“Caring is being ready, even when they are not.”
Definition: Motivational Interviewing is a counselling approach, designed to assess readiness for change, while exploring ambivalence and meeting the individual in their own therapeutic space. Motivational Interviewing elicits the forward movement of personal strength through basic communication techniques that avoid extrinsic coercion.
The Deep Dive – Motivational Interviewing
In an earlier article titled, “The Therapist’s Confessional – What We Think About Our Clients,” we provided an overview of how clinicians approach their work with clients, both personally and professionally. Today, we dive deep into one of the covered theoretical approaches, Motivational Interviewing.
The Birth of Motivational Interviewing
William R. Miller and Stephen Rollnick published the first edition of, “Motivational Interviewing – Helping People Change,” in 1992. Prior, over the course of ten years, Miller and Rollnick published extensive research supporting the model. At the time, Motivational Interviewing (MI), was seen as a contrast to the well established AA/NA model of treatment. In fact, the forward in the initial edition made this explicitly clear, by introducing clinical counselling concepts for entrenched substance misusers.
The research supporting Motivational Interviewing revolutionized clinical perspectives on addiction. Most notably, the paradigm believes in the inherent power of the individual, dropping the concept of, ‘personal defectiveness,’ and addictive personalities. Instead, MI techniques are designed to assess readiness for change, while empowering motivation through a stepwise therapeutic approach.
The Stages of Change – Addiction Psychology
Motivational Interviewing was first applied in the field of substance misuse. Miller and Rollnick noted five distinct stages individuals go through as they move towards an adaptive lifestyle. The stages often occur naturally as new information is acquired. However, depending on the severity of the maladaptive behaviour (e.g., alcoholism), change may move forward quite slowly, or not at all.
The following stages of change typically occur in a linear fashion:
As stated above, each stage moves in a step-wise fashion from pre-contemplation to maintenance. Therefore, change is a result of increasing openness, along with an awareness of the impact the maladaptive behaviour has on the person’s life.
From the perspective of AA/NA circles, a person’s lack of ability to remain abstinent is a result of denial reinforced by the disease concept. Alternatively, Miller and Rollnick assert that stalled change is simply the result of delayed personal readiness, caused by deflated intrinsic motivation, that when healthy, quickly propels forward momentum.
Readiness – The Total Continuum
Forced change is temporary change. Above and beyond the specific stages of change, personal readiness is the most important concept to understand. It informs both understanding of the individuals situation, and treatment approach. Moreover, a clear understanding of readiness communicates acceptance through a lack of judgment about the circumstances the substance misusing person finds themselves in.
Readiness ranges from a firm sense that the maladaptive choices have no impact, to enthusiasm through a strong sense of self-efficacy and adaptability. How we approach readiness in others is particularly critical.
Clinical Strategies Promoting Readiness
The #1 approach that promotes readiness in others, is not promoting readiness! It is important to believe and communicate a clear acceptance of the other person’s situation, regardless of the cause. This is particularly difficult if you have a personal relationship with the individual. In fact, in such a situation, seeking support as the affected other is absolutely merited.
Professionally, any hint of frustration about where the person finds themselves, is the first sign of a failed therapeutic relationship. It is strongly suggested that you disengage from the battle and simply express your concern for the person’s wellbeing. At this level, applying harm reduction is potentially life saving, and indicates that you care about their wellbeing above and beyond the poor choices they are making.
To recap, never conceptualize the other persons decision making from a moral standpoint. Conceptualize their situation from the standpoint of readiness, supported by your commitment to meet them where they are at. This shows caring as a priority and reduces stigma.
Clinical Strategies Motivating Change
The field of Addiction Psychology offers a robust collection of therapeutic strategies. Cognitive Behavioural Therapy (CBT) has dominated clinical practice due to the fact that research questions are easy to operationalize and create measurable outcomes.
Miller and Rollnick put forth a series of strategies designed to encourage intrinsic motivation that encourages progress through the identified five stages of change. You will notice that many of the strategies are familiar – They are common techniques used in standard psychotherapy practice:
- Open-Ended Questions: Asking questions that avoid, ‘yes,’ and, ‘no,’ answers. (e.g., “What did you get up to today?”)
- Affirmations: Identify the other person’s strengths, or positive qualities, and affirm that you notice them.
- Reflections: Notice the specifics of what the other person is saying, and paraphrase them back periodically. This confirms understanding.
- Summaries: Simply summarize the journey the person has been on in recent past.
Eliciting Change Talk – The Drill Down
Finally, eliciting change talk, is a specific set of techniques designed to support the internalization of goals. You will notice that the above initial strategies fall into the category of communication techniques found in every therapeutic relationship. Change talk techniques, on the other hand, pull for an internalized response by the individual:
- Ask Evocative Questions: Encourage change talk through an evocative open ended question (e.g., “What might happen if you never stopped drinking?”).
- Explore Decisional Balance: Pull for the pros of and cons of the maladaptive behaviour in questioning. (e.g., “How might things improve if you decreased your drinking?”)
- Good Things/Not-So-Good Things: Inquire about the positives and negatives of the target outcome.
- Ask for Elaboration: Simply asking for more information, allows for the other person to dig deeper into their rationale.
- Looking Back: Inquire about what life was like before the maladaptive behaviour became status quo.
- Looking Forward: Ask about what their life might be like five to ten years from now. Urge them to be specific with clear descriptive details.
- Query Extremes: Go to the ends of the continuum, asking the individual what their life might be like on either end if they were there today.
- Implement Change Rules: Use a scale (1-10) to measure importance of changing the identified maladaptive behaviour.
- Explore Goals and Values: Dig into personal goals and values by asking what they want out of life. Inquire if target behaviour is congruent with this vision.
- Walk Alongside The Dark Side: While avoiding sarcasm, play the devils advocate with a statement like, “Maybe drinking is so important that there is little likelihood you will give it up, regardless of what anyone else thinks.”
Application For Improved Personal Relationships
Earlier we suggested the application of Motivational Interviewing in personal relationships. As you grow in understanding about the specific techniques of the approach, some of which we have covered here today, it is only a short leap to see how wide the application truly is. The philosophical approach and techniques are easily applied to a wide range of helping professions. It is also very easily applicable to personal relationships.
Every relationship in our life, being personal or professional, benefits from decreased judgment, compassion, and clarity through communication. In the end, you have to be willing to accept the readiness of the other person, while not giving up on the end goal. However, remember that your goal is not always the goal of the other person – Therefore, in the end, you get to decide if your paths are parallel.
Suggested Addiction Psychology Reading
We strongly suggest you dive deep into the original work by Miller and Rollnick. Motivational Interviewing is a must-have resource for every therapist, teacher, parent, and spouse. Click on the image below for the most resent pricing: