What is Motivational Interviewing?

Motivational Interviewing (MI) is a method of helping people change. It provides a framework and set of techniques to support someone in deciding whether to change and implement any changes they wish to make.

It was originally developed for the field of addiction counselling but is now used in healthcare, psychotherapy and coaching.

Why do we need Motivational Interviewing?

People do stuff that is bad for them. This might be drugs and alcohol. Eating too much. Procrastinating. Sleeping too much when they feel depressed.

Original models of treating addiction or helping people improve supposed that they lacked information. That if we could only explain how bad smoking was, or how they wouldn't get in trouble if they stopped talking back, or would swim faster if they trained four times a week, they would make the change.

However, modern theories of change recognise that people have all of the information they need. They know smoking is bad for them. They know shouting at their boss ends badly. They know fitness comes from a higher training load.

But knowing it is not enough. People don't do the "right thing" for very good reasons that make sense from their point of view. And that only they can decide to change. Motivational Interviewing was designed to support this process.

Principles of Motivational Interviewing

MI believes that people already have the skills and knowledge that they need to change. But they are ambivalent about change: there are good reasons to change and good reasons to stay the same.

As a coach or counsellor, it is our job to build a relationship with them that allows them to explore and resolve this ambivalence, allowing them to decide whether to change or not.

We do this by exploring any discrepancies between how they currently behave and what they value. When we recognise there is a gap here, we help the client explore this gap and develop their own reasons in favour of making a change.

What are the core processes?

Motivational Interviewing is built on four core processes that guide the conversation and interaction between the coach and the client. They are:

Engaging: The foundation of motivational interviewing is the relationship between the coach and the client. Engaging is the process of building a working, collaborative relationship, and it involves active listening and expressing empathy. This helps to create a safe and non-judgmental space for the client to explore their thoughts and feelings about change.

Focusing: Once a good rapport is established, the next step is focusing. This is about determining the direction of the conversation. The coach helps the client identify and focus on a specific goal or behaviour they want to change. This provides clarity and direction for the motivational interviewing process.

Evoking: Evoking involves eliciting the client's own motivations for change. The coach uses open-ended questions, reflective listening, and other techniques to draw out the client's reasons, ability, and commitment to change. The goal is to create a discrepancy between the client's current behaviour and their values or goals, which can motivate change.

Planning: The final process is planning. This involves developing a concrete plan of action for change. The counselor guides the client in developing a plan that is realistic and achievable, and that the client is willing to commit to. This may involve identifying potential barriers to change and brainstorming solutions, as well as determining how the client will monitor their progress and handle any setbacks.

These processes are not necessarily linear and can be revisited as needed throughout the motivational interviewing process. They provide a framework for facilitating and supporting change in a collaborative and client-centred way.

What does it look like?

Let's look at an example of good and bad ways to facilitate change. In reality, these conversations would play out over many sessions. But for this article, I have exaggerated. In this first example, the coach makes the client feel judged. The client then becomes defensive and protective of the behaviour.

Coach: You know that smoking is bad for you, right?
Client: But I like it!
Coach: But if you continue to smoke, you will seriously damage your health.
Client: I know.
Coach: What about your grandchildren? Don't you care about them?
Client: Of course I do! But I've smoked for 40 years and I'm fine.
Coach: It sounds like you're addicted.
Client: I'm not an addict! I just like it and I don't want to stop!

In this second example, the coach makes the client feel understood and helps the client explore their own reasons for quitting.

Coach: You mentioned that you smoke. Tell me more about that.
Client: Yeah, just a pack a day. It relaxes me.
Coach: It feels good at the time. What are some other reasons you like smoking?
Client: I like having a cigarette break at work because it clears my head.
Coach: Okay, so those are some good reasons to keep smoking. What are some reasons to stop?
Client: Well, my wife doesn't like it. And it is expensive now. And the grandchildren.
Coach: You want to be around as long as possible to them?
Client: Yeah, I love them to bits so it would be good to be healthier.

The first example demonstrates the futility of trying to make someone change. The second shows the power of having someone explore their own reasons for change.

Does it work?

Motivational Interviewing (MI) has been widely researched in a variety of contexts and populations, consistently demonstrating its effectiveness in fostering behaviour change.

A meta-analysis of 72 studies conducted by Lundahl and colleagues (2010) found that MI outperformed traditional advice-giving in approximately 75% of studies and led to substantial clinical changes in a variety of areas, including substance use, health promotion, medical treatment adherence, and mental health treatment.

Research has particularly supported the use of MI in substance abuse treatment. According to a review by Smedslund et al. (2011), MI was found to be more effective than no treatment, and it was equally effective as other viable treatments for substance misuse. MI has also shown promising results in healthcare settings. For instance, a systematic review by Rubak et al. (2005) concluded that MI has a significant and clinically relevant effect on behaviour change in relation to chronic diseases, especially in diet and exercise for diabetes and cardiovascular patients.

Additionally, studies have indicated the effectiveness of MI in mental health settings. Westra et al. (2011) found that integrating MI with cognitive behavioural therapy for generalised anxiety disorder improved treatment outcomes. Despite these promising findings, more research is needed to understand the mechanisms through which MI effects change and to determine the specific contexts in which it is most effective.

Conclusion

Motivational Interviewing is an effective way for supporting clients in making changes in their lives. It gives us a systematic and evidence-based framework for helping people change that works much better than simply telling people what to do.

References

Lundahl B, Moleni T, Burke BL, et al. (2010). Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling.

Smedslund G, Berg RC, Hammerstrøm KT, et al. (2011). Motivational interviewing for substance abuse. Cochrane Database of Systematic Reviews.

Rubak S, Sandbaek A, Lauritzen T, et al. (2005). Motivational interviewing: a systematic review and meta-analysis. The British Journal of General Practice.

Westra HA, Aviram A, Doell FK, et al. (2011). Extending motivational interviewing to the treatment of major mental health problems: Current directions and evidence. Canadian Journal of Psychiatry.