The following content is adapted from Clinical Interviewing (6th ed., 2017).
In their 2013 edition of Motivational Interviewing, Miller and Rollnick offer “Layperson’s,” Practitioner’s,” and “Technical” definitions of MI. For practitioners, Motivational interviewing is:
. . . a person-centered counseling style for addressing the common problem of ambivalence about change. (p. 29)
As a person-centered approach to therapy, MI relies substantially on four central listening skills, referred to as OARS (open questions, affirming, reflecting, and summarizing). MI is designed to help clients change from less healthy to more healthy behavior patterns. However, consistent with PCT, MI practitioners don’t interpret, confront, or pressure clients in any way. Instead, they use listening skills to encourage clients to talk about reasons for engaging in healthy or positive behaviors.
Moving Away From Confrontation and Education
In his research with problem drinkers, William R. Miller was studying the efficacy of behavioral self-control techniques. To his surprise, he found that structured behavioral treatments were no more effective than an encouragement-based control group. When he explored the data for an explanation, he found that regardless of treatment protocol, therapist empathy ratings were the strongest predictors of positive outcomes at 6 months (r = .82), 12 months (r = .71), and 2 years (r = .51; W. R. Miller, 1978; W. R. Miller & Taylor, 1980). Consequently, he concluded that positive treatment outcomes with problem drinkers were less related to behavioral treatment and more related to reflective listening and empathy. He also found that active confrontation and education generally triggered client resistance. These discoveries led him to develop motivational interviewing (MI).
Miller met Stephen Rollnick while on sabbatical in Australia in 1989. Rollnick was enthused about MI and its popularity in the UK. Miller and Rollnick began collaborating and subsequently published the first edition of Motivational Interviewing in 1991. Rollnick is credited with identifying client ambivalence as a central focus for change (Jones-Smith, 2016, p. 320).
Client ambivalence is a primary target of MI. Miller and Rollnick (2013) have consistently noted that ambivalence is a natural part of individual decision-making. They wrote: “Ambivalence is simultaneously wanting and not wanting something, or wanting both of two incompatible things. It has been human nature since the dawn of time” (2013, p. 6).
Although MI has been used as an intervention for a variety of problems and integrated into many different treatment protocols, it was originally a treatment approach for addictions and later became popular for influencing other health-related behaviors. This focus is important because ambivalence is especially prevalent among individuals who are contemplating their personal health. Smokers, problem drinkers, and sedentary individuals often recognize they could choose more healthy behaviors, but they also want to keep smoking, drinking, or being sedentary. This is the essence of ambivalence as it relates to health behaviors. When faced with clients who are ambivalent about whether to make changes, it’s not unusual for professional helpers to be tempted to push those clients toward health. Miller and Rollnick (2013) call this the “righting reflex” (p. 10). They described what happens when well-meaning helping professionals try to nudge clients toward healthy behaviors (note that this description is an apt rationale for a person-centered approach, but that it’s also consistent with the Gestalt therapy ideas of polarizing forces within individuals):
[The therapist] then proceeds to advise, teach, persuade, counsel or argue for this particular resolution to [the client’s] ambivalence. One does not need a doctorate in psychology to anticipate [how clients are likely to respond] in this situation. By virtue of ambivalence, [clients are] apt to argue the opposite, or at least point out problems and shortcomings of the proposed solution. It is natural for [clients] to do so, because [they] feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence. (2002, pp. 20–21)
The ubiquity of ambivalence leads to Miller and Rollnick’s (2013) foundational person-centered principle of treatment:
Ideally, the client should be voicing the reasons for change (p. 9).
MI is both a set of techniques and a person-centered philosophy. The philosophical MI perspective emphasizes that motivation for change is not something therapists should impose on clients. Change must be drawn out from clients, gently, and with careful timing. Motivational interviewers do not use direct persuasion.
The Spirit of MI
The “underlying spirit” of MI “lies squarely within the long-standing tradition of person-centered care” (Miller & Rollnick, 2013, p. 22). They identified four overlapping components that the spirit of MI “emerges” from. These include:
MI involves partnership or collaboration. It’s described as dancing, not wrestling. Your goal is not to “pin” the client; in fact, you should even avoid stepping on their toes. This is consistent with the first principle of person-centered therapy. The counselor and client make contact, and in that contact there’s an inherent or implied partnership to work together on behalf of the client.
Person centered (and MI) counselors de-emphasize their expertness. Miller and Rollnick refer to this as avoiding the expert trap. Expert traps occur when you communicate “that, based on your professional expertise, you have the answer to the person’s dilemma” (p. 16). In writing about collaboration, Miller and Rollnick (2013) sound very much like Carl Rogers, “Your purpose is to understand the life before you, to see the world through this person’s eyes rather than superimposing your own vision” (p.16).
Consistent with Rogerian philosophy, MI counselors hold an “attitude of profound acceptance of what the client brings” (p. 16). This profound acceptance includes four parts:
- Absolute Worth: This is Rogerian unconditional positive regard
- Accurate Empathy: This is pure Rogerian.
- Autonomy Support: This part of acceptance involves honoring each person’s “irrevocable right and capacity of self-direction” (p. 17)
- Affirmation: This involves an active search or focus on what’s right with people instead of what’s wrong or pathological about people.
In the third edition of Motivational Interviewing, Miller and Rollnick added compassion to their previous list of the three elements of MI spirit. Why? Their reasoning was that it was possible for practitioners to adopt the other three elements, but still be operating from a place of self-interest. In other words, practitioners could use collaboration, acceptance, and evocation to further their self-interest to get clients to change. By adding compassion and defining it as “a deliberate commitment to pursue the welfare and best interests of the other” Miller and Rollnick are protecting against practitioners confusing self-interest with the client’s best interests.
Evocation is somewhat unique, but also consistent with person-centered theory. Miller and Rollnick contend that clients have already explored both sides of their natural ambivalence. As a consequence, they know the arguments in both directions and know their own positive motivations for change. Additionally, they note, “From an MI perspective, the assumption is that there is a deep well of wisdom and experience within the person from which the counselor can draw” (p. 21). It’s the counselor’s job to use evocation to draw out (or evoke) client strengths so these strengths can be used to initiate and maintain change.
A Sampling of MI Techniques
One distinction between MI and classical PCT is that Miller and Rollnick (2013) identify techniques that practitioners can and should use. These techniques are generally designed to operate within the spirit of MI and to help clients engage in change talk instead of sustain talk. Change talk is defined as client talk that focuses on their desire, ability, reason, and need to change their behavior, as well as their commitment to change. Sustain talk is the opposite; clients may be talking about lack of desire, ability, reason, and need to change. Overall, researchers have shown that clients who engage in more MI change talk are more likely to make efforts to enact positive change.
MI appears simple, but it’s a complicated approach and challenging to learn (Atkinson & Woods, 2017). Miller and Rollnick (2013) have noted that having a solid foundation of person-centered listening skills makes learning MI much easier. The following content is only a sampling of MI techniques.
MI practitioners use techniques from the OARS listening skills. In particular, there’s a strong emphasis on skillful and intentional use of reflections, instead of questions or directives. Here are examples.
Simple reflections stick very closely to what the client said.
Client: I’ve just been pretty anxious lately.
Simple Reflection: Seems like you’ve been feeling anxious.
Client: Being sober sucks.
Simple Reflection: You don’t like being sober.
Simple reflections have two primary functions. First, they convey to clients that you’ve heard what they said. This usually enhances rapport and interpersonal connection. Second, as you provide a simple reflection, it lets clients hear what they’ve said. Hearing their words back—from the outside in—can be illuminating for clients.
Complex reflections add meaning, focus, or a particular emphasis to what the client said.
Client: I haven’t had an HIV test for quite a while.
Complex reflection: Getting an HIV test has been on your mind.
Client: I only had a couple drinks. Even when I got pulled over, I didn’t think I was over the limit.
Complex reflection: That was a surprise to you. You might have assumed “I can tell when I’m over the limit” but in this case you couldn’t really tell.
Complex reflections go beyond the surface and make educated guesses about what clients are thinking, feeling, or doing. Clients tend to talk more and get deeper into their issues when MI therapists use complex reflections effectively. Also, if your complex reflection is correct, it’s likely to deepen rapport and might evoke change talk.
An amplified reflection involves an intentional overstatement of the client’s main message. Generally, when therapists overstate, clients make an effort to correct the reflection.
Client: I’m pissed at my roommate. She won’t pick up her clothes or do the dishes or anything.
Interviewer: You’d like to fire her as a roommate.
Client: No. Not that. There are lots of things I like about her, but her messiness really annoys me. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 440)
Client: My child has a serious disability and so I have to be home for him.
Interviewer: You really need to be home 24/7 and have to turn off any needs you have to get out and take a break.
Client: Actually, that’s not totally true. Sometimes, I think I need to take some breaks so I can do a better job when I am home. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 441)
Sometimes MI practitioners accidentally amplify a reflection. Other times amplification is intentional. When intentionally amplifying reflections, it’s important to be careful because it can feel manipulative.
The opposite of amplified reflection is undershooting. Undershooting involves intentionally understating what your client is saying.
Client: I can’t stand it when my mom criticizes my friends right in front of me.
Therapist: You find that a little annoying.
Client: It’s way more than annoying. It pisses me off.
Therapist: What is it that pisses you off when your mom criticizes your friends?
Client: It’s because she doesn’t trust me and my judgment. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 441)
In this example, the therapist undershoots the client’s emotion and then follows with an open question. Clients often elaborate when therapists undershoot.
As noted, the preceding content is a small taste of MI technical strategies; if you want to become a competent MI practitioner, advanced training is needed (see Atkinson & Woods, 2017; Miller & Rollnick, 2013).
Now that you’ve read a brief summary of MI, check out the following video link. In this link, John S-F is using a few MI techniques/strategies with a client who has a history of excessive alcohol use. The video is part of our published video package accompanying our Clinical Interviewing textbook, and includes me weaving in a few more traditional clinical interviewing questions (e.g., the CAGE) along with the MI content. There’s also light commentary by Rita and me, as well as a short clip in the middle of me interviewing a Licensed Addictions Counselor on the topic of how to handle clients who are probably lying. Here’s the link to the approximately 22 minute video: https://youtu.be/rtN7kEk0Sv4
If you have questions, comments, praise, or constructive feedback on this blog or the video, I’d love to hear from you. You can post here, on Youtube, or email me directly at email@example.com.