This chapter will address the following American College of Graduate Medical Education competency: interpersonal and communication skills.

Interpersonal and Communication Skills: Use of MI is a key skill in the prevention and treatment of childhood obesity and a core competency for all pediatric health care providers. This chapter will review core principles of MI and how to implement MI in a clinical practice in obesity prevention and treatment.

In the early 1990s, Stephen Rollnick and William Miller described a novel approach for the treatment of “problem drinkers,” called MI.¹ This approach was based on the insight that the failure to adopt important changes in health behaviors is rooted in ambivalence to change; and that “problem drinkers” and other patients must overcome their own ambivalence to successfully adopt more healthful behaviors. MI is a counseling technique and communication style designed to direct patients to explore their ambivalence by talking about the positive aspects of adopting change. This positive change talk increases a patient’s intrinsic motivation for change, commitment to change, and confidence that he or she will be successful, and is the goal of MI which hopes to increase the likelihood that the patient will be successful in adopting change.

In their original published work, Miller and Rollnick provided the following definition:

The key features of this technique reflect an emphasis on the need for patients to develop intrinsic motivation rather than imposed instructions for change from the physician or counselor. Miller and Rollnick² (p 25) instruct that the motivation to change is elicited from the client and not imposed by the counselor. They suggest that the patient must give voice to and resolve their ambivalence rather than have it pointed out directly. They caution that direct persuasion is not effective; rather the counselor must be quiet and eliciting. At the same time the counselor is directive in focusing the conversation on the examination and resolution of ambivalence.

Miller and Rollnick also describe a key shift in perspective that drives MI. This new perspective recognizes that readiness to change is a dynamic phenomenon and is influenced by interactions with the counselor and others. There is also a shift in power that recognizes the therapeutic relationship as a partnership rather than authoritative expert and passive recipient. Thus, the counselor does not provide a prescription for change or a persuasive argument. Instead, the counselor uses communication skills that include reflective listening, expression of empathy, affirmation of expressed emotions, eliciting motivational statements that reflect the positive aspects of change, tailoring the discussion to the patient’s readiness to change, and affirmation of expressions of autonomy.

In its original form, MI was designed to replace counseling by specialists that typically lasted 45 minutes to an hour. However, Rollnick and Bell determined that MI techniques might be more broadly applied if adapted to brief clinical encounters.³ This belief was based on their conclusion that many individuals with substance use or abuse problems do not seek or have access to formal counseling. These individuals are more likely to have typical brief encounters in medical settings with a primary care provider or emergency department clinician. In 1992, they published a description of “brief motivational interviewing,” a set of MI skills adapted for use in quick counseling sessions. They provided a menu of specific skills or tools that could be chosen by the clinician based on a patient’s readiness to adopt behavior change. They estimated that these skills could be used effectively in a 5- to 15-minute encounter.

Following the original publications describing MI and brief MI, numerous randomized clinical trials have been conducted to determine their effectiveness in treating patients with substance abuse and numerous other behaviorally driven health problems. In a review of 74 studies, Hettema et al⁴ published a meta-analysis of trials employing brief MI alone or in combination with other interventions to address health behaviors. They describe the breadth of conditions for which brief MI was used. These include smoking cessation, HIV or AIDS prevention, drug abuse, medication or other treatment adherence, gambling, problematic intimate relationships, adherence to recommended water purification strategies for disease prevention, eating disorders, and diet and exercise. They concluded that overall, brief MI had a significant effect on successful adoption of behavior change. However, the effect size of brief MI varied greatly depending on several factors, including (1) the setting in which it was delivered (inpatient, educational, community organizations, health clinics, emergency departments, halfway houses, jails, patient homes, and over the telephone); (2) variation in the delivery among clinicians (duration, frequency, and specific techniques used); and (3) the length of time over which patients were followed (the effect was often seen early and then diminished over a year of follow-up). They found the strongest evidence for MI in the treatment of alcohol abuse, the condition for which it was originally designed. In addition, they found that brief MI was more effective and the effects longer lasting when combined with other treatments.¹

In 2005, Rubak et al⁵ published a systematic review and meta-analysis of 72 articles describing randomized controlled trials of brief MI. They found a significant effect of brief MI on adoption of behavior change in 74% of included studies. The effect was slightly diminished (to 64%) among trials where brief MI was delivered in encounters lasting less than 20 minutes. They also concluded that the likelihood of effect increased with multiple encounters. When they examined the relationship between effectiveness of brief MI and the condition studied, they found that 72% of studies targeting physiological outcomes were successful and 75% with psychological outcomes were successful (with studies using both direct and indirect outcome measures).² The weight of this evidence suggests that brief MI can be effective alone and in combination with other therapeutic techniques in supporting successful behavior change across a variety of settings and conditions. However, it remains important to focus closely on how brief MI is delivered. The personnel delivering MI, the adequacy of their training, the delivery setting, the frequency and duration of brief MI, its use with appropriate adjunctive therapies, and its timely reinforcement appear to be critical to its success.

Brief MI for obesity, diet, and exercise

In the past 20 years, numerous studies focused on the use of brief MI for the improvement of diet and exercise, and weight management. Although brief MI has been studied alone as a weight management intervention, it is more often used as an adjunct to other treatments. In 2011, Armstrong et al⁶ published a systematic review and meta-analysis of 11 randomized controlled trials that employed brief MI as one of the techniques for reducing weight among adult patients. They found that MI significantly enhanced weight loss among the included trials. This effect was greater among trials in which MI was delivered over more than 6 months and where attempts were made to ensure the quality of the MI delivered to participants. They noted that MI was often combined with other treatments in these studies, so many in the control group also lost weight; this might have underestimated the potential impact of MI alone. In a 2007 review, Van Dorsten⁷ cites several studies demonstrating that adjunctive use of brief MI enhanced adherence to other components of weight loss treatment. Specifically, MI increased adherence to a weight loss intervention program,⁸ improved HbA1C in adolescents,⁹ and improved exercise in older adults.¹⁰ However, variation in how brief MI is delivered has an impact on its measured effect.

MI and obesity among children and youth

The efficacy of brief MI in improving health behaviors among children and adolescents is less well studied. Childhood presents a dynamic landscape with respect to autonomy and self-direction, 2 concepts at the heart of MI. A child’s level of autonomy naturally changes as he or she develops cognitive and emotional skills over time. These maturational processes are not always predictable or linear. Autonomy is also influenced by parenting styles, cultural norms, and life circumstances, with some children expected to demonstrate more autonomy at earlier ages and states of development relative to others. In addition, parenting and child care are often shared tasks involving multiple adults in many different settings, each of whom might have slightly different expectations of a child. All these factors present a challenge to translating brief MI into pediatric health care settings for the prevention or treatment of obesity.

There have been several small studies of brief MI used to manage weight as well as dietary and physical activity behaviors in children. In 2007, Schwartz et al¹¹ published a feasibility study of brief MI applied in outpatient clinical settings to prevent obesity among children who were overweight. Pediatricians and dietitians were trained in brief MI and delivered 0, 1, or 2 sessions to patients and their primary caregivers, randomized to the control, minimal intervention, or intensive intervention arms. Dropout rates were high in both treatment arms. Although the average weight loss was greater among patients who received MI compared with controls, the sample size was insufficient to demonstrate a statistically significant difference among the groups. In addition, the use of only 1 or 2 sessions might represent an insufficient dose of brief MI, given the evidence supporting a greater effect with longer and more sustained MI among adults.

Brennan et al¹² published a description of a randomized controlled trial of a cognitive behavioral intervention used in conjunction with brief MI to promote weight loss among adolescents in 2007. Although the results of the trial were published in 2008 and demonstrated a positive effect of the cognitive behavioral interventions, the effect of brief MI was not reported. Flattum et al¹³ also described the use of brief MI in a school-based trial of a series of physical education classes combined with nutrition and health education. Approximately 25% of the participants received MI and demonstrated improved adherence to other components of the intervention compared with participants who did not receive MI. In 2008, Limbers et al¹⁴ published a systematic review of studies employing MI in children to promote weight loss or improvements in diet and physical activity levels. They found a lack of completed trials and concluded that there was insufficient evidence to draw conclusions.

To address this gap, the Pediatric Research in Office Settings (PROS) network has conducted a randomized controlled trial called “brief motivational interviewing to reduce body mass index study (BMI2).”¹⁵ The purpose of this study was to improve the efficacy of obesity counseling in pediatric primary care. The BMI2 practitioners were trained in brief MI. Individual practices were randomized to provide usual care (control), pediatrician-delivered counseling (the lower-level intervention), or combination counseling from a pediatrician and registered dietitian (the high-level intervention). The primary outcome was reduction in the children’s BMI percentile at 2-year follow-up. Secondary outcomes included an increased fruit and vegetable intake and a decrease in screen time for children receiving the high-level intervention. Results indicated a statistically significant decrease in BMI percentile of children who received the high-level intervention.

In 2007, the Expert Committee recommended the use of MI techniques for addressing weight management in pediatric settings¹⁶ due, in part, to the prevailing evidence of the positive effect of MI in adults and the clear evidence that MI does help some individuals adopt and sustain behavior change. Data from this study showed a significant reduction in BMI percentile in children in the high level intervention at 2 years.^16a The family-centered collaborative structure of MI communication techniques also makes this approach well-aligned with pediatric preventive care.

The spirit of MI is a collaborative and nonhierarchical approach to conducting an interview. Rather than assume the role of the expert who informs the patient, the pediatric health care provider assumes that the patient and family already have much of the information they need to change a behavior, and that they can evaluate any new information given by the provider. As a result, the encounter is a collaborative discussion in which a nonjudgmental, supportive, and trusting atmosphere is created to allow the patient and family explore the feelings, thoughts, and values related to changing a behavior and become more in touch with their motivation to change. This facilitates the resolution of ambivalence about making a change.

Ambivalence

Ambivalence happens when someone feels 2 ways about something. For example, a person might want to do something that is good for his or her health but also not want to give up doing the things that are bad for their health. Within an MI framework, ambivalence is considered totally normal. To be human is to have ambivalence—about lots of things, especially about making a change. Ambivalence only becomes problematic for a person when the person is stuck in it.

People usually are ambivalent about changing their behavior. Obesity often involves both a strong desire to lose weight and the recognition that certain behaviors (eg, overeating, choosing poor-quality foods, engaging in a sedentary lifestyle) are harmful or at least counterproductive. Nevertheless, it is difficult for a patient with obesity to simply eat a healthy diet and increase his or her amount of exercise. The same applies to parents. While some parents are genuinely naïve about what they need to do to promote weight loss in their children or to help their children maintain a healthy weight, producing the desired outcome usually involves more than simply providing education about diet and exercise. Parents usually want their children to be healthy, but they often are stuck in their ambivalence about making a change to their own behaviors. An important goal of MI is helping the patient, and parents, resolve the ambivalence associated with making behavioral changes.

A key aspect of MI is that the patient and parents are entirely responsible for changing their behavior. This sometimes is not as easy as it sounds. Allowing patients or families this degree of autonomy involves letting go of one’s sense of responsibility for the outcome of the encounter, recognizing that the movement toward change ultimately is the patient’s or family’s responsibility.

There are 4 general principles of MI² (pp 36-41; see also Box 15-1 later in this chapter)—express empathy, develop discrepancy, roll with resistance, and support self-efficacy.

Express empathy

Expressing empathy is a core feature of all MI encounters. By expressing empathy, the pediatric health care provider communicates respect, understanding, and nonjudgmental acceptance of the family’s feelings and perspectives. This creates a safe atmosphere that allows the family to let down defenses and examine any ambivalence associated with changing maladaptive behaviors.

Reflective listening is the core strategy used to express empathy. Reflective listening can be thought of as a 2-step process. It first involves actively listening to the content of what is said, observing the nonverbal aspects of how it is said, and processing the implied or stated meaning of it for the individual. It then involves communicating back the provider’s understanding of the thoughts and feelings conveyed (eg, “It sounds like you’re saying that you feel tired of feeling so self-conscious, but you’re unsure how you might make a change in your eating that would really get you down to a healthier weight”). In addition to communicating empathy, reflective listening also is useful when the provider is unsure which direction to take next in the interview, because if they have communicated an accurate understanding to the family, reflective listening has the effect of encouraging the family to continue to tell the provider more. Providers are unlikely to harm a patient or family with an inaccurate reflection, and at least it will provide information that helps the provider better understand the family’s perceptions and experiences, as well as communicate that the provider is trying their best to understand and to help.

Develop discrepancy

MI is a directive approach, although patients often feel so understood and accepted that they may not realize the degree to which the provider is directing the conversation. During the course of an MI encounter, the provider can help a patient develop a greater awareness of the discrepancy between how he or she is and how he or she wants to be, and this will increase the patient’s motivation to change a behavior. By guiding the conversation toward the resolution of ambivalence and change, the provider will help the patient consider his or her values, the cost(s) of not making a change, and the benefits of making a change. It is important for the patient, and not the provider, to articulate the argument for change, because hearing herself state the argument for change is far more motivating than hearing someone else such as the provider make the argument. Patients’ attitudes and intentions are shaped by the statements they make.^17,18 In fact, arguments made by someone else have been shown to be less effective for promoting change than arguments made by the individual.

There are a variety of strategies used to develop discrepancies. The provider might ask the patient how he or she will feel about themselves 5 years from now if he or she continues to gain weight at the same rate. The provider might also ask how his or her life will change if he or she is successful at managing their weight. Exploring the pros and cons of continuing without making a change versus the pros and cons of making a change can also be helpful. The use of importance rulers and confidence rulers is another means of developing the family’s awareness of a discrepancy.

Because of the development of discrepancy, the family will articulate “change talk.” Change talk is language that reflects a person’s motivation to change a particular behavior. Miller and Rollnick (2002) refer to change talk as “self-motivating speech,” because the act of arguing for something actually increases a person’s commitment to it.¹⁸ Change talk can involve the person stating the disadvantages of the status quo (eg, “If she continues to gain weight, she might develop diabetes, like I did”). Change talk might also involve a patient stating the advantages of making a change (eg, “If she loses weight, maybe her blood pressure will improve”). It might also involve the parent stating their intention to change (eg, “I’m going to start offering her fruits for dessert instead of cookies, cake, and ice cream”). It may include a statement that reflects optimism for change (eg, “I know we can go for a walk together after dinner at least 3-4 nights per week”). Change talk is desirable because over the course of the provider’s MI encounter, the more a patient expresses change talk, the greater the likelihood that he or she actually will change their behavior.² In general, when the family expresses change talk, it is important to recognize it and respond in ways that encourage the continued articulation of change talk, such as reflecting it, asking for elaboration or clarification of it, affirming it, and summarizing what the person has said.

Roll with resistance

Patients tend to feel threatened and become defensive when their health care provider takes a confrontational stance (eg, “You really need to feed her a healthier diet with less junk food”). In response to being confronted, a patient’s parent may state the advantages of the status quo (eg, “Eating a dessert after dinner loads her up on carbs and helps her get to sleep”). Alternatively, the parent may state the disadvantages of making a change (eg, “If I offer her fruit after dinner instead of a dessert, she’ll probably become irritated with me, and we might get into a fight”). Because of resistance, a parent may even state her intention not to change (eg, “I can’t see myself serving her vegetables with dinner; I know she doesn’t like them, so what’s the point?”). Patients sometimes express pessimism about change when they feel defensive (eg, “It would be so hard to hang out with my friends and eat low calorie meals while they eat whatever they want; I don’t think I can do it”). Some other kinds of resistance might involve the patient interrupting the provider out of defensiveness, not attending to what the provider is saying, or offering no response.

Rather than confront the patient or argue against his or her resistance, it is important to “roll” with their resistance or go with the flow by expressing empathy or reflecting back to them what they are saying, often in a way that reframes it slightly (eg, “It sounds easy, but changing a child’s diet is really a hard thing to do; you’re concerned that if you change her diet she’ll get angry at you, so you find yourself feeding her desserts just to keep her satisfied”). Expressions of resistance generally are an indication that the provider should shift the approach and respond in ways that might decrease it. The experience of receiving empathy helps a person to feel understood and effectively disarms his or her defensiveness.

Giving unsolicited advice is more likely to produce resistance than giving solicited advice. As a result, it is useful to ask permission prior to giving advice¹⁹ (pp 91-92). By giving the provider permission, the family is, in effect, signing on to consider their advice. It is often helpful for the provider to preface advice with permission to disagree or disregard his or her advice (eg, “I have some thoughts about how you might go about working exercise into your week. They may sound reasonable to you, but you might also think they would be difficult to use on a regular basis. Is it okay with you if I share them?”). Offering several options rather than suggesting only 1 option is often helpful, because resistance is less likely to surface when it is possible to make a choice between more than 1 alternative.

Support self-efficacy

Self-efficacy is a person’s belief in his or her ability to succeed at doing something. When a person believes in his or her ability to successfully use a particular strategy, the person is more likely to attempt to do so.²⁰ If a patient is motivated to make a behavioral change, but perceives he or she is incapable of making the change, the attempt to change is less likely. Therefore, MI involves attention to the patient’s confidence in his or her ability to change as well as assistance in consideration of the barriers to change that might jeopardize their success.