Have you ever experienced the frustration of working with a client who just cannot seem to find the motivation to change their problematic behavior?
Learning more about motivational interviewing might just help you to overcome the impasse.
Motivational interviewing (MI) is “a directive, patient-centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence” (Rollnick & Miller, 1995).
First developed as a brief intervention for the treatment of alcohol problems (Miller & Rollnick, 1991), in which lack of motivation is a common obstacle to change, the approach builds on Carl Rogers’s optimistic and humanistic theories.
This article looks at the key MI techniques of open questioning, affirmation, reflective listening, summarizing, considering ways to elicit change talk, and examples of affirmations.
Before you continue, we thought you might like to download these three Goal Achievement Exercises for free. These detailed, science-based exercises will help you or your clients create actionable goals and master techniques to create lasting behavior change.
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A Look at the OARS
Open questions, affirmations, reflective listening, and summary reflections (OARS) are the basic interaction techniques and skills used in the motivational interviewing approach. These are considered the four core skills (Miller & Rollnick, 2013).
Open questions are designed to encourage clients to tell their story in their own words. They enable you to explore, clarify, and gain an insight into your client’s world and demonstrate curiosity and interest in the person. Importantly, using open questions can prompt a discussion about the reasons for making changes.
Examples of open questions and inquiring statements include:
- Help me understand…
- How would you like things to be different?
- What do you want to do next?
- Tell me more about…
Miller and Rollnick (2013) identify affirmation as a key element of motivational interviewing and building and maintaining a therapeutic relationship with the client. The use of affirmations identifies clients’ strengths and acknowledges the client’s efforts in their struggles.
Personal affirmations are important supportive statements to help clients increase their confidence in their ability to change. Affirmations are statements of appreciation and understanding.
These statements are intended to make the client feel supported by the practitioner, regardless of the status of their behavioral changes or attempts to change, and play an important role in building the therapeutic alliance. However, affirmations must be genuine for them to truly resonate with a client. One way to ensure authenticity is to focus on specific positive behaviors and acknowledge small successes.
Reflective listening is a primary skill used in MI to demonstrate empathy, interest, and understanding. Reflective listening involves the therapist hearing and understanding and then letting the client know that they are being heard and understood.
In relation to encouraging behavior change, reflective listening helps to clarify and explore reasons for change. In reflective listening, you do not offer your perspective but, instead, keep the focus directly on what your client is saying.
Although the primary focus is on what the client actually says, the therapist can also reflect what they notice in tone of voice, body language, and sometimes by noticing what is not said or gaps in the narrative.
Reflective listening can be viewed as a “checking” process to ensure that both client and therapist understand what is being communicated.
Summarizing in MI is an application of reflective listening and should be used throughout the session. As with reflective listening, summaries can be a good way to check that you have thoroughly understood your client. Summarizing can be a particularly useful technique to assist a client in organizing their experience.
For the most part, therapists should aim to summarize elements that will help the client move forward. Nonetheless, suppose a client is ambivalent about change. In that case, it is important to reflect this authentically by including both sides in the summary (for example, saying something like, “on the one hand xx, but on the other hand xx”).
10 Strategies for Eliciting Change Talk
Miller and Rollnick (2013, p. 159) define change talk as “any self-expressed language that is an argument for change.”
Eliciting change talk is an essential, active ingredient of MI (Miller & Rollnick, 2013), and it has been shown to predict improved outcomes in therapy (Walker, Stephens, Rowland, & Roffman, 2011).
One of the most critical tasks for therapists is to recognize change talk when it occurs. Miller and Rollnick (2013) use the acronym DARN CAT to describe various types of change talk:
- Commitment language
- Action (current movement)
- Taking steps toward change
So what techniques or strategies can you utilize to encourage your client to express and explore change talk? We have identified 10 strategies you might like to employ in your MI work.
- Ask evocative questions:
Ask open questions that have an emphasis on change (for example, “How would you like things to be different?”)
- The ruler strategy:
One of the most commonly used methods to elicit change talk through MI is the 0–10 ruler strategy (Resnicow, Gobat, & Naar, 2015). This usually takes the form of two questions:
- On a scale from zero to ten, how important is it for you to (change), where zero is not at all important, and ten is extremely important?
- On a scale from zero to ten, how confident are you that you could (change)?
On obtaining a rating, the therapist can prompt further exploration by asking why the client did not choose a higher/lower number and what it would take to alter the number.
- Explore costs and benefits:
Explore both the costs and benefits of maintaining the current situation and then the costs and benefits of change. This can be done in the form of writing a list together to discuss further.
- Ask the client to elaborate:
When you hear change talk, ask the client to provide more details (for example, “Tell me more…” or “What might that look like?”)
- Encourage the client to provide examples:
When a change talk theme is identified, ask for specific examples. This helps to engage further in the talk.
- Look back:
Ask the client about a time before the current concern emerged. How were things better or different then?
- Look forward:
This is where you can try using the miracle question, “If you were 100% successful in making the changes you want, what would be different?” Or simply ask how they would ideally like their life to be in the future. It can also help to consider what life would look like if the changes were not made and explore what the consequences of that might be.
- Identify extremes:
Particularly useful when there is little expressed desire for change. Ask the client to describe possible extremes:“What is the worst-case scenario if you don’t make this change?” and “What are the best things that might happen if you do make this change?”
- Explore goals and values:
Be curious about your client’s values and encourage active investigation of them. Explore what is truly important to them and what their goals are in life. If possible, ask your client to state goals explicitly. If there is a “problem” behavior, ask how that behavior fits in with the person’s goals or values. Does it help realize a goal or value, or does it interfere with achieving it?
- Come alongside:
Here the therapist explicitly sides with the negative side of ambivalence (i.e., not making a change). “Perhaps xxx feels so important to you that you won’t give it up, no matter what the consequence.”
17 Motivational Interviewing Affirmations:
As already mentioned, affirmations are a key tool in MI. For them to be effective, there are a few suggestions to follow. In keeping with the person-centered spirit of motivational interviewing, the most important quality of any affirmation is that it must be genuine and express positive regard.
Affirmations should be used to emphasize your client’s strengths and notice and appreciate any positive actions they take, particularly when this is in the direction of the specific change you are working toward.
Some useful examples:
- You are determined to get your health back.
- I appreciate your efforts despite the discomfort you’re in.
- Thank you for all your hard work today.
- You’re determined to make changes.
- Despite your difficulties, you’re still willing to try.
- You are clearly a very resourceful person.
- Even though things are difficult right now, you try so hard to…
- You handled yourself really well in that situation.
- That’s a good suggestion.
- You’re a strong person, a real survivor.
- I appreciate your openness and honesty today.
- That was a lot of work.
- You pulled it off.
- You don’t give up, even when it’s tough going.
- You worked so hard to figure it out.
- You didn’t know if you could do it, but you tried anyway.
- It took a lot of courage to come in today.
Helpful Exercises for Your Sessions
It is important to note that MI is not a technique or clearly demarcated procedure but, rather, a guiding style for enhancing intrinsic motivation to change (Rollnick, Miller, & Butler, 2008).
The strategies suggested above for eliciting change talk should be used flexibly, and for motivational interviewing to be effective, therapists should stay true to the humanistic underpinnings of the MI spirit (Miller & Rollnick, 2009).
The skill in MI is to use the OARS to encourage, support, and motivate your client while staying alert to any change talk and responding directly to this. For these reasons, there are few suggested exercises, but the following ideas are considered intrinsically rooted in MI principles:
The therapist uses the OARS skills to encourage the client to establish the conversation’s focus and what they want to achieve from the session. A collaborative agenda should be developed that ensures the work concentrates on the most pertinent issue.
Continuing the paragraph
This is a reflective listening method in which the therapist offers what might be the next (as yet unspoken) sentence in the client’s paragraph. This encourages progression in the ideas the client is beginning to express.
Elicit, provide, elicit (EPE)
EPE is an “information exchange process that begins and ends with exploring the client’s own experiences to frame whatever information is being provided to the client” (Miller & Rollnick, 2013). The aim is to first “elicit” what the client already knows, then fill in any gaps or misconceptions (provide), and finally to explore how that fits with the client’s experience (elicit).
A Note on MI in CBT
Research has demonstrated that motivational interviewing can be synergistic with Cognitive Behavioral Therapy (CBT) and lead to improved treatment outcomes (e.g., Arkowitz & Burke, 2008; Flynn, 2011).
MI can be used during CBT to enhance motivation, resolve ambivalence, and reduce resistance (Arkowitz & Burke, 2008). There are useful similarities in the collaborative approach to working with clients inherent in both approaches, emphasizing goal setting and focusing on specific problems or behaviors (Flynn, 2011).
However, one notable difference is that in MI, the client is always viewed as the expert and the key change agent, whereas in CBT, the therapist is usually assumed to be the key change agent (Flynn, 2011).
CBT is intended to provide clients with something they lack, such as coping skills, restructured cognitions, or psychoeducation. In contrast, MI is focused on “eliciting from people that which is already there” (Miller & Rollnick, 2009, p. 134).
As mentioned, MI techniques can be woven into the CBT treatment to enhance motivation to change. CBT does not directly address ambivalence about change but rather focuses on providing the client with the motivation tools required to make changes. As such, integrating the two might be particularly beneficial when working with a highly ambivalent client.
Using MI skills integrated into CBT sessions is likely to enhance initial treatment engagement, treatment adherence, and treatment retention (Arkowitz & Burke, 2008).
If you are interested in really digging deeper into the topic of motivation, we have an excellent Motivation & Goal Achievement Masterclass© available on our website for you to access.
In addition, our site has numerous motivational interviewing resources, including specific MI questions, skills, and worksheets, to assist with your client’s readiness to change.
Three articles you might find particularly helpful:
- What Is Motivational Interviewing? A Practical Theory of Change
- 17 Motivational Interviewing Questions and Skills
- The 6 Stages of Change: Worksheets for Helping Your Clients
We also have a wide range of helpful worksheets; these four are particularly pertinent:
- Basic Need Satisfaction Through Communication
- Motivational Vision Board
- Daily Motivational Awareness
- Basic Needs Satisfaction Through a General Scale
17 Motivation & Goal-Achievement Exercises – If you’re looking for more science-based ways to help others reach their goals, this collection contains 17 validated motivation & goals-achievement tools for practitioners. Use them to help others turn their dreams into reality by applying the latest science-based behavioral change techniques.
A Take-Home Message
When you take a moment to let it sink in, you start to realize how much potential the seemingly simple approach of motivational interviewing offers.
Perhaps it really is possible to empower clients to make positive changes that fit with their own goals and values, using an artfully guided conversation.
Are you motivated to give it a try?
We hope you enjoyed reading this article. Don’t forget to download our three Goal Achievement Exercises for free.
- Arkowitz, H., & Burke, B. L. (2008). Motivational interviewing as an integrative framework for the treatment of depression. In H. Arkowitz, H. A. Westra, W. R. Miller, & S. Rollnick (Eds.), Applications of motivational interviewing. Motivational interviewing in the treatment of psychological problems (pp. 145–272). Guilford Press.
- Flynn, H. A. (2011). Setting the stage for the integration of motivational interviewing with cognitive behavioral therapy in the treatment of depression. Cognitive and Behavioral Practice, 18(1), 46–54.
- Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. Guilford Press.
- Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37(2), 129–140.
- Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
- Resnicow, K., Gobat, N., & Naar, S. (2015). Intensifying and igniting change talk in motivational interviewing: A theoretical and practical framework. European Health Psychologist, 17(3), 102–110.
- Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care. Guilford Press.
- Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325–334.
- Walker, D., Stephens, R., Rowland, J., & Roffman, R. (2011). The influence of client behavior during motivational interviewing on marijuana treatment outcome. Addictive Behaviors, 36, 669–673.