Have you ever been “healed” by a long conversation with someone where you were given full attention and felt the other person really listened to you without judgment?
Has a particular relationship made you feel normal, lighter, or good about yourself again? Chances are this happened in an environment that was trusting, open, and frank.
If I can provide a certain type of relationship, the other person will discover within himself the capacity to use that relationship for growth, and change and personal development will occur.
This article describes the underlying principles and techniques of one such form of communication known as Motivational Interviewing. Most commonly used to increase motivation toward behavioral change, motivational interviewing is an evidence-based approach designed to encourage clients to talk themselves into making beneficial changes in their lives.
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Motivation to change varies from person to person, from one situation to another, and over time. Some of us are unwilling, others are unable to change, and many are not fully ready.
Motivational Interviewing techniques rest on the findings in clinical experience and research that simply show that clients who believe that they can change do so, and “those who are told that they are not expected to improve indeed do not” (Miller, & Rollnick, 2014).
People are better persuaded by the reasons they themselves discovered than those that come into the minds of others.
Motivational interviewing is a patient-centered counseling style based on the principles of the humanistic psychology of Carl Rogers. He argued that for a person to “grow,” we need an environment that provides us with genuine openness that enables self-disclosure, acceptance that includes being seen with unconditional positive regard, and empathy where we feel like we are being listened to and understood.
Rogers discovered that it was more effective to let clients guide the direction of the process in the person-centered form of therapy.
The curious paradox is that when I accept myself just as I am, then I can change.
Motivational Interviewing (MI) is a technique for increasing motivation to change and has proven to be particularly effective with people that may be unwilling or unable to change.
Originally used within the setting of alcohol addiction treatment in the 1980s, motivational interviewing encouraged patients to think and talk about their reasons to change. Soon it was discovered that this minimized their resistance and increased their motivation.
Part of the reason was that motivational interviewing accepts that ambivalence about change is a normal human experience and often a necessary step in the process of change.
Motivational interviewing rests on the assumption that people are ambivalent about change versus weak or resistant to doing so. It’s an optimistic approach to change aimed at resolving this ambivalence through eliciting and reinforcing change talk.
Change talk is the statements we make that reflect our desire to change, focus on our ability to do so, list specific reasons for change, and express the commitment to change. Studies show that change talk, particularly in clinical settings, has been linked with successful behavior change (Sobell & Sobell, 2008).
The only person who is educated is the one who has learned how to learn and change.
Motivational interviewing aims to encourage the patient’s autonomy in decision making where the clinician acts as a guide, clarifying the patient’s strengths and aspirations, listening to their concerns, boosting their confidence in their ability to change, and eventually collaborating with them on a plan for change.
The process consists of engaging patients, deciding on what to change, evoking their reasons for making the change, and agreeing on a concrete plan.
One relevant psychological theory that explains how and why motivational interviewing works is self-determination theory. It states that we are more likely to change if our three basic psychological needs are attended to:
Another useful theory is that when we hear ourselves talk about change, it tends to increase our motivation. Within motivational interviewing, this is known as “change talk.” An emerging body of research is currently tracking the language that patients use when talking about change, and it appears that change talk predicts better outcomes (Gaume, at al, 2013).
Finally, it was also noted that practitioners’ behavior could influence clients’ behavior in measurable ways. One review of research suggests that minimizing practitioners’ behavior that is inconsistent with motivational interviewing, such as disagreeing with and confronting clients, has a clear positive influence on outcomes (Gaume, at al, 2013).
The aim of motivational interviewing is to encourage the patient to become an active participant in the change process by evoking their intrinsic motivations for change.
And all this despite ambivalence and what often seems like resistance, which is considered a normal part of the change process.
Evoking is central to motivational interviewing, but it is also most challenging to master as it is vastly different from traditional advice-giving.
Motivational interviewing requires four key communication skills that support and strengthen the process of eliciting change talk, also known as OARS:
Open-ended questions in motivational interviewing allow us to find out more about the client’s perspective and ideas about change. They are also crucial in building and strengthening a collaborative relationship. Finally, they are also useful in the process of evoking the client’s motivations for change.
Affirming can be done through recognizing and commenting on the patient’s strengths and abilities. Affirming is excellent for rapport building and can increase it further by using some of the well-known coaching techniques and incorporating acknowledging and validating clients’ emotions.
Sounds like this is really challenging. No wonder you feel overwhelmed.
Reflective listening can be employed effectively through summarizing. When we repeat what the client has told us in our own words and in the form of a statement rather than a question, we encourage them to continue talking. The most crucial benefit of reflective listening is that it helps to build engagement with the client, particularly when he or she is upset or angry as it can help them to calm down and feel understood.
What I hear you say is…
Most importantly, however, reflective listening allows practitioners to clarify what the client is saying both for the purpose of understanding correctly but also to reflect back to the client so they can hear what they are saying and can either pause to reflect or choose to move forward.
In motivational interviewing, reflective listening is used purposefully to help the patient consider a change. This is one of the strongest characteristics of the evoking process.
Summarizing is also used for further collection of reflections, allowing the practitioner and the client to identify the core ideas of the client’s story. When we employ reflective listening and combine it with effective summarizing, the clients find themselves hearing themselves talk about change.
As the practitioner empathically reflects back to the client what they just said, it becomes a part of the powerful process of evoking the client’s own motivation for change.
In motivational interviewing, OARS or open-ended questions, affirmations, reflections, and summarizing are employed toward eliciting change talk. Evoking self-motivational statements is a primary goal of MI approach and unlike OARS, is more directive. The goal is to help the client identify and resolve ambivalence so he or she can move forward.
Change talk is the client making statements that are in favor of change. It signals he or she is more willing, able, or ready to make the change. The practitioner’s role is to elicit change talk from the client in a collaborative fashion and avoid imposing it. Motivational interviewing is a consensual, negotiated process between the counselor and client.
Change talk can occur in several forms and is exemplified by a statement that indicates the desire for, the ability to, the reasons for, and the need to change.
Desire statements indicating a desire to make a change:
Getting in shape would make me feel so much better about myself.
Ability statements speak to the client’s self-efficacy or belief in the ability to make changes:
I think with some help, I might be able to cut back.
Reasons statements reflect the reasons the client gives for considering a change:
I have to quit smoking because of my asthma.
Need statements indicate a need for change where the emphasis is more emotional than in the case of reasons statements, which are more cognitive and rational:
Something has to change, or my marriage will fall apart.
The most important aspect of motivational interviewing is for the practitioner to recognize and then emphasize change talk and pay particular attention to commitment language. When the client uses verbs that express authentic and robust commitment to change, this presents an opportunity to get them to elaborate further and strengthen the commitment level.
Miller worked with a linguist to show that commitment language matters, and the more a client is making strong commitment statements, the more likely the client’s behavior is going to change.
The process of eliciting change talk must also take place with adequate focus. After the client and practitioner have clarified a goal for change, an agreement should be established on the direction for the conversation. This helps to avoid making assumptions and jumping too quickly into a new change topic.
It is also a great opportunity to raise a difficult subject in a non-confrontational way by merely mentioning it and allowing the patient the opportunity to decide whether to talk about it.
There is also an issue of information sharing and advising, which could become a deterrent if not used appropriately. It should be reserved for when the patient asks, or more spontaneously when there is good engagement.
When some level of rapport is established, a practitioner can also initiate a more formal discussion about the stages of change or level of the client’s motivation. This may include helping the client develop a rating of current importance, confidence, readiness, and commitment to change to explore how any of these dimensions might be strengthened.
This is a more directive way of eliciting a client’s change talk and addressing a client’s commitment to change in a way that resembles planting the seed and gradually moving toward the negotiation of specific change plans.
Motivational Interviewing skills are not unlike some of the coaching skills, but never the less they are not easy to master. There are several training manuals for how to practice motivational interviewing skills, and here are a few of them. One way to assess the practitioner’s ability to elicit change talk is to compare it to the following examples of higher skill:
