Motivational interviewing: Developing intrinsic motivation for change

by Michael D. Anestis, M.S.

I often have a difficult time watching films and television shows that depict psychotherapy.  This is true for a variety of reasons: the tendency to make-up disorders, the tendency to depict bizarre ineffective or even harmful therapeutic approaches (e.g., "rebirthing"), the tendency to depict therapists having inappropriate relationships with clients, and many others.  One particular aspect of popular media presentations of therapy that absolutely horrifies me is the frequent display of confrontational interventions in which an individual is told about all of the horrific consequences of his or her actions and change is demanded.  Theoretically, I can see why this is appealing to some - it lets people victimized by somebody else's behavior express themselves and provides what might seem to be some sort of "eureka" moment in which the poorly behaved individual suddenly realizes the gravity of the situation and becomes inspired to change.  Here's the problem: such approaches, far more often than not, do not work.

Perhaps the most important question then is: why do confrontational interventions not seem to live up to their expectations?  William Miller and Stephen Rollnick, the creators of motivational interviewing (MI), argue that the most significant obstacle is ambivalence.  Individuals with a substance use disorder (SUD), for instance, may see reasons why they want to quit, but also may see reasons why they do not.  It could be that they enjoy using the substance, that the threat of withdrawal seems daunting enough to diminish the threat of the consequences of continuing to use, or any of a number of other reasons.  This is not to say that the reasons for continuing a harmful behavior are reasonable, but rather, that they exist and, as long as the individual feels little to no motivation to change on their own (intrinsic motivation), they are unlikely to follow through on an effective plan for change.  Motivation from within, Miller and Rollnick argue, is essential.  Motivation from external resources (e.g., family members), on the other hand, is less likely to induce long-standing change.

This bring us to Miller and Rollnick's solution to ambivalence - motivational interviewing.   MI is a program for behavior change highly consistent with the tenets of self-determination theory (SDT).  SDT argues that, by making an individual feel more autonomous, outcomes can be improved.  With respect to therapy, autonomy is developed through perspective taking, choice provision, and rationale provision.  Perspective taking involves acknowledging how the client feels and why they feel compelled to behave the way they do.  Notably, this acknowledgment does not involve judgment or the endorsement of bad behavior but rather simply points out that there are reasons why bad behaviors have been sustained and that the therapist recognizes this.  Choice provision involves presenting the client with all potential options for treatment.  From a scientific standpoint, this means presenting the client with a list and description of all empirically supported treatments (ESTs) for their particular diagnosis or diagnoses and leaving the final selection of which therapeutic approach to use up to the client.  Rationale provision involves explaining to the client exactly why certain decisions must be made when choice is not available.  For instance, providing the client with thorough, careful, accurate diagnostic feedback and a description of the evidence supporting specific treatments for that disorder would be necessary in order to explain why other diagnoses and treatment options are not provided.

MI itself involves two stages:

1. Building a commitment to change
2. Developing a plan for change

It is important that the therapist not transition to step 2 too early.  As such, frequent evaluations with assessment tools that measure motivation to change and discussion of these assessments are key.  In order to accomplish the goals of these two stages, MI maintains a series of theoretical stances.  These include:

• An emphasis on the expression of empathy.  The therapist should explain that ambivalence towards change is, in fact, the norm, rather than a sign of a deep character flaw.  In doing this, the client can quickly learn that the therapist is a collaborator willing to listen to his or her perspective.  One particularly effective tool for demonstrating empathy in therapy through an MI framework is reflective listening.  A classic Rogerian tool, reflective listening involves repeating statements by the client back to them with slight variations.  In other words, if the client says "my world has just seemed very dark and hopeless lately," the therapist might say "you've been feeling upset lately and the world does not seem to be offering you any clear light at the end of the tunnel."  Reflective listening is one of those tools that, prior to practice, might seem likely to come across as awkward or insincere; however, in real world practice, therapists quickly learn that it is actually readily accepted by clients and fosters an immediate sense on the part of the client that the therapist is, in fact, listening to what they have to say.

• A non-confrontational development of a discrepancy between the client's current behavior and his or her goals and self-image.  This facet of MI can take many forms, but it often centers around the provision of data.  In some cases, data refers to normative numbers (e.g., percentage of undergraduate students who consume as much alcohol as the client reports consuming).  In other cases, data refers to the collection of new information through self-monitoring (e.g., the client notes every time they engage in the target behavior in order to determine whether their beliefs about frequency/severity match reality).  Here again, the client is not confronted with numbers.  Instead, the therapist should ask the client his or her opinion on the numbers, present objective data, and ask the client for his or her take on any discrepancy.  Another method for developing discrepancies is through amplification, a form of reflective listening.  In this case, rather than directly reflecting the client's statement, the therapist exaggerates or adjusts the tone of the statement.  For example, if a client referred to therapy for alcohol abuse after a DUI arrest says "drinking just isn't a problem for me," the therapist might say "you have never gotten in trouble as a result of drinking."  The therapist must be extremely careful with his or her tone when using this skill, as any sense on the part of the client that the therapist is being condescending, judgmental, or mocking will be detrimental to treatment.

• Avoidance of any arguments or confrontations.  Miller and Rollnick argue that pushing a person to one perspective will cause them to defend the other perspective.  In other words, if you push, they will push back.  Wanting somebody to want something does not make them actually want it.  As such, rather than creating an environment in which the therapist serves as the representative of one side of an argument and the client serves as a representative of the other side, MI works to develop a sense that two individuals, the therapist and the client, are working together to assess a situation and determine if change is desired and, if so, precisely what changes are desired and how they will be attained.

• Rolling with resistance.  Similar to the previous point, rolling with resistance involves decreasing the strength of language or any forceful urging by the therapist when the client resists.  As such, MI views it as beholden upon the therapist to recognize the degree to which the client overtly desires change and to work with him or her at a level consistent with that desire.  Pushing any harder or criticizing resistant behaviors, while natural inclinations, simply are not effective methods for effecting change.  As such, an emphasis is placed on positively reinforcing change statements and positive behaviors rather than punishing resistance.

• Supporting self-efficacy and change statements.  When a client makes any statement that indicates he or she desires to make a positive change, the therapist must leap at the opportunity to positively reinforce such behavior.  Obviously, the tone of the reinforcement should be age appropriate and the level of enthusiasm should be within a range that prevents the client from feeling uncomfortable, but ultimately, such statements are believed to be the mechanism through which MI works and, as such, the therapist must use the most effective means for maximizing their natural occurrence. 

MI can be an extremely brief stand alone intervention - Project MATCH demonstrated efficacy for a 4-session MI intervention in the treatment of alcohol abuse (Finney & Moos, 2002) - or it can serve as an adjunct to other treatments when the client exhibits treatment resistant behaviors (e.g., missed appointments, incomplete homework).  Research has demonstrated preliminary efficacy for MI in the treatment of alcohol abuse, heroin abuse, smoking, HIV risky behaviors, pain management, diabetic treatment adherence, and gambling (Hodkins, Curry, & el-Guebaly, 2001; Miller, 1996).  APA Division 12 does not currently list any treatments for substance use disorders, the diagnoses for which there is the strongest empirical support for MI; however, future updates to the list will likely include MI due to the wealth of evidence for its utility in treatment.

Importantly, MI takes the stance that some individuals are ready for change at a particular moment and others are not.  The therapist can work with the client to utilize his or her own intrinsic motivation, but they can not make an individual want to change, at least not in a sustainable sense.  There are certain to be exceptions to this; however, without any systematic method for identifying such exceptions, the general rule must stand. 

The information above represents a very brief introduction to the basic structure of MI; however, such a brief description necessarily requires minimal coverage of much of the theoretical framework and research behind the treatment.  In future posts, we intend to present more detailed information on MI.  In the meantime, we would love to hear about your experiences with MI, your impression of it as a therapist, client, or general reader, any questions you have regarding why such an approach would be effective, or any other topic relevant to MI.

If you would like to learn more about motivational interviewing, there are several potentially valuable resources available.  Sheldon, Williams, and Joiner (2003) provide a coherent description of MI in a chapter in the book Self-Determination Theory in the Clinic: Motivating Physical and Mental Health.

Additionally, you can read Miller and Rollnick's description of MI and a step-by-step description of how to implement this intervention in their book Motivational Interviewing, Second Edition: Preparing People for Change.

Additional resources include:

• Motivational Interviewing in Health Care: Helping Patients Change Behavior

• Motivational Interviewing in the Treatment of Psychological Problems

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.