Motivational Interviewing (MI) is a patient-centered counseling approach rooted in key theoretical principles—including decisional balance, self-perception theory, and the transtheoretical model of change—that uses directed techniques to enhance patients’ intrinsic motivations for and reduce their ambivalence toward behavior change.  Introduced in the early 1980s as a counseling strategy for encouraging behavior change among people with alcohol dependence, the principles, methods, and specific techniques employed in MI have been researched and analyzed for a variety of health conditions for which behavior change is a critical part of health-promoting interventions.  MI has now been firmly established as an effective, evidence-based practice in the treatment of substance use disorders (SUDs) and other health conditions including diabetes, obesity, and smoking cessation.

MI uses principles of collaboration between the provider and client (rather than confrontation), the intent of which is to develop rapport and trust, along with evocation of the client’s own thoughts and ideas (rather than imposing the provider’s opinions), and autonomy and self-efficacy (rather than authority).  MI recognizes that true motivation for behavioral change rests within the client. While the provider may have different opinions about the timing or approach to a particular condition, an understanding of the client’s experience and beliefs and ultimately eliciting the client’s own motivations for changing unhealthful behaviors is more likely to result in lasting change.

The optimal implementation of this best practice would be for hospital and office-based providers to organize MI trainings and regular practice opportunities for all of their staff, especially clinical staff involved in gathering patient information who might have the opportunity to motivate behavior change.  In the absence of resources for MI training, this best practice includes several techniques that can be employed without significant training.  Additionally, the curriculum included in the Resources section of this Best Practice incorporates links to several web-based videos demonstrating some of these techniques that may be helpful adjuncts to staff interested in further MI exposure and practice.

Ideally, providers can use MI curricula to become more proficient in these techniques, and all levels of staff can participate in these curricula and employ these techniques. One such curriculum is included in the Resources section for this Best Practice. In the absence of formal training, several specific MI strategies and techniques are described below.

Incorporate the foundational principles of MI into communication with pregnant and parenting women with opioid use disorder (OUD).  These foundational principles of MI should be employed continuously over time and include:

Employ the following general style of MI in all patient communication:

The following are specific motivational skills and strategies that can be practiced and incorporated into all patient engagements, especially those that involve behavior change and compliance with treatment plans.  Each of these strategies is described in more detail in the MI Curriculum included in the Resources section of this Best Practice. 

Employ the OARS+ model as one set of specific MI skills.

Rolling with resistance requires the listener/provider to pause and shift conversations when signs of an argument or confrontation begin to appear.  Resistance behavior occurs when points of view differ, generally when the provider is moving the patient ahead too quickly, or the provider fails to understand something of importance to the patient. When resistance appears, the listener/provider should change strategies and utilize OARS techniques.

Developing discrepancy involves the listener/provider guiding the conversation so the patient can articulate their personal beliefs and future goals (listen especially for statements about life, family, health, financial status, living situation, and other personal considerations). Developing discrepancy between the patient’s behaviors and their broader life goals is essential because patients are more often motivated to change when they arrive at that conclusion themselves rather than hearing it from someone else.

Change Talk is defined as statements made by the patient that indicate motivation for, consideration of, or commitment to change behavior. There are clear correlations between patients’ change talk and outcomes. Once the listener/provider and patient have established a trusting relationship and have open communication about the patient’s substance use, the listener/provider can guide the patient to expressions of change talk using some of the techniques listed below.  Each of these strategies is described in more detail in the Motivational Interviewing Curriculum included in the Resources section of this Best Practice, along with additional strategies for eliciting change talk.

Coding and Reimbursement – MI focused on increasing the patient’s understanding of the impact of their substance use and motivating behavior change can be coded for reimbursement whenever a positive screen (through interview, formal screening tool, or toxicology) is identified and documented in the medical records. Evaluation and Management (E/M) service codes for both assessment and intervention are listed below (and can be coded with modifier 25 when they are performed during the same clinical visit as other E/M services):