New and Emerging Therapies: Motivational Interviewing

//New and Emerging Therapies: Motivational Interviewing
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New and Emerging Therapies: Motivational Interviewing 2020-07-06T01:20:02+00:00

New and Emerging Therapies: Motivational InterviewingAs any therapist, counselor, or social worker will tell you, one of the greatest daily challenges they face is motivating their clients to accomplish the goals they’ve set out. At the beginning of treatment, they present as highly driven. Their goals are often clearly defined and pointed. Yet, in a few weeks or days, they suddenly seem ambivalent. The excitement is gone. They may even wonder if they have the right goals at all. So, how do we motivate clients and keep them motivated?

That’s a fundamental question which motivational interviewing seeks to address. Developed by clinical psychologists William R. Miller and Stephen Rollnick in the 1990s, motivational interviewing is a directive, client-centered counseling approach that seeks to help clients overcome ambivalence and stay motivated towards their goals. The intent behind the technique functions less for general therapeutic exploration and serves more for the sole purpose of directing clients to behavior change. In other words, motivational interviewing would not be as helpful as a tool to deeply explore the behaviors, stimuli, affect, and emotional life of the client. Although some of that is involved, it’s more focused on determining what negative behavior the client wants to change and then driving them towards that change.

Principles of Motivational Interviewing

What principles guide motivational interviewing? When Miller and Rollnick first created the technique, they were serving in addictions treatment. They sought to help their clients find the internal motivation to change for themselves.

With this in mind, five general principles guide the practice of motivational interviewing:

  • Express empathy through reflective listening.
  • Expose the discrepancy between the clients’ goals or values and their current behavior.
  • Avoid argument and direct confrontation.
  • Adjust to client resistance rather than opposing it directly.
  • Support self-efficacy and optimism.

Why these five principles? How do these principles inform motivational interviewing? To explain, motivational interviewing is person-centered. MI values client self-determination first and foremost. It does not seek to determine valuable goals in abstraction from the clients themselves. Nor does it seek to determine motivators for said goals in abstraction from the client. Both the means and the ends for change find their center in the client. When someone practices motivational interviewing, they seek to learn what the client values, and then to use those values as motivators for changed behavior.

Let’s say you’re working with an alcoholic who also struggles with depression and anxiety. They use alcohol to self-medicate. However, during their sessions with you, they keep insisting that alcohol is not their problem, but the depression and anxiety are the real problems. They’re afraid to let go of their alcohol use because it provides a measure of comfort for their conditions. Nevertheless, it remains palpably clear that their alcoholism worsens their depression and anxiety, and may perhaps cause it! A motivational interviewer will identify that the person wants to work on their depression and anxiety, and then help the client see that the alcohol gets in the way of that goal.

Motivational interviewing is based on the value of the relationship. Influenced by Otto Rank and Carl Rogers, MI identifies the counselor as an ingredient in the change process. Although the approach is client-centered, it cannot rightly be said that the counselor fills a neutral role. Rather, MI assumes that lasting change occurs in the context of relationship. The motivational interviewer builds a helping relationship with the client, accepts them, and then sees that relationship as the vehicle for change. In the words of Miller and Rollnick themselves, “Motivational interviewing is a way of being with a client, not just a set of techniques for doing counseling.”

Other assumptions in motivational interviewing include:

  • Ambivalence about change is normal. Yet, it is an obstacle to recovery.
  • Client and counselor can resolve ambivalence by working with the client’s own intrinsic motivations and values.
  • The client and counselor must form an alliance in which each of them brings important expertise.
  • An empathic, supportive, yet directive, counseling style provides conditions under which change can occur.

Questions During a Motivational Interview

What questions should be asked in a motivational interview? As you begin to grow the therapeutic relationship with the client, it’s important to ask open-ended questions to learn what the client values. These can include:

  • What’s it like to be you?
  • What makes you tick?
  • Why are you here (at this treatment center or recovery house)?
  • What’s the most important thing to you?
  • I hear how much Person X wants for you. But what do you want?

If the client has already conveyed a desire to change, you can ask questions like:

  • Why do you want to get better?
  • What will life be like for you once you’re better and out of here?
  • What do you want out of life?
  • What concerns you about your drinking/addiction?

It’s important to note here that if the client is using things they willingly lost (job, house, car) in order to maintain their addiction, then deeper, more significant motivators might be necessary.

Once their values are identified, you can use these to build a foundation that will help drive towards change. In order to overcome their own ambivalence, the client needs to see how their presenting problem gets in the way of what they value. So, you might ask:

  • I hear you saying that you really value/care about/want X. What might get in the way of that?
  • I see how X is so important to you. What can we do about protecting/getting/helping that?
  • If you stopped drinking/using, how might that help you get/keep/serve X?
  • I hear that you’re concerned about X. Why are you concerned? What can we do about that?

This provides just a small taste of what the beginning of motivational interviewing looks like. It’s also essential to keep in mind that you need to listen reflectively to be effective, affirm positive steps toward change, and believe that the client can change alongside them.

Examples of Motivational Interviewing

Can motivational interviewing be used for things besides addictions recovery?

Fortunately, yes. The term “recovery” has been finding widespread use throughout mental health, and not just in addictions recovery. It can be used in any context in which a client faces a habit, relationship, or thought pattern that resists change. Negative thoughts about the self can become almost a way to self-soothe. It’s familiar territory; it feels safer than recovery; it’s easy. The client may acknowledge that change needs to occur, but feels ambivalent about that change even though it gets in the way of greater goals. While the way motivational interviewing would be done in that context might look a bit different, the principles guiding it remain the same.

If you’d like to learn more about the principles of motivational interviewing, effective questions, or other examples of motivational interviewing, you can read Enhancing Motivation for Change in Substance Abuse Treatment, Motivational Interviewing with Adolescents and Young Adults, or look up other related works.

John Sherk

Master of Divinity (M.Div.) | Westminster Theological Seminary  (2020 Graduation)

Bachelor’s of Social Work, Bachelor of Science (B.S.), Bible | Cairn University

December 2019

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