How motivational interviewing can be a useful tool in therapy

Motivational interviewing (MI) is not a modality in itself but can be a very useful add-on when practicing integratively in counselling and psychotherapy. It emerged as a collaborative approach to promoting client change in substance abuse treatment centres from the 1980s. Miller & Rollnick, (2002) explain that it came about essentially as an alternative to the prevailing treatment approaches at the time in the field of substance abuse that were considered to be coercive and confrontational, when the counsellor saw themselves very much as the expert.

MI has since moved into other fields beyond substance abuse. It has been applied increasingly to issues such as behavioural addictions, health and medical issues, spirituality, anxiety, treatment compliance, and more.

Miller and Rollnick defined MI as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (2002, p.25). Implicit in this approach is the acceptance that ambivalence toward behavioural change is a given, particularly when dealing with people who are in active addiction.

So-called argumentation can be averted since the individual seeking to make behavioural change is not being persuaded to change. That usually results in the person verbally defending the status quo. This is particularly true for those with active addictions since rationale is a huge defence in their lives. They have a reason for doing what they are doing and seemingly have an answer for everything. Intrinsic motivation for change, on the other hand, can be achieved when a person can see an apparent conflict between what they are currently doing and where they hope their behaviour to be in the future.

According to the MI model, the therapist’s role, therefore, could be to explore where they expect their behaviour to be (their goals and values) and to elicit statements or perspectives that support behavioural change. MI can, therefore, be a useful tool in dealing with the issues presented by ambivalence in the consulting room.

The three components of MI

MI is a communication style that invites individuals to voice their own reasons for making a change. It is, however, vital that the therapist embraces the spirit of the approach. Miller and Rollnick make it clear that the spirit of MI is integral to its successful practice, as they have encountered practitioners and trainers “mimicking…component techniques without understanding their overall context” (p. 33).  The spirit of MI is comprised of three components: collaboration, evocation, and autonomy.

1. Collaboration

It is not the role of the therapist to be confrontational. Counselling is a process that involves a partnership that respects the person’s expertise and perspectives. The therapist helps to create an atmosphere that is conducive rather than coercive to change.

2. Evocation

The spirit of MI is that the person being helped has not only the resources for change within themselves but also the motivation for change. Intrinsic motivation for change is enhanced by drawing on the person’s own perceptions, goals, and values. Education, such as normative feedback, might, of course, be a tool used within MI, but it is not the goal.

3. Autonomy

The role of a therapist is to affirm the person’s right and capacity for self-direction and to facilitate informed choice. In this sense, autonomy is seen in stark contrast with authority, whereby the person is to be told what they should do.

These aforementioned components will be familiar territory for anyone trained in basic counselling theory when thinking of creating a safe container whether that is Rogerian core conditions, particularly the view that the therapist is not the expert, Egan’s the Skilled Helper, Winnicott’s holding and so on. What is useful about MI is the extensive number of techniques attached to each process that the therapist can draw upon.

The 5 principles of motivational interviewing are expression of empathy, development of discrepancy, avoiding argumentation, rolling with resistance and supporting self-efficacy. The concept of ambivalence is an important aspect of working with people especially when active addictions are a feature of their presentation. Ambivalence is like the committee in the mind, as there can seem like there are a plethora of many different perspectives. Anyone well versed in the language of sub-personalities, the dialogical self theory, internal family systems, Gestalt, and so on, will be very familiar in working not just with ambivalence but the multiple aspects of the mind.

Core sills of MI

When thinking of the core sills of MI the idea of OARS can be useful:

Open questions: Aim to have clients talk more than 50% of session. This is better facilitated by open questions as opposed to closed sessions.

Affirming: Be aware of recognising strengths and look to spot when client is doing something positively reinforcing.

Reflective listening: This involves seeking to get inside your client’s inner world, possibly reflect unspoken meaning behind their statements.

Summarising: Being strategic, collecting and linking change talk, presenting it in a summary to your client.  Change talk is “Any self-expressed language that is an argument for change” (Miller & Rollnick, 2013, p.159).

When seeking to spot change talk it can be useful to think of DARN. Desire “I want things to be different” Ability “I’ve quit taking drugs before, I can probably do it again” Reasons “I know my relationship will end if I keep using pornography like this” and Need “I cannot keep living like this. I need to set a better example for my kids.” Change talk is almost the complete opposite of sustain talk, which supports no change or the status-quo. Examples of sustain talk are “Pornography helps me relax at night. I need it to sleep” or “Sex is natural. How can it be an addiction? I could be doing a lot of worse things.” or “I tried to quit gambling before and it didn’t last.”

Four Processes of MI and examples of appropriate techniques within each process.

Engaging

This process involves establishing a connection with the person you are seeing, and building rapport and a secure working relationship. This is where it is important to avoid the ‘expert trap’, or labelling or blaming. The aim of engaging is to build trust so that the person feels heard and understood. What do they want?  How do they think you can help them?

One useful technique could be to continuing the paragraph: “Venturing what might be the next sentence in the client’s paragraph instead of merely echoing the last one” (Miller & Rollnick, 2013, p.54).  

Also, explore values and goals (their sources of motivation), which is something a thorough assessment form should be asking anyway.

Focusing

This process involves devising and developing a specific direction for your work together.

A useful technique is to consider multiple options and determine a focus as part of agenda mapping. You could also exchange information and fill in gaps.

Evoking

This process involves eliciting the person’s own motivation for positive change. This is where the therapist will be looking for where the person voices their own arguments for change.

Your job as the therapist in MI is to draw out change talk. The difficulties are that people often use sustain and change talk in the very same sentence so it is important to not get lost in their narrative. Ambivalence is a common part of the process so the key is to encourage, elicit and highlight their own pro-change speech. Questions to evoke change talk involve framing a question to which the answer is change talk. Examples could be  “what would you like to be different”?, “What is the downside of how things are now”? or “what might be the advantages of making a change”?

You could also employ the importance ruler. Ask them on a scale from 0 to 10, how important is it for them to change their problem behaviour?” And perhaps why did they select a 5 and not a 3?

Planning

This process involves developing specific plan for action and involves strengthening a commitment.

Techniques could be assessing readiness, looking for the ratio of sustain/change talk, confirming a goal and developing a plan. You could offer a menu of options, which could offer the person a sense of empowerment. Your basic counselling skills of increasing skills will be useful particularly in this stage. A change plan can be a way of boosting commitment.

In summary, MI can be a useful addition to the range of tools and techniques open to the integrative practitioner in counselling and psychotherapy. It can be a directive approach but need not be if you embrace the principles of the approach. It can be very useful to help progress the therapeutic work with people who might be in much emotional and mental distress from behavioural addictions but who are contemplating change. Remember the spirit of MI, though, “if you as the helper are arguing for change and your client is arguing against it, you’ve got it exactly backwards” (Miller & Rollnick, 2013, p.9).

Noel Bell is a UKCP accredited psychotherapist based in London and can be contacted on 07852407140 or noel@noelbell.net