Motivational Interviewing Principles: 4 Steps to Elicit Change

Motivational Interviewing PrinciplesMotivational interviewing is an excellent tool to help motivate your clients to achieve their goals.

By getting clients to engage in behavior change, it is an antidote to malaise and indecision. It provides structure for helping clients who are stuck.

Motivational interviewing (MI) is useful for a variety of different presenting problems. Traditionally, it has been used with medical issues such as diabetes (Li, Chen, Yan, Liang, & Wong, 2020) and substance use (Walker, Jaffe, Pierce, Walton, & Kaysen, 2020). But it can also be used in other settings, such as the workplace (Foldal et al., 2020).

The good news is that MI is not just for clinicians; it can also be a useful tool for helping friends and family or motivating employees at work.

Clinicians using MI help clients explore and resolve ambivalence, solidify personal motivation, and develop individualized plans for change. In this post, we zoom in on the principles in MI that help clients change.

Consider this a practical primer to kickstart your use of MI principles in clinical practice, work, or everyday life. This related article – Motivational Interviewing Theory – is a comprehensive introduction to MI.

Before you continue, we thought you might like to download our 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.

Step 1. Express Empathy

In motivational interviewing, clinicians express empathy through careful listening and nonjudgmental curiosity about the client’s presenting problem. This is different from empathy in other therapeutic approaches, which focus more on verbal expressions of empathy. Instead, MI requires the creation of a context of empathy, which is done through the distinctive listening style on which MI is based.

Almost everyone experiences some ambivalence when making a big change. Many clients feel shame about the part of themselves that does not want to change or even enjoys the behavior, even though they know it is harmful. In these cases, the clinician expresses empathy by being willing to explore both sides of an issue.

In MI, empathy means nonjudgmentally helping the client explore both sides of their ambivalence, especially the side that others would deem “unhealthy.”

 

Accurate empathy

The MI term accurate empathy gets to the root of this principle. Accurate empathy refers to the clinician’s sincere desire to understand the client’s experience and motivations, as they relate to the problem (Schumacher & Madson, 2014). This is very different from expressing sympathy or identifying with the client, both of which are much less likely to empower the client or lead to change.

This is a relatively straightforward concept. If you are going to be empathic, make sure that you understand where the person is coming from first. This is actually what empathy means: understanding where someone is coming from, feeling some fraction of that feeling yourself, and expressing that understanding to the person that you are sitting with.

There is another, more dramatic term for inaccurate empathy: empathic failure. An empathic failure is when someone has a lack of understanding for another person’s thoughts, perceptions, or feelings (American Psychological Association, 2020). This is why MI places such heavy emphasis on deep listening; unless you have a good understanding of the person you are sitting with, your empathy is likely to fall flat.

 

Guide vs. expert

When used correctly, empathy is inherent in the MI process because of the role that the clinician plays in their work. This approach is best defined as being a “guide,” rather than being an “expert.”

A “guide” helps the person to get where they need to go, whereas an “expert” tells the person what they need to do. Being an MI clinician means that you are guiding the conversation toward change talk, or arguments for change, and away from sustain talk, or arguments against change (Miller & Rollnick, 2013).

Although the clinician avoids acting as an expert, they are still the expert in the room when it comes to clinical issues and human behavior. MI-consistent treatment allows the clinician to offer information and their point of view, but only when it has been solicited or if the clinician first asks for permission.

This approach ensures respect for the client’s autonomy and intelligence. It gives them a chance to convince themselves of the reasons for change and to solve their problems.

For much of MI treatment, the roles may seem a bit backward. The client is treated as the expert on themselves, while the clinician’s job is to empower them to develop and implement their own plan for change. The MI clinician’s real expertise is in evoking the intrinsic motivation of the person sitting before them.

 

Step 2. Develop Discrepancy

Develop DiscrepancyPeople are more likely to change when they can see that their actions are not in line with their values.

To help clients see this, clinicians “develop discrepancy” between what the client says they want and what they are doing.

 

Discrepancy as a tool

As a first step, the client must become conscious of their values. The clinician helps accomplish this through careful questioning to elicit change talk. Change talk includes the client revealing consideration, motivation, or commitment to change (Schumacher & Madson, 2014).

The most direct way to elicit the client’s motivations for change is to ask about them.

For example, asking “why would you want to make a change like this?” encourages the client to start talking about change. In MI, the client should be the one talking about change, not the clinician (Rollnick, Miller, & Butler, 2008). Clinicians should spend more time listening and asking open-ended questions than describing the reasons for change.

Open-ended questions allow the client to explore their values, and by talking about them in session, these values become more clearly defined. Once these values are defined, discrepancy can be used as a tool to increase client motivation for change. Clients will be more likely to change if they can see for themselves the discrepancy between their actions and underlying values.

 

Listening as an art form

Developing discrepancy can be done quickly by asking direct questions, but it is also a process that takes place throughout treatment. In therapy, active listening is an art form, in which the clinician picks up subtle hints about the client’s values over time, sometimes without even realizing it.

For example, a mother who struggles with obesity and overeating may complain about low energy and struggle to maintain a consistent exercise routine. At the same time, she may talk about her children and wish for more energy to play with them.

This client may offer subtle hints about her values over time. She may complain about her fatigue, or she may become tearful when talking about her children. It is the therapist’s job to listen for these emotional moments and comment on them, allowing the client to speak about these values and define them more clearly.

Helping this client to connect her values (being an involved and energetic parent) to her behavior (overeating and not exercising) will help create motivation. However, MI is based on the idea that change is more likely if the client can make these connections themselves, rather than being informed of them by the clinician (Schumacher & Madson, 2014).

 

Step 3. Roll With Resistance

Clinicians love to help people. This is part of why they have answered the call to service in their life’s work. Can you think of an experience when you saw someone you cared about doing something harmful or dangerous? It can be difficult to resist jumping in and trying to convince them to change.

 

The righting reflex

In the cases where we see someone headed “off course,” it can become automatic to try to convince them of the right path to take. In MI, this automatic pull toward helping is known as the “righting reflex” and often has the paradoxical effect of provoking resistance (Schumacher & Madson, 2014).

When clients are doing something harmful, such as abusing drugs or overeating, they usually feel two ways about it. Part of them knows the harm and wants to stop, while the other part enjoys the act and wants to continue. When clinicians side with the part they deem “sensible,” it is natural for the client to respond by strengthening the position of the other side.

Resisting the righting reflex is in line with the above distinction of guide vs. expert. The clinician who is pulled by their righting reflex into listing the reasons why the person should change, no matter how valid they are, is playing the role of expert in the session. They are also acting unmindfully and outside of the MI scope.

In order to be a guide and to resist the righting reflex, it is important to have faith that the client is capable of changing. Believing that the client is capable of change is one of the core tenets of doing MI work. Without it, the clinician may be in “rescue mode,” automatically trying to pull out all the stops to make the client change before it is too late.

 

Reasons for resistance

There are multiple reasons for resistance. For one, the client may not be ready to make a change. Clients are often in the beginning stages of change, as described in the transtheoretical model of change (Prochaska & Velicer, 1997), and resistance is a natural and expected part of treatment. Another reason is that humans have a natural reflex to resist being persuaded.

While the clinician is talking about why the client shouldn’t do something, the client’s mind is likely generating reasons why they should.

Human beings also tend to believe what we hear ourselves say, and this is why the goal of MI is to elicit change talk (Rollnick et al., 2008). A clinician who is arguing in favor of change is acting outside of MI principles. Clients are less likely to experience resistance when they are discussing change themselves.

Another reason for resistance might be what MI defines as “discord.” The concept of discord is about the relationship between the clinicians and the client and refers to moments in treatment when the two parties are not on the same page (Schumacher & Madson, 2014).

When a clinician senses discord, they are encouraged to alter their behavior to repair the rift in the working alliance. Clinicians take several steps toward this aim, including avoiding arguing with the client, listening more carefully, and responding in a non-confrontational manner, which is more likely to change the energy toward discussing positive change (Schumacher & Madson, 2014).

A clinician is “rolling with resistance” when they are working skillfully to elicit the client’s own motivations for change. A combination of basic clinical skills (reflective listening, affirmations, asking open-ended questions, and summarizing) and the spirit of MI (respecting client autonomy, supporting choice, and acknowledging ambivalence) create this unique flow state.

 

Step 4. Support Self-Efficacy and Optimism

Support OptimismEmpowerment is a major principle in motivational interviewing (Rollnick et al., 2008).

Clinicians are experts on many things – mental health, physical health, the benefits of exercise, and consistent sleep, to name a few – but clients are the experts on themselves.

Clients do better when they are encouraged to take an active role in their treatment, and MI is a tool for this aim.

 

Client as consultant

In MI, the clinician becomes a facilitator for the client’s expertise. In a successful MI intervention, the client becomes a consultant on their own lives, answering the clinician’s questions to form a collaborative and personalized solution (Rollnick et al., 2008).

This approach is not unique to MI but is instead a sign of good therapy. No matter how long the clinician and client have been working together, the client will always be the one with the most expertise on themselves. This is one reason why it is so important for clinicians to remain humble and put their expertise in listening on par with their expertise in other matters.

Since MI is a strengths-based approach, the clinician strives to recognize client efforts toward change while eliciting their existing strengths and resources (Schumacher & Madson, 2014). A common tool in MI is to affirm clients verbally.

 

Attitudes that support change

Clients who receive treatment have often failed to change their behavior in the past. This may sensitize them to rejection in treatment. In any case, clients are highly attuned to their clinician’s attitude. In order to help clients change and grow, it is important to truly believe that they are capable of this. Portraying optimism through consistently applying these four principles will help the client to adopt this attitude themselves.

The MI clinician is not an obvious cheerleader. Instead, their encouragement is more subtle and also more powerful. By creating the context in which the client’s self-knowledge and problem-solving skills are revered, they empower their clients to believe in their abilities.

By listening to them deeply, showing empathy, and rolling with resistance, the clinician shows the client that they are worthwhile, important, and capable of change.

 

A Note on Exploring Ambivalence

As discussed above, clients often feel two ways about any problem behavior. Combating ambivalence paradoxically ignites resistance, and the goal of the MI clinician is to work through resistance while encouraging positive change talk.

Although you may know why the client should change, it is more MI consistent to explore ambivalence than to advocate for a prescribed behavior change.

One of the basic skills that is most useful for exploring ambivalence and eliciting change talk is open questioning (Schumacher & Madson, 2014). Open questions are broad, require more than one- or two-word answers, and allow flexibility in how clients respond. They allow the client to begin exploring previously unexplored parts of themselves and, through voicing change talk, move closer to change.

Open questioning is only one of four basic clinical skills in MI. Together they form the acronym OARS:

  • Open questioning
  • Affirmations
  • Reflective listening
  • Summarization

All four skills, when used in the context of an MI client engagement, help to push the client toward change. Check out our post on Motivational Interviewing Questions and Skills for more information on OARS.

Exploring ambivalence is one of the foundational aspects of MI. In this approach, ambivalence is not seen as a weakness or a lack of willingness to change, but as a natural part of the change process.

 

PositivePsychology.com Valuable Resources

Our site has numerous motivational interviewing resources including specific MI questions, skills, and worksheets to assist with your clients’ readiness to change.

These three articles are particularly helpful for building your knowledge of motivational interviewing:

While these four worksheets can be helpful with the above principles:

 

A Take-Home Message

Simply convincing a client to change will not make them do it.

Instead, the willingness to hear the client out, with empathy and acceptance, helps to deepen the relationship and move the client toward change.

That is the advantage of motivational interviewing as a communication style. It can be very useful in clinical situations that involve behavior change.

However, learning MI is more complicated than reading a book. It requires practice and dedication over time. If you are interested in learning more about MI, you should acquire training and supervision, and seek out experiences to practice in real life. If MI fits with your work and your style as a clinician, it can be one of the most effective motivation tools that you employ throughout your career.

We hope you enjoyed reading this article. Don’t forget to download our three Goal Achievement Exercises for free.

If you’d like to help others succeed in life, our Motivation & Goal Achievement Masterclass© is a comprehensive training template for practitioners that contains everything you need to help your clients reach their goals and master motivation-enhancing techniques.

  • American Psychological Association. (2020). Empathic failure. APA dictionary of psychology. Retrieved on December 21, 2020, from https://dictionary.apa.org/empathic-failure.
  • Foldal, V. S., Standal, M. I., Aasdahl, L., Hagen, R., Bagøien, G., Fors, E. A., … Solbjør, M. (2020). Sick-listed workers’ experiences with motivational interviewing in the return to work process: A qualitative interview study. BMC Public Health, 20(1), 276.
  • Li, Z., Chen, Q., Yan, J., Liang, W., & Wong, W. C. W. (2020). Effectiveness of motivational interviewing on improving care for patients with type 2 diabetes in China: A randomized controlled trial. BMC Health Services Research, 20(1), 57.
  • Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.
  • Prochaska, J., & Velicer, W. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48.
  • Rollnick, S., Miller, W. R., & Butler, C. (2008). Motivational interviewing in health care: Helping patients change behavior. Guilford Press.
  • Schumacher, J. A., & Madson A. B. (2014). Fundamentals of motivational interviewing: Tips and strategies for addressing common clinical challenges. Oxford University Press.
  • Walker, D. D., Jaffe, A. E., Pierce, A. R., Walton, T. O., & Kaysen, D. L. (2020). Discussing substance use with clients during the COVID-19 pandemic: A motivational interviewing approach. Psychological Trauma : Theory, Research, Practice and Policy, 12(1), 115–117.

About the Author

Joshua Schultz, Psy.D. is a therapist and writer based in Philadelphia. He holds a doctorate in Clinical Psychology from Widener University, where his dissertation focused on compassion in leadership. He believes in systemic justice and is interested in reforming organizations and institutions through the introduction of love and empathy. Joshua approaches his clinical engagements from an Acceptance and Commitment Therapy perspective. His work is aimed at helping others act with compassion while living a life they find meaningful.

Comments

  1. Matt Racz

    Absolutely loved this entire article and the accompanying resources. Thank you so much for taking the time to share all of this, Joshua! It is truly inspiring and so much of it immediately actionable even in my personal life with friends and family, but certainly with clients and coworkers. Much appreciated 🙏

    Reply

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