571524

research-articleXXXX
AJLXXX10.1177/1559827615571524American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine

vol. 10 • no. 6 American 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
discussed as useful for supporting the cause of death in the United
implementation and maintenance of States, and improving health
goals. Thus, there is a need for health behaviors (eg, physical activity, proper
care providers to develop such tools to nutrition) is fundamental to preventing
empower sustained behavior change. and controlling chronic disease.1-3
The additional support of a new role, Individuals generally recognize the need
a health coach who specializes in for behavior change, but are still unable
ability to choose by and for themselves,”
is a key concept to promoting healthy
behaviors.5 The purpose of this review is
to highlight evidence-based methods
and resources that health care providers
can use to increase patient
empowerment and facilitate sustainable
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)

429
 American Journal of Lifestyle Medicine
Self-Determination
Theory
Data support that the quality of health
care provider–patient communication
promotes patient-empowerment and
positive health outcomes.6 Self-
Determination Theory (SDT) is a
particularly useful self-regulation theory
for understanding how the role of a
health care provider can influence
individuals’ behavior change. SDT
emphasizes the importance of
individuals’ sense of autonomy
regarding their motivation to change a
behavior, as opposed to feeling that
they should change, in empowering
them to engage in and sustain healthy
behaviors.5,7 Providers may support this
sense of autonomy by encouraging
individuals to choose to adopt healthy
behaviors that are derived from patients’
personal values. For example, an
individual may decide to quit smoking
to increase his ability to run a race with
his son rather than for a reason that
may be important to the provider (eg,
reducing the individual’s risk of lung
cancer). The opposite of being
autonomy supportive is being
controlling. Motivation that derives from
a health care provider’s advice can still
be autonomous if the patient adopts the
behavior by his or her own choice, free
from cohersion.8
SDT also posits that increased support
for autonomy leads to patients’
increased perceived competence, and
sense of relatedness (feeling cared for by
others), which results in changes in
their mental and physical health.9
Supporting autonomy further helps
individuals successfully deal with
barriers to change, and conveys feelings
of acceptance and respect.9,10 Indeed,
data support that patients with providers
who support autonomy show improved
health outcomes (eg, HbA1c values,
depressive symptoms).11,12 This
relationship between providers’ support
of autonomy and sustained
improvement in health outcomes is
empirically explained in part through
increasing patients’ autonomy, perceived
competence, and relatedness.9
430
Autonomy Support
The concept of supporting an
individual’s autonomy in SDT is
consistent with the concept of providing
patient-centered care. Reports published
by the Institute of Medicine have
identified patient-centered care as a key
component of high-quality health
care.13,14 The scope of this current
review will focus on the influence of
health care providers, although patient
and health system factors also influence
aspects of patient-centered care.15
Specifically, the literature on patient-
centered care (also referred to as
collaborative care) recommends that
health care providers adopt a patient-
centered communication style. This style
focuses on how the health care provider
exchanges information, fosters healing
relationships, recognizes and responds
to emotions, manages uncertainty, makes
decisions, and enables patient self-
management.16 In this approach “while
professionals are experts about diseases,
patients are experts about their own
lives.”17(p2470)
Motivational Interviewing
One of the most commonly adopted
interventions to enhance health care
providers’ patient-centered
communication skills is motivational
interviewing. Motivational interviewing is
characterized by an overall spirit that
consists of autonomy support, elicitation
of patients’ own reasons for change, and
collaboration with a focus on increasing
patients’ readiness for behavior change.18
Some specific skills used in motivational
interviewing include reflective statements
(ie, repeating what the patient
conveyed), open-ended questions, and
eliciting what the patient knows before
providing relevant education.
•• Reflective statements demonstrate
active listening and offer the
opportunity for a patient to elaborate
or clarify what was said. For example,
stating back to a patient what you
heard them say (eg, “It sounds like
you are frustrated that you keep
waking up in the morning feeling
Nov • Dec 2016
sick”) may allow him or her to affirm
and think more about the topic (eg,
“Yes, I would like to stop drinking so
much at night so that I can do more
activities I enjoy each day”).
•• Open-ended questions usually start
with the words “what” or “how.” An
example of an open-ended question
commonly used to elicit a patient’s
values is, “What is important about
that to you?” Tying health behaviors
to patients’ values is likely to help
them find their own motivation for
change.
•• Understanding what patients know
already before providing education
allows the provider to target
information and increases patients’
receptivity of material. For example,
asking a patient “What resources are
you aware of that may help you quit
smoking?” allows the provider to
discover that that the patient is
already aware of plenty of resources.
This knowledge enables the provider
to direct the conversation to be more
relevant to the patient and saves time
used to discuss topics that are not of
interest.
This self-discovery process facilitated by
motivational interviewing encourages
patients to explore and generate their
individual reasons for change.
Motivational interviewing is an
approach that was derived experientially
and is usually applied to a specific
aspect of behavior (eg, alcohol abuse,
exercise).19 Motivational interviewing
may be either a stand-alone treatment or
an addition to other treatments.20,21
Research supporting the efficacy of
motivational interviewing is strongest in
the areas of addictive and health
behaviors.19,22 Motivational interviewing
is most useful for patients who are not
yet motivated to change.
A limitation of motivational
interviewing is that it may not be
effective for those who are already
prepared to take actions toward
behavioral change.19 Furthermore, the
effects of motivational interviewing
decrease with time since the
intervention19 and the optimal duration
 vol. 10 • no. 6
for the intervention is unknown. The
emphasis on increasing the quantity of
change talk (ie, number of times the
patient mentions the intention to
change) in motivational interviewing
may also not capture the importance of
a patient’s true desire to change.23 That
is, patients may express many plans for
behavior change consistent with what
they expect the provider would like for
them to do (eg, “I plan to join a gym so
that I will achieve the recommended
amount of exercise”) rather than change
consistent with their personal values (eg,
“I plan to walk daily on the trails near
my house because feeling connected
with nature is important to me”). Recent
interest in the application of SDT to
motivational interviewing has
encouraged a shift in the emphasis from
the quantity of the change talk to
ensuring that the quality of the change
talk is autonomously motivated.23,24
Therefore, SDT can be adopted to
explain the efficacy of motivational
interviewing when motivational
interviewing emphasizes increasing the
same construct important to achieve
behavior change proposed in SDT (ie,
autonomy support).
Mindfulness
The mindfulness of a health care
provider, or tendency to be “attentive to
and aware of what is taking place in the
present,”25 supports patient
autonomy.25-28 Mindfulness in this context
is considered a disposition, or general
tendency, that can be enhanced by
practicing a mindful state through
techniques such as meditation.25
Meditation is primarily training your
attention to focus on the present moment
without judgment. Instructions for a
meditation practice could be as simple as
the following:
Aim to keep your attention on your
breath for the next 5 minutes (set a
timer). Notice what moves in your
body as you breathe. If your mind
wanders, gently remind yourself to
bring your attention back to your
breathing. Each time you remember to
bring your attention back, you are
strengthening your ability to be
mindful. There is no right or wrong
way to do this exercise. Just notice
your reactions and know that this
meditation practice will likely be
different each time you try it.
Indeed, research is emerging to support
that a mindful disposition is associated
with and mindfulness practices increase
the patient-centeredness of health care
providers.26,29-31 For example, health care
providers (N = 45; physicians, nurse
practitioners, physician assistants) with a
higher self-reported mindfulness
disposition were more likely to deliver
patient-centered care than those with
lower mindfulness scores.26 In addition,
patients of health care providers who
were high in dispositional mindfulness
engaged in higher quality patient–
physician communication even after
adjusting for covariates such as length of
visit. Patients of health care providers
high in dispositional mindfulness also
reported high overall satisfaction with
care.
Another study of health care providers
(N = 20 physicians) who completed an
8-week course on learning mindfulness
practices revealed that they qualitatively
perceived an improved ability to be
attentive to their patients’ concerns and
more effectively respond to such
concerns.30 One provider in this study
stated,
I am much more attuned to listening. I
put a mental stopwatch in my head. I
[now] have a heightened awareness
and sensitivity to people’s
conversation. I look at my own
communication and pay much more
attention to that. I pay much more
attention in general.
Thus illustrating a specific instance of
how mindfulness can influence the
patient-centeredness of communication.
Furthermore, a study of 70 health care
providers (ie, primary care physicians)
who completed an 8-week course on
mindfulness practices reported positive
changes in providers’ own health in
addition to increases in their empathy
and belief that patients’ psychosocial
issues are important, which are
American Journal of Lifestyle Medicine
characteristics related to providing
patient-centered care.29 Therefore, the
health care providers themselves are
likely to benefit from the practice of
mindfulness in addition to the positive
effect of mindfulness on their patients.
Indeed, other studies support the
benefits of mindfulness practices for
health care providers such as reduced
burnout, improved job satisfaction, and
improved emotional well-being.29,32-34
The goals of a mindfulness practice
include understanding one’s own
responses and biases so that it is possible
to accurately understand and skillfully
relate to the patient.27 When both the
physician and patient are engaged, their
interaction can lead to a greater outcome
than either person could achieve
separately.35 The importance of the
relationship between the patient and
provider is also consistent with the
concept of individual’s need for
relatedness in SDT.36 Relationships can
help individuals process complex
information and come to an informed
decision.37 People consider multiple
components when making decisions,
including analytic thinking, feelings, and
intuition. If both the patient and provider
mindfully experience these multiple
components when a medical decision is
presented, the discussion of their unique
experiences can lead to a more sound
decision.37 Understanding patients’ desire
for involvement in decision making is
considered an important component of
patient-centered care.16 It is particularly
important to engage patients in the
decisions that involve a personal
preference such as the decision to
change a behavior.38 Therefore, it is
likely that increasing the mindfulness of
both the patient and health care provider
will increase the patient-centeredness of
the interaction and likelihood that a
patient will decide on an autonomously
motivated reason for behavior change.
Facilitating Autonomous
Self-Regulation
Self-regulation, or the processes related
to achieving a desired outcome,4 can be
facilitated by motivational interviewing
431
 American Journal of Lifestyle Medicine
and mindfulness. Self-regulation consists
of 2 overarching processes: goal setting
and goal striving.4,39 Patients who are
involved in the first process of goal
setting may not yet be considering a
behavior change. As mentioned
previously, motivational interviewing is
likely most useful for patients in this
stage.19 Mindfulness, or self-awareness, is
viewed as the first step in facilitating self-
regulation according to the self-
regulation theory presented by SDT.28
Mindfulness enhances patients’ ongoing
ability to accurately perceive their
behavior and how that differs from their
desired outcome. In addition, preliminary
evidence supports that enhancing
mindfulness thorough mind–body
practices (eg, meditation, yoga) is related
to improvements in lifestyle change
(eating disorders, smoking cessation).40,41
For example, noticing the effects of food
on the body may influence the desire for
an improved diet and result in weight
loss (eg, “I notice that I feel sluggish after
eating fried food and would like to eat it
less so that I am more able to
concentrate on my work”).40 Highlighting
discrepancies between current and
desired states is also used as a technique
in motivational interviewing to generate
autonomous motivation for and the
intention to change.19 Patients who are
aware of such discrepancies are more
likely to generate intrinsic goals, or goals
that are motivated by a self-determined
(autonomous) rather than an externally
determined reason.7 Intrinsically
motivated goals are more likely to be
achieved than goals that are extrinsically
motivated.4 This point is also illustrated
by an intervention to facilitate the self-
management of chronic diseases (ie,
heart disease, lung disease, stroke, or
arthritis) that provided participants with
the opportunity to self-select their goals
rather than prescribing specific behavior
changes.42 Results showed that this
process of autonomous goal setting
successfully changed health behaviors
and reduced hospitalizations.42
Goal Setting
Once patients have determined their
motivation to act, health care providers
432
may choose to shift the focus of the
conversation to goal setting. Some
guidance for goal setting includes having
patients4:
•• Develop goals that are framed toward
obtaining a desired rather than an
undesired outcome because this
makes it more feasible to assess
success. For example, it is more
tangible to determine if one has
attained the goal of walking more
frequently than a goal of being less
sedentary. One exception is if there is
an existing undesired outcome that
one would like to eliminate such as a
cough from smoking.
•• Set a goal that is balanced between
being ideal and at a realistic level of
difficulty. That is, ideal goals such as
winning a gold medal in the
Olympics may be quite motivating
and serve as a useful overarching
vision; however, starting with a more
short-term goal of beating your
personal best performance in the
chosen sport may be a more realistic
first step. Choosing a goal with the
appropriate level of difficulty will
increase expectations for a positive
outcome and beliefs that one is
capable of achieving the goal.
•• Create a goal that is focused on
gradually mastering the process of
developing a new behavior rather
than an “all-or-nothing” strategy for
immediately achieving the ultimate
outcome.
Goal setting is an effective strategy that
leads to behavior change as at least
partially explained through increasing
perceived competence (also called
self-efficacy).43,44 Perceived competence
is important at different stages of
behavior change (ie, goal setting and
goal striving).39
Goal Striving
Once patients have set a goal to initiate
a behavior change, the next step is to
engage in goal pursuit. This process
involves performing and sustaining the
intended action.39 In this process, it is
important to cultivate a patient’s
Nov • Dec 2016
perceived competence for performing the
behaviors needed to achieve a goal (eg,
knowledge of when, where, how
behaviors will be performed) and
perceived competence for maintaining
the goal once the new behavior is
initiated (eg, confidence in identifying
barriers and planning alternative actions).
Some recommended strategies for
supporting successful goal pursuit
include having patients4:
•• Specify what actions will be taken
and when to achieve the goal.
•• Prevent disruptions to goal
achievement using various strategies
such as (a) identify possible obstacles
and plan ways to alter consequences
of taking undesired actions, (b) create
automatic habits by consistently
engaging in the desired behavior in a
particular context, and (c) find ways
to remember to think of big picture
related to the overall goal rather than
the specific situation that may contain
an obstacle.
A successful action process also includes
self-monitoring (eg, identifying methods
for developing accountability to
achieving goal), which is another
strategy supported by evidence for
inclusion in behavior change
interventions.45-47 The process of goal
striving will be supported by regular
interactions with a health care provider
who is knowledgeable of the patient’s
goals.48
Figure 1 illustrates evidence-based
relationships among the SDT concepts
discussed.7,9,10
Health Coaching
Health coaching is a new profession
that draws from multiple evidence-based
tools for facilitating patients’ autonomous
self-regulation (eg, motivational
interviewing, mindfulness, self-
monitoring) to address the growing need
for an increase in healthy behaviors.
Health coaches generally support
individuals in identifying health behavior
change goals and maintaining desired
changes over a series of coaching
 vol. 10 • no. 6
Figure 1.
A Self-Regulation Model for Enhancing Patients’ Sustained Behavior Change.
Autonomy Support from
Healthcare Providers
sessions. Health coaches have emerged
from 2 general perspectives: (a) within a
health care context with the goal of
managing chronic medical conditions
and (b) from a life coaching background
with the goal of supporting optimal
health. A National Consortium for
Credentialing Health and Wellness
Coaches (http://ncchwc.org/) has
convened and is in the process of
creating a formal uniform definition.
Although there is considerable variability
in the current definition of a health
coach, a recent systematic review has
identified similarities within these diverse
existing interventions such that most
include the following common
components: a patient-centered
approach, encouragement of self-
discovery, content education, goal setting
determined by the patient, and
mechanisms such as self-monitoring for
developing accountability.49 Thus, health
coaching is an approach that emphasizes
supporting the autonomy of the patient
in facilitating behavior change and is
consistent with the principles of behavior
changed outlined by SDT.23,50
Reviews of the existing literature on the
overall efficacy of health coaching are
promising yet inconclusive due to the
previous variability in the definition of
health coaching and limited number of
high-quality studies.49,51-54 In general,
these reviews provide preliminary
support for the capacity of health
coaching to improve behavior change
and mental and physical health
Autonomy
Autonomous
Perceived Competence for Self-Regulation
Behavior Change (e.g., goal setting and
striving)
Relatedness
(feeling cared for by others)
outcomes. Published interventions that
utilize the term “health coach” in the
context of health also differ with regard
to variables such as the educational
background, level of training as a health
coach,49 level of experience, and
additional skills that may be incorporated
(eg, mindfulness practices).55 The
background of health coaches varies
with a majority who hold additional
professional degrees (eg, 51% allied
health professionals and 42% nurses).49
Therefore, future research with stronger
methodological designs that adopt the
newly established definition of a health
coach and include reporting of treatment
fidelity processes are needed.49,53
Health Coaching and
Motivational Interviewing
The encouragement of self-discovery in
health coaching is similar to the focus of
evoking a patient’s self-determined
reason for behavior change used in
motivational interviewing. Thus, a health
coach may adopt motivational
interviewing as one of multiple tools
utilized.56 This approach engages
patients in problem solving rather than
the health care provider didactically
prescribing behavioral change. Health
coaches enable patients to develop
individualized action plans by eliciting
what content education is needed,
facilitating autonomous goal setting, and
mechanisms for developing
accountability. Although many coaching
techniques are drawn from a subset of
American Journal of Lifestyle Medicine
Health
Outcomes
the psychological literature, diagnosing
or working with psychopathology is not
within the scope of a health coach’s
role.57
Recent individual studies with strong
methodology demonstrate the efficacy of
coaching to improve some specific
health behaviors and outcomes. For
example, a randomized controlled trial
(N = 415) found that coaching
implemented both in person and
remotely as compared to a self-directed
control group resulted in sustained
weight loss at 24 months for obese
patients who had at least one
cardiovascular risk factor.58 Another
randomized controlled trial (N = 410)
found that a telephone-based coaching
intervention as compared to usual care
improved moderate physical activity,
body mass index, and dietary habits after
12 months in colorectal cancer
survivors.59 Both of these health
coaching interventions used motivational
interviewing plus additional behavior
change techniques (eg, self-monitoring,
mindfulness) and found a significant
effect of multiple coaching contacts (ie,
>10 sessions) implemented remotely.58,59
Health Coaching and
Mindfulness
Mindfulness is likely to strengthen both
the health care provider’s support of the
patient’s autonomy and the patient’s
ability to autonomously engage in the
self-regulation process. That is,
mindfulness may augment the
433
 American Journal of Lifestyle Medicine
patient-centeredness of the interaction
between patient and provider and
subsequently optimize the likelihood of
a patient’s successful behavioral change.
The International Coach Federation
identifies coaching presence as a core
competency of coaching in general (not
specific to “health” coaching). A
component of coaching presence, that a
coach “is present and flexible during the
coaching process, dancing in the
moment,” is consistent with being
mindful (http://www.coachfederation.
org/). Thus, coaching as a field
recognizes that mindfulness is essential
to a coaching relationship; however, not
all training programs specifically include
mindfulness practices as tools to enhance
this competency. An existing health
coaching intervention that has adopted
mindfulness (ie, self-awareness) as a
central component found improved self-
efficacy, accountability, and clinical
outcomes in patients with diabetes.60 Yet,
the specific impact of mindfulness on the
efficacy of health coaching has not been
investigated. An exciting direction for
future research and clinical practice will
be the evaluation of enhancing
mindfulness among health coaches to
improve efficacy.
Future Directions
Given the impact of poor health
behaviors, strategies to promote and
sustain behavioral change are a
fundamental public health concern.
Presently, there are a lack of programs
and resources in health care to support
behavioral change as we have outlined.
Possible cost savings resulting from
successful behavior change and thus
possible reduced health care utilization61
may generate the resources needed to
support behavior change interventions.
Health care providers interested in
strengthening their mindfulness and
behavioral change skills may choose to
pursue training in these tools separately
or in combination. For example,
mindfulness may be learned through
Mindfulness Based Stress Reduction
courses that are offered at many
locations (http://w3.umassmed.edu/
434
MBSR/public/searchmember.aspx) and
motivational interviewing may be learned
through trainings offered by the
Motivational Interviewing Network of
Trainers (http://www.motivationalinter
viewing.org/). Health coaching programs
are offered remotely or in person at
various independent locations and
universities with some programs that
specifically incorporate mindfulness
training components (eg http://www
.instituteofcoaching.org/images/ARticles/
Heath%20and%20Wellness%20
CoachTrainingPrograms-July-2011.pdf).
The optimal role of a health coach in
health care has yet to be determined.
One proposed model is that medical
practices could optimize their patients’
health outcomes by hiring a health coach
as a new professional who specifically
focuses on the behavior change
process.62 Future documentation of
clinical outcomes and research reporting
on the efficacy of health coaching will
be necessary to clarify this new role.
Health coaches have the potential to
improve the burden of chronic disease
on patients and ultimately the overall
population.
Acknowledgments
Research reported in this publication was supported by the
National Institutes of Health (NIH), Office of Research on
Women’s Health, Building Interdisciplinary Research Careers in
Women’s Health (BIRCWH) Scholar Program (2K12HD043483-
11) and the NIH, National Center for Complementary &
Alternative Medicine Grant K23 AT006965-01A1. The content
is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes
of Health. AJLM
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