Review Paper

Motivational Interviewing and Clinical Psychiatry

Florence Chanut, MD, FRCPC¹, Thomas G Brown, PhD², Maurice Dongier, MD, FRCPC³

Objective:Our objectives were as follows: 1) to survey the literature on motivational interviewing (MI), “a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence” and a well-established method of brief intervention, especially in the field of addictions treatment; 2) to review hypotheses about its mode of action; and 3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communications skills. Method: Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarized. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our team’s experiences with MI. Results: There is no evidence that MI achieves better results than other established techniques for treating addictions; it may simply work faster. The explanation for the method’s rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured. Conclusion: MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients’ medication compliance and professionals’ communication skills. Questions remain concerning MI’s feasibility in psychiatry settings. (Can J Psychiatry 2005;50:715–721, reprinted from Can J Psychiatry 2005;50:548–554) Click here for author affiliations.  Clinical Implications MI adaptations can improve treatment adherence and dual disorder outcomes among psychiatric patients. MI implies the systematic practice of empathic communication skills. These skills could be improved during psychotherapy training. Existing objective measures can contribute to this improvement. As a brief intervention, MI could probably be more easily embedded into psychiatric care than comprehensive integrated treatment for dual disorders, although it cannot yet claim to replace more elaborate programs. Limitations The literature on MI adapted to psychiatric care is relatively sparse and heterogeneous, which limits our recommendations. Objective data explaining the specific MI mechanisms and speed of action are currently lacking, which constrains us to hypothetical explanations. Rigorous training in MI techniques requires time and follow-up coaching, which could limit its dissemination. Key Words: motivation, motivational interviewing, brief intervention, psychotherapy, communication skills, dual disorder, addiction treatment, phenomenology Résumé : La technique d’entrevue motivationnelle et la psychiatrie clinique

Worldwide, motivational interviewing (MI) is a well-established approach to treating addictions. It has been defined as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence” (1). Ambivalence may prevent some patients from achieving desired changes, even after they seek or are referred to professional treatment. Motivational interviewers make a fundamental effort to match their patients’ levels of problem recognition and motivation to change with specific strategies and goals.

Two decades ago, the high dropout rates commonly seen in addictions treatment stimulated William R Miller and Stephen Rollnick to experiment with a brief (up to 4 sessions) preparatory intervention aimed at improving motivation for regular treatment (1). Subsequently, it was shown that brief MI, when provided as a stand-alone treatment, could lead to improvements in drinking outcomes that compared well with those seen in 12-step programs (that is, facilitation of adherence to AA principles and attendance) and in cognitive-behavioural treatment—interventions that are more intensive and longer (2,3). With these results, interest in MI has expanded to include not only treatment of other psychoactive substance use disorders, such as cannabis and cocaine abuse, but also treatment of other health behaviour problems. Of these, medication compliance, diet and exercise, reduction of HIV-risk behaviours, smoking cessation, and eating disorders have to date been the most studied. Notably, preliminary data suggest that dual diagnosis patients show significant improvement when successfully engaged in a treatment program and that MI may improve engagement in this population (4). Given that substance abuse, compliance to medication regimens, and treatment engagement are interrelated and crucial to the management of patients with severe mental illnesses (5), MI may have wide-ranging beneficial effects.

Consideration of MI’s role in psychiatry settings seems particularly relevant at this time. Interest in improving communication skills in medicine and psychiatry—an area on which MI places heavy emphasis—is growing, even as the current environment of cost containment makes the feasibility of introducing any new psychotherapeutic approach uncertain. Resolution of this problem is complex, yet many mental health professionals see their patients facing daily substance abuse, motivation, and compliance issues—especially those suffering from mental illnesses, such as schizophrenia, that require long-term treatment adherence. Does MI have a role to play in the overall success of psychiatric treatment?

What is MI?

Four basic principles guide the conduct of MI: 1) expressing empathy, 2) developing discrepancy, 3) supporting self-efficacy, and 4) rolling with resistance (2–4,6). First, empathy, although essential to all psychotherapies, is more specifically defined in MI. In addition to verbal and nonverbal listening skills, it takes the highly valued form of reflective listening, also described by Carl Rogers as accurate empathy (7). Through successive reflections, the therapist attempts to maximize the patient’s perception that all efforts are being made to fully understand him or her.

This basic reflective listening skill is also instrumental to developing discrepancy, the second principle of MI. A key hypothesis—that the patient’s perspective on the importance of change is fundamental to the patient’s readiness to change—concerns this principle and directs therapists during interviews. To develop discrepancy, the therapist makes a concerted effort to increase perceived cognitive dissonance, or discrepancy, between the patient’s present behaviour and his or her core values. Reflective listening combined with the aforementioned empathic communication style creates an environment amenable to a full exploration and articulation of these values, which can be then juxtaposed with the patient’s current behaviour. Motivational interviewers actively formulate reflections to subtly lead the session toward resolving patient ambivalence and initiating change.

It is also hypothesized that patients’ confidence in their ability to achieve the desired change is a key issue. This is the basis of the third principle of MI practice: supporting self-efficacy. Perception of self-efficacy is a reliable predictor of positive outcome from psychotherapy, and here, the directive component of MI significantly departs from pure Rogerian therapy: In addition to supporting the patient’s self-efficacy, the therapist shows unwavering optimism regarding the patient’s capacity for meaningful change.

According to the last principle, rolling with resistance, the therapist takes care not to directly confront the patient’s perception of his or her own problems. Again, reflective listening is used to deal with client resistance and to avoid argument. Unlike many therapeutic approaches, MI views resistance not as a patient characteristic but as a gauge of the health of the collaborative relationship and therapeutic rapport between therapist and patient. Resistance arises when the level of intervention offered by the therapist is incompatible with the patient’s level of problem recognition or stage of change (8,9). A common example of this occurs when the therapist encourages concrete solutions while the patient is still not fully convinced that he or she has a problem or needs to take action. In this case, patient resistance to the suggested change is a signal for the therapist to adjust strategies and perhaps reconsider the patient’s degree of problem recognition, prior to providing a solution. In another major strategy for reducing resistance, the clinician avoids explicitly advocating for change and attempts instead to encourage the patient to do this. An individual’s verbalization of his or her intent to change is significantly more predictive of change than therapist exhortations alone (6). A repertoire of MI tactics can help patients deepen their exploration of the advantages (and inconveniences) of change in an environment of security, objectivity, and patient–clinician collaboration.

The MI concept of resistance proceeds directly from the MI concept of motivation. MI posits that motivation, in addition to being a modifiable and fluctuating state rather than a permanent trait, depends on the behaviour being considered. For instance, a patient may be highly motivated to take his or her medication but not motivated to quit smoking. Consequently, an indispensable first step is for the therapist to jointly negotiate with the patient a specific behavioural target, among multiple possible targets, that will be the focus of the interview.

The major technical strategies for conducting MI sessions are summarized by the acronym OARS:

O open questions that lead to active elaboration by patients, rather than    closed questions

A affirmation of patients’ self-efficacy and support

R reflections ranging from simple rephrasing of patients’ thoughts to more    complex bouquets of patients’ desires, abilities, reasons, needs, and    commitments

S summaries, a specific form of complex reflection used intermittently to    organize patients’ narratives to resolve ambivalence and promote    consideration of change

Literature Survey

MI Efficacy Studies

Compelling evidence exists for MI’s effectiveness in treating addiction as well as other problem behaviours. In the last 10 years, 3 methodologically exemplary studies (2,10,11) have demonstrated MI’s efficacy in the alcohol and drug addiction field. For smoking and HIV-risk behaviours, the 4 available studies (12–15) failed to discern significant effects for MI. A recent metaanalysis investigated MI delivered individually to treat several behavioural problems (16). From a selection of 30 well-controlled clinical trials and conservative data analyses, the authors concluded that MI produced significant beneficial effects in the moderate range (effect size = 0.25 to 0.57) in 3 problem areas: alcohol and drug abuse, diet, and exercise. Moreover, these effects were superior to those observed with either no treatment or placebo and were equivalent to those obtained with other bona fide treatments (16). The same investigators also examined whether MI’s therapeutic effects were sustained over time and at what minimum dosages. They found that MI’s impact (effect size = 0.13; n = 1519) on outcomes at about 20 weeks posttreatment persisted up to 67 weeks (effect size = 0.11, n = 1479). In certain cases, these effects were observed at 4-year follow-up. The medium effect sizes seen in studies of MI are comparable to those seen with psychotherapies in general, according to the metaanalytic data available (17), but at far smaller dosages (that is, under 100 minutes) than are used in typical psychosocial interventions. Thus, if we can conclude from the above that MI works and works rapidly with addiction clients, what can be said about MI’s impact on psychiatric patients with or without substance use disorders?

Studies Involving Psychiatric Patients

No metaanalyses or review articles have been published so far on MI applied to psychiatric patients. In March 2004, we conducted a literature survey wherein we searched the term motivational interviewing in the PubMed and Medline databases, as well as in relevant bibliographies, and then manually selected all English articles related to psychiatric patients. Of the 161 articles retrieved in this way, 30 specifically examined MI efficacy in this population, with all reports published after 1996.

Overall, the literature is sparse and suffers from several methodological shortcomings. The dual diagnosis populations investigated are diverse, comprising inpatients and out-patients, variable therapeutic and organizational environments, substance use disorders involving either abuse or dependence, and case mixes that involve different diagnostic categories. The most common Axis I diagnoses are either schizophrenia or mood disorder. Methodologies also vary greatly among studies, although samples are generally small and follow-up periods limited.

Notwithstanding these limitations, the findings are so far promising. To date, research inquiry can be broken down into 3 specific outcome categories: engagement in inpatient or outpatient treatment, reduction in alcohol or substance misuse, and medication compliance.

Engagement in Treatment

Several trials have found that one session of MI produced increased attendance at psychiatric outpatient care if applied just prior to hospital discharge (18,19). When applied shortly after inpatient admission, MI did not significantly affect engagement (20). One session of MI before or early in a course of psychotherapy, however, did have a positive impact (21).

Reduction in Alcohol or Drug Misuse

At baseline, most adults with schizophrenia and substance abuse have little motivation to quit (22). Some evidence is emerging that MI may in fact be more effective with patients having the lowest levels of motivation pretreatment but less effective with those in a higher motivational state (15). Compared with simple referral by the medical team to a nonpsychiatric specialized addiction unit, MI in addition to active postdischarge community follow-up could increase the number of patients actually accepting specialist care (23).

Apart from one recent study that found treatment effects with MI in a dual diagnosis population comparable to those found in nonpsychiatric populations (24), all other studies produced positive, but more modest, results (25–27). This finding has led several investigators (25,28,29) to conclude that a longer or more intensive MI format may be necessary to achieve maximum benefits with dual diagnosis patients.

Medication Adherence

Common features of successful interventions to improve medication adherence have been identified through a systematic literature review (30). These include the use of motivational or concrete problem solving techniques that directly target problems of nonadherence. Other authors have advocated for the use of MI to improve medication compliance among patients suffering from psychosis (31–33). One group of investigators has created an adaptation of MI for patients with psychosis, named “compliance therapy,” that focuses on treatment adherence (34). Their RCT supported the finding that compliance therapy offered significant advantages in regard to improved functioning and social stability over an 18-month period (35).

Other Research

Combined Approaches for Dual Disorders

Two studies investigated the impact of MI combined with other treatment modalities for dual diagnosis patients. An RCT of routine care for patients with comorbid schizophrenia, alone or combined with MI, CBT, and family intervention, demonstrated the superior effectiveness of combined approaches (36); however, the relative efficacy of the different treatment components was unclear. Another combined treatment protocol targeting the same population achieved similar results (37).

Mechanisms of Action and Delivery Modality

That MI acts to increase readiness to change has been supported in research with schizophrenia patients (38). It has also proved feasible to clinically implement MI in either group or individual format in both inpatient and outpatient psychiatric services for dually diagnosed individuals, although the evidence for the effectiveness of group-delivered MI is so far tentative (39).

Adaptations of MI

Specific modifications have been proposed to adapt MI to a population of substance-abusing patients with psychotic disorders (18,30,33,40–42). In particular, treatment components related to psychiatric care may be necessary additions to the formal MI approach. Moreover, the cognitive deficits and disordered thinking that often accompany psychosis may necessitate adapted strategies, including simplified reflections, repetition, and increased MI duration. At the same time, it has been argued that the nonconfrontational style of MI is more suitable for schizophrenia patients than the confrontational methods favoured in many traditional substance abuse treatments (39).

Summary

The research on MI applied to psychiatric patients has important methodological shortcomings. Nevertheless, it has generally shown positive results, especially increased treatment engagement and adherence, although modifications of MI for this population may be necessary. One remarkable aspect of this literature survey is that it reveals how rapidly significant change can occur, especially in addiction-treatment populations. The rapidity of its apparent action is probably the main reason why MI has garnered so much attention (and, in some circles, scepticism) worldwide. Our focus in the next section turns to a consideration of this distinctive aspect.

Significant and Lasting Changes in a 2-Session Intervention? A Hypothesis

MI includes many of the nonspecific factors common to most psychotherapies (43); however, its rapid action requires explanation. MI attempts to reduce the obstacles to rapid change that are hypothesized to originate from clinician behaviour (6). In part, MI is thought to help suppress what its proponents call the “righting reflex,” that is, the tendency to offer a solution based on the therapist’s knowledge. Overly eager provision of advice or a prescription for change can increase resistance under certain conditions, especially when clients have poor problem recognition or find the proposed prescription poorly adapted to their needs.

Emphasis on diagnosis can also undermine motivation. Although instrumental to the selection of appropriate treatment or referral, insistence that patients accept a diagnosis (like the insistence on accepting the label “alcoholic” in traditional substance abuse milieus) can sometimes lead to dissension in the therapeutic relationship. Stigma associated with a psychiatric label and role is a common and important obstacle to a patient’s readiness to comply, as is the tacit acceptance of a psychiatric diagnosis implied by active engagement in treatment. Therapists’ temporary suspension of diagnostic judgment or differentiation between “normal” and “abnormal” can help circumvent these pitfalls—especially, early in the therapeutic process. In short, during MI, 2 common attitudes of the mental health professional are briefly suspended or bracketed: the expert stance and the diagnostic preoccupation.

There are similarities between Miller’s descriptions of MI (44,45) and those of phenomenological and existential psychotherapists (46–49). The competent expert’s natural attitude is suspended during the clinical encounter in favour of an intersubjective endeavour to jointly examine a lived experience. Miller has described this as an essential feature of MI; namely, it involves replacing the therapist’s attitude of “doing to” with an attitude of “being with.” Thus it seems that MI is consistent with Kafka’s comment “ Prescribing is so easy, understanding people so hard” (50, p 24)

Assessment Methods

Unique to MI are quantitative methods to assess treatment adherence and reliability (see http://casaa.unm.edu/ tandc.html). The 2 methods presently available provide global measures to assess adherence to the spirit of MI (for example empathy) as well as specific behaviour counts for such features as open questions and simple reflections. The MISC (51,52) requires transcripts and at least 3 passes of the audiotape reviews by trained coders. Both patient and therapist utterances are coded. A recent study has found its reliability to be acceptable (53).

Moyers and colleagues (54) have derived a simpler coding method from the MISC. The MITI, available in preliminary form, provides structured and formal feedback to improve practice in nonresearch settings and measure the treatment integrity of clinical trials that use MI. Its exclusive focus is therapist utterances. Normally, the MITI requires a single, 20-minute review of audiotapes and no transcripts. Its ease of use, relative to the MISC, promises to enhance its feasible application in nonresearch clinical settings.

Our results from a preliminary investigation of the MITI’s interrater reliability suggest that the MITI could provide a viable alternative to the more demanding MISC (55). Moreover, following an introductory workshop in MI techniques, MITI training and MI coaching appeared complementary in terms of trainees’ achieving greater autonomy and greater mastery of MI. The direct supervision carried out with taped interviews of real sessions and with attention paid to every therapist utterance may hasten trainees’ progress and deepen their mastery of MI’s humanistic spirit and communication style. This may be critical to the feasibility of MI. In a rare empirical study on MI training using the MISC as the outcome measure of adherence to MI (56), researchers found that, without continual supervision in MI, no significant effect of initial training persisted beyond 4 months for most trainees.

Possible Impact on Clinical Psychiatry

The MI approach has developed mostly outside the field of psychiatry. However, several pragmatic incentives could make it attractive to mental health professionals, even to those who have little interest in the field of addictions. These include

• an integrated, although contrived, approach to dual diagnoses (whereas complex, expensive programs are likely to remain scarce in spite of their demonstrated superiority) (57)

• a tool to improve treatment adherence when compliance may be problematic

• a rigorous method to improve therapists’ communications skills, often taken for granted in psychiatric training (58).

At the organizational level, brief therapies such as MI might help psychiatric teams follow the present health care trend for ambulatory care. The obligation for motivational interviewers to focus on a restricted number of topics during a time-limited sequence of interviews may usefully and efficiently concentrate patient and clinician efforts. Also, the MI interpersonal view of resistance and the therapist’s effort to adapt quickly to this view may contribute to a more respectful and collaborative environment within mental health settings.

Given the evidence for MI’s effectiveness and suitability in psychiatric settings, it might be tempting to argue that widespread training of psychiatrists in MI is warranted. However, important obstacles may impede the dissemination of MI. In-depth training and a long-term commitment to ensure MI fidelity and quality are time-intensive and require significant resources. Moreover, MI practice implies a paradigm shift that in many ways contradicts the psychiatrist’s role as expert, which could impede its ready adoption. Related research underscores the difficulty of transferring other brief intervention techniques for substance misuse into primary care settings outside a research protocol (59–66). The feasibility of specialists’ adoption of MI practice is also uncertain. It may be more feasible to coach students or residents-in- training (67–71). Another strategy could be to designate specific members of a mental health team (specialized or not) as MI practitioners. These professionals might be better placed than psychiatrists to suspend the diagnostic approach to psychiatric treatment and expose a larger proportion of psychiatric patients to MI. Strong leadership and modelling by psychiatrists, as well as the organizational will to adopt this treatment technology, are paramount to the success and longevity of any implementation strategy.

Conclusion

Motivation and treatment adherence are key issues in daily psychiatry practice. They are often the cornerstones of patient outcomes, because even the most powerful treatments are ineffectual if patients are not prepared to comply. In treating a population typically grappling with multiple problems, adopting a structured, flexible, stepwise approach that accommodates patient priorities may also be beneficial. MI seems well suited to address these needs. However, a significant allocation of resources for proper training and a profound paradigm shift in the patient–professional interaction are required for its successful incorporation into practice. Determining MI’s ultimate role in psychiatry awaits more research into how it must be adapted to the specific needs of psychiatric patients, together with innovative approaches to its effective dissemination in mental health settings.

Funding and Support

Dr Chanut was supported grants from the Psychiatry Fellowship program of the Province of Quebec, the Douglas Hospital Foundation, and the Canadian Psychiatric Association Foundation.

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Author(s)

Manuscript received May 2004, revised, and accepted February 2005.

1. Fellow in Addiction Psychiatry, Addiction Research Program, Douglas Hospital, McGill University, Montreal, Quebec; Lecturer in Clinical Psychiatry, University of Montreal, Montreal, Quebec.

2. Director, Addiction Research Program, Douglas Hospital, McGill University, Montreal, Quebec; Assistant Professor, Department of Psychiatry, Douglas Hospital Research Center, McGill University, Montreal, Quebec; Head of Research, Pavillon Foster Addiction Rehabilitation Center, St Philippe de LaPrairie, Quebec.

3. Professor, Department of Psychiatry, McGill University, Montreal, Quebec.

Address for correspondence: Dr F Chanut, Pavillon Albert-Prévost, Hôpital Sacré-Coeur de Montréal, 6555, Gouin Blvd West, Montreal, QC H4K 1B3

e-mail: f.chanut@videotron.ca

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