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Motivational interviewing.

Motivational Interviewing (MI) is an evidence-based practice for intentional human behavior change. First described by William Miller in 1983, as a practice to be used in substance abuse, it has now been applied to over 20 problem behaviors and translated into 39 languages. (1) (2) (3)

This article first briefly describes the main theoretical foundations of MI and then the basic counseling skills which are attributed to it.

To begin, the main theoretical foundations of MI include; the definition, its spirit, the four main principles, the research which supports it as an evidence-based practice.

Definition:

MI is a client-centered, directive method of communication, for enhancing intrinsic motivation to change by exploring and resolving ambivalence. It is deeply rooted in the work of Carl Rogers in its focus on trying to understand a client's internal experience and frame of reference related to a particular problem behavior. (2) (4)

Spirit:

The spirit of MI compliments the above definition with two beliefs which are vital to counselor success in facilitating change. First is the belief, people have a natural tendency to want to feel better about their unhealthy behavior, i.e. they want to feel less pain. Second is the belief that people are also ambivalent about changing their unhealthy behavior, i.e. at the same time they have reasons to change and reasons not to. Counselors who cannot accept the attitude reflected by the spirit of MI usually fail in using it with their clients. (4)

A counselor can implement this spirit of MI by adhering to three principles in their practice with clients. First, is for the counselor to be Collaborative in their work with clients. In a therapeutic relationship the counselor avoids an authoritarian stance and accepts the differences between an ideal plan for the client, which the counselor would like and what the client is actually willing to do. (4)

The second principle related to the spirit of MI calls for the counselor to be Evocative in their therapeutic interactions with a client. In doing this the counselor is drawing out or asking the client about their own desires and reasons for changing behavior. This practice helps to get at the client's intrinsic motivations for change and is in stark contrast to other counseling practices, in which the counselor is trying to instill motivation or tell the client what to do. (4)

The third principle which underpins this spirit of MI is Autonomy. Autonomy is also a major ethical principle found in most helping professions. It calls upon the counselor to respect the client's right to self-determination in their choice about changing the problem behavior. This principle recognizes one of the truths about change, that is, ultimately the client decides what they will or will not do. (4)

In sum, the spirit of MI suggests a way for a counselor to be with clients. It shapes the attitude of a counselor, in addition to providing a set of therapeutic strategies and techniques. (4)

Main Principles:

There are also four main principles for the counselor to follow when practicing MI. When used in practice they increase a client's motivation to change. The first is to Express Empathy. Expressing empathy is not just a feeling or attitude which a counselor has, it is a behavior which needs to be expressed. When a counselor expresses empathy they demonstrate acceptance and openness to the client by listening. This counselor behavior is crucial to engaging the client in a therapeutic relationship, it encourages the client to be less defensive and more willing to risk discussing their ambivalence about change. (4)

Develop Discrepancy is the second of these principles. Client change

is motivated by the difference they perceive between their current behavior and their personal goals or values. In order to use discrepancies to promote change, the counselor points out the contradictions or gaps between the client's current behavior and their goals, values, or priorities. How the counselor brings these discrepancies to the client's attention is important. Doing this in a confrontational manner will only increase client resistant's to change. Doing this is a gentle manner in which the counsel's tone is one of seeking to clarify the discrepancy is what promotes change. (4)

Rolling with Resistance is the third main principle of MI. By doing this the counselor avoids arguing with or trying to persuade the client to change. When a counselor argues or attempts to persuade a client to change this leaves the client with one option in these interactions, that is, to argue against change and defend the status quo. These counselor behaviors often increase client defensiveness and resistance to change. Instead, the counselor avoids arguments and responds to client resistance by listening and reflecting what the client is saying rather than directly opposing it. We will discuss the skill of reflection later in this article. (4)

The fourth and last principle of MI calls for the counselor to support a client's Self-efficacy. This requires the counselor to change their view of a client's motivation for change. That is, instead of believing a client lacks motivation for change, it is more helpful for the counselor to think the client lacks confidence or hope in the ability to change. If a counselor can do this, then the work with the client can focus on building self-efficacy, i.e. confidence in and ability to change. (4)

The Research:

There is a robust body of research which supports MI as an evidence-based practice. It has been studied across a wide array of applications including substance abuse, mental health, corrections, diet, exercise, smoking and eating disorders. There have been over 100 randomized clinical trials of MI along with a number of reviews summarizing these research findings. (2) (3) A meta-analysis rates MI as the second of eighteen alcoholism treatment approaches, with the most evidence of effectiveness. (5)

The remainder of this article briefly discusses the counseling skills which are attributed to MI. This includes; applications, basic counseling skills ("OARS"), and "Change Talk."

Applications:

MI works best as a therapeutic approach when two conditions are present. One, there is a target behavior to be changed, i.e. stopping alcohol and/or drug use. Second, the client is ambivalent about changing that behavior, i.e. they feel two ways about it. It is also important to note that MI is not appropriate to use when people are suicidal, violent, psychotic, or have a severe medical condition, when a more directive therapeutic intervention is called for. (2) (4)

Basic Counseling Skills:

There are four basic counseling skills fundamental to the practice of MI. They are asking open-ended questions, using affirmations, reflective listening, and summarization. These are commonly referred to by the acronym "OARS."

This first basic counseling skill used in MI is to ask the client open-ended questions. These are questions which cannot be answered with a simple "yes" or "no" answer. Open-ended questions encourage the client to talk more about and provide more information about their unique situation. Done well, open-ended questions provide a way for the counselor to reflect an unbiased, non-judgmental attitude which also promotes and supports the therapeutic relationship with the client. (4)

Examples of open-ended questions are; "What was it like for you to get that DWI?" "What concerns do you have about your use?" "What would be the biggest challenges for you in getting sober?" Open-ended questions focus on the "what," "which," "where," and "how," related to the client's experience. They are most effective when followed by a reflective statement made by the counselor (see below).

Affirmations are the second basic counseling skill used in MI. Affirmations are statements which a counselor makes to support, encourage, reinforce, and acknowledge efforts at change made by the client. (4)

There are three different types of affirmations which a counselor can use in MI. They are statements of appreciation, for example, "I appreciate how hard it is for you to. ..." Expressing understanding, for example, "This must be very difficult for you." And complements, for example, "It's great that you. ..." (4)

To be effective, affirmations must be sincere, specific to the client's situation and immediate. Affirmations are not cheerleading or statements which tell the client to "just do it," nor "this will get better if you try." The effect of affirmations is to help the client build self-esteem, self-efficacy and hope. They also help the counselor to build rapport with the client. (4)

Making reflective statements are the most used and most important of these basic counseling skills used in MI. Reflections are defined as therapeutic hunches, guesses, presumptions, or hypothesis about what the client is trying to express about their inner experience. The content of a counselor's reflections are the thoughts, feelings, and meaning of what a client is saying. (4)

Reflective statements are often grouped into two categories, i.e. simple reflections and complex reflections. Simple reflections are statements made by the counselor which echo, repeat, rephrase, or reword what the client has just said. Complex reflections are also statements made by the counselor but they require more skill and practice. They are statements in which the counselor paraphrases or reflects the deeper meaning or feeling of what the client has just said. Examples of complex reflections might be, "this is all very confusing to you." "What you believe is. ..." "It is very important to you. ..." (4)

Counselors more skilled in the use of reflections may also use a double-sided reflection to make a statement about a client's ambivalence to change, an amplified reflection to overstate the meaning or feeling of what the client has just said, or use a metaphor to provide an example of the explicit meaning of what the client has just said. An example of the use of metaphor as a complex reflection might be, "Your loneness is like playing a flute in an empty concert hall." (4)

The main purpose of using reflections is to help the counselor to understand what the client is saying. This also helps the counselor to express empathy, one of the main principals of MI (see above). The result of using reflective statements is the client feels listened to, understood, and less resistant and more motivated to change. (4)

The final basic counseling skill is summarizing. A summary is a special form of reflective listening, which a counselor uses periodically to review what the client has discussed so far. In doing a summary the counselor expresses their understanding of client's recognition of the problem, concerns about it, reasons for change, and optimism for change. (4)

There are three types of summaries which a counselor may use. In a collecting summary the counselor reflects the collected statements which the client has made about a particular part of the problem behavior. In a linking summary the counselor makes connections between different feelings, meaning, or motivators for the client. Transitional summaries are used by the counselor when moving from one main discussion point to another in a counseling session. (4)

Change Talk:

Change talk is what makes MI unique, it is the essence of MI. Change talk involves client statements which favor changing their behavior. Change talk can be categorized as self-motivational statements which the client makes related to problem recognition, concerns they have about the problem, their awareness of the problem, the potential benefits of change, or the costs of not changing. (4)

A newer conceptualization of change talk is referred to as "DARN" language in which the client makes statements related to their desire ("D") to change ("want to," "like to," "wish to"), their ability ("A") to change ("I can," I could"), their reasons to change ("If., then"), or their need

("N") to change ("I have to," "I need to"). (2)

Research has indicated why focusing on client Change Talk is so important. The amount and intensity of client Change Talk in a counseling session is predictive of client outcome, i.e. the more the client talks about change the more likely they will. Bem (6) suggested, the more a person argues for a particular point of view, the more committed they become to it. When a client takes on a position which supports behavior change, the more committed they become to it. (2)

Using these basic counseling skills related to MI ("OARS") and focusing on client "Change Talk" helps to counselor to implement the definition, spirit and principles of MI. This results in client engagement in the therapeutic relationship, better rates of treatment completion and improved client outcomes.

Bibliography:

(1.) Motivational Interviewing: research, practice, and puzzles. Miller, William. 6, s.l.: Addictive Behaviors, Vol. 21, pp. 835-842.

(2.) Arkowitz, H., Westra, H., Miller, W., Rollnick, S. Motivational Interviewing in the Treatment of Psychological Problems. New York : Guilford Press, 2008.

(3.) Wagner, C., Conners, W. Motivational Interviewing. [Online] Mid-Atlantic Addiction Technology Transfer Center, March 2008. http://www.motivationalinterview.org.

(4.) Miller, W. & Rollnick, S. MotivationalInternviewing. 2nd. New York : Guilford Press, 2002.

(5.) Hester, R. & Miller, W. Handbook of Alcoholism Treatment Approaches. 3rd. Boston : Allyn & Bacon, 2003.

(6.) Self Perception Theory. Bem, D. J. 1972, Advances in Experimental Social Psychology, Vol.

William J. Payne, Associate Professor, Metropolitan State University
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Author:Payne, William J.
Publication:Forum on Public Policy: A Journal of the Oxford Round Table
Geographic Code:1USA
Date:Mar 22, 2010
Words:2182
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