Building Motivational Interviewing Skills

1. Motivational Interviewing (MI) is a collaborative, goal-oriented communication style

MI is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion.

Partnership is key. MI moves away from the expert-recipient dynamic, instead fostering a collaborative relationship where the client's expertise on themselves is valued alongside the practitioner's professional knowledge. This approach recognizes that lasting change must come from within the client, not imposed from outside.

Goal-oriented but client-centered. While MI is directional, aiming to resolve ambivalence in favor of change, it does so by drawing out the client's own motivations and values. The practitioner guides the conversation toward change talk, but ultimately respects the client's autonomy in deciding whether and how to change.

Attention to language. MI practitioners pay close attention to client language, differentiating between change talk (statements supporting change) and sustain talk (arguments for maintaining the status quo). By selectively reinforcing change talk and softening sustain talk, practitioners help tip the scales toward positive change.

2. The MI spirit emphasizes partnership, acceptance, compassion, and evocation

There is a guiding philosophy that informs how we interact with clients and it originates with the client-centered writing of Carl Rogers.

Partnership involves working collaboratively with the client, recognizing their expertise on their own life and experiences. This creates a non-hierarchical relationship where both parties contribute valuable insights.

Acceptance includes four components:

• Absolute worth: Valuing the inherent dignity of every person
• Accurate empathy: Striving to understand the client's perspective
• Autonomy support: Respecting the client's right to make their own choices
• Affirmation: Acknowledging and appreciating the client's strengths and efforts

Compassion goes beyond sympathy to actively promote the client's welfare, ensuring that the practitioner's actions serve the client's best interests.

Evocation involves drawing out the client's own motivations, values, and solutions rather than imposing them from outside. This recognizes that the client already possesses the resources needed for change.

3. OARS+I are the core skills of MI: Open questions, Affirmations, Reflections, Summaries, and Information exchange

OARS+I are referred to as the "core skills" of MI and are basic to good MI practice.

Open questions invite elaboration and exploration, allowing clients to tell their story. They often begin with "what," "how," "tell me about," or "in what ways."

Affirmations recognize and reinforce the client's strengths, efforts, and positive qualities. They help build self-efficacy and create a positive, supportive atmosphere.

Reflections are statements, not questions, that express understanding of what the client has said. They can be simple (repeating or rephrasing) or complex (adding meaning or continuing the paragraph).

Summaries collect and link important points from the conversation, helping to organize the client's experience and maintain focus.

Information exchange involves sharing knowledge or advice in a collaborative manner, often using the Elicit-Provide-Elicit format to ensure relevance and understanding.

4. Engaging is the foundational process of building rapport and trust

Engaging is establishing a safe place within which the client can explore difficult realities and a working relationship.

Creating safety and welcome. The practitioner strives to create an environment where the client feels valued, respected, and comfortable discussing sensitive topics. This involves both verbal and non-verbal communication that conveys warmth and acceptance.

Asking and listening. Engaging involves genuine curiosity about the client's experiences, perspectives, and values. The practitioner uses open questions and reflective listening to understand the client's world.

Offering small bites of information. During engaging, any information provided is done so judiciously, ensuring it's relevant to the client's expressed concerns and interests.

Key strategies for engaging include:

• Exploring the client's hopes and goals for the interaction
• Understanding the client's perception of the problem or situation
• Clarifying roles and expectations
• Addressing any concerns or hesitations the client may have

5. Focusing helps identify the client's goals and direction for change

Focusing is coming to understand what matters most to the client and defining an agenda for moving forward.

Collaborative agenda setting. The practitioner works with the client to identify areas of concern and priorities for change. This may involve using tools like agenda mapping or simply having an open discussion about what the client hopes to achieve.

Exploring values and goals. Understanding what's truly important to the client helps align the change process with their deeper motivations and aspirations. Techniques like the Values Card Sort can be helpful in this exploration.

Finding a focus. While multiple concerns may be present, focusing involves narrowing down to one or two specific areas to work on. This provides a clear direction for the conversation and subsequent change efforts.

The focusing process can be viewed along a continuum:

1. Clear focus: A specific goal or behavior change is already identified
2. Agenda mapping: Several potential areas for change are explored and prioritized
3. Orienting: The client is unsure of their goals, requiring broader exploration

6. Evoking elicits the client's own motivations for change

Change talk statements are those that indicate the person is oriented toward making a positive change in a behavior, thought, attitude, or situation.

Recognizing change talk. Practitioners listen for and respond to client statements that express desire, ability, reasons, need, commitment, activation, or taking steps toward change (DARN-CAT).

Strategies for evoking change talk:

• Asking evocative questions
• Using the importance/confidence rulers
• Exploring goals and values
• Looking forward/looking back
• Exploring extremes
• Using the decisional balance

Responding to change talk. When change talk emerges, practitioners use EARS (Elaborate, Affirm, Reflect, Summarize) to reinforce and expand upon it, encouraging the client to continue in this direction.

7. Planning bridges motivation to concrete steps for change

Planning is putting into place the methods by which the client will act on this commitment.

Assessing readiness. Before moving into planning, the practitioner gauges whether the client has sufficient motivation and confidence to proceed. This may involve using scaling questions or listening for strong commitment language.

Developing a change plan. The practitioner supports the client in creating a specific, realistic plan for change. This typically includes:

• Setting clear, achievable goals
• Brainstorming potential strategies
• Anticipating potential obstacles and solutions
• Identifying sources of support

Strengthening commitment. Throughout the planning process, the practitioner continues to evoke and reinforce change talk, helping to solidify the client's commitment to the plan.

Supporting change. The practitioner helps the client identify specific actions they can take to implement their plan, often breaking larger goals into smaller, manageable steps.

8. Change talk and sustain talk are key indicators of client readiness

Research findings show the type of language a client engages in predicts whether that client will change, and the type of behavior a practitioner engages in influences the type of client language.

Change talk includes statements expressing desire, ability, reasons, need, commitment, activation, or taking steps toward change. It predicts positive outcomes and should be reinforced.

Sustain talk includes statements in favor of maintaining the status quo or against change. It predicts poorer outcomes and should be explored empathically but not reinforced.

Discord is a special form of sustain talk that indicates tension in the therapeutic relationship. It requires careful attention to re-establish rapport and collaboration.

Practitioner strategies:

• Listen for and selectively respond to change talk
• Reflect change talk to amplify its impact
• Ask questions that are likely to elicit change talk
• Summarize, emphasizing change talk
• Respond to sustain talk and discord without reinforcing it

9. Reflective listening is the cornerstone skill in MI

Reflective listening is typically used to engage clients and create momentum, which can then be channeled in directions that are productive.

Types of reflections:

• Simple: Restates or slightly rephrases what the client said
• Complex: Adds meaning or makes inferences about what was said
• Amplified: Overstates to test the strength of the client's position
• Double-sided: Acknowledges both sides of ambivalence
• Continuing the paragraph: Guesses at the unspoken meaning or what might come next

Depth of reflection. Practitioners vary the depth of their reflections, sometimes staying close to what was said (above the waterline) and other times diving deeper to explore underlying meanings and emotions (below the waterline).

Strategic use. In MI, reflections are used intentionally to:

• Express empathy and build rapport
• Highlight discrepancies between values and behavior
• Selectively reinforce change talk
• Reframe sustain talk in a way that points toward change
• Guide the conversation in a particular direction

10. MI is directional, guiding clients toward positive change

The directional element of MI, which asks the client to continue to move toward her goal.

Intentional listening. While MI is client-centered, it is not non-directive. Practitioners listen selectively, choosing to respond to and amplify certain aspects of client speech while letting others pass.

Strategic responses. The practitioner's responses are carefully chosen to evoke and reinforce change talk, softening sustain talk, and guide the conversation toward positive change.

Maintaining focus. Throughout the MI process, the practitioner helps maintain focus on the target behavior or goal, gently redirecting when necessary while respecting client autonomy.

Strategies for maintaining direction:

• Using summaries to highlight change-oriented elements
• Asking questions that point toward change
• Offering reflections that emphasize change talk
• Providing information and advice in a way that supports autonomy and evokes change talk

11. Practitioner responses significantly influence client language and outcomes

What we do as practitioners influences the appearance of change talk. It is also what the research demonstrates directly.

EARS (Evoke, Affirm, Reflect, Summarize). These skills are used strategically to elicit and reinforce change talk, guiding the client toward positive change.

Avoiding traps. Practitioners must be aware of common pitfalls that can hinder progress:

• The expert trap: Feeling pressure to have all the answers
• The righting reflex: The urge to fix the client's problems
• The labeling trap: Getting caught up in diagnostic labels
• The premature focus trap: Zeroing in on a problem before the client is ready

Responding to sustain talk and discord. When clients express reasons not to change or push back against the process, practitioners:

• Avoid arguing or persuading
• Use reflective listening to express empathy
• Reframe in a way that points toward change
• Emphasize personal choice and control
• Shift focus to areas of agreement

By skillfully navigating these challenges and consistently applying MI-consistent responses, practitioners can significantly increase the likelihood of positive client outcomes.

Last updated: August 30, 2024