coming up with her own solutions builds confidence.
The approach recognizes that ambivalence is a major part of making any change, including weight loss, and patients typically go back and forth between resistance (known as sustain talk) and change talk. "The research has shown that change talk is the active ingredient here," Dr. Ames said. However, change never happens overnight. And if patients develop the plan to change, it seems to work better.
For Miss Jones, for instance, her sustain talk was noting that it was easier to eat out than fix meals at home, but recognizing that wouldn't work well once she had the surgery. Then she moved on to change talk—what steps she needed to take to eat at home most often, such as making time to go to the market.
Motivational Interviewing: Evidence, Feedback
Research has found motivational interviewing to improve weight loss works better than traditional methods, Coghlin said.
In a meta-analysis of 11 published studies, published in Obesity Reviews, motivational interviewing was associated with a significant reduction in body weight compared to those in the control group (Weighted mean difference = -1.47 Kg [95% CI-2.05, -0.88]).1
The time needed to do motivational interviewing is less than most health care providers think, Ames said. "You can do this MI interaction in literally five to 10 minutes," she said.
“Motivational interviewing helps health care providers learn what a patient's motivation and goals are,” said Kerrie Warne, Program Director at St. Alexius Hospital New Start program at the Center for Surgical Weight-Management in St. Louis. "Sometimes our goals are not the same as the patient's," she said. Knowing their goals can help health care providers guide patients better.
November 20, 2015
Ames G, Coughlin J. Integrated Health: Motivational Interviewing. The Obesity Society, ObesityWeek 2015, Los Angeles, CA. November 2-6, 2015.
1. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ, Campbell TS, Hemmelgarn BR. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev. 2011;12(9):709-723. http://www.ncbi.nlm.nih.gov/pubmed/21692966.