Motivational Interviewing

Motivational Interviewing is defined as a collaborative, goal-oriented style of communication with particular attention to the language of change.

From: Lung Cancer Rehabilitation, 2023

Chapters and Articles

Motivational Interviewing

Robert Rhode PhD, in Integrative Medicine (Fourth Edition), 2018

Foundation or Spirit of Motivational Interviewing

A motivational interviewing approach is built upon four foundational values. Most health care providers, particularly integrative medicine ones, find that these are already part of their consultations or interactions:

1.

Accepting the client. This includes empathizing with the client and recognizing that the client is valuable and competent regardless of his or her circumstances. It also involves recognizing that it is the client who has to adopt the health-promoting behavior; the health care provider cannot do it to the client or for the client. This also includes demonstrating support for the client’s ability to decide to change now, later, or not at all.

2.

Compassion. Dedication to others’ welfare and well-being has often been present in the health care provider’s life and values long before formal training and working with clients.

3.

Collaboration. Involves coming along side, joining up, or looking at the client’s life or situation with the client; partnering with the client to consider a difficult situation.

4.

Curiosity. Instead of trying to instill knowledge or motivation, the health care provider helps the client access his desire and reasons for doing the health-promoting behavior. The health care provider does not lead with his or her expertise but rather solicits and learns what the client knows first.

A directive helping style does not involve a lot of collaboration with the client because the health care provider is adopting an expert role and “driving the bus.” Similarly, it is not so important to be curious about the client’s experience because the clinician is deciding what needs to be done. An example of this is when the clinician tells the client that he or she is drinking too much, meets the criteria for alcoholism, needs to attend Alcoholics Anonymous meetings, and should abstain from drinking. The client’s objection to the diagnosis and treatment recommendation does not change the clinician’s directions and is often labeled, very logically, by the clinician as an example of the client’s denying reality or the truth (“The patient is in denial.”).

Noncompliance is often used to blame the patient that does not follow a directive helping style. In fact, noncompliance is two people working towards different goals.

When a motivational interviewing style is used, the clinician respects the client as capable and competent, and therefore it makes sense to collaborate with him or her. If the clinician intends to collaborate with the client, it makes sense to respect and support his or her autonomy. The client will literally be the one to implement (or not) the health-promoting behavior. During a stay in the hospital, health care providers may have more control over the patient’s diet, activity, and medication. When the client is out of the hospital, he or she decides what to eat, what to do, and what medication to take. Respecting this reality and explicitly recognizing that the client will make these decisions relieves the clinician of the frustrating task of trying to control the client. The clinician is no longer driving the bus but is “on the bus” with the client, looking at health behaviors and decisions with the client. If the client is capable, competent, and believed to be the key person to implement any treatment, then it makes perfect sense to be curious about the client’s experience and his or her reasons for embracing or rejecting the health-promoting behaviors.

The client who is drinking too much is approached differently with this mindset. The clinician still maintains a focus on the destination of less drinking or abstaining, but instead of telling the client what the problem is, he or she now asks what the client thinks about the drinking and how it fits with other goals or values. Instead of pushing a treatment, the clinician explores what makes sense to the client. The client’s objections to abstaining are not heard as denial but rather as the client’s natural ambivalence to giving up something that he or she enjoys or to which he or she is attached. The clinician may help the client find his or her motivation to change this drinking by exploring which of the client’s goals or experiences are diminished by the current drinking.

This collaboration with a client who is recognized as capable seems consistent with integrative medicine as described by Andrew Weil:7 “There is this tremendous innate healing capacity that we all have. When I sit with a person who is sick, always at the back of my mind is the question, What is blocking healing here? What is preventing it? What can I do from outside that can facilitate that process?

Table 101.1 describes some ways to experiment with a helping style that is consistent with motivational interviewing. This can be summarized as, “Don’t tell, ask.”

A similar way to generate a motivational interviewing consistent approach is for the health care provider to suspend the expert role. He or she will very likely join the client who is facing the challenge of improving well-being or managing a chronic condition. Although “care” today has the connotation of intervening in a beneficial way, another meaning is “to be with.” Collaborating includes looking together at the situation. While looking in the same direction, being curious about the client’s motivation for the health-promoting behaviors is easier. Table 101.2 outlines four questions that have been used in this manner.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780323358682001018

Motivational Interviewing

Richard L. Brown MD, MPH, in Integrative Medicine (Second Edition), 2007

Effectiveness of Motivational Interviewing

Many studies document the effectiveness of motivational interviewing. Project MATCH, the largest randomized controlled trial ever performed in the behavioral realm, found that motivational interviewing is as effective as 12-step oriented therapy and cognitive behavioral treatment for alcohol dependence.3

A meta-analysis conducted by Hettema and colleagues4 considered 72 studies of various designs, in which motivational interviewing was (1) compared with other treatments, usual treatments, or no treatment, (2) added to other or usual treatments, or (3) studied by itself. The most commonly studied behaviors were alcohol, drug, and tobacco use, risk behaviors for human immunodeficiency virus infection, treatment behaviors, water purification, diet, and exercise. Studies took place in a wide variety of settings with a great diversity of professionals delivering the counseling. The average duration of the counseling intervention was 2.2 hours. At 3-month follow-up, effect sizes ranged from .41 to .71 (moderate to strong) for most behaviors.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9781416029540501058

Motivational Interviewing for Addictions

Lisa H. Glynn, Theresa B. Moyers, in Evidence-Based Addiction Treatment, 2009

Common Misconceptions About Motivational Interviewing

Motivational interviewing is sometimes confused with other treatments and some of the elements of MI are easy to misunderstand. The following are some common myths about MI.

Motivational interviewing is just “being nice” to a client. Although empathy is an important component of MI, it is considered an insufficient condition for change. Other therapist factors, such as direction and evocation of change talk, are also likely play a role in treatment outcomes.

Motivational interviewing should be used with every substance abuse client. As mentioned earlier, MI is useful for very specific (and common) problems in substance abuse treatment. When clients are ambivalent about changing, research tells us that MI is likely to be helpful. Other approaches, including cognitive–behavioral treatments, are often needed as well.

Clients who have not recognized their addiction cannot benefit from therapy. Individuals who are precontemplative actually can benefit greatly from MI therapy. The therapist’s job is to raise importance by educating the client about the risks of current behavior (only after asking permission) and then soliciting the client’s take on that information. Offering “what if” scenarios can be helpful here.

Motivational interviewing can be used to treat nearly any condition. Although MI has empirical support for a number of addictions and other health behaviors, it should not be considered a cure for every condition. Nonetheless, reflective listening and the MI “way of being” can be useful in many interpersonal interactions, including most therapies.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780123743480000094

Motivational Enhancement Approaches

Steve Martino, in Interventions for Addiction, 2013

Other Applications

The empirical base of MI and the ubiquitous nature of motivational issues as part of most behavior change efforts have created substantial interest and broad application of MI into many areas other than addictions. Of particular interest to the addiction field is the integration of MI into the treatment of psychological (e.g. depression, anxiety, or psychosis) and health-related behavior problems (e.g. diet, exercise, or risky behavior), both areas of high comorbidity for people with substance use disorders. Extensive reviews of this literature and demonstrations of these kinds of clinical applications are now available. Moreover, given that many offenders are adjudicated on drug-related crimes, the corrections field has become increasingly interested in applying MI to rehabilitate offenders. Many parole and probation officers and other correction professionals are now learning how to use MI to interact with offenders at all stages of legal supervision. Empirical evidence for the use of MI for these new applications awaits controlled clinical research.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780123983381000026

Adults: Clinical Formulation & Treatment

Robin J. Davidson, in Comprehensive Clinical Psychology, 1998

6.25.3.1 Motivational Interviewing

Motivational interviewing was described by Stockwell (1992) as the most important and influential therapeutic development within the field of addiction over the past decade. In his original account of motivational interviewing, Miller (1983) saw motivational problems as a result of the therapist/client dialogue, with the behavior of the therapist influencing the expectations, attributions, and behavior of the client. Denial was said to be a product of the more traditional, confrontational, therapeutic interaction. During motivational interviewing the individual is encouraged to reach his or her own decision about change, while the role of the therapist is simply to facilitate this process through clarification, advice when appropriate, accurate feedback, and empathy. The aim of therapy is to increase cognitive dissonance until a critical mass of motivation has been achieved and the individual is ready to move from precontemplation to eventual action. At this point commitment to real behavioral change is a likely outcome. Motivational interviewers operationally define motivation as the probability that a person will enter into, continue, and adhere to a specific change strategy and there is a strong emphasis on ambivalence resolution and the decisional balance. Essentially the client begins to present his or her own argument for change rather than being directed by a coercive therapist, while it is the therapist's role to set in place the optimum conditions for change. Specific motivational interviewing strategies and the treatment rationale have been detailed elsewhere (Miller & Rollnick, S., 1991).

Motivational interviewing is something of a misnomer in as much as it has little to do with contemporary cognitive theories of motivation. Rather it seems to be an example of the phenomenological approach to change and adapts the psychology of self-actualization to the promotion of personal change among alcohol and drug abusers. Miller and Rollnick, S. (1991) contrast motivational interviewing with client-centered counseling by arguing, for example, that empathic reflection is invariably and noncontingently employed in client-centered counseling but used only selectively in motivational interviewing. Furthermore, they say that the good motivational interviewer is not afraid to proffer advice and will actively attempt to create discomfort and discrepancy rather than passively follow the client. Davidson (1996) suggests that this analysis is based on something of a caricature of the Rogerian position and that neo-Rogerian client-centered approaches are more active and task-focused than was hitherto the case. While the distinction between motivational interviewing and contemporary client-centered counseling may be little more than semantic, this is no bad thing. Motivational interviewing is an excellent example of a therapeutic system, squarely based on psychological principles, tailored to individual change in addictive behavior.

Rollnick, Heather, and Bell (1992) described a brief form of motivational interviewing that is beginning to be used to good effect in primary care settings. Miller and Baca (1993) found some evidence of better long-term outcome in a small group of patients who received a brief motivational interview over those who experienced a more directive, traditional style of interview. Baker, Kochan, Dixon, Heather, and Wodak (1994), however, could demonstrate no significant difference in HIV risk-taking behavior between a brief motivational interview and a nonintervention control condition. Kuchipudi, Hobein, Fleckinger, and Iber (1990) found brief motivational interviewing to be unsuccessful in reducing future drinking. Saunders, Wilkinson, and Phillips (1995) present a controlled trial of a brief motivational intervention with 122 drug abusers attending a methadone clinic. Subjects were randomly assigned to a motivational condition or a control, educational procedure. After six months, the motivational subjects showed significantly greater commitment to abstinence, reported more positive outcome expectancies and relapsed less quickly than the control group. The authors concluded that motivational interventions can be a useful adjunct to a methadone program. Heather, Rollnick, Bell, and Richmond (1996) reported a comparison between brief motivational interviewing, skill-based counseling, and a nonintervention control condition in a sample of heavy drinkers. While there were no significant differences between the intervention conditions in terms of a quantity/frequency measure at six months, clients who were evaluated at baseline as “not ready to change” responded better to motivational interviewing. This is interpreted as providing support for the view that motivational interviewing is most appropriate for those in the contemplation stage. Noonan and Moyers (1997) conducted a review of 11 trials that compared motivational interviewing with a range of other treatments. It seemed that motivational interviewing was uniquely effective if it succeeded in eliciting positive motivational responses without evoking resistance. It was, however, not particularly effective in the more severely dependent drinkers. Nonetheless the authors concluded that motivational interviewing was essential for all groups in the assessment interview as it reduced attrition rates.

The enormous popularity of motivational interviewing is in contrast to relative paucity of positive outcome studies. However, on balance it would seem that motivational interviewing strategies act in some way to resolve ambivalence and promote greater commitment to change.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B0080427073002340

Behavioral Treatments for Smoking

Sheila M. Alessi, David M. Ledgerwood, in Interventions for Addiction, 2013

Motivational Interviewing

Motivational interviewing is a client-centered counseling style focused on developing motivation to change. The therapist’s role is to uncover and help build rapport, resolve ambivalence, provide normative feedback, and evoke commitment to change in an empathetic and collaborative manner. The principles of motivational interviewing are to express empathy, develop discrepancy, roll with resistance to change, and support self-efficacy to make changes. Content covered includes personalized relevance of change, risks and rewards of change, roadblocks to change, and the need for repetition in these efforts. The overall goal is to evoke the client’s own intrinsic motivation and to empower the client to make decisions rather than having decisions imposed by others. Conceptually, this therapeutic style should be most effective in persons who demonstrate low motivation to change, although the research literature is mixed in that regard. A recent meta-analysis by the Cochrane Collaboration found that motivational interviewing was associated with increased abstinence at 6-month follow-up compared to brief advice or usual care, and counseling contact longer than 20 min was especially effective. Findings of increased odds of smoking cessation with motivational interviewing are further supported by two additional meta-analyses to date. Beneficial effects may be less substantial in pregnant women compared to nonpregnant women. In general, though, improvements in outcomes with motivational interviewing seem on par with benefits with other effective psychosocial therapies.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780123983381000178

Smoking Cessation

M. Glover, H. McRobbie, in International Encyclopedia of Public Health, 2008

Motivational interviewing

Motivational interviewing is a client-centered directive method for enhancing intrinsic motivation to change smoking behavior by exploring and resolving ambivalence. Health professionals using motivational interviewing usually demonstrate the principles of expressing empathy, supporting self-efficacy, rolling with resistance, and developing discrepancy for the client (for more on motivational interviewing, see section titled ‘Relevant Websites’). Motivation interacts with dependence and can guide the level of treatment that can be provided. Measurement of the degree of motivation can be useful in knowing whether to offer treatment. However, once a smoker has decided to embark on a quit attempt the degree of motivation has little bearing on the outcome of the quit attempt.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780123739605003518

Clinical Implications of Network Principles 3–12

Warren W. Tryon, in Cognitive Neuroscience and Psychotherapy, 2014

Motivational Interviewing

Motivational interviewing (MI) is now an established evidence-based intervention. Miller and Rollnick (2002) provided a book-length description of motivational interviewing. The following URL contains several good sources including an 8-minute video covering the background and basics of MI (http://www.motivationalinterview.org/). In it one learns that MI arose as a part of the professional treatment of alcoholism instead of using recovered alcoholics as therapists. MI recognizes that people with substance abuse are ambivalent and conflicted about change. On the one hand they seek treatment because their substance abuse is causing problems, but on the other hand they continue to enjoy their substance of choice or use it to avoid uncomfortable cravings and withdrawal symptoms. Therapists traditionally take a change perspective in that their interventions are presented as a way to make change. The natural dialectic is for client’s to take the other side and automatically, unconsciously, resist change. Therapists traditionally assume that people who abuse substances are overly defensive. This prompts therapists to try to breach perceived defenses via some form of confrontation. Challenging these clients to change only makes them angrier and more defensive, thus confirming the traditional therapist’s assumption that their underlying problems are anger and defensiveness. The typical result is that these clients drop out of treatment unless therapy is court-ordered, which only fosters more anger and more resistance. Traditional therapists then typically conclude that their clients were not sufficiently motivated to change and thus are poor candidates for therapy. By contrast, MI therapists see their task as helping the individual develop their own reasons and methods for changing their behavior. Draycott and Dabbs (1998b) noted that MI grew out of William Miller’s personal style of therapy (see Miller, 1983, 1996). Again we sadly see that an effective treatment was developed by a clinician as a result of their clinical practice, rather than as a reasoned extension of psychological science.

Draycott and Dabbs (1998a) observed that clinical psychology was not making full use of the then-available psychological research. These authors then reviewed the research on cognitive dissonance and concluded that it was relevant to clinical psychology. They reviewed the social psychological literature regarding ways to increase, maintain, and reduce dissonance. The final section of their article concerns the clinical applications of dissonance theory which they developed further in regard to MI in their subsequent article (Draycott & Dabbs, 1998b). One of the five clinical objectives of MI is to develop discrepancies between strongly held cognitions, beliefs, and their substance abuse behaviors in order to generate internal motivation for change. Another clinical objective is to help the person reduce this dissonance in a responsible way (cf. Tashiro & Mortensen, 2006).

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780124200715000119

Motivating the Kidney Disease Patient to Nutrition Adherence and Other Healthy Lifestyle Activities

Steve Martino, ... Frederic Finkelstein, in Nutritional Management of Renal Disease (Third Edition), 2013

Roll with Resistance

In MI, resistance refers to a patient’s statements about what sustains his problematic behaviors. These expressions may be about the reasons for the behaviors (“Eating a lot relaxes me”) or the difficulties of trying to change them (“I can’t resist the urge to smoke”). Resistance informs providers about dilemmas faced by individuals, thereby providing opportunities for addressing obstacles to change. In using MI, a provider would avoid adopting a confrontational, authoritative, warning, or threatening tone (all inconsistent with MI), which might cause the patient to become even less engaged in treatment [14].

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780123919342000461

Motivating the patient with kidney disease to nutrition adherence and other healthy lifestyle activities

Noel Quinn, ... Steve Martino, in Nutritional Management of Renal Disease (Fourth Edition), 2022

Conclusion

MI is a recognized evidence-based practice for addressing behavioral problems that holds great promise for motivating patients with kidney disease to adhere to various aspects of the complex treatment regimens and other healthy lifestyle activities that are important for these patients. MI has a clear set of principles and strategies that guide implementation and substantial training resources to prepare providers to conduct MI proficiently. The popularity of MI continues to grow and the health-care field remains challenged to study if and how it works within its new applications, such as for the management of kidney disease, and to ensure that providers implement it with integrity to improve treatment outcomes. The nephrology community should learn how to apply MI techniques in CKD clinics and dialysis facilities. Carefully done studies will then need to be done to document the impact of MI on a variety of patient outcomes.

Read full chapter
URL: https://www.sciencedirect.com/science/article/pii/B9780128185407000422