Motivational Interviewing is a therapeutic approach that clinicians take when trying to help patients change certain behaviors. Many people assume that when people gain new information about behavior that’s unhealthy or dangerous, they’ll stop engaging in the behavior based on their new knowledge. However, evidence shows that this is rarely the case. Just because people know they need to change doesn’t mean they will change or they want to change.
This is where Motivational Interviewing (MI) comes in. Through a specific, evidence-based method of asking questions and listening nonjudgmentally, the therapist guides the patient through the process of eliminating harmful, risky behaviors – or forming new, positive habits. The goal of MI is to attempt to motivate the patient to change on their own. MI is particularly helpful for patients who are ambivalent, reluctant, or defensive about their problems.
History of Motivational Interviewing
Psychologists William (Bill) Miller and Stephen Rollnick co-founded MI in 1983 while treating patients struggling with substance abuse and alcohol addiction. At the time, clinicians in addiction treatment often utilized confrontational tactics to precipitate behavioral change.
In a 2012 interview with Counselor Magazine, Dr. Miller said:
“The state of the art was lecturing and confronting people, as if they didn’t know themselves and were incapable of perceiving reality…It was common practice in the field at that time to get in people’s faces and yell at them.”
In contrast, Dr. Miller focused on training his clinicians to use empathy with their patients, rather than argumentation or confrontation. He found that people with alcohol or drug use problems didn’t keep using substances because they lacked knowledge about how harmful it was. Rather, they lacked the motivation to stop their behavior. Empathy on the part of the clinician, Miller discovered, worked far better than logic in inspiring motivation.
In fact, in one of his experiments (Miller, Taylor, & West, 1980), he found that patient-centered empathy was the strongest known factor of success in getting people to quit using substances. The study found that the more empathic the counselor, the better patient outcomes would be, even years later.
Accurate empathy became a main principle of Motivational Interviewing. Miller and Rollnick found that staying empathic and reflective, and letting the patient eventually articulate their own arguments for change, worked far better than lecturing or confronting the patient on how important it was to change.
In the words of Dr. Rollnick:
“The more you try to insert information and advice into others, the more they tend to back off and resist. This was the original insight that generated our search for a more satisfying and effective approach. Put simply, this involves coming alongside the person and helping them to say why and how they might change for themselves.”
Miller and Rollnick identified four aspects that make up what they call the “Spirit of Motivational Interviewing.” These include:
- Partnership: The therapist and patient work together as equals, in a collaborative process.
- Acceptance: The clinician is nonjudgmental and understands that the patient has autonomy in their life.
- Compassion: The therapist wants what’s best for the patient.
- Evocation: The therapist’s role is to elicit the patient’s own articulations for change.
Motivational Interviewing Today
Though the founders of MI initially developed this technique to treat drug and alcohol problems, today this counseling style is applied in a variety of different fields, including:
- Criminal Justice
- Dental health
- Physical therapy
- Medication adherence
Healthcare professionals, teachers, coaches, and even parents have found that MI skills are extremely effective to get anyone to change or improve any kind of behaviors.
Four Principles of Motivational Interviewing
In addition to the four aspects that constitute the “Spirit of MI,” Miller and Rollnick identified four Principles of MI. Clinicians adopt the following principles when treating their patients with this approach:
1. Express empathy
Inspired by the work of Carl Rogers, who argued that a patient-centered and empathic approach has the best chances of success, Dr. Miller emphasized that accurate empathy is the cornerstone of MI. When clinicians show nonjudgmental acceptance, displaying genuine interest and curiosity without blaming or criticizing, patients feel respected, supported, and safe. They feel comfortable in the therapeutic relationship and more inclined to honestly explore their true feelings about change. Clinicians can be trained to show accurate empathy by utilizing the skill of reflective listening.
2. Develop discrepancy
Patients usually don’t want to keep engaging in substance use, self-injurious behavior, or other risky/life-threatening actions forever. The therapist’s job is to help the patient realize there’s a discrepancy between their current behaviors and their desired behaviors, or between their present self and their ideal self. When patients understand how their current actions are inconsistent with their values and goals – such as physical health, academic success, long-term happiness, financial stability, or peer acceptance – the patient eventually realizes that if they don’t change their current habits, there are consequences both now and in the future.
3. Roll with Resistance
Sometimes, therapists are tempted to argue with a patient when the patient displays resistance or defends their current behaviors. Other times, clinicians have an urge to confront or correct a patient when they express ambivalence about changing. MI frowns on both practices. In MI, clinicians are not supposed to try and convince the patient to change through debate or arguments. In fact, Miller and Rollnick found that the more you try to convince someone with logic, arguments, or new information, the more likely it is they’ll back off, defend themselves, and engage in further resistance. In MI, therefore, therapists are patient and allow the patient to explore the idea of changing (or not changing) on their own.
4. Support self-efficacy
When someone is self-efficacious, they believe they can accomplish something. Research shows that strong self-efficacy leads to success. If a patient doesn’t believe they can change, it discourages them from trying. This can happen if a patient has tried multiple times – without success – to quit using substances, refrain from self-injurious behaviors, or eliminate other risky behaviors. Clinicians engaging in MI attempt to increase the patient’s self-confidence by expressing to them that they truly believe they can change, despite past setbacks.
What is Ambivalence?
When it comes to breaking an ingrained habit or forming a positive one, people are often unsure of themselves. They might want to change but not be willing to change at the same time. For example, teens may know that skipping class is detrimental, but also know it takes them too much effort to sit still for so long. Or they may realize that lying is wrong, but since it keeps them from getting in trouble, they keep doing it.
This ambivalence is a normal part of the natural change process. The goal of MI is to help the patient explore all aspects of their ambivalence and eventually help them resolve it.
How Does MI Work?
There are four steps in the MI process, which aims to resolve ambivalence about behavior change.
1. Engaging. The first step of MI is for the clinician to build a trusting and mutually respectful therapeutic relationship. Patients who don’t trust their therapist won’t open up to them, and will likely offer resistance to change. That’s why therapists take the time to foster an atmosphere of acceptance and safety through the use of positive body language and genuine warmth. They also avoid labelling their patient, speaking too much like an expert, or telling their patient how to fix the problem. All these practices turn off patients.
2. Focusing. The next step is for the patient and clinician to decide what specific problem they want to work on. In this stage, a clear agenda and direction for therapy is set. Narrowing down a particular focus helps maintain direction and keeps sessions moving along. Clinicians can either direct the patient towards a particular area of change or guide the patient towards deciding on a specific issue. Alternatively, sometimes the patient comes in with a clear picture of what they know they need to fix. In this case, the therapist will simply follow the patient’s lead.
3. Evoking. After the clinician and patient decide on what the particular issue is, it’s time to understand why the patient should attempt to change their behavior. In this step, the therapist’s role is to elicit “change talk” from the patient. Change talk is “speech that favors movement in the direction of change.”The following are examples of change talk:
- “I wish I could stop doing this.”
- “It would definitely be better if I…”
- “I can start doing this…”
When patients engage in change talk, they become motivated intrinsically to change their behavior. The more patients bring up “change talk” themselves, the more likely they are to go implement change. Sometimes, though, patients at this stage aren’t ready to bring up change talk. To elicit it, clinicians might ask the following questions:
- What are the benefits of changing?
- What reasons are there to change?
- What would making a change entail?
4. Planning. The last stage of MI is figuring out how the patient would actually go about changing. Together, clinician and patient develop a specific plan that is measurable, achievable, relevant, and time-bound. At this stage, the patient is usually ready and willing to implement the plan – and be hopeful about its success.
How Therapists Use Motivational Interviewing to Inspire Change
Clinicians use a variety of tools to accomplish the above. These tools are summarized by the acronym OARS:
In MI, therapists refrain from asking closed questions that usually just elicit yes-or-no answers. Instead, they ask their patients open-ended questions. For example:
- Instead of “Are you doing okay now?” they ask, “How are you feeling today about your progress?”
- Instead of “Don’t you think your choice of friends is preventing you from quitting?” they might ask. “How do you feel about your friends and their relationship to your drug use?”
- Instead of “Do you think your alcohol use is harmful?” they’ll ask, “How does alcohol impact your day-to-day life?”
- Instead of “Do you think you should be more respectful of your parents’ curfew rule?” they might ask What are your thoughts on your curfew?”
The goal is to get the patient to talk honestly about everything on their mind that’s related to the topic under discussion – rather than just giving a brief answer (even if it’s the right one). A longer discussion will eventually lead to the patient engaging in “change talk.”
As mentioned earlier, self-efficacy is a powerful predictor of change. The opposite is true as well: if the patient is too discouraged, they won’t try changing at all. That’s why, in MI, the clinician is lavish in their encouragement. Positive affirmations increase the patient’s self-efficacy and self-confidence, which in turn will lead the patient to change. The clinician can encourage the patient by highlighting their history of past achievements, no matter how small.
For example, the clinician could bring up the fact that the patient abstained from drug use for a week last month. Or the therapist will point out anything positive they notice about the patient’s progress or efforts. In MI, patients will often hear:
“That was a big step!”
“This is really difficult, and you’re putting in so much effort.”
“I can see that you really care a lot about your friends and school.”
“I think it’s great that you feel you should do something about this issue.”
Positive, motivating words from someone they know and trust helps patients believe in themselves, and believe they can successfully implement change they previously thought they couldn’t.
In MI, clinicians engage in reflective listening. This therapeutic skill involves listening carefully to patients, processing what they said, and then reflecting it back to them in a way that shows they understand. Through reflective listening, the therapist helps the patient continue exploring their own train of thought and eventually engage in the “change talk” mentioned above.
Reflective listening conveys empathy and understanding. It also shows the patient that the therapist sees and understands their perspective. According to Dr. Miller, reflective, empathic listening “is the opposite of an expert model that says, I’m going to fix you. It is a respectful, hopeful, engaged kind of listening that brings out the best in people.”
Below is one example of a typical therapist-patient interaction in which the clinician utilizes MI to explore a teen’s vaping behavior. (Adapted from Enhancing Motivation for Change in Substance Use Treatment)
Clinician: What else concerns you about your vaping?
Patient: Um… I’m not sure it’s really that bad, but I do wonder sometimes if maybe vaping is actually worse than people say it is.
Clinician: Than people say it is…?
Patient: Yeah, I mean, obviously it’s not as bad as smoking…But sometimes it gets me really high, and I can’t concentrate on anything…
Clinician: It messes up your thinking…
Patient: Yes, and sometimes it makes me do things I really shouldn’t do.
Patient: Just stupid stuff at school… fighting with people, pulling pranks… sometimes it gets violent.
Clinician: And you wonder if that might be because you’re vaping too much?
Patient: Well, I know it is sometimes.
Clinician: Um-hmm. I can see why that would worry you.
Patient: But I don’t think I’m an addict or anything.
Clinician: You don’t think you’re that bad off, but you do wonder if maybe you’re overdoing it and damaging yourself in the process.
Clinician: Hmm…Kind of a scary thought. What else worries you?
This exchange shows how a therapist can direct a patient towards change without being directive about it. This is effective for people who are resistant to change, and anyone who parents, teaches, or works with teenagers can see how valuable this technique might be in guiding them toward behavioral change and productive decision-making.
Summaries go hand-in-hand with reflective listening in helping the patient feel understood. After a patient finishes discussing the pros and cons of changing, the therapist provides a brief summary of everything the patient said. A summary not only consolidates everything for the patient, but also helps them move on to the next issue at hand. It also shows the patient that the therapist is listening to them carefully, from the very beginning. At times, summaries give the patient the chance to correct details and more clearly articulate their arguments for or against change.
Motivational Interviewing and Other Treatments
MI is usually not a stand-alone treatment for mental health and/or substance use issues. It’s a technique that clinicians use in conjunction with other intensive treatments or approaches, depending on the patient’s specific needs.
It’s used to support other approaches because for people with mental health issues, negative habits are often symptoms of underlying mental health disorder rather than the root cause. For example, a teen might use substances if they experience post-traumatic stress disorder. Or a patient might consistently self-harm if they have depression. In these cases, MI on its own would be ineffective.
In addition to MI, patients would need more intensive therapy, such as cognitive behavioral therapy (CBT), or dialectical behavior therapy (DBT), or medication to help them restore self-efficacy and smooth daily functioning.
The Source of Change
If you want to get someone to do something, have them articulate it themselves.
This, in a nutshell, is what Motivational Interviewing is all about.
Motivational Interviewing works by instilling intrinsic motivation within the patient in order to elicit behavior change. Instead of trying to push and convince them – which evidence shows usually backfires – the therapist gently and empathically guides them to articulate why they want to change on their own. The evidence shows that hearing yourself argue for change is the best way to promote change – and that’s why MI continues to function as a practical and effective addition to traditional therapy.