Motivational Interviewing

by Ellen R. Glovsky and Gary S. Rose

As health care providers, we are often asked to be the agent of change with our clients, students, and colleagues. Our role is often to help people make the necessary health behavior change by instructing them in the “whys” and “hows” of making such changes. We may have been trained to believe that if we just teach our clients what they need to do to change and do it effectively enough, they certainly will do so. However, knowledge is just a small part of the equation. If the focus is only on teaching the “facts of the case” we have missed some very important aspects of the counseling relationship.

An alternative to this “top down” approach is Motivational Interviewing (Rollnick, Miller, & Butler, 2008), a style of talking with clients in a constructive manner about health-risk reduction and behavior change. Based upon the idea that most individuals already have at least some of the skills they need to successfully modify lifestyle and decrease health risk, MI uses strategies that will enhance the client’s own motivation to change. Motivational Interviewing integrates an empathic, non-confrontational style of counseling with powerful behavioral strategies for helping clients convince themselves that they ought to change.

Motivational Interviewing is a learned counseling style that is directive but uses instruction as only a part of the counseling relationship. While Motivational Interviewing includes a number of techniques, this is only a part of the story. The “spirit of MI” is the foundation, and refers to some basic ideas that inform the behavior of the clinician. Other important elements of the MI style are the careful, practiced listening skills and specific techniques designed to create a productive atmosphere in which the client can decide what and when to change.

The Spirit of MI

The basic assumptions of MI differ from traditional or typical medical counseling, and this is what is meant by the term “spirit.” Rather than the “the practitioner is the expert and the client will be taught” approach, MI assumes a “dual expertise” between client and practitioner (Rollnick, Miller and Butler, 2008). MI assumes that both the client and the practitioner are experts in the counseling relationship, which is collaborative in nature, and careful listening to what the client says is essential. The clinician may be the expert in what the client ought to do, but our clients have the expertise in what is important to them, and what is possible in the context of their lives. MI assumes that clients have at least some of the answers they need and our job is to assist in the evocation of this information. The third “spirit point” of MI is that ambivalence is normal when people are confronted with the possibility of changing their behavior, even when the evidence in favor of change is very clear or even overwhelming. We know that people are more likely to change when they talk about it themselves. In MI we call this “change talk”, and helping bring this about is a critical element.

Key Elements of MI Listening Style

The four key elements of MI address both what is discussed with the client and the manner in which it is discussed: express empathy, roll with resistance, develop discrepancy and support self-efficacy.

Empathy refers to letting the client know that you understand how they feel about the targeted behavior, and that you understand, but are neutral in your attitude about what the client should do. Roll with resistance is related to empathy in that we avoid arguing with the client or trying to convince them that they are wrong or misguided. Resistance is a cue to stop pursuing this line of conversation, and means that the client is simply not ready to discuss the topic at this time. Develop discrepancy refers to helping clients understand the inconsistency between the current behavior and personal values and goals.

Supporting self-efficacy simply means that wanting to change is not always enough. People may need help believing that change is possible, and that it takes persistence.

The Two Phases of MI

There are two distinct phases in Motivational Interviewing. Phase one is the exploration of the client’s ideas and attitudes about the proposed changes. Phase two is where instruction occurs, and is done with great sensitivity to the client’s readiness to learn about specific topics. An understanding of these two phases and that there are two phases is crucial in the MI style of counseling.

Listening Skills in MI

Finely honed listening skills are at the heart of Phase One in MI. These skills allow us to develop a true understanding of all sides of the story from the client’s point of view. They also help to develop empathy in our relationship with the client, one of the key elements of the MI guiding style. In addition, these techniques offer a wonderful alternative to instruction and resistance, a style which may lead to confrontation and to a principal source of conflict between client and clinician. (Rose, et al, 2004).

The acronym OARS is used to describe these listening skills: ask Open-ended questions, Affirm, listen Reflectively, and Summarize (Miller and Rollnick, 2002). Open ended questions are those that do not have a “yes” or “no” answer, and are the best type to help the clinician understand all sides of the issue for the client. Affirmations let the client know we are listening, understand, and offer them the empowerment necessary to make changes, as well as help in building rapport with our clients. Reflective listening helps the listener know that you heard what they have to say and to clarify what you heard them say. Summarizations are an opportunity to link material the client has offered, and to ask if your understanding is accurate.

Phase 2: Toward Instruction

Once the client has presented some “change talk” and readiness to hear about the options for change, Phase 2 can begin. The two most important aspects are to provide relevant information, and to maintain rapport. In the spirit of collaboration, the MI practitioner always asks permission first. For example, “May I make a suggestion?” or “Would you like to hear about the kinds of changes you could make if you wanted to?”

In Phase 2 it is critical to keep the information provided succinct and relevant to the client. We use the formula “elicit-provide- elicit”, by which we mean offer information, then check in and listen carefully to see if this is information your client is ready to hear. Three key ideas at this point are the use of conditional language, offering a menu of options, and taking time for short reflection breaks. Conditional language means that instead of sentences that begin with “you should”, substitute phrases such as “other people have found”, “you might consider”, or “some of my clients have found”. Offering a menu of options means the practitioner offers number of choices of changes that can be considered. Short reflection breaks can be used to maintain rapport, let the client know that you care what he or she thinks, and to avoid information overdose.

Conclusion

Motivational Interviewing is a very powerful style of counseling for many health behavior changes. Once learned, the MI style of appreciating the limits of trying to persuade our clients to change their behavior makes our job much easier. We are not responsible for whether or not they change, but for helping them decided if they want to or can change, and if so, how to do so.

Ellen R. Glovsky, PhD, RD, LD, is a principal of the Institute for Motivation and Change and the program coordinator of the graduate program in nutrition at Northeastern University in Boston.
Gary Rose, PhD, is a principal of the Institute for Motivation and Change and is a member of the core faculty at the Massachusetts School of Professional Psychology.