Guiding Motivational Interviewing Philosophy

"Motivational interviewing is a directive, clientcentered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. "

Rollnick and Miller (1995, p. 326)

Ambivalence is a normal and understandable component of the change process. Any decision to change can involve competing motivations, each of which has costs and benefits associated with it. Motivational interviewing is a strategy that is used to help individuals examine, understand, and resolve their ambivalence to change; it is a strategy used to enhance a person's motivation to change.

Individuals will not change if they are not motivated to change, and how motivated or ready a person is to change fluctuates as a function of time and situation. A person's motivation to change can actually be influenced by others in their life, including their clinician. The challenge for the clinician is to appropriately assess where the patient is in the process of change and to respond accordingly. Directing the patient to make changes in their life when they haven't even considered the need to make changes or are ambivalent about changing is likely to backfire and result in resistance.

We cannot control a patient's behavior and make patients change. Only patients can take charge of their own health. In motivational interviewing, the role of the clinician is to help patients explore the possibility of change. Providing patients with information and advice has been found to be effective in changing behavior in only 5% to 20% of patients (Glynn & Manley, 1989; Law & Tang, 1995; The Smoking Cessation Clinical Practice Guideline Panel and Staff, 1996). This type of approach is only effective with patients who are ready and motivated to change. A clinician must build a patient's commitment to change before he/she can teach the patient how to change. In other words, the clinician should respond in a way to help motivate the patient to move in the direction of positive change; this does not mean confronting and directly persuading the patient. It means empathetically encouraging the patient to explore their risky behavior.

Motivational interviewing is a brief intervention that has been found to be effective in the treatment of alcoholrelated problems; it has been modified for the Options/Opciones Project to deal specifically with HIV risk reduction. Rather than taking on an authoritarian role and acting as expert and prescribing change, the clinician leaves the responsibility for change with the patient. This does not mean that the clinician is not directive. To the contrary, the clinician has a clear goal, which is to reduce HIV risk behavior, and she/he uses various strategies to achieve that goal. The clinician does a brief assessment of where the patient is, provides feedback based on that assessment, discusses various strategies for changing behavior, and negotiates a goal with the patient. The patient is intimately involved in every step of the process, especially in the selection of the goals. The relationship between the patient and the clinician is thus a collaboration one in which the patient and clinician work together to negotiate an individualized plan for positive change.

"The strategies of Motivational Interviewing are more persuasive than coercive, more supportive than argumentative. The clinician seeks to create a positive atmosphere that is conducive to change. The overall goal is to increase the patient's intrinsic motivation, so that change arises from within rather than being imposed from without. When this approach is done properly, it is the patient who presents the arguments for change, rather than the clinician. "

Miller and Rollnick (1991, p. 52)

Key Components of Motivational Interviewing:

  • It is the individual's personal responsibility and choice whether or not to change their behavior.
  • Whereas the clinician is an expert on how people in general can change their behavior, the patient is the expert on how they themselves can change. Each patient is unique in what motivates them to change, and it is assumed that the patient has important insight and ideas for how to solve their own problems.
  • The clinician should ask simple openended questions (as opposed to closeended, or yesno questions) to encourage exploration and decisionmaking.
  • The clinician should use skillful reflective listening. Reflective listening involves briefly summarizing what the patient is saying in order to show that you understand the meaning of what they are saying. It also provides the opportunity to verify your understanding of the patient's perspective. It is only by carefully listening to your patient that you can learn what it will take for them to change.
  • The clinician should create and amplify, in the patient's mind, any discrepancies between present behaviors (where they're at now) and broader goals (where they want to be).
  • The clinician should embrace ambivalence. Many patients are ambivalent about change, and they have very good reasons for not changing their highrisk behavior. It is important for the clinician to understand those reasons. Allowing the patient to discuss what they like about their highrisk behavior can paradoxically serve as a catalyst for positive behavior change.
  • The clinician should avoid arguing, confronting, and pressuring the patient into action. Arguing, confronting, and pressuring can lead to the patient to take a defensive and rigid posture, and thus not be amenable to making any changes.
  • Approaches that support the patient's autonomy are more effective in helping a patient to change than are coercive measures. A patient is more likely to adopt healthy behaviors if they "want to" than if they "ought to" or "have to. " Adopting a controlling and paternalistic approach is antithetical to supporting the patient's autonomy. Patients are more likely to make healthy choices if the clinician acknowledges and supports their right to choose than if the clinician behaves as if she/he can make the patient change. (Botelho, 2000)
  • The clinician should work at a pace that is sensitive to her/his patient's needs and their readiness to change. If the clinician pushes the patient ahead of where they are ready to be, the clinician is likely to engender resistance on the part of the patient.
  • The clinician should roll with resistance; any statement made by the patient can be rephrased or reframed to create momentum toward change. Resistance (e.g., denial, arguing, objecting, refusing to engage in conversation) is influenced by the way in which the clinician interacts with the patient. It is a function of the interpersonal interaction between the patient and the clinician, and it can either be exacerbated or diminished depending on the clinician's response to it. Resistance is a signal that the clinician and patient are not at the same place. Further exploration or shifting focus may help to "melt" the resistance. (Rollnick, Mason, & Butler, 1999)
  • The clinician should provide non judgmental feedback and information. The role of the clinician is to understand the patient's feelings and perspectives without judging, criticizing, or blaming.
  • Acceptance facilitates change. By adopting an attitude of acceptance and respect, the patient's selfesteem is supported, which frees them to change. (Acceptance refers to "understanding" the patient's perspective. It does not mean approving of their behavior.)
  • The clinician should support and increase the patient's selfefficacy and her/his ability to cope with obstacles and succeed at change. Selfefficacy refers to a person's confidence in her/his ability to make a specific change in behavior (Rollnick, Mason, & Butler, 1999, p.92). The clinician should help the patient to believe that healthy outcomes are possible.
  • Negotiate goals that are realistic and attainable. It is critical that the patient be successful in their efforts to reach their goals so that their selfefficacy and their motivation to make changes increases. Therefore, it is important that realistic goals be chosen, and that may mean choosing smaller goals at which they can succeed rather than large behavior change goals at which they will fail.

PRESENTING THE FIVE PRINCIPLES OF MOTIVATIONAL INTERVIEWING

Possible Points to Emphasize

THE SPIRIT OF MI

We find it useful, before moving into principles, to emphasize that there is an overall spirit or guiding set of perspectives that underlie motivational interviewing. MI is not a technique, but more a style, a facilitative way of being with people. This is particularly discussed in the article What Is Motivational Interviewing (Rollnick & Miller, 1995). It is within that overall context that the following five principles are best understood.

  1. EXPRESS EMPATHY
  • The general goal here is to create a supportive, clientcentered atmosphere in which it is safe for the client to explore conflicts and come face to face with difficult realities.
  • The establishment of such a therapeutic relationship can be accomplished relatively quickly, and is best promoted by providing the conditions first outlined by Carl Rogers: nonpossessive warmth, accurate understanding, and unconditional positive regard. The easiest of these to shape and learn is accurate understanding, manifested primarily through the skill of reflective listening, which in turn communicates and shapes the other critical conditions. Developing a high level of empathic, reflective listening skill is a prerequisite for motivational interviewing,
  • This principle works against the idea that "If you can just make the person feel bad enough, he or she will change." There is an underlying paradox, that an atmosphere of acceptance facilitates change, whereas pressure to change blocks it.
  • By "empathy" we specifically do not mean identification with the client. "Having been there" is not a necessary or sufficient condition for effective intervention. In fact, overidentification with clients can interfere with effective counseling.
  1. DEVELOP DISCREPANCY
  • A motivating discrepancy is that between where I see myself being, and where I want to be
  • Consequently, two good topics for discussion in motivational interviewing are the client's most important goals or values (where I want to be), and the client's present condition with regard to the target behavior (where I am).
  • Consistent with selfperception theory, it is the client who should present the arguments for change. The strategies for eliciting self-motivational statements are designed to evoke such language from the client. Selfmotivational statements (see pp. 8081 in MI) include problem recognition, expression of concern, intention to change, and optimism for change.
  • Remember that discrepancy is not imposed from without. The discrepancy is between the client's problem behavior and those inner goals and values that are more important or more dear to the client. and which are jeopardized by or inconsistent with the problem behavior.
  1. AVOID ARGUMENTATION
  • Research suggests that a key to effective motivational interviewing is to keep client resistance levels low (Miller, Benefield & Tonigan, 1993). The more a client resists, the less likely he or she is to change. Minimize resistance!
  • Client resistance behavior is heavily influenced by how the therapist responds. One memorable teaching phrase to capture this is: "Denial ,is not a problem of client personality, but of therapist skill."
  • The primary therapist behaviors that elicit and drive client resistance are overtly confrontational tactics such as arguing and challenging, headtohead disputes, restating negative information about the client, sarcasm, and incredulity. The more a therapist confronts in this way, the less a client changes (Miller, Benefield & Tonigan 1993).
  • Avoid the confrontationdenial trap. If you find yourself arguing for change while the client argues against it, change your strategy fast!
  • Labeling is unnecessary, and is a common source of argumentation and resistance. It is not necessary for a client to accept a label or diagnosis in order to change. Bill Wilson's own admonition against labeling others (see p. 7 in MI) is a useful observation here.
  1. ROLL WITH RESISTANCE
  • Opposing resistance generally reinforces it. Don't push against client resistance.
  • If you see resistance intensifying, you need to respond differently.
  • Invite new perceptions in your client (reframe), but don't impose or argue for them.
  • Don't feel obliged to answer a client's objections or resistances. Turn them back, and use the client as a resource in finding solutions.
  • It is useful about here to remind trainees that these are the overall goals of motivational interviewing, and that specific strategies for accomplishing them will be covered later in the workshop.

5. SUPPORT SELFEFFICACY

  • Remember that without selfefficacy, perceived risk turns to defensiveness instead of behavior change.
  • Impart belief in the possibility of change. A useful form of such optimism is the truth: that there are many options, many different pathways to change. A further point is that most people who decide to make a change (in drinking) eventually succeed.
  • Remember that it is always the client's choice whether and how to change. No matter how much you want to make this decision for the client, you cannot.,

AETC Faculty Development, Secondary Prevention 2003

Developed by Cicatelli Associates Inc.

Elements of Effective Brief Intervention

Miller and Sanchez (1994) reviewed studies of brief intervention to identify common elements of effective counseling (cf. Bien, Miller & Tonigan. 1993). They found six components present in all or most effective brief interventions, represented by the act acronym FRAMES:

FEEDBACK / Effective brief interventions offer: provide clients with personal Feed back regarding their individual status in The alcohol field this has included confirmation of alcohol problems. feedback: or personal alcohol consumption relative to norms, information about elevated liver enzyme values, etc. Such feedback is not to be confused with lecturing people information about alcohol problems, e.g. about the adverse effects of alcohol on people in general.
RESPONSIBILITY / Effective brief interventions have also emphasized the individual's freedom of choice, and personal responsibility for change.General themes are: (1) It's up to you; you're free to decide to change or not: (2) No one else can decide for you or force you to change: (3) You're the one who has to do it if it's going to happen
ADVICE / Nevertheless, effective brief counseling has almost universally included a clear recommendation or advice on the need for change, typically in a supportive and concerned rather than authoritarian manner.
MENU / When specific strategies for change have been offered, they have often been in menu form providing a variety of options from among which clients may pick those that seem more suitable or appealing.
EMPATHY / When counselor stele has been described in studies of effective brief intervention, emphasis has been placed on an empathic, reflective, warm and supportive manner. Research has specifically linked this Rogerian style to more positive treatment outcomes.
SELFEFFICACY / Finally, effective brief interventions have also often reinforced selfefficacy, the client's expectation that he or she can change.

AETC Faculty Development, Secondary Prevention 2003

Developed by Cicatelli Associates Inc.

AETC Faculty Development, Secondary Prevention 2003

Developed by Cicatelli Associates Inc.

  1. QUESTION – ANSWER TRAP
/ This sets up the expectation that the therapist will ask enough questions and then have the answer, fostering client passivity. It can happen inadvertently by asking many specific questions to “fill out forms” early in treatment. Consider having clients fill out questionnaires in advance, or wait until the end of the session to obtain the details you need. This is a specific form of a more general “Expert” trap. This is best remedied by asking open-ended questions, letting the client talk, and using reflective listening.
  1. CONFRONTATIONAL – DENIAL TRAP
/ This is the classic mistake of the therapist taking responsibility for the “healthy” side of ambivalence and the client arguing for the opposite. Another form is for the counselor to make a suggestion and the client to explain why it won’t work (Yes, but…). If you find yourself falling into this role, change strategies.
  1. LABELLING TRAP
/ Diagnostic and other labels represent a common obstacle to change. There is no persuasive reason to focus on labels, and positive change is not dependent upon acceptance of a diagnostic label. If it seems a sensitive issue, avoid problem” labels, or refocus attention (e.g., “Labels are not important. You are important, and I’d like to hear more about…”).
  1. PREMATURE FOCUS TRAP
/ Some clients are not ready at the outset to talk about what the therapist sees as a target problem, and premature pressure to focus on “the problem” may elicit resistance. Explore the client’s own concerns, and look for ways to tie these in.
  1. BLAMING TRAP
/ Clients may also expect that an early task of counseling is to determine who is at fault, who is sick, etc. If this seems an issue, it is useful to defuse it early by explaining that placing of blame is not a purpose of counseling.

Adapted from Miller and Rollnick, 1995

THOMAS GORDON'S TWELVE ROADBLOCKS

Source: Thomas Gordon, T.E.T. (Teacher Effectiveness Training)

1. Ordering,directing . in , or commanding. Here a direction is given with the force of some authority behind it. There may be actual authority (as with a parent or employer), or the words may simply be phrased in an authoritarian way. Some examples:

Don't say that.

You've got to face up to reality.

Go right back there and tell her you're sorry!

2. Warning or threatening. These messages are similar to directing, but they also carry an overt or covert threat of impending negative consequences if the advice or direction is not followed. It may be a threat that the individual will carry out, or simply a prediction of a bad outcome if the other doesn't comply.

You'd better start treating him better or you'll lose him.

If you don't listen to me you'll be sorry.

You're really asking for trouble when you do that. '

3. Giving advice, makingsuggestions,providingsolutions. Here the individual draws on her or his own store of knowledge and experience to recommend a course of action. These often begin with the words:

What I would do is...

Why don't you...