What is it?

Motivational interviewing (MI) was originally developed by specialists working with problem drinkers (see Miller, 1991). MI is a useful technique to use with people who are initially ambivalent or reluctant to change, particularly when the problematic behaviour is rewarding (e.g. smoking, drinking excessively). This technique avoids confronting the client (e.g., disagreeing, emphasising evidence of impairment, arguing), as this is associated with higher levels of resistance and lowers the likelihood of behaviour change , Benefield, & Tonigan, 1993). Instead, reasons for concern and change are elicited from the patient. These are then explored with the patient in a supportive manner. The goal is to highlight any discrepancies between present behavior and desired goals, as there is evidence to indicate that this can trigger behaviour change (Miller & Rollnick, 1991). Miller and Rollnick (1991) outline five key elements involved in MI:

1. Express empathy.
2. Develop discrepancy.
3. Avoid argumentation.
4. Roll with resistance.
5. Support self-efficacy.

Does it work?

Studies have shown that the behaviour of the therapist has an influence on treatment outcome (e.g., Miller , Benefield, & Tonian, 1993). Such studies lend support to one of the core ideas behind MI, that is, the more you confront the patient about their problem, the more they will engage in the problem behaviour (e.g., drinking). MI advocates that the clinician will be most effective if he or she adopts an empathic approach and works with the patient to enhance motivation for change. Thus, while the evidence is promising, further empirical support is needed, particularly, as there is growing interest in applying this technique to a wide variety of problem behaviours (see Emmons & Rollnick, 2001).

How do you do it?

Miller and Rollnick (1991) have outlined the process of motivational interviewing in detail. It is recommended that the following summary is supplemented with further detailed reading.

1. The first step is to build the patient's motivation for change. It is assumed that initially, the patient will be ambivalent about changing and this is described as the contemplation' or 'precontemplation' stage. Prochaska and DiClemente (1982) have described a six stages of change model which serves as a guide for understanding how and why people change. The six stages are pre-contemplation, contemplation, determination, action, maintenance and permanent exit.
   
   
2. There are five strategies that are recommended for building the patient's motivation for change. These are:
   (i) Ask open-ended questions. This is important first step in order to establish rapport between the patient and yourself. Some examples include, 'I'd like to understand how you see things. What's brought you here? What's been the problem?
   (ii) Listen reflectively. This can be explained as a way of 'checking', rather than 'assuming' that you now what the patient means.
   (iii) Affirm. This can take the form of compliments or statements that indicate and appreciation and understanding of the patient's situation. For example, 'I appreciate how hard it must have been for you to decide to come here'.
   (iv) Summarise. Use summary statements to link information that has been provided by the patient, to summarise ambivalence (e.g., 'it sounds like you are torn two ways…..'), and to check that you have understood him or her correctly.
   (v) Elicit self-motivational statements. The goal is to facilitate the patient's ability to decide upon their own arguments for change, rather than providing the reasons for them. Ideally, you want the patient to arrive at statements such as: 'this is serious…, I've got to do something about this…, I'm going to overcome this problem…'. ```````
   
   
   
3. The next major step is to ascertain how ready the patient is for change. This can be done by exploring the advantages and disadvantages of the present problematic behaviour. The aim at the end of this process is for the patient to realise that the costs of their problem behaviour outweigh any benefits. Formal assessment methods can also be used to assist with this process. Feedback about the results on these measures can be used to enhance motivation and further illustrate any discrepancies between current and desired behaviour.
   For example, Miller and Rollnick (1991) recommend that for drinking problems, the patient is provided with their scores on a relevant measure and an explanation about their score in relation to the population (or other relevant comparison data). It is best to avoid any 'scare tactics' when presenting this information and it can be prefaced with, 'this may or may not concern you…'. Eliciting the patient's reactions to this information is also useful, 'is this what you expected…', how do you feel about this…'.
   
   
4. It is suggested that at the end of this stage of assessment a summary of what has been discussed is provided. This should include (Miller & Rollnick, 1991, p. 99):
   (i) the risks and problems that have emerged from assessment findings;
   (ii) the patient's own reactions to the feedback, including any self-motivational statements that have been made; and
   (iii) an invititation for the client to add or correct the summary.
   
   
5. The next phase is to continue to strengthen the commitment to change and to negotiate a treatment plan with the patient.
   

References and recommended reading:

1. Emmons, K. M. & Rollnick, S. (2001). Motivational interviewing in health care settings. Opportunities and limitations. American Journal of Preventive Medicine, 20(1), 68-74.
2. Miller, W., Benefield, R., & Tonigan, S. (1993). Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 4550-61.
3. Miller, W. R. & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.