Motivational interviewing as a brief intervention to improve cardiovascular health

A major challenge in cardiovascular disease management is initiating and maintaining healthy behaviour. Health behaviour change, such as increasing physical activity, reducing alcohol consumption and stopping smoking, is largely determined by a complex interplay between an individual’s knowledge and understanding of one’s disease, the personal meaning and relevance of that knowledge and the confidence in one’s ability to make changes. ¹ The American Heart Association recommends that clinicians use counselling interventions to promote a healthful diet and physical activity that combine two or more of the following strategies: set specific, proximal goals; provide feedback on progress; provide strategies for self-monitoring; establish a plan for frequency and follow-up; use motivational interviewing (MI); build self-efficacy. ² One of these strategies – MI ³ – is of growing interest and appeal in helping patients change behaviour.

Unlike most behavioural counselling interventions, MI is not founded on theory ³ but has evolved from a client-centred counselling approach. ⁴ It is a directive, individual-centred counselling style for eliciting behaviour change with a prime purpose of helping individuals to explore and resolve their ambivalence. ⁵ It consists of enhancing intrinsic motivation for change by exploring and resolving resistance and strengthening commitment to change. ³ The primary goals for MI counsellors are: expressing empathy; developing discrepancy between clients’ values and current behaviour; ‘rolling with resistance’ or avoiding confrontation; supporting self-efficacy. ³ MI has demonstrated its usefulness, outperforming traditional advice giving, in the treatment of various lifestyle problems and diseases. ⁶ The underlying principle of MI is to elicit and strengthen the client’s intrinsic motivation to change making it particularly useful for those who are reluctant or ambivalent about changing their behaviour.

Brief MI (15–20 min duration) is relatively simple to integrate into a patient consultation in a variety of settings, including medical, public health and nursing,^7,8 and takes less time than comparison treatments and with no apparent adverse or harmful effects, signifying a cost-effective alternative to traditional behavioural counselling interventions.^3,9,10 For example, a recent trial showed that nurse-based MI in addition to routine lifestyle screening and feedback significantly increased smoking cessation in high risk cardiovascular patients. ¹¹ However, as MI is largely dependent on the therapist’s capacity to instil or enhance one’s belief in their ability to change, the quality of the consultation has a critical effect on outcome. ¹²

A recent systematic review examining the usefulness of MI for treating cardiovascular patients attests to MI being an effective means of changing behaviour in the cardiovascular health setting. ¹³ Importantly, it also identified the need for appropriate training and evaluation to ensure adherence to the ‘spirit’ and technique of MI and suggested the use of assessment tools such as the MI Skills Code and the MI Treatment Integrity Code to maintain quality assurance in MI. ¹³

A recent randomised controlled trial found that up to four 30–60 min of individual, weekly sessions of MI improved patients’ mood and reduced mortality 12 months after a stroke. ¹⁴ The protective effect of MI on survival is striking and suggests that improving mood could also increase survival. Further research is warranted to examine factors such as whether the frequency of MI sessions is more important than the timeframe, whether there are differences in therapist effect and whether there are differences when using training and/or supervision. ¹⁵ Finally, more research is needed to explore the mechanisms by which MI exerts its effect.

A number of challenges to MI have been identified. First, most studies using MI have targeted a single behaviour; yet many individuals with cardiovascular disease probably need to change multiple behaviours. ¹³ Second, the number of MI encounters and follow-up periods appear important, e.g. follow-up of less than 3 months increases the risk of counselling failure. ⁶ Third, MI training is often delivered through a single workshop, yet technical comprehension and skill required for effective MI may take longer to develop.^16,17 Finally, the effectiveness of MI is dependent on the proficiency of the clinician in their ability to skilfully deliver the intervention.^{12 –14,17}

Instigating and maintaining behaviour change in patients with cardiovascular disease poses a major challenge in health care. There is growing empirical evidence attesting to the effectiveness of MI as a brief intervention to bring about such change, but more research is needed into elucidating the mechanisms by which MI exerts its effect and exploring more proficient delivery modes that take account of issues such as interview skills and fidelity measures.