Motivational Interviewing Defined.

MI is an evidence-based clinical practice used in the treatment of individuals with substance use disorders.

MI focuses on ambivalence, on exploring and resolving the centers of the motivational processes within the individual in order to facilitate change. It is different from other methods that are viewed as coercive or externally driven as a way of motivating change.

External methods do not appear to have the same success of MI because they impose change that may be inconsistent with the person's values, beliefs or wishes. MI supports a person’s change in a manner that runs parallel to that person's values and concerns.  In fact, the primary spirit of MI is collaborative and puts the client in charge of how, when, and what they want to change.  The therapist is a partner who actively resists the urge to “be the expert” in the client’s change process.

The MI Approach places interviewing in a grounded and respectful stance that focuses on building rapport during the initial stages of the therapeutic relationship.

MI centers on identification, examination, and resolution of ambivalence concerning a person’s changing behavior. Ambivalence, the feeling of wanting to change and wanting to stay the same, at the same time, is seen as a natural issue in the change process and not an aberration.

Using MI allows the interventionist to “tune in to” the person’s ambivalence, therefore allowing the interventionist to recognize ambivalence and “readiness for change.” They are then able to use these strategies thoughtfully with the responsive client.  The interventionist listens for “change talk” and helps the client be aware of his own ambivalence.

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MI includes three essential elements.

First it is a specific type of conversation about the change a client wants to and needs to embrace.

Second, it is a collaborative effort that places the client at the center and honors the autonomy of the client. It assumes the client is the expert and supports the client in bringing forth their expertise.

Finally, MI seeks to call forth the client’s own motivation and commitment. It evocates client change by evoking internal responses. It is internally driven, not externally forced.

To the non-professional MI is a collaborative conversation used to strengthen the client’s own motivation to change.

For the professional, MI is a person-centered counseling method which allows the client to address their common, acknowledged issues and their internal ambivalence regarding the need to change.

MI is a collaborative, goal directed method of communication between the interventionist and the client, with a very specific focus on the “language of change.”  It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change.

MI is more than just a set of technical interventions. It is an intervention set with a spirit. This “spirit”, or “way of being” involves the technical aspects of MI as they play out in the context of the client-therapist relationship. One cannot be divorced from the other.

The SPIRIT of MI can be understood if you can visualize the intervention resting on three, very specific elements. They are:

1)      Collaboration between the client and therapist

2)      Drawing out the client’s ideas for change
3)      Placing the emphasis for change on the client. (punctuation)

•        Collaboration (vs. Confrontation)

Collaboration is a partnership formed between the therapist and the client, grounded in the point of view and experiences of the client. This partnership removes the therapist from the “expert role” and keeps the therapist from imposing their perspective on the client’s substance use patterns.

This collaboration allows the building of rapport and allows the client to develop a deep level of trust in the relationship. It keeps the relationship on a more unilateral level, instead of a hierarchical relationship.

 It is important to remember this collaboration does not mean the therapist and the client will agree on the problem, its scope or its solution. The MI therapeutic process is focused on mutual understanding.

·         Evocation (Drawing Out, Rather Than Imposing Ideas)

MI values the therapist’s ability to assist the client and “draw out” their ideas, opinions, thoughts and feelings, instead of having the therapist impose their desires, opinions and motivations on the client.  Like water drawn from a well, the client’s motivations to change are already there, the MI therapist merely helps the client bring them to the surface.

Change due to internal motivation and commitment is more powerful and durable than change related to external motivation (such as someone else saying you should or have to do something).  MI purports that lasting change is more likely to occur when the clients discover their own reasons and determination to change.  With MI the therapist's job is not to tell them what to do or why they should do it.

·         Autonomy (vs. Authority)                 

MI understands that the true power for change rests within the client.

Ultimately, it is the individual who needs to follow through and make change happen.

This allows empowerment while also allowing the responsibility to rest squarely on the client’s shoulders.  Sometimes, client’s simply are not ready to change yet.

In MI, the therapist job is also to help the client understand there is no one "right way" to change, but there are many ways that change can occur.

 
While clients are encouraged to make changes, they are also encouraged to develop a list or “menu” of various options and how to achieve and implement these options.

In addition to the three pillars of on which rests the “Spirit of MI” there are FOUR distinct principles that guide the practice of MI.

 

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The FOUR Principles of MI

In order to use MI appropriately, you, the therapist must adhere to these principles.

• Express Empathy

Empathy requires the therapist see the world through the eyes of the client. This includes thinking about things the way the client thinks and feeling things like the client feels them.

This principle allows for clients to be heard and understood, and in turn, it is more likely the clients will share their experiences honestly. If the client is able to feel the therapist can see their world from their point of view, the process of EMPATHY has been effective.

• Support Self‐Efficacy

MI is a strength-based approach, based on the idea clients have the capacity to change within themselves. They simple need assistance accessing this ability. In order for change to occur the client must be able to believe in the possibility of change. The therapist role is to help instill the hope necessary for the changes to occur. This belief in an ability to change is called self-efficacy.

This is not always an easy task, as clients have often tried to change in the past and have failed; now doubting their abilities. The MI therapist will always support this self-efficacy through focus on previous success and client skill and strength.

• Roll with Resistance (aka: Dancing with Discord)

MI therapists believe that resistance to change comes from previous unsuccessful changes and where a client perceives a conflict between their view of the “problem” or “solution” and the clinician’s view of the “problem” or “solution”. This conflict violates the freedom and autonomy of the client that results in frustration in failure.

The MI therapist will avoid creating or eliciting resistance. Avoiding confrontation does this when resistance occurs. The therapist will de-escalate the situation and avoid a negative interaction. This is known as “rolling with it.”

When the client demonstrates actions or makes statements that demonstrate resistance, these should remain unchallenged by the MI therapist during the early stages of the therapeutic relationship.

When the therapist “rolls with the resistance” they disrupt any “struggle” that can occur during the session. This lack of resistance keeps the client from avoiding change by playing the games of "devil's advocate" or “yes, but” when the counselor makes suggestions.  MI places a high value on the client’s ability to define the problem and to develop his or her own solutions. This approach makes it difficult for the client to resist change.

When exploring the client’s concerns, the therapist invites the client to examine a new point of view without presenting the therapist’s point of view. Finally, the therapist needs to avoid the tendency to make sure the client understands and agrees with the need to change. This is known as the “righting reflex.”  Therapists want to help their clients and may try to “fix” things by directing clients to the “right way” to solve their problems. The MI therapist avoids using this “righting reflex” at all times during a session.

• Develop Discrepancy

This occurs when the therapist is able to help the client see the mismatch between “where they are and where they want to be.” This awareness creates the motivation to change. The MI therapist helps the client develop this by helping them examine the discrepancies between their current circumstances/behavior and their values and future goals.

Once the client realizes their current behaviors place them in conflict with either their values or goals, they are more likely to increase their motivation to make the changes they need in order to reduce the conflict.

The MI therapist should never use strategies that create conflict and discrepancy. They should help the client slowly become aware of the discrepancy between their behavior and their progress towards their current goals.

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Harvey Norris, MSW, LCSW

Harvey Norris received his MSW from Florida State University in 1990 and passed the license exam in 1993.  Harvey Norris, his wife  and five children live in Central Louisiana where he continues to practice "The Worlds Best Profession!"