Motivational Interviewing : Emerging Theory, Research, and Practice

What Is Motivational Interviewing?

Motivational interviewing (MI) is a therapeutic approach used to explore and resolve ambivalence about behavior change. There is a strong evidence base to suggest that it reduces substance use problems and a growing evidence base for other problems. MI is an empathic therapeutic approach that explores and resolves lingering ambivalence about change. The clinician intentionally pursues the resolution of ambivalence and initiation of positive change as central goals, while maintaining focus on the client’s concerns, perceptions, hopes, and goals rather than on those of the provider. MI communications are primarily reflections, open questions, and affirmations, avoiding an expert stance implied by a clinician-centered therapeutic agenda and heavy use of closed questions, information-provision, and advice. Thus while focusing on and eliciting the client’s perceptions, the MI clinician explores areas of unresolved ambivalence and guides the client to resolve them to improve the client’s life.

MI was first described as a way to work with people having problems with drinking. From an MI perspective, addiction is viewed as “fundamentally a problem of motivation” (p. 134). Cravings, urges, temptations, expectancies, problem recognition, perceived social norms and contingencies, perceived importance of and ability to change, and other addiction-related constructs all have significant motivational components. The development of addiction involves a process of diminishing volitional control of the addictive behaviors involved. As addiction intensifies, capacity for self-regulation diminishes—never below retrievable levels, but enough that it becomes ever more difficult for the person to consistently behave in consciously chosen ways.

Along the pathway to addiction, people often have mixed feelings and thoughts about their drug and alcohol use. Although they may perceive some negative consequences of drinking or using, they also enjoy positive experiences such as intoxication, disinhibition, socialization, and pleasure. Alternatively, they may strongly want to change but feel unable. Whether mild or more extreme, these ambivalence conflicts often remain unresolved for years before significant changes are made. Understanding and resolving this ambivalence is a central goal of MI and is accomplished through elicitation rather than persuasion. Clinicians elicit the client’s ideas and feelings about the current behavior, how the behavior fits in with their values, and what changes they might make to move toward a better future. The provider elicits the client’s own motives and rationale for possible change, referred to in MI research as “change talk.” In essence, MI is focused more on the whether and why to change than on the how .

Because MI is a therapy with a humanistic core, the basis of its conceptualization of addiction is that a person’s process of natural growth and development is being blocked and that the person has become stuck. The process of helping the person is not one of curing a disorder or altering a learning history, but of enabling growth and development. Like releasing a river that has become dammed, the process of helping may be as simple as opening up a channel to allow the flow to begin again; the river itself often takes care of the rest. Unresolved ambivalence makes up the core of the dam, slowing the river’s momentum. Removing the barrier of unresolved ambivalence allows for a return to the natural flow toward health and well-being.

The counseling style used in MI is “quiet and eliciting” and the “therapeutic relationship is more like a partnership….than expert/recipient roles.” The spirit of MI may be more important than techniques, per se. The MI spirit is one of collaboration between two experts, the client having intimate knowledge of the self and the provider having skill in guiding conversations so that clarity of purpose emerges along with an increased sense of empowerment to take action. The spirit of MI is based on a respect and admiration for the client’s autonomy, which is manifested as explicit support for the client’s ability and authority to consider options, make choices, and take action. Finally, the spirit of MI is evocative. Clinicians explore and reflect the client’s perceptions in such a way that a new understanding or commitment is evoked through the conversation. The provider explores the client’s own concerns and elicits from the client a desire for change and a working plan to make it happen in a way that the client feels optimistic about it.

Although the clinician has a goal of facilitating the exploration and resolution of ambivalence, and may have ideas about promising directions, the provider is not attached to any single, specific outcome or pathway to get there. By remaining focused on the client’s concerns and ideas about change, clinicians can assess the client’s current readiness to change and tailor the strategies they use.

The relational stance in MI is one of respect and collaboration. MI clinicians believe that clients have expertise on themselves that can be used to make healthy changes. Using this approach, clinicians elicit more information than they provide. The client does more of the talking, explaining, exploring, and considering. Complementing the client’s effort, the provider offers reflections, questions, and summaries, while affirming the client’s work. Clinicians using the MI approach tend to ask rather than tell, and to listen rather than advise. MI clinicians show curiosity rather than content expertise, even when they have substantial expertise in the area of the client’s concern. It is more important that the MI clinician focus on developing an understanding of the client’s perspective rather than providing information, education, or persuasion, all of which may provoke resistance or reluctance.

MI practice builds upon this collaborative relationship with a basic communication style that is used throughout consultation or counseling sessions. The style is summarized with the acronym OARS— O pen questions that encourage further elaboration and consideration, A ffirmations that foster positive feelings in the consultation, R eflections that indicate that the provider has heard and accurately understood the client, and S ummaries that extend the basic reflections to include a sense of momentum or build interest in changing direction. These fundamental techniques are used to build rapport and gain understanding of a client’s issues, to mend rifts in the treatment relationship, to redirect clients to more useful areas of consideration, and to solidify commitment to change in an established relationship where therapeutic alliance is strongly present.

In addition to the emphasis on using OARS as a basic communication style, MI clinicians use broader conversational strategies in the context of four general therapeutic processes: engaging, focusing, evoking, and planning.

A Brief History of MI

Although it has strong roots in client-centered counseling, MI developed more out of practical experience than theoretical conviction and can be considered atheoretical or theoretically eclectic. Bill Miller’s exploration with Norwegian colleagues of his intuitive practice guided him to elucidate the principles underpinning his approach, which integrated cognitive and behavioral elements into a broadly client-centered style. Miller’s original principles were supplemented by collaborator Steve Rollnick’s observation that ambivalence was a central aspect of change, and that MI specifically targeted ambivalence. Working together, Miller and Rollnick developed the clinical methods and described them in their 1991 book. They anchored their discussion of the rationale for elements of the clinical methods on discussion of the theories to which the elements were logically linked. The first related theory was Carl Rogers’ theory of the necessary and sufficient conditions for therapeutic change, such as genuineness, congruence, and accurate empathy. A second related theory was cognitive dissonance theory, in which Festinger posited that people would work to reduce thoughts that were strongly dissonant with their behaviors by altering either their attitudes/thoughts or their behaviors. Although cognitive dissonance theory as a whole is no longer part of the model of MI, recent versions of MI have retained the idea of the related concept of discrepancy. A third related theory was Bem’s self-perception theory, in which people observed themselves, their behaviors, and their statements, and inferred from those actions what they believed and valued.

Although the scientific literature on MI helped to increase its popularity, a significant factor in its dissemination was the development of a network of skilled trainers who trained clinicians in MI across settings and in many countries across the globe. Rather than disseminating MI through writing only, Bill Miller and Steve Rollnick personally trained the first generation of MI Trainers. This group began meeting regularly at the time of the annual Training of New Trainers conducted by Miller and Rollnick and was initially a loose collaboration of volunteers. As new trainers were trained, the group outgrew its original small format and added online support for its growing community. With early technical assistance from the Mid-Atlantic Addiction Technology Transfer Center, the MI Network of Trainers grew into an active international community of many hundreds of trainers who interact via listservs, annual meetings, an online journal, and collaborative commercial and charitable training projects around the world. The MI Network of Trainers is now an independent entity that counts many of the most active MI researchers among its members, thus developing a strong communication loop between researchers, practitioners, and administrators in a wide variety of cultures and professional settings. MI researchers have had their own conference (International Conference on Motivational Interviewing) that has occurred biannually in Europe and the United States since 2008.

Theoretical Concepts and Emerging Models of MI

Although MI was derived from practice-based evidence, there are ongoing attempts to understand it theoretically. Currently, there is no comprehensive theory of MI that thoroughly explains its actions or drives its development, although there are several papers that hypothesize likely threads. In this section, we consider how an emerging model of MI might be woven from the threads of self-determination theory, the transtheoretical model of behavior change, emotions theory, interpersonal theory and psychotherapy, and data on MI and some of its potential mechanisms.

Defining MI

As practice evolves and new evidence about effectiveness and process-outcome relationships emerges, it is likely that definitions of MI will change. In some ways, this has already happened. There are at least four perspectives on defining MI. One is that MI is a creation of and is defined by its original developers . MI was described initially by Miller and then by Miller and Rollnick, and these founders of the approach may continually revise and update it as their own experiences and thoughts develop. Therefore the principles, goals, techniques, strategies, and terms of MI follow from the founders’ decisions, which may be influenced by data or practice or by exposure to other ideas. If the founders are the sole arbiters in defining MI, it is whatever they say it is, and elements may be added or deleted based on their preferences.

From the clinical research perspective, MI may be viewed instead as a set of attitudes, techniques, and strategies that can be described in a manual and can be evaluated with measures of treatment fidelity. This clinical research perspective focuses on sharp boundaries, specified timeframes, clearly defined strategies and techniques to address specific target behaviors, and attempts to isolate the unique elements of MI. The clinical research definition of MI results in a binary decision in that either MI is being done or MI is not being done. From this perspective, that MI is a specific definable intervention, a provider could be seen as doing MI in some sessions and not others, or possibly during some moments and not others.

Yet another perspective is the practitioner’s angle. Practitioners might view MI as an overarching counseling style, a general way of working with clients. The practitioner using this style weaves whatever strands are most useful in the moment, no matter where those elements might have originated (in MI, in adaptations of MI, or in similar or complementary therapeutic approaches, disciplines, or experiences). From this perspective, practitioners may see themselves as doing MI even when a video sample of a discrete moment in therapy might show them to be providing a cognitive-behavioral therapy–derived intervention, albeit in an MI-consistent style. In such practice, a decision rule might be “can one smoothly transition in and out of elements borrowed from elsewhere?” The provider may be exploring ambivalence with a client and notice a bit of distorted thinking, slip unnoticed into working with the client on exploring the background of that thinking or its fit with reality or rationality, and then slip back out and back to exploring ambivalence. To the practitioner, this whole session may be thought of as MI if MI’s spirit and techniques are present and if the client’s responses indicate that the therapeutic alliance is steady.

A fourth perspective is that MI is a set of ideas or concepts that originated with Miller and Rollnick but are now independent from them. A conceptual perspective might define MI as a set of specific ideas that fit into a nomological net, a framework of logically coherent and connected constructs into which empirical and practice findings are placed and interrelated. A conceptual perspective on defining MI may be based less on either need for clear definition and fidelity to that definition, as in the clinical research perspective, or need for pragmatism and devotion to doing what works best in the moment, as in the practice perspective.

MI as an Activator of Autonomous Motivations and Growth

MI seeks to build internal motivation to change, even in the context of clients seeking to change due to some duress or external situation. Individuals with higher levels of internal motivation for change may be more likely to succeed in achieving and maintaining the desired change. MI seeks to elicit the person’s healthy aspirations and propensity for positive growth. These aspirations and growth experiences are often internally motivating rather than resulting from external reinforcement alone. These goals of activating intrinsic motivations overlap somewhat with self-determination theory. Self-determination theory posits an alternative to some views of human motivation as originating in physiological needs, or as a drive state seeking to amend deficits. Instead, self-determination theory proposes that growth-oriented activity is the central source of motivation. Self-determination theory states that people have innate needs for competence, relatedness, and autonomy, and that these needs can explain intrinsic motivation. Self-determination theory proposes that motivation becomes internalized naturally because humans are ready to internalize ambient values and regulations. Individuals come to grasp the importance of social values as children. Over time, they transform observed social mores into personal values and self-regulation. Self-determination theory proposes that internal motivation is most likely when a person has a sense of efficacy, control, or self-regulation with regard to the required behavior. Self-determination theory outlines a continuum of motivations ranging from externally regulated to truly intrinsic. Markland and colleagues propose that MI is not focused on truly intrinsic motivations (defined by self-determination theory as engaging in behaviors because they are inherently interesting or enjoyable). Rather, MI focuses on a broader range of autonomous motivations regarding behaviors that lead toward desired outcomes for the person. These outcomes may involve extrinsic gain or increased coordination with one’s values and self-identity.

MI as a Method to Move People Through Stages of Change

MI is a counseling style concerned with encouraging behavior change. The transtheoretical model is a model of how people make deliberate changes, especially when it comes to eliminating problem behaviors and beginning new, healthier behaviors. The most well-known aspect of the transtheoretical model is the Stages of Change model, in which behavior change is seen as a process that progresses from low awareness and no intention to change through high awareness and active efforts to initiate or maintain change. The five stages of change are precontemplation, in which people may not recognize their behavior as problematic and are not planning to change; contemplation, in which people are considering change but remain ambivalent because there are also benefits resulting from their current behavior; preparation, in which people have decided to make a change and are making plans to change; action, in which people are actively taking steps to change, and maintenance, in which people are integrating the new behaviors into their ongoing lifestyle.

Although distinct, the transtheoretical model and model of stages of change and MI “grew up together” and complement one another. Specifically, MI is a valuable approach to use when people are in the early stages of change, to build interest and motivation for change. The concept of stages may be better as a heuristic than as a reflection of reality. In clinical encounters, readiness for change can fluctuate within a single discussion about change. By maintaining a client-centered perspective and eliciting client readiness to change rather than attempting to use pressure to motivate change, the provider using MI can avoid evoking resistance that can inadvertently be elicited by getting ahead of the client.