This document was prepared for Suppers facilitators. The original document by Rollnick and Miller appeared in Behavioral and Cognitive Psychotherapy, 1995. Notes on operating in the spirit of MI for Suppers facilitators are in italics.
Introduction
The concept of Motivational Interviewing evolved from experience in the treatment of problem drinkers, and was first described by Miller (1983) in an article published in Behavioural Psychotherapy. These fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. A noteworthy omission from both of these documents, however, was a clear definition of Motivational Interviewing.
We thought it timely to describe our own conceptions of the essential nature of Motivational Interviewing. Any innovation tends to be diluted and changed with diffusion (Rogers, 1994). Furthermore, some approaches being delivered under the name of motivational interviewing (c.g., Kuchipudi, Hobein, Fleckinger and Iber, 1990) bear little resemblance to our understanding of its essence, and indeed in some cases directly violate what we regard to be central characteristics. For these reasons, we have prepared this description of: (1) a definition of Motivational Interviewing; (2) a terse account of what we regard to be the essential spirit of the approach; (3) differentiation of Motivational Interviewing from related methods with which it tends to be confused; (4) a brief update on outcome research evaluating its efficacy; and (5) a discussion of new applications that are emerging.
Definition
Our best current definition is this: Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal.
The Spirit of Motivational Interviewing
Consider how we can operate in this spirit at Suppers.
We believe it is vital to distinguish between the spirit of Motivational Interviewing and techniques that we have recommended to manifest that spirit. Clinicians and trainers who become too focused on matters of technique can lose sight of the spirit and style that are central to the approach. There are as many variations in technique as there are clinical encounters. The spirit of the method, however, is more enduring and can be characterized in a few key points.
1. Motivation to change is elicited from the client, and not imposed from without. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from Motivational Interviewing, which relies upon identifying and mobilizing the client's intrinsic values and goals to stimulate behaviour change.
An example that comes up often at Suppers is what motivates dietary change for people with type 2 diabetes or other health challenges related to habits of diet and lifestyle. What do you personally need when you are working on change?
2. It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict, for example, “If I stop smoking I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive.” The counselor’s task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that triggers change.
We can examine this nonjudgmentally using the “once-around-the-table” approach, with no crosstalk or opinions on another’s sharing.
3. Direct persuasion is not an effective method for resolving ambivalence. It is tempting to try to be “helpful” by persuading the client of the urgency of the problem about the benefits of change. It is fairly clear, however, that these tactics generally increase client resistance and diminish the probability of change (Miller, Benefield and Tonigan, 1993, Miller and Rollnick, 1991).
Let’s examine our own inclinations to be urgent about others. Some of us may be able to describe how other’s urgency to make us change has worked for us.
4. The counseling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of Motivational Interviewing and are explicitly proscribed in this approach. To a counselor accustomed to confronting and giving advice, Motivational Interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to “confront client denial,” easily slip into pushing clients to make changes for which they are not ready.
For facilitators, it may help to consider what happened when someone told us we were in denial or tried to push us into healthier decisions.
5. The counselor is directive in helping the client to examine and resolve ambivalence. Motivational Interviewing involves no training of clients in behavioural coping skills, although the two approaches are not incompatible. The operational assumption in Motivational Interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of Motivational Interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere.
Can anyone share on how the gentle, nonjudgmental environment at Suppers allowed their decisions about change to emerge?
6. Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction. The therapist is therefore highly attentive and responsive to the client’s motivational signs. Resistance and “denial” are seen not as client traits, but as feedback regarding therapist behaviour. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.
In the case of Suppers facilitators, “resistance” lets us know we need to examine our own methods and motivations. Examples?
7. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client's autonomy and freedom of choice (and consequences) regarding his or her own behavior.
Our version is therapeutic friendship. Share examples of healing that have taken place in the context of Suppers relationships.
Viewed in this way, it is inappropriate to think of Motivational Interviewing as a technique or set of techniques that are applied to or (worse) “used on” people. Rather, it is an interpersonal style, not at all restricted to formal counseling settings. It is a subtle balance of directive and client-centered components, shaped by a guiding philosophy and understanding of what triggers change. If it becomes a trick or a manipulative technique, its essence has been lost (Miller, 1994).
There are, nevertheless, specific and trainable therapist behaviors that are characteristic of a Motivational Interviewing style. Foremost among these are:
- Seeking to understand the person’s frame of reference, particularly via reflective listening. We all work on this at meetings, as the active practice of nonjudgment is one of only three absolute requirements of the program. The others being: 1) that our only food bias is that in favor of whole food, and 2) our intolerance of commercial messages or the promotion of particular diets, products, or services.
- Expressing acceptance and affirmation. In our case, boundary 7, honoring each other’s competence to find our own path to better health.
- Eliciting and selectively reinforcing the client’s own self-motivational statements expressions of problem recognition, concern, desire and intention to change, and ability to change. Again, evidenced in our requirement to keep the focus on one’s self, including the facilitator, and honor each other’s competence.
- Monitoring the client’s degree of readiness to change, and ensuring that resistance is not generated by jumping ahead of the client. In our case, reiterating at each meeting that they receive support regardless of the pace of their progress.
- Affirming the client’s freedom of choice and self-direction. We operate in this spirit with our first boundary: The only requirement for membership is the desire to lead a healthier life.
The point is that it is the spirit of Motivational Interviewing that gives rise to these and other specific strategies, and informs their use. A more complete description of the clinical style has been provided by Miller and Rollnick (1991).
Facilitators are invited to notice how, now that you have had this introduction to the model of Motivational Interviewing, you see the spirit of MI at work in our program design and the environment of our meetings.