Motivational interviewing is an approach, first reported in the addiction literature, to improve adherence (Miller & Rollnick, 2002); it is both an assessment strategy and an intervention. Motivational interviewing is used to determine a person's readiness to engage in a target behavior - such as taking a medication as prescribed - and then applying specific skills and strategies based on the person's level of readiness to create a favorable climate for change.

Motivational interviewing is a person-centered, directive method of communicating with the goal of enhancing a person's intrinsic motivation to change by exploring and resolving ambivalence and resistance (Miller & Rollnick, 2002). Motivational interviewing techniques try to avoid simply telling a person what they need to do. People can easily dismiss such suggestions or come up with a number of reasons why the suggested change is not possible.

The essence of motivational interviewing is in its collaborative nature, communicating in a partner-like relationship, where the interviewer seeks to create a positive interpersonal atmosphere. In motivational interviewing, responsibility for change is left to the person; the overall goal is to increase the person's intrinsic motivation, so that change arises from within rather than being imposed.

It must be recognized that it is the person, not the health care provider, who will ultimately need to make changes that will affect their health. Thus, change must be negotiated, not dictated. Consistent with the collaborative model, the health care provider functions not to motivate the person, but to draw out intrinsic motivation based on the person's own personal goals and values.

Motivational interviewing uses a number of person-centered techniques to create a favorable climate for change. There are five general principles that underlie motivational interviewing (Miller & Rollnick, 2002). The key principles are arranged to form the acronym READS, to help providers remember these key concepts (Table 7). These principles are not necessarily applied in this particular order, and all of these techniques should be used throughout the interaction.

Resistance can take several forms, such negating, blaming, excusing, minimizing, arguing, challenging, interrupting, and ignoring. In motivational interviewing one does not directly oppose resistance but, rather, rolls or flows with it. Direct confrontation will create additional barriers that will make change more difficult. A person's resistance during motivational interviewing is expected and should not be viewed as a negative outcome. In fact, a person who resists is providing information about factors that foster or reduce motivation to adhere to behavioral change. Rolling with resistance, then, includes involving the person actively in the process of problem solving.

Resistant behavior may be a signal that the person does not believe or accept information that has been presented. The health care provider should provide information and alternatives, and explore possible solutions. Exploring the reasons behind the resistant behavior can lead the person to seriously consider possibilities for change.

Because motivational interviewing relies to a great extent on establishing and maintaining rapport with the person, the ability to express empathy is critical to this process. This requires skillful, reflective listening to understand a person's feelings and perspectives without judging, criticizing, or blaming. An attitude of acceptance and respect contributes to the development of an effective, helping relationship and enhances the person's self-esteem. Empathic responses demonstrate that the health care provider understands the person's point of view and provides an important basis for engaging the person in a process of change.

Resistance to change is strongly affected by the health care provider's response; therefore, arguments should be avoided. Direct confrontations usually result in defensive reactions and increased resistance to change. Resistance is an indication that the health care provider should change strategies rather than argue. The emphasis should focus on helping the person with self-recognition of problem areas rather than coerced admission.

The principle of developing discrepancy is based on the understanding that motivation for change is created when the person perceives a discrepancy between their present behavior and important personal goals (Miller & Rollnick, 2002). This often involves identifying and clarifying the person's own goals. The goals need to be those of the person and not those of the health care provider, otherwise the person will feel as though they are being coerced and may become more resistant to change. An important objective of motivational interviewing is to help a person recognize or amplify the discrepancy between their behavior and their personal goals.

There are a number of techniques that can be used to help develop discrepancy. One technique is to ask the person what is good or positive about a particular behavior and what is bad or not so good about that same behavior. Reflecting back and examining the positive and negative will help discrepancy emerge. When skillfully done, motivational interviewing changes the person's perceptions of discrepancy without creating a sense of being pressured of coerced.

Self-efficacy is a person's belief or confidence in their ability to carry out a target behavior successfully. A general goal of motivational interviewing is to enhance the person's confidence in their ability to overcome barriers and succeed in change.

Health care providers can support self-efficacy by recognizing small positive steps that the person is taking to change their behavior. Even when the person is simply contemplating a change, there is an opportunity to provide recognition and support. Supportive statements can be as simple as "It's great to hear that you are interested in getting more information about your diabetes."

Setting reasonable and reachable goals that the person can actually accomplish will also help build confidence. It is important that the person be involved in setting the goal. For an overweight person that is physically inactive, even getting them to exercise five to 10 minutes twice a week is a move in the right direction. Seeing that they can accomplish this will give them additional motivation to continue to exercise.

Lastly, it is important that the health care provider believes that the person can achieve the goal. This belief in the person can have a powerful positive effect on the outcome.

The person, not the health care provider, is the primary source of solutions for dealing with their medical problems. In order for the person to take responsibility for their own health, they need to become an active participant in sessions with their health care providers.

Motivational interviewing uses the general concept of elicit, provide, elicit, which is a continuous process Information is elicited from the person so the health care provider can better understand their attitudes, beliefs, values, and readiness to change. The health care provider can check for understanding of what the person is saying by using reflective listening skills and asking for additional clarification when required; this will help establish a collaborative relationship and build empathy. Information elicited can also be used to help develop discrepancy.

After eliciting information, the health care provider can then provide information to address any knowledge gaps identified. It may be appropriate at times to ask permission from the person to provide them with additional information. This may increase acceptance of the information, as the person will not feel that information is simply being imposed on them.

Lastly, whenever the person is presented with new information, the health care provider should elicit information on the person's understanding of the new information and their feelings about it. This can identify concerns or questions that the person may have regarding the information presented.