The Spirit of Motivational Interviewing

What is Motivational Interviewing?

written by Dr Gary Mendoza

Motivational interviewing (MI) is a way of being with a client, not just a set of techniques for doing counselling (Miller and Rollnick. 1991). A laypersons definition would be ‘MI is a collaborative conversation style for strengthening a person’s own motivation and commitment to change’.

To understand what MI is it is helpful to understand MI spirit. The following diagram taken from the basic MI training workshop sums this up very well.

Figure 1. The MI Spirit (diagram from basic MI training workshop)

It is very much person centred and very much about accepting that an individual has complete autonomy of their choices and actions. MI is not some magic technique that your practice on an individual. It is also not a method for manipulating an individual to make changes. MI recognises that the person who knows you best is you. Through a conversational style the counsellor/trainer draws on this knowledge and reflects it back to the client.

Listening is a key skill to master in MI and is often referred to as active listening. It is this ability to listen and recognise different aspects of a person’s language that sets a person skilled in MI apart from others.

MI is very much client centered and the aspect that separates an MI conversation apart from your everyday conversation is that it has direction. Using the basic skills of OARS (see definition below) the conversation is guided in a useful direction.

 

The basic skills of MI are built around O.A.R.S :

  • Open questions
  • Affirmations
  • Reflections
  • Summary

 

Using these skills, the counsellor/trainer moves in a general direction through the foundational steps of MI. These steps are as follows:

Figure 2. The Foundational processes of MI (diagram from basic MI training workshop)

Using the idea of weight loss, you can see how this might work. It is not too much an assumption to make that the population have a general idea about what healthy eating entails. It would also be reasonable to assume that the majority of the population understand the importance of exercise/activity in terms of health and weight loss.

If these assumptions are accurate then why do we have an obesity epidemic? One answer may be that although people know what they should do they choose not to. Many people can see the advantages of eating healthier and being more active and could no doubt tell you what they are. On the other hand they can equally see as many reasons why they can’t eat healthily and exercise more. In MI terms this is called ‘ambivalence’. In other words, the pros and cons of change are pretty much in balance.

 

The treatment improvement protocol from rockville1 describes MI as follows and takes account of ambivalence within this:

“Motivational interviewing is a counselling style based on the following assumptions:

  • Ambivalence about substance use (and change) is normal and constitutes an important motivational obstacle in recovery.
  • Ambivalence can be resolved by working with your client’s intrinsic motivations and values.
  • The alliance between you and your client is a collaborative partnership to which you each bring important expertise.
  • An empathic, supportive, yet directive, counselling style provides conditions under which change can occur. (Direct argument and aggressive confrontation may tend to increase client defensiveness and reduce the likelihood of behavioural change.)”

 

With MI you very much work with the client and their knowledge. As an expert in a field there is temptation to think that you know all the answers and all you need to do is tell your client what to do. This form of information giving is known as ‘directing’ in MI. Equally if you just sit and listen to a client the conversation is likely to go around in circles and this is known as ‘following’.

What you are aiming for is the middle ground between these two extremes and this is called ‘guiding’. As the MI counsellor you are gently guiding the client in a direction that will be beneficial to resolving their issue and you are using their knowledge and understanding to come up with solutions.

You are listening for the clients “change talk”. This is language that is used that can see the positives for changing. The flip-side of this language is “sustain talk”. When we are ambivalent about a change the sustain talk and change talk tend to balance out. In MI the counsellor/trainer reflects the change talk back to the client. Research shows that hearing your own words (change talk) repeated back to you can be a powerful stimulus to ultimately making a change; this is at the heart of MI.

That is not to say that you cannot offer advice and information within MI. You can and it needs to be MI consistent. You may have noticed that I said “offer advice” and not “give advice”. By offering advice/information I am being MI consistent because I fully respect the client’s right to ignore it. As part of the basic training in MI you learn how to offer advice in an MI consistent manner.

I am not a huge fan of anything that has cultish undertones but one thing I do appreciate is that in order to become proficient at delivering MI you need to become more MI consistent in your daily life. That means accepting everyone for who they are and listening to them properly without judgement but with curiosity. To my mind that is no bad thing and we all could benefit from that.

I think it is appropriate that the final words on MI should come from the co-founders of motivational interviewing, Professors Stephen Rollnick and William Miller2:

“Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change.  It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”

 

Reference:

  1. Treatment Improvement Protocol (TIP) Series, No. 35. Center for Substance Abuse Treatment. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (http://www.ncbi.nlm.nih.gov/books/NBK64964/)

 

  1. Motivational Interviewing: Helping People Change. William R Miller, PhD, Stephen Rollnick, PhD. Guilford Press, Sep 2012.