About

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Motivational Interviewing, often abbreviated as “MI,” is the evidence-based, client-centered, or patient-centered counseling approach for use by clinicians and counselors of all types designed to help clients change behavior toward healthier options. Behavior change is a significant component of almost all health related treatments, from simply taking medications regularly to complete lifestyle change. But change is not easy and people have to be motivated to change their behavior. They have to see the benefits of doing something so difficult when maintaining the status quo, no matter what that might be, seems easier.

Often, the benefits of change seem obvious to the clinician. Avoiding AIDS if one is HIV positive seems important enough for patients to take a small daily dose of medication. And yet, according to the World Health Organization, only 50% of people in developed countries worldwide who have life-threatening illnesses are adherent to their treatment regimens. Despite knowing the danger of tobacco products, millions of people still smoke. Obesity is a major health concern and a clear harbinger of disease and death, yet populations in wealthy countries keep getting more obese. And the list goes on.

Counselors, physicians, health care providers of all kinds often naively believe that all they have to do is educate people to the negative consequences of their behavior to persuade people to change. There are lots of pages on the internet about how to persuade people. In at least one article in the scientific literature, doctors are encouraged to present patients with gruesome videos of lung cancer patients in order to get them to quit smoking.  (Swindell J, McGuire AL, Halpern SD. Beneficent persuasion: techniques and ethical guidelines to improve patients’ decisions. Ann Fam Med. 2010;8(3):260-264.) While change isn’t easy, persuading people to change, even if it is in their own best interest, is also difficult.

This is not to say that there aren’t good therapeutic interventions available to professionals of all kinds. Great medications and medical treatments, if used, can keep patients healthy. Many kinds of psychotherapy have proven to be effective at relieving psychological suffering from anxiety, depression, post-traumatic stress disorder and so on. Drug and alcohol treatment programs are also effective as is coaching, academic counseling, even advice giving, if people are motivated to begin with. But what if people are ambivalent or even resistant about changing? Then these programs are ineffective and counselors feel frustrated and burned out. But, if people become motivated especially for intrinsic or internal reasons, they will make use of these great interventions to change their behavior.

So, the issue is often how to get clients more motivated first before applying evidence-based treatment regimes. And this is where Motivational Interviewing comes in.

Motivational Interviewing was developed, at first, as an adjunct to alcoholism treatment. Dr. Bill Miller conducted a study in 1980 on the behavioral treatment of alcoholism and surprisingly found that therapist style rather than the type of behavioral treatment used, was a better predictor of treatment outcome even 2 years after treatment. After some reflection and further refinement, including continuing clinical trials, Motivational Interviewing was born. Early clinical trials clearly showed that a treatment program for alcoholism was twice as effective when preceded by Motivational Interview as compared to no Motivational Interviewing. Over the years, and with an ever increasing evidence base of clinical trials, Motivational Interviewing has been shown to be similarly effective in many areas including: “cardiovascular rehabilitation, diabetes management, dietary change, hypertension, illicit drug use, infection risk reduction, management of chronic mental disorders, problem drinking, problem gambling, smoking, and concomitant mental and substance use disorders.” (Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. The American psychologist, 64(6), 527–537. doi:10.1037/a0016830.) And the research continues. For a summary of recent articles, the reader is directed to the Motivational Interviewing Network of Trainers website: www.motivationalinterviewing.org.

Motivational Interviewing borrows heavily from the client-centered approach of Carl Rogers and is an extension and evolution of Rogers’ work. The main difference being that Rogers was non-directive in his approach whereas MI focuses on a target behavior and is therefore directional.

There are psychological theories that help to explain the effectiveness of Motivational Interviewing. Prochaska and DiClemente's Transtheoretical Model of Change, sometimes referred to as the Stages of Change Model, helps to understand how people change their behavior and why it is important to know where the client is on the continuum of change before initiating treatment. For example, if the client is in the Contemplation stage of change, which is marked by ambivalence, information, advice, and treatment procedures are often not accepted. This can lead the provider of services to see the client as being "resistant" or unwilling to change because he or she doesn't readily act on the clinician's plan. If the clinician first assesses that the client is in the Contemplation Stage of change, then the ambivalence can be dealt with first and treatment progresses smoothly. In Motivational Interviewing, ambivalence is dealt with directly, resolved, and the client, now motivated, can then move on and benefit from treatment. Motivational interviewing provides 2 ways to assess clients' stage of change.

Two other theories in psychology help to understand why people may not act on good advice, doctors' prescriptions, or psychological interventions. "Reactance Theory" states that people will resist persuasion, especially about something they feel ambivalent about. (Brehm J. W. (1966). A theory of psychological reactance. New York, NY: Academic Press.) And "Self-perception Theory" states that people will come to believe what they hear themselves saying. (Bem, D. J. (1972). Self-perception theory. Advances in experimental social psychology, 6, 1-62.) Thus, if a counselor is trying to persuade an ambivalent person to change behavior and the client is ambivalent about that change, it is likely, according to these two theories, that the client will resist that persuasion, and, hearing his/her own arguments, will become more reluctant to change. In Motivational Interviewing, the tendency of helping professionals to persuade their clients through the use of arguments, information, advice, and persuasion is know as the Righting Reflex. The Righting Reflex is thus counter-productive to change and is to be avoided in Motivational Interviewing.

Ryan and Deci's "Self Determination Theory" helps us to understand the differences between intrinsic and extrinsic motivations and the importance of supporting clients' innate psychological need for autonomy. (www.selfdeterminationtheory.org)  In Motivational Interviewing, using autonomy supportive language is one way to assure that information the counselor has for the client is readily accepted and not resisted. 

The power of Motivational Interviewing comes from the skillful use of basic client-centered counseling skills, called the OARS skills in MI. OARS is an acronym that stands for: Open-ended questions, Affirmations, Reflections, and Summaries. These skills are used to generate "change talk" and reduce "sustain talk" during a session. Careful listening and differential responding to these two types of client statements allows the clinician to move a client toward healthy behavioral change. When information or advice is required, Motivational Interviewing provides 4 specific ways to deliver the information that circumnavigate the difficulties of Reactance and Self-perception theories and allows the client to accept and act on the information.

There are many ways to learn how to do Motivational Interviewing. The skills are relatively easy to learn, especially for clinicians who have a background in basic client-centered or patient-centered communication techniques. Applying the skills as described above, to generate change talk and reduce sustain talk,  takes practice. But the basics can be learned by reading a book, taking an online training course, or attending a seminar or workshop. This web site is designed to provide some options for anyone interested in learning more about Motivational Interviewing.

Bill Matulich, Ph.D.