Motivational Interviewing

1. Motivational Interviewing: A collaborative approach to behavior change

Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

Collaborative partnership. Motivational interviewing (MI) is a counseling approach that helps people resolve ambivalence and find their own reasons for change. Unlike traditional confrontational or advice-giving methods, MI creates a partnership between the counselor and client. The counselor's role is to evoke the client's own motivations and resources for change, rather than imposing external pressure or solutions.

Resolving ambivalence. MI recognizes that ambivalence about change is normal and expected. The counselor helps the client explore both sides of their ambivalence, gently guiding them toward change without pushing or arguing. This approach respects the client's autonomy and right to make their own decisions about change.

Enhancing intrinsic motivation. By focusing on the client's own values, goals, and reasons for change, MI taps into intrinsic motivation – the most powerful and sustainable driver of behavior change. The counselor skillfully elicits and reinforces "change talk" from the client, strengthening their commitment to change from within.

2. The spirit of motivational interviewing: Partnership, acceptance, compassion, and evocation

The attitude underlying this principle of empathy is properly termed "acceptance." Through skillful reflective listening, the counselor seeks to understand the client's feelings and perspectives without judging, criticizing, or blaming.

Partnership. MI is a collaborative process where the counselor and client work together as equal partners. The counselor avoids the expert role and instead draws out the client's own expertise and ideas about change.

Acceptance. The counselor demonstrates unconditional positive regard for the client, accepting them as they are without judgment. This includes:

• Absolute worth: Valuing the client as a person
• Accurate empathy: Seeking to understand the client's perspective
• Autonomy support: Respecting the client's right to make their own choices
• Affirmation: Recognizing and affirming the client's strengths and efforts

Compassion. The counselor genuinely cares about the client's wellbeing and prioritizes their needs.

Evocation. Rather than imposing ideas, the counselor elicits the client's own motivations, values, and solutions. This recognizes that the client already has within them the resources needed for change.

3. Core skills: Open questions, affirmations, reflections, and summaries (OARS)

Reflective listening is one of the most important and most challenging skills required for motivational interviewing.

Open questions. These invite the client to elaborate and explore, rather than eliciting brief answers. Examples:

• "What concerns you about your drinking?"
• "How would you like things to be different?"

Affirmations. Genuine statements that recognize client strengths and efforts:

• "You've shown a lot of persistence in trying to quit smoking."
• "I appreciate your honesty in sharing that with me."

Reflections. The counselor's statements that capture and return the meaning of what the client has said. Simple reflections repeat or rephrase, while complex reflections add meaning or emphasis:

• Client: "I'm tired of feeling this way."
• Counselor (simple): "You're feeling worn out."
• Counselor (complex): "You're ready for a change in your life."

Summaries. Longer reflections that pull together several things the client has said, often used to transition between topics or reinforce change talk.

4. Change talk: Recognizing and reinforcing client language about change

Change talk generally falls into one of these four categories: Disadvantages of the status quo, advantages of change, optimism for change, and intention to change.

Types of change talk:

• Desire: "I want to quit smoking."
• Ability: "I could exercise more if I tried."
• Reasons: "My health would improve if I lost weight."
• Need: "I have to get my drinking under control."
• Commitment: "I will cut back on my gambling."
• Taking steps: "I've started looking for a new job."

Responding to change talk. When clients express change talk, the counselor should:

1. Reflect it back to reinforce it
2. Ask for elaboration or examples
3. Affirm the client's change-oriented statements
4. Summarize change talk to strengthen its impact

Evoking change talk. Counselors can use various strategies to elicit change talk:

• Asking evocative questions: "What worries you about your current situation?"
• Using the importance/confidence rulers: "On a scale of 0-10, how important is it for you to make this change?"
• Exploring goals and values: "How does your drinking fit with the kind of person you want to be?"

5. Responding to resistance: Rolling with it rather than confronting

Resistance is an interpersonal phenomenon, and how the counselor responds will influence whether it increases or diminishes.

Understanding resistance. Resistance is not a client trait, but a signal of dissonance in the counseling relationship. It often occurs when the counselor pushes too hard or gets ahead of the client's readiness for change.

Rolling with resistance. Instead of arguing or confronting, the counselor "rolls with" resistance:

• Simple reflection: Acknowledge the client's perspective
• Amplified reflection: Exaggerate the resistance slightly to invite the client to argue the other side
• Double-sided reflection: Reflect both sides of the client's ambivalence
• Shifting focus: Change the subject to a less contentious area
• Reframing: Offer a new perspective on the client's statement
• Emphasizing personal choice and control: Remind the client that they are in charge of their decisions

Avoiding the righting reflex. Counselors must resist the urge to jump in and fix things, which often increases resistance. Instead, they should elicit the client's own ideas and solutions.

6. Developing discrepancy: Helping clients see the gap between current behavior and values

Motivational interviewing begins to depart from classic client-centered counseling. Motivational interviewing is intentionally directive—directed toward the resolution of ambivalence in the service of change.

Creating cognitive dissonance. The counselor helps the client become aware of discrepancies between their current behavior and their broader goals, values, or self-image. This internal conflict can motivate change.

Exploring values. The counselor helps the client clarify their core values and how their current behavior aligns or conflicts with these values. This might involve:

• Values clarification exercises
• Discussing life goals and aspirations
• Exploring the client's ideal self

Amplifying discrepancy. Once discrepancies are identified, the counselor gently amplifies them:

• "On the one hand, you value being a good role model for your kids. On the other hand, you're concerned about how your drinking affects them."
• "You've said that health is important to you, yet you're worried about how smoking is impacting your breathing."

Letting the client voice discrepancy. The counselor guides the conversation so that the client, not the counselor, voices the arguments for change. This is more powerful than if the counselor points out the discrepancies.

7. Enhancing self-efficacy: Building confidence in the ability to change

A person's belief in the possibility of change is an important motivator.

Importance of self-efficacy. Even if a client sees the importance of change, they may not attempt it if they lack confidence in their ability to succeed. Enhancing self-efficacy is crucial for moving from contemplation to action.

Strategies for building confidence:

• Explore past successes: "Tell me about a time when you successfully made a difficult change in your life."
• Identify personal strengths: "What qualities do you have that could help you succeed?"
• Discuss hypothetical change: "If you decided to change, how might you go about it?"
• Provide information and skills training: Offer tools and strategies for change
• Use the confidence ruler: "On a scale of 0-10, how confident are you that you could make this change if you decided to?"

Affirming client capabilities. The counselor's belief in the client's ability to change can become a self-fulfilling prophecy. Genuine affirmations of the client's strengths and efforts can boost confidence.

8. Stages of change: Tailoring interventions to client readiness

The stages of change represent a key component of the TTM and describe a series of stages though which people pass as they change a behavior.

Stages of change model:

1. Precontemplation: Not considering change
2. Contemplation: Aware of pros and cons, but ambivalent
3. Preparation: Planning to take action soon
4. Action: Actively modifying behavior
5. Maintenance: Sustaining change over time

Matching interventions to stage:

• Precontemplation: Raise awareness of risks and problems
• Contemplation: Explore ambivalence, build motivation
• Preparation: Develop a change plan, build confidence
• Action: Provide skills and support for change
• Maintenance: Develop coping strategies, prevent relapse

Avoiding mismatches. Pushing action strategies on a precontemplator or contemplator often increases resistance. The counselor should assess the client's stage and tailor their approach accordingly.

9. Adapting motivational interviewing for brief encounters and various settings

The spirit of motivational interviewing honors and respects the individual's autonomy to choose.

Brief interventions. MI principles can be adapted for short encounters (5-15 minutes) in settings like primary care, emergency departments, or social services. Key elements:

• Raise the subject
• Provide feedback (if appropriate)
• Enhance motivation using OARS skills
• Negotiate a plan (if the client is ready)

Various settings. MI has been applied in diverse fields:

• Healthcare: Chronic disease management, medication adherence
• Public health: HIV prevention, health promotion
• Criminal justice: Probation, domestic violence intervention
• Education: Academic motivation, career counseling

Maintaining the spirit. Even in brief encounters, practitioners should strive to embody the MI spirit of partnership, acceptance, compassion, and evocation.

10. The role of values in motivational interviewing: Aligning behavior with personal ideals

Focusing on values helps the person appreciate those things in life that are more vital to the person than drug use or other problematic behaviors.

Values as motivators. Personal values can be powerful drivers of behavior change when clients recognize discrepancies between their values and current actions.

Exploring values in MI:

• Ask about life goals and aspirations
• Use values card sorts or other exercises
• Discuss the client's ideal self or desired legacy

Linking values to behavior. The counselor helps the client explore how their current behavior aligns or conflicts with their core values:

• "How does your drinking fit with your value of being a responsible parent?"
• "In what ways does quitting smoking support your goal of living a healthy life?"

Values and sustaining change. Connecting behavior change to deeply held values can increase intrinsic motivation and help sustain long-term change.

Last updated: August 30, 2024