The Committee on Health Care for Underserved Women would like to thank Ann Honebrink, MD, for her assistance in the development of this document.
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Many common diseases affecting women's health can be moderated or controlled by "behavior change." However, promoting changes in a patient's dietary habits, alcohol use, or sexual practices usually is daunting to the obstetrician–gynecologist. The practice of motivational interviewing is emerging as an effective and efficient catalyst for behavior change. Motivational interviewing tactics have been successfully used within the clinical setting to promote weight reduction, dietary modification, exercise, and smoking cessation, thus having a potential profound impact on heart disease, hypertension, and diabetes mellitus. Prompting patients to use safe sex practices and to use contraception more consistently also has been achieved through motivational interviewing techniques (1).
Communication with patients that indicates sensitivity and empathy is an approach used successfully by obstetrician–gynecologists (2). Whereas the traditional manner by which physicians give advice often is enough to motivate some patients to adopt more healthy behaviors, advice alone has little impact for those engaged in risky health behaviors (3). This resistance to change may be associated with the patient's misunderstanding of the connection between the activity and the health risk. The resistance also may be associated with minimizing the risk, valuing a social connection associated with the behavior, or even addiction. Evidence suggests that motivational interviewing is one technique that can be used to break through this resistance and achieve behavior change within the constraints of an active clinical practice (4). The American College of Obstetricians and Gynecologists (ACOG) encourages the use of motivational interviewing as one effective approach to elicit behavior change.
Definition of Motivational Interviewing
Motivational interviewing is defined as, "a directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence" (5). Initially, it was used to motivate patients who abused alcohol to modify their drinking behaviors. The goal of motivational interviewing is to "help patients identify and change behaviors that place them at risk of developing health problems or that may be preventing optimal management of a chronic condition" (6). Recognizing the dynamics of an individual patient's readiness to change behavior is integral to this approach (7). The goal of using motivational interviewing is to help patients move through the stages of readiness for change in dealing with risky or unhealthy behavior (see the box).
In motivational interviewing, the traditional approach of "advice giving" gives way to one of "reflective listening." Although a physician may give sound and logical advice, the patient, often concurrently, experiences resistance to that advice. Motivational interviewing reframes the patient–physician interaction but does not necessarily add time to the patient visit. Studies show that when a patient is allowed to talk and the physician is actively listening and reflecting back to the patient what he or she has heard, no more than 3 minutes are added to the encounter (8). Use of the reflective listening approach helps to better define patient concerns and decreases "late-arising concerns" at the end of the patient's visit (9).
Principles and Practice of Motivational Interviewing
Motivational interviewing helps the patient identify the thoughts and feelings that cause her to continue "unhealthy" behaviors and help her to develop new thought patterns to aid in behavior change. This technique is implemented most effectively after the physician has established a trusting rapport with the patient. Once the desired outcome (eg, weight loss, better compliance with contraception, smoking cessation) is set, the health care provider then uses the following principles during the interview:
- Express empathy and avoid arguments—For example, as part of a discussion about weight loss in a patient with diabetes mellitus, the physician can state, "I understand that is has been difficult for you to exercise and lose weight in the past. Many of my patients find this to be difficult. I think it is still important for us to try to find ways for you to work on this. What do you think you can do to exercise more and eat less?"
- Develop discrepancies—The physician can help the patient understand the difference between her behavior and her goals. For example, consider stating, "You have told me that you would like to feel better and cut down on your medication. I think you know that losing weight would help with this. Why do you think it is hard for you to find more time to exercise?"
- Roll with resistance and provide personalized feedback. When patients express reasons for not achieving goals, the physician can help them find ways to succeed. For example, consider stating, "I know you are tired when you get home from work, but do you think you could try walking up the stairs at work instead of taking the elevator?"
- Support self-efficacy, elicit self-motivation—For example, the physician can state, "Let's talk about what you can do to be more physically active."
Motivational interviewing techniques have been evaluated and found to be effective in randomized clinical trials. These trials have examined the impact of the use of motivational interviewing to elicit behavior modification such as smoking cessation, human immunodeficiency virus (HIV) risk reduction, and increased diet and exercise (4, 10). In a meta-analysis of 72 randomized clinical trials on the effectiveness of motivational interviewing in eliciting behavior change such as smoking cessation, weight loss, decreased alcohol use, and cholesterol level control, it was found that motivational interviewing had a significant and clinically relevant effect in modifying behaviors in approximately 75% of the studies, with an approximate equal effect on those with physiologic and psychologic diseases (11). More than one encounter ensured greater effectiveness with the patient. Discussion of behavior change to improve health outcomes is not associated with diminished patient satisfaction. In fact, tobacco use assessment and counseling by the physician are associated with greater satisfaction (12).
Applications for the Obstetrician–Gynecologist
The use of motivational interviewing has been shown to help reduce alcohol consumption in heavy drinkers during pregnancy and help drinkers who do not want to become pregnant use contraception more effectively (13). Other studies suggest that the use of motivational interviewing may increase the duration of breast-feeding and improve smoking cessation efforts. Some studies support the use of motivational interviewing to reduce risky behaviors in individuals with HIV infection as well as improve adherence with medication regimens. The use of motivational interviewing has been successful in such diverse areas as reducing the fear of childbirth, and thus decreasing the rate of cesarean delivery (14), and in lifestyle intervention for women with polycystic ovary syndrome. Studies have shown the effective application of the use of motivational interviewing in changing "risk behavior" in adolescents (15, 16). The use of motivational interviewing also has been used in the general population to aid in counseling for effective contraception use and to reduce the risk of sexually transmitted diseases. Specific Current Procedural Terminology (CPT) codes are available for billing for the counseling of patients regarding smoking cessation and other substance abuse. In addition, evaluation and management codes can be selected, using the time component, when working with patients to modify specific behaviors related to a medical diagnosis. The use of motivational interviewing is one of the strategies for structured brief intervention mentioned within the coding requirements.
Traditional medical training has not included the principles of motivational interviewing, but curricula have been developed and evaluated for both postgraduate and medical student training (11). Several approaches, known by their acronyms, have been developed for use in training. One such approach is FRAMES (17):
||Feedback—Compare the patient's risk behavior with nonrisk behavior patterns. She may not be aware that what she considers normal is risky.
||Responsibility—Stress that it is her responsibility to make the change.
||Advice—Give direct advice (not insistence) to change the behavior.
||Menu—Identify "risk situations" and offer options for coping.
||Empathy—Use a style of interaction that is understanding and involved.
||Self-efficacy—Elicit and reinforce self-motivating statements such as "I am confident that I can stop drinking." Help the patient to develop strategies, implement them, and commit to change.
An example of an intervention, using the FRAMES approach, with a nonpregnant woman is listed as follows:
"Your drinking is in the range that we call 'risky drinking' because it can cause health risks for you. These risks include…It is important to reduce your drinking to no more than seven drinks per week and no more than three drinks on one occasion." The health care provider should ask for a response to this advice to ensure that the patient understands the need to take action: "What do you think about what I just said? How do you feel about reducing your drinking below risky levels? What about using effective birth control?" If the patient agrees, consider establishing goals and creating a "change plan" to reinforce her behavior change.
Other successful motivational interviewing approaches can be found within the ACOG "Drinking and Reproductive Health Tool Kit" (17).
Training courses in motivational interviewing can be brief. In one clinical trial, it was noted that obstetric care clinicians who viewed a 20-minute motivational interviewing training video showed greater empathy, minimized patient defensiveness, and supported women's beliefs in their ability to change (18). Presentation of techniques used for motivational interviewing and case examples are suitable for Grand Rounds or other continuing medical education activities.
As of 2008, new CPT codes have been developed for patient counseling using motivational interviewing and other structured counseling techniques for smoking cessation and for screening and intervention in cases of alcohol and substance abuse. Smoking cessation coding information is available on the ACOG web site at http://www.acog.org/About-ACOG/ACOG-Departments/Tobacco--Alcohol--and-Substance-Abuse.
For patients with positive screening results for substance use or alcohol abuse, a motivational discussion by the physician or a qualified staff member that is focused on increasing the patient's understanding of the impact of substance use and motivating behavior change can be coded for reimbursement. Evaluation and Management (E/M) service codes are listed as follows (both assessment and intervention components must be documented):
99408—Alcohol and/or substance (other than tobacco) abuse structured assessment and brief intervention services 15–30 minutes
99409—Screening and brief intervention services greater than 30 minutes
These E/M services are separate from other E/M services that are performed during the same clinical visit. Modifier 25, indicating an additional separate and distinct E/M service, may be coded for some health plans.
G0396—Alcohol and/or substance (other than tobacco) abuse structured assessment and brief intervention services 15–30 minutes
G0397—Screening and brief intervention services greater than 30 minutes
Applying principles of motivational interviewing to everyday patient interactions has the potential to elicit behavior change that contributes to positive health outcomes. These changes could have an important impact on the management of major diseases in women. In addition, the principle of effective listening improves physician– patient communication and patient satisfaction during all types of physician–patient encounters. Motivational interviewing principles should be incorporated into physician and medical student training. Although the groundwork for eliciting behavior change can be set during a brief encounter, follow-up is helpful and often necessary to aid in the achievement of long term, often incremental, results. Current Procedural Terminology codes are available to aid in obtaining reimbursement for time spent engaging patients in motivational interviewing. Incorporation of motivational interviewing tools into everyday clinical encounters enhances the obstetrician–gynecologist's ability to serve patients.
- Miller WR, Rollnick S. Motivational interviewing: preparing people for change. 2nd ed. New York (NY): Guilford Press; 2002
- Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: helping patients change behavior. New York (NY): Guilford Press; 2008
- Miller WR. Motivational interviewing. Albuquerque (NM): University of New Mexico; 1989. Available from the author at the Department of Psychology, University of New Mexico, Albuquerque, NM 87131, (505) 277-4121.
- Hester RK, Handmaker NS. Motivating pregnant women to stop drinking. Albuquerque (NM): Behavior Therapy Associates; 1997. Available from Behavior Therapy Associates, 9426 Indian School Road NE, Suite 1, Albuquerque, NM 87112, (505) 345-6100.
- Additional video training materials available at: www.motivationalinterview.org/training/videos.html
- Golin CE, Patel S, Tiller K, Quinlivan EB, Grodensky CA, Boland M. Start talking about risks: development of a motivational interviewing-based safer sex program for people living with HIV. AIDS Behav 2007;11(suppl):S72–83.
- American College of Obstetricians and Gynecologists. Patient communication. In: Special issues in women's health. Washington, DC: ACOG; 2003. p. 3–9.
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- Floyd RL, Sobell M, Velasquez MM, Ingersoll K, Nettleman M, Sobell L, et al. Preventing alcohol-exposed pregnancies: a randomized controlled trial. Project CHOICES Efficacy Study Group [published erratum appears in Am J Prev Med 2007;32:360]. Am J Prev Med 2007;32:1–10.
- Saisto T, Salmela-Aro K, Nurmi JE, Kononen T, Halmesmaki E. A randomized controlled trial of intervention in fear of childbirth. Obstet Gynecol 2001;98:820–6.
- Knight JR, Sherritt L, Van Hook S, Gates EC, Levy S, Chang G. Motivational interviewing for adolescent substance use: a pilot study. J Adolesc Health 2005;37:167–9.
- Erickson SJ, Gerstle M, Feldstein SW. Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review. Arch Pediatr Adolesc Med 2005;159:1173–80.
- American College of Obstetricians and Gynecologists. Drinking and reproductive health: a fetal alcohol spectrum disorders prevention tool kit. Washington, DC: ACOG; 2006. Available at: FASDToolKit.pdf. Retrieved September 19, 2008.
- Handmaker NS, Hester RK, Delaney HD. Videotaped training in alcohol counseling for obstetric care practitioners: a randomized controlled trial. Obstet Gynecol 1999;93:213–8.