What is motivational interviewing? - Chapter 11

This last chapter describes the motivational interviewing approach. Motivational interviewing (MI) a directive, client-centered counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It was originally developed as an intervention to address drugs and alcohol addiction within the health care sector. Nowadays, it is used and found to be effective in various domains and under different conditions. MI is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship. 

What is the evidence base of motivational interviewing?

MI is supported by a substantial amount or research evidence, gathered from hundreds of studies in a wide range of settings from health to organizations. In the remainder of this section, two questions are answered: (1) Does MI work? (2) What are the active ingredients within MI?

Does MI work?

There are more than 650 outcome studies on MI. It has also been subjected to 18 meta-analyses and several systematic reviews on its effectiveness. To summarize all these studies, it can be said that a wide range of meta-studies have found that MI is a highly effective intervention for a wide range of clinical presenting issues and that it is as effective as equivalent levels of cognitive behavioural therapy (CBT) and is even more effective than CBT for some types of presenting issues. In addition, the results achieved appear to be sustainable over longer periods of time, suggesting that MI is highly effective at delivering sustained behavioural change for even the most challenging of habituated behaviours. 

What are the active ingredients within MI?

Why is MI so powerful? What are the active ingredients? The six active ingredients of MI appear to be:

1. Actively listening to the language of the client.
2. Recognizing changes in language as signals of changes in attitude.
3. Formulating questions and affirmations which echo changes in the language of the client.
4. Building discrepancy in the mind of the client between the new thoughts and recent past behaviours.
5. Consistency in the behaviour of the coach. 
6. Using feedback as a tool.

What practical tools and techniques are available for MI?

The spirit

The spirit of MI is characterized by the following three adjectives:

• Evocative: MI tries to draw things out from the client, instead of put things in.
• Collaborative: MI is an approach in which coach and client work together in partnership.
• Autonomy supporting: in MI the client is always the active decision maker. 

The principles

Next, the principles of MI are summarized with the acronym RULE which stands for:

• Resist the righting reflex, that is the natural tendency in humans to want to fix things and to make them better.
• Understand and explore the motivation of the client.
• Listen with empathy.
• Empower the client, encourage hope and optimism.

In addition to the RULE principles, some extra principles have been added to MI:

• Roll with resistance: minimize the manifestation of resistance and adapt to reduce resistance, as opposed to confronting and directly challenging.
• Information sharing: sometimes the information is not there, the coach has to share it so that the client can make an informed decision.
• Develop discrepancy: helping clients to become more aware of the gap between how things are right now and how they would like things to be.

The core skills 

Some of the core skills, also called micro-skills, of MI coaches are described in this section. The MI coach seeks to ask open questions. Open questions encourage the client to talk more than closed questions. Instead of asking 'Could you ...' it is preferred to ask a question like 'Why do you want to ...?' or 'What do you think might be most helpful?' Next, MI coaches make affirmations: statements recognizing and acknowledging some aspect of client effort or character. For example, the coach could say: 'You are the kind of person who sticks with things once you have made up your mind'. Further, MI coaches commonly use reflective listening or accurate empathy statements to check whether they understand the client correctly, helping the client to feel understood and perhaps even to generate some insight in the client as they hear what they said (and think) articulated back to them, but with a slight (hopefully helpful) change of wording. And lastly, MI coaches use summaries intermittently throughout the session to check and reflect on progress. 

Model of change

MI is commonly used within a model of change. Below are the stages of change listed, as well as their most useful interventions.

1. Pre-contemplation
   • Create relationship through empathy and rapport.
   • Use reflective listening
   • If the client is reluctant to change, encourage gathering of evidence or feedback.
   • If the client lacks believe that he or she can change, offer belief, encourage and hope.
   • If the client is giving reasons for not changing, explore wider values, beliefs and impact of behaviours of others.
2. Contemplation
   • Explore the reasons not to change and reasons to change.
   • Explore the 'problem'.
   • Explore the most important aspects or goals of the client's life.
   • Reflect on discrepancy between goals / values and current behaviour.
   • Explore confidence to change.
   • Explore barriers to change.
   • Reflect on desire to change and confidence statements.
3. Planning
   • Check for congruence in change communications.
   • Explore confidence to change.
   • Clarify and refine goals.
   • Review options and select chosen options.
   • Identify allies to support client.
   • Use visualization to build confidence.
4. Action
   • Monitor and affirm small steps.
   • Explore next steps.
   • Explore barriers being encountered.
   • Plan actions to overcome barriers.
5. Maintenance
   • Provide positive feedback on success
   • Plan for coping if the client slips back.
   • Reinforce long-term goals that fit with the client's values.
   • Encourage use of allies to continue positive progress.
6. Managing relapse
   • Empathize and normalize.
   • Explore reasons for relapse.
   • Plan to prevent next time.
   • Explore successes and affirm.
   • Reflect back positive statements of desire for change.
   • Return to contemplation actions.

Common techniques

Ten common MI techniques are:

1. Setting the scene.
2. Agenda mapping, that is agreeing the agenda.
3. Typical day.
4. Decisional balance.
5. Importance and confident rulers.
6. Looking back, looking forwards.
7. Two possible futures.
8. The key question.
9. Exploring options.
10. Agreeing a plan. 

Agenda mapping offers an opportunity to help the client to establish for themselves the focus of the conversation and therefore explain to themselves and the coach what they want to achieve from the coaching sessions. Possible questions the coach may ask are: 'What change shall we talk about?' and 'Why are we talking about ... and not about ...?' During agenda mapping it is important not to dive into too much detail. Rather, the aim is to remain at a high level and to move across a number of different issues before settling on the most important ones to the client. 

With the typical day technique, the coach aims to encourage the client to talk in detail about their current reality. But rather than talking specifically about the perceived problem, the coach asks a more open question to take a wider view of the issue within the context. The coach may ask: 'Perhaps you could help me get a better understanding of how our average day goes, starting from when you wake up in the morning until when you go to bed?' The overall aim is to encourage the client to start talking and continue from an evidence-based perspective about their day and how the issue that they wish to focus on manifests itself within their day. At the end of the exercise, it is helpful for the client if the coach summarizes the key points that have emerged. 

The decisional balance helps people think through their ambivalence in an open and systematic way. It works best when the client itself, rather than the coach, writes down the points on the decisional balance sheet, which is divided into 'good things' and 'less good things'. 

Evoking change talk lies at the heart of MI. With this technique the coach encourages the client to talk positively and actively about making the change. The coach is aware of the present state of change that the client is in (pre-contemplation or contemplation) and encourages the client to move to the next stage of making the change. 

When might MI be most suitable?

MI is very effective for many health-based assignments. It appears to be as effective, and in many cases more effective, than cognitive behavioural therapy for addictive behaviours including drugs, alcohol, smoking and weight loss coaching. More specifically, MI appears to be more likely to achieve the desired goal and for the clients to show continued adherence to their goals after the intervention, compared to other intervention techniques. However, the use of MI for other areas, such as career transition, managing redundancy or poor programmes, is more controversial and lacks evidence to support the claim that MI is more efficacious than CBT or other intervention techniques. In fact, for most areas of coaching, we are unable to make such claims as the evidence from comparative studies is not present. 

This last chapter describes the motivational interviewing approach. Motivational interviewing (MI) a directive, client-centered counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It was originally developed as an intervention to address drugs and alcohol addiction within the health care sector. Nowadays, it is used and found to be effective in various domains and under different conditions. MI is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship.