9 Motivational Interviewing

Learning Objectives

What is Motivational Interviewing?

“Motivational interviewing  is a person-centered counseling style for addressing the common problem of ambivalence about change.

MI is a counseling style based on the following assumptions:

• Ambivalence about substance use and change is normal and is an important motivational barrier to substance use behavior change.
• Ambivalence can be resolved by exploring the client’s intrinsic motivations and values.
• Your alliance with the client is a collaborative partnership to which you each bring important expertise.
• An empathic, supportive counseling style provides conditions under which change can occur.

You can use MI to effectively reduce or eliminate client substance use and other health-risk behaviors in many settings and across genders, ages, races, and ethnicities. The MI counseling style helps clients resolve ambivalence that keeps them from reaching personal goals. MI builds on Carl Rogers’s (1965) humanistic theories about people’s capacity for exercising free choice and self-determination. Rogers identified the sufficient conditions for client change, which are now called “common factors” of therapy, including counselor empathy (SAMHSA, 2019).

As a counselor, your main goals in MI are to express empathy and elicit clients’ reasons for and commitment to changing substance use behaviors. MI is particularly helpful when clients are in the Precontemplation and Contemplation stages of the Stages of Change (SOC), when readiness to change is low, but it can also be useful throughout the change cycle.

Watch the following video regarding using MI as a therapeutic counseling method from founder, Dr. Michael Miller.

The Spirit of MI

Use an MI counseling style to support partnership with clients. Collaborative counselor–client relationships are the essence of MI, without which MI counseling techniques are ineffective. Counselor MI spirit is associated with positive client engagement behaviors (e.g., self-disclosure, cooperation) (SAMHSA, 2019) and positive client outcomes in health-related behaviors (e.g., exercise, medication adherence) similar to those in addiction treatment.

The spirit of MI comprises the following elements:

• Partnership refers to an active collaboration between you and the client. A client is more willing to express concerns when you are empathetic and show genuine curiosity about the client’s perspective. In this partnership, you are influential, but the client drives the conversation.
• Acceptance refers to your respect for and approval of the client. This doesn’t mean agreeing with everything the client says but is a demonstration of your intention to understand the client’s point of view and concerns. In the context of MI, there are four components of acceptance:
  • Absolute worth: Prizing the inherent worth and potential of the client
  • Accurate empathy: An active interest in, and an effort to understand, the client’s internal perspective reflected by your genuine curiosity and reflective listening
  • Autonomy support: Honoring and respecting a client’s right to and capacity for self-direction
  • Affirmation: Acknowledging the client’s values and strengths
• Compassion refers to your active promotion of the client’s welfare and prioritization of client needs.
• Evocation elicits and explores motivations, values, strengths, and resources the client already has.

To remember the four elements, use the acronym PACE.  The specific counseling strategies you use in your counseling approach should emphasize one or more of these elements (SAMHSA, 2019).

MI reflects a longstanding tradition of humanistic counseling and the person-centered approach of Carl Rogers. It is theoretically linked to his theory of the “critical conditions for change,” which states that clients change when they are engaged in a therapeutic relationship in which the counselor is genuine and warm, expresses unconditional positive regard, and displays accurate empathy (Rogers, 1965).

MI adds another dimension in your efforts to provide person-centered counseling. In MI, the counselor follows the principles of person-centered counseling, but also guides the conversation toward a specific, client-driven change goal. MI is more directive than purely person-centered counseling; it is guided by the following broad person-centered counseling principles:

• SUD treatment services exist to help recipients. The needs of the client take precedence over the counselor’s or organization’s needs or goals.
• The client engages in a process of self-change. You facilitate the client’s natural process of change.
• The client is the expert on his or her own life and has knowledge of what works and what doesn’t.
• As the counselor, you do not make change happen.
• People have their own motivation, strengths, and resources. Counselors help activate those resources.
• You are not responsible for coming up with all the good ideas about change, and you probably don’t have the best ideas for any particular client.
• Change requires a partnership and “collaboration of expertise.”
• You must understand the client’s perspectives on his or her problems and need to change.
• The counseling relationship is not a power struggle. Conversations about change should not become debates. Avoid arguing with or trying to persuade the client that your position is correct.
• Motivation for change is evoked from, not given to, the client.
• People make their own decisions about taking action. It is not a change goal until the client says so.
• The spirit of MI and client-centered counseling principles foster a sound therapeutic alliance.

Research on person-centered counseling approaches consistent with MI in treating alcohol use disorder (AUD) found that several sessions improved client outcomes, including readiness to change and reductions in alcohol use (SAMHSA, 2019)

Four Processes of MI

MI has moved away from the idea of phases of change to overlapping processes that more accurately describe how MI works in clinical practice. This change is a shift away from a linear, rigid model of change to a circular, fluid model of change within the context of the counseling relationship. This section reviews these MI processes, summarizes counseling strategies appropriate for each process, and integrates the four principles of MI from previous versions (Andrea Polites; Bruce Sewick; Jason Florin; and Julie Trytek, 2024).

Engaging

Engaging clients is the first step in all counseling approaches. Specific counseling strategies or techniques will not be effective if you and the client haven’t established a strong working relationship. MI is no exception to this. Miller and Rollnick (2013) define engaging in MI “as the process of establishing a mutually trusting and respectful helping relationship” (p. 40). Research supports the link between your ability to develop this kind of helping relationship and positive treatment outcomes such as reduced drinking.

Opening strategies

Opening strategies promote engagement in MI by emphasizing OARS in the following ways:

• Ask open questions instead of closed questions.
• Offer affirmations of client self-efficacy, hope, and confidence in the client’s ability to change.
• Emphasize reflective listening.
• Summarize to reinforce that you are listening and genuinely interested in the client’s perspective.
• Determine the client’s readiness to change or and specific stage in the SOC (see Chapters 1 and 2).
• Avoid prematurely focusing on taking action.
• Try not to identify the client’s treatment goals until you have sufficiently explored the client’s readiness. Then you can address the client’s ambivalence.

These opening strategies ensure support for the client and help the client explore ambivalence in a safe setting. In the following initial conversation, the counselor uses OARS to establish rapport and address the client’s drinking through reflective listening and asking open questions:

Counselor: Jerry, thanks for coming in. (Affirmation) What brings you here today? (Open question)

Client: My wife thinks I drink too much. She says that’s why we argue all the time. She also thinks that my drinking is ruining my health.

Counselor: So your wife has some concerns about your drinking interfering with your relationship and harming your health. (Reflection)

Client: Yeah, she worries a lot.

Counselor: You wife worries a lot about the drinking. (Reflection) What concerns you about it? (Open question)

Client: I’m not sure I’m concerned about it, but I do wonder sometimes if I’m drinking too much.

Counselor: You are wondering about the drinking. (Reflection) Too much for…? (Open question that invites the client to complete the sentence)

Client: For my own good, I guess. I mean it’s not like it’s really serious, but sometimes when I wake up in the morning, I feel really awful, and I can’t think straight most of the morning.

Counselor: It messes up your thinking, your concentration. (Reflection)

Client: Yeah, and sometimes I have trouble remembering things.

Counselor: And you wonder if these problems are related to drinking too much. (Reflection)

Client: Well, I know it is sometimes.

Counselor: You’re certain that sometimes drinking too much hurts you. (Reflection) Tell me what it’s like to lose concentration and have trouble remembering. (Open question in the form of a statement)

Client: It’s kind of scary. I am way too young to have trouble with my memory. And now that I think about it, that’s what usually causes the arguments with my wife. She’ll ask me to pick up something from the store and when I forget to stop on my way home from work, she starts yelling at me.

Counselor: You’re scared that drinking is starting to have some negative effects on what’s important to you, like your ability to think clearly and good communication with your wife. (Reflection)

Client: Yeah. But I don’t think I’m an alcoholic or anything.

Counselor: You don’t think you’re that bad off, but you do wonder if maybe you’re overdoing it and hurting yourself and your relationship with your wife. (Reflection)

Client: Yeah.

Counselor: You know, Jerry, it takes courage to come talk to a stranger about something that’s scary to talk about. (Affirmation) What do you think? (Open question)

Client: I never thought of it like that. I guess it is important to figure out what to do about my drinking.

Counselor: So, Jerry, let’s take a minute to review where we are today. Your wife is concerned about how much you drink. You have been having trouble concentrating and remembering things and are wondering if that has to do with how much you are drinking.  You are now thinking that you need to figure out what to do about the drinking. Did I miss anything? (Summary)

Avoiding traps

Identify and avoid traps to help preserve client engagement. The above conversation shows use of core MI skills to engage the client and help him feel heard, understood, and respected while moving the conversation toward change.  The counselor avoids common traps that increase disengagement.

Common traps to avoid include the following (Miller & Rollnick, 2013):

• • The Expert Trap: People often see a professional, like a primary care physician or nurse practitioner, to get answers to questions and to help them make important decisions. But relying on another person (even a professional) to have all the answers is contrary to the spirit of MI and the principles of person-centered care. Both you and the client have expertise. You have knowledge and skills in listening and interviewing; the client has knowledge based on his or her life experience. In your conversations with a client, remember that you do not have to have all the answers, and trust that the client has knowledge about what is important to him or her, what needs to change, and what steps need to be taken to make those changes. Avoid falling into the expert trap by:
    • Refraining from acting on the “righting reflex,” the natural impulse to jump into action and direct the client toward a specific change. Such a directive style is likely to produce sustain talk and discord in the counseling relationship.
    • Not arguing with the client. If you try to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for change.

• • The Labeling Trap: Diagnoses and labels like “alcoholic” or “addict” can evoke shame in clients. There is no evidence that forcing a client to accept a label is helpful; in fact, it usually evokes discord in the counseling relationship. In the conversation above, the counselor didn’t argue with Jerry about whether he is an “alcoholic.” If the counselor had done so, the outcome would likely have been different:

Client: But I don’t think I’m an alcoholic or anything.

Counselor: Well, based on what you’ve told me, I think we should do a comprehensive assessment to determine whether or not you are.

Client: Wait a minute. That’s not what I came for. I don’t think counseling is going to help me.

• • The Question-and-Answer Trap: When your focus is on getting information from a client, particularly during an assessment, you and the client can easily fall into the question-and-answer trap. This can feel like an interrogation rather than a conversation. In addition, a pattern of asking closed questions and giving short answers sets you up in the expert role, and the client becomes a passive recipient of the treatment intervention instead of an active partner in the process. Remember to ask open questions, and follow them with reflective listening responses to avoid the question-and-answer trap.
  • The Premature Focus Trap: You can fall into this trap when you focus on an agenda for change before the client is ready—for example, jumping into solving problems before developing a strong working alliance. When you focus on an issue that is important to you (e.g., admission to an inpatient treatment program), but not to the client, discord will occur. Remember that your approach should match where the client is with regard to his or her readiness to change.
  • The Blaming Trap: Clients often enter treatment focused on who is to blame for their substance use problem. They may feel guarded and defensive, expecting you to judge them harshly as family, friends, coworkers, or others may have. Avoid the blame trap by immediately reassuring clients that you are uninterested in blaming anyone and that your role is to listen to what troubles them.

Focusing

Once you have engaged the client, the next step in MI is to find a direction for the conversation and the counseling process as a whole. This is called focusing in MI. With the client, you develop a mutually agreed-on agenda that promotes change and then identify a specific target behavior to discuss. Without a clear focus, conversations about change can be unwieldy and unproductive (Miller & Rollnick, 2013).

Deciding on an agenda

MI is essentially a conversation you and the client have about change. The direction of the conversation is influenced by the client, the counselor, and the clinical setting (Miller & Rollnick, 2013). For example, a client walking through the door of an outpatient SUD treatment program understands that his or her use of alcohol and other drugs will be on the agenda.

Clients, however, may be mandated to treatment and may not see their substance use as a problem, or they may have multiple issues (e.g., child care, relational, financial, legal problems) that interfere with recovery and that need to be addressed. When clients bring multiple problems to the table or are confused or uncertain about the direction of the conversation, you can engage in agenda mapping, which is a process consistent with MI that helps you and clients decide on the counseling focus. Exhibit 3.7 displays the components in an agenda map.

Identifying a target behavior

Once you and the client agree on a general direction, focus on a specific behavior the client is ready to discuss. Change talk links to a specific behavior change target (Miller & Rollnick, 2010); you can’t evoke change talk until you identify a target behavior. For example, if the client is ready to discuss drinking, guide the conversation toward details specific to that concern. A sample of such a conversation follows:

Counselor: Marla, you said you’d like to talk about your drinking. It would help if you’d give me a sense of what your specific concerns are about drinking. (Open question in the form of a statement)

Client: Well, after work I go home to my apartment and I am so tired; I don’t want to do anything but watch TV, microwave a meal, and drink till I fall asleep. Then I wake up with a big hangover in the morning and have a hard time getting to work on time. My supervisor has given me a warning.

Counselor: You’re worried that the amount you drink affects your sleep and ability to get to work on time. (Reflection) What do you think you’d like to change about the drinking? (Open question)

Client: I think I need to stop drinking completely for a while, so I can get into a healthy sleep pattern.

Counselor: So I’d like to put stop drinking for a while on the map, is that okay? [Asks permission. Pauses. Waits for permission.] Let’s focus our conversations on that goal.

Notice that this client is already expressing change talk about her alcohol use. By narrowing the focus from drinking as a general concern to stopping drinking as a possible target behavior, the counselor moved into the MI process of evoking.

Evoking

Evoking elicits client motivations for change. It shapes conversations in ways that encourage clients, not counselors, to argue for change.  Evoking is the core of MI and differentiates it from other counseling methods (Miller & Rollnick, 2013). The following sections explore evoking change talk, responding to change talk and sustain talk, developing discrepancy, evoking hope and confidence to support self-efficacy, recognizing signs of readiness to change, and asking key questions.

Evoking change talk

Engaging the client in the process of change is the fundamental task of MI. Rather than identifying the problem and promoting ways to solve it, your task is to help clients recognize that their use of substances may be contributing to their distress and that they have a choice about how to move forward in life in ways that enhance their health and well-being. One signal that clients’ ambivalence about change is decreasing is when they start to express change talk.

 The first step to evoking change talk is to ask open questions. There are seven kinds of change talk, reflected in the DARN acronym. DARN questions can help you generate open questions that evoke change talk. Exhibit 3.8 provides examples of open questions that elicit change talk in preparation for taking steps to change.

supplemental videos

References

Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series, No. 41. HHS Publication No. (SMA) 15-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.

Miller & Rollnick, 2013. Motivational Interviewing: Helping People Change (3rd ed.), pp. 171‒173. Adapted with permission from Guilford Press.

Substance Abuse and Mental Health Services Administration. Enhancing Motivation for Change in Substance Use Disorder Treatment. Treatment Improvement Protocol (TIP) Series No. SAMHSA  Publication No. PEP19-02-01-003. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2019.

Andrea Polites; Bruce Sewick; Jason Florin; and Julie Trytek (2024). Addictions Counseling Essentials. Press Publishing.