Motivational Interviewing(MI) is a clinical approach useful for working with clients that are not currently motivated to change in their treatment. Through MI, a counselor works with the client to help them explore and resolve ambivalence and to find internal motivation for changing behaviors. MI is especially useful with certain populations that have been historically categorized as “treatment resistant,” such as individuals with addiction, individuals on probation, and individuals in in-patient treatment such as residential treatment programs (RTF) and hospitals.
MI was developed by clinical psychologists William R Miller and Stephen Rollnick in the 1980s and 1990s, originally for treatment of problem drinkers. It was found that lasting motivation to change had to be elicited internally from the client, rather than from outside forces. The main goals of the counselor in MI are to create a therapeutic relationship resembling a partnership, and to provide information and content that the client has not previously expressed.
It is the spirit of MI that drives the relationship between counselor and client. This spirit is encompassed by four key elements: collaboration, evocation, autonomy and compassion.
- The therapeutic partnership between counselor and client is The client is seen as the expert on themselves, their histories, their circumstances and their prior attempts to change. Collaboration builds rapport and establishes trust. This does not mean that the counselor must agree with everything that the client states; this process is focused on mutual understanding, not on “being right.”
- Evocation is the act of helping the client draw out their own thoughts and ideas, rather than imposing opinions on them. The motivation to change is most durable when it comes from the client.
- Empowering the client to make their own lasting change is called autonomy. The counselor’s role is to provide all of the options and consequences so that the client can choose their own actions.
- Compassion encompasses the counselor’s commitment to encourage their client’s welfare and to seek to understand their experiences, values and motivations. Compassion is being respectful of the client’s path and choices and understanding that difficult emotions will be experienced along the way.
Stages of Change
Clients are often in a state of flux in regards to their motivations to change. This concept is summed up in the stages of change found in the Transtheoretical Model of Behavior Change (TTM):
- Pre-contemplation is marked by the client not seeing any reasons or motivations to change.
- Contemplation occurs when a client is willing to consider the possibility of a problem, but has no desire to change.
- Preparation is marked by the client making a commitment to change and creating a change plan.
- The Action stage takes place when the client has identified that there is a problem, has committed to making a change, and has taken the first steps in actively changing the baseline behavior of concern (BOC).
- The Maintenance stage can be identified when a client has shown some proficiency in their changed behavior, and have shown consistency in their choice to use these changed behaviors over their previous BOCs. (Note: Relapse is a sub-stage of both Action and Maintenance, marked by a return to the previous BOCs.)
- Termination occurs when a client has made a lasting change and has shown proficiency in their changed behaviors. While this stage may identify as termination, most clients will agree that change, and the idea of support, will continue.
Many clients will fall within the first two stages when first entering treatment. MI will be useful for working with clients in these early stages.
Phases, Principles and Skills
MI has two phases. In the first phase, the motivation to change is built primarily through eliciting change talk– when the client actively discusses change and their commitment to do so. Change talk is heard in five categories: desire, ability, need, reason and commitment. Change talk is elicited by adhering to the principlesand basic interaction skillsof MI.
The four principles of MI can be summed up with the acronym RULE:
- Resisting the “righting reflex” – The righting reflex is the tendency of those in the helping profession to want to actively fix the problems of our clients. However, this has a paradoxical effect: because of ambivalence, the client is apt to point out the problems with the solution or provide reasons not to change the behavior. Furthermore, the client may not see change as possible. Therefore, it is important for the counselor to resist this reflex so that the client can come to their own reasons and motivation for change.
- Understand the client’s own motivations -Since change must occur from the client’s own motivations, it is the counselor’s responsibility to openly explore the client’s interests, concerns and values and to understand them, in order to help the client identify motivations and possible barriers to change.
- Listen with empathy. Listening to the client is the counselor’s most essential tool to identify change talk. In addition, active listening skills will portray empathy and will allow for a greater alliance between the counselor and client. Finally, listening will allow the counselor to better understand and accept the client’s feelings and perspective.
- Empower your patient – Change and motivation can only occur if the client feels that they play an active part in their treatment. Empowerment leads to hope that change is possible, paves the way for more ideas, and makes the realization that change is in the control of the client.
These four principles are the backbone of MI, but it is the four basic intervention skills that build the motivation to change. The acronym here is OARS:
- Ask Open-ended questions
- Make Affirmations
- Use Reflecting Listening
- Provide Summary statements
Open-ended questions give the counselor the opportunity to learn more about the client’s values and what may or may not motivate them. They are imperative in eliciting change talk so that the client can talk more and make the realization that their current behaviors are not working or are not good for them.
Affirmations help validate and support the client as they see reasons for motivation. Affirmations are crucial when the counselor hears change talk, in order to support strengths and efforts for change.
Reflective listening involves the skill of rephrasing statements in order to amplify or reinforce efforts to change. Reflections seize upon the implicit meanings and feelings of the client’s statements. This allows the client to continue personal exploration and understand their motivations toward change.
Summary statements ensure mutual understanding of the conversation by providing check-ins of what was said. They allow the counselor to introduce discrepancies between what the client says and the observed or reported actions, as well as their current situations and their future goals.
In MI’s second phase, the therapist and client focus on strengthening the commitment to change. This is done by summarizing the client’s current situation, laying out the reasons for change, providing asked-for information and advice, creating the change plan with the client’s commitment to that plan, and then putting the plan in action.
At its most effective, MI works in tandem with the client, bringing their needs and interests to the forefront in order for them to discover their own motivations for change. By discovering this internal motivation, they will be able to make lasting change in their lives. This then leads to the benefits of increased client self-efficacy and engagement in treatment, and a greater likelihood for long-term success.
Dominick DiSalvo, M.A., LPC is Senior Director of Clinical Services for KidsPeace’s Pennsylvania residential program, overseeing all aspects of clinical treatment in the program to ensure quality, integrity and coordination in the residential program. DiSalvo holds a master’s degree in clinical counseling from LaSalle University and is a Licensed Professional Counselor. He has worked in a variety of clinical and supervisory roles since joining KidsPeace in 2012.
Jason R Frei, LCSW, MPA is the Life Skills Manager for KidsPeace’s Pennsylvania residential (RTF) program, overseeing and monitoring all aspects of the Life Skills program. Frei holds Master’s degrees in Social Work and Public Administration from Kutztown University and is a Licensed Clinical Social Worker. He has worked as a clinician and a supervisor since joining KidsPeace in 2015.