Motivational interviewing enables us to apply specific change strategies with the basic attitudes of empathy, positive regard and congruence. In other words, we can build on all fundamental aspects of the coach-client relationship, generate change in the client and strengthen their self-commitment. We succeed in this after consistent application, by revealing problematic behaviour and the related cognitions and emotions with the client, reflecting on them and developing solutions.
(William Miller and Stephan Rollnick) Motivational Interviewing (MI) is more than applying a set of conversational techniques, it’s a way, or actually a method of turning people into change by talking about change.
MI is a client-centred counselling style to enhance personal motivation for behaviour change by exploring and overcome ambivalence (Miller, 2004). It was originally designed as a prelude to integrate with other clinical methods to assist clients through motivational obstacles to change (Miller, 2004). It can also be given as a brief stand-alone intervention usually in one or two sessions (Hettema et al., 2005). Based on the transtheoretical model of change, it is to prepare clients to shift from the precontemplation and contemplation to the real stage for change (Miller & Rollnick, 2009). Clients who are ready for change are unlikely to benefit from MI. Clients who appear to be angry, resistant and less ready for change seem to benefit most from MI (Miller & Rollnick, 2009). The beauty of MI is to selectively reinforce clients’ own reason for change, almost like clients talk themselves into change (Miller & Rollnick, 2009). A skilful therapist walks with the client along a road from initially ambivalence to motivational readiness, an achievable plan for change, and commitment to the change (Miller & Moyers, 2006). Therefore, MI encompasses two phases: stimulating motivation for change and reinforcing commitment for change (Miller & Rollnick, 2009).
Central Aspects and background
MI owes great debt to Carl Rogers’ client-centred psychotherapy which emphasises the positive human potential (Miller, 2004). Given the appropriate empathic understanding, positive regard, and radical acceptance, people will naturally move towards a healthy, self-fulfilling state (Hettema et al., 2005). Clearly the insights and methods of Carl Rogers are the fundamental practice of MI, but also Miller claims MI is one step more advanced as it is counselling oriented toward change (Miller & Rollnick, 2009). Typically, in a MI session, the client speaks most of the time as the therapist listens. This asymmetry of communication is especially notable around the client’s of motivation for change (Miller & Rollnick, 2009).
Self-perception theory postulates that when people defend an attitude which is not what they originally believe, they tend to act or speak more in favour of this new attitude (Miller, 2004). In other words, the support on their previous beliefs is weakened or even diminished. In relation to MI, when the client speaks of change of their own free will, it results in that person feeling more favourable towards the change and being more able to take steps towards improvement (Miller, 2004).
The SPIRITof the method, however, is more enduring and can be characterized in a few key points:
- Motivation to change is elicited from the client and is not imposed from outside forces.
- It is the client’s task, not the coach’s, to articulate and resolve the client’s ambivalence.
- Direct persuasion is not an effective method for resolving ambivalence.
- The coaching style is generally quiet and elicits information from the client.
- The coaching is directive, in that they help the client to examine and resolve ambivalence.
- Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction.
- The therapeutic relationship resembles a partnership or companionship.
There are four overlapping processes that comprise Motivational Interviewing: engaging, focusing, evoking and planning. They are both sequential and recursive, and often depicted in diagrams as stair steps, with engaging at the bottom as the first step.
While evidence-based practice is established as the standard in clinical practice, Miller & Rollnick take one chapter to discuss the spirit of MI.3 This discussion reflects the importance of therapeutic relationship versus overemphasis on techniques. In a book written for health care practitioners, Miller, Rollnick & Butler present MI in a technical process with abundant examples to teach the MI conversation style. The discussion of MI spirit is short and brief in their 2008 book, which looks more like guidelines than essential elements. Miller and Rollnick provide a well- developed version of the MI spirit with detailed explanations of its four elements:
A clinician practicing MI must realize that MI is not a word game in which the therapeutic effectiveness relies on insertion and imposition of the clinician’s choices through skillful manipulation. Miller and Rollnick portray MI spirit in a humanistic and supportive manner, which emphasizes the collaboration of the therapeutic process, empathetic understanding and commitment to clients, and the empowering of clients’ strengths.
FROM ENGAGING TO PLANNING
Miller & Rollnick plan a four-step process in MI. The four processes begin with engaging, focusing, evoking, and end with planning. From there on, the book is arranged in four major parts. These parts are labelled with the names of the four processes, and each part organizes several chapters to further the discussion of concepts and techniques under each of the four processes. Although these chapters lay a map for technique seekers, there is a clear thread of MI spirit flowing beneath the concepts and practice of MI techniques. It is fair to say that the practice of MI techniques aims to execute the contents sketched in the four elements of MI spirit. The fulfilment of MI spirit leads to the success of MI processes.
Step I Engaging
Engaging an individual who is either willing or not willing to receive substance abuse treatment is what clinicians encounter daily in their offices. The engaging process in MI stems from the MI spirit to carefully build a collaborative relationship, which is nurtured by the partnership of the MI spirit. Miller & Rollnick first emphasize the critical role of relationship serving as the foundation of the therapeutic process. Literature cited by Miller & Rollnick provides support for this evidence-based practice when it indicates that quality of relationship, or therapeutic alliance, greatly contributes to the outcomes of therapy. The warning of traps, which hinder relationship building, active listening, and reflection, are given to better prepare clinicians in engaging. A technical acronym, OARS, is described as the “foundational tools” for establishing therapeutic alliance. OARS stands for: Open questions-Affirming-Reflecting-Summarizing. These technical tools follow the MI spirit in acceptance and compassion, when clinicians are able to affirm clients’ worth, and to reflect and summarize contents with understanding and commitment to clients’ dilemma.
Step II Focusing
Miller & Rollnick describe focusing as a continuous process, which aims to keep the therapeutic process on track. Unlike the non-directive approach proposed by Carl Roger’s person-centered therapy, MI pays attention to the direction of therapy. However, Miller and Rollnick do not suggest taking a directive charge to the therapeutic goals. Instead, focusing takes a collaborative process where clinicians and clients share the control and the clients’ autonomy is respected and supported. Focusing is a process to help clinicians avoid the ineffective processes and traps that may not contribute to clients’ change. With the focusing process starting early in the engaging process, it assists clinicians in maintaining a clear vision of the therapeutic process and guides clients to explore the direction towards their desired changes.
Step III Evoking
Evoking is recognized by Miller & Rollnick as a unique process endorsed by MI. While engaging and focusing would be conceptualized in different ways and used in other forms of therapeutic approaches, evoking adds a new aspect and separates MI from other therapeutic approaches. Building upon the foundation of the relationship established through engaging and focusing, evoking starts a process to move clients toward changing current behaviours. The conversation is heard with ears tuned into clients’ ambivalence towards change and the potential towards change in change talk. Clinicians work with change talk to elicit motivation to change and avoid sustain talk, which stops clients from making changes. They also utilize the OARS to engage change talk and enhance the direction towards change. Even though in a process to push towards change, evoking does respect clients’ autonomy and their choices without blaming or shaming them for failure. This is also a process to provide confidence and hope to those who are clear about their direction, but lack trust in their own ability to succeed. However, according to the MI spirit, Miller & Rollnick clearly depict the evoking process as a collaborative and supportive process. Evoking is not a one-way insertion of clinicians’ intended goals into clients’ action plans. It is rather a process where clinicians use the MI techniques to promote changes within clients and help them clear the roadblocks such as ambivalence, sustain talk, and lack of confidence.
Step IV Planning
The last MI process is planning, which involves composing a strategic plan on how to achieve desired change. Miller & Rollnick indicate planning is a necessary process to prevent relapse and loss of motivation after clients go through engaging, focusing, and evoking. Clinicians assess clients’ readiness for planning when observing increased change talk and reduced sustain talk. In the planning process, it calls for developing specific steps in the plan and dealing with uncertainty and reluctance with strengthened commitment. Clinicians facilitate the planning process and encourage clients to commit to execution of the plan, while they continue to provide clients support and guidance when challenges emerge during the execution of the plan. The therapeutic process continues even when clinicians have to re-visit the beginning of the four processes. There will be time when clinicians should help clients in re-engaging and re-focusing steps to align them on the track towards change.
Source: ©2017 Guo et al on http://medcraveonline.com/MOJAMT/MOJAMT-03-00062.php
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially.
The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.