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Motivational Interviewing – Can clients talk themselves into change?

When I was at University there was a joke going around, I’m sure you heard it – How many Social Workers does it take to change a light bulb?  One.. but the lightbulb has to WANT to change.  So lame…I was embarking on this career for serious reasons!  It was no laughing matter.  

But what were my reasons?.. To contribute to society, to ease the suffering of others, to live out my values (I also liked to socialise and drink coffee and social workers seemed to do a lot of that).  All of the above, however, its easy to feel a bit.. I’m embarrassed to say.. superior sometimes, entitled to fall into lecturing and talking clients into change (and getting frustrated with how resistant they are to my ideas).  Resisting the “righting reflex” as it is called in Motivational Interviewing (MI) can prevent these good intentions from becoming counterproductive.  When I stumbled across this model – I knew I had better take a closer look.

Developed by Dr William Miller and Stephen Rollick in the late 1980’s Motivational Interviewing (MI) is defined as a “collaborative conversation style for strengthening a person’s own motivation and commitment to change” (Miller and Rollnick 2013: 12).  Inviting the “client rather than the counsellor to voice the arguments for change” (Miller and Rose 2009: 528) is at the heart of MI.  

Originally developed for the treatment of addictions, the first measurable intervention designed was in 1988, The Drinker’s Check Up (DCU).  Through this brief treatment, potential problems related to the persons alcohol usage was assessed and communicated.  This study demonstrated that understanding and evoking clients own concerns rather than persuading clients to change resulted in half as much resistance and twice and much change talk (Miller and Sovereign 1989).  MI has also shown promising results in the area of diabetes management, chronic mental health problems, dietary change and smoking cessation (see for example Burke, Arkowitz and Menchola 2003).

Motivational Interviewing in practice.  

MI consists of a relational component (MI Spirit) and a technical / strategic component (evoking).  Sitting under this are the four fundamental processes of Engaging, Focussing, Evoking and Planning, outlined below.  These processes act as a guide to the work rather than a linear formula as the therapist may need to return to earlier parts of the model throughout the counselling process.

Stage 1:  Engaging

The underlying approach to MI (also called MI Spirit) embodies the way the therapist is with the client. The acronym PACE is used to illustrate the following qualities of the essence of MI:  Partnership, Acceptance, Compassion, Evocation. The therapist works collaboratively with the client, expressing empathy, supporting autonomy and calling forth the clients commitment to change.  This relational component is influenced by Carl Rogers’ (1942) humanistic and person-centred ideas which emphasise the importance of respecting clients ideas and an acceptance of clients decisions.

Following, Guiding or Directing?

MI draws the comparison to the therapist being a tour guide, a middle ground between directing and following.  Someone who is a good listener and offering advice when needed, rather than telling a person what to see … or simply following them around.  At times the therapist may be more directive however there is a combination of “informing, asking and listening”.  Therapist guides the conversation towards the possibility of change. 

The therapist uses client centred counselling skills symbolised by the acronym OARS: 

Open questions: “How do you hope I might be able to help you today”

Affirming: “You’re already moving in the right direction”

Reflections:  Responding with a statement rather than a question, making a guess about what the person means”  e.g. “you think your drinking is a problem but its a puzzle as to how how to break out of the cycle”.  MI also call this “continuing the paragraph”.

Summarising: Pulling together several things a client has said and describing this back to the client.  

Stage 2:  Focussing

Focussing involves establishing the direction of the conversation, and in an ongoing way, seeking and maintaining direction.  The therapist can use hypothetical language such as … “we might”…”we could…”another possibility that occurs to me”… to establish a place to start. One strategy used in this area is agenda mapping whereby the therapist draws 10 or 11 medium size circles randomly placed on a page.  Each circle can then be filled in by the client in session and used as a tool to choose and prioritise the way ahead.  Once a focus is established, the therapist moves on to the evoking stage of the model and specifically looks for change talk.

Stage 3:  Evoking 

In this stage there is effort by the therapist to develop discrepancy in the client’s thinking about a problem. This can be achieved by amplifying change talk statements expressed by the client such as “I want to, I can, I need to, I have”, and are symbolised by the acronym DARN CATs: Desire to change, Ability to change, Reason for change, Need to change, Commitment,  Action, Taking Steps.  The therapist may respond with statements that elicit commitment and activation such as:

“What makes you think you need make a change”

“Its quite important to you that you have a go”

“You’re really not wanting things to be like this in 6 months time”.

Evoking involves listening for change talk statements such as: “I need to think about doing things differently”, “I want to make a change”, “I know what I need to do” etc.  During the therapeutic conversation the therapist will also hear sustain talk (the clients stated reasons for staying the same or disadvantages of changing).  Sustain talk  such as: “it’s daunting to do this”, “I’m doing all I can do right now”, is described as “counterchange arguments” as opposed to resistance.  The therapist attempts to draw out “change talk” and spend less time on “sustain talk”.  

Resistance, Sustain Talk and Discord 

There have been several changes to the language around resistance due to the implied message that client ambivalence is seen as the client being difficult.  Through the research on therapist influence on client language (Moyers 2006) it became apparent that  sustain talk (which is about the ambivalence about changing target behaviours) was different to what is called “discord”.  Discord resembled something more like a disagreement, a client interrupting, or discounting the therapist. 

It was realised that sustain talk was being labelled as resistance, rather than considering it as normal to have both change and sustain talk.  The purpose of considering discord as a separate entity means there is a focus on maintaining a collaborative relationship, not on the problem of resistance residing within the client.  

To discourage therapy from becoming confrontational, the MI therapist avoids creating further defensiveness (and desire to stay the same).  This is done by reflecting both sides of the clients argument but evoking reasons for change. 

Some examples of this may sound like the following:

“You’re not ready yet to make a change on this but can see yourself doing something”.

“I am really hearing you would like to make a change but haven’t found a way that works for you to do this  yet”.

Stage 4:  Planning 

Planning is carried out by asking for and listening to the client’s own experience of what will work for them.   The therapist can “test the water” for signs of client readiness for change.  For example:

“Would it make sense to think about planning some steps forward or am I getting ahead of things”

Moving towards planning involves summarising a clients motivations for change and handing over the decision to the client in the form of a key question such as: 

“So where does this leave you now”

“I wondered what you are thinking of doing now”

“Should we talk about some possibilities to help you feel better”

Developing a plan involves clarifying the goal, troubleshooting possible obstacles and ensuring there are specific targets.  Strengthening commitment to change may also include telling close friends or family about the plan and structured self monitoring. 

In summary:

While I feel privileged to be working in my chosen profession as a Social Worker, I am also learning to laugh at myself.  This model has encouraged me to step down from my soap-box and enable clients to embrace their own journey of change. Feeling less responsible for the outcome enables me to collaborate rather than control. I am sure my clients are happier too, however, I seem to need more naps these days.

References

Burke B. L, Arkowitz H and Menchola M (2003).  The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials.  Journal of Consulting and Clinical Psychology, 71, 843-861.

Rogers, Carl (1942) Counselling and Psychotherapy.  Boston: Houghton Mifflin. 

McGregor, T (2016)  – Workshop notes.  Motivational Interviewing 1:  Core Skills and Sprit

McGregor, T (2016)  – Workshop notes.  Motivational Interviewing 2:  The Power of Process and Change Talk

Miller W and Rollnick S (2013) Motivational Interviewing: Helping People Change.  Third Edition.  The Guilford Press NY.

Miller, W and Rose, G (2009). Toward a Theory of Motivational Interviewing. In American Psychologist Vol.64 No.6 527-537.

Miller and Sovereign (1989).  The Check-up.  A model for early intervention in addictive behaviours.  In T Loberg et.al. Addictive Behaviours Prevention and Early Intervention.

Moyers, T, and Martin T (2006).  Therapist Influence on Client Language During Motivational Interviewing Sessions.  Journal of Substance Abuse Treatment 30, 245 -252.  

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