Treating Generalised Anxiety with Motivational Interviewing

Motivational interviewing (MI) began as a way to help elicit motivation for change, but now its ever-broadening remit includes working with anxiety. This article shows how it can work.

Related articles: Reviewing Generalised Anxiety Disorder, Treating Generalised Anxiety with Cognitive Behavioural Therapy, Motivational Interviewing: Update Your Understanding.

Introduction

In two previous articles, we reviewed what generalised anxiety disorder (GAD) is and then we showed what one treatment program for it looked like through a lens of CBT. In this final article of the series, we discuss how a treatment program for probable GAD could be formulated using an MI approach. We use the same case example: a 35-year-old woman named Heather who presents with issues of anxiety around climate change but is revealed to engage excessive worry in multiple domains of her life.

If you know little about GAD, we recommend that you read the first article in the series (Reviewing Generalised Anxiety Disorder) before embarking on this one. Similarly, the second article (Treating Generalised Anxiety with Cognitive Behavioural Therapy) should be read before this one to find out the details of Heather’s case. In this article, we can only undertake an overview; if you know little about MI, you can engage a fuller exploration of the topic in the MHA course, Treating Anxiety with Motivational Interviewing.

Overview of the Motivational Interviewing therapeutic process

While different MI theorists espouse divergent frameworks for moving through the therapeutic process with a client considering change, there is agreement that:

1. The clinician must find a way to engage the client, to help them to commit to being in session and to find a sense that the effort will be worthwhile.
2. Once present and engaged, clinician and client together must work out what the sessions will focus on: what is the priority for the client to turn attention and change effort to?
3. As an agenda is mapped out, the clinician looks to identify and evoke change talk in the client. This stage of the process involves working intensively with ambivalence, recognising and eliciting change talk and responding to sustain talk, as well as responding to (“rolling with”) resistance.
4. When sufficient “change steam” has gathered and the client is ready to begin taking change actions, the clinician can begin to plan with the client. This fourth and final stage involves evoking client expertise, sharing (sometimes) the practitioner’s expertise, developing a change plan, and strengthening commitment to change.

For this article, we bring Heather back to the therapy stage of the first session. What if, instead of a CBT-trained therapist, she had come this time to an MI-trained therapist? How might her therapy program be formulated through an MI lens?

Engaging: Monitoring motivation and readiness to change

An early therapeutic task is to build the therapeutic alliance, which means building trust through a mutually respectful relationship so that treatment goals can be established and tasks to reach the goals can be elaborated. Additionally, MI observes that, in order to engage, clients must feel that their therapist is supportive and empathetic. Thus, a key to engaging the client is being able to assess readiness to change and respond flexibly to minimise resistance. Resistance (client movement away from the therapist, away from engagement) can be seen both in the counselling process and in client speech.

Identifying resistance

In the process

Heather expressed high anxiety about the impact she predicted climate change would have on her life. As the intake session unfolded, she would have disclosed the destructive effect of anxiety in most of her other major life domains as well. Had the therapist said, “Well, clearly, Heather, you need to meditate so that you can get that mind of yours under control”, Heather is likely to have expressed resistance to the therapist’s directives through responses such as:

• Disagreeing
• Expressing hopelessness or blame
• Defending herself
• Side-tracking
• Being silent or withdrawing
• Disqualifying earlier statements she made

In the client’s speech

Therapists can also learn to tune into client speech as a means of understanding the self-protectiveness behind resistance. One form of speech resistance includes utterances in which the client makes some expression of needing to change, but quickly negates or contradicts the statement, adding that he or she is unable to change. Some statements exemplifying such struggle or approach/avoidance include:

• “I want to, but . . .”
• “Even though I don’t want to, it feels like I have to”
• “I know it logically, but emotionally . . .”
• “On the one hand . . . on the other hand”
• “I know it doesn’t make sense, but I can’t seem to stop”
• “That all makes sense, but I don’t believe it”
• “I know it would be good for me, but . . .”
• “I know I should, but . . .”

The above utterances are largely “sustain talk” (made when clients are not ready to change). Heather, for example, had been anxious for many years and had tried to reduce the anxiety on her own. As a psychologist, she knew about various anxiety reduction techniques, but given that her solo efforts had largely failed, she would have been likely to feel that the therapist was either unempathetic or dismissive – or both – had he suggested a single technique and instructed her to do it right off the bat. Initially, she had low confidence in her ability to change. Beyond that, she believed that her anxiety, as little as she liked it, helped her to get things done. So, she would certainly have felt some resistance, perhaps expressed in some of the above ways, which needed to be factored in to her ultimate readiness (or not) to change from an anxious state.

For more on how clients resist change, read From Resistance To Acceptance.

Therapist-induced resistance

MI asks the therapist to see resistance as an indication that the therapist has gone off-track and needs to rectify the relationship. Ways that therapists inadvertently do this include positioning themselves as the “expert”, labelling clients (who then feel “boxed in” and unseen), asking many closed questions (although these may be required at intake by the therapist’s agency), or through premature focus before the therapist has really understood what is happening in the client’s anxiety.

Heather, for example, was ashamed of her perception that individual or group clients might think she was a poor therapist, so she would have held back that source of anxiety, disclosing it slowly, if at all. Moreover, she herself could claim to be an “expert” on anxiety by virtue of being in the same general profession as the therapist; thus, she would likely have bristled at any behaviour on the part of the therapist which was overly directive or labelling.

For more on how therapists may inadvertently build resistance in clients, read 5 Ways Clinicians Build Resistance in Clients.

Engagement-promoting interventions

In addition to avoiding resistance-building traps, what can therapist and client do to enhance engagement? Aspects which can heighten engagement get at the desires or goals, importance, positivity, expectations, and hope that the therapist may be able to imbue in the client.

Enhancing engagement

An example intervention to do with desires/goals could be: “What do you hope to get out of the sessions?” The therapist is listening for an answer to: “Why is Heather coming to see me now; what does she want?”

Exploring ambivalence

In the context of anxiety disorders, the question becomes what is good and not good about continuing behaviours of anxiety versus what is good and not good about changing. The aim would be to help Heather reflect on her experience and behaviour, ultimately allowing the process of linking her concerns to her core values, which spring from her sense of purpose and meaning. It is better to start with broad questions and then move to more specific concerns. An example here could be: “What needs are being met through having anxiety over climate change and other aspects of your life?” (Status quo) versus, “What is/are the most distressing part(s) of high anxiety about things, especially including climate change?” (Change, of freedom from anxiety).

Heather is likely to have been holding strong ambivalence, given that she knew cognitively how to shift her anxiety, but failed to do it. She likely would have addressed the above questions by insisting that the “good” aspects about her anxiety were that she delivered high-quality write-ups of clients through having super-high standards, even if the “cost” was fatigue and near-burnout from working so many extra hours. She would have expressed relief that no clients were suing her or even complaining about her “because” she worked hard to find out what their various gestures/remarks/behaviours meant, even though she would also have acknowledged the cost of oversensitivity: the anxiety and relentless scrambling to “find out what they really meant”. Her frequent phone calls to her partner at work would have been framed as “assurance that he is ok; a move to strengthen the relationship” – even though she also noted that he sometimes got irritated by the calls, which undermined their closeness. Heather’s worries about climate change were good, she said, because she needed to be a sentinel around the issue, yet her sense of hopelessness and imminent doom as a result of global warming belied any positive take on her anxiety around the issue.

An in-depth exploration of this strong ambivalence could help Heather and the therapist move to the stage of focusing, a process best carried out on the back of solid engagement.

Focusing: Choosing the strategic direction

Focusing in MI is an ongoing process of seeking and maintaining direction. MI experts identify three sources of focus, three styles of focusing, and three focusing scenarios.

Sources

The most common focus is one in which the client arrives for the session, letting the practitioner know what the problem is to be worked on and what their goals are. In these cases, such as with Heather, the motivation to fuel the change may be less difficult to evoke than if the therapist is choosing the focus.

There are also setting and clinician-expertise foci. When the setting determines the focus, it is typically because of the specific type of program/service it is set up and funded to operate, such as an alcohol and drug recovery centre. In the case of anxiety, the setting could well be a specialist clinic dealing with specific anxiety issues. When the setting “chooses” the focus, the client walks in the door, often at someone else’s insistence, knowing what the conversations will be about.

The source of focus is practitioner expertise when the client comes in looking to meet one goal or receive one service and the practitioner sees that another change is needed, for example where a parent brings a child for treatment for a black eye but injury is likely to recur if the domestic violence is not addressed.

Styles: Directing, following, or guiding?

Whichever of the sources the focus comes from, there are three styles of guiding that may be chosen in MI. Directing occurs more typically in agencies set up to deal with particular concerns (such as substance abuse or care and protection of children). Following is client-centred counselling at the extreme other end if the client solely determines the focus, according to their moment-to-moment priorities, which the therapist follows. Both of these have serious limitations for the issue of anxiety. Directing may evoke too much resistance to accomplish the goal and following may not ever get the client past the tendency to avoid anxiety-provoking situations, thus coming to grips with them. The MI therapist in Heather’s case should probably go for guiding, realising that the potential efficacy of a collaborative approach will ensure that Heather “owns” the goal, thereby being more likely to continue engaging the work necessary to alleviate the anxiety.

Three focusing scenarios

Even when the source of focus is known and both clinician and client are clear on the style to be used, there is a continuum from greater to lesser clarity about the end goal; it has at least three positions on it.

Scenario One: The focus is clear; the parties know where they are going. It would seem that Heather should be classified into this scenario, as she comes saying clearly that she wants to get rid of her anxiety around climate change, yet she also complains of other symptoms.

Scenario Two: There are several options; a focus needs to be chosen.In some cases, clients may acknowledge other issues, ones which they may not see as related to their presenting issue. Here the therapist may figuratively bring out a “map” with several “destinations” on it. Heather’s fatigue, irritability, poor sleep, as well as anxiety about her job performance and her relationships, were in the mix right behind the presenting issue of climate change anxiety. Thus, “agenda mapping”, in which all the concerns are listed and urgency is addressed, would be warranted to enable client and practitioner to collaboratively search for causal and other relationships between the concerns presented and establish a focus relatively more quickly. MI has techniques, such as structuring, considering options, zooming in, and using visual aids to help clarify the therapeutic focus.

Scenario Three: Unclear focus and need for exploration.Sometimes clients come in with a general complaint, such as, “My life is all messed up” and they have many interrelated concerns. When anxiety is the underlying issue, it is not uncommon to see Scenario Three, as clients may obsess about a range of problems or issues in their lives. Some may not even be aware that the underlying connection is the anxiety, which they are attaching to a variety of other concerns.

Flexibility. With good insight, Heather would quickly realise that her anxiety, attaching to climate change as the presenting issue, was at the base of other symptoms as well. Thus, for her, Scenario Two would probably be the most efficient way to work, but flexibility in focusing would ensure that Heather stayed engaged and movement could continue toward the third stage of treatment: evoking, which entails recognising and eliciting change talk and responding to sustain talk and resistance.

The fine art of evoking

To understand why skilful evoking of change talk and responding to that and to sustain talk is so critical to an anxiety-disordered client’s change effort, we go back to Heather’s strong desire to deal with the anxiety, but also her doubt that anything can help her.

Evoking change talk

Because Heather has been anxious for many years, what she has been most in touch with is the automatic response of her brain to perceived threats – and myriad stimuli seem threatening. When part of the brain (the old part) senses that survival is at stake, it hijacks all available resources to deal with the threat. Thus both cognitive and emotional responses to less critical-for-survival aspects of her life, such as her main purpose in life, her deep desires for herself, and her core values, get put aside in order to mobilise for the threat. Now in therapy, Heather suddenly has the opportunity to reflect on these aspects, and there can be a burgeoning sense of who she truly is as she makes contact with authentic parts of herself residing beneath the anxiety.

Along with that, change talk likely begins to emerge as the contemplation of her desired life comes into dramatic focus against the background of the anxiety problem that inhibits it. In other words, exploring her ambivalence to change can help Heather to develop the discrepancy between authentic goals and visions for an ideal life and the current behaviour that makes that impossible. The therapist’s role in this is skilful eliciting, recognition of, and response to change talk and competent response to Heather’s sustain talk as she makes the inevitable journey jockeying back and forth between changing to a life free from anxiety and keeping the status quo of having it.

What follows in this section are examples of interventions the therapist can use to help Heather elaborate change talk, support her intention to change, and instil confidence that she can do it.  

To establish disadvantages of remaining anxious, fatigued, and on edge (that is, the status quo):

• “What makes you think you need to do something about your anxiety over climate change?”
• “What would happen in, say, a year or two, if nothing changes with your levels of anxiety?”

To elaborate the advantages of change (reining in the anxiety):

• “The fact that you’ve come to see me means that part of you is interested in having something different happen around anxiety. What are the main reasons you see for possibly making a change?”
• “If you could wake up tomorrow and suddenly the anxiety was all gone, how might things be better for you?”

Clients can want to change very much, but if they believe that they are unable to do so, change is unlikely to happen. Thus, the attentive therapist needs to be able to identify when the missing element is a sense of “can-do” about the change. Because Heather had tried to quell her anxiety on her own, she regarded herself as generally incapable of organising and sustaining a change effort. Thus, some interventions would be needed to help inspire in her a sense of optimism that, if she decides to change, she can indeed do so.

To instil confidence about change:

• “When else in your life have you made a big change like this? How did you do it?”
• “Who could help support you while you are making these changes?”

The therapist can use interventions similar to the following to test and strengthen Heather’s commitment to changing.

To support intention to change:

• “You are speaking from two minds. What would have to change for you to speak as a single mind?”
• “What do you intend to do about your many hours spent worrying about what might happen?”

Responding to change talk

As the sessions get underway, being deeply listened to by the therapist is likely to bring Heather back to “what really matters”. It could be deeply-held fears about her own competence (hence, the oversensitivity to what clients are expressing with non-verbal gestures or the perfectionistic approach to paperwork for them). It could be fears of being abandoned by her partner or friends. At some point, the “dam” is likely to break, with Heather manifesting a highly emotional response. The therapist will know at this point that they are very close to Heather’s central values, and the appropriate MI response would be to ask her to elaborate.

Asking for elaboration:

• “So many tears. Can you tell me what they are about? Can you speak from the tears?”
• “You noted that worry helps you to feel in control and that you are protecting yourself, your relationships, and maybe even the planet. How successful is it at helping you to achieve those goals?”

Querying extremes:

• “What might be the best outcome you could hope for if you do make a change?”

Looking back:

• “What were things like for you before you started becoming so anxious?” “Tell me about how you were in your early teens [before the onset of GAD].”

Looking forward with change/no change:

• “Is there a time in the future when being just as you are now just wouldn’t work for you anymore . . . the price would just be too high?” [Upon hearing a ‘yes’]. “Describe that for me.”

Exploring goals and values:

• “How important, on a scale of 1 to 10, is this cost of not changing/benefit of change?”
• “To what degree does this fit or not fit with whom you really are/where you are going in life/what you want and value?”
• “Speak from the part of you that is really suffering from/disturbed (hurt) by the anxiety.”

Nurturing change talk

The importance of speaking our change

People become committed to what they hear themselves saying, so an important task at the evoking stage is to discover what those cherished values and prized life directions are and then invite the client to elaborate on them. In a successful application of MI, clients are literally talking themselves into changing!

Early change talk can be fragile and is normally interspersed with retreats to the status quo position. Overshooting can occur when a client speaks an utterance of change talk and the practitioner responds too enthusiastically or with too strong of an endorsement of the change intention; the client retreats to sustain talk, maintaining the status quo. Undershooting occurs, conversely, when the practitioner undershoots, responding cautiously and with slight under-emphasis of the change position, leaving the client free to elaborate more of the change position. An example here could be:

Heather’s change utterance: I feel so bad that I continue to worry about every little look of a client in session; it crowds out my ability to focus on the client.

Therapist overshoot (resulting in sustain talk): You are deeply ashamed that your anxiety is messing up all your client interactions and need to sort it out now!

Therapist undershoot (resulting in more change talk): You care about your clients and do not wish for them to have less than ideal treatment due to your concerns.

Further skills to encourage change talk

MI practitioners know that the progression from a life-limiting condition such as anxiety to freedom from it is not a linear one and most people ricochet back and forth between the change and status quo stances as they inch forward toward resolution of the ambivalence. The practitioner needs to be able to change tack quickly, as the flow between the two positions may be rapid: in some instances within a single utterance. Thus, they have several skills in their repertoire to pull out as appropriate for a client like Heather.

Rolling with resistance

When clients express doubt about making the change, the therapist can try to talk them back into “change mode” but that is likely to evoke more resistance. In this case it is all the more important to roll with the resistance, which might mean a simple acknowledgement of how hard the proposed change will be. Such mirroring helps the client to return more easily to elaborating the change position.

Developing discrepancy

Systematically exposing the contradictions between what people say that they prize (their values) and how they are behaving is a core principle of MI. People try to become more consistent, generally by changing behaviour (more of a surface phenomenon) than values (which go deeper). Helping clients to see the value-behaviour gap must be done without humiliating, correcting, or confronting the client – or insisting on change. Preservation of respect and client autonomy is called for. Heather’s therapist would be likely to call on some of the following techniques to develop discrepancy:

Asking about readiness through importance: “What would it take for you to go from x (lower number of importance) to y (higher number)?”

Respecting client autonomy: “It’s really up to you, Heather. I wonder what you’ll decide to do.”

Reframing: Discrepancy can also be developed when the therapist suggests a different meaning or perspective for what the client says.

Agreeing with a twist: Heather: “I just can’t imagine myself without anxiety about the climate. It’s part of who I am, everything I do.”

Therapist: “You just wouldn’t be you if you didn’t have it. You may have to keep having it no matter what the cost.”

Bringing two sides of the ambivalence together: Once both the change and the status quo sides have been thoroughly explored, the therapist can systematically bring them together, inviting the client to wrestle with the contradictions in their competing agendas.

In contemplating a move toward change, clients like Heather would be likely to remark at some stage on what an energy-draining nuisance it is to ruminate and worry so incessantly, concluding that change has to happen. At other points as they begin to think about what it will take, clients may protest that it is just “too hard” to do; perhaps things are better left as they are. The MI therapist should help bring the “It’s too hard” side together with the “I must change” side, which in Heather’s case could result in interventions such as:

“I’m wondering if you can help me get clear here. During one session you said that staying the same is easier, much less hassle, but today you noted how the constant worry sucks your energy so much that you are always tired and unable to concentrate. Tell me, how do those fit together?”

The other possibility for working this technique is that the person speaks from each side, and then the two sides speak together.

In summary, when as human beings we face contradictions between our inherent purpose and values on the one hand and our behaviour on the other, we are uncomfortable and wish to change something in order be consistent and not experience that dissonance. Therapists who – without arguing with or humiliating the client – are able to help the client see such value-behaviour discrepancies have a powerful tool to help the client face and resolve the contradictions, becoming ready to take change action born of planning.

The planning phase

The purpose of developing discrepancy at the evoking stage is to increase the client’s motivation toward and urgency about changing through experiencing the distress of their value-behaviour contradictions. Now at planning, MI moves from discussing importance to discussing a specific change plan that the person is willing to implement. The four parts of this are: transitioning from evoking to planning, negotiating a change plan in an MI-consistent way, strengthening client commitment to a plan, and supporting the process of change

Two guidelines will help you to know when it is the right time to go into planning mode: observing signs of readiness to change and asking a key question.

Signs of readiness for change

Let’s assume that Heather has deeply engaged the therapeutic process and, concomitantly, the therapeutic alliance has built correspondingly. There are seven “symptoms” of change readiness that her therapist could be on the lookout for:

• Resistance/sustain talk decreases (no more “yes, but . . . “)
• There is less discussion about the problem. 
• Resolve. Heather seems calmer and more settled around the issue.
• Change talk increases. Heather may express an intention to change, possibly with a sense of confidence in the ability to stop being crippled by worry/anxiety.
• Change questions emerge. She may ask how others have reduced their anxiety.
• Envisioning. She may begin to look ahead, imagining how life might be without the disorder, feeling her way into a different future.
• Experimenting. Heather may have begun experimenting with possible change actions.

Upon observing enough readiness, it is time to pose the key question.

The key question

The second guideline involves giving back to a change-ready client a summary of their reasons for change (possibly with some but not too much inclusion of sustain talk), followed by the asking of an open question designed to “test the waters”:

• “So what do you think you’ll do?”
• “So where does this leave you in terms of the climate change anxiety?”

This is to be followed by the hardest thing of all for some mental health practitioners: just be quiet! The pregnant pause is rich and must not be hurried.

Negotiating a change plan

Getting over the intention-action gap isn’t always easy. The spirit of MI is not to be abandoned at the planning stage, but the dynamics are different in each of the three possible scenarios a client may face as the change plan gets formulated.

Scenario One: When there is a clear plan: We earlier posed the possibility that Heather could be engaged with a Scenario One focus, in that she clearly stated a desire to get rid of anxiety about the future (climate). If the therapist had determined that she was close to readiness for change, he could have elicited mobilising change talk, including interventions such as:

• “How ready are you to take concrete actions to reduce this anxiety?”
• “When could you do that?”

This would be followed by troubleshooting of unanticipated difficulties. We noted, however, that Heather had anxiety in multiple domains of her life.

Scenario Two: When there are several clear options: Given that a Scenario Two focus (meaning: one with options) may have been more appropriate at the outset, a Scenario Two approach to planning sees a task of choosing from options seen and prioritising which path(s) will be taken. Heather knew about numerous anxiety reduction techniques through her work, but either did not engage them or else tried them half-heartedly. Coming into the process of MI, she would likely come to a more conscious realisation of the cost of her anxiety and perfectionism and thus come to be more willing to re-examine some of the options that, without her owning and engaging them before, had failed her in earlier (solo) efforts. The difference would be that now – with eyes wide open as to how much she is “paying” through ongoing anxiety – she would be more likely to see how some of those treatment components might be necessary, and how they may help. Thus the therapist’s work with her could fruitfully involve standard MI planning under Scenario 2:

• Confirm the main goal and relevant sub-goals
• Itemise the options that are available or have been discussed
• Elicit Heather’s thoughts/preferences as to the best way forward
• Summarise the plan and strengthen commitment
• Troubleshoot, raising any concerns (adapted from Miller and Rollnick, 2013).

For Heather, this would be likely to mean taking each domain of life into which anxiety intruded and breaking the overall treatment into components with small, do-able objectives, starting by learning which thoughts and consequent behaviours were generating anxiety and then replacing them with more adaptive choices, such as alternate calls to, say, a friend rather than her working partner, or embracing mindfulness/breathing exercises. Psychoeducation could help her improve sleep hygiene.

We note here that working through a CBT lens, as discussed in the second article of this series, is not precluded by MI work. Rather –  had Heather not completed a course of CBT counselling – CBT interventions would likely be even more efficacious when preceded by therapeutic work, such as MI, which engages the client and gains their commitment by resolving ambivalence. Thus, treatment options such as journalling or disputing unrealistic, unhelpful thoughts (e.g., about climate concerns) may be effective CBT-oriented components of treatment for anxiety which the therapist could include in an MI-style change plan. We also reiterate the usefulness of Heather generating an action plan of pro-environmental actions she could take as an antidote to the sense of hopelessness and lack of agency she feels about climate change at the start of therapy.

Working Scenario Two for this phase of the planning means that the therapist would include interventions such as:

• “What options do you know about for gaining control of anxiety?”
• “There are some additional options to help with anxiety; would you like to hear about them?” And then: “Only you can decide if these would be right for you or not.”

The therapist would want to summarise the plan he understood Heather to be committing to and strengthen her commitment with further interventions. Finally, they would do trouble-shooting for when things go awry, such as having a Plan B for times when, say, breathing and mindfulness failed to keep the anxiety at bay.

Scenario Three: When the plan must be developed from scratch: Sometimes the client’s issue is one for which there is no single clear path, as in Scenario One, nor even a finite set of possible paths, as seen in Scenario Two. Thus the planning process is more complex, in that alternatives must be generated. Thus the tasks for Scenario Three are:

• Confirm the main goal and relevant sub-goals
• Generate a list of possible options to include in the change plan
• Evaluate the various options, itemising those which seem more workable
• Elicit the client’s thoughts as to the best way forward
• Summarise the plan and strengthen commitment
• Troubleshoot, raising any concerns

Strengthening commitment to the plan

MI recognises that change is rarely a discrete-event occurrence. More often, it is a gradual thing, happening over time. We note the after-plan work of strengthening commitment to a change plan that is an integral part of MI. It is comprised of listening for mobilising language, asking for implementation intentions, and evoking intention.

Listening for mobilising (Commitment, Action, Taking steps, or CAT) language

The attuned MI practitioner distinguishes between language which still expresses ambivalence  from more change-ready mobilising language. The latter type of talk includes utterances such as:

• “I’m willing/ready/prepared to keep a journal of anxious thoughts.”
• “I probably will take a course on mindfulness meditation.”
• “I am thinking about learning AI-generated ways to make client paperwork more efficient.”

One step further on, Commitment language expresses an actual intention to carry out the plan; it essentially says, “Yes, I’ll do this.” Weaker to stronger versions from Heather could look like this:

• Weaker: “I plan to sign up for my continuing education provider’s next mindfulness course.”
• Solid: “I am going to pay attention to my thoughts by keeping a thought diary.”
• Stronger: “I have signed up for volunteer work two hours a week in my community to help educate people about carbon emissions.”

Heather’s therapist would generally seek to clarify to what extent she was willing to carry out the plan, and what steps she might already have taken toward the goal. Her therapist would also likely be looking for expression of intention to implement the plan.

Asking for implementation intention

A specific plan of action with an interpersonal statement of intent to do it has been called “implementation intention” and makes change more likely to occur. In Heather’s case, some of the specific intentions relating to larger likely goals might be expressed as:

• “I will keep a worry thought journal every day for four weeks starting today” (as part of a larger goal of changing her tendency to ruminate and obsess about worries).
• “I will register for and attend the course on using AI for client paperwork starting on October 20th” (as part of a larger goal of reducing burnout from extra work hours due to paperwork).

Always, an MI therapist is on the lookout for ways to break down the larger, ultimate goals into smaller, more concrete, do-able steps, asking: “What would be a reasonable next step?” “How will that step be taken?”

Evoking and sharing intention

Let’s pose for a moment that Heather and her therapist have gone through the MI process, formulated a change, Heather has said “yes” to both specific and general plans for change, and her implementation intention has been declared. The last step is about asking about intention to change. At this step Heather’s therapist would usefully recapitulate the plan agreed to and then ask for a final, capping-off commitment. For example, after summarising the plan, her therapist could ask a key question – for once, a closed question is acceptable – such as: “Is that what you’re willing to do?” or (with Commitment language): “Is that what you’re going to do?” To consolidate the commitment, the therapist can encourage the client to share the intention.

We note here, finally, that change can sometimes germinate “underground”, less consciously than examples we have posed here. Operating with the MI spirit means that you take whatever readiness, willingness, and ability to change your client is able to give. It is their life that is changing, after all, and pushing for more change faster is unproductive. For best results, clients must be in the driver’s seat of their own changes. We predict that a client like Heather would do well with an MI approach to moving out of chronic anxiety.

Conclusion

This article has examined how an MI approach can help a client with anxiety, using the case example of Heather with probable GAD. The rationale for using this therapy is that even robust therapies of demonstrated efficacy such as CBT have a significant proportion of clients who do not respond to treatment, probably because they are unable to seriously engage with and commit to processes foisted on them. MI, conversely, is a directive yet client-centred therapy which seeks to resolve the resistance-generating ambivalence inherent in significant change; it does this while honouring client autonomy. A successful treatment plan is comprised of engaging, focusing, evoking, and planning, which we discussed.

We have outlined MI-consistent ways of working with anxiety within each aspect. We see that, if we work in a genuine spirit of respect for the client combined with curiosity about how their attitudes and choices make sense given reality as the client sees it, we are far more able to work in a truly collaborative manner. Working in a spirit deeply permeated with this understanding generates the high success rate of change attained by MI practitioners. While this article has posed it as an alternative to CBT for client Heather, we note that many have found it highly efficacious as a prelude to work in other modalities, including CBT. Ultimately, MI is a clinical style for conversations about change that clients say they want.

Key takeaways

• MI treatment plans consist of engaging, focusing, evoking, and planning.
• Engaging includes identifying resistance and exploring ambivalence.
• Focusing is about choosing a strategic direction from among multiple sources, styles, and scenarios of possible focus.
• Evoking elaborates, nurtures, and responses to change talk, develops discrepancy, supports intention to change, and instils confidence in the client to be able to change.
• Planning involves looking for signs of readiness to change, negotiating a change plan, and strengthening commitment to the plan.

Anxiety courses and training

Numerous Mental Health Academy courses cover the topic of working clinically with anxiety and anxiety disorders. Click the following links to learn more about each course:

• Anxiety: Symptoms, Causes, and Treatment
• Using CBT with Generalised Anxiety Disorder
• Using CBT with Panic Disorder
• Using CBT with Social Anxiety Disorder
• Treating Anxiety with Motivational Interviewing
• Helping Clients with Hoarding Disorder
• Working with Paediatric Anxiety
• Men’s Anxiety, Why It Matters, and What is Needed to Limit its Risk for Male Suicide
• Clinical Applications of Emotional Freedom Techniques (EFT) for Anxiety
• The Psychopharmacology of Anxiety

Note: MHA 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.

References

• Chamberlain, P., Patterson, G., Reid, J., Kavanagh, K., & Forgatch, M. (1984). Observation of client resistance. Behavior Therapy, 15, 144-155.
• Festinger, L. (1957). A theory of cognitive dissonance. Stanford, CA: Stanford University Press.
• Gollwitzer, P.M. (1999). Implementation intentions: Simple effects of simple plans. American Psychologist (54), 493-503.
• Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. 2nd ed. New York: The Guilford Press.
• Miller, W.R. & Rollnick, S. (2013). Motivational interviewing: Helping people change, Third edition. New York: Guilford Press.
• Rosengren, D.A. (2009). Building motivational interviewing skills: A practitioner workbook. New York: Guilford Press.
• Westra, H.A. (2012). Motivational interviewing in the treatment of anxiety. New York: Guilford Press.