Motivational Interviewing

Introduction

The concept of motivational interviewing evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in Behavioural Psychotherapy. These fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. A noteworthy omission from both of these documents, however, was a clear definition of motivational interviewing.

We thought it timely to describe our own conceptions of the essential nature of motivational interviewing. Any innovation tends to be diluted and changed with diffusion (Rogers, 1994). Furthermore, some approaches being delivered under the name of motivational interviewing (c.g., Kuchipudi, Hobein, Fleckinger and Iber, 1990) bear little resemblance to our understanding of its essence, and indeed in some cases directly violate what we regard to be central characteristics. For these reasons, we have prepared this description of: (1) a definition of motivational interviewing, (2) a terse account of what we regard to be the essential spirit of the approach; (3) differentiation of motivational interviewing from related methods with which it tends to be confused; (4) a brief update on outcome research evaluating its efficacy; and (5) a discussion of new applications that are emerging.

Definition

Our best current definition is this: Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with nondirective counselling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal.

The spirit of motivational interviewing

We believe it is vital to distinguish between the spirit of motivational interviewing and techniques that we have recommended to manifest that spirit. Clinicians and trainers who become too focused on matters of technique can lose sight of the spirit and style that are central to the approach. There are as many variations in technique there are clinical encounters. The spirit of the method, however, is move enduring and can be characterized in a few key points.

1. Motivation to change is elicited from the client, and not imposed from without. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilizing the client's intrinsic values and goals to stimulate behaviour change. 2. It is the client's task, not the counsellor's, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict, for example, "If I stop smoking I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive." The counsellor's task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that triggers change. 3. Direct persuasion is not an effective method for resolving ambivalence. It is tempting to try to be "helpful" by persuading the client of the urgency of the problem about the benefits of change. It is fairly clear, however, that these tactics generally increase client resistance and diminish the probability of change (Miller, Benefield and Tonigan, 1993, Miller and Rollnick, 1991). 4. The counselling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of motivational interviewing and are explicitly proscribed in this approach. To a counsellor accustomed to confronting and giving advice, motivational interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to "confront client denial," easily slip into pushing clients to make changes for which they are not ready. 5. The counsellor is directive in helping the client to examine and resolve ambivalence. Motivational interviewing involves no training of clients in behavioural coping skills, although the two approaches not incompatible. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centred and respectful counselling atmosphere. 6. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction. The therapist is therefore highly attentive and responsive to the client's motivational signs. Resistance and "denial" are seen not as client traits, but as feedback regarding therapist behaviour. Client resistance is often a signal that the counsellor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies. 7. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client's autonomy and freedom of choice (and consequences) regarding his or her own behaviour.

Viewed in this way, it is inappropriate to think of motivational interviewing as a technique or set of techniques that are applied to or (worse) "used on" people. Rather, it is an interpersonal style, not at all restricted to formal counselling settings. It is a subtle balance of directive and client-centred components. shaped by a guiding philosophy and understanding of what triggers change. If it becomes a trick or a manipulative technique, its essence has been lost (Miller, 1994).

There are, nevertheless, specific and trainable therapist behaviours that are characteristic of a motivational interviewing style. Foremost among these are:

* Seeking to understand the person's frame of reference, particularly via reflective listening * Expressing acceptance and affirmation * Eliciting and selectively reinforcing the client's own self motivational statements expressions of problem recognition, concern, desire and intention to change, and ability to change * Monitoring the client's degree of readiness to change, and ensuring that resistance is not generated by jumping ahead of the client. * Affirming the client's freedom of choice and self-direction

The point is that it is the spirit of motivational interviewing that gives rise to these and other specific strategies, and informs their use. A more complete description of the clinical style has been provided by Miller and Rollnick (1991).

Differences From Related Methods

The check-up

A number of specific intervention methods have been derived from motivational interviewing. The Drinker's Check-up (Miller and Sovereign, 1989; Schippers, Brokken and Otten, 1994) is an assessment-based strategy developed as a brief contact intervention with problem drinkers. It involves a comprehensive assessment of the client's drinking and related behaviours, followed by systematic feedback to the client of findings. (The check-up strategy can be and has been adapted to other problem areas as well. The key is to provide meaningful personal feedback that can be compared with some normative reference.) Motivational interviewing is the style with which this feedback is delivered. It is quite possible, however, to offer motivational interviewing without formal assessment of any kind. It is also possible to provide assessment feedback without any interpersonal interaction such as motivational interviewing (e.g., by mail), and there is evidence that even such feedback can itself trigger behaviour change (Agostinelli, Brown and Miller, 1995).

Motivational Enhancement Therapy (MET)

MET is a four-session adaptation of the check-up intervention (Miller, Zweben, DiClemente and Rychtarik, 1992). It was developed specifically as one of three interventions tested in Project MATCH (1993), a multisite clinical trial of treatments for alcohol abuse and dependence. Two follow-up sessions (at weeks 6 and 12) were added to the traditional two-session check-up format to parallel the 12-week (and 12 session) format of two more intensive treatments in the trial. Motivational interviewing is the predominant style used by counsellors throughout MET.

Brief motivational interviewing

A menu of concrete strategies formed the basis for "Brief Motivational Interviewing", which was developed for use in a single session (around 40 minutes) in primary care settings with non-help-seeking excessive drinkers (Rollnick, Bell and Heather, 1992). We found that it was not immediately apparent to primary care workers how to apply the generic style of motivational interviewing during brief medical contacts. Therefore Rollnick and Bell designed this set of quick, concrete techniques meant to manifest the spirit and practice of motivational interviewing in brief contact settings. An unresolved issue is whether the spirit of motivational interviewing can be captured in still briefer encounters of as little as 5-10 minutes. Numerous attempts to do this are underway, although only one method has been published to date (Stott, Rollnick, Rees and Pill, 1995).

Brief intervention

This raises a fourth common confusion. Brief intervention in general has been confused with motivational interviewing, helped perhaps by the introduction of more generic terms such as "brief motivational counselling" (Holder, Longabaugh, Miller and Rubonis, 1991). Such brief interventions, as focused on drinking, have been offered to two broad client groups: heavy drinkers in general medical settings who have not asked for help, and help-seeking problem drinkers in specialist settings (Bien, Miller and Tonigan, 1993).

Attempts to understand the generally demonstrated effectiveness of brief intervention, have pointed to common underlying ingredients, one expression of which is found in the acronym FRAMES originally devised by Miller and Sanchez (1994). The letters of FRAMES refer to the use of Feedback, Responsibility for change lying with the individual, Advice-giving, providing a Menu of change options, an Empathic counselling style, and the enhancement of Self-efficacy (see Bien et al., 1993; Miller and Rollnick, 1991). Although many of these ingredients are clearly congruent with a motivational interviewing style, some applications (e.g., of advice-giving) are not (Rollnick, Kinnersley and Stott 1993). Therefore motivational interviewing ought not be confused with brief interventions in general. We suggest that the word "motivational" be used only when there is a primary intentional focus on increasing readiness for change. Further, "motivational interviewing" should be used only when careful attention has been paid to the definition and characteristic spirit described above. Put simply, if direct persuasion, appeals to professional authority, and directive advice-giving are part of the (brief) intervention, a description of the approach as "motivational interviewing" is inappropriate. We are concerned to prevent an ever-widening variety of methods from being erroneously presented (and tested) as motivational interviewing. It should also be useful to distinguish between explanations of the mechanisms by which brief interventions work (which might or might not involve motivational processes) and specific methods, derived from motivational interviewing, which are designed to encourage behaviour change.

Differences From More Confrontational Approaches

Although motivational interviewing does, in one sense, seek to "confront" clients with reality, this method differs substantially from more aggressive styles of confrontation. More specifically, we would regard motivational interviewing as not being offered when a therapist;

* argues that the person has a problem and needs to change * offers direct advice or prescribes solutions to the problem without the person's permission or without actively encouraging the person to make his or her own choices * uses an authoritative/expert stance leaving the client in a passive role * does most of the talking, or functions as a unidirectional information delivery system * imposes a diagnostic label * behaves in a punitive or coercive manner