Have you ever been “healed” by a long conversation with someone where you were given full attention and felt the other person really listened to you without judgment?
Has a particular relationship made you feel normal, lighter, or good about yourself again? Chances are this happened in an environment that was trusting, open, and frank.
If I can provide a certain type of relationship, the other person will discover within himself the capacity to use that relationship for growth, and change and personal development will occur.
This article describes the underlying principles and techniques of one such form of communication known as Motivational Interviewing. Most commonly used to increase motivation toward behavioral change, motivational interviewing is an evidence-based approach designed to encourage clients to talk themselves into making beneficial changes in their lives.
This article contains:
What is Motivational Interviewing
Motivation to change varies from person to person, from one situation to another, and over time. Some of us are unwilling, others are unable to change, and many are not fully ready.
Motivational Interviewing techniques rest on the findings in clinical experience and research that simply show that clients who believe that they can change do so, and “those who are told that they are not expected to improve indeed do not” (Miller, & Rollnick, 2014).
People are better persuaded by the reasons they themselves discovered than those that come into the minds of others.
Motivational interviewing is a patient-centered counseling style based on the principles of the humanistic psychology of Carl Rogers. He argued that for a person to “grow,” we need an environment that provides us with genuine openness that enables self-disclosure, acceptance that includes being seen with unconditional positive regard, and empathy where we feel like we are being listened to and understood.
Rogers discovered that it was more effective to let clients guide the direction of the process in the person-centered form of therapy.
The curious paradox is that when I accept myself just as I am, then I can change.
Motivational Interviewing (MI) is a technique for increasing motivation to change and has proven to be particularly effective with people that may be unwilling or unable to change.
Originally used within the setting of alcohol addiction treatment in the 1980s, motivational interviewing encouraged patients to think and talk about their reasons to change. Soon it was discovered that this minimized their resistance and increased their motivation.
Part of the reason was that motivational interviewing accepts that ambivalence about change is a normal human experience and often a necessary step in the process of change.
Motivational interviewing rests on the assumption that people are ambivalent about change versus weak or resistant to doing so. It’s an optimistic approach to change aimed at resolving this ambivalence through eliciting and reinforcing change talk.
Change talk is the statements we make that reflect our desire to change, focus on our ability to do so, list specific reasons for change, and express the commitment to change. Studies show that change talk, particularly in clinical settings, has been linked with successful behavior change (Sobell & Sobell, 2008).
The only person who is educated is the one who has learned how to learn and change.
Motivational interviewing aims to encourage the patient’s autonomy in decision making where the clinician acts as a guide, clarifying the patient’s strengths and aspirations, listening to their concerns, boosting their confidence in their ability to change, and eventually collaborating with them on a plan for change.
The process consists of engaging patients, deciding on what to change, evoking their reasons for making the change, and agreeing on a concrete plan.
One relevant psychological theory that explains how and why motivational interviewing works is self-determination theory. It states that we are more likely to change if our three basic psychological needs are attended to:
- Autonomy in making decisions
- Mastery and a sense of our competence in making the change
- Relatedness and a sense of being supported by key people around us, including healthcare professionals.
Another useful theory is that when we hear ourselves talk about change, it tends to increase our motivation. Within motivational interviewing, this is known as “change talk.” An emerging body of research is currently tracking the language that patients use when talking about change, and it appears that change talk predicts better outcomes (Gaume, at al, 2013).
Finally, it was also noted that practitioners’ behavior could influence clients’ behavior in measurable ways. One review of research suggests that minimizing practitioners’ behavior that is inconsistent with motivational interviewing, such as disagreeing with and confronting clients, has a clear positive influence on outcomes (Gaume, at al, 2013).
Motivational Interviewing Questions and Skills
The aim of motivational interviewing is to encourage the patient to become an active participant in the change process by evoking their intrinsic motivations for change. And all this despite ambivalence and what often seems like resistance, which is considered a normal part of the change process. Evoking is central to motivational interviewing, but it is also most challenging to master as it is vastly different from traditional advice-giving.
Motivational interviewing requires four key communication skills that support and strengthen the process of eliciting change talk, also known as OARS:
- Open-ended questions
- Reflective listening
Open-ended questions in motivational interviewing allow us to find out more about the client’s perspective and ideas about change. They are also crucial in building and strengthening a collaborative relationship. Finally, they are also useful in the process of evoking the client’s motivations for change.
Affirming can be done through recognizing and commenting on the patient’s strengths and abilities. Affirming is excellent for rapport building and can increase it further by using some of the well-known coaching techniques and incorporating acknowledging and validating clients’ emotions.
Sounds like this is really challenging. No wonder you feel overwhelmed.
Reflective listening can be employed effectively through summarizing. When we repeat what the client has told us in our own words and in the form of a statement rather than a question, we encourage them to continue talking. The most crucial benefit of reflective listening is that it helps to build engagement with the client, particularly when he or she is upset or angry as it can help them to calm down and feel understood.
What I hear you say is…
Most importantly, however, reflective listening allows practitioners to clarify what the client is saying both for the purpose of understanding correctly but also to reflect back to the client so they can hear what they are saying and can either pause to reflect or choose to move forward.
In motivational interviewing, reflective listening is used purposefully to help the patient consider a change. This is one of the strongest characteristics of the evoking process.
Summarizing is also used for further collection of reflections, allowing the practitioner and the client to identify the core ideas of the client’s story. When we employ reflective listening and combine it with effective summarizing, the clients find themselves hearing themselves talk about change.
As the practitioner empathically reflects back to the client what they just said, it becomes a part of the powerful process of evoking the client’s own motivation for change.
In motivational interviewing, OARS or open-ended questions, affirmations, reflections, and summarizing are employed toward eliciting change talk. Evoking self-motivational statements is a primary goal of MI approach and unlike OARS, is more directive. The goal is to help the client identify and resolve ambivalence so he or she can move forward.
Change talk is the client making statements that are in favor of change. It signals he or she is more willing, able, or ready to make the change. The practitioner’s role is to elicit change talk from the client in a collaborative fashion and avoid imposing it. Motivational interviewing is a consensual, negotiated process between the counselor and client.
Change talk can occur in several forms and is exemplified by a statement that indicates the desire for, the ability to, the reasons for, and the need to change.
Desire statements indicating a desire to make a change:
Getting in shape would make me feel so much better about myself.
Ability statements speak to the client’s self-efficacy or belief in the ability to make changes:
I think with some help, I might be able to cut back.
Reasons statements reflect the reasons the client gives for considering a change:
I have to quit smoking because of my asthma.
Need statements indicate a need for change where the emphasis is more emotional than in the case of reasons statements, which are more cognitive and rational:
Something has to change, or my marriage will fall apart.
The most important aspect of motivational interviewing is for the practitioner to recognize and then emphasize change talk and pay particular attention to commitment language. When the client uses verbs that express authentic and robust commitment to change, this presents an opportunity to get them to elaborate further and strengthen the commitment level.
Miller worked with a linguist to show that commitment language matters, and the more a client is making strong commitment statements, the more likely the client’s behavior is going to change.
The process of eliciting change talk must also take place with adequate focus. After the client and practitioner have clarified a goal for change, an agreement should be established on the direction for the conversation. This helps to avoid making assumptions and jumping too quickly into a new change topic.
It is also a great opportunity to raise a difficult subject in a non-confrontational way by merely mentioning it and allowing the patient the opportunity to decide whether to talk about it.
There is also an issue of information sharing and advising, which could become a deterrent if not used appropriately. It should be reserved for when the patient asks, or more spontaneously when there is good engagement.
When some level of rapport is established, a practitioner can also initiate a more formal discussion about the stages of change or level of the client’s motivation. This may include helping the client develop a rating of current importance, confidence, readiness, and commitment to change to explore how any of these dimensions might be strengthened.
This is a more directive way of eliciting a client’s change talk and addressing a client’s commitment to change in a way that resembles planting the seed and gradually moving toward the negotiation of specific change plans.
Motivational Interviewing skills are not unlike some of the coaching skills, but never the less they are not easy to master. There are several training manuals for how to practice motivational interviewing skills, and here are a few of them. One way to assess the practitioner’s ability to elicit change talk is to compare it to the following examples of higher skill:
- The practitioner uses evocative questions that are targeted to the client’s current level of motivation, e.g. if the client recognizes a problem with his behavior, the practitioner asks the client to explore any concerns or problematic aspects of it;
- Practitioner query the client about factors that might impact intent or optimism for change when the client is uncertain about his or her capacity to change;
- The practitioner explores current readiness to change in depth by combining rating scales and open-ended follow-up questions and reflections that prompt the client’s arguments for change, optimism, and self-efficacy (see the next section on readiness for change, self-efficacy and decisional balance).
Readiness for Change and Motivation
What people say about change predicts subsequent behavior because it reflects motivation for and commitment to change. When clients make arguments against change, often counterproductively referred to as exhibiting resistance, it produces less change.
Today we know that successful interventions into behavioral change require a systematic stage-based approach that involves first assessing readiness to change and then application of motivational strategies that target the context of change defined by the client’s stage of readiness (Zimmerman, Olsen, & Bosworth, 2000). The Stages of Change model of Prochaska, et al. (1994), also known as the Transtheoretical Model of Change (TMC), defines the stages of change.
The model identifies six stages ranging from a “pre-contemplation stage,” where there is no intention to change, to a “termination stage,” where the desired behavior is well established, and a life-long change is part of the individual’s new identity (Zimmerman, Olsen, & Bosworth, 2000; Winnipeg Regional Health Authority, 2007). TMC informs approaches to therapy so practitioners can tailor them to clients’ current level of motivation.
|Stage||Attitude||Core thoughts||Critical Markers||Description|
|Precontemplation||No||I don’t need to change||Reluctant
|In the precontemplation stage, there are four possible reasons for resistance to change:
Reluctance: the client is unwilling to consider change, comfortable and averse to taking a risk, unaware of consequences
Rebellion: client can be resistant to change because they value their independence
Resignation: client feels helpless and overwhelmed by problems and feels like a failure
Rationalizing: client employs rationalization as a form of protection; unlike rebellion more about thoughts than emotions
|Contemplation||Yes and No||I don’t need to change||Ambivalence||In the contemplation stage, the client is thinking about the change but is ambivalent while weighing and examining the benefits of and obstacles to change. Some clients will find themselves in this stage for prolonged periods experiencing stress as they feel stuck.|
|Preparation||Yes, but||I will change||Procrastination||In the preparation stage, clients will see change as important and view themselves capable of change but will often make “yes, but” statements and put off taking steps toward change. They will usually find themselves having experimented with changing the desired behavior, seeking support, identifying barriers, and resources.|
|Action||Yes||I am changing||Behavioral Steps||In the action stage, change is visible and equated with progress. Alterations in awareness thought processes, emotions, and self-image occur as client exhibits diligence and puts a lot of effort into the process. Most clients will experience setbacks and periodically resume the old behavior at this stage, which may halt the change process, make them feel demoralized over occasional “slips,” and can sometimes result in the client giving up. These are normal, and a part of this stage and are not seen as failure or relapse.|
|Maintenance||Yes||I have changed||Commitment||In the maintenance stage, the client has successfully made the change in behavior and accomplished the goals he set for himself, usually after six months. This is a difficult stage as clients can become complacent, and onsets of negative circumstances can influence the commitment and threaten the sustained, long-term effort if no maintenance strategy is developed.|
Both TMC and Motivational Interviewing (MI) recognize three critical markers of readiness for change:
- willingness to change,
- ability to make the desire changed and
- readiness to take action to make the change.
In the early stages of change, the level of ambivalence the clients are experiencing is usually high. In the case of clients who score high in the pre-contemplation stage, willingness or ability are usually implicated in one’s levels of motivation to change behavior.
Motivational Interviewing techniques used in the pre-contemplation stage intervene in the client’s beliefs about the importance of change and may also be used to increase self-efficacy about the ability to make the desired changes.
This distinction can be based on either a formal readiness assessment or a self-reported measurement like the change readiness ruler.
To assess the desire and willingness, we may ask the client to rate the importance of making the desired change using the following questions:
Step 1. Assess the importance of change
On the scale of 0 to 100, how much do you want to make this change right now? Answer the question by marking 1 if making the change is not at all important and selecting 100 if you are willing to work hard to achieve the desired change.
Use the following scale as a visual aid:
|Not important||Less important than other things I want to achieve||Equally important to other goals in my life||More important than most things I want to achieve||Most important thing in my life right now|
Write your importance rating (1-100) here: _______
Step 2. Reflect on the answers provided
Ask the client to reflect on the reasons for their answers, inquiring about the answer that produced the lower score first. You may phrase the question as follows:
- What led you to choose this specific number on the scale versus a lower number?
- What would it take for you to move to a higher number?
Step 3. Elicit change talk
If the client scored low on willingness to change, explore values or hopes, and elicit change talk through introducing discrepancy.
When a client has a low desire to change, exploring the discrepancy between the client’s values and the current state can be an effective method to encourage change talk. Explore the client’s current values by asking the following or similar questions:
- Tell me what is most important in your life at this moment?
- Tell me about the things you value and are a priority?
- In what way are you living out these values?
– Hopes and Goals
When a client struggle with seeing the importance of change it may also help to explore the client’s hopes and goals by asking the following or similar questions that can lead to the exploration of the WHY of the change:
- What are some of the things you wish to move toward in your life?
- When you think about the future, what are some things you would like to have in it?
- When you were a child, what did you dream about doing with your life? How about now?
- If we were to be successful in our work together, what would that look like?
Another formal method to elicit future goals is to engage the client in the envisioning process.
– Elicit Discrepancy
Elicit discrepancy by placing the current behavior in the context of current values or desired future.
- Tell me about the times you are not living out your values as fully as you would like?
- How does your current behavior fit within your values?
- How can this value help you achieve the aims you set for yourself?
- How does your current behavior support your future goals?
Self-efficacy and Motivation
Most people select goals they believe they can achieve. As Bandura (1986) suggests, “unless people believe that they can produce desired effects and forestall undesired ones by their actions, they have little incentive to act. Whatever other factors may operate as motivators, they are rooted in the core belief that one has the power to produce the desired results” (p.228).
A key construct in this context is self-efficacy. A person who has a high level of self-efficacy generally believes he or she can carry out what is necessary to realize his or her goals (Bandura, 1997). This person is confident that he or she can employ the skills required to resist temptation, cope with stress, and mobilize necessary resources to meet the situational demands.
Because people with high self-efficacy beliefs assume that they have high ability, they adopt more challenging goals and perform better on tasks compared to people with low self-efficacy beliefs (Brown et al., 2011). Studies show that adopting more difficult goals is linked to superior performance (Locke & Latham, 1990).
Some changes look negative on the surface but you will soon realize that space is being created in your life for something new to emerge.
Self-efficacy beliefs determine whether instrumental actions will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and failure (Bandura, 1992, Bandura & Cervone, 1983).
In contrast, if a person sees no possibility that a goal can be reached, little or no effort will be put in trying to reach the goal, no matter how much the goal might be valued. For that reason, exploring levels of client’s self-efficacy in any behavioral change intervention is crucial.
Assessing the lack of self-efficacy can be done by observing the client, making statements that have the following characteristics:
- avoid accepting challenges as they fear failure.
- firmly believe that they are not capable of performing complicated tasks.
- focus on failures and adversities as personal shortcomings.
- are less confident about themselves.
- lack a sense of commitment to their works.
- have a hard time recovering from setbacks and under-achievements.
- quickly lose interest in activities and works they were a part of.
- expect results without putting in an effort.
- are highly susceptible to depression and anxiety about facing failures.
- focus more on their weaknesses and less on their strengths.
Motivational Interviewing (MI) has proven to be particularly useful with clients that lack self-efficacy and believe they may be unable to change.
Motivational Interviewing, when used as a technique to increase self-efficacy, is more than merely planting a seed that change is possible. It is very much a collaborative process of careful cultivation of the client’s belief in his or her ability to achieve their goals. Motivational interviewing strategies increase what is known as change talk. They do not ask if the client is motivated, but instead, what motivates him or her.
We can assess levels of self-efficacy, asking the client to rate his or her ability to make the desired change. You may phrase the question as follows:
On the scale of 1 to 100, how confident are you that if you chose to make the change, you could change. Mark 0 if you do not at all believe that you can succeed and select 100 if you are extremely confident that you have the skills to achieve your goals for change. Use the following scale as a guide.
|Do not believe at all that I have the skills to change||50-50 chance I will achieve my goal||Completely confident I will succeed|
If the client scored low on the self-efficacy scale and feels resigned and unable to change, increasing optimism about the possibility of change and focusing on internal strengths are some of the effective methods to encourage change talk and increase belief in one’s ability to change.
This can be done through the following questions:
- Tell me about a time you made changes in your life. How did you do it?
- What personal strengths do you have that would help you succeed?
- Imagine you decided to change, what about you would enable you to do it?
- What encourages and inspires you?
- Who could offer you support in making this change?
Decisional Balance and Motivation
We all differ in the extent to which they are motivated and able to change. Often, people say they want to change, but they do not know-how, are unable to, or are not fully ready to change.
Simply put, it is not that people do not want to change, but they are often not ready yet. Employing a directive, client-centered style of interaction, motivational interviewing aims to resolve this ambivalence and help people to make positive changes (Miller & Rollnick, 2002).
This can be accomplished through questions or comments designed to:
- promote greater awareness of a problem,
- recognition of the advantages of change,
- increased intent to change, or
- elaboration on a topic related to change.
While doing so, the motivation comes from the other person. One does not give or instill motivation in the other person to change their behavior. Instead, motivation is elicited.
One tool that can help a client resolve ambivalence about making the change is the Decisional Balance worksheet. It explores Pro’s and Con’s or the good and not-so-good things about the behavior in question. The counselor can facilitate the process during the session by eliciting client responses that would correspond with each of the four quadrants representing differing aspects of changing the behavior or making a change.
What is the current situation costing you? (this could be a scaling question)
What challenges will you face to make the change?
How are you benefiting from the current situation?
What can you gain by making the change?
How important is that to you? (this could be a scaling question)
Doing this cost-benefits analysis includes discussing specific consequences of the client’s behavior, and assessing the positive or negative aspects of the client’s past, present, or future. An essential component of using this tool effectively is to verbalize an appreciation for ambivalence as a normal part of the client’s experience as he/she considers change.
The goal here is to discuss the client’s ambivalence in detail and facilitate a costs/benefits analysis through soliciting the client’s input about making a change versus continuing the same behavior. It can also be done by developing a written Pros and Cons list with the client, either during the counseling session or reviewing in detail, a list completed before the session.
A Take-Home Message
Carl Rogers used to say that psychologists had the most important job in the world, because ultimately, what we need more than new discoveries in the physical sciences are better interactions between human beings.
The good life is a process, not a state of being. It is a direction not a destination.
Motivational interviewing strategies do not ask IF the client is motivated, but WHAT motivates him or her.
Do you believe motivation is something we all possess?
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