Primary care providers are on the front lines of managing essential care for individuals experiencing chronic pain. With pain affecting 100 million Americans, 25 million of whom report chronic daily pain,¹ at an estimated economic cost of $560 to 635 billion/year,² chronic pain is one of the most important issues in population health and primary care. Yet providers and patients are often dissatisfied with treatment processes and outcomes.³ Motivational interviewing (MI) promotes self-management and assists patients in moving toward health-related behaviors that aid in chronic pain management.

MI, with its roots in the addiction field, offers an evidence-based approach to address the behaviors related to chronic pain and opiate addiction. MI has been shown to outperform traditional advice giving in the treatment of behavioral problems and diseases related to alcohol abuse, drug addiction, smoking cessation, weight loss, poor treatment adherence, physical inactivity, asthma, and diabetes.⁴ Individuals experiencing chronic pain also present with many of the lifestyle-related conditions mentioned above.⁵ Pain and its associated symptoms can be modified by behavioral changes. An MI approach has been shown to be successful in relieving pain, improving function, and enhancing the use of self-management skills for people with pain.⁶

Miller and Rollnick (2002) describe MI as a “directive, patient-centered counseling style for enhancing intrinsic motivation to change by exploring and resolving ambivalence.”⁷ MI is more than the use of a set of techniques or strategies. It is characterized by a particular “spirit” or clinical “way of being” that is the context or interpersonal relationship within which the techniques are employed. That is, the effectiveness of MI depends on the fundamental aspect of how the provider relates to the patient.

The spirit of MI is based on 3 key elements: collaboration between the provider and the patient; evoking or drawing out the patient’s ideas about change; and emphasizing the autonomy of the patient.

Collaboration (vs. confrontation) is a partnership between the provider and the patient, grounded in the point of view and experiences of the patient. This contrasts with the traditional biomedical model where the physician is the expert and the patient is passive. Collaboration builds rapport and facilitates trust in the helping relationship, which can be challenging in a more hierarchical relationship. This does not mean that the provider automatically agrees with the patient about the nature of the problem or the changes that may be most appropriate. Although the provider and patient may see
things differently, the therapeutic process is focused on mutual understanding, not the provider being right or the patient dictating treatment.

Using MI, the provider draws out the individual’s own thoughts and ideas, rather than imposing his or her opinion. This tends to increase the patient’s motivation, as commitment to change is most powerful and sustainable when it comes from the patient. Lasting change occurs when the patient discovers his or her own reasons and determination to change. The provider’s job is to “draw out” the person’s own motivations and skills for change, not to tell him or her what to do or why he or she should do it, no matter how scientifically valid or clinically convincing the provider’s reasons may be.

The final element is based on the bioethical principle of autonomy. Unlike the traditional biomedical model that emphasizes the clinician as an authority figure, MI recognizes that the true power for change rests within the patient. Ultimately, the patient is responsible to make a behavioral change that improves his or her health and pain management. This empowers the patient and increases his or her sense of responsibility to take action in his or her pain management care. Providers reinforce that there is no single “right way” to change and that there are multiple ways in which change can occur. In addition to deciding whether they will make a change, patients are encouraged to take the lead in developing a “menu of options” as to how to achieve the desired change.

There are 4 principles that guide the practice of MI: (1) Express Empathy, (2) Support Self-Efficacy, (3) Roll with Resistance, and (4) Develop Discrepancy (Table 4-1). Empathy involves seeing the world through the patient’s eyes, thinking about things as the patient thinks about them, and feeling things as the patient feels them to share in the patient’s experiences. This approach provides the basis for patients to be heard and understood, and in turn, patients are more likely to honestly share his or her experiences in depth.

For example, a patient tells the primary care provider that he cannot go to work because of his pain and is worried about his finances. The provider mentally places herself in the patient’s life and states the following:

In the above scenarios, the provider communicates to the patient the core emotion that another would feel if they “put him/herself in their shoes.” Ultimately, the patient feels emotionally heard. This opens the door to the initial stages of building mutual trust.

Regarding Self-Efficacy, MI promotes a strengths-based approach. This means that patients have within themselves the capabilities to change successfully. A patient’s belief that change is possible (i.e., self-efficacy) is needed to instill hope about making those difficult changes. Patients often have previously tried and been unable to achieve or maintain the desired change, creating doubt about their ability to succeed. In MI, providers support self-efficacy by focusing on previous successes and highlighting skills and strengths that the patient already has. For example, the provider may state the following to promote self-efficacy:

“Rolling with Resistance” means slowing down and reflecting back the patient’s concerns. From an MI perspective, resistance in treatment occurs when the patient experiences a conflict between their view of the “problem” or the “solution” and that of the clinician or when the patient experiences their freedom or autonomy being impinged upon. These experiences are often based on the patient’s ambivalence about change, which is a normal part of the change process. In MI, providers avoid eliciting resistance by not confronting the patient, and when resistance occurs, they work to de-escalate and avoid a negative interaction, instead “rolling with it.” Actions and statements that demonstrate resistance remain unchallenged especially early in the treatment relationship. The MI value on having the patient define the problem and develop his or her own solutions leaves little for the patient to resist. A frequently used metaphor is “dancing” rather than “wrestling” with the patient. In exploring patient concerns, health care providers invite patients to examine new points of view and are careful not to impose their own ways of thinking. A key concept is that providers avoid the “righting reflex,” a tendency born from concern, to ensure that the patient understands and agrees with the need to change and to solve the problem for the patient. An example of rolling with resistance includes the following: