Motivational interviewing

Motivational interviewing (MI) refers to a counseling approach in part developed by clinical psychologists Professor William R Miller, Ph.D. and Professor Stephen Rollnick, Ph.D. The concept of motivational interviewing evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in Behavioural Psychotherapy. These fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. Motivational interviewing is a semi-directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it's more focused and goal-directed. Motivational Interviewing is a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior. The examination and resolution of ambivalence is a central purpose, and the counselor is intentionally directive in pursuing this goal.

Motivational interviewing recognizes and accepts the fact that clients who need to make changes in their lives approach counseling at different levels of readiness to change their behavior. If the counseling is mandated, they may never have thought of changing the behavior in question. Some may have thought about it but not taken steps to change it. Others, especially those voluntarily seeking counseling, may be actively trying to change their behavior and may have been doing so unsuccessfully for years. In order for a therapist to be successful at motivational interviewing, four basic skills should first be established. These skills include: the ability to ask open ended questions, the ability to provide affirmations, the capacity for reflective listening, and the ability to periodically provide summary statements to the client.

Motivational interviewing is non-judgmental, non-confrontational and non-adversarial. The approach attempts to increase the client's awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Alternately, therapists help clients envision a better future, and become increasingly motivated to achieve it. Either way, the strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change. Motivational interviewing focuses on the present, and entails working with a client to access motivation to change a particular behavior, that is not consistent with a client's personal value or goal. Warmth, genuine empathy, and unconditional positive regard are necessary to foster therapeutic gain (Rogers, 1961) within motivational interviewing. Another central concept is that ambivalence about decisions is resolved by conscious or unconscious weighing of pros and cons of change vs. not changing (Ajzen, 1980). It is critical to meet patients/clients where they are (Prochaska, 1983), and to not force a client towards change when they have not expressed a desire to do so.

Motivational interviewing is considered to be both client-centered and semi-directive. It departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than non-directively explore themselves. Motivational interviewing is based upon four general principles:

Four General Principles

Express empathy.

Empathy involves seeing the world through the client's eyes, thinking about things as the client thinks about them, feeling things as the client feels them, sharing in the client's experiences. Expression of empathy is critical to the MI approach. When clients feel that they are understood, they are more able to open up to their own experiences and share those experiences with others. Having clients share their experiences with you in depth allows you to assess when and where they need support, and what potential pitfalls may need focused on in the change planning process. In short, the counselor's accurate understanding of the client's experience facilitates change.

Develop discrepancy.

This guides therapists to help clients appreciate the value of change by exploring the discrepancy between how clients want their lives to be vs. how they currently are (or between their deeply-held values and their day-to-day behavior). MI counselors work to develop this situation through helping clients examine the discrepancies between their current behavior and future goals. When clients perceive that their current behaviors are not leading toward some important future goal, they become more motivated to make important life changes. Techniques used can include decisional balance sheets

Roll with resistance.

In MI, the counselor does not fight client resistance, but "rolls with it." Statements demonstrating resistance are not challenged. Instead the counselor uses the client's "momentum" to further explore the client's views. Using this approach, resistance tends to be decreased rather than increased, as clients are not reinforced for becoming argumentative. MI encourages clients to develop their own solutions to the problems that they themselves have defined. In exploring client concerns, counselors may invite clients to examine new perspectives, but counselors do not impose new ways of thinking on clients. Rolling with resistance allows therapists to accept client reluctance to change as natural rather than pathological.

Support self-efficacy.

This guides therapists to explicitly embrace client autonomy (even when clients choose to not change) and help clients move toward change successfully and with confidence. As clients are held responsible for choosing and carrying out actions to change in the MI approach, counselors focus their efforts on helping the clients stay motivated, and supporting clients' sense of self-efficacy is a great way to do that. One source of hope for clients using the MI approach is that there is no "right way" to change, and if a given plan for change does not work, clients are only limited by their own creativity as to the number of other plans that might be tried.

The main goals of motivational interviewing are to establish rapport, elicit change talk, and establish commitment language from the client. For example, change talk can be elicited by asking the client questions, such as "What makes you think this is a problem for you?" or "How does ______ interfere with things that you would like to do?" It is important to keep in mind that client behavioral issues are common in the process of motivational interviewing. Change often takes a long time, and the pace of change will vary from client to client. Knowledge alone is usually not sufficient to motivate change within a client, and relapse behaviors should be thought of as the rule, not the exception. Ultimately, therapists must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future.

While there are as many variations in technique as there are clinical encounters, the spirit of the method, however, is more enduring and can be characterized in a few key points:

1. Motivation to change is elicited from the client, and is not imposed from outside forces
2. It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence
3. Direct persuasion is not an effective method for resolving ambivalence
4. The counseling style is generally quiet and elicits information from the client
5. The counselor is directive, in that they help the client to examine and resolve ambivalence
6. Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction
7. The therapeutic relationship resembles a partnership or companionship

Adaptations of motivational interviewing include Motivational Enhancement Therapy, a time-limited four-session adaptation used in Project MATCH, a US-government-funded study of treatment for alcohol problems and the Drinkers' Check-up, which provides normative-based feedback and explores client motivation to change in light of the feedback. Motivational interviewing is supported by over 80 randomized clinical control trials across a range of target populations and behaviors, including substance abuse, health-promotion behaviors, medical adherence, and mental health issues.

Motivational interviewing techniques are sometimes used in a corporate environment as part of the human relations process. Corporates may also use the techniques during sales and marketing presentations and during workshop sessions allied to conventions and conferences. Using some of the techniques in this different environment is not properly called Motivational Interviewing, as MI is a therapeutic method that always contains the best interests of clients, not a set of techniques used to influence others to act in ways that are to the benefit of the individual using the techniques.

Applications of Motivational interviewing

Examples of fields in which motivational interviewing is being applied include:

• Substance dependence
• Health Coaching
• Mental Illness and Psychological disorder
• Corrections and Criminal Justice
• Gambling
• Adherence to treatment in chronic illness
• Dual Diagnosis

Sources

• Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall.
• Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change, 2nd ed. NY: Guilford Press, 2002. ISBN 1-57230-563-0.
• Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.
• Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37.
• Prochaska, J. O. (1983). "Self changers vs. therapy changers vs.Schachter." American Psychologist 38: 853-854.
• Rogers, Carl (1961). On becoming a person: A therapist's view of psychotherapy. London: Constable. ISBN 1-84529-057-7.
• Rollnick, S., Miller, W.R., & Butler, C.C. "Motivational Interviewing in Health Care: Helping Patients Change Behavior". NY: Guilford Press, 2007. ISBN 1-59385-612-1.

External links

• "Dual Diagnosis Treatment and Motivational Interviewing for Co-occurring Disorders" in National Council Magazine 2007
• NIAAA web site: Project MATCH, MET treatment manual
• Steve Rollnick official website
• Motivational Interviewing Glossary and Fact Sheet, Kathleen Sciacca, 2009