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Motivational Interviewing Back to Course Index

MOTIVATIONAL INTERVIEWING

 

Change happens easily when there are clear punishments for continued same behavior and clear rewards for changed behavior.  We stop touching hot stoves early on because we get hurt. If we find out that something makes us feel happy and there are no costs, we’re going to do it more often. But sometimes, change can be more complex. Making the decision to leave a romantic partner, or to switch careers, might take years of thought and heartache. There are countless pros and cons that cannot easily be boiled down to “better” or “worse”.

Psychotherapy is the art and science of helping others create change through psychological means, and the countless approaches give us several ways to achieve these goals. Some theories view change as a purely behavioral process. Others focus on genetics as the influence on behavior.  Still others suggest that the answer is education. If a person learns about the possible consequences of a behavior, they will change.

Motivational interviewing, sometime referred to as MI, is a client-centered, directive counseling method aimed at enhancing intrinsic motivation that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behavior. It is a practical, empathetic, and short-term process that takes into consideration how difficult it is to make life changes.

Motivational interviewing is often used to address addiction and the management of physical conditions such as diabetes, heart disease, and asthma. This intervention helps people become motivated to change the behaviors that are preventing them from making healthier choices. It can also serve as a pre-curser to other types of therapies that can address other issues. Research has shown that this intervention works well with individuals who start off unmotivated or unprepared for change. Motivational interviewing is also appropriate for people who are angry or hostile regarding the changes that are necessary. They may not be ready to commit to change, but motivational interviewing can help them move through the emotional stages of change necessary to find their drive and make peace with change.

Motivational interviewing evolved from Carl Roger’s person-centered, or client-centered, approach to counseling and therapy. It shares Carl Rogers’ optimistic and humanistic theory about people’s capabilities for exercising free choice and changing through a process of self-actualization. The therapeutic relationship for both Rogerian and motivational interviewers is a democratic partnership.  Jumping off from this foundation, clinical psychologists William R. Miller and Stephen Rollnick elaborated on these fundamental concepts and approaches in 1991 in a more detailed description of clinical procedures. Core concepts evolved from experience in the treatment of problem drinkers, and Motivational Interviewing was first described by) in an article published in Behavioural Psychotherapy.   Compared with non-directive counseling, it is more focused and goal-directed, and departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. 

Client-Centered therapy uses an empathetic style of interaction.  The therapist expresses acceptance toward the client, even if they feel their behaviors are harming them or their loved ones.  The therapist does not need to condone the behavior, but acceptance is key.  Acceptance is the willingness to listen, understand, and to respect the client as a human being. 

The Motivational Interviewing process is aimed increasing an individual’s reason for change and then for the individual to fully commit to the change that is necessary. As opposed to simply stating a need or desire to change, hearing themselves express a commitment out loud has been shown to help improve a client’s ability to make those changes. The role of the therapist is more about listening than intervening. Motivational interviewing is often combined or followed up with other interventions, such as cognitive therapy, support groups such as Alcoholics Anonymous and stress management and coping strategy training.

There are four overlapping processes that comprise Motivational Interviewing: engaging, focusing, evoking and planning. They are both sequential and recursive, and often depicted in diagrams as stair steps, with engaging at the bottom as the first step.

  1. Engaging: the process of establishing a working relationship based on trust and respect. The client should be doing most of the talking, as the counselor utilizes the skill of reflective listening throughout the process. Both the client and counselor make an agreement on treatment goals and collaborate on the tasks that will help the client reach those goals.
  2. Focusing: the ongoing process of seeking and maintaining direction.
  3. Evoking: eliciting the client’s own motivations for change, while evoking hope and confidence.
  4. Planning: involves the client making a commitment to change, and together with the counselor, developing a specific plan of action.

 

Motivational interviewing is a counseling style based on the following assumptions:

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

 

This course will discuss ambivalence and its role in client motivation, overall and specific to substance abuse issues. We will explore the five basic principles of Motivational Interviewing that can be used to address ambivalence and to facilitate the change process. We will also look at approaches to use with clients in the early stages of treatment.

 

Ambivalence

Ambivalence is defined as the state of having mixed feelings or contradictory ideas about something whereas denial is defined as the action of declaring something untrue.  It is important to see the difference in these two.  They both might be part of an issue, but they are different.  An individual who is obese, addicted to substances or gambling or perhaps has anger issues is usually aware of the dangers of their behavior but continue anyway. They are somewhat unsure of their ability to control these behaviors.  There is certainly an element of denial in the seriousness of the issue, but everyone knows that smoking is bad for your lungs.  Everyone is aware that donuts are not a healthy snack.  An individual may want to stop smoking, but at the same time they don’t want to quit either.  There is a positive intention and most of the time a reward for their behavior despite the knowledge they have regarding the drawbacks of continuing the behavior.  They enter treatment programs because a family member or court system makes them while they express the problem isn’t that big.  These disparate feelings can be characterized as ambivalence, and they are natural, regardless of the client’s state of readiness. It is important to understand and accept the client’s ambivalence because ambivalence is often the central problem.  If a counselor interprets ambivalence as only denial or resistance, friction between the counselor and the client tends to occur.  Ambivalence is, “I want to quit drinking because I’m an angry drunk and always fight with my wife when I drink but I enjoy the social aspects and its so hard.”  Denial is, “the only issue with my drinking is my wife is no fun and gets on my case”. 

The motivational interviewing style facilitates exploration of stage-specific motivational conflicts that can potentially hinder further progress. However, each dilemma also offers an opportunity to use the motivational style to help your client explore and resolve opposing attitudes.

To effectively implement Motivational Interviewing Dr. Miller and Dr. Rollnick developed three mnemonics to assist: RULEPACE, and OARS.

RULE can be used to remember the core principles of MI.  First, Resist the righting reflex, which means the counselor should resist giving suggestions to the client for his or her problem. While the counselor may mean well, offering suggestions might make the patient less likely to make a positive change. A counselor can attempt to Understand the client’s motivation by being a careful listener and attempting to elicit the client’s own underlying motivation for change. Listen with a patient-centered, empathic approach. Lastly, Empower the client. He must understand that he is in control of his actions, and any change he desires will require him to take steps toward that change.

 

PACE

PACE is the “spirit” or mindset that clinicians should have when conducting MI.  Always work in Partnership with the patient; this allows the patient and clinician to collaborate on the same level. While the counselor is a clinical expert, the client is an expert in prior efforts at trying to change his or her circumstances for the better. The therapeutic environment should be as positive as possible so that the client will find it comfortable to discuss change. The client should see the clinician as a guide who offers information about paths the patient may choose, not someone who decides the destination.  While the counselor continues to educate the client about the harms of behaviors such as excessive drinking or substance use, they recognize that ultimately the decision is the clients. Every effort should be made to draw from the clients’ goals and values, so that the client, and not the clinician, can argue for why change is needed. This Acceptance helps foster an attitude that the counselor is on the client’s side and that his past choices in life do not negatively affect the counselor’s perception of him. The client should be accepted for who he is, and not met with disapproval over any personal decisions that he made. Exercise Compassion towards the client’s struggles and experiences, and never be punitive. Every attempt to have discussions that can be Evocative for the client should be made. Strong feelings and memories can be particularly salient to discuss, especially if they could help change the patient’s attitude towards maladaptive behaviors.

 

OARS

OARS is an acronym to represent core interviewing skills.  OARS stands for Open-ended questions, Affirmations, Reflection, and Summaries

Open-ended questions get the client to think before responding, providing frequent affirmations of the client’s positive traits, using reflective listening techniques while the client talks about his disorder, and providing succinct summaries of the experiences expressed by the client throughout the encounter to invite continued exploration of his behaviors are all skills for the counselor to develop.

Examples of open-ended questions include:

“What brought you here today?”
“Help me…” or “Tell me more about…”
“What will happen if you don’t….”
“Suppose you don’t make a change, what is the worst that might happen?”
“What would you like to see different about your current situation?”

 

Affirmations are used to recognize a client’s strengths, successes and efforts to change.  Examples of affirmations include:

“Your commitment really shows by….”
“You showed a lot of strength by…..”
“It is clear this is important to you because you….”

 

Reflections keep the counselor connected to the client’s thoughts, suspending judgement, acknowledging what the client said and helps them to feel validated.  Examples of reflections include:

“What I hear you saying is….”
“It seems as if….”
“I get the sense that your want to change, and you have concerns about…”
“It sounds like…”

 

Summaries can be used throughout an interaction.  They are a form of reflective listening.  Examples of summarizing include:

“So what I understand you have said is….”
“If I hear you….”

 

Five Principals in Motivational Interviewing

Motivational interviewing has been practical in focus. The strategies of motivational interviewing are more persuasive than coercive, more supportive than argumentative. The motivational interviewer must proceed with a strong sense of purpose, clear strategies and skills for pursuing that purpose, and a sense of timing to intervene in particular ways at incisive moments (Miller and Rollnick, 1991, pp. 51-51).

The clinician practices motivational interviewing with five general principles in mind:

  1. Express empathy through reflective listening.
  2. Develop discrepancy between clients’ goals or values and their current behavior.
  3. Avoid argument and direct confrontation.
  4. Adjust to client resistance rather than opposing it directly.
  5. Support self-efficacy and optimism.

 

Empathy

Empathy is the ability to understand and share the feelings of another.  It is the experience of understanding another person’s thoughts, feelings, and condition from his or her point of view, rather than from one’s own. Empathy facilitates pro-social or helping behaviors that come from within, rather than being forced, so that people behave in a more compassionate manner.  Reflective listening is sometime used to build and show empathy through understanding.  It is a communication strategy involving seeking to understand a speaker’s idea, then offering the idea back to the speaker, to confirm the idea has been understood correctly. It attempts to reconstruct what the client is thinking and feeling and to relay this understanding back to the client.

Empathy should not be confused with identification with the client or the sharing of common past experiences. The key component to expressing empathy is reflective listening.

An empathetic style:

  • Communicates respect for and acceptance of clients and their feelings
  • Encourages a nonjudgmental, collaborative relationship
  • Allows you to be a supportive and knowledgeable consultant
  • Sincerely compliments rather than denigrates
  • Listens rather than tells
  • Gently persuades, with the understanding that the decision to change is the client’s
  • Provides support throughout the recovery process

Empathic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change. A fundamental component of motivational interviewing is understanding each client’s unique perspective, feelings, and values. The attitude of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected is again a very important piece of this approach. Motivational interviewing is most successful when a trusting relationship is established between you and your client.

Understanding and empathy can be conveyed through skillful reflective listening with the knowledge that acceptance facilitates change and ambivalence is a normal feeling. 

 

Discrepancy Between Client’s Goals or Values and Current Behavior

Although MI is client-centered, unlike classic Rogerian therapy, it is more goal-driven and directional. That is, there is a clear positive behavioral outcome, e.g., quitting smoking, losing weight, adhering to medication. As clients experience discrepancy between their current behavior and their personal core values or life goals through their own words a clarification of values occurs that often leads to an affliction of the comfortable.  When clients perceive discrepancies between their current situation and their hopes for the future change is likely to occur.

The counselor’s task is to help focus the client’s attention on how current behavior differs from ideal or desired behavior. Discrepancy is initially highlighted by raising your clients’ awareness of the negative personal, familial, or community consequences of a problem behavior and helping them confront the behavior, i.e. substance use, that contributed to the consequences. Although helping a client perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.

A successful strategy is to separate the behavior from the person and help the client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current behavior. This requires the counselor to listen carefully to the client’s statements about values and connections to community, family, and church. If the client shows concern about the effects of personal behavior, highlighting this concern to heighten the client’s perception and acknowledgment of discrepancy can help produce the client’s own cognitive shift.

Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, the counselor can amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.

One useful tactic for helping a client perceive discrepancy is sometimes called the “Columbo approach” (Kanfer and Schefft, 1988). This approach is particularly useful with a client who prefers to be in control. Essentially, the clinician expresses understanding and continuously seeks clarification of the client’s problems but appears unable to perceive any solution. A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician (Van Bilsen, 1991).

Motivational Interviewing information is frequently presented using an ELICIT-PROVIDE-ELICIT framework. The counselor first elicits the person’s understanding and need for information, then provides new information in a neutral manner, followed by eliciting what this information might mean for client, using a question such as, “What does this mean to you” or “How do you make sense of all this?” MI practitioners avoid trying to persuade clients with “pre-digested” health messages and instead allow clients to process information and find what is personally relevant for them. Autonomy is supported by also asking how much information the client might desire.

Developing discrepancies includes:

  • Developing awareness of consequences helps clients to examine their behavior
  • A discrepancy between present behavior and important goals motivates change.
  • The client presents the arguments for change.

 

Avoid Argument

A counselor may occasionally be tempted to argue with a client who is unsure about changing or unwilling to change, especially if the client is hostile, defiant, or provocative. However, trying to convince a client that a problem exists or that change is needed could precipitate even more resistance. If the counselor tries to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for beneficial change. When it is the client, not the counselor, who voices arguments for change, progress can be made. The goal is to “walk” with clients (i.e., accompany clients through treatment), not “drag” them along (i.e., direct clients’ treatment).

Resistance can be seen as a signal to change strategies or listen more carefully to the client’s reasons for a particular behavior.  Resistance offers the counselor an opportunity to respond in a new, perhaps surprising way to gain an alliance toward overcoming a legitimate obstacle to a new behavior.

 

Roll With Resistance

Confronting clients can evoke reactance and shut them down. Therefore, Motivational Interviewing counselors “roll with resistance” rather than attempt to argue with the client. Such reflections can be thought of as “comforting the afflicted.” The counselor can “pull up alongside clients,” essentially agreeing with the client, even if the statement is factually incorrect or unfairly places blame on others. Examples include: “You really enjoy smoking weed. You look forward to lighting up at night and giving it up seems very difficult” or “eating at McDonalds has filled a need for you. It’s cheap, convenient, and really works given your busy schedule”. Such reflections help capture the client’s reasons for not changing and allow them to express their resistance without feeling pressured to change or worrying about being judged.

Resistance is a legitimate concern for the clinician because it is predictive of poor treatment outcomes and lack of involvement in the therapeutic process. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, viewpoint is that resistance is a signal that the client views the situation differently. This requires the counselor to understand the client’s perspective and proceed from there.

Adjusting to resistance is similar to avoiding argument in that it offers another chance to express empathy by remaining nonjudgmental and respectful, encouraging the client to talk and stay involved. Try to avoid evoking resistance whenever possible and divert or deflect the energy the client is investing in resistance toward positive change.

 

Simple Reflection:

The simplest approach to responding to resistance is with nonresistance, by repeating the client’s statement in a neutral way. This acknowledges and validates what the client has said and can elicit an opposite response.

Client: I don’t plan to quit drinking anytime soon.

Clinician: You don’t think that abstinence would work for you right now.

 

Amplified Reflection:

Another strategy is to reflect the client’s statement in an exaggerated form–to state it in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.

Client: I don’t know why my wife is worried about this. I don’t drink any more than any of my friends.

Clinician: So, your wife is worrying needlessly.

Amplified negative reflections are a way of arguing against change by exaggerating the benefits of or minimizing the harm associated with a risky behavior.  It may take the form of “, so you see no benefit in changing XX”.  The counselor, by arguing against change can exhaust the client’s negativity. In response, clients will often then reverse their course, and start to argue for change. This type of reflection poses some potential risks and can occasionally backfire. Important here, is for the counselor to avoid any tone of sarcasm. This type of reflection is particularly useful when clients appear stuck in a “yes, but” mindset.

 

Double-Sided Reflection:

A third strategy entails acknowledging what the client has said but then also stating contrary things they have said in the past. This requires the use of information that the client has offered previously, although perhaps not in the same session.

Client: I know you want me to give up drinking completely, but I’m not going to do that!

Clinician: You can see that there are some real problems here, but you’re not willing to think about quitting altogether.

Double-sided reflections capture client ambivalence and communicate to the client that the counselor heard their reasons both for and against change; that the counselor understands the decision is complex, and they are not going to prematurely push them to change. Double-sided reflections typically take the form of “on the one hand, you would like to change XX, but on the other hand changing XX would mean giving up XX” or “you are torn about changing XX….”

 

Shifting Focus

A counselor can defuse resistance by helping the client shift focus away from obstacles and barriers. This method offers an opportunity to affirm the client’s personal choice regarding the conduct of his own life.

Client: I can’t stop smoking pot when all my friends are doing it.

Clinician: You’re way ahead of me. We’re still exploring your concerns about whether you can get into college. We’re not ready yet to decide how marijuana fits into your goals.

 

Reframing a client’s reflections can help them feel understood so the need for resistance is lower. 

Client:  I don’t understand why my wife attacks me about my drinking.  I drink a lot less than most people.  Everyone I know drinks after work.

Clinician:  It sounds like your wife really cares about you, but you feel judged by how she brings it to your attention.

Rolling with resistance can shift perceptions and create new ways of thinking without imposing on them on a client.  The client is a valuable resource for finding solutions to his or her problem.

 

Reflection On Omission:

Sometimes a counselor can reflect to clients what they have not said. This can include reflecting on the client’s silence or reluctance to talk about a particular issue; “you don’t seem like talking today or you didn’t have much of a reaction to what I just said. ” In such cases, an omission reflection is an extension of rolling with resistance. However, an additional permutation includes reflecting to the client beliefs, solutions to problems, sources of help, etc. that have not been raised. For example, if an otherwise happily married woman states that she has no one to exercise with, the counselor could reflect “so it sounds like your husband is not the answer.” Another variation might include, “so I assume you probably have thought about trying XX solution/option but that doesn’t seem to work for you.”

 

Support Self-Efficacy

The client’s feeling of selfefficacy through his or her having an active role in the decision-making process ultimately has a very positive effect on the outcome of therapy.  Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. This requires the counselor to recognize the client’s strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is crucial the clinician also believes in the clients’ capacity to reach their goals.

A strong sense of efficacy can be developed through mastery experiences, vicarious learning experiences, and physical and emotional states.

Mastery experiences are personal experiences that give people a sense of accomplishment and a feeling of mastery. By managing challenges through successive achievable steps, people develop a sense of mastery. Mastery experiences are the most effective way to develop a strong sense of efficacy because they offer the most authentic evidence that one can do what it takes to succeed. Success experiences help build self-efficacy, while failures undermine it. For example, using the weight loss example, a person who has lost weight in the past is more likely to have higher self-efficacy in this area than someone who has not been able to lose weight previously. 

Vicarious experiences through social modeling are another way to develop self-efficacy. If people see others similar to themselves succeed through persistent effort, they may come to believe they, too, can succeed in similar activities. The impact vicarious experiences have on self-efficacy depends on how similar to the model people perceive themselves to be. The greater the perceived similarity, the more impact the model’s successes and failures will have on a person’s self-efficacy beliefs.

Clients frequently use their physical and emotional states to judge their capabilities. An elevated mood can enhance self-efficacy, while a negative mood may diminish it. Clients tend to associate stress, tension, and other unpleasant physiological signs with poor performance and perceived incompetence. In activities requiring strength and stamina, feelings of fatigue and pain cause self-efficacy beliefs to decrease. Clients with a strong sense of efficacy are more likely to view their state of emotional arousal as energizing, while people with a weak sense of efficacy will view their state of emotional arousal as debilitating.

Discussing treatment or change options that might still be attractive to clients is helpful when helping to develop self-efficacy, even though they may have had limited success in the past. It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward. The AA motto, “one day at a time,” may help clients focus and embark on the immediate and small changes that they believe are feasible.

Education can increase clients’ sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how to make changes. A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.

A belief in the possibility of change is an important motivator.  The client is responsible for choosing and carrying out personal change. 

 

Overview Of Motivational Interviewing As A Therapy

(Parts of this section are from Stephen Rollnick, Ph.D., & William R. Miller, Ph.D. What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.  Dr. Rollnick and Dr. Miller are credited in part with the developed Motivational Interviewing.)

When implementing motivational interviewing it is important to distinguish between the spirit of motivational interviewing and the specific techniques of the therapy. Clinicians who become too focused on techniques can lose sight of the concepts that are central to the approach. A counselor should focus on the idea that motivation to change is elicited from the client, and not be imposed. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilizing the client’s intrinsic values and goals to stimulate behavior change. 

It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict. For example, “If I stop smoking, I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive.” The counselor’s task is to facilitate expression of both sides of the ambivalence impasse and guide the client toward an acceptable resolution that triggers change.  

Direct persuasion is not an effective method for resolving ambivalence.  These tactics generally increase client resistance and diminish the probability of change.  

The counseling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of motivational interviewing and are explicitly proscribed in this approach. To a counselor accustomed to confronting and giving advice, motivational interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to “confront client denial,” easily slip into pushing clients to make changes for which they are not ready.  

The counselor is directive in helping the client to examine and resolve ambivalence. Motivational interviewing involves no training of clients in behavioral coping skills, although the two approaches are not incompatible. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere.

Resistance and “denial” are seen not as client traits, but as feedback regarding therapist behavior. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client’s autonomy and freedom of choice (and consequences) regarding his or her own behavior. Viewed in this way, it is inappropriate to think of motivational interviewing as a technique or set of techniques that are applied to or (worse) “used on” people. Rather, it is an interpersonal style, not at all restricted to formal counseling settings. It is a subtle balance of directive and client-centered components shaped by a guiding philosophy and understanding of what triggers change.

Motivational interviewing style includes:

  • Seeking to understand the person’s frame of reference, particularly via reflective listening
    Expressing acceptance and affirmation
  • Eliciting and selectively reinforcing the client’s own self motivational statements and expressions of problem recognition, concern, desire and intention to change, and ability to change
  • Monitoring the client’s degree of readiness to change and ensuring that resistance is not generated by jumping ahead of the client.
  • Affirming the client’s freedom of choice and self-direction. The point is that it is the spirit of motivational interviewing that gives rise to these and other specific strategies and informs their use.

 

In early treatment sessions, a counselor should determine the client’s readiness to change through asking open-ended questions.  Open-ended questions help a counselor understand the clients’ point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response. They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, they help the counselor to avoid making premature judgments, and they keep communication moving forward.

Reflective listening, summarizing, affirming, eliciting self-motivational statements can all help the client move to new behaviors that better serve their values and goals.

Components of successful Motivational Interviewing:

  • Empathy– the ability to understand and identify another person’s experience and communicate that perception back to the person is one of the main components of establishing rapport. Empathy and Hope are the most important components of good counseling.
  • Active Listening– involves attending skills and reflective listening. This helps counselors connect with the client by reflecting what the client’s underlying thoughts and feelings are back to the client.  The counselor can also provide useful feedback to the client that may include observations that the client had not considered.
  • Concreteness– the counselor will translate the vague aspects of the client’s statements and experiences into specific concrete terms in order to help the client develop more effective coping skills.
  • Paraphrasing– includes the therapeutic qualities of empathy and warmth. Comprises the counselor’s verbal responses that rephrase the content of the client’s statements into a meaningful conclusion. It allows the client to hear what he or she has just said and applies added clarity of meaning for the client.  This helps increase trust and reduces the client’s resistance.
  • Reflecting– This occurs when the counselor rephrases content that generated emotion in the client. It reflects feeling.  Reflection captures the essence of what a client is feeling and states it back to the client. This helps the client be aware of his or her own expressed emotions and how the counselor understood the client’s emotional message.  Counselors are warned not to interpret their clients’ feelings.  Do not offer opinions, judgments or advice at this point.
  • Simplifying– includes reflection and restatement of what the client is trying to convey in a concise and clear way. It removes confusion and avoids intellectualization. Simplifying helps clients stay focused on specific problems in the here and now.”
  • Summarizing– involves tying together the main points, themes and issues.
  • Attending– refers to how the counselor pays attention to the client using cues.
  • Probing– consists of asking open-ended questions in order to clarify information and help the client gain insightful understanding.
  • Reframing– involves offering a different perspective on a problem or circumstance the client is facing.
  • Exploring Alternatives– helping the client develop and consider various options.
  • Self-disclosure– this is when the counselor shares something personal about himself or herself that is beneficial to the client.
  • Confrontation– this is when a counselor raises a point to challenge a discrepancy that the client presented.
  • Immediacy– this involves interpersonal counseling, where the clinician discusses issues between himself or herself and the client in the present.

Motivational interviewing has been shown to be a useful clinical intervention and is an effective, efficient, and adaptive therapeutic style.

Motivational interviewing has the following benefits:

  • Low cost. Motivational interviewing was designed from the outset to be a brief intervention and is normally delivered in two to four outpatient sessions.
  • Efficacy. There is strong evidence that motivational interviewing triggers change in high-risk lifestyle behaviors.
  • Effectiveness. Large effects from brief motivational counseling have held up across a wide variety of real-life clinical settings.
  • Mobilizing client resources. Motivational interviewing focuses on mobilizing the client’s own resources for change.
  • Compatibility with health care delivery. Motivational interviewing does not assume a long-term client-therapist relationship. Even a single session has been found to invoke behavior change, and motivational interviewing can be delivered within the context of larger health care delivery systems.
  • Emphasizing client motivation. Client motivation is a strong predictor of change, and this approach puts primary emphasis on first building client motivation for change. Thus, even if clients do not stay for a long course of treatment (as is often the case with substance abuse), they have been given something that is likely to help them within the first few sessions.
  • Enhancing adherence. Motivational interviewing is also a sensible prelude to other health care interventions because it has been shown to increase adherence, which in turn improves treatment outcomes.

Motivational interviewing is non-judgmental, non-confrontational and non-adversarial. The approach attempts to increase the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of the behavior in question. Therapists help clients envision a better future and become increasingly motivated to achieve it.  The strategy seeks to help clients think differently about their behavior and ultimately to consider what might be gained through change.  

 

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