Toward an Emerging Role for Motivational Interviewing in Primary Care

  • Robert KeeleyEmail author
  • Matthew Engel
  • Alex Reed
  • David Brody
  • Brian L. Burke
Psychiatry in Primary Care (BN Gaynes, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Psychiatry in Primary Care


Purpose of Review

Implementing Motivational Interviewing (MI) in primary care settings has been problematic due in part to persistent gaps in knowledge. Examples include poor understanding of how to effectively train persons to conduct MI, or of which aspects of MI-related communication are associated with better outcomes for patients. This review describes how recent research findings addressing the knowledge gaps support a growing role for MI in primary care.

Recent Findings

Two trials of MI training combined classroom time with ongoing coaching and feedback, resulting in enhanced MI ability relative to a control arm where PCPs received minimal or no MI training. A third MI training trial excluded coaching and feedback, failing to increase use of MI. Adding to a growing list of behavioral health-related problems for which MI training has shown some effectiveness, a trial of training PCPs to use MI with depressed patients was associated with significantly improved depressive symptoms. Moreover, aspects of the PCPs’ MI-related language and patients’ arguments for positive behavior changes, “change talk,” appeared to explain the positive effects of MI training on depression outcome.


MI-training approaches have improved such that PCPs and possibly other clinic staff may want to consider MI training as a way to more effectively support their patients as they address behavioral health-related problems (e.g., tobacco use). MI training should focus on eliciting “change talk” from patients. Researchers and funding agencies might collaborate to continue closing knowledge gaps in the MI literature.


Motivational Interviewing Primary care MI training 


Compliance with Ethical Standards

Conflict of Interest

Robert Keeley, Matthew Engel, Alex Reed, David Brody, and Brian L. Burke each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Murray CJ, Abraham J, Ali MK, Alvarado M, Atkinson C, Baddour LM, et al. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591–606.CrossRefPubMedGoogle Scholar
  2. 2.
    Petterson SM, Liaw WR, Phillips RL Jr, Rabin DL, Meyers DS, Bazemore AW. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503–9. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. The Milbank Quarterly. 2005;83(3):457–502. Scholar
  4. 4.
    Organization WH. The world health report 2006: working together for health: World Health Organization; 2006.Google Scholar
  5. 5.
    Petterson SM, Liaw WR, Phillips RL, Rabin DL, Meyers DS, Bazemore AW. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503–9.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Bock C, Diehl K, Schneider S, Diehm C, Litaker D. Behavioral counseling for cardiovascular disease prevention in primary care settings: a systematic review of practice and associated factors. Med Care Res Rev. 2012;69(5):495–518. Scholar
  7. 7.
    Fleming P, Godwin M. Lifestyle interventions in primary care: systematic review of randomized controlled trials. Can Fam Physician. 2008;54(12):1706–13.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Solberg LI, Maciosek MV, Edwards NM. Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness. Am J Prev Med. 2008;34(2):143–52. Scholar
  9. 9.
    Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction. 2012;107(6):1066–73. Scholar
  10. 10.
    Bodenheimer T, Handley MA. Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns. 2009;76(2):174–80. Scholar
  11. 11.
    Hung DY, Green LA. Paying for prevention: associations between pay for performance and cessation counseling in primary care practices. Am J Health Promot. 2012;26(4):230–4. Scholar
  12. 12.
    White WL, Miller WR. The use of confrontation in addiction treatment: history, science and time for change. Counselor. 2007;8(4):12–30.Google Scholar
  13. 13.
    Rost K, Nutting P, Smith J, Coyne JC, Cooper-Patrick L, Rubenstein LV. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9(2):150–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Frank E, Schlair S, Elon L, Saraiya M. Do US medical students report more training on evidence-based prevention topics? Health Educ Res. 2012;28(2):265–75.CrossRefPubMedGoogle Scholar
  15. 15.
    Butler CC, Simpson SA, Hood K, Cohen D, Pickles T, Spanou C, et al. Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial. BMJ. 2013;346:f1191.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Miller RM, Rollnick S. Motivational Interviewing: Helping people change. 3rd ed. New York: Guilford Press; 2013.Google Scholar
  17. 17.
    Moyers TB, Houck J, Glynn LH, Hallgren KA, Manuel JK. A randomized controlled trial to influence client language in substance use disorder treatment. Drug Alcohol Depend. 2017;172:43–50.doi: Epub 7 Jan 12.
  18. 18.
    Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64(6):527–37.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Apodaca TR, Longabaugh R. Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction. 2009;104(5):705–15. Scholar
  20. 20.
    Moyers TB, Martin T, Houck JM, Christopher PJ, Tonigan JS. From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing. J Consult Clin Psychol. 2009;77(6):1113–24.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Vader AM, Walters ST, Prabhu GC, Houck JM, Field CA. The language of motivational interviewing and feedback: counselor language, client language, and client drinking outcomes. Psychol Addict Behav. 2010;24(2):190–7.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Magill M, Apodaca TR, Borsari B, Gaume J, Hoadley A, Gordon REF, et al. A meta-analysis of motivational interviewing process: technical, relational, and conditional process models of change. J Consult Clin Psychol. 2018;86(2):140–57. Epub 2017 Dec 21CrossRefPubMedGoogle Scholar
  23. 23.
    Miller WR, Yahne CE, Moyers TB, Martinez J, Pirritano M. A randomized trial of methods to help clinicians learn motivational interviewing. J Consult Clin Psychol. 2004;72(6):1050–62.CrossRefPubMedGoogle Scholar
  24. 24.
    Miller WR, Benefield RG, Tonigan JS. Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. J Consult Clin Psychol. 1993;61(3):455–61.CrossRefPubMedGoogle Scholar
  25. 25.
    McCambridge J, Strang J. The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial. Addiction. 2004;99(1):39–52.CrossRefPubMedGoogle Scholar
  26. 26.
    Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. Am J Prev Med. 2001;20(1):68–74.CrossRefPubMedGoogle Scholar
  27. 27.
    Fisher L, Polonsky WH, Hessler D, Potter MB. A practical framework for encouraging and supporting positive behaviour change in diabetes. Diabet Med. 2017;34:1658–66. Scholar
  28. 28.
    Hunter CL, Goodie JL, Oordt MS, Dobmeyer AC. Integrated behavioral health in primary care: step-by-step guidance for assessment and intervention. Washington, DC, US: American Psychological Association; 2017.CrossRefGoogle Scholar
  29. 29.
    Lundahl B, Moleni T, Burke BL, Butters R, Tollefson D, Butler C, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013;93(2):157–68.CrossRefPubMedGoogle Scholar
  30. 30.
    Gayes LA, Steele RGA. Meta-analysis of motivational interviewing interventions for pediatric health behavior change. J Consult Clin Psychol. 2014;82(3):521–35. Epub 2014 Feb 17CrossRefPubMedGoogle Scholar
  31. 31.
    VanBuskirk KA, Wetherell JL. Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med. 2014;37(4):768–80.CrossRefPubMedGoogle Scholar
  32. 32.
    Ahluwalia JS, Okuyemi K, Nollen N, Choi WS, Kaur H, Pulvers K, et al. The effects of nicotine gum and counseling among African American light smokers: a 2 × 2 factorial design. Addiction. 2006;101(6):883–91. Scholar
  33. 33.
    Ball GD, Mackenzie-Rife KA, Newton MS, Alloway CA, Slack JM, Plotnikoff RC, et al. One-on-one lifestyle coaching for managing adolescent obesity: findings from a pilot, randomized controlled trial in a real-world, clinical setting. Paediatr Child Health. 2011;16(6):345–50.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Barkin SL, Finch SA, Ip EH, Scheindlin B, Craig JA, Steffes J, et al. Is office-based counseling about media use, timeouts, and firearm storage effective? Results from a cluster-randomized, controlled trial. Pediatrics. 2008;122(1):e15–25. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Black MM, Hager ER, Le K, Anliker J, Arteaga SS, Diclemente C, et al. Challenge! Health promotion/obesity prevention mentorship model among urban, black adolescents. Pediatrics. 2010;126(2):280–8. Epub 2010 Jul 26CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Barnet B, Liu J, DeVoe M, Duggan AK, Gold MA, Pecukonis E. Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial. Ann Fam Med. 2009;7(5):436–45. Scholar
  37. 37.
    Chacko MR, Wiemann CM, Kozinetz CA, von Sternberg K, Velasquez MM, Smith PB, et al. Efficacy of a motivational behavioral intervention to promote chlamydia and gonorrhea screening in young women: a randomized controlled trial. J Adolesc Health. 46(2):152–61.
  38. 38.
    D'Amico EJ, Miles JN, Stern SA, Meredith LS. Brief motivational interviewing for teens at risk of substance use consequences: a randomized pilot study in a primary care clinic. J Subst Abus Treat. 2008;35(1):53–61. Scholar
  39. 39.
    Emmen MJ, Schippers GM, Wollersheim H, Bleijenberg G. Adding psychologist's intervention to physicians’ advice to problem drinkers in the outpatient clinic. Alcohol Alcohol. 2005;40(3):219–26. Epub 2005 Feb 7 CrossRefPubMedGoogle Scholar
  40. 40.
    Greaves CJ, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Steele A, et al. Motivational interviewing for modifying diabetes risk: a randomised controlled trial. Br J Gen Pract. 2008;58(553):535–40. Scholar
  41. 41.
    Hardcastle S, Taylor A, Bailey M, Castle R. A randomised controlled trial on the effectiveness of a primary health care based counselling intervention on physical activity, diet and CHD risk factors. Patient Educ Couns. 2008;70(1):31–9. Epub Nov 7.
  42. 42.
    Hillsdon M, Thorogood M, White I, Foster C. Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care. Int J Epidemiol. 2002;31(4):808–15.CrossRefPubMedGoogle Scholar
  43. 43.
    Maisto SA, Conigliaro J, McNeil M, Kraemer K, Conigliaro RL, Kelley ME. Effects of two types of brief intervention and readiness to change on alcohol use in hazardous drinkers. J Stud Alcohol. 2001;62(5):605–14.CrossRefPubMedGoogle Scholar
  44. 44.
    • Menon U, Belue R, Wahab S, Rugen K, Kinney AY, Maramaldi P, et al. A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence. Ann Behav Med. 2011;42(3):294–303. This may be the first trial of MI in primary care to assess and report MI training outcomes with a valid approach to measuring fidelity, thus taking a step toward addressing limited understanding of how well MI is conducted in trials. CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Noknoy S, Rangsin R, Saengcharnchai P, Tantibhaedhyangkul U, McCambridge J. RCT of effectiveness of motivational enhancement therapy delivered by nurses for hazardous drinkers in primary care units in Thailand. Alcohol Alcohol. 2010;45(3):263–70.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Obarzanek E, Kimm SY, Barton BA, Van Horn LL, Kwiterovich PO Jr, Simons-Morton DG, et al. Long-term safety and efficacy of a cholesterol-lowering diet in children with elevated low-density lipoprotein cholesterol: seven-year results of the Dietary Intervention Study in Children (DISC). Pediatrics. 2001;107(2):256–64.CrossRefPubMedGoogle Scholar
  47. 47.
    Olson AL, Gaffney CA, Lee PW, Starr P. Changing adolescent health behaviors: the healthy teens counseling approach. Am J Prev Med. 2008;35(5 Suppl):S359–64. Scholar
  48. 48.
    Ogedegbe G, Chaplin W, Schoenthaler A, Statman D, Berger D, Richardson T, et al. A practice-based trial of motivational interviewing and adherence in hypertensive African Americans. Am J Hypertens. 2008;21(10):1137–43. Epub Jul 24CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Rubak S, Sandbaek A, Lauritzen T, Borch-Johnsen K, Christensen B. General practitioners trained in motivational interviewing can positively affect the attitude to behaviour change in people with type 2 diabetes. One year follow-up of an RCT, ADDITION Denmark. Scand J Prim Health Care. 2009;27(3):172–9. Scholar
  50. 50.
    Schaus JF, Sole ML, McCoy TP, Mullett N, O’Brien MC. Alcohol screening and brief intervention in a college student health center: a randomized controlled trial. J Stud Alcohol Drugs Suppl. 2009;(16):131–41.Google Scholar
  51. 51.
    Senft RA, Polen MR, Freeborn DK, Hollis JF. Brief intervention in a primary care setting for hazardous drinkers. Am J Prev Med. 1997;13(6):464–70.CrossRefPubMedGoogle Scholar
  52. 52.
    Soria R, Legido A, Escolano C, Lopez Yeste A, Montoya J. A randomised controlled trial of motivational interviewing for smoking cessation. Br J Gen Pract. 2006;56(531):768–74.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Van Voorhees BW, Fogel J, Pomper BE, Marko M, Reid N, Watson N, et al. Adolescent dose and ratings of an internet-based depression prevention program: a randomized trial of primary care physician brief advice versus a motivational interview. J Cogn Behav Psychother. 2009;9(1):1–19.PubMedPubMedCentralGoogle Scholar
  54. 54.
    Ogedegbe G, Schoenthaler A, Richardson T, Lewis L, Belue R, Espinosa E, et al. An RCT of the effect of motivational interviewing on medication adherence in hypertensive African Americans: rationale and design. Contemp Clin Trials. 2007;28(2):169–81. Scholar
  55. 55.
    Hardcastle S, Taylor A, Bailey M, Castle R. A randomised controlled trial on the effectiveness of a primary health care based counselling intervention on physical activity, diet and CHD risk factors. Patient Educ Couns. 2008;70(1):31–9.CrossRefPubMedGoogle Scholar
  56. 56.
    Copeland L, McNamara R, Kelson M, Simpson S. Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: a systematic review. Patient Educ Couns. 2015;98(4):401–11. Scholar
  57. 57.
    Madson MB, Loignon AC, Lane C. Training in motivational interviewing: a systematic review. J Subst Abus Treat. 2008;Google Scholar
  58. 58.
    Soderlund LL, Nilsen P. Feasibility of using motivational interviewing in a Swedish pharmacy setting. Int J Pharm Pract. 2009;17(3):143–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH behavior change consortium. Health Psychol. 2004;23(5):443–51. Scholar
  60. 60.
    Lundahl BW, Tollefson GD, Kunz C, Brownell C, Burke BL. Meta-analysis of motivational interviewing: twenty five years of research. Res Social Work Pract. 2010;20:137–60.CrossRefGoogle Scholar
  61. 61.
    Morton K, Beauchamp M, Prothero A, Joyce L, Saunders L, Spencer-Bowdage S, et al. The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review. Health Psychol Rev. 2015;9(2):205–23.CrossRefPubMedGoogle Scholar
  62. 62.
    Kraemer HC, Wilson GT, Fairburn CG, Agras WS. Mediators and moderators of treatment effects in randomized clinical trials. Arch Gen Psychiatry. 2002;59(10):877–83.CrossRefPubMedGoogle Scholar
  63. 63.
    Kraemer HCA. Mediator effect size in randomized clinical trials. Int J Methods Psychiatr Res. 2014;18(10)Google Scholar
  64. 64.
    •• Fu SS, Roth C, Battaglia CT, Nelson DB, Farmer MM, Do T, et al. Training primary care clinicians in motivational interviewing: a comparison of two models. Patient Educ Couns. 2015;98(1):61–8. This MI training trial appears to be the first to include primary care staff and demonstrate that classroom training with ongoing coaching and booster sessions was associated with superior provision of MI over 12 weeks relative to a classroom-only training. CrossRefPubMedGoogle Scholar
  65. 65.
    •• Jansink R, Braspenning J, Laurant M, Keizer E, Elwyn G, Weijden T, et al. Minimal improvement of nurses’ motivational interviewing skills in routine diabetes care one year after training: a cluster randomized trial. BMC Fam Pract. 2013;14:44. This trial of MI training made substantive contributions to addressing two knowledge gaps in the literature by contributing toward understanding what approaches are impactful or not for MI training, and how to measure fidelity. CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    •• Jansink R, Braspenning J, Keizer E, van der Weijden T, Elwyn G, Grol R. No identifiable Hb1Ac or lifestyle change after a comprehensive diabetes programme including motivational interviewing: a cluster randomised trial. Scand J Prim Health Care. 2013;31(2):119–27. This clinical trial of MI training for improving patients’ sugar control and lifestyle made substantive contributions to addressing the third knowledge gap, puzzling heterogeneity in outcomes, by demonstrating how fidelity information provided context for a negative trial. CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    •• Keeley RD, Burke BL, Brody D, Dimidjian S, Engel M, Emsermann C, et al. Training to use motivational interviewing techniques for depression: a cluster randomized trial. J Am Board Fam Med. 2014;27(5):621–36. This trial of MI training appeared to result in improvements in some but not all MI techniques that persisted over 2 years, contributing to addressing the first two knowledge gaps pertaining to how to train persons to conduct MI and how to measure fidelity. CrossRefPubMedGoogle Scholar
  68. 68.
    •• Keeley RD, Brody DS, Engel M, Burke BL, Nordstrom K, Moralez E, et al. Motivational interviewing improves depression outcome in primary care: a cluster randomized trial. J Consult Clin Psychol. 2016;84(11):993–1007. Epub 2016 Sep 5. This trial begins to address the fourth knowledge gap, which is poor understanding of MI's mechanisms. Google Scholar
  69. 69.
    Hall K, Staiger PK, Simpson A, Best D, Lubman DI. After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing? Addiction. 2016;111(7):1144–50.CrossRefPubMedGoogle Scholar
  70. 70.
    Schwalbe CS, Oh HY, Zweben A. Sustaining motivational interviewing: a meta-analysis of training studies. Addiction. 2014;109(8):1287–94.CrossRefPubMedGoogle Scholar
  71. 71.
    Cox ME, Yancy WS Jr, Coffman CJ, Ostbye T, Tulsky JA, Alexander SC, et al. Effects of counseling techniques on patients’ weight-related attitudes and behaviors in a primary care clinic. Patient Educ Couns. 2011;85(3):363–8. Scholar
  72. 72.
    Romano M, Peters L. Understanding the process of motivational interviewing: a review of the relational and technical hypotheses. Psychother Res. 2016;26(2):220–40. Epub 2014 Sep 10CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Robert Keeley
    • 1
    • 2
    Email author
  • Matthew Engel
    • 3
  • Alex Reed
    • 1
  • David Brody
    • 4
    • 5
  • Brian L. Burke
    • 6
  1. 1.Department of Family MedicineUniversity of Colorado DenverAuroraUSA
  2. 2.Denver HealthDenverUSA
  3. 3.University of Kansas School of Medicine-WichitaWichitaUSA
  4. 4.Department of Internal MedicineUniversity of Colorado DenverAuroraUSA
  5. 5.Colorado Community Health AllianceDenverUSA
  6. 6.Department of PsychologyFort Lewis CollegeDurangoUSA

Personalised recommendations