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AJLXXX10.1177/1559827615571524American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine
Analytic Stephanie Jean Sohl, PhD, Gurjeet Birdee, MD, MPH, and Roy Elam, MD
Complementary Tools to
Empower and Sustain Behavior
Change: Motivational Interviewing
and Mindfulness
Abstract: Improving health behaviors facilitating the process of health-related to change their behavior.4 Thus, it is
is fundamental to preventing and behavior change, may be required to necessary to empower individuals to
controlling chronic disease. Health care substantially influence public health. take an active role in self-regulating
providers who have a patient-centered their health behaviors on an ongoing
communication style and appropriate Keywords: health behavior; basis to improve health outcomes.
behavioral change tools can empower mindfulness; motivational interviewing; Individual empowerment, the concept
patients to engage in and sustain health coaching that “human beings have the right and
healthy behaviors. This review highlights
motivational interviewing and
mindfulness along with other evidence- Self-Determination Theory (SDT) is a
based strategies for enhancing patient-
centered communication and the particularly useful self-regulation
behavior change process. Motivational
interviewing and mindfulness are theory for understanding how the role
especially useful for empowering
patients to set self-determined, or
of a healthcare provider can influence
autonomous, goals for behavior
change. This is important because
individuals’ behavior change.
autonomously motivated behavioral
change is more sustainable. Additional
C
strategies such as self-monitoring are hronic diseases are the leading ability to choose by and for themselves,”
discussed as useful for supporting the cause of death in the United is a key concept to promoting healthy
implementation and maintenance of States, and improving health behaviors.5 The purpose of this review is
goals. Thus, there is a need for health behaviors (eg, physical activity, proper to highlight evidence-based methods
care providers to develop such tools to nutrition) is fundamental to preventing and resources that health care providers
empower sustained behavior change. and controlling chronic disease.1-3 can use to increase patient
The additional support of a new role, Individuals generally recognize the need empowerment and facilitate sustainable
a health coach who specializes in for behavior change, but are still unable behavior change.
DOI: 10.1177/1559827615571524. Manuscript received February 21, 2014; revised December 8, 2014; accepted December 9, 2014. From the Osher Center for
Integrative Medicine at Vanderbilt University, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. Address correspondence to Stephanie Jean
Sohl, PhD, Center for Health Services Research & Osher Center for Integrative Medicine at Vanderbilt University, Department of Medicine, Vanderbilt University Medical Center,
Sixth Floor, Suite 600, 2525 West End Avenue, Nashville, TN 37203-1738; e-mail: stephanie.sohl@Vanderbilt.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2015 The Author(s)
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vol. 10 • no. 6 American Journal of Lifestyle Medicine
for the intervention is unknown. The mindful. There is no right or wrong characteristics related to providing
emphasis on increasing the quantity of way to do this exercise. Just notice patient-centered care.29 Therefore, the
change talk (ie, number of times the your reactions and know that this health care providers themselves are
patient mentions the intention to meditation practice will likely be likely to benefit from the practice of
different each time you try it.
change) in motivational interviewing mindfulness in addition to the positive
may also not capture the importance of effect of mindfulness on their patients.
a patient’s true desire to change.23 That Indeed, research is emerging to support Indeed, other studies support the
is, patients may express many plans for that a mindful disposition is associated benefits of mindfulness practices for
behavior change consistent with what with and mindfulness practices increase health care providers such as reduced
they expect the provider would like for the patient-centeredness of health care burnout, improved job satisfaction, and
them to do (eg, “I plan to join a gym so providers.26,29-31 For example, health care improved emotional well-being.29,32-34
that I will achieve the recommended providers (N = 45; physicians, nurse The goals of a mindfulness practice
amount of exercise”) rather than change practitioners, physician assistants) with a include understanding one’s own
consistent with their personal values (eg, higher self-reported mindfulness responses and biases so that it is possible
“I plan to walk daily on the trails near disposition were more likely to deliver to accurately understand and skillfully
my house because feeling connected patient-centered care than those with relate to the patient.27 When both the
with nature is important to me”). Recent lower mindfulness scores.26 In addition, physician and patient are engaged, their
interest in the application of SDT to patients of health care providers who interaction can lead to a greater outcome
motivational interviewing has were high in dispositional mindfulness than either person could achieve
encouraged a shift in the emphasis from engaged in higher quality patient– separately.35 The importance of the
the quantity of the change talk to physician communication even after relationship between the patient and
ensuring that the quality of the change adjusting for covariates such as length of provider is also consistent with the
talk is autonomously motivated.23,24 visit. Patients of health care providers concept of individual’s need for
Therefore, SDT can be adopted to high in dispositional mindfulness also relatedness in SDT.36 Relationships can
explain the efficacy of motivational reported high overall satisfaction with help individuals process complex
interviewing when motivational care. information and come to an informed
interviewing emphasizes increasing the Another study of health care providers decision.37 People consider multiple
same construct important to achieve (N = 20 physicians) who completed an components when making decisions,
behavior change proposed in SDT (ie, 8-week course on learning mindfulness including analytic thinking, feelings, and
autonomy support). practices revealed that they qualitatively intuition. If both the patient and provider
perceived an improved ability to be mindfully experience these multiple
Mindfulness attentive to their patients’ concerns and components when a medical decision is
The mindfulness of a health care more effectively respond to such presented, the discussion of their unique
provider, or tendency to be “attentive to concerns.30 One provider in this study experiences can lead to a more sound
and aware of what is taking place in the stated, decision.37 Understanding patients’ desire
present,”25 supports patient for involvement in decision making is
I am much more attuned to listening. I
autonomy.25-28 Mindfulness in this context considered an important component of
put a mental stopwatch in my head. I
is considered a disposition, or general patient-centered care.16 It is particularly
[now] have a heightened awareness
tendency, that can be enhanced by and sensitivity to people’s important to engage patients in the
practicing a mindful state through conversation. I look at my own decisions that involve a personal
techniques such as meditation.25 communication and pay much more preference such as the decision to
Meditation is primarily training your attention to that. I pay much more change a behavior.38 Therefore, it is
attention to focus on the present moment attention in general. likely that increasing the mindfulness of
without judgment. Instructions for a both the patient and health care provider
meditation practice could be as simple as Thus illustrating a specific instance of will increase the patient-centeredness of
the following: how mindfulness can influence the the interaction and likelihood that a
patient-centeredness of communication. patient will decide on an autonomously
Aim to keep your attention on your Furthermore, a study of 70 health care motivated reason for behavior change.
breath for the next 5 minutes (set a providers (ie, primary care physicians)
timer). Notice what moves in your who completed an 8-week course on
body as you breathe. If your mind mindfulness practices reported positive Facilitating Autonomous
wanders, gently remind yourself to
changes in providers’ own health in Self-Regulation
bring your attention back to your
breathing. Each time you remember to
addition to increases in their empathy Self-regulation, or the processes related
bring your attention back, you are and belief that patients’ psychosocial to achieving a desired outcome,4 can be
strengthening your ability to be issues are important, which are facilitated by motivational interviewing
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American Journal of Lifestyle Medicine Nov • Dec 2016
and mindfulness. Self-regulation consists may choose to shift the focus of the perceived competence for performing the
of 2 overarching processes: goal setting conversation to goal setting. Some behaviors needed to achieve a goal (eg,
and goal striving.4,39 Patients who are guidance for goal setting includes having knowledge of when, where, how
involved in the first process of goal patients4: behaviors will be performed) and
setting may not yet be considering a perceived competence for maintaining
behavior change. As mentioned •• Develop goals that are framed toward the goal once the new behavior is
previously, motivational interviewing is obtaining a desired rather than an initiated (eg, confidence in identifying
likely most useful for patients in this undesired outcome because this barriers and planning alternative actions).
stage.19 Mindfulness, or self-awareness, is makes it more feasible to assess Some recommended strategies for
viewed as the first step in facilitating self- success. For example, it is more supporting successful goal pursuit
regulation according to the self- tangible to determine if one has include having patients4:
regulation theory presented by SDT.28 attained the goal of walking more
Mindfulness enhances patients’ ongoing frequently than a goal of being less •• Specify what actions will be taken
ability to accurately perceive their sedentary. One exception is if there is and when to achieve the goal.
behavior and how that differs from their an existing undesired outcome that •• Prevent disruptions to goal
desired outcome. In addition, preliminary one would like to eliminate such as a achievement using various strategies
evidence supports that enhancing cough from smoking. such as (a) identify possible obstacles
mindfulness thorough mind–body •• Set a goal that is balanced between and plan ways to alter consequences
practices (eg, meditation, yoga) is related being ideal and at a realistic level of of taking undesired actions, (b) create
to improvements in lifestyle change difficulty. That is, ideal goals such as automatic habits by consistently
(eating disorders, smoking cessation).40,41 winning a gold medal in the engaging in the desired behavior in a
For example, noticing the effects of food Olympics may be quite motivating particular context, and (c) find ways
on the body may influence the desire for and serve as a useful overarching to remember to think of big picture
an improved diet and result in weight vision; however, starting with a more related to the overall goal rather than
loss (eg, “I notice that I feel sluggish after short-term goal of beating your the specific situation that may contain
eating fried food and would like to eat it personal best performance in the an obstacle.
less so that I am more able to chosen sport may be a more realistic
concentrate on my work”).40 Highlighting first step. Choosing a goal with the A successful action process also includes
discrepancies between current and appropriate level of difficulty will self-monitoring (eg, identifying methods
desired states is also used as a technique increase expectations for a positive for developing accountability to
in motivational interviewing to generate outcome and beliefs that one is achieving goal), which is another
autonomous motivation for and the capable of achieving the goal. strategy supported by evidence for
intention to change.19 Patients who are •• Create a goal that is focused on inclusion in behavior change
aware of such discrepancies are more gradually mastering the process of interventions.45-47 The process of goal
likely to generate intrinsic goals, or goals developing a new behavior rather striving will be supported by regular
that are motivated by a self-determined than an “all-or-nothing” strategy for interactions with a health care provider
(autonomous) rather than an externally immediately achieving the ultimate who is knowledgeable of the patient’s
determined reason.7 Intrinsically outcome. goals.48
motivated goals are more likely to be Figure 1 illustrates evidence-based
achieved than goals that are extrinsically Goal setting is an effective strategy that relationships among the SDT concepts
motivated.4 This point is also illustrated leads to behavior change as at least discussed.7,9,10
by an intervention to facilitate the self- partially explained through increasing
management of chronic diseases (ie, perceived competence (also called
Health Coaching
heart disease, lung disease, stroke, or self-efficacy).43,44 Perceived competence
arthritis) that provided participants with is important at different stages of Health coaching is a new profession
the opportunity to self-select their goals behavior change (ie, goal setting and that draws from multiple evidence-based
rather than prescribing specific behavior goal striving).39 tools for facilitating patients’ autonomous
changes.42 Results showed that this self-regulation (eg, motivational
process of autonomous goal setting Goal Striving interviewing, mindfulness, self-
successfully changed health behaviors Once patients have set a goal to initiate monitoring) to address the growing need
and reduced hospitalizations.42 a behavior change, the next step is to for an increase in healthy behaviors.
engage in goal pursuit. This process Health coaches generally support
Goal Setting involves performing and sustaining the individuals in identifying health behavior
Once patients have determined their intended action.39 In this process, it is change goals and maintaining desired
motivation to act, health care providers important to cultivate a patient’s changes over a series of coaching
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vol. 10 • no. 6 American Journal of Lifestyle Medicine
Figure 1.
A Self-Regulation Model for Enhancing Patients’ Sustained Behavior Change.
Autonomy
Autonomous
Autonomy Support from Perceived Competence for Self-Regulation Health
Healthcare Providers Behavior Change (e.g., goal setting and Outcomes
striving)
Relatedness
(feeling cared for by others)
sessions. Health coaches have emerged outcomes. Published interventions that the psychological literature, diagnosing
from 2 general perspectives: (a) within a utilize the term “health coach” in the or working with psychopathology is not
health care context with the goal of context of health also differ with regard within the scope of a health coach’s
managing chronic medical conditions to variables such as the educational role.57
and (b) from a life coaching background background, level of training as a health Recent individual studies with strong
with the goal of supporting optimal coach,49 level of experience, and methodology demonstrate the efficacy of
health. A National Consortium for additional skills that may be incorporated coaching to improve some specific
Credentialing Health and Wellness (eg, mindfulness practices).55 The health behaviors and outcomes. For
Coaches (http://ncchwc.org/) has background of health coaches varies example, a randomized controlled trial
convened and is in the process of with a majority who hold additional (N = 415) found that coaching
creating a formal uniform definition. professional degrees (eg, 51% allied implemented both in person and
Although there is considerable variability health professionals and 42% nurses).49 remotely as compared to a self-directed
in the current definition of a health Therefore, future research with stronger control group resulted in sustained
coach, a recent systematic review has methodological designs that adopt the weight loss at 24 months for obese
identified similarities within these diverse newly established definition of a health patients who had at least one
existing interventions such that most coach and include reporting of treatment cardiovascular risk factor.58 Another
include the following common fidelity processes are needed.49,53 randomized controlled trial (N = 410)
components: a patient-centered found that a telephone-based coaching
approach, encouragement of self- Health Coaching and intervention as compared to usual care
Motivational Interviewing
discovery, content education, goal setting improved moderate physical activity,
determined by the patient, and The encouragement of self-discovery in body mass index, and dietary habits after
mechanisms such as self-monitoring for health coaching is similar to the focus of 12 months in colorectal cancer
developing accountability.49 Thus, health evoking a patient’s self-determined survivors.59 Both of these health
coaching is an approach that emphasizes reason for behavior change used in coaching interventions used motivational
supporting the autonomy of the patient motivational interviewing. Thus, a health interviewing plus additional behavior
in facilitating behavior change and is coach may adopt motivational change techniques (eg, self-monitoring,
consistent with the principles of behavior interviewing as one of multiple tools mindfulness) and found a significant
changed outlined by SDT.23,50 utilized.56 This approach engages effect of multiple coaching contacts (ie,
Reviews of the existing literature on the patients in problem solving rather than >10 sessions) implemented remotely.58,59
overall efficacy of health coaching are the health care provider didactically
promising yet inconclusive due to the prescribing behavioral change. Health Health Coaching and
coaches enable patients to develop Mindfulness
previous variability in the definition of
health coaching and limited number of individualized action plans by eliciting Mindfulness is likely to strengthen both
high-quality studies.49,51-54 In general, what content education is needed, the health care provider’s support of the
these reviews provide preliminary facilitating autonomous goal setting, and patient’s autonomy and the patient’s
support for the capacity of health mechanisms for developing ability to autonomously engage in the
coaching to improve behavior change accountability. Although many coaching self-regulation process. That is,
and mental and physical health techniques are drawn from a subset of mindfulness may augment the
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