Motivational interviewing

Motivational interviewing (MI) refers to a counseling approach in part developed by clinical psychologists Professor William R Miller, Ph.D. and Professor Stephen Rollnick, Ph.D. The concept of motivational interviewing evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in Behavioural Psychotherapy. These fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. Motivational Interviewing is a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior.[2] MI is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it's more focused and goal-directed. It 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 non-directively explore themselves.^[1] The examination and resolution of ambivalence is a central purpose, and the counselor is intentionally directive in pursuing this goal.^[2]

MI recognizes and accepts the fact that clients who need to make changes in their lives approach counseling at different levels of readiness to change their behavior.^[3] During counseling, some patients may have thought about it but not taken steps to change it while some may be actively trying to change their behavior and may have been doing so unsuccessfully for years. In order for a therapist to be successful at motivational interviewing, four basic interaction skills should first be established.^[4] These skills include: the ability to ask open ended questions, the ability to provide affirmations, the capacity for reflective listening, and the ability to periodically provide summary statements to the client.^[5] These skills are used strategically, while focusing on a variety of topics like looking back, a typical day, the importance of change, looking forward, confidence about change, and so on.

Motivational interviewing is non-judgmental, non-confrontational and non-adversarial.^[6] The approach attempts to increase the client's awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Alternately, therapists help clients envision a better future, and become increasingly motivated to achieve it.^[7] Either way, the strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.^[8] Motivational interviewing focuses on the present, and entails working with a client to access motivation to change a particular behavior, that is not consistent with a client's personal value or goal.^[9] Warmth, genuine empathy, and acceptance are necessary to foster therapeutic gain (Rogers, 1961) within motivational interviewing. Another central concept is that ambivalence about decisions is resolved by conscious or unconscious weighing of pros and cons of change vs. not changing (Ajzen, 1980).

The main goals of motivational interviewing are to engage clients, elicit change talk, and evoke motivation to make positive changes from the client. For example, change talk can be elicited by asking the client questions, such as "How might you like things to be different?" or "How does ______ interfere with things that you would like to do?" Change may occur quickly or may take considerable time, and the pace of change will vary from client to client. Knowledge alone is usually not sufficient to motivate change within a client, and challenges in maintaining change should be thought of as the rule, not the exception. Ultimately, practitioners must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future.^[10]

While there are as many variations in technique as there are clinical encounters, the spirit of the method, however, is more enduring and can be characterized in a few key points:^[6]

1. Motivation to change is elicited from the client, and is not imposed from outside forces
2. It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence
3. Direct persuasion is not an effective method for resolving ambivalence
4. The counseling style is generally quiet and elicits information from the client
5. The counselor is directive, in that they help the client to examine and resolve ambivalence
6. Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction
7. The therapeutic relationship resembles a partnership or companionship

Four general processes

MI uses four general processes to achieve its ends:

1. Engaging - used to involve the client in talking about issues, concerns and hopes, and to establish a trusting relationship with a counselor.
2. Focusing - used to narrow the conversation to habits or patterns that clients want to change.
3. Evoking - used to elicit client motivation for change by increasing clients' sense of the importance of change, their confidence about change, and their readiness to change.
4. Planning - used to develop the practical steps clients want to use to implement the changes they desire.

Adaptations of motivational interviewing

• Motivational Enhancement Therapy ^[11]

It is a time-limited four-session adaptation used in Project MATCH, a US-government-funded study of treatment for alcohol problems and the Drinkers' Check-up, which provides normative-based feedback and explores client motivation to change in light of the feedback.^[12]

Motivational interviewing is supported by over 200 randomized clinical control trials ^[13] across a range of target populations and behaviors including substance abuse, health-promotion behaviors, medical adherence, and mental health issues.

• MI Groups ^[14]

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:

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

• Limitations of Motivational Interviewing

Many studies using MI have specific inclusion/exclusion criteria. For example, Project MATCH excluded those who were homeless and involved in the criminal justice system. A randomized trial in drug abuse services conducted by Miller and Rollnick (2002) provided Motivational Interviewing sessions to patients in order to elicit behavior change by exploring and resolving ambivalence. They enrolled 152 outpatient and 56 inpatient clients who were entering a public agency for drug problems. The researchers reported and excluded clients if they reported insufficient residential stability.

This is not an attempt to take away from the credibility of Motivational Interviewing or any Motivational Interviewing research. It seems to work very well with specific groups in specific environments. Future interventions must include every client entering the facility under study (within the parameters of informed consent) or they will not represent real world clinical activities (Patterson, 2008 & 2009).

Applications of Motivational interviewing

Examples of fields in which motivational interviewing is being applied include:

• Substance dependence
• Health Coaching
• Mental disorder
• Problem gambling
• Dual Diagnosis

References

Sources

• Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall. ISBN 978-0139364358.
• Brennan, T. (1982) Commitment to Counseling: Effects of Motivational Interviewing and Contractual Agreements on Help-seeking Attitudes and Behavior. Doctoral Thesis:University.of Nebraska.
• Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.
• Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change, 2nd ed. NY: Guilford Press, 2002. ISBN 978-1572305632.
• Miller, W.R., & Rollnick, S. Motivational Interviewing, 3rd ed. Guilford Press, 2012. ISBN 978-1-60918-227-4.
• Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37.
• Patterson, D. A. (2008). Motivational interviewing: Does it increase retention in outpatient treatment? Substance Abuse, 29(1), 17-23.
• Patterson, D. A. (2009). Retaining Addicted & HIV-Infected Clients in Treatment Services. Saarbrücken, Germany: VDM Publishing House Ltd. ISBN 978-3639076714.
• Prochaska, J. O. (1983). "Self changers vs. therapy changers vs.Schachter." American Psychologist 38: 853-854.
• Rogers, Carl (1961). On becoming a person: A therapist's view of psychotherapy. London: Constable. ISBN 1-84529-057-7.
• Rollnick, S., Miller, W.R., & Butler, C.C. "Motivational Interviewing in Health Care: Helping Patients Change Behavior". NY: Guilford Press, 2007. ISBN 978-1-59385-613-7.
• Wagner, C.C., Ingersoll, K.S., & contributors (2013). Motivational Interviewing in Groups. New York: Guilford Press.

External links

• Motivational Interviewing Glossary and Fact Sheet Kathleen Sciacca
• "Dual Diagnosis Treatment and Motivational Interviewing for Co-occurring Disorders" in National Council Magazine 2007
• NIAAA web site: Project MATCH, MET treatment manual
• Steve Rollnick official website
• Motivational Interviewing Network of Trainers (MINT) website