Jassin M. Jouria, MD

Motivational Interviewing

Jassin M. Jouria, MD

INTRODUCTION

Motivational interviewing (MI) is a method that promotes behavior change, and can be used in a multitude of environments and situations to foster growth and to help people to take on challenging situations. Motivational interviewing is a collaborative process that edifies the client and makes him or her responsible for personal choices. It is not necessarily a stand-alone type of therapy, but instead can be incorporated into treatments and routine care for clients with various health issues, including those with physical health problems, mental health issues, or substance abuse and addiction. MI has also successfully been used along with other forms of therapy to improve connection between the client and the provider and to alter the process at which the client makes changes in his or her life.

Therapists can use motivational interviewing in a number of situations, yet it should always be recognized that no one could be forced to change. Although the goal of MI is not to directly change a person’s behavior, it does guide the client toward making different choices that can foster change in his or her life.

The concept of motivational interviewing began in the early 1980s with the publication of a book by William R. Miller, PhD, who focused his model of MI on working with people suffering from substance abuse and addiction. The book was titled Motivational Interviewing with Problem Drinkers and it was initially used among psychiatrists and other professionals who provided counseling services for people going through treatment for addiction[5].

Almost twenty years later, Miller and a colleague, Stephen Rollnick, published a second edition of the book. The second edition was geared, not only toward addiction professionals working in the field of psychotherapy, to any professional in the healthcare field who could utilize the principles and put the techniques of MI into practice with their clients[5].

Miller and Rollnick described motivational interviewing as a “directive, client-centered counseling style for eliciting behavior change by helping clients to restore and resolve ambivalence” [5]. Ambivalence is a state in which a person is uncertain about which direction to take, if any. A person who feels ambivalent about his or her need for change or required treatments may approach the situation with a lack of motivation. The person may have such mixed feelings about the situation that making a decision can be paralyzing. When a therapeutic relationship starts, the client may be in various stages of ambivalence depending on the current situation. If he or she was recently diagnosed with an illness or disease, ambivalence may be paired with frustration or anger over the situation. Alternatively, the client may have known for quite some time that change is necessary but has been unwilling or unable to take steps to move forward.

Motivational interviewing is more than just a set of techniques that can be implemented into conversations between healthcare providers and their clients. It recognizes several theories as a basis for its approach, including cognitive dissonance theory, which acknowledges that a person who acts against his or her beliefs will be motivated to either change behaviors or otherwise justify them; and self-perception theory, which is the idea that people conclude certain traits or ideas about themselves based on observing their own behaviors [33].

A basic premise exists in motivational interviewing that talk can be helpful for some situations, but without the motivation to change, talk, or simply telling a person to do something, will not get very far. The provider who is working with a client through motivational interviewing must recognize the level of motivation the client holds and must be willing to work through possible resistance to change in order to foster goal setting and to move forward [33].Motivational interviewing can be used in many different types of specialties for helping clients to change. Although it may be considered a therapeutic approach that would traditionally be used in counseling or in sessions with a psychologist, motivational interviewing can actually be a part of some routine meetings or examinations for brief sessions.

Motivational interviewing has been used successfully in implementing change in numerous situations, such as with drug or alcohol addiction, smoking cessation, vocational rehabilitation, criminal justice, pregnancy, and as a component of treatment for many different medical conditions [29]. Similarly, motivational interviewing is not simply designated for counselors or psychologists. It can be successfully implemented into appointments or interactions with various healthcare providers, including nursing staff, primary care physicians, nurse practitioners, or allied health professionals.

There is some formal training available in developing the techniques associated with motivational interviewing, although learning the techniques and the process of MI is typically either integrated into formal education programs, or through stand-alone training opportunities, such as through workshops, conferences, or online educational programs.

The Motivational Interviewing Network of Trainers (MINT) is a non-profit organization that was started by a group of MI practitioners who were originally trained by Miller and Rollnick in MI techniques. MINT promotes the use of motivational interviewing, as well as continuing research and appropriate training of practitioners. The organization is composed of independent trainers and practitioners and can give details about specific educational opportunities for those who want to learn more about motivational interviewing and to put its methods into practice[30].

STAGES OF READINESS FOR CHANGE

The ultimate goal of working through motivational interviewing is to move the client through the various stages of change, from being ambivalent or unmotivated to dealing with unhealthy behavior and making more positive choices [21]. The stages of readiness for change is actually a cycle of steps identified by James Prochaska, and each step requires various interventions to move the client on to the next step. The stages of change include: precontemplation, contemplation, preparation, action, maintenance, and termination [21, 22].

The precontemplation stage occurs before the client is even aware that a change needs to happen. Family members, friends, and significant others may easily recognize that the client has a problem or that change needs to happen but the client is often unaware. During this phase, the client is resistant to change because he or she does not understand its necessity. The client may even be aware that life is difficult or there are several aspects of life that demand attention that he or she cannot handle, but the concept of change is still foreign.

The contemplation stage is when the client recognizes that a change needs to happen. It is often at this stage where motivational interviewing begins. Although the client may recognize the need for change, he or she may be so ambivalent about making the change or what steps to take that no change occurs at all. Many people remain in the contemplation stage for years, always feeling that something needs to be done, but never taking steps to do anything.

The preparation stage involves planning to make a change soon. People in this stage may still be ambivalent about what to do, but they are planning to try for a change. They may be uncertain that their plans are the best for solving their situation and so may still be somewhat ambivalent about making choices toward change. They often need to convince themselves that change is necessary and that their plans are the best method of working through the problem.

The action stage involves taking the steps to overcome the problem. It is during this stage that the client does a lot of activity that demonstrates working toward the change, such as quitting smoking or exercising more. Others can see the client’s work toward the change as well, which can be encouraging. This stage also requires the most energy to continue with changes, even if they are uncomfortable.

The maintenance stage is the ongoing phase that may be lifelong for some people. This stage occurs after a person has done the work of making changes but then needs to continue to make efforts to maintain the results. For example, a person who has lost 50 pounds needs to maintain the weight loss by continuing with efforts that he or she implemented to lose the weight in the first place. If the person does not maintain the work, he/she may gain the weight back.

The termination phase is one in which the initial issue is no longer a problem. Some people never reach this phase while working for change, as the principles they developed and the work they completed must continue to be maintained and reinforced for the rest of their lives. For others, the termination phase results when the initial change or struggle is no longer a problem and they can move forward into other activities without continuously maintaining their previous efforts [22].

Key principles

Motivational interviewing can be broken down into key principles, followed by significant processes that are used. Each process or principle is then supported by various therapeutic techniques. Each technique may serve to uphold or meet the goals of one or more principle or process throughout the interview. To start, motivational interviewing consists of four key principles that guide practice, which are empathy, discrepancy, rolling with resistance, and supporting self-efficacy [5].

Empathy

Motivational interviewing is characterized by empathy on the part of the provider. Without empathy, no amount of discussion, sympathy, or understanding will stir the client toward change.The client needs empathy from the provider in order to feel as if he or she is not alone in the process and to feel that someone truly understands.Knowing that someone else has empathy can reduce feelings of isolation and can spur change.

The goal of being empathic is to help the patient to feel that he or she can open up. The caregiver provides an open and non-judgmental attitude that conveys warmth. The provider’s demeanor when engaging the client should express unconditional acceptance whereby the patient senses the provider’s response to them to be:

“I know what you are going through; I care about what happens to you”.

The provider during motivational interviewing does not try to change the client’s ambivalence or condemn the situation. Rather, ambivalence should be accepted as part of the process and the provider should expect that the client would have those feelings. If not, then the motivational interview would not otherwise be necessary. The provider should instead look at ambivalence on the part of the client as the reason for their time together and go forward from there.

Discrepancy

Discrepancy describes the state the client is currently in compared to the point at which he or she wants to be. The clinician works through the motivational interview to help the client see not only where he or she is currently, but to remind the client of their goals. The client must understand that these are two different states. The state where he or she currently is -one of ambivalence about a situation requiring change - is not the same as the state where he or she wants to be. If it were, the client would not be working through the motivational interview [6].

To best help the client develop discrepancy the clinician assists the client to see how far he or she has come in other areas of success. The clinician may point out other areas of change such as by saying to the client:

“remember when you used to struggle so much with this?

Look where you are now and how much you have achieved in that

area.”

It can be helpful for the client to know that he or she has overcome ambivalence or past challenges to reach goals in other areas and can know that it can be done in this area as well.

It is important for the clinician to remember that the practice of developing discrepancy requires a non-judgmental attitude. The clinician should also remember to ask before giving advice, and to speak clearly and in a supportive tone. Clarifying those items that do not make sense may also be necessary and is often an ongoing part of the process to avoid misunderstanding. By utilizing these techniques, the client will be better able to have a clear direction and understand where he or she is at in a process of changing behavior versus where the client wants to be at the conclusion of the motivational interviewing process [6].

The provider incorporates these key principles throughout the process of the motivational interview. Instead of being a straightforward path, MI is a somewhat fluid method that uses these principles as a general direction. The provider may also use other processes as part of motivational interviewing that support the initial principles discussed. These processes are: engaging the client, promoting change by supporting self-focus, determining the client’s motivation for change, and formulating a plan [6].

Roll with Resistance

While working with clients through the process of change, there are bound to be times of resistance. When the provider discovers that the client is resistant to ideas, suggestions, or change overall, it is important to take it in stride and not create further tension; in other words, to roll with it. The provider should avoid responding in a manner that is harsh or critical, even if the client presents this type of demeanor.

Often, the idea of change can be threatening and some people may respond negatively out of fear. Even if this is the response of the client, the provider should work to remain calm and to continue with the relationship, providing the most support and direction possible through conversation. When the client starts to become upset or resistant to the MI process, it is a signal for the provider to slow down, avoid being forceful in any way, take a deep breath, and consider how their demeanor and delivery of information is presented to the client.

The provider should consider his or her words, questions, and any types of non-verbal communication that could be threatening to the client and make adjustments as necessary. The provider should then determine how he or she can best present an empathic presence and show more understanding toward the client to prevent further resistance. It might be necessary for the provider to use some specific phrases during the interview that can clarify what the client is trying to say and to defuse the situation as necessary. For example, the provider could say:

• “I hear what you are saying and I just want to make sure that I am understanding you correctly.”
• “That must be very difficult for you; I can’t imagine how hard it is for you.”
• “It sounds as if you want to consider other options for dealing with what we are talking about.”

By responding differently, and not mirroring negative attitudes or behaviors, the provider prevents the conversation from unraveling and prevents the client from turning away from making changes because of feeling threatened or otherwise resisting the motivational interviewing process [6].

Support Self-Efficacy

Self-efficacy defines how a person feels about his or her abilities. It differs from self-esteem, which describes how a person feels about themself and their value as part of society. Instead, self-efficacy is the personal self-confidence to perform a task or to take on a situation. A person may have a strong sense of self-efficacy in one area of life but be weak in another. For example, a client may be strong and confident at his job and may be quite successful as a leader at work; however, the client may also lack self-efficacy when struggling with alcohol use and may be ambivalent about change if they feelunable to overcome the struggle [11].

Although high levels of self-efficacy feelings may help a person to feel more confident in his or her pursuit of a goal or involvement with a certain activity, having self-efficacy does not necessarily guarantee that the person will succeed [11]. A provider may work with a client to help them feel more positive about personal abilities, but unless realistic goals and techniques for achieving those goals are introduced into the equation, the client may still not succeed when trying to change. Self-efficacy requires motivation and effort to be successful.

A person’s belief that he or she can accomplish a goal works as a powerful motivation toward change. Ultimately, it is the work of the client that facilitates change, and not the provider. The client’s ability to make the change, rather than requiring assistance or having a provider do the work for them, further supports self-efficacy in the client because they know that the accomplishment wasachieved specifically by and for them. The provider’s role is to be confident in the client’s ability to change and to empower the client by asking questions and directing the discussion.

Engaging the client

The goal of expressing empathy is to build a relationship of trust between the provider and the client. Empathy involves accepting the client’s state of ambivalence, even if the provider disagrees with the viewpoint. When the providertakes on a non-judgmental stance toward the client, he or she avoids being perceived as critical or otherwise condemning of the situation. This stance engages the client and supports the development of a trusting relationship.