Institute Inbrief - 26/08/2014
Welcome to Edition 209 of Institute Inbrief! As a goal-oriented, client-centred counselling style for eliciting behaviour change, motivational interviewing (MI) helps clients to resolve ambivalence (Wikipedia, 2014).
In this edition’s featured article we define motivational interviewing; outline several approaches which are related, but do not share the spirit or essence of motivational interviewing; and depict the character of the spirit (or essence) of motivational interviewing.
Also in this edition:
- Latest news and updates
- Articles and CPD information
- Social media review
- Upcoming seminar dates
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Connecting with clients
Modern counseling models and techniques are as varied and diverse as the counselors and clients who use them. Most counselors have a particular theory, method or school of thought that they embrace, whether it is cognitive behavior therapy, solution-focused therapy, strength-based, holistic health, person-centered, Adlerian or other. Yet all of these approaches and techniques have at least one thing in common — their potential effectiveness is likely to be squelched unless the counselor is successful in building a strong therapeutic alliance with the client.
The crucial nature of the therapeutic alliance is not a new idea. In 1957, Carl Rogers wrote an article in the Journal of Consulting Psychology outlining the factors he considered necessary for achieving constructive personality change through therapy.
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Motivational interviewing: The definitions, the spirit, and what it is not
The initial description of motivational interviewing (MI), provided by William Miller in 1983, has evolved through both clinical experience and empirical research into the evidence-based practice it is known as today. Differing from more “coercive” methods for motivating change, motivational interviewing does not impose change, but supports it in a way which is congruent with the person’s own values. The most current definition (among a set which has shown continuous evolution) is that MI is:
“... a collaborative, person-centred form of guiding to elicit and strengthen motivation for change” (motivationalinterview.org, n.d.)
Grounded in a respectful stance with a focus on building rapport in the early stages of the therapeutic relationship, motivational interviewing has three essential characteristics. It is:
- Conversation about change; it is thus counselling, therapy, consultation, and also a method of communicating
- Collaborative, meaning person-centred, autonomy-honouring, partnership-driven, and not set up as expert-recipient
- Evocative, seeking to call forth the person’s own motivation and commitment (motivationalinterview.org, n.d.)
Taking those elements into definitions from multiple perspectives, we can offer:
A lay person’s definition, which asks “What is it for?”
“Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change.”
A practitioner’s pragmatic definition, asking, “Why should I use it?”
“Motivational interviewing is a person-centred counselling method for addressing the common problem of ambivalence about change.”
A technical therapeutic definition, which wants to know, “How does it work?”
“Motivational interviewing is a collaborative, goal-oriented method of communication with particular attention to 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” (motivationalinterview.org, n.d.).
In the spirit of the interview
To Rollnick and Miller, it is essential to maintain the spirit of motivational interviewing, especially inasmuch as numerous related practices have sprung up which are different and sometimes violate the spirit of the approach. Even those practitioners who utilise recommended techniques may inadvertently be at odds with the spirit of the MI approach if they are too technique-focused; Rollnick and Miller note that there are as many variations in technique as there are clinical encounters. The spirit, they say, is more enduring. We can depict its character in these several points.
Motivation to change comes from within the client; it is not imposed from without
Imagine a client that was threatened with the loss of his wife if he did not stop drinking. Many motivational approaches work on such bases, coercing through threatened loss of cherished aspects of a person’s life: job, partner, child custody, etc. Persuasion and “constructive confrontation” would also be part of such approaches. Rollnick and Miller do not decry such approaches, conceding that they have a place in evoking change. They are quite different, however, from motivational interviewing, which relies on being able to identify and mobilise the client’s intrinsic values and goals in order to effect change (Rollnick & Miller, 1995).
The client, not the counsellor, must articulate and resolve the client’s ambivalence
The word ambivalence has two (originally Latin) morphemes, “ambi-” meaning both, and “valent”, from a word referring to vigour or strength (Farlex, 2009). An ambivalent person is one who is pursuing – with strength – both (that is: two opposing) courses of action at the same time. In the case of proposed change from overuse of alcohol, for example, the change is from indulgence to restraint. Many clients feel ambivalence – the conflict between two strongly desired choices – in considering such a change, but have not had the opportunity to articulate it or assess the costs and benefits associated with it. The counsellor’s task here is to facilitate expression of both sides of the ambivalence, guiding the client toward an acceptable resolution, one which triggers change (Rollnick & Miller, 1995). A client, for example, may express a strong desire to give up alcohol, but feel an equally strong desire to keep drinking on the grounds that, if he stops, he will have to find a new set of friends and forgo the many hours at the pub with the drinking mates.
Direct persuasion is not an effective method for resolving ambivalence
Would-be change agents are often tempted to persuade the client by virtue of extolling the urgency of the change actions needed in order to ameliorate the problem. Doing so is logical, but it doesn’t work (Miller, Benefield, & Tonigan, 1993). What happens instead is that client resistance increases and change becomes even less probable.
The counselling style is a quiet and eliciting one
The motivational interviewing approach explicitly proscribes aggressive confrontation, direct persuasion, and argumentation, as these are the opposite of the intended style. A mental health helper used to confronting clients and giving advice may wonder if the MI process ever gets anywhere; it seems so slow. Yet ultimately, more gains generally obtain than through aggressive strategies and those counsellors attempting to vigorously confront client denial may find they have pushed clients into changes for which they aren’t ready (Rollnick & Miller, 1995).
The counsellor is directive in helping the client to examine and resolve ambivalence
The assumption with motivational interviewing is that, once the client has been able to understand and resolve any ambivalence, change can be triggered, so training in behavioural skills for coping is not part of MI. Once the ambivalence is transcended, there may or may not be need for skills training. If there is, it is not incompatible with MI. Ultimately, however, the strategies of this modality are designed to elicit, clarify, and resolve ambivalence in a respectful, client-centred environment.
Readiness to change is a product of the interaction, not in the client
Somewhat surprisingly, a corollary to the above assumption (that motivation to change comes from within the client) is that denial and resistance to change are seen not as client qualities, but feedback regarding therapist behaviour. Ideally, the therapist is highly attentive to the client’s motivational signs. When there is resistance, it is often because the therapist is assuming too much readiness to change on the part of the client. In this case, the therapist needs to back off and modify motivational strategies. Readiness to change, then, is seen to fluctuate as a function of interpersonal interactions rather than being a client trait (Rollnick & Miller, 1995).
The therapeutic relationship is more partnership than expert/recipient
The relationship in motivational interviewing is one of autonomy, not authority. Rather than being an authority figure as with other psychologies, counsellors here understand that, because the true power for change rests within the client, it is up to the client to follow through with making change happen. The therapist respects this autonomy and freedom of choice – and the client accepts the responsibility and consequences regarding his or her behaviour that go with it. Counsellors emphasise that there is no single “right way” to change; it can happen in multiple ways. Clients exercising autonomy are encouraged to develop a menu of options as to how they might achieve the desired change. These respective counsellor-client roles speak to partnership more than the unequal roles of an expert “doing” to a recipient (Rollnick & Miller, 1995; motivationalinterview.org, n.d.).
The spirit is an interpersonal style
Given the above characteristics, we can see how we err in thinking of motivational interviewing as a set of techniques, particularly ones “used on” clients. The advantage of seeing it as an interpersonal style is that MI can be applied to other settings. The subtle balance of directive and client-centred elements, shaped by its guiding philosophy and knowledge of what achieves change, means that we can point to the spirit of motivational interviewing as that which gives rise to specific strategies and informs their use. Having delineated what it is, let us see what MI is not: the several approaches which are related, but do not share the spirit or essence of motivational interviewing.
The check-up
Derived from motivational interviewing, the check-up involves doing a comprehensive assessment of the client’s problem behaviours (say, drinking and related behaviours). Systematic feedback of the findings is given to the client in the style of MI. The instrument used for the check-up in the case of alcohol-related behaviours is The Drinker’s Check–up (Miller & Sovereign, 1989). The crucial aspect is to provide meaningful personal feedback which can be compared with normative reference. The check-up strategy can be adapted to other problem areas as well. Clearly, this method does not function in the spirit of MI in that the assessment of “what is wrong” with the client – and should therefore change – comes from an external source: the check-up instrument, although there is evidence that merely receiving the feedback can sometimes trigger change (Agostinelli, Brown, & Miller, 1995).
Motivational Enhancement Therapy (MET)
Developed specifically as one of three interventions tested in a multisite clinical trial of treatments for alcohol abuse and dependence, Motivational Enhancement Therapy is an adaptation of the check-up intervention. It consists of four sessions: two follow-up sessions (at weeks 6 and 12), added to the traditional two-session check-up format. The predominant style used by counsellors doing MET is that of motivational interviewing. Again, the strict (brief) format asks clients to slot into its narrow spaces as a pre-set agenda runs; there appears to be little room for client input or internally-generated resolution of ambivalence (Rollnick & Miller, 1995). Even if the conversation (feedback) is happening in motivational interviewing style, there do not appear to be enough characteristic components of MI to facilitate change in that spirit.
Brief motivational interviewing
As health professionals in primary care settings became interested in using motivational interviewing techniques, Rollnick observed that they did not know how to adapt and apply the generic style of MI in brief medical contacts. In response, he and his colleagues developed a menu of concrete strategies which formed the basis of brief motivational interviewing for use in a single session (say, about 40 minutes) in primary care settings with non-help-seeking excessive drinkers (Rollnick, Bell, & Heather, 1992). The techniques were meant to manifest the spirit and practice of MI in brief-contact settings, but many primary care encounters (say, an appointment with a typical general practitioner) are briefer still: say, around five to ten minutes. Rollnick acknowledges that it is an unresolved question whether the spirit of the MI approach can be captured in such very short sessions (Rollnick & Miller, 1995).
Brief intervention
With this term comes major confusion. Brief intervention has generally been confused with motivational interviewing, probably because of the increasing popularity of terms such as “brief motivational counselling”. Such brief interventions, as applied to alcohol addiction issues, have been typically offered to two client groups: heavy drinkers in general medical settings who have not asked for help, and help-seeking problem drinkers in specialist settings (Bien, Miller, & Tonigan, 1993).
FRAMES to understand brief interventions
Brief interventions have demonstrated some effectiveness, but we can ask: what are the aspects of them which facilitate change? In an attempt to express their common underlying components, the acronym FRAMES was devised (Miller & Sanchez, 1994). The letters refer to: the use of Feedback, Responsibility for change resting with the individual, Advice-giving, providing a Menu of change options, an Empathic counselling style, and the enhancement of Self-efficacy (Bien et al, 1993; Miller & Rollnick, 1991, in Rollnick & Miller, 1995).
Examining how approaches comprised of these ingredients stack up alongside of MI, we can note that, although many of the FRAMES elements are clearly congruent with a motivational interviewing style, some aspects – such as (typical) advice-giving – clearly are not. Thus, Rollnick and Miller advise that MI should not be confused with brief interventions in general. The authors suggest that the word “motivational” only be used when there is major intentional focus on helping someone get ready to change. Moreover, they say, “motivational interviewing” should only be used when careful attention has been paid to the definition and characteristic spirit, as described above. In other words, if direct persuasion, direct advice-giving, and appeals to professional authority are part of the (brief) intervention, it should not be called “motivational interviewing”.
The distinction is important as the MI approach and similar ones gain popularity and increasing numbers of studies are done about their effectiveness. It would be a gross disservice to MI if a similar but contradictory-in-spirit approach were to be presented and tested experimentally as “motivational interviewing”; any subsequent claims of ineffectiveness would unjustly and inaccurately tarnish MI’s reputation (Rollnick & Miller, 1995).
Summary: Differences from more confrontational approaches
In summary, Rollnick & Miller would not agree that motivational interviewing is being offered when a therapist or other mental health helper:
- Tells the person that s/he has a problem and needs to change
- Directly advises or prescribes solutions without gaining permission from the client or actively encouraging the person to make their own choices
- Acts as an authority/expert, rendering the client into a passive role
- Imposes a diagnostic label
- Behaves coercively or punitively
- Does most of the talking and information-giving (adapted from Rollnick & Miller, 1995).
© 2014 Mental Health Academy
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References:
Agostinelli, G., Brown, J. M., & Miller, W. R. (1995). Effects of normative feedback on consumption among heavy drinking college students. Journal of Drug Education, 25, 31-40.
Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88: 315-336.
Farlex. (2009). Ambivalence. The Free Dictionary. Online version of The American Heritage Dictionary of the English Language, 4th ed. Houghton Miflin Company. Retrieved on 16 May, 2014, from: hyperlink.
Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.
Miller, W.R. & Rollnick, S. (1991). Motivational interviewing: Interaction techniques. Excerpts from: Motivational interviewing: Preparing people for change. New York: Guilford Press. Retrieved on 7 May, 2014, from: hyperlink.
Motivationalinterview.org. (n.d.). A definition of motivational interviewing. Retrieved on 12 May, 2014, from: hyperlink.
Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37.
Rollnick, S. & Miller, W.R. (1995). Motivational interviewing: What is it? Behavioural and Cognitive Psychotherapy, 23, 325-334. Retrieved on 7 May, 2014, from: hyperlink.
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