What is MI and how can it be applied in everyday life?
Overview
"When a person has a problem, why don’t they change? Do people fail to see how serious their situation is? When a person is abusing drugs, not exercising, or eating poorly, is it that they don't have enough knowledge to understand that they're destroying their health, or do they simply not care?"
Many health professionals ponder such questions when trying to help patients in a health crisis to change their behaviour. But hesitancy to change is part of human nature (Hettema, Steele & Miller, 2005). Clients presenting to health clinics for help exhibit a wide range of readiness (Miller & Rollnick, 2013). Eight out of those ten in need of change are ambivalent about change (Miller & Rollnick, 2013).
According to Prochaska and Diclemente’s transtheoretical model, behaviour changes encompass a cycle of stages of change: precontemplation, contemplation, preparation, action and maintenance. At the precontemplation and contemplation stages, people often wonder about change, but they don’t act. The primary goal then is for therapists is to help clients overcome the hesitation hurdle in the direction of change (Hettema et al., 2005; Miller, 2004).
This chapter discusses how to utilise motivational interviewing (MI) to resolve ambivalence towards change and thereby to elicit behaviour change. It will start with elucidating what MI is, what are the underlying theories and applications of MI in the real world, especially in the health care settings.
What is MI?
MI is a client-centred counselling style to enhance personal motivation for behaviour change by exploring and overcoming ambivalence (Miller, 2004). It was originally designed as a prelude to integrate with other clinical methods to assist clients through motivational obstacles to change (Miller, 2004). It can also be given as a brief stand-alone intervention usually in one or two sessions (Hettema et al., 2005). Based on the trans-theoretical model of change, it is to prepare clients to shift from the precontemplation and contemplation to the real stage for change (Miller & Rollnick, 2009). Clients who are ready for change are unlikely to benefit from MI. Clients who appear to be angry, resistant and less ready for change seem to benefit most from MI (Miller & Rollnick, 2009). The beauty of MI is to selectively reinforce clients’ own reason for change, almost like clients talk themselves into change (Miller & Rollnick, 2009). A skillful therapist walks with the client along a road from initial ambivalence to motivational readiness, an achievable plan for change, and commitment to the change (Miller & Moyers, 2006). Therefore, MI encompasses two phases: stimulating motivation for change and reinforcing commitment for change (Miller & Rollnick, 2009).
History of MI
MI was introduced by William Miller and Stephen Rollnick in 1980s when treating patients with alcohol abuse. At that time there was a broad-sweeping judgement of alcoholic clients that saw them as deceptive and unreliable, such that counselors had to impart knowledge, insight, and motivation for change. Counselors took an authoritarian position and commonly questioned clients’ wrongdoing in a confrontational style. Counselor-domineering approaches such as disagreeing/arguing could lead to higher level of client resistance, and thereby jeopardize the quality of therapeutic treatment (Miller, 1996). Based on the trans-theoretical model, clients who entered the help program might have not yet committed to change, or still felt ambivalent about change (Miller & Rollnick, 2009). Therefore, Miller believed the priority was to evoke clients’ motivation for change. He advocated an empathetic, client-centered counselling style, and more attention was drawn to strengthening clients’ own words for change. The result was clients under William Miller’s care achieved double the rate of total abstinence at 3-month and 6-month follow-up compared to other clients without receiving MI. Furthermore, clients that received MI were more likely to comply with the treatment and were more motivated for change (Miller & Rose, 2009). Later MI was combined with assessment feedback, resulting in the formation of motivational enhancement therapy (MET). Nowadays, MI and MET have been implemented in various fields, such as cardiovascular rehabilitation, diabetes management, dietary change, hypertension, infection risk reduction, gambling, and smoking (Miller & Rose, 2009).
| Conventional approach | Miller's approach |
|---|---|
| This person ought to change | This person wants to change |
| A tough, confrontational approach is always the best | A negotiation-based approach is the best |
| I'm the expert, I know everything, e.g., I know what you need | I need to evoke the client's intrinsic motivation for change, e.g., You have what you need |
Table 1. Comparison between Miller's approach to the conventional approach
Theoretical basis of MI
Client-centred Counselling
MI owes great debt to Carl Rogers' client-centred psychotherapy which emphasises the positive human potential (Miller, 2004). Given the appropriate empathic understanding, positive regard, and radical acceptance, people will naturally move towards a healthy, self-fulfilling state (Hettema et al., 2005). Clearly the insights and methods of Carl Rogers are the fundamental practice of MI, but also Miller claims MI is one step more advanced as it is counselling oriented toward change (Miller & Rollnick, 2009). Typically, in a MI session, the client speaks most of the time as the therapist listens. This asymmetry of communication is especially notable around the client’s of motivation for change (Miller & Rollnick, 2009).
Self-perception Theory
Self-perception theory postulates that when people defend an attitude which is not what they originally believe, they tend to act or speak more in favour of this new attitude (Miller, 2004). In other words, the support on their previous beliefs is weakened or even diminished. In relation to MI, when the client speaks of change of their own free will, it results in that person feeling more favourable towards the change and being more able to take steps towards improvement (Miller, 2004).
Spirit of MI
Partnership
MI advocates an egalitarian relationship between the therapist and the client (Miller, 2004). Instead of the therapist being the superior expert exhorting what is right, the therapist recognises the client’s hidden capability in knowing what one wants, what works best to achieve that (Miller & Rollnick, 2013). The therapist here is to use his/her expertise to create a supportive interpersonal relationship in which the client is to be aspired for free aspiration (Miller & Rollnick, 2013). Miller portrays MI as a dancing partnership, in which both members in the group collaborate together, with one leading the direction in the movements gracefully without coercion (Miller & Rollnick, 2013). Not surprisingly, this partner-like relationship requires a profound respect to the other. Analogically, running MI is like flipping through a client’s life photo album; it is to understand the world through the client’s point of view, not to dominate the entire process or to offer expert opinion on how to live a rightful way (Miller & Rollnick, 2013).
Acceptance
Acceptance in MI does not refer to the therapist’s personal approval. Acceptance has four aspects consisting of absolute worth, accurate empathy, autonomy, and affirmation, which are deeply rooted in Carl Roger’s humanistic psychotherapy (Miller & Rollnick, 2013).
First, acceptance refers to generalised caring and unconditional positive regard. It recognises every single individual as a complete, separate human being who deserves basic respect and trust (Miller & Rollnick, 2013). Borrowing from Roger’s self-actualising belief, a person can improve or grow towards an ideal direction when appropriate therapeutic conditions are provided. Whereas, when this essential trust/respect cannot be guaranteed, intrinsic change will not occur just like a plant cannot grow in the absence of adequate water and rich soil (Miller & Rollnick, 2013).
Second, accurate empathy indicates a genuine and active interest in understanding the client’s insight. It is noteworthy that empathy differs from sympathy. Sympathy is a feeling of pity and once a therapist starts showing pity, he/she inadvertently takes a more superior status and start judging the client. This contradicts the egalitarian partnership (Miller & Rollnick, 2013).
The third necessary element is autonomy. MI acknowledges clients’ active involvement in decision making regarding when and how to change (Miller, 2004). The change would only effectively occur if willingness to change came from within the client, in agreement with the client's own interests and values (Miller & Rollnick, 2013). In other words, MI discourages argument for change. Miller believes the conventional approach in which the therapist ask questions about why it is important to change, what will happen if change does not occur, will only lead to the client denying there is a problem. This denial, in turn, results in resistance to change (Miller, 2004).
Affirmation encompasses an understanding and recognition of the client’s effort and contribution in the therapy (Miller & Rollnick, 2013). Affirmation ties closely in with the other three elements and, taken as a whole, results in accepting the client as a worthy human and not merely assessing the client’s wrongdoing. Together, the client and therapist can work together to reach a common goal (Miller & Rollnick, 2013).
Compassion
In terms of ethics, compassion posits acting benevolently on the behalf of the client. It is to pursue the gain and welfare of the client and honestly puts clients’ need first. Only by doing so, can it ensure the other three aspects of the spirits are in place thereby an optimal atmosphere for evoking change is made possible (Miller & Rollnick, 2013).
Evocation
The conventional authoritarian approach is based on a deficit model in which the client is being assessed and criticised, the therapist is to utilise the professional knowledge, expertise to correct that deficit (Miller & Rollnick, 2013). In contrast, Miller and Rollnick (2013) believe clients have enough resources and insights, and it is up to the therapists to uncover these abundant hidden resources within the clients (Miller & Rollnick, 2013).
| What to do | What not to do |
|---|---|
| Advocate equal relationship | Dominate the therapy session |
| Guide | Prescribe |
| Evoke intrinsic motivation and confidence | Tell the client why and how to change |
| Create an equal and acceptable atmosphere | Focus on the behaviour change at the cost of empathy |
| Actively listen and encourage change talk | Convince and hand down expertise knowledge/insight |
Table 2. Contrast between MI spirit and conventional therapy approach
Person-centered guiding
These skills derive from Rogers' person-centered counselling aiming to convey the spirit of MI into real practice. There skills emphasise on active listening in order to establish a peaceful therapeutic alliance (Miller & Moyers, 2006). These skills are known as OARS: open-ended questions, affirmation, reflections, and summaries.
Open-ended questions
Open-ended questions are more encouraged in MI than closed-ended questions as they serve the purpose of letting the client do most of the talking so that not only can the client’s insight and concerns be revealed, but more importantly, a peaceful, trustworthy therapeutic alliance can be established (Miller & Rollnick, 2013; Naar-King & Suarez, 2011).
Test yourself, is it an open or a closed question?
However, too many questions in a row can have the opposite effect. People may feel they are being interrogated or interpret the questions as the questioner not listening to them (Naar-King & Suarez, 2011). The purpose is to start up a topic for exploration and then follows with other strategies. A skillful therapist should be able to recognise the most effective and appropriate strategies based on the situation and the client’s characteristics. For instance, some are generally talkative and, in this case, the therapist is to guide the exploration towards change talk. On the other hand, some may not like revealing and discontinue the topic where it is started. Therefore, it is up to the therapist to utilise the skill whenever is appropriate (Miller & Rollnick, 2013).
Affirmation
Another way to maintain rapport in the therapist-client relationship is the use of compliments or statements of appreciation and understanding. The main point here is to focus on honesty and specificity (Naar-King & Suarez, 2011). Below are some examples (Miller & Rollnick, 2013, p. 72):
- “Thanks for coming on time today.”
- “It seems like you are a really strong-willed person in a way.”
- “You enjoy being happy with other people and making them laugh.”
Naar-King and Suarez (2011) also point out that different types of affirmation require careful timing. For instance, when the person is more ready to change, it is better to affirm a specific behaviour (e.g., "It’s great that you cut back on your drinking"). In contrast, if change has not yet occurred, complimenting one’s strength may be more effective (e.g., "You are willing to consider difficult situations in order to make the best choice for yourself") (Naar-King & Suarez, 2011).
Reflections
Miler considers reflective listening is one of the most important and challenging skills required for MI (Miller, 2004). It is frequently used to express accurate empathy and to understand the client’s interpretation of the real world. Reflective listening is not merely being quiet while listening, it is more about the way how the therapist responds to what the client says. The therapist can easily fall into the trap of inactive listening, which is defined as ‘roadblocks’. Some examples include: tell the person what he/she should do; warning; disagreeing/criticising; providing solutions; blaming/criticising; probing. What really behind the ‘roadblocks’ is the therapist diverts from the egalitarian partnership and the underlying message is do what the expert says (Miller & Rollnick, 2013). Below is an example illustrating how the therapist inadvertently sets up roadblocks while listening to a client discussing about an important decision.
Client: I just don’t know whether to leave him or not.
Therapist: You should do what you think is best. (tell the person what she should do)
Client: But I don’t know what is best.
Therapist: Yes, you do, in your heart. (disagreeing/criticising)
Client: Well, I just feel trapped, stifled in our relationship.
Therapist: Have you thought about separating for a while to see how you feel? (giving advise/providing solutions)
Client: But I love him, it would hurt him so much if I left!
Interviewer: Yes, if you don’t do it, you could be wasting your life! (warning/threatening)
(Miller & Rollnick, 2013, p.72)
This exchange illustrates a poor running of MIing as ambivalence is not being explored, rather, the client has been pushed towards one solution. This is not a good example of reflective listening either, because the client is dealing with ‘roadblocks’ rather than be given the chance to fully express or explore (Miller & Rollnick, 2013).
Now let’s look at what a proper reflective listening is like. Here is an example looking at a problem drinker with ambivalent issues.
Client: I worry sometimes I may be drinking too much for my own good.
Therapist: You’ve been drinking quite a bit.
Client: I don’t really feel like it’s that much. I can drink a lot and not feel it.
Therapist: More than most people.
Client: Yes. I can drink most people under the table.
Therapist: And that’s what worries you.
(Miller & Rollnick, 2013, p. 73)
Reflective listening is more like a statement guessing what the client means. Reflective listening is a very skillful technique. The therapist must hear the message correctly, it is not just what is said, more importantly it is what the client means. People do not always say what they mean, and it is up to the therapist to decode the words and find the underlying messages behind it. Unexperienced therapists may only be able to reflect on what the client just said, this can make the conversation run in circles. A competent therapist with good reflective listening skills can go deeper into the conversation resulting in a better understanding of what the client actually means (Miller & Rollnick, 2013).
Summary
The use of summarising is to reinforce those important points which have just been discussed, and to demonstrate to clients that they have been listened to intently, in order to prepare clients to express themselves further. There are three types of summary, and their purposes are listed below (Miller & Rollnick, 2013).
| Types of summary | Explanation |
|---|---|
| Collecting Summary | Often used in the process of exploring, after client made several change talk (will be explained later), this is to reinforce change talk through repeat. It is suggested to end in “what else”, so to prepare client reveal further |
| Linking Summary | Combine what the client just said with new material
Especially useful in addressing ambivalence as it offers client to go back and forth looking at reasons to change and reasons to stay the same |
| Transitional Summary | Often used at the end of a session, before another session starts, so to prepare client for what is going to follow next |
Responding to resistance
Resistance is inevitable in MI and its emergence usually indicates the client is not ready for the next step. When resistance arises, the therapist should acknowledge it and address accordingly (Miller & Rollnick, 2013).
Resistance should be regarded as normal response and how well the therapist deals with resistance is going to hugely impact the treatment outcome. Study has shown resistance happens early in the counselling predicted dropout from the treatment or the client is less likely to initiate change (Miller & Moyers, 2006). When resistance does occur, the therapist should step back, and acknowledge the clients’ emotions and perception and treat these as an opportunity to further explore clients’ needs rather than something to fight against. Here, the therapist needs to demonstrate good reflective listening skills, showing genuineness and empathy. Another approach is to go around the hurdle so to postpone the dissonance and to work on other issues that is less challenging (Miller & Moyers, 2006). No matter what the responses are, it is vital to ensure personal control. If this is not maintained, it will only further frustrate the clients leading to less compliance with treatments (Miller & Rollnick, 2013).
Change talk
Change talk is a motivational statement which expresses intention to change, disadvantages of the status quo, and optimism about change (Naar-King & Suarez, 2011). It implies that MI is working and how the client responds to it will determine whether the client is going to commit to change or stick with the status quo. The general technical approach toward change talk should be elaborating, reflecting, summarising and affirming (Naar-King & Suarez, 2011).
| Types of change talk | What is involved | Examples |
|---|---|---|
| Elaborating change talk | Encourage with particular interest and curiosity both verbally and nonverbally (e.g. pay attention, head nodding), | a. What else have you noticed?
b. What are some other reasons you might want to change? |
| Reflecting change talk | Clarify what the client says, carefully select what to reflect upon in order to reinforce change talk | Client: “I want to quit smoking, but I don’t know if I am ready.”
Therapist: “You really believe you want to quit, let’s try…” |
| Summarising change talk | Selectively gather and encapsulate client’s change talk, so that client can hear it again in a more condensed manner | Therapist: “You mentioned a few concerns about taking anti-depressants. You said your mood is better and have more energy while on antidepressants…” |
Table 3. Three types of change talk
Commitment
This is the point when the client has summed up enough intrinsic motivation for change and it is time to strengthen commitment to a change plan (Miller & Moyers, 2006). It is important to recognise when the person is ready for change. Some of the cues can be used to tell when it is time to offer the change plan.
- Decreased resistance: Dissonance in the counselling diminishes
- Decreased discussion about the problem: less conversations on the concern
- Resolve: the client appears more peaceful, relaxed, open and settled
- Change talk: the client makes direct change talk, less satisfaction with the status quo, more look forward to a new start
- Questions about change: the client asks questions about how to implement change
- Envisioning: the client talks about what benefit will come after the change
- Experimenting: the client tries out change actions between sessions
Back to the essence of spirit of MI, it is always the client who decides what needs to be planned and done. The therapist’s role is to offer expertise when is asked for (Miller & Moyers, 2006). If the ambivalence re-emerges, do not force, instead, follow up with the person and leave the opportunity to the client. It is also helpful to use reflective listening and summarising skills to consolidate change talk (Miller & Moyers, 2006).
MI in the real world
Given the fact MI was originally designed to treat alcohol and substance abuse, there are immense studies addressing MI’s efficacy in this area. Majority of the studies have concluded clients have significantly benefited from MI in terms of treatment retention, motivation, adherence, and positive outcomes (Hettema et al., 2005; William & Miller, 2004). But furHttema et al. (2005) further pointed out in their meta-analysis study that the observed effect sizes varied remarkably from d=0 to more than 3.0, which indicates despite using the same MI treatment targeting the same problem, results can vary tremendously across different sites and populations. This also illustrates the treatment integrity can hugely impact the treatment outcomes (Miller & Moyers, 2006). Particularly, therapists’ interpersonal skills can powerfully influence clients’ participation in the treatment (Moyers, Miller & Hendrickson, 2005). As Miller and Rollnick (2013) have strongly argued, acquiring MI is not only a process in reading the manuals, it is a complex skill requiring extensively progressive guidance and personal follow-up coaching.
Favourable treatment outcomes have also been documented when MI is used in addressing substance abuse and related problems (Burke, Arkowitz & Menchola, 2003; Hettema et al., 2005; Miller, 2004). Again, the observable effect sizes were around medium range and seemed to be sustained at 4-year follow-up posttreatments (Burke et al., 2003). Clients received MI treatment benefited most comparing to waiting list and treatment as usual group (Burke et al., 2003; Hettema et al., 2005). It is noteworthy that smoking cessation has been less responsive to MI treatments (Burke et al., 2003; Hettema et al., 2005; Miller, 2004). It is possibly because there are legal implications behind drug abuse whereas smoking seems to be less debilitating therefore less fatal consequences (Burke et al., 2003).
Studies regarding MI on HIV risk behaviour reduction offer mixed results. Miller (2004) revealed MI successfully reduced unprotective intercourse among women at high risk for HIV infection when compared to health education and placebo groups. On the contrary, Burke et al. (2003) claimed based on analysis of the current randomised trials, the yielded result was not statistically significant to suggest MI is more effective than placebo/education control group. They also mentioned the study in this area may not be reliable due to the small number of researches carried out and all the four studies included in this meta-analysis all came from the same institute (Burke et al., 2003).
MI has also been implemented in promoting healthy life choice among participants with cardiovascular disease. A meta-analysis conducted by Thompson et al. (2011) have concluded although the power was low in this area, there are encouraging evidence showing MI is more efficacious than traditional information/advice in reducing BMI and hypertension among cardiovascular patients. This similar effect of MI was also demonstrated on 356 teenage girls in a 16-week physical education class. In this randomised experiment, MI was in conjunction with social support/self-empowerment sessions, lunch get-together and parent outreach activities. At the 9-month follow-up, girls in the intervention group showed increased participation in physical activity and higher self-efficacy in overcoming barriers to physical activity. Improvement was also observed in vegetable/fruit intake and regular breakfast eating (Neumark-Sztainer et al., 2010).
To sum up, MI has higher statistically significant advantages in alcohol/substance use, health lifestyle promotions, mixed results in HIV risk reduction and no supportive evidence in smoking cessation. MI can be delivered by a wide range of health care professionals, regardless of amount of training and supervision across various setting in different stages of disease (Lundahl et al., 2013). On the other side, due to the lack of regulation, it is hard to ensure MI is being strictly followed in the real practice. In fact, many of the studies did not include careful evaluation of treatment integrity such as videotaping, ongoing supervision, and the skills of the MI administrator were not described or standardised (Burke et al., 2003).
Moreover, because MI is designed as either a stand-alone treatment or a prelude to other interventions, the observed MI efficacy can be cofounded by this combined treatment format.
The effectiveness of MI also proves to be different across different populations (Miller & Rose, 2009). Especially recipients from a minority group such as Native Americans showed more promising outcomes compared to White non-Hispanic Americans. This might because the spirit of MI resembles Indian Americans’ native culture style so that those clients were at ease when receiving MI (Miller & Rose, 2009).
Conclusion
MI can be a useful counselling method with broad applicability in health care and promotion settings. It is particularly designed for promoting motivation for change. MI can be delivered as a free-standing intervention in 1-2 sessions. In spite of the moderate effect sizes in most of the clinical trials, MI still appears better than conventional intervention or placebo control group. But when considering MI elicits similar effect much quicker than other traditional therapies, MI may truly be more cost effective (Burke et al., 2003). In addition, Hettema et al. (2005) postulated refreshing sessions may be added at later follow-ups to bolster its long-term effect. Furthermore, extensive empirical evidence proves MI can be added to other interventions to improve retention, adherence and self-efficacy in achieving desirable goals.
Our understanding of MI is still at a preliminary stage as there are still lots of variability in delivering MI to different clients across many settings. The future focus of the research should be discovering other factors that can alter the efficacy of MI thereby more effective training program can be developed to enhance the application of MI in even broader areas.
See also
- Motivational interviewing (Wikipedia)
- Illicit substance motivation (Book chapter, 2016)
References
Hettema, J., Steele J., & Miller, W. (2005). Motivational interviewing. Annu. Rev. Clin. Psychol,1, 91-111.doi: 10.1146/annurev.clinpsy.1.102803.143833
Lundahl, B., Moleni, T., Burke, B., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counselling, 93, 157-168. Retrieved from http://dx.doi.org/10.1016/j.pec.2013.07.012
Miller, W. (1996). Motivational interviewing: research, practice, and puzzles. Addictive Behaviour, 21(6), 835-842.
Miller, W. (2004). Motivational interviewing in service to health promotion. The Art of Health Promotion, 1,1-6.
Miller, W., & Moyers, T. (2006). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions, 5(1), 3-16.doi: 10.1300/J188v05n01_02
Miller, W., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy,37, 129-140. doi: 10.1017/S1352465809005128
Miller, W., & Rollnick, S. (Ed.). (2013). Motivational interviewing. New York, USA: The Guilford Press.
Miller, W., & Rose, G. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527-537.doi: 10.1037/a0016830
Moyers, T., Miller, W., & Hendrickson, S. (2005). how does motivational interviewing work? Therapist interpersonal skill predicts client involvement within motivational interviewing sessions. Journal of Consulting and Clinical Psychology, 73(4), 590-598.doi: 10.1037/0022-006x.73.4.590
Naar-King, S., & Suarez, M. (2011). Motivational interviewing with adolescents and young adults. New York, USA: The Guilford Press.
Neumark-Sztainer, D., Friend, S., Flattum, C., Hannan, P., Story, M., Bauer, K., ...Petrich, C. (2010). New moves—preventing weight-related problems in adolescent girls: a group-randomized study. American Journal of Preventative Medicine, 39(5), 421-432. doi:10/1016/j.amepre.2010.07.017
Thompson, D., Chair, S., Chan, S., Astin, F., Davidson, P., & Ski, C. (2011). Motivational interviewing: a useful approach to improving cardiovascular health? Journal of Clinical Nursing, 20, 1236-1244.