The latest in Motivational Interviewing

I recently had the pleasure of spending three days in a “train the trainer” workshop presented by William Miller, whose 1983 article on Motivational Interviewing (MI) changed the world.1 MI is a person-centered, goal-directed counseling method for resolving ambivalence and promoting positive change by eliciting and strengthening the client's own motivation for change. It has revolutionized the face of addiction treatment, as well as many other human services industries.

Several exciting developments have made MI easier to learn and easier to teach. Also, supervision instruments that measure fidelity to the MI approach have been developed. Much of the MI information that I summarize below comes from lectures, discussions and handouts at Miller's workshop, presented in November 2008 and sponsored by the New York State Office of Alcoholism and Substance Abuse Services (OASAS).

The acronym D-A-R-N C-A-T

MI focuses on change talk, which is any speech that favors movement toward change. (Change talk was referred to as self-motivational statements in early MI literature.) Some change talk is preparatory, and this includes talk about the Desirability of change, the Ability to change, expression or affirmations of Reasons to change, and talk about Needing to change.

Counselors are instructed in the use of MI techniques to fan the flames of preparatory change talk until the client breaks into mobilizing change talk. Mobilizing change talk includes talk of a Commitment to change, signs of Activation that include talk about being willing to change, and reports that the client has actually begun Taking Steps toward change.

In MI, a distinction is made between “resistance” and “sustain talk.” Sustain talk is any talk that supports the status quo, and is not a major cause for concern. It is just the other side of the client's ambivalence toward change, and is to be expected. Ambivalence is a counselor's friend, and MI techniques help counselors tip that ambivalence in favor of positive change. On the other hand, resistance is not related to ambivalence and manifests itself as an unwillingness to participate.

Techniques employed

Motivational Interviewing is client-centered, but differs from other therapies because it is goal-directed. There is a target behavior to extinguish, a target behavior to develop, or both. The techniques provide direction by carefully selecting questions, reflections, elaborations, summaries and affirmations that gently guide the client toward the goal.

The acronym used for these techniques is O-A-R-S, referring to Open-ended questions, Affirmations, Reflections and Summaries.

Open-ended questions are used to help explore client ambivalence and to develop discrepancy. Open-ended questions encourage the client to elaborate, since they can't be answered by a “yes” or “no” or other short answer. For example, “Do you want help in quitting drugs?” will probably result in less useful information than something such as “Tell me what your concerns are about continued drug use.” (In MI, “Tell me about…” counts as an open-ended question, even though it is not technically an interrogative.)

Counselors generally ask too many questions, and too many of the questions they ask are closed. As a general guideline, counselors should ask more open than closed questions, and offer two reflections (see below) for each question asked. This will likely generate the most productive discussion with the client.

Affirmations notice and appreciate client strengths, or express care, concern and positive regard for the client. To be effective, affirmations must be sincere and goal-directed. The goal is usually to increase self-efficacy.

Affirmations are especially underutilized in addiction counseling, where taking responsibility for choices is often a goal. But validation and affirmation are in no way incompatible with accepting responsibility-it's a misunderstanding of the concepts that makes some counselors leery.

For example, a counselor would never say something such as, “Oh, you murdered your husband and sold your children into prostitution; that's not so bad.” The counselor only affirms and validates positive attributes that can be a component of quality sobriety. This is important because a belief that change is possible is an important ingredient in motivation to change.

Reflections are often preferable to questions because they don't make clients uncomfortable or place any demand on them. Simple reflections either repeat what the client has shared or rephrase it. More complex reflections paraphrase what the client has said, or reflect feelings or body language. They make an educated guess about the client's meaning.

It's important not to make a reflection a question by inflecting one's voice up toward the end of the reflection. Inflecting one's voice down makes the client more comfortable, offering the client the opportunity to agree with the reflection or correct it.

Reflections are at the core of MI, and give clients the opportunity to figure things out for themselves. Especially in the early stages of change, reflections help improve the therapeutic relationship and are much more helpful to clients than offering advice. To be effective in these early stages, counselors must resist the “righting reflex”-the temptation we all face to offer advice.

Summaries report back to clients what they have offered in session, link something just said with something said earlier, or draw together what has transpired and transition to a new task. Summaries should be a sampling of client statements that the counselor has collected like individual flowers and returned to the client like a bouquet.

The four traditional principles of MI (express empathy, develop discrepancy, roll with resistance and support self-efficacy) have been coupled with four rules. These are: listen to the client, understand the client's motivations, resist the “righting reflex”, and empower the client.

For more information about Motivational Interviewing, visit https://www.motivationalinterview.org.

Reference

1. Miller WR. Motivational interviewing with problem drinkers. Behavioural Psychotherapy 1983; 11:147-72.