Using Motivational Interviewing
Michelle Blose, M.S.
The following information has been provided by Drs. Linda and Mark Sobell.
What is motivational interviewing (MI)? It is a directive, patient-centered counseling style that elicits behavior change by helping patients explore and resolve ambivalence. It helps resolve ambivalence by increasing discrepancy between patient’s current behaviors and desired goals while minimizing resistance. In addition, it is a communication style that is motivational rather than judgmental in nature. The goal of MI is to get people to resolve their ambivalence (i.e., conflict) about changing their behavior, while not evoking resistance. Thus, who is for? It is for patients who are ambivalent about changing. Why use MI? To help build rapport. How does one use MI? In an empathetic manner to increase patients’ motivation to change. What is the aim of MI? To elicit reasons for changing from patients versus confronting or telling them to change. Furthermore, instead of the therapist telling the patient what to do, MI has a collaborative approach that recognizes that patients are ambivalent, patients have responsibility for changing, patients play an active role in change process, and patients give voice to the need to change.
MI was developed in the early 1980s by Bill Miller and Steve Rollnick. It was developed initially for substance abusers who had high dropout rates, high relapse rates, and poor outcomes and who were viewed as resistant and unmotivated. Today, motivational interviewing has been extended to many types of people and behaviors. For example, in terms of problems/behaviors, it has been extended to individuals struggling with medication compliance, hypertension, asthma, insulin dependent diabetes, risky sexual behaviors, alcohol use, and/or smoking. In regards to populations, it has been extended to both mental health and health care, including primary care, as well as college students. One can use MI in individual therapy, group therapy, telephone counseling, or over the internet.
What are the benefits of using MI? Research studies show that using MI skills and techniques results in: significantly reduced health care costs, increased compliance with medication and treatment recommendations, decreased malpractice litigation, greater patient satisfaction, and improved outcomes.
The two key components of the motivational approach are as follows: style- how you say it and content- what you say. Therefore, use an empathic, non-judgmental, non-confrontational, supportive manner. Some of the MI techniques include: asking permission, decisional balancing, assessing readiness to change, normalizing, asking open-ended questions, reflective listening, and rolling with resistance.
Asking permission. The rational for asking permission is that it communicates respect for patients. Also, patients are more likely to discuss changing when asked, than when being lectured or being told to change. The value of asking permission provides opportunity to discuss behaviors, particularly when they are not the primary presenting problem, allows conversation to continue even if patient not thinking of changing, and it is respectful and reduces resistance.
Decisional balancing. The goal of decisional balancing is a two-fold: to realize that (a) the patients get some benefits from their risky/problem behavior, and (b) there will be some costs if the patients decide to change their behavior.
Assessing readiness to change. The readiness ruler is typically used at assessment or early in treatment. It tells therapists where their patients are in terms of readiness to change and it helps therapists recognize and deal with a patient’s ambivalence about changing. Additionally, it allows patients to give voice:
- Where are you now?
- Where were you 6 months ago?
- How did you get from a 3 6 months ago to a 6 now?
Normalizing. Normalizing communicates to patients that difficulty in changing, quitting, or participating is not uncommon — others have had similar experiences. Two examples include:
- “A lot of people are concerned about gaining weight when quitting.”
- “That is not unusual, many people have made several quit attempts.”
Asking open-ended questions. Why use open-ended questions? It gives the therapist more information, it allows the interview to move in a smoother manner, and rapport is established as it is a dialogue not an interrogation. Thus, the goal of asking open-ended questions is to ask questions with widest possible scope of response.
Reflective listening. Reflective listening is the primary way of responding to patients. After a patient speaks, therapist reflects back what the patient said. Some examples include:
- “It sounds like…”
- “It seems as if…”
- “What I hear you saying…”
- “I get a sense that…”
- “What I seem to be hearing…”
- “It feels as though…”
- “It sounds like this is difficult for you to talk about.”
It is helpful to reflect what people are feeling when they speak. The goal is to engage patients in continued personal exploration about problems/concerns.
Eliciting change talk. The aim is to help people express reasons for change. It is beneficial to use it with patients who are ambivalent or who are not changing. The key is that the elicit reasons for change comes from the patient not the therapist. Ways to evoke change talk:
- “What would you like to see different about your current situation?”
- “What makes you think you need to change?”
- “Why are others concerned about your (insert behavior)?”
- “What will things be like if you don’t change?”
- “Tell me about a change you have been able to make in the past.”
- “What will be different if you make changes?”
Rolling with resistance. MI approaches resistance, or heightened ambivalence, as a natural part of therapeutic process. Rolling with resistance rather than attacking it creates opportunity for further discussions between patients and practitioners. MI suggests practitioner’s response to a patient’s resistance can largely determine the patient’s subsequent response.
How we understand a problem dictates how we respond to it. Motivational interviewing creates a different understanding of why people do what they do.