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Motivational Interviewing

Change happens easily when there are clear rewards and punishments. We stop touching hot stoves early on because we get hurt. If we find out that something makes us feel happy and there are no costs, we're going to do it more often. But sometimes, change can be more complex. Making the decision to leave a romantic partner, or to switch careers, might take years of thought and heartache. There are countless pros and cons that cannot easily be boiled down to "better" or "worse".

Psychotherapy is the art and science of helping others create change through psychological means, and the countless approaches give us a number of ways to achieve these goals. Some theories view change as a purely behavioral process. Someone who has a problem with alcohol must stop drinking--who cares how or why? Others suggest that the answer is education. If a person learns about the possible consequences of excessive alcohol use, they will quit.

One approach to counseling called motivational interviewing emphasizes the importance of a person's motivation for change. Someone who thinks about leaving their job and searching for a new career will likely be wrought with ambivalence. Their thought process might look something like this:

Pros of Current Career Cons of Current Career
I'm good at what I do. I'm unhappy at my job.
I have stable income. This career requires too much time.
I worked hard to get where I am. I feel unfulfilled in my job.
The person with these thoughts has a lot of ambivalence which leads to them lacking motivation for change. This is where motivational interviewing shines.

This treatment guide will give an overview of the theory and implementation of motivational interviewing. Because motivational interviewing is so commonly associated with substance use and addictions, they will be the focus of examples for the rest of the guide. However, keep in mind that this theory can be used when working with a variety of issues.

Theory

The seminal text on motivational interviewing (Motivational Interviewing: Preparing People for Change) by Miller & Rollnick defines the theory as a "client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence" (1). Let's break the definition down to better understand the theoretical underpinnings of this approach.

Client-Centered

Using an empathetic style of interaction is a fundamental characteristic of motivational interviewing. This means expressing acceptance toward your client, even if you feel that their behaviors are harming them or their loved ones. You do not need to condone their behavior or agree--just accept. Acceptance shows your willingness to listen, understand, and to respect your client as a human being. Research indicates that empathic client-therapist relationships have a significant positive influence on treatment outcome (1).

Directive

Although the therapist will be acting in a way that expresses acceptance of the client's behavior, they will also be subtly directing them toward change. This will be achieved by encouraging change talk, which will be described later in the guide.

Enhancing Intrinsic Motivation

One goal of motivational interviewing is to increase a client's internal motivation for change. Enhancing motivation will also require your client to build confidence in their ability to make changes. If the goal of changing seems unattainable, it will be difficult to generate enough motivation to try. As motivation increases, your client will begin to make the desired changes to their behavior.

Exploring and Resolving Ambivalence

"Ambivalence" refers to a person's mixed feelings about change. Motivation can be increased by exploring and resolving these feelings of ambivalence. You will use reflection, empathy, and various other techniques to help your client better understand their ambivalence, while subtly directing them toward a resolution.

Building Motivation for Change

Initiating Change Talk

Directing a client toward change talk will help them overcome ambivalence. Change talk occurs when a client discusses the changes they would like to make in a positive light, such as identifying the benefits of quitting a harmful drug. Listed below are several techniques to help with this process:

Motivation Ruler

Ask your client to describe how motivated they are to make a change on a scale of 1 to 10. At 1, they have no motivation to change, and 10 they have no doubt about wanting to change. It can be helpful to present them with a ruler or the linked worksheet to help them visualize the task.

After the client responds--even if their number is low--you can ask why it isn't lower. Why did they choose "4" instead of "1"? Having the client verbalize why they have some motivation for change rather than none at all will lead them to speak in favor of making the change. As a follow-up question, you can ask: "How could we move you from a 4 to a 6 on the ruler?"

Asking About Extremes

Try asking some hypothetical questions about best and worst case scenarios. Here are some examples:

"If you continue using drugs, what's the worst that could happen over the next 5 years?"

"What do you worry about the most with regard to your alcohol use?"

"What would be the best possible outcome if you quit using drugs?"

Exploring Values

Assist a client in identifying and exploring their values to better understand which ones they are living up to, and which they are failing. If a client states that they value family and success, it can be meaningful when they realize these are two areas that are damaged by their drug use. Try using this worksheet to guide the process:

It will be important to keep in mind that your values might differ from the client's. For example, just because success in your career means a lot to you doesn't mean it will mean much to your client. Be sure to appeal to your client's values, not your own.

Continuing Change Talk

When a client begins to use change talk, it is the therapist's role to make sure it continues. This can be achieved in a number of ways:

Ask for more detail:
"In what ways will you feel better if you quit smoking?"

Reflect change talk:
"You're really starting to consider quitting cigarettes for good."

Affirm change talk with body language (head nod) or agreement:
"You're making a good point!"

The more time a client spends engaging in change talk, the more likely they are to actually make the changes.

Rolling with Resistance

"Resistance" in counseling refers to a client's behaviors that are in opposition to making desired changes. For example, a resistant client receiving treatment for an alcohol problem might argue that "everyone else drinks", or they might continue to put themselves in risky situations such as spending time with friends who are using alcohol. Although unproductive, it can be tempting to argue back with statements like: "No, not everyone drinks. And even if they do, it's still dangerous". This response to resistance creates a situation where the client and therapist are opposed to one another.

When using motivational interviewing, the clinician will attempt to roll with the client's resistance. This means, instead of engaging in an argument, you will continue to make sure the client feels heard through the use of reflections. During periods of resistance, you can use several different reflection techniques to continue moving the conversation forward.

Amplified Reflection

Reflect the client's statement in an exaggerated form. Be careful not to cross the line into sarcasm or condescension.

Client: "I don't know why my family keeps pushing for me to get help. I hardly ever drink."

Therapist: "Your family doesn't have anything to worry about because you barely drink."

Client: "Well, I mean, I do drink. And sometimes I make some pretty bad choices afterwards."

Reframing

Create a new and more positive interpretation of events that have been described by the client.

Client: "My parents are trying to get rid of me, that's why they want me to go to rehab."

Therapist: "It sounds like your parents are doing their best to help, but they've made some mistakes along the way. They aren't sure how to help you without hurting you too."

Double-sided Reflection

Reflect the client's statement, but also add information they have previously shared that is contrary to their current resistance.

Client: "I don't want to quit drinking. It just isn't a problem for me."

Therapist: "You don't feel that drinking is a big enough problem for you to worry about, except for those times--like shared last week--when you get really angry at your family."

Building Confidence

Would you like to reach your hands above your head, look up, and fly away like Superman? I'm guessing:yes. Do you believe you can actually do it? Hopefully not. This example illustrates the point that, no matter how badly someone wants to do something, they won't even try if they don't believe it's possible. When it comes to addictions and other major changes, many clients will feel totally helpless and incapable. Once someone has made the decision to change, it will be necessary to make sure they have the confidence to do so.

Ask Open Questions about Change

Help your client envision themselves making the desired change by asking open questions. Some examples are:

"What will be the first step to making this change?"

"What might trip you up, and how can you deal with that problem?"

"Even if it's tough, what might help you be successful?"

Identify Personal Strengths

Spend time discussing a client's strengths (especially those that will help them make a change). If your client has difficulty generating their own strengths, try to lead them in the right direction while still encouraging them to be the one to generate the answers. Keep the conversation going by asking the client to elaborate when they are able to come up with strengths.

Discuss Past Success

Search for examples of times when the client has made positive changes that they are proud of. Gather information such as what worked, what motivated them, and what skills they used to be successful. Again, keep the conversation going by asking for elaboration.

Strengthening the Commitment to Change

At some point you will recognize that your client has decided to change, and they've built the confidence to do so. Indications of a client reaching this point are decreased resistance, frequent change talk, experimenting with the change (for example, brief periods of sobriety between sessions), or asking questions about how to make the change.

During this final stage of treatment, it will be important to maintain your client-centered approach. Just because the client has made the choice to change doesn't mean the therapist should begin dishing out advice indiscriminately, lecturing, or taking over session. At this point, you will want to collaborate with the client to create a change plan.

Establish Goals

Work with your client to create clear goals for change. Sometimes your goals and the client's will not perfectly align. For example, you might believe that lifelong abstinence from all drugs will be necessary for recovery, while your client might want to have the option of drinking a beer, or a glass of wine with dinner. Arguing these points will usually result in taking a step backward as your client feels forced to defend their own goals in opposition to yours.

Create a Plan

Next, you will want to come up with a list of options of how to create change. Help the client generate their own ideas, or provide them with options to choose between. Strategies for change should include specific actions such as avoiding people who trigger the unwanted behavior, or reaching out to social support when necessary. Also consider obstacles, and how they can be managed.

Commit to the Plan

Finally, you want to make sure the client has bought into the plan. If the client doesn't feel ready, don't force them. Ask questions about where there are problems, and tweak the plan as necessary. If possible, it can be helpful to have your client share the plan with an important loved one to enhance their commitment and garner social support.

Once your client has agreed to a change plan, the process of motivational interviewing has been completed. Future sessions can be used to check in, tweak the change plan when there are difficulties, and maintaining motivation with change talk.

Other Resources

Motivational Interviewing: Helping People Change (3rd Edition) is an essential text for any clinician who hopes to use the intervention in their practice.

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