Motivational Interviewing

Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it is more focused and goal-directed and 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 engaging in non-directive therapeutic exploration. The examination and resolution of ambivalence is a central purpose, and the counselor is intentionally directive in pursuing this goal.^[rx] MI is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationships.^[rx]

Motivational interviewing is a skilled technique. It has specific key qualities, such as a guided communication style, which is used while following (effectively listening) and directing (providing advice and information). It helps to empower people by eliciting their narratives of meaning, pertinence, and capacity to change.

This technique is based on a manner that is both respectful of and curious about people. It supports the process of change naturally and respects the client’s autonomy (Miller & Rollnick, 2013).

MI is evidence-based. There is a magnitude of research from clinical trials and other studies that points to MI’s effectiveness. So, let’s look at what the evidence says about using MI to make necessary behavior transformations.

Smoking cessation

Smoking is a global problem that leads to preventable illnesses and deaths (Peto, López, & Boreham, 1992).

MI versus anti-smoking advice

Soria, Legido, Escolano, Yeste, and Montoya (2006) found that MI can be used effectively to encourage a client to give up smoking and is more effective than anti-smoking advice.

The randomized experimental study provided 114 participants with MI. The control group of 86 participants received anti-smoking advice. They were all interviewed 6 and 12 months after the intervention.

The MI group was more effective at giving up smoking (18.4%) than the anti-smoking advice group (3.4%). MI may be more effective at encouraging quitting smoking than just giving straightforward advice.

Smokers with cardiac disease

In another study, MI was used to help patients with cardiac disease stop smoking (Okasha et al., 2017).

Smokers with cardiac diseases at a clinic received MI sessions and were monitored before, after, and in follow-up sessions. The MI treatment group had fewer heart attacks than the control group by at least 50%. They were much more likely to want to quit smoking (at least over 90% more), and they reported a much lower level of nicotine dependence (between 82% and 85%).

The most exciting finding is that nearly 92% of the experimental group stopped smoking successfully compared to the control group (45%). MI can potentially help patients quit smoking with less stress and more self-efficacy.

Alcohol and illicit drug reduction and abstinence

People who develop dysfunctional alcohol and drug use issues are often found to be ambivalent about their destructive behaviors. MI evolved from treatment for alcohol abuse as first described by Miller (1983).

When addicts can no longer control their alcohol or drug use, despite the negative impact on their lives, they experience distress when they are not drinking (National Institute on Alcohol Abuse and Alcoholism, 2018), and they need help.

Hazardous drinking

A fascinating study by Satre et al. (2016) examined the use of MI to reduce hazardous drinking in 307 adults assigned to receive MI, printed literature, or routine outpatient care. These patients were also being treated for depression as outpatients before the commencement of the study.

Participants assigned to the MI group were more effective at reducing hazardous drinking, especially for those also using cannabis. In addition, depression improved for these hazardous drinkers who were also using drugs.

Alcohol abuse in the military

Motivational interviewing has also proven effective in reducing alcohol abuse within the military, especially if the drinking is classified as hazardous. Brown (2010) investigated the effectiveness of individual and group MI and used a randomized control trial to probe this issue.

Personnel in the Air Force Alcohol and Drug Abuse Prevention and Treatment program because of an alcohol incident were self-referred and consented to one of three interventions: group MI, individual MI, or a substance abuse awareness seminar.

There were follow-up sessions with all groups after 3, 6, and 12 months. The results showed that individual MI was most effective at reducing alcohol use, allowing participants to remain in their jobs and not give up their military careers.

Weight loss and obesity

Obesity affects more than a third of U.S. adults (Ogden, Carroll, Kit, & Flegal, 2014). There are further costs to society, such as medical costs (Finkelstein, Trogdon, Cohen, & Dietz, 2009) and the quality of life that the person can lead.

MI versus nutrition education

MI was studied as an effective technique to improve weight loss in 100 overweight women (Mirkarimi et al., 2017). Participants attended a nutrition clinic where they were randomly assigned to either five sessions of group MI or four sessions of group nutrition education.

MI was more successful at eliciting positive weight efficacy and lifestyle among the participants than nutritional education, such as literature related to controlling weight.

Preventing obesity in childhood

MI is effective at preventing obesity in children and adults. In a large study in Sweden, families with infants were randomly assigned to either a MI group (of both individual and group sessions) or a standard group with usual care (Doring et al., 2016). Evidence pointed toward healthier food habits among both mothers and children in the MI group.

Principles Behind Motivational Interviewing

Although each person’s journey is different, counselors who use motivational interviewing hold to four principles throughout the recovery process. These principles are vital to establishing trust within the therapeutic relationship.1

Express Empathy

People may initially be reluctant to go to therapy for fear of being judged by their therapist. Some may even feel guilty about their negative behavior, making that judgment valid in their eyes. But judgment is not what motivational interviewing is about.

Instead of judging, counselors focus on understanding the situation from their client’s points of view. This is known as empathy.

Develop Discrepancy

Developing discrepancy is based on the belief that a person becomes more motivated to change once they see the mismatch between where they are and where they want to be.

It is a counselor’s job to help clients identify their core values and clarify their personal goals. Goals and actions are developed in a trusting, collaborative atmosphere free from pressure. This offers an environment that is based on the person’s needs, wishes, goals, values, and strengths.

Roll With Resistance

Motivational interviewing understands that change doesn’t always happen just because you want it. It’s natural to change your mind many times about whether you want to change your behavior and what that process or new lifestyle looks like.

Rather than challenging, opposing, or criticizing clients, it’s a counselor’s job to help them reach a new understanding of themselves and their behaviors. One way they do this is by reframing or offering different interpretations of certain situations. This changing viewpoint increases the person’s motivation to change. It is based on their own goals and values.

For example, if a client reveals that they started drinking to cope with a partner’s infidelity, the counselor might help them reframe the situation. Instead of the client blaming themselves, they may begin to see that the person cheated because of their issues.

Support Self-Efficacy

Self-efficacy is a person’s belief or confidence in their ability to perform a target behavior.2 A counselor following the motivational interviewing approach supports their client’s self-efficacy by reinforcing their power to make the changes they want. They guide them through the behavior change process, recognize the positive changes clients make, and offer encouragement along the way.

In the beginning, the therapist may have more confidence in the individual than they have in themselves, but this can change with ongoing support. Soon, the client starts to recognize their strengths and ability to change their behavior for the better.

Techniques

In motivational interviewing, counselors help people explore their feelings and find their own motivations. They do this using four basic techniques.

Open-Ended Questions

Open-ended questions are questions you can’t answer with a simple “yes” or “no.” These types of questions encourage you to think more deeply about an issue.

Such questions often start with words like “how” or “what,” and they give your therapist the opportunity to learn more about you. Examples of open-ended questions include:

• “How would you like things to be different?”
• “What have you tried before to make a change?”
• “What can you tell me about your relationship with your parents?”

Affirmations

Affirmations are statements that recognize a person’s strengths and acknowledge their positive behaviors. Done right, affirmations can help build a person’s confidence in their ability to change.

Examples of affirming responses include:

• “You’re clearly a very resourceful person.”
• “You handled yourself really well in that situation.”
• “I’m so glad you came into the clinic today. I know it isn’t always easy to seek help.”
• “I appreciate that it took a lot of courage for you to discuss this with me today.”

Reflective Listening

Reflection or reflective listening is perhaps the most crucial skill therapists use. Reflection lets a client know that their therapist is listening and trying to understand their point of view. It also gives the client the opportunity to correct any misunderstandings and to elaborate on their feelings.

What Motivational Interviewing Can Help With

Originally, motivational interviewing was focused more on treating substance use disorders by preparing people to change addition-related behavior. Over time, however, motivational interviewing has been found to be a useful intervention strategy in addressing other health behaviors and conditions such as:

• Diabetes control
• Diet
• Obesity prevention
• Physical activity
• Sexual behavior
• Smoking

Motivational interviewing can also be used as a supplement to cognitive behavioral therapy (CBT) for anxiety disorders, such as generalized anxiety disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD).3 This approach has even been used to reduce the fear of childbirth.

Benefits of Motivational Interviewing

There are several reasons why motivational interviewing is a widely used form of mental health therapy, including:

• Building the client’s self-confidence and trust in themselves
• Helping clients take responsibility for themselves and their actions
• Lowering the chance of future relapse
• Preparing clients to become more receptive to treatment
• Showing clients that they have the power to change their lives themselves
• Teaching clients to take responsibility for themselves

Motivational interviewing is especially beneficial to people who are initially resistant to starting a treatment program or who are unprepared to make the necessary life changes.

Core elements of Motivational Interviewing

• MI is practiced with an underlying spirit or way of being with people:
  • Partnership. MI is a collaborative process. The MI practitioner is an expert in helping people change; people are the experts of their own lives.
  • Evocation. People have within themselves the resources and skills needed for change. MI draws out the person’s priorities, values, and wisdom to explore reasons for change and support success.
  • Acceptance. The MI practitioner takes a nonjudgmental stance, seeks to understand the person’s perspectives and experiences, expresses empathy, highlights strengths, and respects a person’s right to make informed choices about changing or not changing.
  • Compassion. The MI practitioner actively promotes and prioritizes clients’ welfare and wellbeing in a selfless manner.
• MI has core skills of OARS, attending to the language of change and the artful exchange of information:
  • Open questions draw out and explore the person’s experiences, perspectives, and ideas. Evocative questions guide the client to reflect on  how change may be meaningful or possible. Information is often offered within a structure of open questions (Elicit-Provide-Elicit) that first explores what the person already knows, then seeks permission to offer what the practitioner knows and then explores the person’s response.
  • Affirmation of strengths, efforts, and past successes help to build the person’s hope and confidence in their ability to change.
  • Reflections are based on careful listening and trying to understand what the person is saying, by repeating, rephrasing, or offering a deeper guess about what the person is trying to communicate. This is a foundational skill of MI and how we express empathy.
  • Summarizing ensures shared understanding and reinforces key points made by the client.
  • Attending to the language of change identifies what is being said against change (sustain talk) and in favor of change (change talk) and, where appropriate, encourages a movement away from sustain talk toward change talk.
  • Exchange of information respects that both the clinician and client have expertise. Sharing information is considered a two way street and needs to be responsive to what the client is saying.
• MI has four fundamental processes. These processes describe the “flow” of the conversation although we may move back and forth among processes as needed:
  • Engaging: This is the foundation of MI. The goal is to establish a productive working relationship through careful listening to understand and accurately reflect the person’s experience and perspective while affirming strengths and supporting autonomy.
  • Focusing: In this process an agenda is negotiated that draws on both the client and practitioner expertise to agree on a shared purpose, which gives the clinician permission to move into a directional conversation about change.
  • Evoking: In this process the clinician gently explores and helps the person to build their own “why” of change through eliciting the client’s ideas and motivations. Ambivalence is normalized, explored without judgement and, as a result, may be resolved. This process requires skillful attention to the person’s talk about change.
  • Planning: Planning explores the “how” of change where the MI practitioner supports the person to consolidate commitment to change and develop a plan based on the person’s own insights and expertise. This process  is optional and may not be required, but if it is the timing and readiness of the client for planning is important.

MI is framed as a method of communication rather than an intervention, sometimes used on its own or combined with other treatment approaches. There are a number of benefits of learning MI amongst other approaches to helping conversations:

• MI has been applied across a broad range of settings (e.g. health, corrections, human services, education), populations (e.g. age, ethnicity, religion, sexuality and gender identities), languages, treatment format (e.g. individual, group, telemedicine) and presenting concerns (e.g. health, fitness, nutrition, risky sex, treatment adherence, medication adherence, substance use, mental health, illegal behaviors, gambling, parenting).
• MI compares well to other evidence-based approaches in formal research studies.
• MI is compatible with the values of many disciplines and evidence-based approaches.
• Although the full framework is a complex skill set that requires time and practice, the principles of MI have an intuitive or “common sense” appeal and core elements of MI can be readily applied in practice as the clinician learns the approach.
• MI has observable practice behaviors that allow clinicians to receive clear and objective feedback from a trainer, consultant or supervisor.

Motivational interviewing groups

MI groups are highly interactive, focused on positive change, and harness group processes for evoking and supporting positive change. They are delivered in four phases:^[rx]

1. Engaging the group
2. Evoking member perspectives
3. Broadening perspectives and building momentum for change
4. Moving into action

Behaviour Change Counselling (BCC)

Behavior change counseling (BCC) is an adaptation of MI that focuses on promoting behavior change in a healthcare setting using brief consultations. BCC’s main goal is to understand the patient’s point of view, how they’re feeling and their idea of change. It was created with a “more modest goal in mind”,^[rx] as it simply aims to “help the person talk through the why and how of change”^[rx] and encourage behavior change. It focuses on patient-centered care and is based on several overlapping principles of MI, such as respect for patient choice, asking open-ended questions, empathetic listening and summarizing. Multiple behavior change counselling tools were developed to assess and scale the effectiveness of behaviour change counselling in promoting behavior change such as the Behaviour Change Counselling Index (BECCI) and the Behaviour Change Counselling Scale (BCCS).^[rx]

Behaviour Change Counselling Scale (BCCS)

The Behaviour Change Counselling Scale (BCCS) is a tool used to assess lifestyle counseling using BCC, focusing on feedback on the skill achieved. “Items of BCCS were scored on 1-7 Likert scales and items were tallied into 4 sub-scales, reflecting the 3 skill-sets: MI and readiness assessment, behavior modification, and emotion management”.^[rx] The data obtained is then presented on: item characteristics, sub-scale characteristics, interrater reliability, test-retest reliability and construct validity. Based on a study conducted by Vallis, the results suggest that BCCS is a potentially useful tool in assessing BCC and aid to training practitioners as well as assessing training outcomes.^[rx]

Behaviour Change Counselling Index (BECCI)

The Behaviour Change Counselling Index (BECCI) is a BCC tool that assesses general practitioner behavior and incites behavior change through talking about change, encouraging the patient to think about change and respecting the patient’s choices in regards to behavior change.^[rx] BECCI was developed to assess a practitioner’s competence in the use of Behaviour Change Counselling (BCC) methods to elicit behavior change. Used primarily for the use of learning practitioners in a simulated environment to practice and learn the skills of BCC. It “provides valuable information about the standard of BCC that practitioners were trained to deliver in studies of BCC as an intervention”.^[rx] Rather than the result and response from the patient, the tool emphasizes and measures the practitioner’s behaviors, skills and attitude. Results from the study show that after receiving training in BCC, practitioners show great improvement based on BECCI. However, as BECCI has only been used in a simulated clinical environment, more study is required to assess its reliability in a real patient environment. Furthermore, it focuses heavily on practitioner behavior rather than patient behavior. Therefore, BECCI may be useful for trainers to assess the reliability and effectiveness of BCC skills but further research and use is required, especially in a real consultation environment.^[rx]

Technology Assisted Motivational Interview (TAMI)

Technology Assisted Motivational Interview (TAMI) is “used to define adaptations of MI delivered via technology and various types of media”.^[rx] This may include technological devices and creations such as computers, mobile phones, telephones, videos and animations. A review of multiple studies shows the potential effectiveness of the use of technology in delivering motivational interviewing consultations to encourage behavior change. However, some limitations include: the lack of empathy that may be expressed through the use of technology and the lack of face-to-face interaction may either produce a positive or negative effect on the patient.^[rx] Further studies are required to determine whether face-to-face consultations to deliver MI is more effective in comparison to those delivered via technology.^[rx]

A Look at 5 Benefits and Common Criticisms

What then are the benefits of motivational interviewing?

Let us look at these here and, to be fair, evaluate some criticisms.

5 Benefits

1. Increases participation in treatment

MI is a practical and user-friendly technique, making it straightforward to engage with clients, who are then more receptive to their treatment.

MI seems to elicit greater adherence to treatments than alternative therapies. A study by Westra, Constantino, and Antony (2016) explored the benefits of MI as opposed to Cognitive-Behavioral Therapy (CBT) alone for severe generalized anxiety disorder. Twice as many people in the CBT group dropped out of treatment as the MI group.

2. Changes high-risk lifestyle behaviors

MI is effective for people who have alcohol and substance use problems. Many people with alcohol and drug problems experience difficulty with their habits. They often view alcohol and drug rehabilitation programs negatively.

Giving up alcohol entirely may seem unrealistic. They may, deep down, know that using these substances is ruining their lives, yet they find it hard to admit that they need to change.

MI can help high-risk clients build motivation for their treatment. A review of studies by Lundahl and Burke (2009) found that MI was 10% to 20% more effective at reducing risky behaviors and increasing engagement than no treatment at all.

3. Builds self-confidence

Many people who want to make changes experience lowered self-esteem and confidence, which is an obstacle to making the relevant changes needed.

MI allows these people to build confidence as they take on the responsibility to make the changes. As they see their desired result through behavior change, such as weight loss from healthier eating, this brings about a greater sense of confidence in themselves, with longer lasting results. Clients can visualize and see a future free of negative health-related behaviors.

4. People become more self-reliant and responsible for the change

MI allows people to take on the responsibility and rely on themselves to make changes – a healthier approach in the long term.

Rather than relying on medication alone to control diabetes, for instance, people learn that lifestyle changes, such as following a specific diet and exercising, can help regulate their blood sugar levels. They no longer have to rely solely on the medication to do this for them.

5. Increases confidence of health professionals in their communication with patients

MI is beneficial not only for the recipient, but also for the professional providing the technique. When health professionals communicated with patients using MI, they had increased confidence when teaching and educating patients.

After learning MI techniques, nurses who educate patients about diabetes showed a significant improvement in confidence (Stoffers & Hatler, 2017), which also improves job satisfaction.

5 Criticisms

1. Needs time to build a relationship

MI requires a considerable time investment to engage clients and build rapport. It cannot be undertaken in a hurry, and so the practitioner and the client need to have the time and resources available to make the intervention effective.

2. Needs a certain degree of cognitive clarity and motivation

Some clients do not have the mental resources or cognitive clarity to focus on the advantages and disadvantages of mental illness (such as bipolar condition or schizophrenia) to formulate a plan. They may not benefit from MI, and a different approach may be necessary.

Clients who have been diagnosed with depression often lack motivation. This is an essential requirement for MI. This technique may not work for them, especially if they have clinical depression and are heavily sedated.

3. One size does not fit all

All individuals have differing narratives, obstacles, levels of motivation, and lifestyles. MI is not an approach that can be used for everyone (Hogden, Short, Taylor, & Dugdale, 2012).

4. Follow-up is crucial

Unless you follow up with clients after using MI techniques, you cannot track their changes or see the effectiveness of the approach. A one-off meeting with a client is not an effective way to implement MI. You need to follow up at differing points, such as 6 weeks, 3 months, 6 months, and even 12 months after the first meeting.

5. Requires patient engagement and awareness

Although MI improves engagement, initial engagement from the client is necessary to make it work. If the client does not engage or isn’t aware of their problem, then it won’t be easy to move forward with this approach. There may be obstacles that are hindering their engagement and awareness. These can be time limitations, motivation, lack of cognitive clarity, and even denial.

10 Pros and Cons of Motivational Interviewing

To establish whether MI is an effective technique to use, consider the following pros and cons.

5 Pros

1. It is effective for clients with addiction behaviors and for managing physical health conditions such as diabetes, hypertension, and obesity.
2. It helps clients manage their own health and be less reliant on medications and medical appointments.
3. It avoids confrontation and promotes positivity and optimism for clients and practitioners alike.
4. It allows clients to find their own solutions for longer lasting results.
5. It allows clients to feel listened to and understood, an important aspect to enable change.

5 Cons

1. It will not work well for clients with trauma or depression, as motivation may be limited.
2. It can be a dangerous approach for clients with bipolar conditions and schizophrenia.
3. It will not work for a client already highly motivated to make a change.
4. It will not work for clients without a problem.
5. It is time consuming and requires a time and cost investment.

A Take-Home Message

MI is a process that can work wonders in helping clients make healthy changes in their behavior for the long term.

It is also a beneficial tool for clinicians and practitioners and enables them to increase their confidence.

There are many benefits to this tool. Many clients experience the necessary behavior changes regarding their health and well-being in a positive manner.

But, and there is always a but, it is not ideal for all clients; therefore, it is essential to understand the considerations that need to be made before deciding on its use for a particular client.

However, when used appropriately, research has proven that it will provide excellent long-term benefits for the client.