Understanding Motivational Interviewing

Motivational interviewing is a client-centered approach that aims to facilitate positive behavior change by helping individuals explore and resolve their ambivalence towards change. Developed by psychologists William R. Miller and Stephen Rollnick, this evidence-based technique has been widely used in various fields, including healthcare, counseling, and addiction treatment.

What is Motivational Interviewing?                      

“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.”  (Miller & Rollnick, 2013, p. 29)

The most current version of MI is described in detail in Miller and Rollnick (2013) Motivational Interviewing: Helping people to change (3rd edition). Key qualities include:

• MI is a guiding style of communication, that sits between following (good listening) and directing (giving information and advice).
• MI is designed to empower people to change by drawing out their own meaning, importance and capacity for change.
• MI is based on a respectful and curious way of being with people that facilitates the natural process of change and honors client autonomy.

It is important to note that MI requires the clinician to engage with the client as an equal partner and refrain from unsolicited advice, confronting, instructing, directing, or warning. It is not a way to “get people to change” or a set of techniques to impose on the conversation. MI takes time, practice and requires self-awareness and discipline from the clinician. (Miller & Rollnick, 2009)

While the principles and skills of MI are useful in a wide range of conversations, MI is particularly useful to help people examine their situation and options when any of the following are present:

• Ambivalence is high and people are stuck in mixed feelings about change
• Confidence is low and people doubt their abilities to change
• Desire is low and people are uncertain about whether they want to make a change
• Importance is low and the benefits of change and disadvantages of the current situation are unclear.

Core elements of Motivational Interviewing

TTM identifies six stages of readiness experienced by an individual attempting to change (Prochaska & Velicer, 1997; Liu, Kueh, Arifin, Kim, & Kuan, 2018):

1. Precontemplation – failing to recognize the need for change
2. Contemplation – seriously considering the need for change
3. Preparation – making small changes
4. Action – exercising for less than six months
5. Maintenance – regular exercise lasting longer than six months
6. Relapse

• 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 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, encouraging 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 require time and practice, the principles of MI have 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.