If you treat an individual as he is, he will remain how he is. But if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be.”― Johann Wolfgang von Goethe

What is Motivational Interviewing?

A simple definition: MI is an evidence-based way of talking with people about change in a way that strengthens the person’s own motivation and commitment to change.

MI is backed by a lot of evidence that has been published in major psychological and medical journals and has been around since the 1980s. It is evidence based.  The psychologists William R. Miller and Stephen Rollnick developed Motivational Interviewing (MI) in the early 1980s first as part of their treatment of alcoholics.

MI has been shown to be effective in helping people change addictions, smoking, drinking, study habits, dental health practices, exercise, etc.

What Motivational Interviewing (MI) does

  • MI addresses the problem of ambivalence about change.
  • MI strengthens a person’s own motivation and commitment to change.
  • MI elicits and explores the patient’s own reasons for change in an accepting and compassionate atmosphere.
  • MI recipient-centered.
  • Is collaborative.
  • Is a goal-oriented style of communication.
  • MI pays attention to the language of change.

The Spirit / Heart-Set / Mindset of MI

Motivational interviewing moves the practitioner to develop a paradigm shift, a new mindset, a new way of seeing change.

The heart or spirit of MI can be denoted by the acronym CARE.

  1. Compassion.
  2. Acceptance. Acceptance doesn’t mean approval. According to Carl Rogers acceptance includes 1) recognizing and prizing the absolute inherent worth of every person, 2) Affirmation, 3) Accurate empathy, 4) Autonomy. 
  3. Relationship-centered Partnership (or collaboration). In MI, the clinician is a facilitator, not an expert. The patient is the focus. MI is a collaboration between experts.
  4. Evocation. Evocation means to call forth, draw forth, or draw out as from a well. MI seeks to draw out or call forth the person’s own motivation and commitment to change.

What happens if you practice MI without this underlying spirit? Miller and Rollnick, the originators of what we know today as motivational interviewing say without this spirit, MI becomes “a cynical trick, a way of trying to manipulate people into doing what they don’t want to do: the expert magician skillfully steers the hapless client into the right choice. In short, it becomes just another version of the righting reflex, a battle of wits in which the goal is to outsmart your adversary.”

Counsel in a person’s heart is deep water; but one who has insight draws it out.” Prov. 20:5

Assumptions of MI

  1. People are inherently self-actualizing and naturally incline to do the right thing when given the essential therapeutic conditions.
  2. People already have within them much of what is needed and the job of the counselor is to evoke it, call it forth, or draw it out as one draws water from a well. Miller and Rollnick say, the implicit message of MI is, “You have what you need, and together we will find it.” They go on to say that the counselor then should “focus on and understand the person’s strengths and resources rather than probe for deficits… From an MI perspective, the assumption is that there is a deep well of wisdom and experience within the person from which the counselor can draw. Much of what is needed is already there, and it’s a matter of drawing it out, calling it forth. The MI practitioner is therefore keenly interested in understanding the client’s perspective and wisdom.”

Basic Counseling Skills Used in MI (OARS)

The following are basic counseling skills are not unique to MI but are a crucial part of MI

  1. Open questions
  2. Affirmations
  3. Reflective listening
  4. Summaries

Four Key Processes in MI

Miller and Rollnick described 4 key processes in MI:

  1. Engaging – You meet the patient, establish rapport, connect with them, win their trust, and build a working or therapeutic relationship. This is necessary for the other processes that follow to be effective.
  2. Focusing – Agenda mapping or creation of a shared agenda and prioritizing the things we want to focus on. Focusing helps set expectations and maintain direction in the conversation about change.
  3. Evoking – With one or a few change goals as the focus, evoking elicits the client’s own motivations for change. Evoking is at the heart of MI. You get the clients to talk about why and how they might want to change.
  4. Planning – When the patient is motivated to change and ones to take action, planning gets the client to start talking about when and how to change and less about whether and why.

Evoking

Eliciting Change Talk

Decisions to change are often very difficult and some take over 6 months from the time of making the decision to actually changing.

When change is difficult, it’s usually not because of denial, resistance, lack of info, laziness, oppositional personality etc. Instead, it’s often because the person lacks motivation or is simply ambivalent. Ambivalent means they are pulled in two directions. They want to change and don’t want to change all at the same time. They have reasons for change and reasons not to change. Ambivalence is a perfectly normal part of preparing for change. However, a person can remain stuck in the middle of this tug of war for a long time.

Ambivalence causes stress, anxiety, and procrastination which makes it difficult to actually change. A big mistake that is often made is to see this ambivalence as resistance to change. That’s a huge mistake and clinicians shouldn’t do that. Ambivalence is a natural thing and is nothing intentional on the part of the patient. MI helps to resolve that ambivalence by eliciting the person’s own motivation to change. It does that by getting them to talk about change.

Ambivalent people usually have two kinds of talk mixed in their conversations. One type is change talk–which is language moving towards change. The other is sustain talk, which is language moving away from change and towards sustaining the status quo. A person might say, “I need to quit smoking [change talk] because my father recently got diagnosed with lung cancer, but I’m too stressed right now and smoking calms my nerves [Sustain talk]. When you talk to people who are ambivalent about quitting alcohol, losing weight, exercising, etc, their language is full of both change talk and sustain talk, often in the same sentences.

5Ws and 1 H

You can use the 5Ws and 1H to help you ask questions that will elicit change talk. When you get change talk, you need to affirm it and encourage it.

5 Ws and 1 H are: Why, What, Where, When, Who, and How.

  1. What change might he make – describe the change.
  2. Why do you want to make a change? What are the reasons you want to change — I love to start with why?
  3. What would some of the benefits be to you?
  4. How might you go about making the change?
  5. What would be your first step?
  6. Where do you want to be when this happens? — Community, location.
  7. When might be a good time for you to make a change?
  8. Who might you get involve to help you?

GROWTH framework

Also, my GROWTH framework for strategy is a very good tool to use to encourage change talk. As you go through it, you frame the questions in ways that will elicit change talk.

Some Key Things to Keep in Mind

  • Have the client, not the clinician voice the reasons for change.
  • Get the client to focus on change talk.
  • Acknowledge sustain talk but don’t focus on it.
  • Basically, you get them to talk positively about the change they want to make.
  • The best ideas about change come from the client.
  • People are more likely to be persuaded by what they hear themselves saying than by what someone else tells them. This is why self-affirmations are effective.
  • MI calls people forth, not out; calls them up, not out.

The 4 Guiding Principles of MI

Miller and Rollnick recommend the following 4 guiding principles for MI represented by the mnemonic RULE:

  1. Resist the righting reflex
  2. Understand the patient’s own motivations
  3. Listen with empathy
  4. Empower the patient.

 

Some References

  1. William R. Miller and Stephen Rollnick, Motivational Interviewing: Helping People Change, 3rd Edition
  2. Kathleen G. Reims, MD, FAAFP, and Denise Ernst, PhD, “Using Motivational Interviewing to Promote Healthy Weight”, Fam Pract Manag. 2016 Sep-Oct;23(5):32-38.
  3. Simmons, Leigh Ann, and Ruth Q. Wolever. “Integrative Health Coaching and Motivational Interviewing: Synergistic Approaches to Behavior Change in Healthcare.” Global Advances in Health and Medicine 2.4 (2013): 28–35. PMC. Web. 17 Mar. 2017.
  4. https://www.umass.edu/studentlife/sites/default/files/documents/pdf/Motivational_Interviewing_Definition_Principles_Approach.pdf, Last Accessed 3/17/2017
  5. Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care. Helping patients change behavior. New York: The Guilford Press, 2008
  6. Elizabeth E. Stewart, PhD, and Chester Fox, MD “Encouraging Patients to Change Unhealthy Behaviors With Motivational Interviewing.” Fam Pract Manag. 2011 May-June;18(3):21-25.
  7. AAFP CME training resources. Motivational Interviewing: A Patient-Centered Approach to Obesity Management. http://www.aafp.org/cme/cme-topic/all/motivational-interviewing-obesity.html
  8. https://www.linkedin.com/pulse/using-motivational-interviewing-coaching-john-quinn-hooks-
  9. http://www.motivationalinterviewing.org, MI Presentation, Last Accessed 3/17/2017
  10. Bill Matulich, PhD. MI Presentation. http://motivationalinterviewingonline.com/Welcome.html
  11. http://www.racgp.org.au/afp/2012/september/motivational-interviewing-techniques/
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