Motivational Interviewing: Facilitating Behaviour Change

What is motivational interviewing?

Motivational interviewing is a counselling method that has existed since the 1980s. American psychologist William R. Miller, PhD, described a therapeutic approach he used with some success for clients with alcohol problems. The technique’s uses have since expanded to encompass more than 1,000 publications and more than 200 randomized clinical trials.

But what exactly is motivational interviewing? It’s best described as a form of communication that is collaborative and goal-oriented, with particular attention to the language of change. This is predominantly achieved by helping clients explore and resolve ambivalence. By strengthening personal motivation for and commitment to a specific goal by eliciting and exploring the person’s reasons for change within an atmosphere of acceptance and compassion, the hope is that permanent behaviour change will occur.

Ultimately, motivational interviewing helps guide a conversation to facilitate the client’s desire to change and gives them the confidence to do so. This is in stark contrast to many other change strategies healthcare professionals employ, such as education, persuasion and scare tactics. A critical tenet of the method is that the motivation for change must emanate from the client rather than the clinician. Although most motivational interviewing training and studies involve focused therapy, there is evidence that very brief (five-minute) sessions have positive results, particularly when clients are highly resistant to change.

The Foundation of Motivational Interviewing: OARS

The “OARS” acronym highlights four essential aspects of motivational interviewing.

Open-ended questions

The goal is to elicit the client’s thoughts because behaviour change must originate with the client.

For example, “I understand you have some concerns about your smoking. Can you tell me about them?”

Instead of,“Are you concerned about your drinking?”

Affirmations

This can take the form of compliments or statements of appreciation and understanding. It helps build rapport, validate, and support the client during the change process. It is most effective when the client’s strengths and efforts for change are noticed and affirmed.

For example, “I appreciate that it took a lot of courage for you to discuss your drug use with me today, you appear to have a lot of resourcefulness to have coped with all these difficulties.”

Reflective listening

Reflective listening involves letting clients express their thoughts and then, instead of telling them what to do, capturing the essence of what they have said and helping them arrive at an idea for change. Here’s an example:

Client: “I wish I remembered to take my medication every day.”
Doctor: “You forget to take your medication every day?”
Client: “Pretty much every day. I know I shouldn’t, but I forget when things get hectic.”
Doctor: “It’s difficult to remember to take your medications because you have a lot of things going on at the moment.”
Client: “And I can’t remember everything, I try and remember to do all the important stuff but can’t seem to be able to do this.”
Doctor: “So you would like to take your medication every day because it’s important to you, but you forget to because life is too busy at the moment.”
Client: “Right. … I guess I could try setting a reminder on my phone.”

Summarize the visit

This involves recapping what has been said, calling attention to the salient elements of the discussion, and allowing for the correction of any misunderstandings.

The summary should end with an open-ended statement such as, “I am wondering what you think your next step should be.” This should be a specific goal, however small, that the client is willing to accomplish, not just try.

The Stages of Change model and motivational interviewing

Prochaska and DiClemente proposed readiness for change as a vital mediator of behavioural change. Their transtheoretical model of behaviour change (the ‘Stages of Change‘) describes readiness to change as a dynamic process in which the pros and cons of changing generate ambivalence. Ambivalence is particularly evident in situations where there is a conflict between an immediate reward and longer-term adverse consequences, such as substance abuse and weight management. This change process is modelled in five parts: from an initial pre-contemplative stage, where the individual is not considering change, to a contemplative stage, where the individual is actively ambivalent about change; to preparation, where the individual begins to plan and commit to change.

Successful progression through these stages leads to action, where the necessary steps to achieve change are undertaken. If successful, action leads to the final stage, maintenance, where the person works to maintain and sustain long-term change.

In motivational interviewing, relapse is considered an important stage in the change process and is used as an opportunity to learn about sustaining maintenance in the future. Motivational interviewing is an effective counselling method that enhances motivation by resolving ambivalence. It grew from the Prochaska and DiClemente model described above and Miller and Rollnick’s work in addiction medicine, drawing on the phrase ‘ready, willing and able’ to outline three critical components of motivation. These were:

the importance of change for the client (willingness)

the confidence to change (ability)

whether change is an immediate priority (readiness).

Using motivational interviewing techniques, the practitioner can tailor motivational strategies to the individual’s stage of change according to the Prochaska and DiClemente model.

The four principles of motivational interviewing

In general practice, the particular difficulties associated with quick consultation times can present unique challenges in implementing motivational interviewing. Miller and Rollnick have attempted to simplify the practice of motivational interviewing for healthcare settings by developing four guiding principles, represented by the acronym RULE:

• Resist the righting reflex
• Understand the client’s motivations.
• Listen with empathy
• Empower the client

Resist the righting reflex

The righting reflex describes the tendency of health professionals to advise clients about the right path to good health. This can often have a paradoxical effect, inadvertently reinforcing the argument to maintain the status quo. Most people resist persuasion when ambivalent about change and will respond by recalling their reasons for maintaining the behaviour. Motivational interviewing in practice requires clinicians to initially recognise their triggers and then suppress the righting reflex so that they can explore the client’s motivations for change.

Understand your client’s motivations

The client’s own reasons for change will ultimately result in behaviour change. By approaching their interests, concerns, and values with curiosity and openly exploring the client’s motivations for change, the practitioner will begin to get a better understanding of the client’s motivations and potential barriers to change.

Listen with empathy

Effective listening skills are essential for understanding what motivates the client and the pros and cons of their situation. A general rule of thumb in motivational interviewing is that equal amounts of time in a consultation should be spent listening and talking.

Empower your client

Client outcomes improve when they are an active collaborator in their treatment. Empowering them involves exploring their ideas about how they can make changes to improve their health and drawing on the client’s personal knowledge about what has succeeded in the past. A truly collaborative therapeutic relationship is a powerful motivator. Clients benefit from this relationship the most when the practitioner embodies the hope that change is possible.

Change talk

Change talk generally refers to clients’ statements about their desire, ability, reasons and need for change. Research shows that change talk is associated with enhanced motivation for change, and motivation is associated with an increased likelihood of actual change. This supports the emphasis that motivational interviewing places on listening for–and eliciting–change talk as key counselling skills.

Sustain talk

Sustain talk is the opposite of change talk. Clients may use sustain talk to indicate their desire to maintain the status quo, their worries about being able to change, and their reasons not to change.

Motivational interviewing emphasises reflecting on change talk and moving away from reflecting on sustain talk. This keeps the momentum of the conversation toward enhancing motivation for change.

Strengthening commitment to change

This involves goal setting and negotiating a ‘change plan of action’. In the absence of a goal-directed approach, applying the strategies or spirit of motivational interviewing can result in the maintenance of ambivalence, where clients and practitioners remain stuck. This trap can be avoided by employing strategies to elicit ‘change talk’. There are many strategies to elicit ‘change talk’, but the simplest and most direct way is to elicit a client’s intention to change by asking a series of targeted questions from the following four categories:

disadvantages of the status quo
advantages of change
optimism for change
intention to change

Following this process, a ‘change plan’ is decided on together. This involves standard goal-setting techniques whilst eliciting from the client what they plan to do (rather than instructing or advising).

Examples of key questions to build a ‘change plan’ include:

It sounds like things can’t stay the same as they are. What do you think you might do?

What changes were you thinking about making?

Where do we go from here?

How would you like things to turn out?

It is common for clients to ask for answers or ‘quick fixes’ at some point. In keeping with the spirit of motivational interviewing, a simple phrase reminding the client of their autonomy is useful: ‘You are the expert on you, so I’m not sure I am the best person to judge what will work for you. But I can give you an idea of what the evidence tells us and what other people have done in your situation.’

The theory behind motivational interviewing

A cohesive theory base for motivational interviewing has started to take shape. Some influences on the development of motivational interviewing include:  

• Self-determination theory, which posits that autonomy support, autonomous motivation and perceived competence predict health and behavioural outcomes, appears especially congenial to the spirit and strategies of motivational interviewing
• Cognitive dissonance theory (e.g., the gap between current behaviours and future goals) is relevant to some aspects of motivational interviewing, especially the clinical skill of developing discrepancy.
• Self-perception theory, which proposes that hearing oneself argue for change affects motivation, relates to motivational interviewing’s focus on eliciting client change talk (the elements in clients’ speech that favour change).

The evidence

Since the 1980s, research and clinical articles on motivational interviewing have doubled every three years (Miller & Rollnick, 2009, 2010).

Two meta-analyses link to support the efficacy of motivational interviewing in addiction and in other health behaviour change areas (e.g., mental health problems, diabetes, obesity, hypertension, criminal justice, homelessness, HIV/ AIDS).

Motivational interviewing has also been researched in various formats, including as a stand-alone treatment intervention, a brief (i.e., a few minutes) counselling intervention, a combination with other approaches, and in groups.

Further reading

Selected references

Britton, P.C., Williams, G.C. & Conner, K/R. (2006) “Self-determination theory, motivational interviewing, and the treatment of clients with acute suicidal ideation” Journal of Clinical Psychology., https://doi.org/10.1002/jclp.20430

Draycott, S. & Dabbs, A. (1998) “Cognitive dissonance 2: A theoretical grounding of motivational interviewing” British Journal of Clinical Psychology.  https://doi.org/10.1111/j.2044-8260.1998.tb01391.x

 Lundahl, B. & Burke, B.L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65, 1232–1245.

Maarten Vansteenkiste, Kennon M. Sheldon, (2006) “There’s nothing more practical than a good theory: Integrating motivational interviewing and self-determination theory”, British Journal of Clinical Pscychology. https://doi.org/10.1348/014466505X34192

“MI model” Motivational Interviewing”, https://www.porticonetwork.ca/treatments/treatment-methods/motivational-interviewing

Miller WR. Motivational interviewing with problem drinkers. Behavioural Psychotherapy. 1983;11:147172.

Miller, W.R. & Rose, G.S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64, 527–537.

Miller, W.R. and Rose, G.S. (2010) “Toward a Theory of Motivational Interviewing,” Am Psychol. 2009 Sep; 64(6): 527–537. doi: 10.1037/a0016830

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.

Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change, 2nd ed. New York: Guilford Press; 2002.

Miller, W.R & Rollnick, S., “Ten Things that Motivational Interviewing Is Not”. Behavioural and Cognitive Psychotherapy, 2009, 37, 129–140

Moyers, T. B., Martin, T., Houck, J. M., Christopher, P. J., & Tonigan, J. S. (2009). From in-session behaviors to drinking outcomes: A causal chain for motivational interviewing. Journal of Consulting and Clinical Psychology, 77, 1113–1124. http://psycnet.apa.org/doi/10.1037/a0017189

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. https://doi.org/10.1037/0022-006X.51.3.390

Rollnick S, Miller WR. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995;23:325334.

STEWART, E.E. PhD, AND CHESTER FOX, MD “ENCOURAGING ClientS TO CHANGE UNHEALTHY BEHAVIORS WITH MOTIVATIONAL INTERVIEWING”      http://www.aafp.org/fpm/2011/0500/p21.html

 “Understanding Motivational Interviewing”, MINT Network (2020) https://motivationalinterviewing.org/understanding-motivational-interviewing