Motivational Interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” – Miller & Rollnick, 2002
“Helping people talk themselves into changing”
Motivational Interviewing (MI) is an evidenced-based model to describe how people change. Changing behavior (or changing habits) can be very difficult for most of us. When the dentist told us “you really need to floss more” or the doctor told us “you need to lose weight”, did we run to the store for floss? Probably not.
Motivational interviewing is a therapeutic technique to encourage individuals to find their own motivation for change by recognizing their resistances to change. By identifying our fears and ambivalences about change, we can work to overcome them. This is not a series of techniques therapist’s use to “trick” us into changing. Instead, it’s a skillful bedside manner for sparking inner motivation to make changes.
Motivational Interviewing is about guiding more than directing, eliciting more than imparting, and listening at least as much as telling. It is effective across populations and cultures, improves adherence and retention in care (by involving individuals in their own care), and reduces clinician burnout.
Guiding Principles of Motivational Interviewing
(1) Resisting the “righting” reflex: It is tempting to tell people they should change. But this is rarely effective.
(2) Understanding and exploring the individual’s own motivation: It is important to understand why the individual wants to change and what fears or ambivalences are working against them
(3) Listening with empathy: People are more likely to change when they feel validated rather than discouraged. Active listening is a key principle of motivational interviewing
(4) Empowering and instilling hope and optimism: Empowering others to change requires cultivating an optimistic and hopeful attitude.
What is Motivation?
Motivation is the reason(s) one has for acting or behaving in a particular way. It is the willingness of someone to do something. Motivation is multidimensional, dynamic, and has external and internal factors. It is the key to change. Motivation can be elicited and enhanced and is an important factor in someone’s readiness to change.
There are two important dimensions of motivation:
(1) Importance: the “why” of change
(2) Confidence: the “how” of change
There are three components of Motivation:
(1) Ready: a matter of priorities
(2) Willing: importance of change
(3) Able: confidence to change
The ABCs of Motivation and Change
Accept: The individual must accept that the behavior is a problem
Believe: The individual must believe that they will be better off if they change
Confidence: The individual must have confidence in their ability to change
6 Stages of Change
Precontemplation: No way I can do this. Nope. Not happening! (Denial)
Contemplation: Okay, maybe I can do this. (Ambivalent)
Determination/Preparation: Let’s do this! (Motivated)
Action: I’m doing it!
Maintenance: I’m continuing it. I’m living it!
Relapse/Recycle: Ugh! Okay, I’m back to 1…
The OARS Tool
The OARS tools is a way to remember techniques and strategies for enhancing motivation in others (such as our clients or patients).
O: Open-Ended Questions
Open-ended questions encourage clients or patients to talk more and helps us learn about their concerns.
- What makes you feel it might be time for a change?
- Can you tell me more about that?
- What have you noticed about your ____?
- What concerns you most?
- How would you like things to be different?
- What will you lose if you give up drinking?
- What have you tried before?
- What do you want to do next?
Affirmations are statements that show recognition of a client’s or patient’s attempts at change. Examples include:
- “So you’ve started walking this past week!”
- “You didn’t want to come today, but you did!”
- “You are down to 5 cigarettes/day?! That’s great! You were smoking 8 cigarettes last week!”
R: Reflective Listening
Reflective listening means listening and trying to understand the patient’s point of view even if you disagree with it. It means communicating your understanding of the client’s or patient’s experience, behavior and/or feelings from their point of view. The following are not congruent with reflective listening:
- Ordering, directing or commanding
- Warning, cautioning or threatening
- Giving advice, making suggestions or providing solutions or providing solutions
- Persuading with logic, arguing, lecturing
- Telling people what they should do Telling
- Disagreeing, judging, criticizing or blaming
Summarizing is a special form of reflective listening that ensures clear communication and is used at transitions in conversation. Try to be concise and bring up the patient’s ambivalence/resistance to change.
- “Let me see if I understand thus far…”
The four (4) major tasks of the clinician
- Express Empathy
- Develop Discrepancy
- Roll with Resistance
- Support Self-efficacy
Examples of questions used in MI to motivate the patient, explore ambivalence, and minimize resistance
- What are some of the good things about X behavior?
- People usually do X because they feel it helps in some way. How has it helped you?
- What do you like about the effects of X?
- What would you miss if you weren’t doing X?
- Can you tell me about the down side?
- What are some aspects you are not so happy about?
- What are the things you wouldn’t miss?
- If you continued as before, how do you see yourself in a couple of years from now if you don’t change?
- On a scale of 1-10, how important is it to you to change X behavior?
- Why did you give it a higher # and not a (lower #) ?”
- What would have to happen to raise that score from # to #
- McCarron, Robert M., et al. Lippincotts Primary Care Psychiatry: for Primary Care Clinicians and Trainees, Medical Specialists, Neurologists, Emergency Medical Professionals, Mental Health Providers, and Trainees. Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.
- Focus Psychiatry Review, Dsm-5: Dsm-5 Revised Edition by Deborah J. Hales (Author, Editor), Mark Hyman Rapaport (Author, Editor)
- Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
- Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
- Hales et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 6th
- Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia :Lippincott Williams & Wilkins, 2000.
- Motivational Interviewing | Psychology Today
- Understanding Motivational Interviewing | Motivational Interviewing Network of Trainers (MINT)