Motivational Interviewing

motivational interviewing tips

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Motivational interviewing (MI) is a technique in which you become a helper in the change process and express acceptance of your client. It’s a way to interact with clients and a style of counseling that can help resolve the ambivalence that prevents clients from realizing personal goals. Motivational interviewing builds on Carl Rogers’ optimistic and humanistic theories about people’s capabilities for exercising free choice and changing through a process of self-actualization.

Your role in motivational interviewing is directive, with a goal of eliciting self-motivational statements and behavioral change from the client in addition to creating client discrepancy to enhance motivation for positive change. Motivational interviewing is a counseling style based on the following assumptions:

  • Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery.
  • Ambivalence can be resolved by working with your client’s intrinsic motivations and values.
  • The alliance between you and your client is a collaborative partnership to which you each bring important expertise.
  • An empathic, supportive, yet directive, counseling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioral change.)

–NCBI

The Guiding Principles of Motivational Interviewing

The practice of MI has four guiding principles:

  1. To resist the righting reflex: People who enter helping professions often have a powerful desire to set things right, to heal, to prevent harm, and promote well-being, which is called the “Righting Reflex”. Rolling with resistance prevents a breakdown in communication between clients and helpers and allows the clients to explore their views. Avoid arguing for change. Do not directly oppose resistance. New perspectives are offered but not imposed. The clients are a primary resource in finding answers and solutions. Resistance is a signal for the helpers to respond differently.
  2. To understand and explore the clients’ own motivations: Developing discrepancy enables the clients to see that their present situation does not necessarily fit into their values and what they would like in the future. The clients rather than the helpers should present the arguments for change. Change is motivated by a perceived discrepancy between present behavior and important personal goals and values.
  3. To listen with empathy: Expressing empathy towards the clients shows acceptance and increases the chance of developing a rapport. Acceptance enhances self-esteem and facilitates change. Skillful reflective listening is fundamental. Clients’ ambivalence is normal.
  4. To empower the clients, encouraging hope and optimism: Self-efficacy is a crucial component to facilitating change. If the clients believe that they have the ability to change, the likelihood of change occurring is greatly increased. Beliefs in the possibility of change is an important motivator. The clients, not the helpers, are responsible for choosing and carrying out change. The helpers’ believe in the clients’ ability to change becomes a self-fulfilling prophecy.

These four principles fit the acronym RULE: Resist, Understand, Listen, and Empower (Rollnick, Miller, & Butler, 2008).

Four Processes in Motivational Interviewing (Miller & Rollnick, 2013)

  1. Engaging: is the process by which both parties establish a helpful connection and a working relationship. Therapeutic engagement is a prerequisite for everything that follows, and it involves developing a working alliance.
  2. Focusing: is the process by which helpers and clients develop and maintain a specific direction in the conversation about change. In the course of helping relationships, a direction towards one or more change goals usually emerges.
  3. Evoking: involves eliciting the clients’ own motivations for change, and it has always been at the heart of MI. It occurs when there is a focus on a particular change and the providers harness the clients’ own ideas and feelings about why and how they might do it. Evoking is having the clients voice the arguments for change.
  4. Planning: encompasses both developing commitments to change and formulating a specific plan of action. It’s a conversation about action that can cover a range of topics, conducted with a sharp ear for eliciting clients’ own solutions, promoting their autonomy of decision making, and continuing to elicit and strengthen change talk as a plan emerges.

Motivational Interviewing Skills and Strategies

The practice of Motivational Interviewing involves the skillful use of certain techniques for bringing to life the “MI spirit”, demonstrating the MI principles, and guiding the process toward eliciting clients’ change talk and commitment for change. Change talk involves statements or non-verbal communications indicating the clients may be considering the possibility of change. (Miller & Rollnick, 2013)

OARS: a mnemonic to remember the basic approach used in Motivational Interviewing. Open-Ended Questions, Affirmations, Reflections, and Summaries are core counselor behaviors employed to move the process forward by establishing a therapeutic alliance and eliciting discussion about change:

  • O – Open-ended questions are those that are not easily answered with a “yes/no” or short answer containing only a specific, limited piece of information. Open-ended questions invite elaboration and thinking more deeply about an issue. Although closed questions have their place and are at times valuable (e.g., when collecting specific information in an assessment), open-ended questions create forward momentum used to help the clients explore the reasons for and possibility of change.
  • A – Affirmations are statements that recognize clients’ strengths. They assist in building rapport and in helping the clients see themselves in a different, more positive light. To be effective they must be congruent and genuine. The use of affirmations can help clients feel that change is possible even when previous efforts have been unsuccessful. Affirmations often involve reframing behaviors or concerns as evidence of positive clients’ qualities. Affirmations are a key element in facilitating the MI principle of Supporting Self-efficacy.
  • R – Reflections or reflective listening is perhaps the most crucial skill in Motivational Interviewing. It has two primary purposes. First is to bring to life the principle of Expressing Empathy. By careful listening and reflective responses, the clients come to feel that the helpers understand the issues from their perspective. Beyond this, the strategic use of reflective listening is a core intervention toward guiding the clients toward change, supporting the goal‐directed aspect of MI. In this use of reflections, the helpers guide the clients towards resolving ambivalence by a focus on the negative aspects of the status quo and the positives of making a change. There are several levels of reflection ranging from simple to more complex. Different types of reflections are skillfully used as clients demonstrate different levels of readiness for change. For example, some types of reflections are more helpful when the clients seem resistant and others are more appropriate when the clients offer statements more indicative of a commitment to change.
  • S – Summaries are a special type of reflection where the helpers recap what has occurred in all or part of a counseling session(s). Summaries communicate interest, understanding and call attention to important elements of the discussion. They may be used to shift attention or direction and prepare the clients to “move on.” Summaries can highlight both sides of clients’ ambivalence about change and promote the development of discrepancy by strategically selecting what information.

Change Talk

Change talk is defined as statements by the clients revealing consideration of, motivation for, or commitment to change. In Motivational Interviewing, the helpers seek to guide the clients to expressions of change talk as the pathway to change. Research indicates a clear correlation between clients’ statements about change and outcomes-client-reported levels of success in changing a behavior. The more clients talk about change, the more likely they are to change (Miller & Rollnick, 2013). Different types of change talk can be described using the mnemonic DARN-CAT:

Preparatory Change Talk

  • D – Desire (I want to change)
  • A – Ability (I can change)
  • R – Reason (It’s important to change)
  • N – Need (I should change)

And most predictive of a positive outcome:

Implementing Change Talk

  • C – Commitment (I will make changes)
  • A – Activation (I am ready, prepared, willing to change)
  • T – Taking Steps (I am taking specific actions to change)

Strategies for Evoking Change Talk 

There are specific therapeutic strategies that are likely to elicit and support change talk in Motivational Interviewing (Miller & Rollnick, 2013):

  1. Ask Evocative Questions: Ask an open question, the answer to which is likely to be change talk.
  2. Explore Decisional Balance: Ask first for the good things about the status quo, then ask for the not-so-good things.
  3. Ask for Elaboration: When a change talk theme emerges, ask for more details. In what ways? Tell me more…? What does that look like?
  4. Ask for Examples: When a change talk theme emerges, ask for specific examples. When was the last time that happened? Give me an example. What else?
  5. Look Back: Ask about a time before the target behavior emerged. How were things better, different?
  6. Look Forward: Ask what may happen if things continue as they are (status quo). Try the miracle question: If you were 100% successful in making the changes you want, what would be different? How would you like your life to be five years from now?
  7. Query Extremes: What are the worst things that might happen if you don’t make this change? What are the best things that might happen if you do make this change?
  8. Use Change Rulers: Ask: “On a scale from 1 to 10, how important is it to you to change (the specific target behavior) where 1 is not at all important, and a 10 is extremely important? Follow up: “And why are you at ___ and not ____ (a lower number than stated)?” “What might happen that could move you from _____to ____ (a higher number)?” Alternatively, you could also ask “How confident are that you could make the change if you decided to do it?” NOTE: Instead of “how important” (need), you could also ask how much you want (desire), or how confident you are that you could (ability), or how committed are you to (commitment). Asking “how ready are you?” tends to be confusing because it combines competing components of desire, ability, reasons and need.
  9. Explore Goals and Values: Ask what the clients’ guiding values are. What do they want in life? Ask how the continuation of target behavior fits in with the clients’ goals or values. Does it help realize an important goal or value, interfere with it, or is it irrelevant?
  10. Come Alongside: Explicitly side with the negative (status quo) side of ambivalence. “Perhaps ____is so important to you that you won’t give it up, no matter what the cost.”

Change Talk vs Sustain Talk (Miller & Rollnick, 2013)

  • What is Sustain Talk? Sustain Talk is when clients talk about their favoring their “status quo” rather than movement toward “change goals.”
  • What is Change Talk? Change Talk is when clients talk about their favoring movement towards “change goals.” What is Discord? It is the interpersonal behavior in the MI process that reflects dissonance in the working relationship between the helpers and clients.

Sustain talk in itself does not constitute discord. Discord in MI has the following various elements (examples):

  • Arguing: Clients contest the accuracy, expertise, or integrity of the helpers.
  • Interrupting: Clients break in and interrupt the helpers in a defensive manner.
  • Discounting: Clients express unwillingness to recognize problems, cooperate, accept responsibility, or take advice.
  • Ignoring: Clients show evidence of ignoring or not following the helpers.

What skills are needed to respond to either Sustain Talk or Discord so as to get back to Change Talk:

  • Simple Reflection: The simplest approach to responding to resistance is with nonresistance, by repeating the clients’ statements in a neutral form. This acknowledges and validates what the clients have said and can elicit an opposite response.
  • Shifting Focus: Helpers can defuse resistance by helping the clients shift focus away from obstacles and barriers. This method offers an opportunity to affirm the clients’ personal choices regarding the conduct of their own lives.
  • Reframing: This is a good strategy to use when clients deny personal by offering a new and positive interpretation of negative information provided by the clients. Reframing acknowledges the validity of the clients’ raw observations but offers a new meaning.
  • Rolling with the Resistance: Momentum can be used to good advantage and perceptions can be shifted. New perspectives are invited but not imposed. The clients are a valuable resource in finding solutions to problems.
  • Develop Discrepancy: Motivation for change is enhanced when clients perceive differences between their current situation and their hopes for the future. Developing awareness of consequences helps clients examine their behaviors. A discrepancy between present behaviors and important goals motivates change. The clients should present the arguments for change.

-University of Massachusetts

Learning Motivational Interviewing

12 Steps to Leaning Motivational Interviewing (Miller & Rollnick, 2013)

  1. Understanding the underlying MI Spirit
  2. Developing skill and comfort with reflective listening
  3. Identifying change goals (Focusing)
  4. Exchanging information and providing advice within an MI style (Engaging, Planning, Evoking)
  5. Being able to recognize Change Talk and Sustain Talk
  6. Evoking Change Talk
  7. Responding to Change Talk in a manner that strengthens it
  8. Responding to Sustain Talk and Discord in a way that does not amplify it
  9. Developing hope and confidence
  10. Timing and negotiating a change plan
  11. Strengthening commitment
  12. Flexibility integrating MI with other clinical skills and practices

How can the 12 learning tasks be accomplished? –Miller & Rollnick, 2013

More than obtaining knowledge is involved. Feedback is fundamental and the more immediate the better “it’s hard to learn archery in the dark.” Clients provide immediate feedback through their responses to the helper.

Developing Proficiency in MI: What’s needed? Knowledge development and the opportunity for continued learning over time through feedback and coaching based on direct observation. However, coaching need not be extensive. It is a matter of learning and applying the MI criterion which is important and not completing a fixed number of training hours which makes for competent MI helpers.

Personal Tip for Improving your MI Skills

: Listening to your own sessions by recording them (with permission) your session and then:

  • Count your reflections: were they simple or complex? Offer more complex than simple reflections.
  • Count your questions: were they open or closed? Ask more open than closed questions.
  • Count both reflections and questions: what is your ratio? Aim for 2 reflections for every question.
  • Listen for Change Talk and Sustain Talk: count each and determine the ratio. Equal frequency = ambivalence (no change) – When Change Talk occurred, what was the next thing you said? Count your OARS responses.
  • Listen for MI inconsistent responses (giving advice without permission, confronting or arguing with the client, other “righting reflex” responses – How did the client respond to these?

5 Steps to Help Trainees in Learning Motivational Interviewing (Stephen Rollnick’s) 

  1. Unlearn
  2. Slow Down
  3. Be humble
  4. Believe in them
  5. Go with their language about change

-Coping.us

Additional Information & References 

Set of Free Recommended Tools by Case Western Reserve Univ.

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