Motivational interviewing is a therapeutic approach widely used in the treatment of substance abuse that focuses on resolving a person’s ambivalence to change a particular behavior. It is made up of a set of principles and techniques that aim to establish a collaborative relationship between the therapist and the client and elicit the client’s own motivation to quit using drugs or alcohol.
The therapist expresses empathy and understanding for the client and honors their freedom to develop their own reasons and goals for change.
Motivational Interviewing: What It Is and Isn’t
Motivational interviewing is a form of counseling that strengthens a person’s motivation and commitment to change some behavior. It helps people overcome their resistance or ambivalence to participating in treatment.1
Motivational interviewing (MI) is primarily used with people suffering from addiction or other mental health disorders. But it has also been used to help people with chronic health illnesses, such as diabetes and heart conditions, adhere to regimens to improve their health.2
Motivational interviewing gained prominence as an alternative to the more confrontational and guided styles of substance abuse therapy in the 1980s. Several of its principles and interventions are based on the client-centered therapy approach promoted by the therapist Carl Rogers. However, MI is considered more goal-driven than this approach.9
One of the major misconceptions about MI is that it is a way for the therapist to “trick” the person into getting them to do what the therapist wants them to do. In fact, motivational interviewing operates under the assumption that the client should make their own choices, not go along with the choices of the therapist. The desire for change is something that cannot be manufactured externally—it must be inherent.3
Another misunderstanding about MI is that it is based on the popular transtheoretical model of change. This model assumes that people move through 5 distinct stages in the recovery process. According to the creators of MI, William Miller and Stephen Rollnick, motivational interviewing helps people build motivation for change, while the transtheoretical model demonstrates how and why people change. There is a close relationship between the two, but there is no need for the therapist to explain the stages of change when working with a client; they need only to help the client build their motivation to recover.3
Does Motivational Interviewing Work?
Over the years, motivational interviewing has established itself as an evidence-based treatment.1 This means that its usefulness is supported by research.4
MI is very popular in the field of addiction treatment, and many studies have examined its effectiveness:
- One study found that motivational interviewing outperformed traditional counseling techniques in 75% of studies. In these studies, the interventions targeted alcohol abuse, psychiatric diagnoses, and other types of addiction.5
- Another study found that MI was able to improve recovery outcomes when used in combination with other treatment approaches.6
- Yet another study that looked at 4 meta-analyses found that MI was much more effective (10-20%) than no treatment at all and equal to other forms of substance abuse rehabilitation in helping people stop engaging in risky behaviors and participate in treatment.7
- A review of 11 clinical trials found that in 9 of the studies, motivational interviewing produced better outcomes than no treatment, typical care, long-term treatment, or being on a waiting list. In the other 2 studies, researchers believe that the treatment providers may not have effectively followed the “spirit of motivational interviewing”,10 (explained below).
MI has been found to be effective for many addictive behaviors, as well as the management of chronic illnesses.6
The Spirit of MI
Although MI uses a set of interventions, it is grounded in a “spirit” or “way of being” that forms the foundation of the therapist’s work with the client.1
The spirit is comprised of 3 elements:
- Collaboration. The MI approach sees the therapist and the client as partners, as opposed to other therapeutic styles in which the therapist is the “expert” who takes a more confrontational approach.1 In MI, the client is the expert on their addiction and other issues, and the therapist creates an environment that is conducive to change, as opposed to coercive.8
- Evoking. Under an MI approach, the client possesses the resources and motivation to change, and the therapist tries to evoke or draw out this motivation.8 The person is more likely to quit drinking or using drugs if they discover their own reasons and express their commitment to doing it.1
- Autonomy. The client takes responsibility for change and making it happen. The therapist does not believe there is one “right way” to change and lets the client create their own path to recovery. The client is also responsible for coming up with various options for how to change.1 The therapist respects the client’s right and ability to lead their own life.8
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Central Therapeutic Principles of MI
MI therapists adopt several underlying principles that they use when working with clients. These include:1,8
- Expressing empathy. The therapist tries to see the world through the client’s eyes, which helps the client feel heard. It also helps build rapport and makes it more likely that the client will open up and share their thoughts and feelings.
- Developing discrepancy. According to MI, people are more likely to want to change if there is a gap between where they are and where they want to be. The therapist helps the client to identify the discrepancy between the way they are currently living and their values and goals. One way the therapist may do this is to have the person list the pros and cons of their drug-using behavior.
- Rolling with resistance. MI therapists view arguments as both counterproductive and potentially damaging in that they may push the person further away from wanting to change. When a conflict occurs, the therapist tries to dampen it and “roll with it.” They don’t challenge any statements or actions the client makes that show resistance to treatment.
- Supporting self-efficacy. MI puts faith in the client’s ability to change. This is significant because many clients have relapsed and doubt their ability to regain and maintain their sobriety. The therapist focuses on times when the client succeeded and emphasizes their skills and strengths.
The Therapist’s Approach
Typical skills that therapists use in MI include the following, which are sometimes represented by the acronym OARS:
- Open-ended questions. Instead of questions that can be answered with a simple “yes” or “no,” MI therapists use questions that require the client to put more thought into their response, such as “how do you think your drug use hurts you?” They help the therapist better understand the client’s point of view and provide them with more information about the client’s thoughts and feelings. They also help build momentum in communication.1,10
- Affirmations. A therapist uses statements such as “I hear” or “I understand” to acknowledge the difficulties the client is going through. They validate the person’s viewpoint and help them feel more confident about change.10
- Reflective listening. The therapist makes an assumption as to what the client tried to say and expresses this in a statement, instead of a question. It demonstrates that the therapist has accurately heard and understood the client. Reflective statements prompt the client to keep talking, show respect, help strengthen the therapist and client’s relationship, and clarify what the client meant.10
- Summarizing. The therapist summarizes to the client what was discussed in the session. Again, this technique shows that the therapist has properly understood the client. The therapist can focus on important aspects of the discussion and highlight the client’s ambivalence or encourage discrepancy by selecting which information to include in the summary.1
The Importance of Change Talk
Change talk refers to statements the client makes that indicate that they are either considering change, motivated to change, or committed to change. Research has shown a link between change talk and real behavior change. The more change talk a client engages in, the more likely they are to take action.1
Different types of change talk have been defined and are usually explained using the acronym DARN-CAT. The first 4 letters indicate that the person is preparing to change, and the last 3 indicate that they are committed and taking actions. These statements are promising, but they don’t guarantee change.1 The DARN acronym stands for:
Research has shown a link between change talk and real behavior change.
- Desire. The person says that they want something, such as, “I want to stop using marijuana.” Wanting to change is helpful for but not essential to actually changing, as people can still make a change even if they don’t want to.11
- Ability. The person says things such as, “I can” or “I’m able to” that indicate they believe they can change. A person won’t change if they don’t think it’s possible, and these types of statements suggest they have at least some degree of confidence in their ability to make a shift.11
- Reasons. The person gives reasons why they should change. However, even though the person may have good reasons why they want to change, they still may feel as though they aren’t able to succeed.11
- Need. The client expresses their need to change, which also does not necessarily mean they have a desire or ability to change. They may, for example, have been told by a friend or an authority figure that they need to make a change.11
The following types of change talk show a strong movement toward change and may better predict future success:1,11
- Commitment. The client says things such as, “I will” or “I promise.” These statements make it more likely the person will do something.
- Activation. The client makes statements that signal they are ready, willing, and prepared to make a change; however, they may not yet be fully committed.
- Taking steps. The person says something to the therapist that indicates they have taken a step toward change, for example attending an AA meeting or checking into rehab.
Change talk is the opposite of “sustain talk,” or statements the client makes in defense of their current behavior. A client using sustain talk may bring up the advantages of continuing to use drugs, reasons not to quit, and why change is not possible.11
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- University of Massachusetts Amherst. (2011). A Definition of Motivational Interviewing.
- SAMHSA-HRSA Center for Integrated Health Solutions. Motivational Interviewing.
- Miller, W. and Rollnick, S. (2009). Ten Things that Motivational Interviewing Is Not. Behavioural and Cognitive Psychotherapy, 37, 129-140.
- National Institute on Drug Abuse. (2012). Evidence-Based Approaches to Drug Addiction Treatment.
- Rubak, S., Sandbaek, A., Lauritzen, T., and Christensen, B. (2005). Motivational interviewing: a systematic review and meta-analysis. The British Journal of General Practice, 55(513), 305-312.
- Hettema, J., Steele, J., and Miller, W. (2005). Motivational Interviewing. Annual Review of Clinical Psychology, 1, 91-111.
- Lundahl, B., and Burke, B. (2009). The Effectiveness and Applicability of Motivational Interviewing: A Practice-Friendly Review of Four Meta-Analyses. Journal of Clinical Psychology: In Session, 65(11), 1232-1245.
- Bray, J., Kowalchuk, A., and Waters, V. Brief Intervention: Stages of Change and Motivational Interviewing. Baylor College of Medicine, InSight SBIRT Residency Training Program.
- Resnicow, K., and McMaster, F. (2012). Motivational Interviewing: moving from why to how with autonomy support. International Journal of Behavioral Nutrition and Physical Activity, 9:19.
- Substance Abuse and Mental Health Services Administration. (1999). Enhancing Motivation for Change in Substance Abuse Treatment.
- Mee-Lee, D. (2017). Helping People Change: Motivational Interviewing and Engaging People in Collaborative Treatment. 2017 Children’s Justice Act Conference.