Motivational interviewing

Motivational interviewing (MI) refers to a counseling approach in part developed by clinical psychologists Professor William R Miller, Ph.D. and Professor Stephen Rollnick, Ph.D. The concept of motivational interviewing evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in Behavioural Psychotherapy. These fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. Motivational Interviewing is a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior.[2] MI is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it's more focused and goal-directed. It departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than non-directively explore themselves.[1] The examination and resolution of ambivalence is a central purpose, and the counselor is intentionally directive in pursuing this goal.[2]

MI recognizes and accepts the fact that clients who need to make changes in their lives approach counseling at different levels of readiness to change their behavior.[3] During counseling, some clients may have thought about making a behavior change, but may not yet have taken steps to make that change themselves. Alternatively, other clients may be actively trying to change their behavior and may have been doing so unsuccessfully for years. In order for a therapist to be successful at motivational interviewing, four basic interaction skills should first be established.[4] These skills include: the ability to ask open ended questions, the ability to provide affirmations, the capacity for reflective listening, and the ability to periodically provide summary statements to the client.[5] These skills are used strategically, while focusing on a variety of topics, such as looking back, reflecting on a typical day, the importance of change, looking forward, and examining one's confidence about behavior changes.

Motivational interviewing is non-judgmental, non-confrontational and non-adversarial.[6] The approach attempts to increase the client's awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Alternately, therapists help clients envision a better future, and become increasingly motivated to achieve it.[7] Either way, the strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.[8] Motivational interviewing focuses on the present, and entails working with a client to access motivation to change a particular behavior that is not consistent with a client's personal value or goal.[9] Warmth, genuine empathy, and acceptance are necessary to foster therapeutic gain (Rogers, 1961) within motivational interviewing. Another central concept is that ambivalence about decisions is resolved by conscious and unconscious weighing of pros and cons of change vs. not changing (Ajzen, 1980).

The main goals of motivational interviewing are to engage clients, elicit change talk, and evoke motivation to make positive changes from the client. For example, change talk can be elicited by asking the client questions, such as "How might you like things to be different?" or "How does ______ interfere with things that you would like to do?" Change may occur quickly or may take considerable time, and the pace of change will vary from client to client. Knowledge alone is usually not sufficient to motivate change within a client, and challenges in maintaining change should be thought of as the rule, not the exception. Ultimately, practitioners must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future.[10]

While there are as many variations in technique as there are clinical encounters, the spirit of the method, however, is more enduring and can be characterized in a few key points:[6]

  1. Motivation to change is elicited from the client, and is not imposed from outside forces.
  2. It is the client's task, not the counselor's, to articulate and resolve the client's ambivalence.
  3. Direct persuasion is not an effective method for resolving ambivalence.
  4. The counseling style is generally quiet and elicits information from the client.
  5. The counselor is directive, in that they help the client to examine and resolve ambivalence.
  6. Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction.
  7. The therapeutic relationship resembles a partnership or companionship.

Four general processes

MI uses four general processes to achieve its ends:

  1. Engaging - used to involve the client in talking about issues, concerns and hopes, and to establish a trusting relationship with a counselor.
  2. Focusing - used to narrow the conversation to habits or patterns that clients want to change.
  3. Evoking - used to elicit client motivation for change by increasing clients' sense of the importance of change, their confidence about change, and their readiness to change.
  4. Planning - used to develop the practical steps clients want to use to implement the changes they desire.

Adaptations of motivational interviewing

Motivational enhancement therapy

Motivational enhancement therapy[11] is a time-limited four-session adaptation used in Project MATCH, a US-government-funded study of treatment for alcohol problems and the Drinkers' Check-up, which provides normative-based feedback and explores client motivation to change in light of the feedback.[12]

Motivational interviewing is supported by over 200 randomized clinical control trials [13] across a range of target populations and behaviors including substance abuse, health-promotion behaviors, medical adherence, and mental health issues.

MI Groups

MI groups are highly interactive, focused on positive change, and harness group processes for evoking and supporting positive change. They are delivered in four phases:[14]

  1. Engaging the group
  2. Evoking member perspectives
  3. Broadening perspectives and building momentum for change
  4. Moving into action

Limitations of motivational interviewing

Many studies using MI have specific inclusion/exclusion criteria. For example, Project MATCH excluded those who were homeless and involved in the criminal justice system. A randomized trial in drug abuse services conducted by Miller and Rollnick (2002) provided motivational interviewing sessions to clients in order to elicit behavior change by exploring and resolving ambivalence. They enrolled 152 outpatient and 56 inpatient clients who were entering a public agency for drug problems. The researchers excluded clients who reported insufficient residential stability.

A critic of these studies argues that to represent real world clinical activities, such studies must include every client entering the facility under study (within the parameters of informed consent) (Patterson, 2008 & 2009).

Applications of motivational interviewing

Examples of fields in which motivational interviewing is being applied include:

References

  1. ↑ "Dr. William Miller, "Motivational Interviewing: Facilitating Change Across Boundaries"".
  2. ↑ Shannon, S; Smith VJ; Gregory JW (2003). "A pilot study of motivational interviewing in adolescents with diabetes. Arch Dis Child" 88: 680–683.
  3. ↑ Handmaker, NS; Miller WR; Manicke M (2001). "Pilot study of motivational interviewing" 86: 680–683.
  4. ↑ "Motivational Interviewing".
  5. ↑ "Motivational Interviewing: An evidence-based approach to counseling helps patients follow treatment recommendations". American Journal of Nursing. October 2007.
  6. 1 2 Miller, W.R., Zweben, A., DiClemente, C.C., Rychtarik, R.G. (1992) Motivational Enhancement Therapy Manual. Washington, DC:National Institute on Alcohol Abuse and Alcoholism
  7. ↑ Brodie, D.A.; Inoue, A.; Shaw, D. G. (2008). "Motivational interviewing to change quality of life for people with chronic heart failure: A randomised controlled trial". International Journal of Nursing Studies 45 (4): 489–500. doi:10.1016/j.ijnurstu.2006.11.009. PMID 17258218.
  8. ↑ Cummings, S.M.; Cooper, R.L.; Cassie, K.M (2009). "Motivational interviewing to affect behavioral change in older adults". Research on Social Work Practice 19 (2): 195–204. doi:10.1177/1049731508320216.
  9. ↑ Hanson, M; Gutheil, I. A. (2004). "Motivational strategies" 49.
  10. ↑ Freedman, J; Combs, G. (1996). "Narrative Therapy: The Social Construction of Preferred Realities". New York:Norton.
  11. ↑ Miller, W.R.; J. J. Onken, L. S., & Carroll, K. M. (Eds.) (2000). "Motivational Enhancement Therapy: Description of Counseling Approach". National Institute on Drug Abuse: 89–93.
  12. ↑ Miller, W.R.; Rollnick, S. (2002). "Motivational Interviewing: Preparing People to Change". Guilford press.
  13. ↑ Miller, W.R.; Zweben, A.; DiClemente, C.C.; Rychtarik, R.G. (1994). "Motivational Enhancement Therapy Manual". Washington, DC:National Institute on Alcohol Abuse and Alcoholism.
  14. ↑ Wagner, C.C., Ingersoll, K.S., and contributors (2013). Motivational interviewing in groups. New York: Guilford Press, Inc.

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