MI clinicians believe that clients have expertise on themselves that can be used to make healthy changes. Using this approach, clinicians elicit more information than they provide. The client does more of the talking, explaining, exploring, and considering. Clinicians using the MI approach tend to ask rather than tell, and to listen rather than advise. MI practice builds upon this collaborative relationship with a basic communication style that is used throughout consultation or counseling sessions.
The style is summarized with the acronym OARS— O pen questions that encourage further elaboration and consideration, A ffirmations that foster positive feelings in the consultation, R eflections that indicate that the provider has heard and accurately understood the client, and S ummaries that extend the basic reflections to include a sense of momentum or build interest in changing direction. In addition to the emphasis on using OARS as a basic communication style, MI clinicians use broader conversational strategies in the context of four general therapeutic processes: engaging, focusing, evoking, and planning.
MI is dependent on the development of a collaborative relationship between practitioner and client. Without this, the motivational influence of MI is likely to be quite limited.
Good engagement brings clients to a place of openness and nondefensiveness. Clients let go of early questions they may have about the practitioner, the process of counseling, whether they will be looked down on or supported, how safe it is to reveal what they really think and do, and to what extent have they been telling themselves lies or half-truths about a stigmatized habit, pattern, or way of being. Engagement is fostered through a skillful mix of open questions and reflections that highlight client experiences and perspectives.
Engagement can be undermined when clinicians focus prematurely on issues that clients may feel defensive or vulnerable about before establishing a relatively strong therapeutic bond and a pattern of openness in discussion.
Beginning a clinical encounter with extensive assessment is especially risky as it combines both traps, pressing clients to discuss private and sensitive issues before a bond develops and putting them in the role of disempowered reporters who are simply to provide information to the expert on which to make a determination. Although we present engagement as the first process, following Miller and Rollnick, it is important to highlight that it is not intended as a phase of treatment but as a therapeutic process that one may need to bring to the front at various points throughout treatment, when opening a new session or topic, when deepening the focus, and whenever clients are not fully engaged in an MI-style conversation and become defensive, detached, overwhelmed, or intellectualized.
The second process, focusing, primarily involves the mutual discovery of the direction of client change and intended goals involved in making a change. Clients may initially present with a very clear direction and intended outcome. If so, the process of focusing is primarily about developing a shared understanding of what the client already knows. At other times, multiple change priorities may compete with one another, and focusing involves helping clients explore and sort those, as well as decide whether multiple discrete changes may be better bundled together in a broader program of change.
Becoming more assertive is a broader theme that may be more readily addressed than focusing on each distinct situation in which the client feels unable to speak up, defend himself or herself, set limits, and so on. One strategy for focusing is agenda mapping. This is typically used when clients present with multiple competing issues. Agenda mapping involves having a metaconversation—stepping out of focusing on particular concerns or possibilities and instead having a discussion that attempts to sort out how to proceed forward.
As the practitioner moves forward through the topics, he or she can wind the way back to the big picture to check if the priorities remain the same and adjust the plan as needed. Practitioners can also return to mapping if a topic of focus gets overly complex, seems unresolvable, or requires approaching in discrete steps with breaks in between, or if the topic is one that is emotionally intense.
Other clients may have no specific change goals or targets set, and only a vague sense of dissatisfaction, or a stronger sense of depression or anxiety, but these feelings seem disconnected from behavior.
In these times, MI practitioners might shift from focusing on problems to focusing on possibilities, strengths, and successes. A given client may not be able to clearly define what the problem is for them or may have a clearly identified clinical issue such as maladaptive substance use, yet remain unable to perceive that to be a problem or not seem particularly ready to change it. Instead of engaging in guesswork regarding what problems might exist or risking ending up on opposing sides of ambivalence around clinical issues that clearly do exist, MI practitioners may shift the focus of conversation in a way that sidesteps the risk.
For example, the client may be invited to look back and remember times that were better, or to recount some past successes about which he or she feels proud. The practitioner may invite the client to explore good things about his or her current situation, using that as a springboard for then inviting the client to identify what could be better.
MI practitioners might also explore client-identified strengths , shifting the conversation toward more positive ground, and then eliciting ways in which clients could more intentionally utilize their strengths in their current situation. Or clients can be invited to look forward and envision a desired future, exploring imagined possibilities in order to make them seem more real and then utilizing the vision and emotional reactions to it as motivation to pull the client forward toward a better future.
Alternatively, practitioners can broaden the conversation to have a more vague focus, a general sense of improvement, or happiness or satisfaction, and then narrow the conversation by inviting clients to begin to imagine what might lead them to greater fulfillment, thus returning to a clinical focus.
For example, clients may want to focus on specific circumstances that led to an arrest, while clinicians may think it more important to discuss the drinking and using patterns that led up to the event and that may lead to similar events in the future. Rather than fall into the righting reflex trap, practitioners may be better served by broadening the focus in a way that includes both concerns e. Regardless of which situation fits a specific client, the goal is to join them where they are and work together toward next steps.
For many clients with addiction problems, the benefits, drawbacks, and risks for continued substance use are generally well-known to them. There are genuinely few clients who are likely to be unaware of hazards and risks, and perhaps, unlike behavior change in other domains, there is generally little benefit in further provision of information about their situation, condition, or the possible future pathways available to them.
Extrinsic motivation is simply not very motivating for people with substance use problems. Long-term change occurs when it is substantially motivated by these internal factors, independently chosen by the person, even though there may be external reinforcers involved cf. The process of evoking is the core of motivational interviewing. Two overarching strategies in the process of evoking client motivation in MI focus on increasing perceived importance of making changes and increased perceived confidence about making changes.
First, practitioners can explore the good and less good things about a current problematic habit like substance use. Evocative questions focused on the subtypes of change talk related to importance desire, reasons, needs are simple strategies to help clients consider change.
Such questions could include. What are some ways things could be better if you decided to quit drinking? What would you say is the most important thing you could do now to prevent things from getting worse in the future?
Looking back , mentioned previously, can also be used to help clients remember how life was before problems developed if relevant to their situation , thus eliciting motivation to regain what has been lost. Finally, exploring client values can help identify discrepancies between their cherished values and the way they are actually living, or, in a less risky way, skipping the highlighting of discrepancy and just helping clients identify ways they could live in even greater congruence with their deeply held values.
Evoking greater client confidence about change is also motivating. Another parallel strategy is confidence scaling , using the same scaling approach as with importance, only this time focusing on confidence.
R eviewing past successes involves eliciting a discussion of previous accomplishments, how they prepared, what strategies they used, what barriers they faced, and how they worked around them. It can also help them reframe perceived failures as steps along the way to eventual change. Exploring personal strengths and available supports can also be motivating. A final confidence-building strategy involves brainstorming hypothetical change. People seem to find it easier to imagine what-if scenarios about change without the pressure of committing and therefore are less likely to get caught up in a crisis of confidence.
When people have mostly resolved their ambivalence and are interested in figuring out how to get started, MI practitioners use planning strategies to help them prepare for and initiate change. Another strategy to get started is to plan the steps toward change: What should happen and in what sequence?
What supports can be rallied? When should various steps happen? What rewards can the client imagine will result? What might be some challenges that could interfere with the plan? Some clients like to develop a written change plan, while others prefer to make plans through conversation only.
As clients move into action, it can be helpful to continue to provide support and guidance, assisting them in self-monitoring their progress or finding a supportive mutual monitoring situation, such as a group or buddy.
Part of moving into action may involve learning new skills, and it can be useful to bring in other therapies, classes, or practice opportunities at this point. In addition to defining what MI includes, it is also useful to define what it does not include. For example, although occasional advice may be given to clients who are seeking it, unsolicited advice is not offered without first securing client permission.
Similarly, clinicians do not confront or warn clients, engage in domineering or controlling interactions, or express their own concerns about clients or client choices except in extenuating circumstances where clients may be in immediate danger. MI strategies or techniques are not simply added into interactions that are hierarchical in nature; rather, the MI style prescribes that the provider-client relationship is inherently nonhierarchical.
In summary, MI is a counseling approach in which clinicians use a client-centered stance paired with eliciting techniques to help clients explore and resolve their ambivalence about changing behaviors that are not optimally healthy.
Although it has strong roots in client-centered counseling, MI developed more out of practical experience than theoretical conviction and can be considered atheoretical or theoretically eclectic.
Working together, Miller and Rollnick developed the clinical methods and described them in their book. They anchored their discussion of the rationale for elements of the clinical methods on discussion of the theories to which the elements were logically linked.
Although cognitive dissonance theory as a whole is no longer part of the model of MI, recent versions of MI have retained the idea of the related concept of discrepancy. Although the scientific literature on MI helped to increase its popularity, a significant factor in its dissemination was the development of a network of skilled trainers who trained clinicians in MI across settings and in many countries across the globe.
This group began meeting regularly at the time of the annual Training of New Trainers conducted by Miller and Rollnick and was initially a loose collaboration of volunteers. As new trainers were trained, the group outgrew its original small format and added online support for its growing community.
With early technical assistance from the Mid-Atlantic Addiction Technology Transfer Center, the MI Network of Trainers grew into an active international community of many hundreds of trainers who interact via listservs, annual meetings, an online journal, and collaborative commercial and charitable training projects around the world.
The MI Network of Trainers is now an independent entity that counts many of the most active MI researchers among its members, thus developing a strong communication loop between researchers, practitioners, and administrators in a wide variety of cultures and professional settings. MI researchers have had their own conference International Conference on Motivational Interviewing that has occurred biannually in Europe and the United States since Although MI was derived from practice-based evidence, there are ongoing attempts to understand it theoretically.
Currently, there is no comprehensive theory of MI that thoroughly explains its actions or drives its development, although there are several papers that hypothesize likely threads. In this section, we consider how an emerging model of MI might be woven from the threads of self-determination theory, the transtheoretical model of behavior change, emotions theory, interpersonal theory and psychotherapy, and data on MI and some of its potential mechanisms.
As practice evolves and new evidence about effectiveness and process-outcome relationships emerges, it is likely that definitions of MI will change. In some ways, this has already happened. There are at least four perspectives on defining MI. One is that MI is a creation of and is defined by its original developers. MI was described initially by Miller and then by Miller and Rollnick, and these founders of the approach may continually revise and update it as their own experiences and thoughts develop.
Reflecting helps ensure that the direction of the encounter remains client-driven. The simplest level of reflection tests whether the counselor understood the content of the client's statement. Deeper levels explore the meaning or feeling behind what was said. Effective deeper-level reflections can be thought of as the next sentence or next paragraph in the story, i.
We describe seven types of reflections, the final two, reflections on omission and action reflections, are new variants. Content reflections are used to elicit the basic facts in the client's story. Although it is perhaps the simplest and least powerful type of reflection, content reflections can be important when trying to gather background information and build initial rapport.
They generally entail paraphrasing what the client just said but without adding much to the client's initial statement. To avoid parroting, the counselor still slightly changes the client's words. These reflections generally require less risk and less inference than the other types. Often practitioners are reluctant to use emotionally intense words. Glossing over or minimizing client feelings can communicate counselor discomfort with emotional intensity and shut the client down. Conversely, acknowledging emotional intensity is a powerful way to quickly build rapport and encourage the client to fully disclose their thoughts and feelings.
Confronting clients can evoke reactance and shut them down[ 2 ]. Therefore, MI counselors "roll with resistance" rather than attempt to argue with the client. Such reflections can be thought of as "comforting the afflicted. Examples include: "You really enjoy smoking weed. You look forward to lighting up at night, and giving it up seems very difficult" or "eating at McDonalds is a real treat for you. It's cheap, convenient, and really works given your busy schedule".
Such reflections help capture the client's reasons for not changing and allow them to express their resistance without feeling pressured to change or worrying about being judged. Sometimes rolling with resistance is not sufficient to move the client forward. When this occurs an amplified negative reflection, that "afflicts the comfortable" may be appropriate. Paradoxically, amplified negative reflections are a way of arguing against change by exaggerating the benefits of or minimizing the harm associated with a risky behavior.
It may take the form of "so you see no benefit in changing XX" or "XX is all positive for you. In response, clients will often then reverse their course, and start to argue for change. This type of reflection poses some potential risks, and can occasionally backfire. Important here, is for the counselor to avoid any tone of sarcasm.
This type of reflection is particularly useful when clients appear stuck in a "yes, but" mindset. Double-sided reflections typically take the form of "on the one hand, you would like to change XX, but on the other hand changing XX would mean giving up XX" or "you are torn about changing XX Sometimes a counselor can reflect back to clients what they have not said.
This can include reflecting on the client's silence or reluctance to talk about a particular issue; "you don't seem like talking today or you didn't have much of a reaction to what I just said. However, an additional permutation includes reflecting back to the client beliefs, solutions to problems, sources of help, etc that have not been raised.
For example, if an otherwise happily married woman states that she has no one to exercise with, the counselor could reflect back "so it sounds like your husband is not the answer. They incorporate into the reflection, possible solutions to the client's barriers or a potential course of action. They can be essential in establishing specific action steps for change, in an autonomy supportive rather than prescriptive style.
They differ from the more common type of reflections such as those that focus on client feelings, rolling with resistance, or acknowledging ambivalence as they usually contain a potential concrete step that the client has directly or obliquely mentioned.
The action reflection looks forward rather than inward or backward [ 5 , 41 , 50 , 51 ]. Because the client directly mentioned or alluded to the possible course s of action contained within the action reflection or they flow logically from the parameters established by the client, this type of reflection should not be confused with unsolicited advice.
Like any type of reflection, ARs represent the clinician's best guess for what the client has said or more apropos here, where the conversation might be heading. Action reflections can include multiple choices to support the client's autonomy. Because the client directly mentioned or alluded to these possible courses action, this type of reflection should not be confused with unsolicited advice something generally discouraged in MI. There are four subtypes of action reflections:. This is the simplest and often the default type.
It generically takes the form of "Sounds like, in order to move forward, you might want to address barriers a, b, and c. Here, the action is presented in a non-specific way as more an umbrella strategy, with the intent of having the client fill in the details, for example, "So you might consider doing something like x, y, or z.
An advantage of the general fix is that the client can generate the specific strategy which can increase commitment and autonomy. Whereas the general fix may not include a discrete action step, sometimes based on prior discussion, there is a clear solution or multiple solutions that the client has mentioned or alluded to that well match their needs. In these cases, a more specified reflection may be effective. Whereas the reflections above focus on behavioral actions, sometimes moving forward can entail modifying cognitions.
This technique allows the implementation of cognitive therapy strategies within an MI framework. These reflections can be similar to cognitive restructuring techniques, although the new or alternative cognition is presented in the form of a reflection rather than directive advice.
Common cognitive changes can include not applying all-or-nothing thinking, making peace with lack of immediate benefit or even short term discomfort, and understanding from prior experiences that they will be able to endure the discomfort.
Another variant is helping the client view their effort, even if not resulting in success, as a positive expression of commitment rather than a failure of execution. Specifically, this could entail, "so not addressing this is an all or nothing thing or accepting the fact that you have dealt with similar discomfort in the past might help make quitting easier. Suggesting new ways of thinking could also include reflections that help the client accept that that even small changes can be viewed as success e.
For example; "it might be useful for you to consider all your activity when you calculate your daily goals" or "you seem to only include your time in the gym as physical activity but not your walking to and from work or your gardening". Another variant is helping the client view their efforts, even if not resulting in success, as a positive expression of commitment rather than a failure. A core principle of MI is that individuals are more likely to accept and act upon opinions that they voice themselves [ 52 ].
The more a person argues for a position, the greater his or her commitment to it often becomes. Therefore, clients are encouraged to express their own reasons and plans for change or lack thereof. This process is referred to as eliciting change talk. Expression of change talk, particularly a strong crescendo of commitment, appears to be a good predictor of future change, and a key mediator of the MI process[ 5 , 53 ].
This strategy typically begins with two questions: 1 "On a scale from zero to ten, with ten being the highest, how important is it to you to change [insert target behavior]? Clinicians typically follow each of these questions with two probes. If the client answered "five," for example, the counselor would probe first with, "Why did you not choose a lower number, like a three or a four? Other related questions that can be useful in determining motivation include, "how much energy do you feel it would take to change XX", "how much do you dread giving up XX?
The latter is often reserved for the end of Phase II, after an action plan has been determined. A related strategy is to help clients experience discrepancy between their current behavior and their personal core values or life goals; this can lead to values clarification and "afflicting the comfortable. The counselor next asks how if at all the client might connect the health behavior in question with his or her ability to achieve these goals or realize these values.
Alternatively, the counselor may ask how changing the health behavior would be related to these goals or values. The list of values and attributes can be tailored to the particular client population or the health behavior being addressed. For example, the list for adolescents may include values such as "being popular" or "being mature," whereas for an older population the list may include values related to independent living or maintaining youth or vitality.
Alternatively, some practitioners obtain goals and values from clients using open ended questions rather than a list. In standard medical and health counseling practice, practitioners often provide information about the risks of continuing a behavior or the benefits of change with the intent of persuading the client. A traditional counseling statement might be, "It is very important that you change.
This type of communication can elicit reactance, or push back from the client[ 56 , 57 ]. The counselor first elicits the person's understanding and need for information, then provides new information in a neutral manner, followed by eliciting what this information might mean for client, using a question such as, "What does this mean to you" or "How do you make sense of all this? Autonomy is supported by also asking how much information the client might desire.
A key challenge for many clinicians learning MI is determining when and how to transition from building motivation to planning a course of action.
Once resistance or ambivalence are resolved and motivation is solidified, many practitioners struggle with how to transition the discussion to action planning while still retaining the spirit of client centeredness; moving from the WHY phase to the HOW phase in a style that is MI-consistent. For many, there is a perception that the counseling style, skills, and strategies used to build motivation are distinct from those used in action planning.
This can lead to a fractured clinical experience for both the counselor and the client. The WHY to HOW transition does not, however, necessitate abandoning a client-centered style for a more overtly educational or directive style. However, these prior efforts to combine MI and CBT have in effect, simply pasted the two components together, with MI serving as a prelude or pretreatment motivational primer.
Less work has been done on truly integrating the two approaches. In particular there is a need to develop autonomy supportive variants of CBT and other action oriented approaches that are conceptually consistent with MI, not only stitched together.
To this end, we propose a three-component model of MI comprising three core tasks: Exploring, Guiding , and Choosing. This model is an adaptation of models that Rollnick et al. Each task or phase is characterized by different counseling objectives and usually applies specific skills and techniques. The primary objective during this phase is to "comfort the afflicted. Key skills used during this phase include listening, shared agenda setting, open-ended questions, content, feeling, and double-sided reflections.
There is little action planning during this phase, although the counselor may "parking lot" ideas that start to emerge with a verbal note to revisit them later in the encounter. Once rapport has been established and the essence of the client's story has been evoked, the discussion can move to Guiding.
During this phase, the counselor may "afflict the comfortable" by moving the conversation toward the possibility of change.
The counselor elicits change talk by asking the client to consider life with and without change and by building discrepancy between the client's current actions and his or her broader life goals and values. Phase II typically concludes with the counselor summarizing what was discussed including potential reasons for making a change, and asking the client something along the lines of, "so where does that leave you? If the client expresses a clear commitment to making a change, even if small in magnitude, the session can move to Phase III and a more pragmatic discussion of HOW to implement said change.
This is where action oriented approaches are brought to bear. Primary objectives during this phase include helping clients identify a goal, building an action plan, anticipating barriers, and agreeing on a plan for monitoring and if applicable, contingencies for successful effort. Key skills used in this phase include menu building and goal setting, typically executed through the action reflection. When building an action plan there is the potential for the client to refute suggestions, even if they are derived from their prior statements, and offered in a tentative, "undersold" tone by the clinician.
They may elicit a "yes-but" response, either due to underlying resistance or simply because the option does not work for the client based on intuition or experience. It is important to bear in mind that, like any type of reflection, action reflections, represent the clinician's best guess for what the client said or where the story is going.
They are hypotheses and the productive "foul tip" rule applies here as well. That is, action reflections that are rejected by the client can still yield productive information about what does and does work or what should or should not be pursued, which nonetheless helps move the conversation toward resolution.
One means to minimize outright rejection of an action reflection is to provide multiple options within the reflection. For example, "based on what you have said, it appears you have a few options available Choice reduces reactance.
Although the three-task model implies a temporal sequence of Explore-Guide-Choose, and this will often be the case for patients entering counseling in an ambivalent or resistant state, not all clients will follow this linear order. Some patients may come into counseling fully motivated to change and may benefit from Choosing earlier on, whereas others may require recycling through Exploring and Guiding before they can commit to change.
Despite their unique origins, a marriage between MI and SDT may be helpful for both clinicians and theoreticians. For MI clinicians, a more acute awareness of SDT's core needs of autonomy, competence, and relatedness can provide a theoretical framework to guide the format and content of their counseling.
Conversely, for SDT theorists, MI can provide a well-established framework through which to apply their concepts clinically. The three-phase model of MI proposed herein can serve as such a unifying framework for MI clinicians to apply SDT concepts across the full spectrum of clinical practice. Further, using SDT as the theoretical basis for MI, even if only de facto, can help guide research and practice in other ways. For example, how do MI and SDT handle individual and cultural difference in counseling style preferences.
Although many patients report satisfaction with and improved outcomes from patient-centered approaches [ 61 — 63 ] such as MI, some individuals may prefer and benefit from a more directive counseling style[ 64 ]. In one recent study [ 65 ], where rural African American women viewed an MI training tape showing both MI and non-MI consistent practice, many expressed concern that the MI consultation was too patient centered, ''He [provider] was asking the patient more about his decision, instead of him [provider] telling him.
He's supposed to know, he's a doctor. In a recent study we just completed with Mexican Americans with diabetes a substantial proportion indicated that they just "wanted their doctor to tell them what to do. On one hand, SDT would assume a priori that autonomy is a universal need, and any counseling must support client autonomy. So then, how can "directive" counseling still be autonomy supportive?
How can practitioners offer advice while still supporting volition? Given that some clients may respond better to directive advice, there is a need for methods to assess how open clients are to internalizing direct advice versus feeling controlled by and reactive to it.
SDT might propose that even if the source of advice is external, if the person has requested such advice and the clinician still frames the discussion with volition, then autonomy is maintained. And although autonomy is one core need, sometimes, as in the case above, clinicians may need to focus more on relatedness and competence than autonomy. SDT might help MI clinicians think differently about what client needs to focus on during different phases of counseling and how to address different types of patients.
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