Motivational Interviewing: Principles and Techniques

Motivational Interviewing (MI) is a directive client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence (Rollnick, William and Miller, 1995).

Motivational Interviewing is a relatively new cognitive-behavioural therapy, which uses simple, transparent and supportive discussion with the aim of helping the client to:

• understand his or her thought processes related to the problem
• identify and measure the emotional reactions to the problem
• identify how thoughts and feelings interact to produce the patterns of behaviour
• challenge his or her thought patterns and implement alternative behaviours

(Bundy, 2004: p43)

MI is not a stand alone intervention, as it focuses only on preparing the person for behaviour change. It does not provide practical solutions towards change; therefore it should be used together with other therapies such as cognitive or behaviour therapy. To be successful in the use of MI, therapists are required to:

1. Understand the techniques and spirit of motivational interviewing
2. Work in partnership with the client
3. Utilise core communication skills, particularly open and reflective strategies
4. Acknowledge that motivation levels fluctuate
5. Accept that with the nature of motivation, behaviour change may not be long lasting despite counsellor skills and client commitment

General Principles

Four general principles apply to the processes of Motivational Interviewing.

Principle 1: Expressing Empathy - Empathy assists the counsellor to understand issues and situations from the client’s perspective. Expressing empathy helps the client to feel understood and increases the likelihood of the client opening themselves to share their experiences.

This in turn, is critical in the success of motivational interviewing as it allows the counsellor to identify when and where the client needs support during the behaviour change process. Hence, expressing empathy is the first step in building the rapport required to fully understand the client’s experiences and assist in facilitating change.

Principle 2: Support Self-Efficacy - Supporting self-efficacy is a successful way of maintaining a client’s motivation to change. This can be achieved in a number of ways such as:

• Identifying that there is no right or wrong way to change. Should the first strategy to change fail, then another strategy, which may better complement the client, can be tried

• Focus on past successful changes in the client’s life to demonstrate that change is possible and that the client does have the ability to change their own behaviours

Principle 3: Roll with Resistance - When a client demonstrates resistance, it is not the counsellor’s role to change the client’s perspective. Instead, counsellors should ‘roll with resistance’ with the aim of:

• Using the client’s resistance to explore the client’s view.

• Providing an opportunity for the client to solve the problems they have identified.

• While exploring concerns, counsellors can introduce alternative perspectives without dictating how the client should be thinking. This strategy has been found to benefit the client-counsellor relationship has a tendency to reduce resistance, as clients are not being encouraged to become argumentative towards the counsellors’ suggestions.

Principle 4: Develop discrepancy - Focusing on the differences between current behaviours and future goals assists clients to regenerate motivation for change. A client who is able to identify that their current behaviours are leading them away from their goals, rather than closer, develops insight needed to make positive changes.

Techniques

The fundamental approach to interactions contains the following four elements:

1. Open-ended questions
2. Affirmations
3. Reflective listening
4. Summaries

Motivational interviewing creates an acronym OARS from this and the goal in using OARS is to assist the person to move forward, creating change talk and motivation from within. This change talk contains statements that the client may be considering change. There are four categories that these statements can be organised into:

• Problem recognition
• Concern about the problem
• Commitment to change
• Belief that change is possible

Any statement therefore regarding the present or future, either cognitive or emotional may represent a motivational statement. For example a statement such as “I think that using may be causing me problems” (present cognitive), “You know I’m starting to feel that this just might work out” (future emotional).

Open ended questions - These cannot be answered with a ‘yes’ ‘no’ or ‘five times in the past month’. Commonly most sessions commence with an open-ended question, ‘What’s been going on since we last got together?’

This type of question allows the client an opportunity to move forward and whilst closed questions undoubtedly have their place, they do not create the same opportunity. Example:

“I assume, from the fact that you are here that you have something you would like to talk over. What would you like to discuss?”

Affirmations - There are really no better ways of building rapport with a client than offering affirmation. This is particularly relevant to clients suffering from addictions as affirmation for this group has been a historically rare occurrence.

Remember that affirmation has to be commensurate with the step achieved as the client may feel that the counsellor is being insincere if they are over praising them. This can lead to rapport being seriously damaged rather than built. Below are some examples:

“Thanks for coming in on time.” “I must say, if I were in your position, I might have a hard time dealing with that amount of stress.”

Reflective listening - This is really the key. The best motivational advice a counsellor can give to himself is to listen attentively to the client.

All the information a counsellor requires will come from the client, what works, what has failed them etc. However this is a directive approach. The counsellor will actively guide the client by this technique; focusing more on change talk and less on non-change talk.

For example “You are unsure about your readiness to change but you are aware that your drinking has damaged your relationships and your health”. The level of reflection should be varied.

Keeping it at one level could lead to a feeling of moving in circles. Reflections regarding affect, particularly if the effect is unstated can be excellent motivators for example; “Your wife has left you. That appears to be giving you a lot of pain”. If that is correct the intensity of the session deepens, if wrong the client will correct you (or the client may not be ready to deal with this) and the session moves on regardless.

Reflective listening maintains the movement of the interview and forward movement is what motivational interviewing is all about.

Summaries - Summaries are a specialised form of reflective listening and are an effective way to communicate that you have been listening by calling attention to central points and moving attention and concentration. There is no hard and fast rule as to how often you do summarise but the frequency should be quite high as there is a risk that the amount of information given may be too large to give adequate feedback.

When you are about to summarise let the client know that that is what is going to occur and invite the client to correct you where he/she feels necessary. If you feel that there were points that were not clear during this period, inform the client of that when you announce your intention to summarise. Example:

“So, this heart attack has left you feeling really vulnerable. It’s not dying that scares you, really. What worries you is being only half alive, living disabled or being a burden to your family.”

Applications

Below is an eight-stage representation of how to put motivational interviewing in practice.

1. Establishing Rapport

·         Allow time to develop a trusting relationship

·         Do not judge or use bullying tactics

·         Start sessions with a clear aim

·         Finish sessions clearly

1. Setting the Agenda

·         Allow the client to set the agenda

·         Ensure change agenda is achievable and allows enough time

·         Help client to prioritise agenda items

·         Discuss any identifiable difficulties and resources available

·         Review agenda regularly

1. Assessing Readiness to Change

·         Ask questions that will give insight to the client’s readiness, willingness and ability to change.

·         Provide feedback about why you are asking these questions and what they mean

1. Sharpening the Focus

·         Break the behaviour into smaller components

·         Focus on specific behaviours and patterns

1. Identify Ambivalence

·         Identify if the client disagrees, ignores or denies a statement of reflection or requests elaboration

·         Discuss ambivalence with client

·         Identify that there are both positive and negative reasons connected to change

1. Eliciting Self-Motivating Statements

·         Encourage clients to phrase sentences in a positive way.

·         Encourage clients to see positive possibilities and envisage success

·         Reinforce positive statements by paraphrasing

1. Handling Resistance

·         Use opportunity to explore client’s view

·         Suggest alternatives, rather than impose alternatives

1. Shifting the Focus

·         When a client is unable to move past resistance- summarise client’s view, identify that topic can be discussed again, move to another topic.   

© Australian Institute of Professional Counsellors. The Institute is Australia’s largest counsellor training provider, offering the internationally renowned Diploma of Professional Counselling. For more information, visit the following links:

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