Motivational Interviewing

Dr Karen Meechan
Karen.Meechan@slam.nhs.uk
Msc Addictions 28/01/2014
 Aims of Session
To

• Understand the spirit of MI

• Understand the fundamental skills
required for MI
• Understand the four foundational
processes of MI
 Opening Exercise
• Think of something (that you don’t mind
disclosing) that you feel in two minds
about changing
• Split into pairs
• Person 1: Share your dilemma with your
partner
• Person 2: Argue strongly in favour of
change. Whatever the person says - do
not deviate from this position
 Issues Raised?
• Ambivalence about change is normal
• Motivation fluctuates: it is dynamic
• Motivation can be influenced by the way we are
talked to, and talk about it: it is interpersonal
• ‘Resistance’ can be generated in the interaction
• The Righting Reflex influences us as therapists
• The more we say something the more we believe it
(Self-Perception Theory, Bem 1967)
• Confidence to change is crucial (Self-Efficacy)
“People are generally better persuaded by
the reasons which they themselves have
discovered, than by those that have come
into the minds of others”

Blaise Pascal – 17th century

 Motivational Interviewing Origins
• Key people: William Miller and Steve Rollnick
• USA: Culture of conflict in treatment
• ‘Resistance’ attributed to the pathology of
patients, ie.
“Addicts lack motivation and always deny the
severity of the problem”
• William Miller was interested in how the
behaviour of counsellors might influence their
clients’ behaviour
• Direct persuasion elicits resistance and denial
can be experimentally manipulated
 A Definition of MI

“A client-centred, directive method for enhancing

intrinsic motivation to change by exploring and
resolving ambivalence”
Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing –
Preparing People for Change (2nd edition). NY: Guilford Press

“Having a quiet and constructive discussion about

change in which the client drives the process as
much as possible”
Rollnick, S. and Allison, J. (2004) Motivational Interviewing in N.
Heather and T. Stockwell (Eds), Treatment and Prevention of
Alcohol Problems. Chichester: Wiley
 The Spirit of MI
Fundamental approach of MI
Collaboration. Counselling involves a
partnership that honours the client’s
expertise and perspectives. The
counsellor provides an atmosphere
that is conducive rather than coercive
to change.
Evocation. The resources and motivation
for change are presumed to reside
within the client. Intrinsic motivation for
change is enhanced by drawing on the
client’s own perceptions, goals and
values.
Autonomy. The counsellor affirms the
client’s right and capacity for self
direction and facilitates informed
choice.
Compassion – MI-3
Mirror-image opposite approach to
counselling
Confrontation. Counselling involves over-
riding the client’s impaired
perspectives by imposing awareness
and acceptance of reality that the
client cannot see or will not admit.
Education. The client is presumed to lack
key knowledge, insight, and or/skills
that are necessary for change to
occur. The counsellor seeks to
address these deficits by providing the
requisite enlightenment.
Authority. The counsellor tells the client
what he or she must do.
 Summary of MI
• Not just a set of techniques. It is a clinical style
– a way of being with clients
• Provides way of having conversations about
behaviour change
• These conversations can be inherently ‘thorny’
• Aims to resolve ambivalence (which is normal
not pathological)
• Minimises ‘resistance’
• Builds client’s internal motivation for change
 Motivation: “Ready, Willing and
Able”
Willing: Importance of
change - Why? Ready: A matter
of priorities

Able: Confidence for

change - How?
 Principles of MI

• Express empathy

• Roll with resistance

• Support self-efficacy

• Develop discrepancy
Four Foundational Processes in MI

The Bridge to Change

Planning

Evoking The Transition to MI

Guiding The Strategic Focus

The Relational Foundation

Engaging
 Engaging
Therapeutic Empathy
+
The OARS – Fundamental strategies used in MI
(also basic conversation, communication and
counselling skills)
• Ask Open Questions
• Affirm
• Listen Reflectively
• Summarise
 Guiding
The strategic (directional) focus of MI
• Finding a direction and developing changes or
goals
• Agenda setting
• Giving information and advice (ask-provide-
ask)
MI is a guiding style, but not all guiding is MI

Engaging and Guiding are MI-consistent

practice, but not yet (in themselves) MI
 Evoking

• The bridge to MI

• There is a clear change goal

• Selective eliciting (OARS)

– Recognizing change talk

– Eliciting change talk (e.g., selective questions)
– Responding to change talk (e.g. selective reflection)
– Summarizing change talk
– Using the importance and confidence ruler
 Change Continuum (Prochaska and
DiClemente, 1982)
(if you assume the client is more to the right then they are - you are likely
to encounter ‘sustain talk’)

No Change
change

Precontemplation

Contemplation

Decision
Action
 What is Unique to MI?
• Attuned to and guided by certain types of
natural language (change talk)
• Intentional, differential evoking and
strengthening of change talk
• Strategic-directional use of client-centered
counseling methods (reflection, summary)
 Applications in the Research
• Substance misuse, sexual health, dietary change, weight
loss, voice therapy, gambling, physical activity
promotion, medication adherence, diabetes, depression,
anxiety, OCD, eating disorders, dual diagnosis, chronic
leg ulceration, criminal justice, vascular risk, stroke
rehabilitation, chronic pain, self-care, domestic violence,
child health, oral health

• Whole issue of 2009 Journal Clinical Psychology (65, 11)

about MI, including how it can be integrated with other
psychotherapeutic approaches to treat mental health
problems
 Evidence Base
• A lot of research (700 Psychinfo citations 2000-2009),
using variations of MI (eg. MET) and combined with other
therapies, elements of MI only
• Applied to many clinical problems
• Lundahl et al. (2010): Meta Analysis of MI. Significantly
better than TAU/no treatment, as good as other
approaches (eg CBT, 12 step), shorter treatment, effects
are durable over time, severity of problem does not affect
effectiveness
• Ashton (2005): Consistently beneficial for less committed
clients but can worsen outcomes to those already
committed
• Moyers et al. (2009): Client change talk, once mobilised by
therapist behaviour during MI sessions (eg. reflecting
change talk when occurs) leads to reduced drinking
 References
Ashton, M. (2005). The motivational hallo. Drug and Alcohol Findings, 13, 23-
30.
Bem, D.J. (1967). Self-perception theory: an alternative interpretation of
cognitive dissonance phenomena. Psychological Review 73, 183-200.
Lundahl, B.W, Kunz, C., Brownell, C. et al. (2010). A meta analysis of
motivational intervewing: twenty five years of empirical studies. Research on
Social Work Practice, 20 (2), 37-160.
Miller W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing
People to Change (2nd Ed). New York: Guilford Press.
Prochaska, J.O. and DiClemente, C.C. (1982). Transtheoretical therapy:
Towards a more integrative model of change. Psychotherapy: Theory,
Research and Practice, 19, 276-288.
Rollnick, S. and Allison, J. (2004) Motivational Interviewing in N. Heather and
T. Stockwell (Eds), Treatment and Prevention of Alcohol Problems.
Chichester: Wiley
Moyers, T. B., Martin, T., Houck, J.M. et al. (2009). From in-session behaviors
to drinking outcomes: a causal chain for motivational interviewing. Journal
of Consulting and Clinical Psychology, 77, 6, 1113-1124.
 Further Reading

Website resource: www.motivationalinterview.org

Miller, W. (1998) Why do people change addictive behaviour? The
1996 H. David Archibald Lecture Addiction 93 (2), 163- 172.
Miller, W.R. and Rollnick, S. (2009) Ten things that motivational
interviewing is not. Behavioural and Cognitive Psychotherapy
37, 129-140.
Pilling, S., Hesketh, K. and Mitcheson, L. (2010). Routes to Recovery:
Psychosocial Interventions fo Drug Misuse. London: BPS and NTA.
http://www.nta.nhs.uk/uploads/psychosocial_toolkit_june10.pdf
Rollnick, S., Miller, W. and Butler, C. (2008). Motivational Interviewing
in Health Care: Helping Patients Change Behaviour. London:
Guildford Press.