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MOTIVATIONAL INTERVIEWING: A CLINICAL METHOD TO ENHANCE CHANGE

by William W. Deardorff, Ph.D, ABPP.


6 Credit Hours - $99
Last revised: 06/26/2017

Course content © Copyright 2011 - 2017 by William W. Deardorff, Ph.D, ABPP. All rights reserved.



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“The only difference between a rut and a grave is the depth of the hole”

 

Unknown

 

“The first rule of holes….if you are in one, stop digging”

 

Unknown

 

 

Course Outline

 

Introduction

Learning Objectives

An Overview of Motivational Interviewing

Popularity of Motivational Interviewing

Addiction, Corrections, Education, Health Promotion and Beyond

Publication Chart, 1983-2008

Shouldn’t You Know about MI?

What is it?

Changing Definitions (1983-2009)

Characteristics of the Approach

The History

A Chronological Timeline

Theoretical Influences and Associated Models

Person Centered Therapy (Rogers)

Cognitive Dissonance (Festinger)

Self-Efficacy (Bandura)

Theory of Psychological Resistance (Brehm)

Stages of Change Model (Prochaki and DiClemente)

Self-Determination Theory

The Spirit of Motivational Interviewing

Collaborative

Evocative

Honor Client Autonomy

Guiding Principles

Express Empathy

Develop Discrepancy

Roll with Resistance

Support Self-Efficacy

Enhancing Change Talk – The Key to Change

Primary Goal in MI is to Elicit Change Talk

Types of Change Talk

Disadvantage of the Status Quo

Advantages of Change

Optimism for Change

Intention to Change

Early Skills to Elicit Change Talk – OARS

Open Questions

Affirmations

Reflections

Summarize

Elicit Change Talk

Techniques

Resistance and Its Management

Behavioral Signs of Resistance

Arguing

Interrupting

Negating

Ignoring

Managing Resistance

Reflective Responses

Shift Focus

Reframing

Agreeing with a Twist

Emphasizing Personal Choice

Coming Alongside

Optimism for Change

Intention to Change

Phases of a Motivational Interviewing Process

Phase I

Phase II

Training in Motivational Interviewing

Motivational Interviewing is Simple but not Easy

You May Think You’re Doing It, but You’re Not

Proficiency in MI, Self-Study and Workshops

Eight Stage of Learning Motivational Interviewing

Example Intervention

Session I

Session II

Session III

Ten Things that Motivational Interviewing is Not

Efficacy Research

Resources and References

   

Introduction

 

This course is an overview of Motivational Interviewing, a style of counseling developed by Drs. William R. Miller and Stephen Rollnick over the past 25 years.  As described by Miller and Rollnick, motivational interviewing is “simple but not easy”.  It is a powerful clinical method to enhance patient change.  This course is based on information that can be found in the following publications as well as the articles in the reference section.  For the reader who desires more detailed information about MI, the following resources are excellent.  If you find that the MI approach may be something you would like to explore even further, in-person training opportunities can be found through the Motivational Interviewing Network of Trainers (MINT) website.  We hope you enjoy the course. 

 

Arkowiz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds). (2008). Motivational Interviewing in the Treatment of Psychological Problems. New York: Guilford Press.

 

Mason, P. and Butler, C. (2010).  Health Behavior Change: A Guide for Practitioner, Second Edition. Churchill-Livingstone.

 

Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. 2nd Edition. New York: Guilford Press.

 

Miller, W.R. and Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford.

 

Rollnick, S., Mason, P. and Butler, C. (1999).  Health Behavior Change: A Guide for Practitioners. New York: Guilford Press.  

 

Rollnick, S., Miller, R.W., and Butler, C. (2007). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press. 

 

Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook (Applications of Motivational Interviewing).  New York: Guilford Press.

 

When patients present to us for treatment, we are generally safe in assuming at least two things: First, they are in a state of ambivalence or conflict.  Ambivalence takes the form of a conflict in being faced with two or more different courses of action such as indulgence versus restraint or healthy versus unhealthy.  Second, the goal of treatment is to enhance a patient’s “motivation” to change toward healthy behavior (defined dependent on the situation).  Consider the following poem by Portia Nelson.

 

 

An Autobiography in Five Short Chapters

 

 

Chapter One

 

I walk down the street.

There is a deep hole in the sidewalk.

I fall in.

I am lost….I am helpless.

It isn’t my fault.

It takes forever to find a way out.

 

 

Chapter Three

 

I walk down the same street.

There is a deep hole in the sidewalk.

I see it there.

I fall in anyway…..it’s a habit.

Now, my eyes are open and

I know where I am.

It is my fault.

I get out immediately.

 

Chapter Two

 

I walk down the same street.

There is a deep hole in the sidewalk.

I pretend I don’t see it.

I fall in again.

I can’t believe I am in the same place.

But, it isn’t my fault.

It still takes a long time to get out.

 

 

 

Chapter Four

 

I walk down the same street.

There is a deep hole in the sidewalk.

I walk around it.

 

 

Chapter Five

 

I walk down a different street.

 

 

 

Change is by no means an easy process.  Anyone who has been involved in providing counseling and psychotherapy can attest to the fact that many patients, after years of treatment, have great insight but absolutely no change in their behavior.  As the cognitive-behaviorists will often say, “Insight does not necessarily induce behavior change”.  The following are the learning objectives for this course.

 

 

Learning Objectives

 

 

     List five characteristics of Motivational Interviewing (MI)

     Discuss the Spirit of MI

     Describe the four principles of MI

     Explain the OARS clinical methods

     List five things that MI is not

 

 

An Overview of Motivational Interviewing

 

For those not at all familiar with motivational interviewing, some of its characteristics can be found in Table 1.  Although many of these features may not have much meaning now, by the end of the course you will have an understanding of this powerful clinical method.

 

 

Table 1. Characteristics of Motivational Interviewing

 

 

MI is a clinical method and a style of counseling that is not merely a collection of techniques that can be learned quickly.

 

MI is atheoretical and does not purport to present a “school” of psychology

 

MI is intended to address motivational struggles

 

It is client-centered and intentionally directive

 

Client ambivalence or conflicting motivation provides the basis for change

 

Attempting to directly persuade a client to change will be ineffective.  MI avoids arguing for change.

 

Ambivalence and resistance are accepted as normal.

 

MI allows the client to directly express ambivalence as a guide to resolution and behavior change.

 

The client rather than the counselor voices arguments for change.

 

It is the client’s responsibility, not the counselor’s, to decide whether or not to change and how best to go about it.

 

The counselor’s role is to enhance motivation for change (provide alternative perspectives about the problem behavior and potential ways of changing it).

 

The goal of MI is to elicit “change talk” from the client. Change talk leads to a change plan and a commitment to change.

 

MI is generally a brief intervention of between one and four sessions.

 

MI is “simple but not easy”

 

MI can be effectively combined with other active treatments.

 

 

The Popularity of Motivational Interviewing

 

As we will discuss in great detail, motivational interviewing is a brief counseling approach for behavior change that builds on a patient empowerment perspective by enhancing self-esteem and self-efficacy.  Motivational interviewing was originally developed in the early 1980’s for use with patients who suffer from addictions.  However, since that time, it has been applied to a wide range of issues including alcohol and nicotine abuse, healthcare behaviors, health promotion, HIV risk behavior, diabetes care, obesity, education, and use in the correctional system. 

 

Motivational interviewing formally began with the publication of an article in 1983 by William Miller, Ph.D. entitled “Motivational Interviewing With Problem Drinkers,” (1983).  Since that time, the number of publications on motivational interviewing has doubled every three years for the past 27 years (see the MINT Library Bibliography for a list of the many publications about MI).  Currently, there are several hundred publications now available in a variety of areas.  There are now MI trainers and translations in at least 38 languages and more than 1500 people have completed training through the nonprofit organization, Motivational Interviewing Network of Trainers (MINT). 

 

This dissemination in the use of motivational interviewing within a variety of settings has been both formal and informal.  From a formal and structured standpoint, many state agencies and governmental institutions have adopted the approach to address a variety of issues such as counseling on smoking, alcohol, physical activity, and gambling problems.  The approach has also been supported by governmental funds to address issues in educational and correctional settings.  The informal dissemination of MI has occurred as practitioners become aware of the approach through available reading materials and workshops.  The rapid diffusion and dissemination of motivational interviewing raises questions about whether the original method is being used in a valid fashion across all of these situations (See Miller and Rollnick, 2009; Miller and Rose, 2009; and others for a review).  As discussed by Miller and Rollnick (2009):

 

“when a complex method disseminates as widely and rapidly as this happened with MI, it is not surprising that its boundaries become unclear.  With the diffusion of any complex innovation (Rogers, 2003), there is a natural process of ‘reinvention’ whereby practitioners adapt the innovation to their own understanding and style.  Some such modifications may improve the innovation or render it more accessible for a particular population (Miller, Villanueva, Tonigan, and Cuzmar, 2007).  It is also possible that reinvention removes some critical elements of the innovation, ‘active ingredients’ in its efficacy.  It is therefore important to understand what the essential elements are, and components can be altered without disrupting the defining nature of the method” (p. 129-130). 

 

As will be discussed in detail subsequently, efficacy studies of MI when it is used in a valid fashion, have demonstrated excellent results.  Given the rapid dissemination of motivational interviewing, and its demonstrated efficacy with a variety of problems, wouldn’t it be valuable to learn more about this approach? 

 

What is it?:  Descriptions and Definitions

 

Until the development of motivational interviewing, treatments directed at addictions generally involved confrontational approaches.  Particularly in the United States, where 12-Step approaches were predominant, treatment interventions often included aggressive confrontation in group and family settings.  These confrontational therapies would require that the practitioner challenge the patient with the strongest negative effects of their current situation in an effort to emphasize the threat.  The resulting fear brought about by this confrontational approach was thought to energize and enhance the change process.  A similar cognitive approach included rational emotive therapy (RET) which involves confronting patients with their irrational thoughts or cognitions, as defined by the therapist, and pressuring the client to change them to “rational thoughts” (Miller, 1983).  In contrast to the zeitgeist of the times, Miller believed that these confrontational and fear promoting approaches tended to immobilize the individual and decrease the likelihood of change (Miller, Benefield, and Tonigan, 1993). 

 

Due to a variety of circumstances that will be discussed subsequently, Miller published his seminal paper in 1983 initially outlining a motivational interviewing approach. Briefly, MI assumes that most people hold conflicting motivations for change and will fluctuate in their degree of ambivalence and motivation.  MI allows the patients to openly express this ambivalence which, in turn, allows for guiding them to a satisfactory resolution of their conflicting motivations.  Resolution of the conflicting motivations facilitates the desire to make behavioral changes (Rollnick and Miller, 1995).  In motivational interviewing, it is not the practitioner’s function to directly persuade or coerce the patient to change.  This confrontational approach is seen to be ineffective since it inherently takes one side of the conflict that the patient is already experiencing.  As a result, the individual may tend to accept the opposite stance, arguing against the need for change.  An important objective of MI is to increase a patient’s intrinsic motivation to change and this arises from personal goals and values.  Motivational interviewing emphasizes helping a patient to make his or her own decision to change rather than attempting to force change through external pressure, persuasion, or coercion. 

 

In motivational interviewing, the patient bears responsibility for deciding whether or not to change and how best to go about it.  The responsibility for change is not with the practitioner, but rather is elicited from the patient through what is termed “change talk.”  According to Miller and Rollnick (2002), change talk includes overt declarations by the patient that demonstrate recognition of the need for change, concern for their current position, intent to change, or the belief that change is possible.  Research has demonstrated that there is a good relationship between what individuals say they will achieve and what they will actually achieve (Raistrick, 2007).  The practitioner’s role in MI is to enhance this process. 

 

There are typically two phases in MI sessions.  In the first phase, the patient is often ambivalent about change and may not have enough motivation to actually accomplish change.  The aim of the first phase is to resolve the patient’s ambivalence and increase motivation to change.  The second phase of motivational interviewing is heralded by the patient showing signs of readiness to change.  This is often manifested by change talk or questions about change.  The second phase shifts focus to strengthening commitment to change and helping the patient develop and implement a change plan. 

 

Motivational interviewing is a relatively brief intervention, typically delivered in 1-4 sessions.  MI can be completed independently or as a part of other active treatments that can be continued beyond the brief MI intervention.  MI was originally developed as a clinical method for change and is atheoretical.  Research is now ongoing to develop theoretical underpinnings and determine the active treatment ingredients that result in MI’s ability to induce change.  Since the original publication in 1983, the definition of MI has evolved over the years.  The following is a list of the various definitions developed and publications since 1983: 

 

1983:  Dr. Miller described MI as a common sense, pragmatic approach based on principles derived from effective counseling practice and experience.  He conceptualized motivation not as a personality trait, but as part of the process of change in which contemplation and preparation are important early steps that can be influenced by the counselor.  He posited that confrontation and counseling tended to elicit denial and avoidance of further discussion. 

 

1995:  Miller and Rollnick provided the first explicit definition of MI.  They described MI as a directive, client centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence (Rollnick and Miller, 1995). 

 

2002:  In their book Motivational Interviewing: Preparing People for Change, Rollnick and Miller (2002) revised their definition of MI slightly to the following:  “A client centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25). 

 

2007: In the healthcare field, motivational interviewing has been defined as “a skillful clinical style for eliciting from patients their own motivation in making changes in the interest of their health” (Rollnick, Miller, & Butler, 2007) 

 

2009:  In 2009, the definition was again refined (Miller and Rollnick, 2009, p. 137), “A collaborative person centered form of guiding to elicit and strengthen motivation for change.” 

 

As can be seen, the definitions of motivational interviewing have evolved to accurately reflect its core principles and clinical methods. 

 

 

Table 2.  Summary of the Evolution of Definitions of MI

 

 

1983:  MI is a common sense, pragmatic approach based on principles derived from effective counseling practice and experience.  Motivation not as a personality trait, but as part of the process of change in which contemplation and preparation are important early steps that can be influenced by the counselor.   

 

1995:  MI is a directive, client centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. 

 

2002:  A client centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. 

 

2007: Related to healthcare: A skillful clinical style for eliciting from patients their own motivation in making changes in the interest of their health. 

 

2009:  A collaborative person centered form of guiding to elicit and strengthen motivation for change. 

 

 

A Brief History of Motivational Interviewing

 

As discussed in the recent article by Miller and Rose (2009), the origins of motivational interviewing actually grew out of some unanticipated research findings.  Of course, this is not an uncommon process in science in which the researcher sets out to investigate one issue and, if he or she is astute, pays attention to collateral findings that may be even more significant.  According to the article in the American Psychologist, Miller and his group of investigators were preparing for a clinical trial of behavior therapy for problem drinking.  Nine counselors were trained in two techniques:  behavioral self-control training and the client centered skill of accurate empathy.  After the counselors were well trained in both approaches, three supervisors observed them delivering the behavioral intervention with self-referred outpatients.  The supervisors then independently rank ordered the extent to which the counselors exhibited empathic understanding while delivering the behavior therapy.  In the study, therapist empathy during the treatment session predicted “a surprising” two-thirds of the variance in client drinking six months later.  Even at long term follow-up, counselor empathy accounted for one-half of the variance at 12 months and one-quarter of the variance at 24 months.  The surprising results of this study conducted in the early 1980’s were that the effect of therapist style (e.g. empathy) was far greater than differences among the behavioral interventions being compared.  As discussed by Miller and Rose (2009), many other studies done during that time, and subsequently, have also demonstrated that a counselor’s client centered interpersonal functioning accounted for a substantial proportion of the variance in later outcomes (e.g. relapse rates, drug use, etc.). 

 

As reviewed in the Miller and Rose article (2009), Miller subsequently went on sabbatical leave to Bergen, Norway.  During his sabbatical, he was invited to lecture on the behavioral treatment for alcohol problems in addition to meeting regularly with a group of young psychologists.  Typical of practitioners new to the field (and a quest for answers one hopes to never lose), the group asked him many questions about why he was doing what he was doing, especially during the role playing sessions.  This process induced him to verbalize his implicit model that guided his clinical practice.  From his notes on this process, Miller began to develop a conceptual model and clinical guidelines for “motivational interviewing.”  His approach was clearly in stark contrast to the prevalent confrontational styles characteristic of the time.  In more formally developing his approach, he discussed various conceptual links to previous psychological theories including those of Rogers (client centered therapy) and Festinger (cognitive dissonance).  Miller later recalled “they coaxed from me a specification of what I was doing and why.  I wrote this down in a somewhat long and rambling manuscript, which I shared with a few colleagues” (Miller, 1995, p. 3).  Miller did not intend to publish the paper, but sent it to a few colleagues for comment. One of those was Dr. Ray Hodgson, who was then editor of behavioral psychotherapy.  Hodgson suggested that Miller refine the manuscript to a publication format which resulted in the article, “Motivational Interviewing With Problem Drinkers” published in the British Journal of Behavioral Psychotherapy in 1983. 

 

As often happens in the development of new ideas and technologies, the next significant event occurred in 1989 when Miller was on sabbatical in Australia and met Stephen Rollnick.  Dr. Rollnick explained to Miller that MI was a popular addiction treatment in the United Kingdom and he encouraged Miller to write more about MI.  This collaboration led to the original book on motivational interviewing, “Preparing People To Change Addictive Behavior” (1991).  The book included a description of the principles of MI specifically focused on addictive behavior. 

 

During the 1990’s, research and practitioner interest in MI grew steadily.  In fact, requests for training and consultation far exceeded what Miller and Rollnick could provide.  Realizing that there was a need for a group of qualified MI trainers, they decided to provide MI workshops that would be focused on training the trainers.  In 1993, they established Training New Trainers (TNT) and organized the first training conference in Albuquerque, New Mexico.  Subsequently, the Motivational Interviewing Network of Trainers (MINT) was established in 1995.  The MINT is comprised of those individuals who have completed TNT training and desire a network to exchange ideas for research and training.  The first international meeting of MINT was held in 1997 in Malta.  Since that time, these meetings have alternated between Europe and the United States.  The meetings and training workshops are on-going (MINT Training Events).

 

During the 1990’s, motivational interviewing was also being increasingly used in a variety of healthcare settings beyond those dedicated to the treatment of addictions.  This led to the publication of a second book on MI: “Health Behavior Change-A Guide for Practitioners,” (Rollnick, Mason, & Butler; 1999).  This book focuses on the utilization of MI by general healthcare professionals. 

 

In 2002, the second addition (thoroughly revised) of Motivational Interviewing: Preparing People For Change was published (Miller and Rollnick, 2002).  Since then, a number of other books that focus on applying MI to various issues have been published.  For instance, the book        

Motivational Interviewing in Health Care: Helping People Change Behavior (Miller, Rollnick, and Butler) was published in 2007.  Subsequently, the book, Motivational Interviewing in The Treatment of Psychological Problems was published by Arkowitz, Westra, Miller, and Rollnick also in 2007.  The first world conference on motivational interviewing was held in 2008 in Interlaken, Switzerland.  This conference attracted 222 participants from 25 countries. Also, the second edition of the book applying MI principles to healthcare is now available, Health Behavior Change: A Guide for Practitioners, Second Edition (Mason and Butler, 2010). 

 

Theoretical Influences and Associated Models

 

As alluded to previously, there is no currently established theoretical explanation as to how and why MI can be effective.  MI was originally developed as a clinical method and was atheoretical.  Only now, researchers are attempting to establish the active ingredients of MI and establish a unifying theory explaining its effectiveness.  Even so, there are many theoretical ideas and influences that contributed to the development of MI and are often associated with it. 

 

Person Centered Therapy

 

Person centered therapy, also known as client centered therapy, was developed by Carl Rogers in the 1940’s.  The central hypothesis is that the growth potential of any individual will tend to be released in a relationship that helps the person experience and communicate realness, caring, and a deep sense of non-judgmental understanding.  The basic theory of person centered therapy can be summarized in the form of an if-then hypothesis: 

 

If certain conditions are present in the attitudes of the therapist who is in a relationship (e.g. congruence, positive regard, empathic understanding) then growth will change and take place in the client. 

 

The hypothesis underlying person centered therapy is its view of man’s nature.  The theory postulates that man has a tendency towards self actualization.  Self-actualization is defined as an inherent tendency of the organism to develop all its capacities in ways which serve to maintain or enhance the organism (Rogers, 1959).  The forces towards self actualization are part of human nature. 

 

According to person centered therapy, the forces of self-actualization in the infant and child are confronted by conditions that significant others in his life impose upon him.  These conditions imposed upon the individual are termed “conditions of worth.”  Conditions of worth tell individuals they are lovable and acceptable when they behave in accordance with standards imposed by others.  Some of these conditions are assimilated into one’s self concept.  As discussed by Rogers, “he values an experience positively or negatively solely because of these conditions of worth which he has taken over from others, not because the experience enhances or fails to enhance his organism” (1959, p. 209).  Ultimately, an incongruence develops between the organismic forces of self actualization and his ability to translate them into awareness and action.  As such, “psychotherapy is the releasing of an already existing capacity in a potentially competent individual” (Rogers, 1959, p. 221).  If certain definable conditions are present, such as in the psychotherapy relationship, the individual gradually allows the self-actualizing capacity to overcome restrictions he has internalized in the conditions of worth.  These definable conditions include the individual (client, patient) perceiving in the therapeutic relationship genuineness or congruence,  empathetic understanding, and unconditional positive regard. 

 

Person centered theory describes three attitudes necessary and sufficient to affect change in clients.  The theory does not stress technical skills or knowledge of the therapist.  These therapeutic attitudes include: 

 

     being genuine or congruent,

     to be empathic or understanding, and

     to be unpossessively caring or confirming. 

 

It is these attitudes that are the agents of change in the person centered therapeutic relationship.  When this atmosphere is provided, the individual’s self-actualizing tendencies are allowed to emerge.  Again, this is the inherent tendency of the individual to develop in ways that serve to maintain or enhance the person.  The three important attitudes of the therapist have been summarized as being congruent, empathic, and respectful.  Rogers postulated that these three qualities are “necessary and sufficient.”  If the therapist shows these three qualities, the client will improve even if no special “techniques” are used.  If the therapist does not show these three qualities, then the client’s improvement will be minimal, no mater how many “techniques” are used.  One of the primary methods by which client centered therapists communicate these attitudes is through “reflection.”  Reflection is known under many terms such as reflective listening, active listening etc.  Reflective listening is not simply repeating back what a client has said to the therapist (as is often the caricature developed in psychotherapy jokes).  Rather, the reflective listening must successfully communicate to the client that the therapist is being congruent, empathic, and respectful.  Reflecting listening is communicating to the client that the therapist understands him or her at the deepest levels.

 

Relationship to MI. Motivational Interviewing shares many commonalities with person centered therapy.  First, much of the original research completed by Miller demonstrated that the most powerful agent of change was elements of the therapeutic relationship rather than any specific technique.  This agent of change includes therapist empathy and empathic understanding.  The influence of the Rogerian approach on motivational interviewing can be seen in the spirit and guiding principles of MI to be discussed subsequently.  However, motivational interviewing departs from the person centered approach in that MI is intentionally directive and person centered therapy is intentionally non-directive. 

 

Cognitive Dissonance

 

The theory of cognitive dissonance (Festinger, 1957) suggests that we have an inner drive to keep all of our attitudes and beliefs in harmony and to avoid disharmony or “dissonance.”  Cognitive dissonance refers to a situation involving conflicting beliefs, attitudes, or behaviors. 

Festinger postulated that we hold many cognitions about the world and ourselves and, when they clash, a discrepancy is evoked.  When an individual is experiencing a state of cognitive dissonance (tension), he or she is driven towards cognitive consistency.  The principle of cognitive consistency suggests that we seek consistency in our beliefs and attitudes in any situation where two cognitions are inconsistent (cognitive dissonance).  Motives to maintain cognitive consistency can give rise to irrational and maladaptive behavior.    Since cognitive dissonance is unpleasant, we are motivated to reduce or eliminate it and achieve consonance (agreement).  For instance, cognitive dissonance may occur in people who smoke cigarettes (behavior) while knowing that smoking causes cancer (cognition). 

 

Some of Festinger’s early investigations of cognitive dissonance were quite interesting.  In one participant observation study of a cult, members believed that the earth was going to be destroyed by a flood.  The cult members who were very committed decided to give up their homes and jobs to work for the cult.  Ultimately, the cataclysmic flood did not occur (thank goodness!).  Festinger found that fringe members of the group were more inclined to recognize that they had made fools of themselves and to “put it down to experience.”  However, very committed members of the cult were more likely to reinterpret the evidence to show that they were right all along and the earth was not destroyed because of the faithfulness of the cult members.  In this example, cognitive dissonance occurred in the members and resolution was achieved in different ways depending on the level of commitment and “need” to maintain the original belief (we made fools of ourselves versus our faith saved us from the flood occurring). 

 

Since cognitive dissonance is an uncomfortable state, individuals seek to reduce it in a variety of ways.  According to Festinger, dissonance can be reduced in one of three ways.  First, individuals can change one or more of their attitudes, behavior, or beliefs to make the relationship between the two elements a consonant one.  As such, when one of the dissonant elements is a behavior, the individual can change or eliminate the behavior.  This solution tends to be one of the more difficult ones since it is often challenging for people to change well learned behavioral responses (habits such as giving up smoking or changing unhealthy behavior). 

 

A second method of reducing dissonance is to acquire new information that outweighs the dissonant beliefs.  Of course, this new information is not necessarily accurate.  For instance, a person who smokes may realize that research has indicated this will cause lung cancer.  However, the individual may adopt new information such as the belief that research has not proven definitively that smoking causes lung cancer. The person might also focus on the minority of cases in which a person has been known to smoke two packs of cigarettes per day for his entire life and lives to be 100-years-old.  Adopting this “new information” will have a tendency to decrease dissonance, but in an unhealthy manner. 

 

The third way to decrease dissonance is to reduce the importance of the cognition (e.g. the belief or attitude).  This is often done when there is dissonance between a belief and an unhealthy behavior.  Reducing the importance of the cognition might include such things as “it’s better to live for today than for tomorrow,” “it won’t hurt to drink heavily until I’m 40-years-old and then stop,” etc.  This method reduces the importance of the cognition related to the unhealthy behavior and, in some ways, replaces it with one that is erroneously positive (the benefits of living for today outweigh the consequences of tomorrow). 

 

Relationship to MI. In cognitive dissonance, you may have noticed that solutions for decreasing the dissonance (achieving consonance) may or may not be particularly healthy.  In the second principle of motivational interviewing, developed discrepancy involves creating and amplifying, from the client’s perspective, a discrepancy between present behavior and his or her broader goals and values (Miller and Rollnick, 2002, p. 38).  This was originally described by Miller and Rollnick (1991) as creating “cognitive dissonance” from the concepts developed by Festinger.  In more recent conceptualizations of motivational interviewing, developing discrepancy is simply defined as a discrepancy between the present state of affairs and how one wants it to be.  Miller and Rollnick (2002) discuss that this avoids “invoking an inherent drive towards cognitive consistency” that was a key component of Festinger’s theory, but not necessarily in motivational interviewing. 

 

Bandura’s Concept of Self-Efficacy

 

The concept of self-efficacy is a central component of Bandura’s social cognitive theory (SCT).  The social cognitive theory emphasizes the role of observational learning, social experience, and reciprocal determinism in the development of personality.  In SCT, humans are viewed as self-organizing, proactive, and self-regulating rather than as reactively shaped by environmental forces or driven by inner impulses. SCT postulates that human functioning is the product of an interplay of personal, behavioral, and environmental influences. A core concept is reciprocal determinism which is the view that (1) personal factors (cognition, affect, and biological events); (2) behavior; and, (3) environmental influences interact to produce various aspect of personality and function.   According to Bandura, a person’s attitudes, abilities, and cognitive skills comprise the self-system.  This system plays a primary role in how we perceive situations and behave in response to different situations.  Self-efficacy is an essential part of this self-system. 

 

According to Bandura, self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action required to manage perspective situations” (1995, p. 2).  Self-efficacy is an individual’s belief in his or her ability to succeed in a particular situation.  These beliefs are determinants of how people think, behave, and feel.  The concept of self-efficacy was first published in a 1977 paper by Bandura, “Self-Efficacy: Toward a Unifying Theory of Behavioral Change.” 

 

Virtually all of us can identify things that we would like to change and achieve, along with goals we want to accomplish.  However, we also realize that putting these plans into action is not quite so simple.  Researchers have found that an individual’s self-efficacy plays a significant role in how these issues are approached. 

 

People with a strong sense of self-efficacy:

 

view challenging problems as tasks to be mastered

develop deeper interest in activities in which they participate

form a stronger sense of commitment to their interest and activities

recover quickly from setbacks and disappointments

 

In contrast, people with a weak sense of self-efficacy:

 

avoid challenging tasks

believe that difficult tasks and situations are beyond their capabilities

focus on personal failings and negative outcomes

quickly lose confidence in personal abilities

 

Bandura (1992, 1994) postulates that there are four major sources of self-efficacy that influences us over the course of our lives. 

 

Mastery Experiences - “The most effective way of developing a strong sense of efficacy is through mastery experiences” (Bandura, 1994).  Successfully performing a task strengthens one’s sense of self-efficacy.  Alternatively, failing to adequately deal with a task or challenge can undermine and weaken self-efficacy. 

 

Social Modeling - Witnessing other people successfully completing a task is another importance source of self-efficacy.  As discussed by Bandura, seeing people similar to oneself succeed by sustained effort raises observers’ beliefs that they too possess the capabilities to master comparable activities to succeed (1994).

 

Social Persuasion - Bandura also asserted that individuals could be persuaded to believe that they have the skills and capabilities to succeed.  Receiving verbal encouragement from others can help an individual overcome self-doubt and instead focus on their best effort to achieve the task at hand. 

 

Psychological Responses – An individual’s psychological responses (mood, emotional state, physical reactions, and stress) can all impact how he or she feels about their personal abilities in a particular situation.  Bandura discusses that it is not only the intensity of emotional and physical reactions that is important, but how these are perceived and interpreted by the individual (1994).  If a person can learn to minimize stress and elevate mood when faced with difficult or challenging tasks, he or she can improve their sense of self-efficacy. 

 

Relationship to MI. The fourth general principle of MI is supporting self-efficacy (Miller and Rollnick, 2002).  As discussed by the authors, self-efficacy “is a key element in motivation for change and is a reasonably good predictor of treatment outcome” (p. 40).  Aside from helping a patient develop his or her perception that there is an important problem to be addressed, a goal of motivational interviewing is to enhance the person’s confidence in his or her capability to cope with obstacles and to succeed in change.  It is not enough to help a patient take personal responsibility for deciding and directing change, it is important to communicate to the person that change is in indeed possible (self-efficacy). 

 

Psychological Reactance Theory

 

Psychological reactance theory was first proposed by Brehm in 1966.  Psychological reactance is defined as an aversive affective reaction in response to regulations or impositions that impinge on freedom and autonomy.  This reaction is especially common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior.  Psychological reactance occurs when a person perceives a decrease in freedom often in response to feeling encouraged or even coerced to adopt a specific belief.  As a consequence, reactance often augments resistance to persuasion.  Reactance is experienced whenever a free behavior is restricted.  A free behavior, in this context, is defined as any act or choice that individuals could undertake now or very soon.  Linguistic research has identified some statements that seem to elicit psychological reactance and resistance.  This language is dogmatic and often referred to as controlling or explicit (see C.H. Miller et al., 2007; Grandpre et al., 2003; Quick and Stephenson, 2008).  Dogmatic messages that have been perceived as provoking reactance (resistance) include imperatives such as:

 

“you must…….”

 

“you need to…..”

 

 “you cannot deny that…” or “this issue is extremely serious” (absolute allegations)

 

 “any reasonable person would agree that..” (derisions towards other perspectives)

 

“if you do not _____ then _____”  (threatening warnings) 

 

Studies of psychological reactance have found interesting consequences and implications.  For instance, as the level of psychological reactance rises, the motivation to reestablish freedom increases accordingly.  Of course, “freedom” is most often perceived as moving in a direction opposite of the rule or course of action that is being imposed and encouraged.  Specifically, individuals often show “boomerang effects” in which they become more inclined to act to the very behavior that was restricted (Brehm, 1966).  Or, they may act in ways that are similar, but different, to the behavior that has been restricted.  Examples include smoking more often after drugs are prohibited (referred to as related boomerang effects).  In addition, psychological reactance provokes adverse attitudes towards the source of any restriction (e.g. the therapist).  In the therapeutic context, reactance can reduce the efficacy of interventions.  For example, interventions to reduce alcoholism tend to be less effective if clients manifest signs of reactance (see C.H. Miller et al. 2007, for a review). 

 

Relationship to MI. The motivational interviewing principle of avoiding arguing for change or “rolling with resistance” was developed from the ideas of psychological reactance.  In motivational interviewing, it is the goal of the therapist to avoid activating a state of psychological reactance in the patient.  The psychological reactance theory has been investigated extensively within the context of psychotherapeutic interventions.  It has also been quite influential in terms of developing methods for managing client resistance.  In fact, motivational interviewing includes an extensive discussion of identifying and managing resistance.  This is important since client resistance has the potential to completely undermine a motivational interviewing intervention. 

 

Stages of Change Model

 

Transtheoretical Model (TTM) or Stages of Change Model (SCM) was originally developed by Prochaska and Di Clemente (1983) in the late 1970’s and early 1980’s when they were studying how smokers were able to give up their habits.  The idea behind the model is that behavior change does not occur in one step, but rather progresses through different stages.  Progressing through these stages leads to successful change.  Each individual progresses through these stages at his or her own rate that is determined by the individual.  According to the model, an individual has to deal with a different set of issues and tasks in each stage that relates to changing the behavior in question.  The following is a brief description of each stage: 

 

Precontemplation - In this stage, an individual is not thinking seriously about change and is not interested in any kind of help.  People in this stage tend to defend their current unhealthy behavior and do not feel it is a problem.  They may be defensive in the face of other people’s efforts to pressure them to change. 

 

Contemplation - In this stage, the individual is more aware of the personal consequences of the unhealthy behavior and may spend time thinking about the problem.  Although the individual is able to consider the possibility of changing, he or she may tend to be ambivalent about it.  An individual in this stage may begin to weigh the pros and cons of modifying the behavior.  Although they may think about the negative aspects of the behavior and the positives associated with changing it, they may doubt that the long term benefits associated with change will outweigh the short term cost. 

 

Preparation/Determination - In this stage, the individual has made a commitment to make a change.  The motivation for changing is reflected in statements such as “I’ve got to do something about this.”  This is serious, something has to change,” “What can I do?”  For the individual, this is somewhat of an investigational phase in which he or she is taking small steps towards change.  They are trying to gather information about what will be necessary to change the behavior. 

 

Action/Willpower - This is a stage in which the individual believes in his or her ability to change the behavior and is actively involved in taking steps to change the situation.  In this stage, a variety of different techniques may be utilized.  The amount of time an individual spends in action varies and this tends to be the shortest stage.  In this stage, the individual is making overt efforts to change the unhealthy behavior and he or she is at greatest risk for relapse. 

 

Maintenance - This stage involves being able to successfully avoid temptations to return to the unhealthy behavior and to maintain the status quo.  People in this stage must remind themselves of how much progress has been made and constantly reformulate the rules of their lives to avoid relapse. 

 

Relapse - Along the path to permanent change of an unhealthy behavior, most people experience relapse.  Relapse is often accompanied by feelings of discouragement and seeing one’s self as a failure.  Most people do not experience a linear pathway from the unhealthy behavior to successful resolution.  Rather, they cycle through the five stages several times before achieving a stable lifestyle change. 

 

 

change2

Figure: Stages of Change Model

 

Relationship to MI. As can be seen in the literature, motivational interviewing has been closely aligned with TTM.  As discussed by Miller and Rollnick (2009), MI and the Transtheoretical Model of change “grew up together in the early 1980’s” (p. 130).  As discussed in the article, TTM and its best known component, the Stages of Change, revolutionized addiction treatment and how professionals thought about facilitating change.  The authors make the point that there were relatively few treatment approaches designed to do that, and so there was a natural fit between MI and the Trans Theoretical Stages of Change. In fact, both TTM and MI were presented at the Third International Conference on Treatment of Addictive Behaviors in 1984.  As discussed by Miller and Rollnick (2009), the stages “provided a logical way to think about the clinical role of MI, and MI in turn provided a clear example of how clinicians could help people to move from pre-contemplation and contemplation to preparation and action” (p. 130).  However, the authors state that MI was never based on TTM.  As they discuss, TTM “is intended to provide a comprehensive conceptual model of how and why changes occur, whereas MI is a specific clinical method to enhance personal motivation for change.”  In that regard, Miller and Rollnick (2009) are underscoring that TTM does not provide the theoretical underpinnings of MI and “the implicit underlying theory of MI is only now being explicated, and is not intended to be a comprehensive theory of change.”  They also discussed that it is not necessary to assign people to a stage of change as part of, or in preparation for, MI.  To underscore this issue, the second edition of motivational interviewing (Miller and Rollnick, 2002) intentionally did not include any references to TTM in the authored part (first half of the book).  This is in contrast to the original text published in 1991 (Miller and Rollnick, 1991) which did discuss TTM. 

 

Self-Determination Theory

 

Most recently, self-determination theory (SDT) has been proposed as a theoretical rationale for understanding how MI works (Markland et al., 2005).  According to Markland et al., (2005), “fundamental to the theory is the principle that people have an innate organizational tendency toward growth, integration of self, and the resolution of psychological inconsistency” (p. 815).  The authors go on to state that “of particular interest is the question of how people internalize and integrate extrinsic motivations and come to self-regulate their behaviors in order to engage autonomously in actions in their daily life” (p. 815).  The authors state that SDT purports that all behaviors can be understood as lying along on a continuum ranging from external regulation to true self regulation.  Self-determination theory focuses on autonomy support as a crucial determinant of optimal motivation and positive outcomes.  Autonomy is the need to perceive one’s self as a source of one’s behavior.  As such, the practitioner’s support of the client’s independence is “autonomy support.” 

 

Relationship to MI. The extensive discussion related to this issue is beyond the purposes of this course and the reader is referred to Markland et al. (2005).  In brief, three components of autonomy support have been differentiated including:

 

a person in authority such as the counselor, teacher, or parent, should acknowledge the perspective of the person being motivated

 

there should be as much choice as possible within the limits of the context

 

there should be a meaningful rationale in those instances when choice cannot be provided.

 

Researchers have proposed that many of the tenets of SDT are consistent with motivational interviewing principles.  For instance, the idea of autonomy support is consistent with MI principles of reflective listening, summarizing, increasing the patient’s self-awareness, and facilitating making more autonomous choices.  Again, motivational interviewing was developed initially as an atheoretical clinical method and is just now being researched relative to theoretical underpinnings. 

 

The Spirit of Motivational Interviewing

 

The spirit of the motivational interview method can be seen as the style or intention of the practitioner’s disposition with the client (see Miller and Rollnick, 2002; Rollnick and Miller, 1995).  As discussed by Miller and Rollnick (2002), “If motivational interviewing is a way of being with people, then its underlying spirit lies in understanding and experiencing the human nature that gives rise to that way of being.  How one thinks about and understands the interviewing process is vitally important in shaping the interview” (p. 34).  Rollnick, Miller, and Butler (2008) have defined the MI spirit in terms of three key characteristics: 

 

Collaborative - Motivational interviewing is collaborative in nature.  As such, the practitioner strives to create a positive interpersonal atmosphere “that is conducive, but not coercive to change,” (Miller and Rollnick, 2002, page 34).  Collaboration in the counseling relationship involves a “partnership” that honors the client’s expertise and perspectives. 

 

Evocation - Consistent with collaboration, the counselor’s style is not one of “imparting” but rather “eliciting.”  This is the difference between telling someone what to do and drawing the wisdom from the client.  As discussed by Miller and Rollnick (2002, p. 34), “it is not in instilling or installing, but, rather, an eliciting a drawing out of motivation from the person.” 

 

Autonomy - In the motivational interviewing spirit, autonomy signifies the characteristic that the counselor affirms the patient’s right and capacity for self-direction and facilitates informed choice.  Motivational interviewing always respects the individual client’s autonomy and freedom. 

 

As can be seen, these three characteristics of the spirit of motivational interviewing emphasize its client’s centeredness.  The spirit of motivational interviewing also underscores its core assumptions about human nature: that individuals possess wisdom regarding themselves and tend to develop in a positive direction if given proper conditions of support (Miller and Moyers, 2006).  A deeper understanding of the spirit of motivational interviewing can be obtained by looking at other characteristics as outlined by Rollnick and Miller in their 1995 article, “What Is Motivational Interviewing.”  These additional characteristics can be found in Table 3. 

 

 

Table 3. Characteristics of the Spirit of Motivational Interviewing

 

 

The motivation to change is elicited from the client, and not imposed from without.

Confrontational approaches tend to emphasize persuasion, coercion, and use of external contingencies (e.g. punishment).  In contrast, MI relies on the individual’s intrinsic values and goals to enhance behavior change. 

 

It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence.

Ambivalence or dissonance takes the form of conflict between two or more courses of action.  The counselor’s job is to facilitate expression of both sides of the ambivalence and guide the client towards an acceptable resolution, enhancing change. 

 

Direct persuasion is not an effective method for resolving ambivalence.

The practitioner may be tempted to persuade or coerce the client in a direction that the practitioner feels is healthy.  However, clinical research has demonstrated that this type of approach is likely to increase client resistance and decrease the chances of change. 

 

The counseling style is generally a quiet and eliciting one.

Again, motivational interviewing does not include any type of persuasion, confrontation or arguing. 

 

The counselor is directive in helping the client to examine and resolve ambivalence.

Motivational interviewing assumes that ambivalence (or dissonance) is the primary obstacle to overcome in order to effect change.  Once that has been accomplished, there may or may not be the need for further specific interventions. 

 

Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction.

In motivational interviewing, the practitioner is highly attentive and responsive to motivational signs.  For instance, resistance behaviors can be a signal that the therapist is assuming a greater readiness to change than is currently the case. 

 

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

In MI, the practitioner respects the client’s autonomy and freedom of choice regarding his or her own behavior. 

 

 

As discussed by Rollnick and Miller (1995), understanding the spirit of motivational interviewing demonstrates that it should not be viewed as a technique or set of techniques that are applied or “used on” people.  Rather, it is an interpersonal style and is not at all restricted to formal counseling settings.  The spirit of motivational interviewing gives rise to specific strategies and clinical methods.  In fact, the underlying spirit of MI is seen as a crucial component of its efficacy (see Miller and Rose, 2009).  As will be discussed subsequently, the MI spirit has been associated with enhancing “change talk” and favorable outcomes. 

 

The Four General Principles

 

The spirit of motivational interviewing might be conceptualized as the foundation upon which the four broad guiding principles are built.  As discussed by Miller and Rollnick (2002, page 36), “this is one step from the above described general spirit, and toward greater specificity of practice.”  The four general principles are as follows:

 

Express empathy - Similar to Rogerian person-centered therapy, it is assumed that behavior change is only possible when an individual feels personally accepted and valued.  The practitioner’s empathy is crucial in providing the conditions necessary and sufficient for successful exploration of change to take place.  Expressing empathy is primarily done through respectful listening which communicates a desire to understand the client’s perspective completely. 

 

Develop Discrepancy - Motivational interviewing departs from client centered counseling in that MI is intentionally directive.  Part of the process in motivational interviewing is to amplify, from the client’s perspective, a discrepancy between present behavior and his or her broader goals and values.  This idea was borrowed from the concept of “cognitive dissonance” developed by Festinger.  Discrepancy includes the client becoming aware of, and discontented with, the cost of his or her present course of behavior as well as the perceived advantages of behavior change.  In summary, developing discrepancy involves exploring the pros and cons of the client’s current behaviors and their changes to those current behaviors.  This is done within a supportive and accepting atmosphere that promotes or “intensifies” the awareness of the discrepancy between the two (current behavior and broader goals).  Developing discrepancy in this manner elicits movement towards consistency between the client’s behaviors and important personal goals (e.g. health status, living situation, self-image, etc.). 

 

Role With Resistance - Critical to motivational interviewing is the avoidance of arguing with the client about their need for change.  This also includes arguing for one pathway of change over another.  As we previously discussed in reviewing psychological reactants theory (Brehm, 1966), when a clinician argues for one course of action, it can actually provoke behaviors in the opposite direction.  This is due to the client’s perception that his or her “free behavior” is being restricted.  In motivational interviewing, client behaviors that are labeled as “resistant” actually represent a signal for the counselor to shift approach.  The client is always seen as the primary resource in finding answers and solutions. 

 

Support Self-Efficacy - A client may reach the state of understanding that he or she has an important problem that needs to be changed.  However, if the client perceives no hope or possibility for change, then it is highly unlikely that it will occur.  Therefore, the fourth important principle of motivational interviewing is enhancing self-efficacy or the individual’s belief in his or her ability to carry out and succeed with the specific task.  The MI counselor supports self-efficacy by helping clients believe in themselves and become confident that they can carry out the changes they have chosen to pursue. 

 

The four principles of motivational interviewing are summarized in Table 4.

 

 

Table 4. The Four Principle of Motivational Interviewing

 

 

Express empathy - Expressing empathy is primarily done through respectful listening which communicates a desire to understand the client’s perspective completely. 

 

Develop Discrepancy - Part of the process in motivational interviewing is to amplify, from the client’s perspective, a discrepancy between present behavior and his or her broader goals and values.  Developing discrepancy involves exploring the pros and cons of the client’s current behaviors and their changes to current behaviors in an effort to elicit movement towards consistency between the client’s behaviors and important personal goals. 

 

Role With Resistance - Critical to motivational interviewing is the avoidance of arguing with the client about their need for change.  This also includes arguing for one pathway of change over another.  The client is always seen as the primary resource in finding answers and solutions. 

 

Support Self-Efficacy - The fourth important principle of motivational interviewing is enhancing self-efficacy or the individual’s belief in his or her ability to carry out and succeed with the specific task.  The MI counselor supports self-efficacy by helping clients believe in themselves and become confident that they can carry out the changes they have chosen to pursue. 

 

 

At this point in the course,  it is important to summarize and underscore the important components of MI and how they interrelate.  The best way to conceptualize this is illustrated  in the following pyramid.  The Spirit of MI forms the foundation upon which the other elements are built.  The second layer includes the Four General Principles of MI.  The principles are an important component of MI and their effectiveness is contingent upon being done within the context of the spirit.  Lastly, to be discussed subsequently, the skills or techniques are built on the spirit and principles.  The spirit and principles are the sine qua non of MI.

 

 

methods_principles_spirit

Figure: The Motivational Interviewing Pyramid

 

 

Client Centered Counseling Skills-OARS

 

As portrayed in the MI pyramid, it is the underlying “spirit” that epitomizes the clinical method of motivational interviewing (Miller and Moyers, 2006; Miller and Rollnick, 1991, 2002).  This “spirit” includes a set of assumptions about human nature.  Built upon the foundation of this spirit of motivational interviewing are the four principles as we reviewed.  To carry the model further, there are an additional set of skills (techniques or methods) that are built upon the foundation of the MI Spirit and Principles.  Depending upon the source, these are also termed “micro-skills.”  In Miller and Rollnick (2002), these are also termed “five early methods” (p. 65).  They are termed “early” methods not because they are used at the beginning of treatment and then abandoned; rather, it is important to use them right from the beginning of the intervention.  The first four of these methods are derived largely from client centered counseling.  However, Miller and Rollnick (2002) make the point that in motivational interviewing they are used for a particular purpose, “that of helping people to explore their ambivalence and clarify reasons for change” (p. 65).  In other articles, these methods are specifically employed to elicit “change talk.”  Change talk is verbalizations that signal desire, ability, reasons, need, or commitment to change (Miller and Rollnick, 2002; Miller and Moyers, 2006; Miller and Rose, 2009).  The primary goal in motivational interviewing is to elicit change talk and the skills to be discussed are designed to achieve that purpose.  The acronym for the four foundational MI skills is OARS with the fifth skill being defined as eliciting change talk.  The skills are Open-ended questions, Affirm, Reflective listening, and Summarize.  These are defined and described as follows:

 

Open questions - Many mental health practitioners are familiar with the idea of open-ended questions versus closed-ended questions.  Open-ended questions encourage people to talk about whatever is important to them.  In contrast to a closed-ended question which elicits a yes or no response, open questions are designed to encourage longer responses from the client.  Open questions invite the client to “tell their story” in their own words without directing them in any specific manner.  Open questions allow the client to convey his or her thoughts and perspective.  Of course, when asking open-ended questions, the therapist must be willing to carefully listen to the client’s response.  The following examples contrast open versus closed questions.  In this example, one can see how the topic is similar, but the likely response will be very different. 

 

Example of closed-ended questions.

 

Do you have a good relationship with your spouse? (closed)

What can you tell me about your relationship with your spouse? (open)

 

Example of open-ended questions. 

 

What brings you here today? 

What do you like about your drinking? 

How would you like to go about reducing your drinking? 

What was that like?

Help me understand.  How would you like things to be different? 

How would you be most likely to ___? 

What do you think you will lose if you give up ____? 

What have you tried before to make a change? 

What do you want to do next? 

How can I help you with ___?

 

Affirmations - Affirmations are statements and gestures made by the therapist that recognize the client’s strengths, successes, and efforts to change.  Affirmations build confidence in one’s ability to change and, to be effective, must be genuine and congruent.  When providing information, therapists should avoid statements that sound overly ingratiating.  Examples of ingratiating versus affirmative statements include the following:

 

Examples of ingratiating

 

Wow, that’s incredible. 

That’s great; I knew you could do it. 

You are doing an awesome job!

 

 

Examples of affirmative statements

 

You are clearly a very resourceful person. 

That took a lot of courage to…..

You showed a lot of patience in the way you handled….

That is a great idea.

One of your strengths is your ability to….

I have really enjoyed talking with you today.

 

Your commitment really shows by_____. 

You showed a lot of ____ by doing that. 

With all of the obstacles you have now, it’s ____ that you have been able to refrain from engaging in ____. 

You have been really working hard to quit drinking. 

I know you are quite busy and I appreciate you coming in today.

Those are great ideas on how to reduce your drinking. 

 

Reflections - As the reader will likely now be aware, reflective listening is an essential component of motivational interviewing.  Reflective listening is the critical element for engaging the client in the therapeutic relationship, building trust, and fostering motivation to change.  It is also the primary method of building empathy.  Reflective listening involves listening carefully to the client and then making a reasonable guess about what he or she is saying.  It may appear to be deceptively easy, but it is not simply parroting back what the patient is verbalizing.  In fact, if reflective listening is not done properly, it will have the opposite effect and tend to alienate the client since the reflection will sound superficial and trite. 

 

Many authors have discussed that the therapist must actually learn to “think” reflectively.  Thinking reflectively includes having an interest in what the client has to say and respecting the client’s inner wisdom.  It also includes the ability to listen carefully enough to be able to “put yourself in the client’s shoes” and then reflect back a reasonable hypothesis about what the client is expressing.  Ideally, reflections will move the session forward and highlight the client’s change talk.  It is beyond the scope of this course to discuss all of the complexities of effective reflective listening, and the reader is referred elsewhere (See resource list).

 

Reflective listening is designed to close the loop in communication and ensure that “breakdowns” or misunderstandings in communication do not occur.  Reflective listening has also been termed “active listening” in the communication literature.  Three basic levels of reflective listening have been identified and these may increase the effectiveness of the therapeutic relationship.  Various authors discuss that the “depth” of the reflective listening should match the situation.  Examples of the three levels of reflective listening include:

 

Repeat or rephrasing:  The listener simply repeats or substitutes synonyms or phrases, but stays close to what the speaker has said.

 

Paraphrasing:  The listener makes a major restatement in which the speaker’s meaning is inferred. 

 

Reflecting the person’s feelings: The listener emphasizes the emotional aspect of communication through feeling statements.  This is the deepest form of listening. 

 

As discussed by Miller and Rollnick (2002), the depth of reflection increases with counselor skillfulness.  It should be noted that reflective listening is not a passive process.  In fact, it can be quite directive since the therapist decides what to reflect and what to ignore, what to emphasize, and what to de-emphasize, and what words to use in capturing meaning (Miller and Rollnick, 2002, p. 72).  From an operant or behavioral perspective, when a therapist uses reflective listening effectively, he or she is actually reinforcing a certain type of expression of thoughts from the client and ignoring other lines of expression.  Miller and Rollnick (2002) suggest that reflective listening statements should constitute a substantial proportion of the counselor’s response during the early phase of motivational interviewing.  They suggest following-up open-ended questions with reflective listening rather than simply asking a series of questions.  Asking too many questions, too frequently, may evoke resistance more than change talk.  In motivational interviewing, more than half of all therapists’ responses should constitute some type of reflection. 

 

Examples of reflective listening:

 

It sounds like…

What I hear you saying…

So on the one hand it sounds like… and yet on the other hand….

It seems as if

I get the sense that

I feel as though

 

Summaries - Summaries are special applications of reflective listening and are used throughout motivational interviewing.  Summaries can be used for different purposes including allowing clients to expand on a current discussion or transitioning onto another topic.  Summaries require that the therapist listen very carefully to what the client has said throughout the session.  They also help to ensure that there is clear communication between the therapist and the client.  Lastly, summaries are a good way to end a session through offering a summary of the entire session.   Summaries have been discussed as providing a stepping stone toward change (Miller and Rollnick, 2002; Rosengren, 2009).  A structure of summaries has been developed as follows: 

 

 

Table 5. A Structure of Summaries

 

 

Begin with a statement indicating you are making the summary.  For example:

 

Let me see if I understand so far. 

Here is what I have heard, tell me if I have missed anything. 

 

Give special attention to change statements as indicated by the acronym DARN- C:  Desire to change, ability to change, reason to change, need to change, commitment to change. 

 

If the client expresses ambivalence, include both sides in the summary statement. 

 

Include information from other sources such as your own clinical knowledge, research, etc. 

 

Be concise. 

 

End with an invitation such as did I miss anything?  What are other points to consider?  What would you like to add or correct? 

 

If appropriate, plan for taking concrete steps towards the change goal.

 

 

Adapted from Rosengren (2009) and Miller and Rollnick (2002).

 

 

Eliciting Change Talk

 

As discussed by Rollnick and Miller (2002), motivational interviewing is directed toward particular behavior change goals.  A primary process in motivational interviewing is to help clients resolve ambivalence by evoking their own intrinsic motivations for change.  When MI is done well, the client rather than the counselor voices the arguments for change.  Throughout motivational interviewing, particular attention is given to client “change talk” which includes verbalizations that signify desire, ability, reasons, need, or commitment to change (Miller and Rollnick, 2002; Miller and Moyers, 2006).  From an operant perspective, the counselor responds to client speech in a way that differentially reinforces change talk and minimizes verbal commitment to the status quo (Miller and Moyers, 2006).  The therapist is also minimizing resistance that may block the opportunity for change talk to occur.  We will discuss methods for managing resistance subsequently. 

 

Before discussing methods for eliciting change talk (other than OARS), it is important to establish specific characteristics of change talk.  The change talk falls into four general categories as can be seen in Table 6.

 

 

Table 6. The Four Types of Change Talk

 

 

Recognizing disadvantages of the status quo - The first category of change talk involves recognizing the disadvantages of the current situation and “of the status quo.”  Examples of change talk in which the client is recognizing the disadvantages of the status quo include the following:

 

I guess there is more of a problem here than I realized. 

I can see that in the long run this is going to do me in if I don’t make a change. 

 

Recognizing the advantage of change - The second type of change talk reflects potential advantages of change and some examples are as follows:

 

I would probably feel a lot better. 

I’d probably be around to enjoy my grandchildren as they grow up. 

 

Expressing optimism about change - Change talk can also express optimism about change.  Some of this change talk statement examples are as follows: 

 

I think I could probably do it if I decided to. 

I am a fairly stubborn person, but if I put my mind to something I don’t let go until it is done. 

 

Expressing intention to change - This type of change talk implies, directly or indirectly, the client’s determination to change.  Some examples are as follows: 

 

I think it is time for me to think about quitting. 

This isn’t what I want for my family…what can I do?

 

 

As discussed by Miller and Rollnick (2002), these four kinds of change statements encompass cognitive, emotional, and behavioral dimensions of commitment to change.  Eliciting these types of change talk is the primary goal of the motivational interviewing method.  From an empirical standpoint, research has demonstrated that motivational interviewing influences change talk (see Miller and Rose, 2009, for a review).  A variety of studies using different methodologies have demonstrated that the MI approach does increase client utterances and frequency of change talk statements.  In addition, as will be discussed subsequently under efficacy, client change talk has been associated with subsequent and long term behavior change. 

 

Methods for Evoking Change Talk

 

The OARS has been described as specific “early” methods that can be used to elicit change talk.  As discussed by Miller and Rollnick, the OARS method is to be used right from the beginning and throughout the motivational interviewing process.  In addition, there are a variety of other methods available to the MI clinician to assist with evoking, enhancing, and strengthening change talk.  It is beyond the scope of this course to discuss all of the various methods available.  As such, we will only review some of the most predominant methods and then very briefly review some others that have been developed by Miller and Rollnick, as well as other MI researchers. 

 

Asking Evocative Questions

 

As discussed by Miller and Rollnick (2002, page 78), the simplest and most direct approach to elicit change talk is to simply ask the client for such statements.  Consistent with the previous review of reflective listening, this is predominantly done through the use of open-ended questions.  Some examples of open questions to evoke change talk (along with the type of change talk) are as follows:

 

What worries you about your current situation? (disadvantage of the status quo)

 

In what ways does this concern you? (disadvantage of the status quo)

 

How would you like things to be different? (advantages of change)

 

What would you like your life to be like five years from now? (advantage of change)

 

How confident are you that you can make this change? (optimism about change)

 

Who could offer you helpful support in making this change? (optimism about change)

 

What are you thinking about your [problem behavior] at this point? (intention to change)

 

What do you think you might do? (intention to change)

 

What would you be willing to try? (intention to change)

 

It must be underscored that this is not simply a “technique” that can be used repetitively in an effort to evoke a high frequency of change talk and expect reliable behavior change.  Rather, asking evocative questions is part of specific processes for reflecting and reinforcing change talk throughout the MI process (Miller and Rollnick, 2002). 

 

Using the Importance or Confidence Ruler

 

Components of intrinsic motivation for change include both the client’s perception of the importance of change as well as his or her confidence that change can be achieved.  Miller and Rollnick (2002) have developed a simple method that involves using a ruler with gradations from 0-10 for the dimension of importance and confidence. 

 

 

Table 7. Example of Ruler and Decisional Balance

 

 

Patient Name:_________________________

 

Date:_________

 

Target Area:____________________

 

 

Deciding Not to Change

 

Deciding to Change

 

 

Benefits

 

 

Concerns

 

 

Concerns

 

 

Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How important is it to you to change the behavior?

 

1       2       3       4       5       6       7       8       9       10

 

Not Important                                                   Very Important

 

 

How confident are you that it is possible to change the behavior?

 

1       2       3       4       5       6       7       8       9       10

 

Not Confident                                                    Very Confident

 

 

An example of the ruler can be seen in Table 7 (in this illustration it has been combined with the Decisional Balance exercise, to be discussed next).  The MI practitioner has the option of actually using a ruler or simply describing the concepts.  However, there may be something powerful about actually using the ruler(s) in a concrete form. As part of using the importance-confidence ruler in evoking change talk, the therapist can ask for the client’s current rating of importance relative to the issue at hand and then ask the following questions: 

 

Why are you at a ___ and not a zero

What would take for you to go from ___ to ( a higher number)? 

 

Explore the Decisional Balance - It can be helpful to have the client discuss both the positive and negative aspects of their present behavior, or the status quo.  The client may be asked to discuss what they like about continuing with the problem behavior and to list what they don’t like about it.  This has the advantage of getting the client talking and feeling comfortable as well as clarifying both sides of ambivalence.  An example of a decisional balance sheet can be seen in Table 7 which also incorporates the confidence-importance ruler. 

 

Elaborating - Once a client has focused on a reason for change it can be useful to have the client elaborate on the topic before moving on.  This is a way of eliciting further change talk and reinforcing the motivational theme. 

 

Querying Extremes - In a case where there seems to be little desire for change, the client can be asked to describe the extreme of his or her (or others) concerns and to imagine the extreme consequences that each possibility might include. 

 

Looking Back - It can be useful to have the client remember times before the problem emerged and compare these times with the present situation.  This can help to highlight the discrepancy of how the situation is currently and the possibility of improvement.  This, in turn, helps to elicit change talk. 

 

Looking Forward - In this method, the practitioner has the client express how it might be after a change.  Or, invite the client to look ahead to a time and anticipate how things might be if no changes are made. 

 

Exploring Goals and Values - This method involves having the client express what things are most important in his or her life.  As discussed by Miller and Rollnick (2002, page 83) this method can overlap with the looking-forward process.  The process involves having the client express what values or goals the person holds most dear and then discover ways in which the current behavior is inconsistent with these values.  Of course, this can then lead to “change talk” in response to the discrepancy. 

 

Resistance

 

Part of the process of eliciting change talk is also recognizing and responding to resistance responses.  As discussed in Miller and Rollnick (2002) “motivational interviewing tends to evoke high levels of change talk and relatively low levels of resistance” (p. 47).  However, resistance responses must be managed effectively while the process of eliciting and enhancing change talk occurs.  Four process categories of client resistance behaviors have been identified  (Chamberlain et al., 1984):

 

     arguing

     interrupting

     negating

     ignoring

 

From a motivational interviewing perspective, resistance is relational.  It is viewed as a response to dissonance in the provider-client relationship.  Rather than placing blame on the client for “being resistant to wanting help,” motivational interviewing seeks to understand how the practitioner’s own behavior may have prompted the client’s resistance.  Thus, resistance is viewed as a signal for the therapist to make a shift in approach.  Common causes of dissonance in the therapist-client relationship include such things as having different goals, a mismatch of strategies, and a lack of agreement about the rules in the relationship.  Practitioner behaviors that tend to increase resistance include such things as attempts at persuasion for change, assuming the expert role versus collaborating, trying to invoke change by instilling negative emotions, labeling, being hurried, or a paternalistic attitude (“I know what is best for you”). 

 

An important process of motivational interviewing includes responding appropriately to resistance behaviors.  These are discussed in detail in Miller and Rollnick (2002), but can be briefly summarized as follows:

 

Reflective Responses

 

Simple Reflection - A simple reflection acknowledges the person’s disagreement, feeling, or perception and permits further exploration rather than enhancing defensiveness and it avoids the trap of taking sides. 

 

Amplified Reflection - This involves the process of reflecting back to the client in an amplified or exaggerated form.  Of course, this must be done empathetically without any sarcastic tone or an overstatement that is too extreme. 

 

Double-Sided Reflection - This involves capturing both sides of the ambivalence.  For instance, if the client statement manifests only the resistance side of the argument, a double-sided reflection acknowledges what the client has said and adds to it the other side of his or her own ambivalence. 

 

Other methods for responding to resistance are briefly summarized as follows: 

 

Shifting focus - This method involves shifting the client’s attention away from what seems to be a stumbling block to progress.  The general method is to diffuse the initial concern (resistance) and then shift the focus of attention to a more readily workable issue. 

 

Reframing - This method involves reframing what the client is offering in terms of resistance behavior.  First, the therapist acknowledges the validity of the person’s observation, but then offers a new meaning or interpretation.  In this way, the information generated from the client can be explored in a new light which is likely to be more helpful and support change. 

 

Agreeing with a twist - This is another method of “rolling with resistance.”  In this method, the therapist offers initial agreement with a slight twist or change of direction.  This retains a sense of consonance between the therapist and the client while allowing the therapist to continue to influence momentum toward change. 

 

Emphasizing personal choice and control - Resistance often arises from the phenomenon of psychological reactants as we reviewed previously.  This occurs when an individual feels that their freedom of choice is being threatened and they tend to react by taking the exact opposite position.  In this situation, the therapist can assure the client that it is he or she that will determine what happens ultimately. 

 

Coming along side - This is similar to what has been termed paradoxical intention, “reverse psychology” or therapeutic paradox. This method involves having the therapist defend the counter-change side of ambivalence.  However, Miller and Rollnick (2002, page 107) make the point that this is not simply therapeutic paradox.  As they discuss “…. we confess some serious discomfort with the ways in which therapeutic paradox has sometimes been described.  There is often the sense of paradox being a clever way of duping people into doing things for their own good” (Miller and Rollnick, 2002, p. 107).  They make the point that “coming along side” is done in a respectful and collaborative manner rather than being “an innovative way to trick people.” 

 

Phases of Motivational Interviewing

 

Motivational interviewing is conceptualized as occurring in two phases with different, but overlapping goals (Miller and Rollnick, 2002).  Phase I involves building the intrinsic motivation for change.  Since clients present at different levels of readiness to change, Phase I can be of differing duration and intensity.  Using the methods discussed previously, clients progress through Phase I verbalizing progressively stronger statements of their desire, ability, reasons, and need for change.  This, in turn increases the likelihood that “commitment language” will emerge.   The skillful MI therapist will know when to move on to developing a change plan.  Beginning to develop a specific change plan heralds the onset of Phase II in motivational interviewing.  As discussed by Miller and Moyers (2006), the therapist may be tempted to begin to take over the process in Phase II by being more directive and confrontational regarding achieving some goal.  Even when the process of motivational interviewing enters Phase II, all of the principles and spirit of MI remain intact. 

 

Example Motivational Interviewing Sessions

 

Manuel and Moyers (the article can also be found here) have outlined what three sessions of motivation interviewing might look like.  For those not familiar with MI, these examples can help the therapist understand how so much can be accomplished in so little time.  MI interventions are generally not more than four sessions (unless combined with other active treatments).  Four sessions of treatment is probably the absolute maximum for MI but is still far less than what might be considered a “brief” course of treatment such as cognitive-behavioral interventions of 10-20 sessions.

 

Session One

 

The goals of session one are as follows:

 

     Establish rapport with the client

     Provide an overview of treatment

     Assess the client’s motivation for change

     Complete a decisional balance exercise with the client

 

The first session of MI will often begin with the therapist giving an overview of the MI approach and explaining what the client can expect during the sessions.  An adaptation of the example given by Manuel and Moyers is as follows:

 

The purpose of our meeting is to discuss your feelings regarding your substance use [or other problem behavior].  I am not going to change you or make you do anything that you are not comfortable with.  I’m hoping that we can discuss your feelings about your substance use and talk about your current situation.  Again, I won’t be forcing you to make any type of change.  If you decide to change, that’s great, but it has to be your decision.  How does that sound?  So, what brings you here today?

 

The session will proceed with the therapist asking evocative questions and listening in a reflective fashion so that the client feels understood.  The use of open questions and skillful reflective listening move the session along.  In the first session, depending upon the client’s presentation, it is important that there is no pressure to change.  It should be an open discussion between the therapist and client exploring such things as ambivalence, the pros and cons of change, etc. A decisional balance exercise can be completed to help explore both side of behavior change.  At the end of the first session, the therapist should summarize the session content.

 

The key MI skills used in the first session include  (Manuel and Moyers):

 

     Open questions

     Reflections

     Affirmations

     Summary Statements

 

Session Two

 

The goals of session two are as follows:

 

     Summarize key ideas from the first session

     Enhance the client’s commitment for change

     Complete a values card sort exercise

     Elicit change talk

 

The second session should begin with the therapist providing a summary of the first session for the client (check for agreement, etc.).  The therapist should review the client’s progress and motivation throughout this session.  If a commitment to behavior change was made by the client in the first session, this should be reviewed and a recommitment established. The session will be guided by where the client is in terms of ambivalence, commitment to change, and establishing a plan for change.  For instance, if the client is ambivalent about change, the therapist should continue to work to develop a discrepancy between the client’s goals and current behavior.  The therapist should continue to elicit change talk by asking evocative questions, reflecting, etc.

 

Session Three

 

The goals of session three are as follows:

 

     Summarize key ideas from the second session

     Enhance the client’s commitment to change

     Develop a change plan with the client

 

Again, the session can begin with a summary of the previous session.  If the client is ready, the therapist will begin (or has already done so) to assist the client in developing a plan for change.  This is the process of moving from Phase I to Phase II at the appropriate time.  A treatment plan is initiated if the client has expressed his or her intention to change behavior.  If the client is still ambivalent or unwilling to commit to change, attempting to move to Phase II will be counter-productive (e.g. an increase in resistance behavior).  The use of the Importance Ruler can be helpful in gauging a client’s readiness to change.  If the client is ready, then the therapist and client can work collaboratively to develop a plan for change.  During this discussion, the therapist may offer advice or guidance, but this must always be done after asking permission.  Once the plan has been developed, the therapist can assess the client’s self-efficacy related to implementing the plan by using the Confidence Ruler.     

 

Learning Motivational Interviewing

 

If you were previously not familiar with MI, we are hopeful that this course has piqued your interest.  In presenting an overview of MI in a course such as this, the method may appear deceptively easy to implement.  In fact, it is not uncommon for practitioners, after reading an article or book on the subject, to conclude, “That’s what I already do”. But, as Miller and Rollnick (2009) caution, “MI is simple but not easy” and “In actual practice, MI involves quite a complex set of skills that are used flexibly, responding to moment-to-moment changes in what the client says” (p. 135). Based on research, the authors conclude that it is difficult to become proficient and skilled at MI without specific training.  For instance, research has demonstrated a near zero correlation between therapists’ self-perceived competence in reflective listening and in MI with their actual observed proficiency (Miller and Mound, 2001; Miller et al., 2004).  In fact, in one study, attending a two-day workshop that emphasized methods  (skills) convinced clinicians that they had learned MI and did not need further training; however, even though coded practice samples did show an increase in MI-consistent behaviors these were not large enough to make a difference in their clients’ outcomes (Miller and Mount, 2001). 

 

After the above findings, the training approach was changed towards placing emphasis on the underlying assumptions and spirit of MI.  This included the focus on how to learn MI from one’s own clients rather than trying to simply attain a set of specific skills at a workshop.  This new approach (“learning-to-learn”) was actually tested using a re-designed two-day workshop. The  results demonstrated much better acquisition of MI expertise (Miller, Yahne, Palmer, & Fulcher, 2003; Miller, Yahne, Moyers, & Pirritano, 2004).  

 

Based upon the new approach to teaching MI, Miller and Moyers (2006) outlined the Eight Stages of Learning Motivational Interviewing. In the learning process, each of the skills is a prerequisite to acquiring the next.  These are summarized as follows:

 

Openness to collaboration with clients’ own expertise. MI is a clinical approach that is collaborative, evocative, and respectful of client autonomy. The spirit of MI is based on assumptions about human nature including that people possess personal expertise and wisdom regarding themselves and tend to develop in a positive direction if given the proper conditions of support. Clients are not viewed as being deficient but rather of being autonomous and having the wisdom to change. 

 

Proficiency in client-centered counseling including accurate empathy. The second stage of skill development in MI involves the acquisition of client-centered (or person-centered) counseling methods, particularly accurate empathy.  In stark contrast to the stereotypes surrounding caricatures of reflective listening (“It sounds like you are angry”), skillful empathic listening includes accurate reflection of the client’s experience on a deep level.  Along with reflective listening are the OARS: open questions, affirming, reflecting, and summarizing.

 

Recognition of key aspects of client speech that guide the practice of MI. This stage of learning involves being able to recognize “change talk”.  This aspect of MI departs from client-centered counseling in that MI is intentionally directive and goal-oriented.  The process begins with being able to recognize change-talk and then purposefully beginning to elicit it from the client.  Being able to recognize change talk is the beginning of helping clients to resolve ambivalence by evoking their own intrinsic motivation for change. Change talk is intentionally and differentially reinforced, relative to statements that reflect maintaining the status quo or resistance.

 

Eliciting and strengthening client change talk. Once the therapist is able to recognize change talk, it must be elicited and reinforced.  In this stage of learning MI, the clinician acquires the skill to elicit change talk and strengthen it once it has been elicited.  A variety of methods have been developed to help move this process along and some of these have been reviewed previously (e.g. the OARS, asking evocative questions, affirmations, elaborate, etc.).

 

Rolling with resistance. At the other end of the spectrum from change talk, resistance behavior must also be managed. Rather than confronting resistance, MI therapists “roll with resistance”.  Methods for rolling with resistance have been discussed and include such things as reflection (simple, amplified, double-sided), reframing, agreeing with a twist, etc. The key is for the MI therapist to not oppose the resistance which would inadvertently reinforce it.  Rather the therapist becomes skillful at learning how to avoid provoking resistance and responding to it appropriately when it occurs.

 

Negotiating change plans.  The emergence of “commitment language” heralds the conclusion of Phase I and the onset of Phase II.  Commitment language occurs as clients verbalize stronger statements of their desire, ability, reasons, and need for change.  At this point, the treatment can move to developing a change plan (not necessarily a treatment plan) without evoking resistance.  As discussed by Miller and Moyers (2006), part of the skill to be learned is when to move from Phase I to Phase II. In this transition, and into Phase II, there can be a temptation for the therapist to take over the process, but the MI therapist stays client-centered. The client continues to decide what is needed, and when and how to proceed.

 

Consolidating client commitment. After a change plan is developed, client commitment is essential.  Research has demonstrated that behavior change is unlikely to occur unless the client expresses commitment to change. As discussed by Miller and Moyers, the skills for this stage are much like those of “eliciting change talk”: the therapist is listening and reinforcing a specific pattern of speech; however, in this stage the therapist is eliciting commitment language rather than change talk.    

 

Switching flexibly between MI and other intervention styles. As discussed by Miller and Moyers (and others), MI was never meant to be “the only tool in a clinician’s repertoire”.  It was designed to help clients through motivational obstacles of change.  Clients who are ready for action are not likely to need MI since, conceptually, they would already be at the conclusion of Phase II.  MI is often combined effectively with other treatments (to be discussed). Once a client gets to the point of developing and committing to a change plan, if treatment is to continue, the therapist would shift to a style that facilitates action (Miller, 2004). At this point,  the style of MI might continue within the context of another treatment, or the MI approach may be halted altogether.

 

Ten Things that Motivational Interviewing is Not

 

Since its inception over 25 years ago, motivational interviewing has rapidly disseminated in clinical use and research.  As discussed by Miller and Rollnick’s article, Ten Things that Motivational Interviewing is Not (2009), when a complex method is disseminated rapidly and largely beyond the control of the originators, there is “a natural process of ‘reinvention’ whereby practitioners adapt the innovation or render it more adaptable for a particular population” (p. 129).  These modifications have the potential to improve the approach in certain situations, but also to diminish its efficacy if the critical (necessary) ingredients are changed or missing. At some point, interventions and research being conducted under the rubric of “motivational interviewing” may have little semblance to the original approach.  This can cause problems when research and interventions inappropriately called “motivational interviewing” are found to be ineffective since they are invalidly tested or utilized.  In response to these issues, Miller and Rollick (2009) sought to reiterate the nature of MI especially in contrast to other approaches.  The following is a summary of their article:

 

MI is not based on the transtheoretical model.  As discussed previously, the Transtheoretical Model (TTM; also called Stages of Change) was developed in the early 1980’s at the same time as Motivational Interviewing.  The stages of change in TTM provide a logical way of thinking about the clinical role of MI.  Also, MI provides a clinical method for moving clients from one stage of change to another.  Even so, as the authors discuss, MI was never based on TTM.  MI was developed as being atheoretical whereas TTM is a comprehensive model to explain why and how change occurs.  Using the TTM explanatory model is neither essential nor important when using MI and it is not necessary to assign clients to a stage of TTM when using MI.  In the second edition of Motivational Interviewing all references to TTM were removed in the authored (first part) of the book.

 

MI is not a way of tricking people into doing what they don’t want to do. On the contrary, one of the core tenets of MI is honoring and respecting client autonomy.  Deciding to change, as well as the direction and nature of change, comes from the client. MI cannot make a client change if he or she does not desire to do so.

 

MI is not a technique. MI is far more complex than a “technique”.  Rather, it is clinical or communication method “that is learned with considerable practice over time”.  This is substantiated by the finding that simply using some of the skills encompassed by the MI approach (e.g. simple reflective listening, affirmations, etc.) does not produce the behavior changes or outcomes associated with an actual MI intervention.  Miller and Rollnick (2009) give the example of the use of structured treatment manuals often used as part of treatment outcome research (to operationalize and standardize the intervention).  A meta-analytic study of MI outcome research found that studies in which there was no MI therapist guide used yielded double the effect size in which an MI therapist manual was used (Hettema et al., 2005). This is exactly the opposite of what one might expect. In one study using an MI manual, the therapists were required to go through the MI process to the point of developing a change plan at the end of the session (Miller, Yahne, & Tonigan, 2003).  The usual efficacy of MI was not found.  Ultimately, through further analysis, it was determined that many of the clients were not “ready” to establish a change plan even though it was essentially forced upon them due to the requirements of the study.

 

MI is not a decisional balance. The decisional balance involves exploring the pros and cons of change and was first described by Benjamin Franklin.  In MI, the decisional balance is one of many methods used to elicit change talk.  Depending on the situation, the decisional balance may or may not be used with a client.  The decisional balance is a technique and not MI.

 

MI does not require assessment feedback.  The clinical style of MI can proceed with or without structured assessment, findings or feedback to the client.  These are neither necessary nor sufficient for MI.  Assessment feedback has been used in research and can certainly be used in a clinical setting, but it is not necessary and not inherent in MI.

 

MI is not a form of cognitive-behavior therapy.  MI is a clinical method and is not, nor was it derived from, a theoretical base.  MI was not a product of cognitive-behavioral theory and, in fact, is not consistent with that type of intervention (although not antithetical to being combined with it).  In cognitive behavior therapy (CBT) the patient is generally provided with something specific that they lack (e.g. coping thoughts, environmental contingencies, adaptive beliefs, relaxation techniques, etc.).  In addition, it is the therapist’s task to elicit negative automatic thoughts and directly challenge and then substitute coping thoughts.  This “therapist as expert”  and confrontational approach is not consistent with MI.

 

MI is not just client-centered counseling. The client-centered approach of Carl Rogers is foundational to the practice of MI.  However, MI is goal oriented and includes an intentional direction toward change. In MI, the therapist is purposely evoking change talk and moving the client towards commitment to a change plan.

 

MI is not easy.  As discussed by Miller and Rollnick (2009), MI is simple but not easy.  In observing an MI therapist at work, one might assume an easy-going, smooth conversation in which the client becomes increasingly motivated towards, and committed to, change.  In reality, it is a complex interplay of skills guided by the fundamental spirit and principles of MI.

 

MI is not what you are already doing.  As mentioned previously, when clinicians are first introduced to MI, they might respond, “I already do that…”.  However, as we have reviewed, this is not the case.

 

MI is not a panacea.  MI is not meant to be a school of psychotherapy or a comprehensive approach to treatment.  It is a particular method for addressing a particular problem.  It is used when a person may need to make a behavior or lifestyle change and is ambivalent or reluctant to do so.  The following situations are not consistent with MI:

 

A practitioner that offers only MI.  It was never intended to address all problems and situations that present to mental health and other clinicians.

 

Use with people ready for change.  The purpose of MI is to prepare people for change to the point of making a commitment to a change plan.  Its use would not be appropriate for someone who is already committed to change (and it may slow their progress).  

 

MI should not be used for certain lifestyle choices.  MI is specifically designed to favor resolution of ambivalence in a particular direction (e.g. quitting substance abuse, adopting healthy behaviors, etc.).  MI should not be used with patients who present with ambivalence about certain lifestyle or other choices in which it would be entirely inappropriate for the therapist to influence change in a particular direction.

 

MI is a very brief intervention.  MI was designed to be a brief intervention (e.g. 1-4 sessions). As such, it is often combined with other active, longer term treatments, as appropriate.    

 

The Efficacy of Motivational Interviewing

 

MI has evolved from treating alcohol abuse and has now been applied to a number of problem behaviors in areas as diverse as drug addiction, smoking cessation, weight loss, adherence to medical treatment regimens, increasing physical activity, management of diabetes and asthma, educational problems and corrections, among others.  This expansion of MI is due in no small part to its demonstrated efficacy in hundreds of research projects (See the MINT Bibliography for a list of many of these articles). One of the best ways of getting an idea of the overall effectiveness of any intervention is to do a “study of the studies” through meta-analysis. As far as we can tell, the effectiveness of MI has been demonstrated in six meta-analytic studies.  Three of these studies covered all of the randomized controlled trials (RCT) that were available at the time of the meta-analysis (Burke et al., 2003; Ruback et al., 2005; Lundahl et al., 2009).     

 

The Burke et al. (2003) meta-analysis included 30 RCT’s.  Most of the studies included did not use “pure” MI but MI that had been modified in some way. All of the studies used MI that was characterized by the four principles.  The meta-analysis demonstrated that MI was efficacious relative to no treatment control or placebo controls.

 

The meta-analytic review of Rubak et al. (2005) included data from 72 RCT’s.  This study focused only on studies in which MI had been used to address a health-related behavior including such things as alcohol abuse, psychiatric diagnoses, other addiction behaviors, physical problems, and smoking.  The MI interventions were completed by a variety of health care professionals (e.g. physicians, nurses, psychologists, etc.). Also, the MI interventions were of varying duration (10-15 minutes up to 60-120 minutes) and frequency (1 visit to greater than 5). The main findings can be seen in Table 8.

 

 

Table 8. Efficacy of Motivational Interviewing

 

 

MI outperforms traditional advice-giving in approximately 80% of studies

 

The effect of MI was similar for physiologic and psychologic problem behaviors

 

MI can be effective in brief encounters of only 15 minutes

 

More than one encounter increases the likelihood of an effect

 

The MI effect was not related to the provider’s profession (e.g. physician vs psychologist)

 

 

Finally, Lundahl et al. (2009; 2010) completed a meta-analytic study of 119 RCT’s, which included those from the previous meta-analytic studies.  Their results found continued support of the efficacy of MI for changing problem behavior. 

 

As discussed by Miller and Rose (2009), “Not all trials have been positive” (p. 529). It appears that MI efficacy varies across clinicians, populations, and problem behavior.  The authors conclude, “Such variability in outcomes across and within studies suggests the need to understand when, and how a treatment works and the conditions of delivery that may affect its efficacy” (p. 529).  They go on to discuss that research is just now investigating the potent ingredients of MI as well as developing a theory to explain how MI affects behavior change.

 

Resources

 

Arkowiz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds). (2008). Motivational interviewing in the treatment of psychological problems. New York: Guilford Press.

 

Mason, P. and Butler, C. (2010).  Health Behavior Change: A Guide for Practitioner, Second Edition. Churchill-Livingstone.

 

Miller, W.R. and Rollnick, S. (2002). Motivational interviewing: Preparing people for change. 2nd Edition. New York: Guilford Press.

 

Miller, W.R. and Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford.

 

Rollnick, S., Mason, P. and Butler, C. (1999).  Health Behavior Change: A Guide for Practitioners. New York: Guilford Press.  

 

Rollnick, S., Miller, R.W., and Butler, C. (2007). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press. 

 

Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook (Applications of Motivational Interviewing).  New York: Guilford Press.

 

References

 

Arkowiz, H., Westra, H. A., Miller, W. R., & Rollnick, S., editors. (2008). Motivational interviewing in the treatment of psychological problems. New York: Guilford Press.

 

Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychology Review, 84, 191–215.

 

Bandura, A. (1992). Exercise of personal agency through the self-efficacy mechanisms. In R. Schwarzer (Ed.), Self-efficacy: Thought control of action. Washington, D.C.: Hemisphere.

 

Bandura, A. (1994). Self-efficacy. In V.S. Ramachaudran (Ed., p. 71-81), Encyclopedia of human behavior. New York: Free Press.

 

Banduara, A. (1995). Self-efficacy in changing societies. Cambridge University Press.

 

Brehm, J. W. (1966). A theory of psychological reactance. New York: Academic Press.

 

Burke, B. L., Arkowiz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: a meta-analysis of controlled clinical trial. Journal of Consulting and Clinical Psychology, 71, 843–861.

 

Festinger, L. (1957). A theory of cognitive dissonance. Evanston, IL: Row and Peterson.

 

Grandpre, J.R, et al. (2003). Adolescent reactance and anti-smoking campaigns: A theoretical approach.  Health Communication, 15, 349-366.

 

Lundahl, B., & Burke, B.L. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65, 1-14.

 

Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. (2010). A Meta-Analysis of Motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20, 137-160.

 

Markland, D., Ryan, R. M., Tobin, V. J., & Rollnick, S. (2005). Motivational interviewing and self-determination theory. Journal of Social and Clinical Psychology, 24, 811–831.

 

Miller, C.H., et al. (2007). Psychological reactance and promotional health messages. The effects of controlling language, lexical concreteness, and the restoration of freedom. Human Communication Research, 33, 219-240.

 

Miller, W.R. (1983). Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11, 147-172.

 

Miller, W.R., Benefield, R.G., and Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.

 

Miller, W. R., & Moyers, T. B. (2006). Eight stages in learning motivational interviewing. Journal of the Addictions, 5, 3–17.

 

Miller, W.R. and Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

 

Miller, W.R. and Rollnick, S. (2002). Motivational interviewing: Preparing people for change. 2nd Edition. New York: Guilford Press.

 

Miller, W.R. and Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129-140.

 

Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64, 527–537.

 

Miller, W.R., Villanueva, M., Tonigan, J.S., and Cuzmar, I. (2007). Are special treatments needed for special populations? Alcoholism Treatment Quarterly, 25, 63-78.

 

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self change of smoking: toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395.

 

Quick, B.L. and Stephenson, M.T. (2008). Examining the role of trait reactance and sensation seeking of perceived threats, state reactance, and reactance restoration. Human Communication Research, 34, 446-476. 

 

Raistrick, D. (2007). Motivation and barriers to change. In G. Tober & D. Raistrick (editors). Motivational dialogue. New York: Routledge.

 

Rogers, C. R. (1959). A theory of therapy, personality and interpersonal relationships as developed in the client-centred framework. In: S. Koch (editor). Psychology: the study of science, formulations of the person and the social context (pp. 184–256). New York: McGraw-Hill.

 

Rogers, E.M. (2003). Diffusion of innovations (5th ed.). New York: Free Press.

 

Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325–334.

 

Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: helping patients change behavior. New York: Guilford Press.

 

Rubak, S., Sandbaek, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice, 55, 305–312.



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