Motivational interviewing still has the same “spirit”, but the emphasis has changed in recent years. This article reviews the changes to update your understanding of the basic MI approach.
Related articles: What is Person Centred Therapy?, Rethinking Narrative Therapy, What is Acceptance and Commitment Therapy?, What is Dialectical Behaviour Therapy?
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Introduction
Jana is a psychotherapist, helping clients from all walks of life to live happier, more meaningful lives. Tom is a life coach, ready to work with clients to solve various problems that prevent them from realising their dreams. Barbara, a general practitioner, helps her patients to lead healthier lives, while Mary, a CEO, tries to motivate her employees to achieve organisational and individual work goals. What do Jana, Tom, Barbara, and Mary have in common? They are all in the business of behaviour change, a group likely to include you. Motivational interviewing, a popular client-centred therapy for helping people make changes, has enjoyed a meteoric rise in popularity since William Miller and Stephen Rollnick co-founded it in the 1980s (Schultz, 2023; Rollnick, 2023; Miller and Rollnick, 2002). While you have probably heard about MI, and may even use it in your therapeutic work, are you aware of the more recent changes in its emphasis? This article reviews these changes to update your understanding of the basic motivational interviewing approach.
Motivational interviewing: The earlier version
Traditional motivational interviewing asserts that there are four or five principles which express the spirit of MI and guide a clinician to genuinely motivate a client to change. The original version proposed the acronym DEARS to express these principles:
- Develop discrepancy
- Express empathy
- Amplify ambivalence
- Roll with resistance
- Support self-efficacy
More recent (but not the most updated) versions have seen “amplify ambivalence” drop out, so this article reviews how the other four express the spirit of MI (Miller & Rollnick, 2002).
Develop discrepancy
John Galbraith once said that, given a choice between changing and proving that it is not necessary most people get busy with the proof (Latchford, 2010). The client comes (or is mandated to come) to see you because of needing to either change from unhealthy behaviour (such as drinking, smoking, or gambling) or to more healthy habits (such as taking up an exercise regime or adhering to medication). As you begin to establish relationship and a therapeutic alliance with your client, the truth of Galbraith’s words becomes evident; the client is acknowledging that something is not right in their world, but spending serious energy in session disavowing that they really need to change. Thus, your job becomes that of helping them think about change, having an honest discussion about the consequences of not changing as well as changing.
Some of the primary tools for this principle include scaling questions, the decisional matrix, and the Columbo approach (numerous Mental Health Academy motivational interviewing courses provide more information on these and other skills) (adapted from Sobell & Sobell, 2008).
Sample interventions to help develop discrepancy:
- “Tell me some good and not so good things about your behaviour.”
- “How do you think your life would be different if you were not ____ (drinking, smoking, skipping your medication, getting stressed out, etc)?” (Brastaad, n.d.).
Express empathy
One of the most important elements of motivational interviewing is that of empathy: the ability to view the world through the eyes of our client, to step into their shoes, figuratively speaking, and to experience the world as they do. In practical terms, empathic communication calls on our reflective listening skills and our capacity to accurately reflect the client’s perspective without judging, criticising, or blaming. To act with empathy is not to condone a client’s behaviour. Rather, it is to create an open and respectful exchange with the client, whom we approach with genuine curiosity about their feelings and values (Hall et al, 2012). Expressions of empathy minimise resistance.
Sample expressions of empathy:
- “I appreciate how difficult this is.”
- “Yes, making change is hard work: VERY hard work!”
- “That must have been hard on you.”
- “If I were experiencing what you are, I can imagine that I would feel similarly” (Braastad, n.d.).
Roll with resistance
Like ambivalence, resistance is a normal reaction when people are considering change; as a helping practitioner, you must be prepared for a certain amount of it. Avoiding confrontation reduces but does not eliminate it. By paying attention to the client’s discourse patterns, you can spot the words and actions which indicate that the client is resisting. These include arguing, interrupting, denying, and ignoring. Here are some examples of resistance talk:
- Disagreeing: “yes, but . . .”
- Discounting: “I’ve already tried that” (adapted from Latchford, 2010).
Some traditional tools for rolling with resistance include avoiding the “righting reflex” (“I’m right; the client is wrong”), offering advice (the MI way, not directly), and trying the therapeutic paradox (to get clients to argue the case for changing).
Sample rolling-with-resistance statements:
- “It’s ok if you don’t want to quit; it’s your choice.”
- “Perhaps this new regime is just too much to adopt all at once.”
- “Maybe you aren’t ready to quit.”
- “What do you want to do? How do you want to proceed?”
- “Where do you want to go from here?” (Braastad, n.d.)
Support self-efficacy
Even when someone is committed to making a change, the individual can be hugely frustrated by a lack of confidence about their ability to achieve the change. Thus, one of the goals of motivational interviewing is to increase confidence, which helps to enhance self-efficacy: the person’s belief that they can achieve their goal. The central tenets of MI are designed to assist with this.
One way that the therapist can support self-efficacy through eliciting statements of self-motivation is to ask about the problem recognition (“What makes you think that this is a problem?”) or concern (“What is there about your ____ [drinking, spending, gambling, etc] that you or other people might see as reasons for concern?”). The clinician can also enquire about intention to change (“If you were totally successful and things worked out perfectly, what would be different?”) Finally, optimism can be elicited through questions such as, “What makes you think that, if you decide to make a change, you can do it?” (Latchford, 2010)
Sample support-self-efficacy statements:
- “It seems as though you have put a lot of thought into these goals.”
- “You have a good plan of action.”
- “You indicate that you are still struggling with making these changes, and yet you have had some success at making these things happen.”
- “It sounds like you have made real progress; how does that make you feel?” (Braastad, n.d.)
Motivational interviewing 2.0
While the “truth” and “spirit” of MI have not changed, the current version of it now emphasises four processes as the basis for the MI approach:
- Engaging is the relational foundation
- Focusing identifies agenda and change goals
- Evoking uses MI core skills and strategies for moving toward a specific change goal
- Planning is the bridge to behaviour change
Note that these processes overlap, and there is typically not a defined beginning and end to each (Schumacher and Madson, 2014).
Engaging
Building rapport and developing the therapeutic alliance happens at all four processes but is also one of the earliest tasks the therapist mut accomplish: to help the client to feel welcomed, safe, and comfortable enough to discuss their concerns (this article explores essential qualities in a solid therapeutic relationship). The client-centred approach taken by an MI clinician means that the therapist takes a genuine interest in not only the client’s problems, but also their values and goals. Here, the clinician must focus on the person in front of them rather than identifying and solving the problem: a task that, in MI, falls to the client.
Signs of disengagement
Because engagement is so central to the MI treatment, the clinician is always on the lookout for signs of disengagement, which can include interrupting, closed-off body language, silence, passive agreement, giving vague answers, or changing the topic. The therapist must be vigilant, for their part, that they are not guilty of common errors when trying to build the alliance.
Barriers to engaging the client
These include:
- Question and answer trap: asking the client too many closed questions.
- Taking sides: ignoring the client’s ambivalence and prescribing a solution.
- The expert trap: taking the stance that the therapist has all the answers.
- Premature focus: narrowing in on a problem too quickly, which leaves the client behind (Rosengren, 2017)
Read this article to learn more about ways clinicians may inadvertently build resistance in clients, lowering their capacity to effectively engage.
Focusing
Once the client has been engaged, focus can turn to what needs to change. Identifying this “change target”, as MI calls it, is not the role of the therapist, although they are key in guiding the client toward the target.
The three sources of focus are:
- The client (who may come in with stated goals, such as maintaining an exercise program or decreasing use of alcohol).
- The setting, which could involve a gym, a weight loss clinic, or an agency for quitting smoking, as examples.
- The clinician, who could be the source of focus in cases where, say, the client did not wish to take a certain medication – say, for depression – and the clinician, possibly a G.P., would be involved in helping to set up a medication regimen (Schultz, 2023).
Zooming in
The thing that needs to change for the client may be well-defined, such as reducing alcohol dependency, or it may be more amorphous, such as a client who just feels “down” or anxious without knowing why. The “zooming in” aspect of the focus process aims to proceed, like someone pushing the “+” or “-“ buttons on an internet map, to zoom in and out of the issue. Once the target destination is identified, the therapist can help the client plot the route to get there.
Collaborative agenda setting
In the role of guide rather than expert, the therapist allows the client to discuss what they feel is important in the session, setting up the joint agenda-setting with an MI-inspired question such as: “What would be most helpful to discuss first?” Through collaborative agenda-setting, the clinician can ensure that the client is headed in a direction important to them, rather than one chosen – even somewhat unconsciously – by the therapist. Moreover, through being faithful in this way to the spirit of MI, the therapist learns much about the client’s values and goals, which are highlighted in the next process (Schultz, 2023).
Evoking
This process becomes central after a focus and change target are identified and is famous for being the part of MI where “change talk” takes place. Here, maintaining the MI spirit influences what MI coaching for change looks like.
MI spirit
The qualities important for the MI spirit include partnership (respect for the client’s autonomy and wisdom), acceptance (of the intrinsic worth of the client, despite any disagreement with the therapist), compassion (acting in the best interests of the client), and evocation (eliciting the motivation for change from within the client) (Levounis et al, 2017).
Change versus sustain talk
If you have heard anything at all about MI, it is likely that you know about this. A statement indicating that – in their ambivalence about changing – clients are leaning toward the status quo, is sustain talk, while a statement leaning toward motivation or commitment to change is change talk. The therapist’s job is to home in on the latter, encouraging more of it. The skills you may know within the acronym OARS help the therapist accomplish this (Levounis et al, 2017).
Coaching toward change
In sport, coaches are not out on the playing field kicking the goals. Rather, they are alongside of the players on the sidelines, helping to motivate and inspire them to achieve the goals. Good coaches know when to push someone harder and when to back off. Likewise, the MI clinician is skilled at the push and pull that involves harnessing motivation (which waxes and wanes). But always, they seek to elicit the motivation within the client that brought them into therapy, (or brought the player to the coach) in the first place, empowering the client to set their own goals. The final process of planning illuminates the MI tools that change facilitators have at their disposal for this (Schultz, 2023).
Planning
When you notice that your client is making more change talk than sustain talk, that the strength of the change talk is increasing, and/or that spontaneous planning for change is occurring, the client is showing signs of readiness to change and it’s time to move into the fourth process of planning. A good MI-consistent question here is: “What do you want to do next?” A collaborative question like this helps the client to own the solutions and planning agenda they come up with, as opposed to merely being compliant with the therapist, and the client will be the one to benefit from them.
SMART goals
Developing SMART goals (that is: Specific, Measurable, Action-oriented, Realistic, and Time-bound goals) stands as a continuing success strategy for clients. For more on this topic, refer to this course.
OARS techniques
You may recall from previous study of MI that the set of clinical skills encapsulated by the acronym OARS (for Open-ended questions, Affirmations, Reflections, and Summarising) are primary in the planning process.
Keeping track of your (the client’s) progress
While you are always recommended to maintain a 2:1 ratio of reflections to questions, you may find that different skills of the OARS set are required at different process points: more summaries and affirmations at early stages, for example, and more open-ended questions as clients attempt to define their values and articulate their goals. Reflections are useful to avoid the “expert trap” of too many questions to the client (Rosengren, 2017; Schultz, 2023).
If you were aware of MI’s traditional approach before embarking on this article, you can see that the changes in emphasis we have outlined here in no way contradict the original spirit of MI; in fact, they articulate it more clearly. Whether you are working with a client, an athlete, a patient, or an employee, the client-centred MI approach is an effective and powerful way to help people make the changes that they say they want to make.
Motivational interviewing training
Parts of this article were adapted from Mental Health Academy’s motivational interviewing course, Motivational Interviewing: The Basics. This 3-hour motivational interview training program explores the essence of motivational interviewing: the definition; chief principles, techniques, and skills; and interview traps that comprise the practice of motivational interviewing.
Other motivational interviewing courses you may be interested in:
- Introduction to Motivational Interviewing: Resolving Ambivalence and Changing Behaviour
- Using Motivational Interviewing with Alcohol Dependence and Depression
- Using Motivational Interviewing While Working with Ethnic Issues
- Treating Depression with Motivational Interviewing
- Trauma and Addiction: Taking Motivational Interviewing to the Next Level
Note: Mental Health Academy members can access 500+ CPD/OPD courses, including those listed above, for less than $1/day. If you are not currently a member, click here to learn more and join.
Key takeaways
- Motivational interviewing (MI) is a popular client-centred therapy for helping people make changes. The approach was co-founded by William Miller and Stephen Rollnick in the 1980s.
- An older version of motivational interviewing postulated four principles as key to facilitating change: expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy.
- The updated version of MI takes four processes to be the proper basis of MI: engaging (relationally), focusing (to identify agenda and goals), evoking (using MI core skills to move toward a specific change goal), and planning (as a bridge to behaviour change).
References
- Berg-Smith, S. (2001). Making brief patient encounters more effective. In Motivational Interviewing assessment: Supervisory tools for enhancing proficiency. Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University.
- Braastad, J. (n.d.). Using motivational interviewing techniques in SMART recovery. SMART Recovery: Get Smart FAST Distance Training Program. Retrieved on 18 November, 2023 from: https://smartrecovery.org/toolbox
- Hall, K., Gibbie, T., & Lubman, D.I. (2012). Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Australian Family Physician, Vol. 41(9), Sept., 2012, pp 660-667.
- Latchford, G. (2010). A brief guide to motivational interviewing: Year 3 motivational interviewing workshop. NHS: The Leeds Teaching Hospitals. Retrieved on 18 November, 2023, from: http://www.drugsandalcohol.ie/17873/1/Motivational_Interviewing_brief_guide.pdf
- Levounis, P., Arnaout, B., & Marienfeld, C. (2017). Motivational interviewing for clinical practice: A practical guide for clinicians (1st Ed). American Psychiatric Association Publishing.
- Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing. Preparing people for change (2nd Ed.). New York: The Guilford Press.
- Rollnick, S. (2023). About motivational interviewing. Psychwire. Retrieved on 16 November, 2023, from: https://www.stephenrollnick.com/about-motivational-interviewing/
- Rosengren, D.B. (2017). Building motivational interviewing skills: A practitioner workbook. Guilford Press.
- Schultz, J. (2023). Motivational interviewing steps: 4 key processes for change. Positivepsychology.com. Retrieved on 18 November, 2023, from: https://positivepsychology.com/motivational-interviewing-steps/
- Schumacher, J.A., & Madson, A.B. (2014). Fundamentals of motivational interviewing: Tips and strategies for addressing common clinical challenges. Oxford University Press.
- Sobell & Sobell. (2013). Motivational interviewing strategies and techniques: rationales and examples. Retrieved on 18 November, 2023, from: http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf