Motivational Interviewing is a therapeutic approach in which clinicians join and partner with clients in a mutual understanding that clients have the internal resources necessary to create meaningful change in their lives. The clinicians’ role is to guide and facilitate client’s internal motivation for change through a process of “going alongside” in exploration with client. MI clinicians recognize that insight and knowledge of one’s struggles, although critical, is not sufficient to create long term behavioral change for clients. Many well intended approaches designed to “get” clients to change have demonstrated that providing psychoeducation about an issue does not create the intended behavioral change.
This is where Motivational Interviewing (MI) comes in as an evidence-based approach to talking with clients about change. MI is a style of being with clients that is collaborative and designed to cultivate and strengthen client’s own commitment and motivation to change. The MI clinician engages in a process of asking intentional questions and listening nonjudgmentally while guiding the client through a process of examining choices. During this change process the clinician is strategic about choosing questions that respond to client own statements about their strengths, desires and motivation for change. By eliciting the client’s own internal motivation for change and encouraging “change talk” clients begin to take responsibility for their choices and challenging themselves to change. MI is particularly helpful for clients who are ambivalent, reluctant, or defensive about change as the MI approach meets the client where they are at and does not attempt to “force” change on a client. By giving clients the autonomy to change, or not, resistance is eliminated, and the client is empowered to make their own changes with the support and guidance of the clinician.
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:
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 Motivational Interviewing Work?
There are four steps in the MI process, which aims to resolve ambivalence about behavior change.
- “I wish I could stop doing this.”
- “It would definitely be better if I…”
- can start doing this…”
- What are the benefits of changing?
- What reasons are there to change?
- What would making a change entail?
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:
- 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?”
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.
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.
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.